Abstract
Background
The outcomes of total ankle replacements (TAR) in golfers are not known. The primary aim was to assess whether golfers experience similar improvements using the Manchester-Oxford Foot Questionnaire (MOXFQ) compared to the wider population. Secondary aims were to assess difference in demographics, health-related quality of life, and return to golf.
Methods
This was a retrospective review of prospectively collected data. Nineteen golfers and 144 non-golfers were included. Outcomes measured were MOXFQ, EQ5D3L and patient satisfaction.
Results
Golfers had significantly better MOXFQ scores preoperatively (p = 0.02) and postoperatively (p = 0.03), but there was no significant difference in mean change. Postoperative EQ5D3L scores were similar between groups. 52 % returned to golf within 6 months and 79 % within one year, similar to hip, knee and shoulder arthroplasty.
Conclusion
Golfers experience comparable improvements following TAR, with high rates of return to play. These findings may be used to counsel patients and manage expectations preoperatively.
Level of evidence
II
1
Introduction
End-stage ankle arthritis is a debilitating condition that results in reduced health-related quality of life (HRQoL) ,, . Total ankle replacement (TAR) is now an established treatment for end-stage ankle arthritis, offering pain relief and functional improvement ,, . Golf is a popular sport played by > 100 million persons of all ages globally Golf can provide health enhancing physical activity with longevity, physical health and mental health benefits . An estimated 14 % of patients undergoing hip and knee arthroplasty play golf and aim to return following surgery, this has not been well described in the ankle arthroplasty population , . There is evidence to show that 80 % of patients return to golf following hip and knee joint arthroplasty, and there is a positive effect on fitness and outcomes following return to golf , .
Recent studies have shown that up to 80 % of patients return to sport and physical activity following TAR, which is similarly associated with improved outcomes ,, . Taylor et al. demonstrated no significant change in golf handicap before and after TAR . However, there is a paucity of evidence investigating the outcomes and satisfaction of TAR specifically in patients who play golf. The main aim of this study was to assess golfers’ improvement compared to the wider population in an ankle-specific patient reported outcome measure (PROM) using the Manchester-Oxford Foot Questionnaire (MOXFQ). The other aims were to assess: (1) preoperative difference in demographics, (2) difference in HRQoL and (3) rate of return to golf following surgery.
2
Methods
This study was classified by the local research and ethics committee as clinical audit and ethical approval was not required. Patients were identified from a prospectively compiled arthroplasty database held at the study centre. The study included patients who underwent primary TAR from 2011 to 2023. Indications for performing TAR were at the discretion of the two consultant foot and ankle surgeons at the study centre. Patients were excluded if they were lost to follow up or had undergone revision surgery.
Demographic and comorbidities were collected preoperatively. Complications and PROMs were collected at a minimum of one year postoperatively. Patients were followed up retrospectively to identify whether they took part in any sport, and those who responded with ‘golf’ were included in the analysis. Golfers were asked about the timing of their return to golf and their subjective ability in playing golf following TAR.
2.1
Outcomes measured
2.1.1
Manchester oxford foot questionnaire (MOXFQ)
The MOXFQ is a 16-item patient-reported questionnaire comprising of three separate dimensions: Walking/standing (W/S) problems (seven items), Foot Pain (five items), and Social Interaction (S-I; four items) ,,, . Each item is scored from 0 to 4, with 4 representing the most severe state. The raw scale scores of each dimension were summed and converted to an index score ranging from 0 to 100, where 100 represents the most severe state . The minimally clinically important difference (MCID) was set at 13 points .
2.1.2
European quality of Life 5 dimensions 3 level version (EQ-5D-3L)
The EQ-5D-3L is a measure of HRQoL covering five domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression). Each domain is scored on a three-point Likert scale (no problems, some problems, extreme problems), and the responses are used to generate an index value ranging from– 0.586 (a health state worse than death being less than 0) to 1.0 (perfect health). In addition, two visual analogue scales are used: one for overall health state (0–100, with 100 representing perfect health, 0 reflecting worst health) and one for pain (0–100, with 0 representing no pain, and 100 representing the worst pain imaginable) .
2.1.3
Patient satisfaction
Satisfaction was assessed with a five-point Likert scale (1– very satisfied, 2– satisfied, 3– neutral, 4- dissatisfied, 5- very dissatisfied). Patients scoring one or two were considered satisfied, and those scoring three to five considered dissatisfied, in line with previously published literature .
2.2
Statistical analysis
Data were assessed for normal distribution. Student’s t -test and chi-squared test were used to assess significant difference between the two groups for continuous and categorical variables respectively. Fisher’s exact test was used to analyse categorical variables with ≤ 5 patients in one group. All analyses were performed using Statistical Package for Social Sciences v.29.0 (SPSS Inc., Chicago, Illinois). A p-value of < 0.05 was assumed to be significant.
3
Results
3.1
Study cohort characteristics
There were 180 primary TAR recorded in the database. Revision TARs (n = 13) and patients deceased at the time of follow-up (n = 4) were excluded from the analysis. There were 112 (67 %) male patients and 55 (33 %) female patients. The mean age of the study cohort was 67.6 (SD 9.2), and mean Body Mass Index (BMI) was 29.9 (SD 5.4). Preoperative demographic comparisons between the golfer cohort (n = 19, 12 %) and the non-golfer cohort (n = 144, 88 %) are presented in Table 1 .
Table 1
Preoperative demographics and functional outcomes between both golfers and non-golfers. BMI body mass index, SD standard deviation, EQ5D EuroQol 5 dimension, VAS visual analogue scale, MOXFQ Manchester Oxford Foot Questionnaire.
| Demographic | Golfer | Difference/odds ratio (95 % CI) | P value | ||
|---|---|---|---|---|---|
| Study cohort (n = 163) | No (n = 144) | Yes (n = 19) | |||
| Gender (n, %) | |||||
| Male | 112 (67) | 94 (64) | 18 (95) | OR 10.34 (1.3–79.6) | 0.006 |
| Female | 55 (33) | 54 (36) | 1 (5) | ||
| Mean age (years, SD) | 67.6 (9.2) | 67.8 (9.3) | 64.9 (7.7) | Diff 3.0 (−1.4–7.4) | 0.09 |
| BMI (SD) | 29.9 (5.4) | 29.9 (4.8) | 27.7 (3.4) | Diff 2.2 (−0.05–4.4) | 0.04 |
| Comorbidities (n, %) | |||||
| RA | 27 (16) | 25 (17) | 2 (11) | OR 0.58 (0.13–2.7) | 0.48 |
| Diabetes | 16 (10) | 14 (9) | 2 (11) | OR 1.13 (0.24–5.4) | 0.88 |
| PVD | 7 (4) | 6 (4) | 1 (5) | OR 1.31 (0.15–11.6) | 0.80 |
| Cardiovascular disease | 25 (15) | 23 (16) | 2 (11) | OR 0.64 (0.14–2.9) | 0.56 |
| Pre-operative | |||||
| EQ5D VAS | 64.8 (22.0)(n = 145) | 63.9 (22.8)(n = 127) | 71.9 (13.9)(n = 17) | Diff −8 (−19.2–3.2) | 0.09 |
| EQ5D Index | 0.37 (0.31)(n = 127) | 0.36 (0.32)(n = 113) | 0.42 (0.25)(n = 13) | Diff −0.06 (−0.2–0.1) | 0.26 |
| MOXFQ-Index | 75.8 (14.2)(n = 143) | 76.6 (14.4)(n = 126) | 69.7 (11.2)(n = 17) | Diff −6.9 (−0.3–14.1) | 0.02 |
| MOXFQ-Pain | 74.0 (6.9)(n = 143) | 74.5 (17.5)(n = 126) | 70.9 (11.6)(n = 17) | Diff −3.6 (−12.3–5.1) | 0.21 |
| MOXFQ-Walking | 83.8 (15.2)(n = 143) | 84.9 (14.9)(n = 126) | 75.0 (15.5)(n = 17) | Diff −9.9 (−17.5 to −2.3) | 0.006 |
| MOXFQ-Social | 64.2 (19.7)(n = 143) | 64.9 (20.1)(n = 126) | 58.8 (15.9)(n = 17) | Diff −6.1 (−16.1–3.9) | 0.12 |
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