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C OPYRIGHT Ó 2023 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

A commentary by Yuki Tochigi, MD, PhD, is

linked to the online version of this article.

Younger Patients Undergoing Total Ankle

Arthroplasty Experience Higher Complication
Rates and Worse Functional Outcomes
Albert T. Anastasio, MD, Billy I. Kim, MD, Colleen M. Wixted, MD, MBA, James K. DeOrio, MD, James A. Nunley II, MD,
Mark E. Easley, MD, and Samuel B. Adams, MD

Investigation performed at the Duke University Medical Center, Durham, North Carolina

Background: Although many patients with posttraumatic ankle arthritis are of a younger age, studies evaluating the
impact of age on outcomes of primary total ankle arthroplasty (TAA) have revealed heterogenous results. The purpose of
the present study was to determine the effect of age on complication rates and patient-reported outcomes after TAA.
Methods: We retrospectively reviewed the records of 1,115 patients who had undergone primary TAA. The patients were
divided into 3 age cohorts: <55 years (n = 196), 55 to 70 years (n = 657), and >70 years (n = 262). Demographic
characteristics, intraoperative variables, postoperative complications, and patient-reported outcome measures were
compared among groups with use of univariable analyses. Competing-risk regression analysis with adjustment for patient
and implant characteristics was performed to assess the risk of implant failure by age group. The mean duration of follow-
up was 5.6 years.
Results: Compared with the patients who were 55 to 70 years of age and >70 years of age, those who were <55 years of
age had the highest rates of any reoperation (19.9%, 11.7%, and 6.5% for the <55, 55 to 70, and >70-year age groups,
respectively; p < 0.001), implant failure (5.6%, 2.9%, and 1.1% for the <55, 55 to 70, and >70-year age groups,
respectively; p = 0.019), and polyethylene exchange (7.7%, 4.3%, and 2.3% for the <55, 55 to 70, and >70-year age
groups, respectively; p = 0.021). Competing-risk regression revealed a decreased risk of implant failure for patients who
were >70 of age compared with those who were <55 years of age (hazard ratio [HR], 0.21 [95% confidence interval (CI),
0.05 to 0.80]; p = 0.023) and for patients who were 55 to 70 years of age compared with those who were <55 years of age
(HR, 0.35 [95% CI, 0.16 to 0.77]; p = 0.009). For all subscales of the Foot and Ankle Outcome Score (FAOS) measure
except activities of daily living, patients who were <55 years of age reported the lowest (worst) mean preoperative and
postoperative scores compared with those who were 55 to 70 years of age and >70 years of age (p £ 0.001). Patients who
were <55 years of age had the highest mean numerical pain score at the time of the latest follow-up (23.6, 14.4, 12.9 for
the <55, 55 to 70, and >70-year age groups, respectively; p < 0.001).
Conclusions: Studies involving large sample sizes with intermediate to long-term follow-up are critical to reveal age-
related impacts on outcomes after TAA. In the present study, which we believe to be the largest single-institution series to
date evaluating the effect of age on outcomes after TAA, younger patients had higher rates of complications and implant
failure and fared worse on patient-reported outcome measures.
Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

P
rimary osteoarthritis (OA) of the ankle is a less-common
diagnosis compared with primary OA of the hip and
knee1. Posttraumatic arthritis is the etiologic factor in
65% to 80% of cases of advanced-stage degenerative joint disease
involving the ankle2,3. This high prevalence of posttraumatic
arthritis has important implications with respect to the age of
patients presenting for the treatment of arthritis of the ankle.
While patients may be in their seventh or eighth decade of life

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H746).

J Bone Joint Surg Am. 2024;106:10-20 d http://dx.doi.org/10.2106/JBJS.23.00122

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when undergoing total knee arthroplasty (TKA), many patients
with posttraumatic ankle arthritis are much younger, often in
their fifth or sixth decade2,4,5. Patients with rheumatoid arthritis
may present at an even younger age, sometimes in their late 20s
and early 30s6.
Total ankle arthroplasty (TAA) is an effective inter-
vention that provides substantial pain relief and improved
functional outcomes for patients with ankle arthritis7. The
utilization rates of TAA have increased substantially in recent
years8. Despite the increasing use of TAA, few intermediate to
long-term follow-up studies have focused on how patient-
specific factors may impact outcomes and complications
after this procedure, and those that have been published have
demonstrated mixed results. Demetracopoulos et al. reported
that younger patients who underwent TAA had similar out-
comes to older patients at early follow-up9. However, Usuelli
et al. reported greater improvements in patient-reported
outcomes (PROs) following TAA in younger patients10. Other
studies have shown the exact opposite, with higher rates of
Fig. 1
Number of procedures in each age cohort stratified by decade in which surgery was performed.
I M PA C T OF AG E ON T O TA L A N K L E A R T H R O P L A S T Y O U T C O M E S
revision and implant failure in younger cohorts or with
younger age being an independent predictor of all-cause
revisions11-13. To date, no clear consensus regarding the as-
sociation between age and outcomes after TAA has been
established.
The findings in the literature on TKA, in contrast, have
found that younger patients report worse pain and function
scores postoperatively due to a myriad of proposed fac-
tors14,15. A large, recent systematic review indicated that
while TKA is a safe procedure for younger patients, several
studies have shown poor all-cause survivorship in younger
age groups16.
Given the observed trends of increased implant failure
rates, decreased satisfaction rates, and increased pain scores
after TKA in younger patient cohorts, our aim was to analyze
whether these trends exist after TAA. Our hypothesis was that
patients in the youngest age group undergoing TAA would
experience higher complication rates and worse PROs when
compared with older cohorts.
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Materials and Methods 6 weeks, 3 months, and yearly thereafter. The mean duration of
Study Design and Cohort Selection follow-up (and standard deviation) was 5.6 ± 3.2 years.

I nstitutional review board approval was obtained prior to

conducting this study. The STROBE (Strengthening the Re-
porting of OBservational studies in Epidemiology) guidelines
were followed in the design of this study17. We conducted a
retrospective study of all primary TAAs that had been performed
at a single institution between March 2000 and October 2020 by
foot and ankle fellowship-trained surgeons with extensive TAA
experience (Fig. 1). The indication for TAA was end-stage ar-
thritis after failed nonoperative treatment. Patients with in-
flammatory arthropathy, those with active infection, and those
undergoing revision TAA were excluded.
A total of 1,935 patients who had undergone primary TAA
were identified from the institutional database. Three patients
with missing data on age at the time of surgery and 817 patients
with <2 years of follow-up were excluded. The remaining 1,115
patients (57.6%; 1,115 of 1,935) with recorded age at the time of
surgery (range, 22 to 89 years) were divided into 3 cohorts,
stratified by age in a similar fashion to that described by Deme-
tracopoulos et al., for subsequent analysis: <55 years (n = 196), 55
to 70 years (n = 657), and >70 years (n = 262)9. Postoperatively,
patients were evaluated in outpatient clinic visits at 2 weeks,
Variables and Data Sources
The present study utilized data from an institutional database of
primary TAAs that had been performed at a single institution.
Demographic characteristics such as sex, race, body mass index
(BMI), American Society of Anesthesiologists (ASA) physical
status score, smoking status, diabetes diagnosis, and primary
indication for TAA were obtained from the institutional database
(Table I). The ASA score is assigned based on the severity of
systemic disease and underlying comorbidities and has been
found to be a reliable and acceptable predictor of comorbidity
and mortality after surgery18.
Additionally, intraoperative information, including pros-
thesis type, duration of surgery, tourniquet time, and compli-
cations, was collected. Complications included implant failure
(defined as any operation requiring component exchange) and
reoperation (defined as polyethylene exchange and/or compo-
nent removal because of infection, wound breakdown, malleolar
fracture, talar subsidence, or impingement). Information also
was obtained on postoperative outcomes such as pain (defined
as “moderate” relative to the preoperative state), swelling

TABLE I Patient Characteristics

Overall (N = 1,115) <55 Yr (N = 196) 55-70 Yr (N = 657) >70 Yr (N = 262) P Value†

Age* (yr) 63.50 ± 9.50 48.90 ± 5.52 63.18 ± 4.41 75.27 ± 3.69 <0.001
Male sex (no. of patients) 588 (52.7%) 79 (40.3%) 360 (54.8%) 149 (56.9%) <0.001
Race (no. of patients) 0.004
Black/African American 29 (2.6%) 12 (6.1%) 15 (2.3%) 2 (0.8%)
Other 27 (2.4%) 7 (3.6%) 16 (2.4%) 4 (1.5%)
White 1,059 (95.0%) 177 (90.3%) 626 (95.3%) 256 (97.7%)
BMI* (kg/m2) 30.01 ± 5.53 30.44 ± 5.97 30.38 ± 5.56 28.75 ± 4.91 <0.001
ASA score* 2.33 ± 0.54 2.13 ± 0.57 2.34 ± 0.53 2.45 ± 0.51 <0.001
Smoking status‡ (no. of patients) <0.001
Current smoker 31 (2.8%) 13 (6.6%) 16 (2.4%) 2 (0.8%)
Never a smoker 573 (51.3%) 117 (59.7%) 344 (52.4%) 112 (42.7%)
Previous smoker 403 (36.1%) 47 (24.0%) 239 (36.4%) 117 (44.7%)
Diabetes‡ (no. of patients) 98 (8.8%) 9 (4.6%) 58 (8.8%) 31 (11.8%) 0.018
Primary diagnosis (no. of patients) 0.003
Osteoarthritis 402 (36.1%) 52 (26.5%) 234 (35.6%) 116 (44.3%)
Posttraumatic 661 (59.3%) 132 (67.3%) 391 (59.5%) 138 (52.7%)
Other 52 (4.7%) 12 (6.1%) 32 (4.9%) 8 (3.1%)
Implant type‡ (no. of patients) 0.430
Fixed bearing 459 (41.2%) 91 (46.4%) 259 (39.4%) 109 (41.6%)
Mobile bearing 152 (13.6%) 30 (15.3%) 92 (14.0%) 30 (11.5%)
Stemmed 426 (38.2%) 68 (34.7%) 251 (38.2%) 107 (40.8%)
Duration of follow-up* (yr) 5.64 ± 3.15 6.12 ± 3.52 5.80 ± 3.23 4.90 ± 2.48 <0.001

*The values are given as the mean and the standard deviation. †Significant values (p < 0.05) are indicated in bold. ‡The percentages are based on
the number of patients for whom data were available.
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(defined as either patient-reported intermittent swelling with
activity or the presence of mild to moderate effusion on
examination), death, and other complications potentially
attributed to TAA (heterotopic bone formation along either
malleolus, medial malleolar screw protrusion, radiolucency
around the implant, subtalar or talonavicular OA, Achilles
tendon contracture, etc.).
Functional outcome was measured with use of PROs
that were collected preoperatively, 1 year (±3 months) post-
operatively, and at the time of most recent follow-up. The
Foot and Ankle Disability Index (FADI)19 was used to assess
functional limitations due to foot and ankle conditions,
and a numerical pain scale was used to assess pain by asking
patients to rate their current level of pain from 0 (no pain)
to 100 (worst pain imaginable). The Short Musculoskel-
etal Function Assessment (SMFA)20 was used to assess
extremity-specific pain and function, and the Short Form-
36 (SF-36)21 was used to assess changes in health-related
quality of life. The Foot and Ankle Outcome Score (FAOS)
subscales (Pain, Other Symptoms, Activities of Daily Living,
and Ankle-Related Quality of Life) provided additional
measures for assessing various foot and ankle-specific
functional outcomes22.
Statistical Analysis
Continuous variables were reported as the mean and the
standard deviation, whereas categorical variables were reported
as numbers and proportions. Univariable analyses were per-
formed to compare patient variables and outcomes among age
groups with use of 1-way analysis of variance (ANOVA) for
continuous variables and the chi-square test or the Fisher exact
test, as appropriate, for count data. After assessment for nor-
mality both quantitatively (with use of the Shapiro-Wilk nor-
mality test) and visually (with use of histogram plots), the
Kruskal-Wallis test was performed for non-normal continuous
data. To control for type-I errors when testing for overall group
differences in PROs at multiple time points, corrections for
multiple-comparisons were performed with use of the Bon-
ferroni method. For PROs with significant overall differences,
pairwise comparisons between age groups were performed and
the resulting p values were subsequently adjusted for multiple
comparisons.
Competing-risk regression analyses (controlling for pa-
tient sex, BMI, ASA score, and implant type) were performed
to assess the relative risk of implant failure according to the age
group. The outcome of patient death was included as a com-
peting risk in the regression analysis. Similarly, cumulative-
incidence competing-risk estimates of implant failure were
computed at 5 and 10 years. Ninety-five percent confidence
intervals (CIs) were computed. Analysis of variables with
missing data was performed in a complete-case manner, in
which patients with missing data for the variable of interest
were excluded from the analysis but were kept in the overall
cohort. All statistical analysis was performed with use of R
(version 3.6.1; Foundation for Statistical Computing). The
level of significance was set at p < 0.05.

TABLE II Intraoperative Variables and Postoperative Complications

Overall (N = 1,115) <55 Yr (N = 196) 55-70 Yr (N = 657) >70 Yr (N = 262) P Value*

Intraoperative variables
Tourniquet time† (hr) 2.25 ± 0.58 2.34 ± 0.41 2.23 ± 0.67 2.25 ± 0.45 0.095
Intraoperative complications‡ (no. of patients) 6 (0.5%) 1 (0.5%) 4 (0.6%) 1 (0.3%) 0.961
Postoperative complications (no. of patients)
Any reoperation 133 (11.9%) 39 (19.9%) 77 (11.7%) 17 (6.5%) <0.001
Implant failure 33 (3.0%) 11 (5.6%) 19 (2.9%) 3 (1.1%) 0.019
Tibial component 24 (2.2%) 7 (3.6%) 15 (2.3%) 2 (0.8%) 0.090
Talar component 24 (2.2%) 9 (4.6%) 14 (2.1%) 1 (0.4%) 0.008
Polyethylene exchange 49 (4.4%) 15 (7.7%) 28 (4.3%) 6 (2.3%) 0.021
Infection 10 (0.9%) 2 (1.0%) 7 (1.1%) 1 (0.4%) 0.670
Wound breakdown 8 (0.7%) 1 (0.5%) 5 (0.8%) 2 (0.8%) 1.000
Malleolar fracture 1 (0.1%) 0 (0.0%) 1 (0.2%) 0 (0.0%) 1.000
Talar subsidence 8 (0.7%) 3 (1.5%) 4 (0.6%) 1 (0.4%) 0.327
Impingement 77 (6.9%) 26 (13.3%) 44 (6.7%) 7 (2.3%) <0.001
Pain 43 (3.9%) 14 (7.1%) 23 (3.5%) 6 (2.3%) 0.029
Swelling 6 (0.5%) 1 (0.5%) 4 (0.6%) 1 (0.4%) 1.000
Other complication 208 (18.7%) 50 (25.5%) 116 (17.7%) 42 (16.0%) 0.021
Death 1 (0.1%) 0 (0.0%) 0 (0.0%) 1 (0.4%) 0.411

*Significant values (p < 0.05) are indicated in bold. †The values are given as the mean and the standard deviation. ‡The percentages are based on
the number of patients for whom data were available.
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TABLE III Competing-Risk Regression Results for Implant Failure

Cumulative Incidence Estimate (95% CI)

Implant Failure Death
Age Group 5 Yr 10 Yr 5 Yr 10 Yr

<55 yr 3.86 (1.41-8.31) 15.19 (6.77-26.75) 0.97 (0.08-4.80) 1.97 (0.38-6.31)

55-70 yr 1.94 (0.95-3.55) 3.84 (1.87-6.91) 1.25 (0.52-2.62) 9.31 (5.19-14.87)
>70 yr 1.74 (0.46-4.75) 1.74 (0.46-4.75) 12.04 (7.67-17.47) 30.05 (17.86-43.21)

Source of Funding to 70, and >70-year age groups, respectively; p = 0.004), and
No funds were received in support of this investigation. current smokers (6.6%, 2.4%, and 0.8% for the <55, 55 to 70,
and >70-year age groups, respectively; p < 0.001) (Table I).
Results The primary diagnosis of posttraumatic arthritis was most
Patient Information common in the youngest cohort (67.3%, 59.5%, and 52.7%

C ompared with the patients who were 55 to 70 years and

>70 years of age, those who were <55 had the lowest mean
ASA score (2.1, 2.3, and 2.5 for the <55, 55 to 70, and >70-year
for the <55, 55 to 70, and >70-year age groups, respectively;
p = 0.003).

age groups, respectively; p < 0.001) and the greatest propor- Intraoperative and Postoperative Outcomes
tions of female sex (60%, 45%, and 43% for the <55, 55 to 70, There were no differences among age groups with respect to
and >70-year age groups, respectively; p < 0.001), Black/ tourniquet time or the number of intraoperative complications
African American race (6.1%, 2.3%, and 0.8% for the <55, 55 (Table II).

Fig. 2
Risk of implant failure stratified by age cohort. The shading indicates the 95% CI.

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TABLE IV Competing-Risk Regression Results for Implant
Failure, Adjusted*
Relative Risk
(95% CI)
Age group (reference, <55 yr)
55-70 yr 0.35 (0.16-0.77)
>70 yr 0.21 (0.05-0.80)
BMI 0.97 (0.91-1.04)
Female sex 1.18 (0.55-2.56)
ASA score 1.91 (0.89-4.10)
Implant type
(reference, fixed bearing)
Mobile bearing 0.26 (0.03-2.01)
*BMI = body mass index, ASA = American Society of Anesthesi-
ologists. †Significant values (p < 0.05) are indicated in bold.
After a mean duration of follow-up of 5.6 years (range,
2.0 to 22.3 years) the most common postoperative complica-
tions were impingement requiring gutter debridement (77
patients; 6.9%), polyethylene exchange (49 patients; 4.4%), and
postoperative pain (43 patients; 3.9%). Compared with the
patients who were 55 to 70 and >70 years of age, those who
were <55 years of age had the highest rates of any reoperation
(19.9%, 11.7%, and 6.5% for the <55, 55 to 70, and >70-year
age groups, respectively; p < 0.001), implant failure (5.6%,
2.9%, and 1.1% for the <55, 55 to 70, and >70-year age groups,
respectively; p = 0.019), and polyethylene exchange (7.7%,
4.3%, and 2.3% for the <55, 55 to 70, and >70-year age groups,
respectively; p = 0.021) (Table II).
The cumulative-incidence competing-risk estimates for
implant failure were 3.9% (95% CI, 1.4% to 8.3%), 1.9% (95%
CI, 1.0% to 3.6%), and 1.7% (95% CI, 0.5% to 4.8%) at 5 years
and 15.2% (95% CI, 6.8% to 26.8%), 3.8% (95% CI, 1.9% to
6.9%), and 1.7% (95% CI, 0.5% to 4.8%) at 10 years for the
<55, 55 to 70, and >70-year age groups, respectively) (Table III).
Competing-risk regression analysis (adjusted for BMI, sex,
ASA score, and implant type) revealed a decreased risk of
implant failure for the patients who were >70 years of age
compared with those who were <55 years of age (hazard ratio
[HR], 0.21 [95% CI, 0.05 to 0.80]; p = 0.023) and for the
patients who were 55 to 70 years of age compared with those
who were <55 years of age (HR, 0.35 [95% CI, 0.16 to 0.77]; p =
0.009) (Fig. 2, Table IV).
Functional Metrics
Although there were no significant differences among the
groups in terms of preoperative numerical pain scores, patients
who were <55 years of age had the highest mean numerical
pain score at the time of the latest follow-up (23.6, 14.4, and
12.9 for the <55, 55 to 70, and >70-year age groups, respec-
tively; p < 0.001) (Table V). Across all subscales of the FAOS
measure except for the activities of daily living subscale, pa-
15
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tients who were <55 years of age reported the lowest (worst)
mean postoperative scores at one year and at final follow-up
compared with the patients who were 55 to 70 and >70 years of
age (p £ 0.001).
P Value† Compared with the patients who were 55 to 70 years of age,
those who were <55 years of age had comparatively smaller
changes in the FAOS subscales for activities of daily living from the
0.009
preoperative to the latest postoperative visit (p £ 0.006) (Table VI).
0.023
Interestingly, patients who were >70 years of age had relatively
0.420 smaller improvements in SMFA and SF-36 scores compared with
0.670 those who were <55 and 55 to 70 years of age (p < 0.001).
0.096
Discussion
0.200 T AA has become an increasingly popular alternative to ankle
arthrodesis for the treatment of end-stage ankle arthri-
tis23,24. Posttraumatic arthritis of the ankle impacts a generally
younger patient population when compared with primary OA
of the hip and the knee. The aim of the current study was to
determine the effect of age on the outcomes of TAA in what we
believe to be the largest single-institution study, with the lon-
gest follow-up, to date. We found that patients <55 years of age
had the highest rates of all complications, implant failure, and
component removal compared with the older 2 age groups.
Even after adjustment for other demographic variables and
comorbidities, the youngest cohort had an increased risk of
implant failure. With regard to PROs, patients <55 years of age
had the worst preoperative and postoperative scores across the
majority of measures that were used in the study. This younger
cohort experienced the smallest improvements from preoper-
ative to postoperative visits in the activities of daily living
subscales of the FAOS, whereas the oldest cohort experienced
the smallest improvements in more global outcome measures.
Although emerging evidence in the TKA literature sug-
gests a bell-shaped distribution whereby the youngest and
oldest patients undergoing TKA demonstrate inferior out-
comes compared with the middle-aged cohorts, the TAA lit-
erature to date has demonstrated heterogeneous outcomes with
regard to age. Some studies have shown worse clinical out-
comes and implant survivorship in younger patients11,12,25,26.
Spirt et al. and Henricson et al. reported higher rates of revision
and implant failure in their younger patients following TAA11,12.
However, both studies included smaller cohorts and did not
include information on PROs. Other studies have indicated
that younger age may have a positive effect on outcomes after
TAA or have demonstrated no significant differences among
age groups. In a cohort of 70 patients stratified by age of £50
years or ‡51 years, Usuelli et al. found that the younger group
reported significantly greater improvement as measured with
the American Orthopaedic Foot & Ankle Society (AOFAS)
score at the time of the latest follow-up after TAA10. Cottom
et al. stratified their TAA cohort into groups similar to those in
the present study but did not find any significant differences
among the different age groups in terms of AOFAS hindfoot
scores and complication rates27. Demetracopoulos et al. report-
ed no significant age-related differences in outcomes after TAA
when investigating the same cohort utilized in the present
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TABLE V Patient-Reported Outcome Scores

P Value†

Patient-Reported Outcome Scores* Post Hoc

Pairwise, % Data
Overall <55 Yr 55-70 Yr >70 Yr Unadjusted Adjusted‡ Adjusted§ Available

FADI
Preop. 53.73 ± 13.51 54.58 ± 11.96 54.75 ± 13.16 50.70 ± 15.04 0.040 0.120 NA 35.4
1 yr postop. 19.29 ± 14.77 20.83 ± 13.55 19.35 ± 14.91 18.13 ± 15.35 0.682 1.000 NA 20.0
Latest follow-up 19.51 ± 16.90 19.22 ± 15.04 20.47 ± 17.41 17.53 ± 17.03 0.490 1.000 NA 24.1
Numerical pain
Preop. 67.43 ± 24.00 67.41 ± 24.01 68.58 ± 22.69 64.46 ± 27.05 0.164 0.492 NA 66.6
1 yr postop. 11.68 ± 18.38 14.29 ± 19.12 11.39 ± 17.68 10.53 ± 19.49 0.254 0.358 NA 54.3
Latest follow-up 15.67 ± 23.34 23.58 ± 27.11 14.38 ± 21.31 12.86 ± 23.91 <0.001 <0.001 <55 vs. 55-70, 70.1
p < 0.001; <55
vs. >70, p <
0.001; 55-70
vs. >70, p =
0.015
SMFA
Preop. 33.90 ± 13.57 37.30 ± 12.39 34.55 ± 12.96 29.78 ± 14.96 <0.001 <0.001 <55 vs. >70, 68.1
p < 0.001;
55-70 vs. >70,
p < 0.001
1 yr postop. 14.24 ± 12.75 15.47 ± 12.91 14.34 ± 13.09 13.06 ± 11.70 0.332 1.000 NA 54.5
Latest follow-up 16.15 ± 14.05 17.14 ± 13.82 15.70 ± 13.88 16.52 ± 14.68 0.528 1.000 NA 69.6
SF-36
Preop. 51.35 ± 17.71 45.78 ± 17.01 50.21 ± 17.24 58.45 ± 17.41 <0.001 <0.001 <55 vs. 55-70, 63.2
p = 0.049; <55
vs. >70, p <
0.001; 55-70
vs. >70, p <
0.001
1 yr postop. 74.82 ± 18.57 72.46 ± 20.56 74.76 ± 18.71 76.97 ± 16.17 0.198 1.000 NA 49.9
Latest follow-up 71.64 ± 20.17 71.44 ± 20.98 71.76 ± 19.98 71.50 ± 20.12 0.983 1.000 NA 62.4
FAOS pain
Preop. 43.27 ± 18.10 35.46 ± 17.70 41.53 ± 16.01 54.07 ± 20.10 <0.001 <0.001 <55 vs. >70, 29.8
p < 0.001;
55-70 vs. >70,
p < 0.001
1 yr postop. 82.41 ± 16.22 78.48 ± 17.36 81.41 ± 15.97 88.50 ± 14.46 0.001 <0.001 <55 vs. >70, 30.3
p < 0.001;
55-70 vs. >70,
p < 0.001
Latest follow-up 79.46 ± 20.37 73.17 ± 19.93 79.44 ± 19.60 85.30 ± 21.21 <0.001 <0.001 <55 vs. 55-70, 53.9
p = 0.004; <55
vs. >70, p <
0.001; 55-70
vs. >70, p <
0.001
FAOS symptoms
Preop. 39.99 ± 17.82 32.14 ± 13.21 38.26 ± 16.79 49.74 ± 19.29 <0.001 <0.001 <55 vs. >70, 32.4
p < 0.001;
55-70 vs. >70,
p < 0.001
continued
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TABLE V (continued)

P Value†

Patient-Reported Outcome Scores* Post Hoc

Pairwise, % Data
Overall <55 Yr 55-70 Yr >70 Yr Unadjusted Adjusted‡ Adjusted§ Available

1 yr postop. 75.21 ± 17.95 70.14 ± 20.17 74.92 ± 17.82 79.73 ± 15.54 0.006 0.039 <55 vs. >70, 34.1
p = 0.012
Latest follow-up 72.82 ± 20.11 61.32 ± 19.14 73.43 ± 19.50 80.60 ± 18.27 <0.001 <0.001 <55 vs. 55-70, 63.3
p < 0.001; <55
vs. >70, p <
0.001; 55-70
vs. >70, p <
0.001
FAOS activities of
daily living
Preop. 58.36 ± 19.48 56.50 ± 17.19 56.11 ± 18.82 66.32 ± 21.01 0.001 0.002 <55 vs. >70, 29.3
p = 0.019;
55-70 vs. >70,
p < 0.001
1 yr postop. 88.68 ± 12.56 89.87 ± 10.92 87.85 ± 13.28 90.33 ± 11.28 0.252 1.000 NA 31.7
Latest follow-up 72.85 ± 20.11 61.53 ± 19.22 73.43 ± 19.50 80.60 ± 18.27 <0.001 <0.001 <55 vs. 55-70, 63.3
p < 0.001; <55
vs. >70; p <
0.001; 55-70
vs. >70, p <
0.001
FAOS quality of life
Preop. 35.12 ± 14.25 30.10 ± 10.59 33.91 ± 13.48 41.69 ± 16.18 <0.001 <0.001 <55 vs. >70, 33.2
p < 0.001;
55-70 vs. >70,
p < 0.001
1 yr postop. 69.58 ± 18.97 61.83 ± 18.66 68.82 ± 18.30 77.85 ± 18.39 <0.001 <0.001 <55 vs >70, p < 34.4
0.001; 55-70
vs. >70, p <
0.001
Latest follow-up 69.46 ± 22.03 59.59 ± 19.13 70.41 ± 21.50 75.16 ± 23.15 <0.001 <0.001 <55 vs. 55-70, 64.4
p < 0.001; <55
vs. >70, p <
0.001

*The values are given as the mean and the standard deviation. NA = not applicable. †Significant values (p < 0.05) are indicated in bold.
‡Significance of overall differences in mean functional outcome measures; p values were adjusted for multiple comparisons with use of the
Bonferroni method. §Significance of pairwise comparisons between stated age groups; p values were adjusted for multiple comparisons with
use of the Bonferroni method.

study9. The extended follow-up that is now available may
explain in part why significant differences in PROs were de-
tected in the present study. Overall, the literature has yet to
come to any clear consensus regarding the effect of age on
outcomes following TAA.
While massive patient samples with long-term follow-
up have allowed the orthopaedic community to reach a more
accurate understanding regarding age-related outcomes
following TKA, the TAA literature to date consists of relatively
small patient samples with only early to intermediate-term
follow-up. The present study, to our knowledge, presents the
largest single-institution analysis, with the longest-term follow-
up, evaluating the age-based outcomes following TAA. This
large sample size and long-term follow-up allow for the de-
tection of important differential outcomes in younger patients
undergoing TAA.
Across all subscales of the FAOS and the numerical pain
scale, the youngest cohort in the present study had significantly
worse PROs than the older cohorts at the time of the latest
follow-up. Moreover, the younger patients experienced smaller
levels of improvement compared with the older patients after
TAA. This finding may in part be explained by the expectations
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TABLE VI Changes in Patient-Reported Outcome Scores

P Value†

Change in Patient-Reported Outcome Scores* Post Hoc

Pairwise, % Data
Overall <55 Yr 55-70 Yr >70 Yr Unadjusted Adjusted‡ Adjusted§ Available

FADI
1 yr postop. – 234.72 ± 17.03 234.48 ± 17.68 236.00 ± 17.50 232.13 ± 15.49 0.372 1.000 NA 19.0
preop.
Latest follow- 234.76 ± 17.56 235.41 ± 17.15 235.13 ± 17.95 233.33 ± 17.09 0.786 1.000 NA 21.2
up – preop.
Numerical Pain
Scale
1 yr postop. – 254.77 ± 27.71 254.17 ± 27.85 255.80 ± 26.74 252.52 ± 30.15 0.556 1.000 NA 44.0
preop.
Latest follow- 252.21 ± 31.37 244.75 ± 31.94 254.15 ± 30.47 253.08 ± 32.52 0.021 0.105 NA 54.7
up – preop.
SMFA
1 yr postop. – 219.76 ± 12.21 221.79 ± 12.28 219.81 ± 12.34 217.98 ± 11.63 0.090 0.449 NA 44.9
preop.
Latest follow- 218.77 ± 13.48 220.33 ± 12.93 219.89 ± 13.32 214.73 ± 13.59 <0.001 0.001 <55 vs. >70, 55.0
up – preop. p = 0.003;
55-70 vs. >70,
p < 0.001
SF-36
1 yr postop. – 23.56 ± 17.61 24.72 ± 20.73 24.59 ± 17.35 19.43 ± 14.76 0.046 0.231 NA 38.9
preop.
Latest follow- 21.11 ± 20.05 24.36 ± 21.40 22.69 ± 19.68 14.18 ± 18.52 <0.001 <0.001 <55 vs. >70, 47.3
up – preop. p < 0.001;
55-70 vs. >70,
p < 0.001
FAOS pain
1 yr postop. – 39.95 ± 19.55 48.72 ± 20.61 40.48 ± 17.89 31.83 ± 22.08 0.003 0.013 <55 vs. >70, 18.9
preop. p = 0.002;
55-70 vs. >70,
p = 0.046
Latest follow- 37.36 ± 21.69 41.44 ± 23.28 37.96 ± 20.26 31.32 ± 24.65 0.104 0.519 NA 20.5
up – preop.
FAOS symptoms
1 yr postop. – 37.23 ± 21.45 40.83 ± 20.50 38.27 ± 20.36 31.38 ± 24.81 0.094 0.472 NA 21.1
preop.
Latest follow- 34.58 ± 21.28 32.86 ± 18.97 36.80 ± 20.72 28.93 ± 23.55 0.041 0.203 NA 25.1
up – preop.
FAOS activities
of daily living
1 yr postop. – 31.20 ± 17.02 33.60 ± 13.87 31.90 ± 16.77 26.76 ± 19.54 0.202 1.000 NA 18.0
preop.
Latest follow- 15.82 ± 23.49 8.30 ± 19.52 19.32 ± 23.38 10.76 ± 24.78 0.006 0.029 NA 22.7
up – preop.
FAOS quality of
life
1 yr postop. – 35.25 ± 19.35 32.81 ± 20.83 35.97 ± 18.81 34.35 ± 20.46 0.660 1.000 NA 21.8
preop.
Latest follow- 35.44 ± 21.62 29.20 ± 16.21 37.46 ± 21.94 33.88 ± 23.45 0.062 0.311 NA 25.3
up – preop.

*The values are given as the mean and the standard deviation. NA = not applicable. †Significant values (p < 0.05) are indicated in bold. ‡Significance of overall
differences in changes; p values were adjusted for multiple comparisons with use of the Bonferroni method. §Significance of pairwise comparisons between
stated age groups; p values were adjusted for multiple comparisons with use of the Bonferroni method.
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that younger patients have regarding their functional status and
pain relief following TAA. Although it is not uncommon for
patients to have high postoperative expectations, regardless of
the procedure, younger age has been associated with having
the highest expectations after hip preservation surgery and
shoulder surgery28,29. Interestingly, although the patients in the
>70-year age group had the highest preoperative perceived
quality of life according to the SF-36, there were no differences
in scores at the time of the latest follow-up. This finding may
suggest that younger patients are more focused on the ankle
joint itself rather than on how it fits into their overall health and
well-being.
Patients <55 years of age experienced the highest rate
of all complications (including implant failure, polyethylene
exchange, component removal, and impingement) when com-
pared with the older age groups. While younger patients had a
longer average follow-up in the present study (thereby poten-
tially identifying more implant failures), we utilized Cox re-
gression modeling to adjust for the time to implant failure. Cox
regression corroborated our univariable results, providing ev-
idence that younger patients have shorter implant longevity
following TAA. Younger patients may be more active than their
older counterparts and thus may put more stress on the pros-
thesis with increased loading. While further research is needed
to confirm the exact mechanisms of failure following TAA in
young patients, aseptic loosening resulting from osteolysis in
the intermediate to long-term follow-up period may in part
explain why other studies with limited follow-up were unable
to detect differences in revision rates after TAA in various age
groups9,27.
This study had several strengths, including the large sample
size and the duration of follow-up. These 2 factors enabled the
detection of important differences regarding complications in
the postoperative period, revision rates, and PROs. The limi-
tations of this study include its retrospective nature and reliance
on data that were collected prior to the initiation of the study.
This study was performed at a single institution by experienced
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