Primary Arthrodesis vs Open Reduction Internal Fixation for Lisfranc Fracture-Dislocations: A Cost Analysis

Abstract

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc fracture-dislocation is an uncommon but serious injury that currently lacks universal consensus on optimal operative treatment. Two common fixation methods are open reduction and internal fixation (ORIF) and primary arthrodesis (PA). The objective of this study is to analyze the cost difference between ORIF and PA of Lisfranc injuries, along with the contribution of medical services to overall costs. Methods: This was a retrospective cost analysis of the MarketScan database from 2010-2020. Patients undergoing primary ORIF (CPT code 28615) versus PA (28730 and 28740) for Lisfranc fracture-dislocation were identified. The primary independent variable was ORIF versus PA of Lisfranc injury. Costs accrued due to operative management was the primary objective, and was analyzed according to net payment, total payment, coinsurance, copayment, deductible, and coordination of benefits per savings (COB/savings) amounts. Outpatient surgery setting (hospital versus ambulatory surgical center (ASC)) and requirement for secondary arthrodesis within the primary ORIF group were secondary independent variables. The utilization of and costs contributed by medical services were secondary outcomes. These included outpatient clinic visits, foot radiographs, lower extremity magnetic resonance imaging (MRI), lower extremity computed tomography (CT), physical therapy (PT), and opioid prescriptions. Student’s t-test, chi-squared test, and Poisson multivariable regression were used for statistical analysis, with significance set as P < 0.05. Results: From 2010 to 2020, 7,268 patients underwent operative management of Lisfranc injuries, with 5,689 (78.3%) ORIF and 1,579 (21.7%) PA. Of those undergoing initial ORIF, 22 (0.39%) were converted to secondary arthrodesis at a mean ± standard deviation of 10.2 ± 12.1 months after the index surgery. PA was independently associated with increased net payment, total payment, and coinsurance. When compared to primary ORIF, patients undergoing PA utilized more clinic and PT visits and imaging sessions. However, primary ORIF with secondary arthrodesis was associated with more clinic visits, imaging, and generated higher costs from these medical services compared to PA alone. Within hospital and ASCs, PA was associated with increased net and total payments. However, out-of-pocket (OOP) costs were found to be higher in ASCs. Conclusion: Treatment of Lisfranc fracture-dislocation with PA is associated with higher initial costs compared to ORIF with subsequent secondary arthrodesis. Conversely, secondary arthrodesis demonstrated significantly higher costs and resource utilization compared to primary procedures. Specific cost drivers for PA and secondary arthrodesis were clinic visits and perioperative imaging.