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Johns Hopkins Orthopaedics Researchers Uncovering Demographic TAA Disparities

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Fig. 1. Pre and postoperative imaging of a 34-year-old patient with severe ankle valgus ball and socket deformity treated with arthroscopic ankle fusion. (A) Preoperative weight-bearing AP ankle radiograph. (B) Postoperative weight-bearing AP ankle radiograph. (C) Preoperative weight-bearing hindfoot view. (D) Postoperative weight-bearing hindfoot view. radiograph. (E) Preoperative weight-bearing lateral ankle radiograph. (F) Postoperative weight-bearing lateral ankle radiograph.


Uma Srikumaran, associate professor in the Department of Orthopaedic Surgery at The Johns Hopkins University School of Medicine, believes that “although we understand that racial and other disparities are pervasive in health care, we have a great deal left to understand about the extent of those disparities and all the various factors that contribute to them for different pathologies.”

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Uma Srikumaran, M.D., M.B.A., M.P.H. 

Compared to the gold standard of ankle arthrodesis for restoring function for patients with symptomatic arthrosis, deformity or severe instability of the tibiotalar joint, total ankle arthroplasty (TAA) has reemerged with a several of cutting-edge devices as an alternative that may suit some patients. TAA now offers outcomes and efficacy similar to those of arthrodesis — but without the limitations in range of motion. Traditional contraindications for the procedure are changing, and patients who are younger, heavier, more active or who have some degree of deformity may now be candidates for TAA.

However, the choice of treatment is always highly individualized and driven by many factors. Srikumaran’s group investigated whether any of those drivers were racial or socioeconomic in nature. In the paper Racial, Socioeconomic, and Payer Status Disparities in Utilization of Total Ankle Arthroplasty Compared to Ankle Arthrodesis” (Schmerler et al. 2023), co-authored by Srikumaran, patient characteristics were evaluated by Johns Hopkins researchers, who found that Black and Asian patients were significantly less likely than white patients to undergo TAA than arthrodesis, and that patients in higher income brackets were more likely than those in lower income brackets to undergo TAA than arthrodesis.

The researchers postulated that these disparities may be explained by differences in availability of the procedures in hospitals where many minority patients receive care, by the persistence of racial disparities in the provision of total joint replacements and by later presentation, when nonwhite patients may have less preservable mobility and may be less likely to be offered TAA.

Srikumaran observes that the study’s importance can be found in “looking to achieve and promote equity in healthcare and to measure the problem in specific pathologies, populations, geographies, hospitals, and insurance types.” This approach forms the foundation for future research of this type and determining which interventions are most effective for a particular hospital, geographic location or condition, “since solutions are not likely to be ‘one size fits all.’”

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