Original Research|Articles in Press

The Impact of Hospital Size and Teaching Status on Outcomes Following Total Ankle Arthroplasty

Published:November 26, 2022DOI:


      The popularity and utilization of total ankle arthroplasty (TAA) as treatment for ankle arthritis has increased exponentially from 1998 to 2012. Overall the outcomes have improved for TAA with the introduction of new-generation implants and this has increased the focus on optimizing other variables affecting outcomes for TAA. The purpose of this study was to examine the effects of hospital characteristics and teaching status on outcomes for TAA. The Nationwide Inpatient Sample database was queried from 2002 to 2012 using the ICD-9 procedure code for TAA. The primary outcomes evaluated included: in-hospital mortality, length of stay, total hospital charges, discharge disposition, perioperative complications, and patient demographics. Analyses were carried out based on hospital size: small, medium, and large; and teaching status: rural nonteaching, urban nonteaching, and urban teaching. A total weighted national estimate of 16,621 discharges for patients undergoing TAA was reported over the 10-year period. There were significant differences in length of stay and total charges between all hospitals when comparing location and teaching status; however, no significant differences were noted for in-hospital mortality. Rural, nonteaching hospitals had higher odds of perioperative complications. There were also significant differences in length of stay and total charges when comparing hospital sizes. Overall, there is no increased risk of mortality after TAA regardless of hospital size or setting. However, rural hospitals had increased rates of perioperative complications compared to urban hospitals. Our analyses demonstrated important factors affecting cost and resource utilization for TAA, clearly additional work is needed to optimize this relationship, especially in the upcoming bundled payment models.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Valderrabano V
        • Horisberger M
        • Russell I
        • Dougall H
        • Hintermann B.
        Etiology of ankle osteoarthritis.
        Clin Orthop Relat Res. 2009; 467: 1800-1806
        • Gougoulias NE
        • Khanna A
        • Maffulli N.
        History and evolution in total ankle arthroplasty.
        Br Med Bull. 2009; 89: 111-151
        • Sheridan BD
        • Robinson DE
        • Hubble MJ
        • Winson IG
        Ankle arthrodesis and its relationship to ipsilateral arthritis of the hind- and mid-foot.
        J Bone Joint Surg Br. 2006; 88: 206-207
        • Nelissen RGHH
        • Meskers C
        The value of ankle prostheses - a gait analysis approach.
        in: Kofoed H Current Status of Ankle Arthroplasty. Springer-Verlag, Berlin1998: 72-77
        • Wu WL
        • Su FC
        • Cheng YM
        • Huang PJ
        • Chou YL
        • Chou CK.
        Gait analysis after ankle arthrodesis.
        Gait Posture. 2000; 11: 54-61
        • Coester LM
        • Saltzman CL
        • Leupold J
        • Pontarelli W.
        Long-term results following ankle arthrodesis for post-traumatic arthritis.
        J Bone Joint Surg Am. 2001; 83-a: 219-228
        • Barg A
        • Wimmer MD
        • Wiewiorski M
        • Wirtz DC
        • Pagenstert GI
        • Valderrabano V.
        Total ankle replacement: indications, implant designs, and results.
        Deutsches Ärzteblatt Int. 2015; 112: 177-184
        • Jiang JJ
        • Schipper ON
        • Whyte N
        • Koh JL
        • Toolan BC.
        Comparison of perioperative complications and hospitalization outcomes after ankle arthrodesis versus total ankle arthroplasty from 2002 to 2011.
        Foot Ankle Int. 2015; 36: 360-368
        • Haddad SL
        • Coetzee JC
        • Estok R
        • Fahrbach K
        • Banel D
        • Nalysnyk L.
        Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis. A systematic review of the literature.
        J Bone Joint Surg Am. 2007; 89: 1899-1905
        • Caravaggi P
        • Lullini G
        • Leardini A
        • Berti L
        • Vannini F
        • Giannini S.
        Functional and clinical evaluation at 5-year follow-up of a three-component prosthesis and osteochondral allograft transplantation for total ankle replacement.
        Clin Biomech (Bristol, Avon). 2015; 30: 59-65
        • Daniels TR
        • Younger AS
        • Penner M
        • Wing K
        • Dryden PJ
        • Wong H
        • Glazebrook M
        Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study.
        J Bone Joint Surg Am. 2014; 96: 135-142
        • Demetracopoulos CA
        • Halloran JP
        • Maloof P
        • Adams SB
        • Parekh SG.
        Total ankle arthroplasty in end-stage ankle arthritis.
        Curr Rev Musculoskelet Med. 2013; 6: 279-284
        • Singh JA
        • Ramachandran R.
        Time trends in total ankle arthroplasty in the USA: a study of the National Inpatient Sample.
        Clin Rheumatol. 2016; 35: 239-245
        • Kurtz S
        • Mowat F
        • Ong K
        • Chan N
        • Lau E
        • Halpern M.
        Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002.
        J Bone Joint Surg Am. 2005; 87: 1487-1497
        • Haskell A
        • Mann RA.
        Perioperative complication rate of total ankle replacement is reduced by surgeon experience.
        Foot Ankle Int. 2004; 25: 283-289
      1. HCUP National Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP) 2002-2012; Available at: Accessed May 29, 2018.

        • Bramlett K
        • Onel E
        • Viscusi ER
        • Jones K.
        A randomized, double-blind, dose-ranging study comparing wound infiltration of DepoFoam bupivacaine, an extended-release liposomal bupivacaine, to bupivacaine HCl for postsurgical analgesia in total knee arthroplasty.
        Knee. 2012; 19: 530-536
        • Golf M
        • Daniels SE
        • Onel E.
        A phase 3, randomized, placebo-controlled trial of DepoFoam(R) bupivacaine (extended-release bupivacaine local analgesic) in bunionectomy.
        Adv Ther. 2011; 28: 776-788
        • Feierman DE
        • Kronenfeld M
        • Gupta PM
        • Younger N
        • Logvinskiy E.
        Liposomal bupivacaine infiltration into the transversus abdominis plane for postsurgical analgesia in open abdominal umbilical hernia repair: results from a cohort of 13 patients.
        J Pain Res. 2014; 7: 477-482
        • Bourne R
        • Mukhi S
        • Zhu N
        • Keresteci M
        • Marin M.
        Role of obesity on the risk for total hip or knee arthroplasty.
        Clin Orthop Relat Res. 2007; 465: 185-188
        • Jaberi FM
        • Parvizi J
        • Haytmanek CT
        • Joshi A
        • Purtill J.
        Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
        Clin Orthop Relat Res. 2008; 466: 1368-1371
        • DiDomenico LA
        • Treadwell JR
        • Cain LZ.
        Total ankle arthroplasty in the rheumatoid patient.
        Clin Podiatr Med Surg. 2010; 27: 295-311
        • Raikin SM
        • Rasouli MR
        • Espandar R
        • Maltenfort MG.
        Trends in treatment of advanced ankle arthropathy by total ankle replacement or ankle fusion.
        Foot Ankle Int. 2014; 35: 216-224
        • Steck JK
        • Anderson JB.
        Total ankle arthroplasty: indications and avoiding complications.
        Clin Podiatr Med Surg. 2009; 26: 303-324
        • Singh JA
        • Ramachandaran R.
        Does rural residence impact total ankle arthroplasty utilization and outcomes?.
        Clin Rheumatol. 2016; 35: 381-386
        • El Bitar YF
        • Illingworth KD
        • Scaife SL
        • Horberg JV
        • Saleh KJ.
        Hospital length of stay following primary total knee arthroplasty: data from the nationwide inpatient sample database.
        J Arthroplasty. 2015; 30: 1710-1715
        • Dimick JB
        • Cowan Jr, JA
        • Colletti LM
        • Upchurch Jr, GR
        Hospital teaching status and outcomes of complex surgical procedures in the United States.
        Arch Surg. 2004; 139: 137-141
        • Hyder O
        • Sachs T
        • Ejaz A
        • Spolverato G
        • Pawlik TM.
        Impact of hospital teaching status on length of stay and mortality among patients undergoing complex hepatopancreaticobiliary surgery in the USA.
        J Gastrointest Surg. 2013; 17: 2114-2122
        • Dimick JB
        • Welch HG
        • Birkmeyer JD.
        Surgical mortality as an indicator of hospital quality: the problem with small sample size.
        JAMA. 2004; 292: 847-851
        • Mueller SK
        • Lipsitz S
        • Hicks LS.
        Impact of hospital teaching intensity on quality of care and patient outcomes.
        Med Care. 2013; 51: 567-574
        • Basques BA
        • Bitterman A
        • Campbell KJ
        • Haughom BD
        • Lin J
        • Lee S.
        Influence of surgeon volume on inpatient complications, cost, and length of stay following total ankle arthroplasty.
        Foot Ankle Int. 2016; 37: 1046-1051
        • Mulligan RP
        • Parekh DG.
        Safety of outpatient total ankle arthroplasty vs traditional inpatient admission or overnight observation.
        Foot Ankle Int. 2017; 38: 825-831
        • Gonzalez T
        • Fisk E
        • Chiodo C
        • Smith J
        • Bluman EM.
        Economic analysis and patient satisfaction associated with outpatient total ankle arthroplasty.
        Foot Ankle Int. 2017; 38: 507-513
        • Borenstein TR
        • Anand K
        • Li Q
        • Charlton TP
        • Thordarson DB.
        A review of perioperative complicationr of outpatient total ankle arthroplasty.
        Foot Ankle Int. 2018; 39: 143-148
        • Ranganathan P
        • Pramesh C
        • Buyse M.
        Common pitfalls in statistical analysis: clinical versus statistical significance.
        Perspect Clin Res. 2015; 6: 169