Men, women with ankle arthritis may benefit from total ankle replacement, arthrodesis
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Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis, with small differences in pain and function disappearing after controlling for potential confounding variables.
“Physicians should be aware that females often present to orthopedic surgeons with more significant disability than physicians appreciate, and that they may delay surgical treatment longer than males despite their disability,” Andrew Dodd, MD, FRCSC, told Healio. “My hope is that these results will encourage orthopedic surgeons to take time to discuss the potential barriers to proceeding with surgical management of arthritis (especially with females) and to encourage more research into the ‘why’ behind our findings.”
Differences between women, men
Using the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction database, Dodd, Timothy R. Daniels, MD, FRCSC, and colleagues collected patient demographics, revisions, secondary procedures, complications, Ankle Osteoarthritis Scale scores, SF-36 scores, and expectations and satisfaction among 872 patients with end-stage ankle arthritis who underwent either total ankle replacement (n=629) or ankle arthrodesis (n=243) and who had 2 or more years of follow-up. Researchers performed statistical analyses with three-way repeated-measures analysis of variance and multiple linear regression models controlling for inflammatory arthritis, age, preoperative scores and surgery type.
Results showed women had higher pain scores preoperatively in both the total ankle replacement and ankle arthrodesis groups compared with men. Researchers noted both men and women had a significant reduction in pain postoperatively with no significant differences between sexes. Women in both the total ankle replacement and ankle arthrodesis groups also had higher disability scores and lower SF-36 physical component summary scores preoperatively and postoperatively compared with men, according to results. Researchers found significant improvements in postoperative disability and SF-36 scores from baseline in both men and women.
Although sex was not a significant predictor of postoperative SF-36 mental component summary scores or pain or disability scores after controlling for covariates, researchers noted sex explained 0.5% of variance in SF-36 scores. Results also showed preoperative expectations or postoperative satisfaction was not significantly influenced by sex. Researchers noted preoperative and postoperative outcome measures, expectations and satisfaction were similar after exclusion of patients with inflammatory arthritis.
Factors that contribute to surgical delay
Daniels told Healio several factors could contribute to why women with end-stage ankle arthritis have worse preoperative pain and function men. Some of the factors include women may be able to tolerate discomfort and disability longer or may delay surgery due to having more dependents to care for, according to Daniels. He added women may also experience feelings of mistrust toward male orthopedic surgeons.
“We’re still challenged by the fact that 92% of orthopedic surgeons are male and whether that plays a role or not no one knows for sure, but it is a male-dominated profession and there is possibly some mistrust in that direction to begin with combined with reluctance to undergo a major procedure,” Daniels told Healio.
To reduce or eliminate mistrust among patients, Daniels said orthopedic surgeons should adopt better skills communicating with patients of all sexes and races to help them understand the primary goal of the intervention is to improve quality of life, regardless of
“I think we need to and are making definite strides to get more women to be interested in becoming orthopedic surgeons because we believe that there is a desire for women to be managed by other women, which is understandable,” Daniels said.
Daniels noted more research is also needed to identify the reasons women may choose to delay total ankle replacement or ankle arthrodesis, and how those reasons can be addressed by orthopedic surgeons.
“I’m hoping that this study will be an impetus for others to design new studies that are specifically looking at the reasons why a woman might delay her surgery 2, 3, 4 or 5 years longer than a man,” Daniels said. “If the reasons are fixable then [we should] focus on those reasons. Is there more need for social support after surgery? Is there a mistrust, a gap that needs to be bridged? Are there reassurances that need to be more clearly communicated with people that suffer from ankle arthritis and pain?”
Perspective
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Andrew Dodd, MD, FRCSC, and colleagues present another great manuscript from the Canadian Orthopedic Foot and Ankle Society (COFAS) Prospective Ankle Reconstruction Database. This paper investigates sex differences in end-stage ankle arthritis and following its operative management with total ankle replacement or ankle arthrodesis. As the authors state, large systematic reviews have demonstrated significantly worse preoperative and postoperative pain and disability outcomes in women compared with men; however, such a relationship has yet to be investigated in ankle arthritis.
The authors report that their cohort study of 629 patients who had undergone total ankle replacement and 243 patients who had undergone ankle arthrodesis showed that both men and women benefited from each procedure with similar magnitudes of improvement. Furthermore, when controlling for potential confounding variables, there were small differences in pain and function between men and women, but these were likely below the minimum clinically important difference.
This manuscript provides valuable information about the surgical management of this debilitating condition and, most importantly, it allows us to counsel our male and female patients to equally expect good outcomes following either operation.
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