End-stage ankle osteoarthritis (OA) is a highly debilitating condition associated with severe pain, impaired function and reduced quality of life [1
]. The burden of ankle OA is substantial; over 29,000 patients in the United Kingdom (UK) are referred for a surgical opinion each year [3
]. The main surgical treatment options for ankle OA are total ankle replacement (TAR) and ankle fusion (arthrodesis). The superiority of TAR versus ankle fusion remains controversial [4
]. The first prospective randomised controlled trial (RCT) directly comparing these treatments is underway in the UK [6
Previous research suggests patients are influenced by a variety of sources, including their surgeon, peers and the Internet, when deciding between TAR and ankle fusion [7
]. Patients living with both a TAR and ankle fusion have indicated a preference for their TAR due to maintenance of joint flexibility [8
]. Correspondingly, a qualitative study exploring barriers to recruitment to the ongoing RCT comparing TAR and ankle fusion identified that most patients approached about the trial wanted to undergo TAR rather than ankle fusion [9
]. However, another study highlighted that patients were concerned about balance, stability and potential damage to their ankle regardless of the type of surgery they had received [10
]. These studies have increased our understanding of a limited number of aspects of patients’ perspectives of TAR and ankle fusion. However, patients’ lived experiences across the entire care pathway from the decision to seek advice for a painful ankle through to post-operative recovery have not been thoroughly explored.
The aim of this study was to help address an identified gap in practice knowledge by exploring perceptions of surgery, education, rehabilitation and outcomes among patients who have undergone TAR or ankle fusion, to inform clinical practice and future research.
By exploring patients’ lived experiences across the TAR/ankle fusion pathway, this study has helped to address an important gap in existing literature. The findings highlight an array of factors that may contribute to patients’ decision to undergo TAR or ankle fusion and affect how they perceive their care and outcomes. Some factors were common to all participants in our study. For example, pain affecting their valued activities was central to all participants’ decision to seek help. Other factors, such as the influence of participants’ comorbidities on their post-operative outcomes, reflected participants’ individual circumstances and beliefs. A key finding was that the education and clinical support participants received had an important impact on their experiences and perceptions. Despite this, most participants felt that their education and support needs were not fully met.
Our findings about patients’ decision-making, both in terms of when to seek help and which type of surgery to have, largely align with those of a qualitative study by Zaidi et al. [7
]. As in this study, Zaidi et al. [7
] identified that patients may obtain information about TAR and ankle fusion from health professionals and peers, with surgeons having a particularly key influence. Our study expands these findings by highlighting that surgeons and peers may also affect patients’ perceptions of their post-operative outcomes. Another novel finding identified in our study is that some patients may prefer TAR due to “vanity”
, believing that TAR but not ankle fusion will enable them to avoid limping. Correspondingly, our findings suggest that patients may believe TAR will provide them with a “proper ankle”
and be concerned about the lack of joint flexibility following ankle fusion. This corresponds with a qualitative study by Conlin et al. [8
], in which patients who had undergone both TAR and ankle fusion felt that their TAR was more like a “normal ankle”
(p.1155), whilst their ankle fusion provided a feeling of stability.
Our findings highlight that the perception that TAR offers better gait/activity outcomes may result in patients believing TAR is more appropriate at a younger age. This contrasts with the perceptions of surgeons identified in a recent survey by Tai et al. [19
], which suggested that surgeons believe ankle fusion is more appropriate for younger patients. This may be because younger patients are likely to live longer and have higher activity levels, potentially causing more rapid TAR wear and increasing the chances of failure [20
]. Conversely, a recently published retrospective cohort study found that the risk of minor and major revision post-TAR did not differ significantly between younger and older patients [21
]. A potential contributory factor to these differing findings is that perceptions/definitions of a ‘younger’
patient vary. For example, two participants in our study perceived themselves as relatively young at 60 years old, whereas Tai et al. [19
] referred to younger patients as those less than 40 years old.
Our finding that the education patients receive can substantially affect their experiences and perceptions corresponds with literature on other orthopaedic procedures. This suggests that education may influence a patient’s knowledge, skills, expectations, mental wellbeing and satisfaction [22
]. Our findings demonstrate that pre- and post-operative education prior to TAR or ankle fusion was often insufficient and there was variability in the type of information provided. Written information has been shown to facilitate understanding among patients awaiting foot and ankle surgery [25
] but not all participants in our study were provided with sufficient written information. Some participants sought further information about their surgical procedure from the Internet, similar to those in previous studies [7
]. The readability and quality of online information about ankle surgery is often poor [26
], highlighting the important role of health professionals in challenging any misconceptions and providing evidence-based education throughout the care pathway.
Participants in our study perceived various limitations in the clinical support they received such as disjointed care, being discharged too soon, and having a long wait for post-operative physiotherapy. In addition, we found limited evidence of input from podiatrists, orthotists, or occupational therapists, despite the potential for these allied health professionals to support patients both pre- and post-operatively. Whilst most participants in our study appeared satisfied with their surgery overall, two participants who had undergone fusion expressed dissatisfaction due to ongoing discomfort and difficulty walking. Correspondingly, a prospective cohort study by Younger et al. [27
] found patients were more likely to report improved satisfaction with their symptoms post-TAR than post-fusion, although the absolute satisfaction scores were similar for both procedures. Other studies have also suggested that patients’ satisfaction levels with TAR and ankle fusion are similar [5
Our findings must be viewed in light of this study’s limitations. Whilst our sample size of seven is in line with typical sample sizes for phenomenological studies [11
], interviewing further participants may have provided additional insights. One option to help address this would have been to continue interviewing participants until we reached data saturation. However, the concept of saturation is inconsistently defined, challenging to assess and arguably inappropriate for the reflexive thematic analysis approach we employed [29
]. An alternative to saturation is the concept of information power proposed by Malterud et al. [30
]. This suggests that the more relevant information that can be obtained from a sample to address the study aim, the fewer participants are necessary. The seven interviews we conducted provided detailed and relevant information that directly addressed our study aim, supporting the appropriateness of our sample size.
Overall, our purposive sampling strategy captured a broad range of patients regarding gender, age, type of surgery, and duration since surgery. However, we did not interview any patients who had undergone ankle fusion revision surgery. In addition, we recruited participants from a single orthopaedic centre; therefore, our findings may not be transferable to other patients due to variations in service provision. We excluded patients unable to understand and speak English to ensure that participants could provide true informed consent and participate fully in the interviews. In addition, we did not record the ethnicity of participants to help preserve their anonymity, as relatively low numbers of patients undergo TAR. This meant we could not explore the impact of differing cultures and ethnicities on patients’ perceptions. This is an important limitation as previous research has highlighted racial disparities in utilisation of TAR and ankle fusion [31
]. Another potential limitation is that the participants were aware that members of the research team were based at the recruitment site, which may have discouraged them from criticising their care. This did not appear to be a substantial issue as the participants expressed both positive and negative perceptions.
Implications for clinical practice and future research
Our findings demonstrate that education and clinical support for patients undergoing TAR/ankle fusion is not always perceived as adequate by patients. Identifying and addressing such inadequacies is vital to inform patients’ decision-making, guide their preparations for surgery and support their post-operative recovery. We found that patients’ individual circumstances and beliefs had a strong influence on their decision-making and perceptions of their post-operative outcomes, highlighting the need to personally tailor support. Given the lack of definitive evidence in this area, developing consensus-based guidelines on pre- and post-operative support for patients undergoing TAR/ankle fusion would be valuable to guide service provision. There is also a need for further qualitative research to address areas not covered in our study. For example, further research is required to explore which outcomes are most important to patients undergoing TAR/ankle fusion and other stakeholders to inform the development of a standardised core outcome set for ankle surgery.
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