title: Comparison of the short-term results of the first and last 50 Scandinavian total ankle replacements: assessment of the learning curve in a consecutive series.
abstract: BACKGROUND
  Total ankle replacement (TAR) is presently considered to be an acceptable alternative to ankle fusion for patients with debilitating conditions of the ankle. The placing of a total ankle prosthesis is a technically demanding procedure. We hypothesized that the challenging conditions could cause a longer learning curve (>30 cases), and therefore the short-term results of the first and the last 50 cases in a consecutive series of 134 cases were compared.
  
  
  METHODS
  The first and last consecutive 50 cases by a single surgeon in a series of 134 Scandinavian Total Ankle Replacements (STAR; Waldemar Link, Hamburg, Germany), inserted between May 1999 and May 2008, were evaluated. Operation characteristics, clinical outcome (Foot Function Index [FFI], Kofoed score), complications, and the component alignment on X-rays were assessed. The outcome measures for both groups were compared using independent Student t tests, chi-square tests, and nonparametric alternatives (P < .05).
  
  
  RESULTS
  Surgery time decreased from a median of 125 (83-160) to 100 (65-170) minutes (P < .001), and fewer perioperative complications were observed (12 vs 4, P = .04). The sagittal alignment of the tibial component was closer to normal in the last series (P < .001). The clinical outcome did not differ between the 2 series (median FFI: 32 [0-74] vs 25 [0-75], Kofoed score: median 71 [21-96] vs 80.5 [23-100]). The major underlying pathology did change from rheumatoid arthritis (60%) to osteoarthritis (44%; P = .002). No differences in type and number of complications were reported.
  
  
  CONCLUSIONS
  The surgery time did decrease, there were fewer perioperative fractures, and the tibial component orientation improved, suggesting the presence of a learning curve. Operative experience and a shift in major underlying pathology did not influence clinical outcome. In view of this learning curve we suggest more restrictive patient selection for at least the first 50 TARs.
  
  
  METHODS
  Level III, comparative series.
authors.affiliation: Sint Maartenskliniek Nijmegen, Nijmegen, The Netherlands.
authors.forename: Janneke J P
authors.initials: JJ
authors.lastname: Schimmel
authors.forename: Luc H B
authors.initials: LH
authors.lastname: Walschot
authors.forename: Jan Willem K
authors.initials: JW
authors.lastname: Louwerens
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001172:Arthritis, Rheumatoid / Q000601:surgery*; D058737:Arthroplasty, Replacement, Ankle / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D061646:Operative Time; D010003:Osteoarthritis / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D016896:Treatment Outcome
keywords: STAR; learning curve; total ankle replacement