Is There Still a Learning Curve for Primary TAA After Completing a High Volume Ankle Replacement Fellowship? A Multicentered Study
Authors: Higgins Margaret , Cody Elizabeth A. , DiGiovanni Grace , McKeeman Jonathan , Weiss Samantha N. , Lachman James R. 
Published: April 2024

Introduction/Purpose: The learning curve in Total ankle arthroplasty(TAA) has long been reported. Surgeon experience of five to twenty-five ankle replacements have been shown to decrease various perioperative and long term complications in this complex surgery. Fellowship programs with high-volume ankle arthroplasty experiences have been suggested to mitigate this learning curve and provide benefit to early career surgeons with TAA outcomes. The purpose of this study was to evaluate the learning curve for TAA in two high-volume surgeons practices through the first three years of practice. Both surgeons completed fellowships and participated in more than 100 ankle replacements each. We hypothesized that experience during fellowship will help minimize complications and negate any learning curve previously established in the literature. Methods: Prospectively collected data was retrospectively reviewed on all patients who underwent primary TAA surgery during the first three years of clinical practice after fellowship in this IRB approved, multi-centered study. Patient demographics and clinical data, radiographic outcomes, and patient reported outcomes were collected on all patients. Patients undergoing revision TAA (as a first surgery), patients without a minimum of 2 years follow-up, and patients undergoing arthrodesis conversion to TAA were all excluded. The data was analyzed using Chi Squared test and the Moving Average Method where appropriate. All statistical analysis was performed by someone with an expertise in biostatistics. Results: Eighty-seven patients (67.8% male, avg. age 64) met inclusion criteria for the study. Average tourniquet time (111.9 min) and fluoroscopy time(106.3 secs) decreased as surgeon experience increased, with the this trend stabilizing after patient 20. Complication rate (wound complication, infection, return to OR, intraoperative fracture, etc.) was similar throughout the study period. No differences were seen in component positioning (postop AP TT angle, Postop Lateral TT angle), PROMIS Pain interference, PROMIS Depression, or PROMIS Physical function with regards to time during the study. Statistically significant differences (improvements) were seen in in the following postoperative measurements when compared to preoperative values: AP TT angle, Lateral TT angle, and PROMIS Pain Interference/Depression/Physical function. Conclusion: Learning curve as it relates to intraoperative fluoroscopy time and intraoperative tourniquet time remained even after completing a high volume TAA fellowship but clinical and PROs did not show this same trend. Radiographic measurements, complications (both intraop and postop), and patient reported outcomes did not show a time sensitive change after fellowship. Though some variables did show the maintenance of a learning curve, this multi-centered study suggests that completion of a high volume TAA fellowship can mitigate some variables in the learning curve. Study Data Summary