Foot & Ankle International - June 2017 - 641

695111

FAIXXX10.1177/1071100717695111Foot & Ankle InternationalReddy et al

research-article2017

Article

Assessing the Utilization of Total Ankle
Replacement in the United States

Foot & Ankle International®
2017, Vol. 38(6) 641-649
© The Author(s) 2017
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https://doi.org/10.1177/1071100717695111
DOI: 10.1177/1071100717695111
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Sudheer Reddy, MD1, Lane Koenig, PhD2, Berna Demiralp, PhD2,
Jennifer T. Nguyen, MPP2, and Qian Zhang, PhD3

Abstract
Background: Total ankle arthroplasty (TAR) has been shown to be a cost-effective procedure relative to conservative
management and ankle arthrodesis. Although its use has grown considerably over the last 2 decades, it is less common than
arthrodesis. The purpose of this investigation was to analyze the cost and utilization of TAR across hospitals.
Methods: Our analytical sample consisted of Medicare claims data from 2011 and 2012 for Inpatient Prospective Payment
System hospitals. Outcome variables of interest were the likelihood of a hospital performing TAR, the volume of TAR
cases, TAR hospital costs, and hospital profit margins. Data from the 2010 Cost Report and Medicare inpatient claims were
utilized to compute average margins for TAR cases and overall hospital margins. TAR cost was calculated based on the all
payer cost-to-charge ratio for each hospital in the Cost Report. Nationwide Inpatient Sample data were used to generate
descriptive statistics on all TAR patients across payers.
Results: Medicare participants accounted for 47.5% of the overall population of TAR patients. Average implant cost was
$13 034, accounting for approximately 70% of the total all-payer cost. Approximately, one-third of hospitals were profitable
with respect to primary TAR. Profitable hospitals had lower total costs and higher payments leading to a difference in profit
of approximately $11 000 from TAR surgeries between profitable and nonprofitable hospitals. No difference was noted
with respect to length of stay or number of cases performed between profitable and nonprofitable hospitals. TAR surgeries
were more likely to take place in large and major teaching hospitals. Among hospitals performing at least 1 TAR, the margin
on TAR cases was positively associated with the total number of TARs performed by a hospital.
Conclusion: There is an overall significant financial burden associated with performing TAR with many health systems
failing to demonstrate profitability despite its increased utilization. While additional factors such as improved patient
outcomes may be driving utilization of TAR, financial barriers may exist that can affect utilization of TAR across health
systems.
Level of Evidence: Level III, comparative study
Keywords: ankle arthroplasty, utilization, cost

Introduction
Recent studies have demonstrated an increased utilization
of total ankle arthroplasty for the treatment of end-stage
arthritis of the ankle.17,18 Benefits of total ankle arthroplasty relative to ankle arthrodesis include improvements
in gait,3,19 preservation of ankle biomechanics, and potential reduced risk of adjacent joint disease.6 Further, patients
have also been demonstrated to prefer arthroplasty over
ankle arthrodesis due to preservation of ankle motion,
with notable improvements in self-reported pain, function,
and quality of life.14 Utilization of total ankle arthroplasty
over the past 20 years for Medicare beneficiaries has
increased by more than 1000%.17 Much of this increase is
related to improved designs and familiarity with operative
techniques.23 Studies have also demonstrated that the indications for total ankle arthroplasty are broadening to

include patients who are also more medically and surgically complex, such as those with deformity.24 Surgeons
have overall become more confident in its employment as
a result of better mid- to long-term outcomes and improved
implant survival.9,10,17 As a result, increased awareness
and utilization of this technology has resulted in its use in
multiple hospitals and health systems across the United
States.

1

Shady Grove Orthopaedics, Rockville, MD, USA
KNG Health Consulting, LLC, Rockville, MD, USA
3
NCQA, Washington, DC, USA
2

Corresponding Author:
Sudheer Reddy, MD, Shady Grove Orthopaedics, 9601 Blackwell Road,
Suite 100, Rockville, MD 20850, USA.
Email: sreddy8759@yahoo.com
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