Speciality Standards (SpecS) - Management of End Stage Ankle Arthritis

Background and Justification

End stage ankle arthritis is usually treated with Total Ankle Replacement (TAR) or Ankle Fusion (AF) and patients should have either option available. Outcomes may be improved with discussion in an ankle arthritis network and concentrating TAR to centres where they are regularly performed. This facilitates referral and communication, reduces clinical variance, and ensures equitable, cost-effective access to high quality care.

Inclusion:

All patients being considered for primary or revision AF and TAR. Ankle fusion in the context of limb reconstruction should be discussed either in an ankle arthritis network or limb reconstruction MDT that follows the same guidelines.

Exclusions:

Immediate ankle fusion following trauma.

Summary of Standards

1. Healthcare teams providing surgical treatment for ankle arthritis should have access to, and engage with, an ankle arthritis network.
2. An ankle arthritis network should:
   1. reflect local resources and geography
   2. have access to patient records and all relevant imaging
   3. have a designated co-ordinator or lead
   4. occur with sufficient frequency to avoid delays in treatment
   5. record the outcome in the patient’s record
   6. facilitate training of all relevant healthcare providers.
3. Imaging protocols should be agreed and standardised across the network.
4. Transfer and discussion between units should not delay definitive treatment.
5. The discussion with the patient must include and document:
   1. non-operative options
   2. surgical risks, benefits and long-term outcomes of TAR and AF
   3. patient information resources.
6. All patients scheduled for primary or revision TAR must be admitted to a ring-fenced facility that follows GIRFT guidelines and practices.
7. All primary and revision TAR should be performed in a dedicated clean air orthopaedic theatre.
8. Dual surgeon operating is recommended for complex cases and training.
9. Surgeons performing TAR must submit data to a national joint registry.
10. Primary TAR must have clinical and radiological follow up for a minimum of 2 years with direct clinical review available for the lifespan of the implant.
11. AF must have clinical and radiological follow up until clinical and / or radiological evidence of fusion.
12. Revision TAR must have annual clinical and radiological follow up for the lifespan of the implant.
13. Infection must be considered in all failing TARs and management should be directed by the peri-prosthetic joint infection SpecS.
14. Access to plastic and vascular surgeons should be available for all revision TAR, either locally or through the ankle arthritis network.