Surgeon Type and Outcomes After Inpatient Ankle Arthrodesis and Total Ankle Arthroplasty: A Retrospective Cohort Study Using the Nationwide Premier Healthcare Claims Database.

Abstract

Two main treatments for end-stage ankle arthritis are ankle arthrodesis and total ankle arthroplasty (TAA). While both procedures can be performed either by a foot and ankle orthopaedic surgeon or a podiatrist (when within a particular state's scope of practice), studies comparing the surgical outcomes of the 2 surgeon types are lacking. Therefore, in this study, we compared outcomes by surgeon type for TAA and for ankle arthrodesis. This retrospective cohort study utilized data from the nationwide Premier Healthcare claims database (2011 to 2016) regarding TAA (n = 3,674) and ankle arthrodesis (n = 4,980) procedures. Multivariable models estimated associations between surgeon type (podiatrist versus orthopaedic foot and ankle surgeon) and opioid utilization (in oral morphine equivalents [OMEs]), length of stay, and cost of hospitalization. We report percent change (compared with reference) and 95% confidence intervals (CIs). Overall, 76.5% (n = 2,812) and 18.8% (n = 690) of TAA procedures were performed by orthopaedic foot and ankle surgeons and podiatrists, respectively; surgeon type was unknown for 4.7% (n = 172). For ankle arthrodesis, 75.3% (n = 3,752) and 18.3% (n = 912) of the procedures were performed by orthopaedic foot and ankle surgeons and podiatrists, respectively; surgeon type was unknown for 6.3% (n = 316). The proportion of TAA and ankle arthrodesis procedures performed by podiatrists increased over time, from 12.8% and 13.6% in 2011 to 24.6% and 26.0% in 2016, respectively. When adjusting for relevant covariates, procedures performed by podiatrists (compared with orthopaedic foot and ankle surgeons) were associated with increased length of stay: for TAA, +16.7% (95% CI, 7.6% to 26.5%; median, 2 days in both groups) and for ankle arthrodesis, +14.2% (95% CI, 7.9% to 20.9%; median, 3 compared with 2 days) (p < 0.05 for both). In addition, ankle arthrodesis performed by podiatrists was associated with increased cost of hospitalization: +28.5% (95% CI, 22.1% to 35.2%; median, $19,236 compared with $13,433) (p < 0.05). Differences in opioid utilization were nonsignificant in the main analysis: +10.9% (95% CI, -3.1% to 26.8%; median, 345 compared with 250 OMEs) and +2.8% (95% CI, -5.9% to 12.4%; median, 351 compared with 315 OMEs) for TAA and ankle arthrodesis, respectively. An increasing trend in the proportion of procedures performed by podiatrists was coupled with apparent increases in length of stay and cost compared with procedures performed by orthopaedic foot and ankle surgeons. Given the increasing demand for these procedures, factors associated with resource utilization, such as type of surgeon, may be increasingly important on the population level. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.