title: [German Total Ankle Replacement Register of the German Foot and Ankle Society (D. A. F.) - presentation of design and reliability of the data as well as first results].
abstract: BACKGROUND
  Even though arthroplasty of the ankle joint is considered to be an established procedure, only about 1,300 endoprostheses are implanted in Germany annually. Arthrodeses of the ankle joint are performed almost three times more often. This may be due to the availability of the procedure - more than twice as many providers perform arthrodesis - as well as the postulated high frequency of revision procedures of arthroplasties in the literature. In those publications, however, there is often no clear differentiation between revision surgery with exchange of components, subsequent interventions due to complications and subsequent surgery not associated with complications. The German Orthopaedic Foot and Ankle Association's (D. A. F.) registry for total ankle replacement collects data pertaining to perioperative complications as well as cause, nature and extent of the subsequent interventions, and postoperative patient satisfaction.
  
  
  METHODS
  The D. A. F.'s total ankle replacement register is a nation-wide, voluntary registry. After giving written informed consent, the patients can be added to the database by participating providers. Data are collected during hospital stay for surgical treatment, during routine follow-up inspections and in the context of revision surgery. The information can be submitted in paper-based or online formats. The survey instruments are available as minimum data sets or scientific questionnaires which include patient-reported outcome measures (PROMs). The pseudonymous clinical data are collected and evaluated at the Institute for Evaluative Research in Medicine, University of Bern/Switzerland (IEFM). The patient-related data remain on the register's module server in North Rhine-Westphalia, Germany. The registry's methodology as well as the results of the revisions and patient satisfaction for 115 patients with a two year follow-up period are presented. Statistical analyses are performed with SAS™ (Version 9.4, SAS Institute, Inc., Cary, NC, USA).
  
  
  RESULTS
  About 2½ years after the register was launched there are 621 datasets on primary implantations, 1,427 on follow-ups and 121 records on re-operation available. 49 % of the patients received their implants due to post-traumatic osteoarthritis, 27 % because of a primary osteoarthritis and 15 % of patients suffered from a rheumatic disease. More than 90 % of the primary interventions proceeded without complications. Subsequent interventions were recorded for 84 patients, which corresponds to a rate of 13.5 % with respect to the primary implantations. It should be noted that these secondary procedures also include two-stage procedures not due to a complication. "True revisions" are interventions with exchange of components due to mechanical complications and/or infection and were present in 7.6 % of patients. 415 of the patients commented on their satisfaction with the operative result during the last follow-up: 89.9 % of patients evaluate their outcome as excellent or good, 9.4 % as moderate and only 0.7 % (3 patients) as poor. In these three cases a component loosening or symptomatic USG osteoarthritis was present. Two-year follow-up data using the American Orthopedic Foot and Ankle Society Ankle and Hindfoot Scale (AOFAS-AHS) are already available for 115 patients. The median AOFAS-AHS score increased from 33 points preoperatively to more than 80 points three to six months postoperatively. This increase remained nearly constant over the entire two-year follow-up period.
  
  
  CONCLUSIONS
  Covering less than 10 % of the approximately 240 providers in Germany and approximately 12 % of the annually implanted total ankle-replacements, the D. A. F.-register is still far from being seen as a national registry. Nevertheless, geographical coverage and inclusion of "high-" (more than 100 total ankle replacements a year) and "low-volume surgeons" (less than 5 total ankle replacements a year) make the register representative for Germany. The registry data show that the number of subsequent interventions and in particular the "true revision" procedures are markedly lower than the 20 % often postulated in the literature. In addition, a high level of patient satisfaction over the short and medium term is recorded. From the perspective of the authors, these results indicate that total ankle arthroplasty - given a correct indication and appropriate selection of patients - is not inferior to an ankle arthrodesis concerning patients' satisfaction and function. First valid survival rates can be expected about 10 years after the register's start.
authors.affiliation: Institut für Medizinische Biometrie und Epidemiologie, Universität Witten/Herdecke, Witten.
authors.forename: T
authors.initials: T
authors.lastname: Kostuj
authors.affiliation: Zentrum für Fußchirurgie, Aukammklinik, Wiesbaden.
authors.forename: M
authors.initials: M
authors.lastname: Preis
authors.affiliation: Zentrum für Fuß- und Sprunggelenkchirurgie, Schön Klinik München-Harlaching.
authors.forename: M
authors.initials: M
authors.lastname: Walther
authors.affiliation: MEM Forschungszentrum, Institut für Evaluative Forschung in der Medizin Universität Bern/Schweiz.
authors.forename: E
authors.initials: E
authors.lastname: Aghayev
authors.affiliation: Institut für Medizinische Biometrie und Epidemiologie, Universität Witten/Herdecke, Witten.
authors.forename: F
authors.initials: F
authors.lastname: Krummenauer
authors.affiliation: MEM Forschungszentrum, Institut für Evaluative Forschung in der Medizin Universität Bern/Schweiz.
authors.forename: C
authors.initials: C
authors.lastname: Röder
mesh_terms: D000328:Adult; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D016512:Ankle Injuries / Q000453:epidemiology* / Q000601:surgery*; D058737:Arthroplasty, Replacement, Ankle / Q000706:statistics & numerical data*; D015897:Comorbidity; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010003:Osteoarthritis / Q000453:epidemiology* / Q000601:surgery*; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology*; D015995:Prevalence; D012042:Registries; D012086:Reoperation / Q000706:statistics & numerical data; D012107:Research Design; D012307:Risk Factors; D017678:Sex Distribution; D016896:Treatment Outcome; D055815:Young Adult