Isolated Ankle Fractures Research Articles

Early weight bearing is not associated with short-term complications in ankle fractures.

Ankle fractures are common injuries and post-operative protocols continue to vary. We aim to compare postoperative complications between early weight bearing (EWB), intermediate weight bearing (IWB), and delayed weight bearing (DWB) in adult patients with isolated ankle fractures treated with open reduction internal fixation (ORIF). This retrospective cohort study includes 233 adult patients with isolated (medial malleolar, lateral malleolar, posterior malleolar, bimalleolar equivalent) or complex (trimalleolar, trimalleolar equivalent, bimalleolar, and Maisonneuve) ankle fractures treated with ORIF between 2020 and 2022 at a level I trauma center. Patients were weight bearing postoperatively at < 3 weeks (EWB), 3-6 weeks (IWB), or > 6 weeks (DWB). Main outcome measurements include rates of complications requiring reoperation and minor complications. Thirty-one and eight tenths percent (74/233) were EWB, 25.8 % (60/233) were IWB, and 42.5 % (99/233) were DWB. 73.0 % of patients (170/233) had complex fractures, and 27.0 % (63/233) had isolated malleolar fractures. 16.3 % of patients (38/233) developed complications, with 7.7 % (18/233) requiring reoperation. We found no differences in overall complications (14.86 % vs. 11.67 % vs. 20.20 %; p = 0.3396) or complications requiring reoperation (9.46 % vs. 3.33 % vs. 9.09 %; p = 0.3337) among the weight bearing groups for all fractures. Between the complex fracture group and the isolated malleolar fracture group, there were no differences in overall complications (7.94 % vs. 19.41 %; p = 0.0566) or complications requiring reoperation (9.41 % vs. 3.17 %; p = 0.1664). There is not statistical significance between timing to weight bear and complications in ankle fractures treated with ORIF. Level of Evidence: Level 3.

Formal Physical Therapy Improves PROMIS PF for High Anxiety Patients Following Ankle ORIF.

To compare outcomes after ankle fracture fixation between those receiving formal physical therapy (PT) vs. no formal PT and those with high vs. low PROMIS anxiety score (AS), and to evaluate the effect of PT in the setting of PROMIS AS scores. Retrospective cohort study. Level 1 trauma center. Patients aged > 18 undergoing isolated ankle fracture (OTA/AO 44A, 44B, 44C) fixation with documented PROMIS scores postoperatively.Outcome Measures and Comparisons: The post-operative PROMIS physical function (PF) and pain interference (PI) were compared between patients receiving formal PT vs. no PT and those with baseline high vs. low PROMIS AS scores. A sub-analysis was performed between patients with low anxiety and no PT (LANP) vs. low anxiety with PT (LAP) vs. high anxiety and no PT (HANP), and high anxiety with PT (HAP). A total of 161 patients, 111 females (68.9%), with an average age of 46 years (range: 72), were included in this study: 127 PT, 34 no PT, 88 low anxiety, and 73 high anxiety. PT did not yield any significant differences in PROMIS PF (44.9 PT vs 42.6 no PT, p=0.180) or PI (53.5 PT vs 54.4 no PT, p=0.656) at final follow-up. At final follow-up, high anxiety patients had similar PROMIS PF (43.0) vs. low anxiety patients (45.5, p=0.088), but significantly worse PROMIS PI scores (51.5 vs. 56.7, respectively; p=0.001). Univariate analysis demonstrated a significant difference in age between high and low anxiety patients and was thus selected as a control variable in the analysis of HANP, HAP, LANP, and LAP. After controlling for age, pairwise comparisons of estimated PROMIS PF scores at final follow-up were significantly lower for HANP (39.0) than HAP (43.9, p=0.05), LANP (45.1, p=0.05), and LAP patients (45.9, p=0.04). Final PROMIS PI scores were significantly worse for HANP (59.1) and HAP (56.5) when compared to LANP (51.3, p=0.021 vs HANP, p=0.049 vs HAP) and LAP (51.3, p=0.005 vs HANP, p=0.004 vs HAP) groups . Patients with high anxiety who undergo isolated ankle fracture fixation perform worse regarding PROMIS PI irrespective of PT status. However, some patients with high anxiety may benefit from formal PT referral to maximize their functional outcomes. Level III, Prognostic.

Clinical relevance of current patient-reported outcome measures for ankle fracture: surgeons' perspective.

Determine the relevance of the most frequently used patient-reported outcome measures (PROMs) for monitoring patient recovery after ankle fracture, from the clinical perspective of orthopaedic trauma surgeons, given lack of validated PROMs. Prospective cohort. Orthopaedic Trauma Association committee meetings, electronic correspondence. Orthopaedic trauma surgeons. Delphi method for consensus activities. IV. Most clinically relevant PROMs for ankle fracture recovery. Several English-language PROMs were identified based on use in literature and relevance to ankle fractures. 7 were selected by expert consensus. These are the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopaedic Surgeons (AAOS), Foot and Ankle Disability Index (FADI) Score, Lower Extremity Functional Scale (LEFS), Olerud-Molander Ankle Score (OMAS), and Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF). The most clinically relevant PROM is the A-FORM, followed by the AAOS, LEFS, PROMIS PF, FADI, and OMAS, and the least clinically relevant overall, the FAAM. Understanding which PROM best matches physician expectations for tracking recovery is an important step toward a robust, evidence-based approach to patient care. The A-FORM was identified as the most clinically relevant among the most used PROMs. These results will aid surgeons, clinicians, and scientists to identify a uniformly, clinically relevant PROM for the treatment and study of outcomes and recovery after isolated ankle fracture.

Ankle fracture open reduction and internal fixation in patients with cerebral palsy.

To examine patients with cerebral palsy (CP) undergoing open reduction and internal fixation (ORIF) for ankle fractures. This was a retrospective study of adult patients undergoing ankle fracture ORIF for closed, isolated ankle fractures identified in between 2010 and 2021 in the Q1 PearlDiver M151 database. Patients with CP were identified with International Classification of Diseases (ICD)-9 and ICD-10 codes, and were matched to those without 1:10 on age, sex, and Elixhauser comorbidity index (ECI). Ninety-day adverse events were assessed with multivariable logistic regression. A total of 148 993 patients with isolated ankle fracture ORIF were identified, of whom 407 (0.27%) had CP. After matching, 3863 without CP were compared to 389 with CP. Patients with CP were at increased odds of: 90-day urinary tract infection (odds ratios [OR] 6.26), pneumonia (OR 3.50), minor adverse events (OR 3.46), sepsis (OR 3.30), any adverse events (OR 3.04), emergency department visits (OR 2.28), serious adverse events (OR 1.77), and prolonged length of stay more than 4 days (OR 22.44) (p < 0.001 for all). Patients with CP undergoing ORIF for isolated, closed ankle fractures are at increased odds of several 90-day adverse events and prolonged length of stay compared to matched patients without CP.

Predictors of Episode-of-Care Costs for Ankle Fractures

Ankle fractures are one of the most resource-consuming traumatic orthopedic injuries. Few studies have successfully evaluated the episode-of-care costs (EOCC) of common traumatic orthopedic injuries. The objective of this study was to determine the EOCC associated with the surgical management of ankle fractures. A retrospective cohort study of 105 consecutive patients who underwent open reduction internal fixation of an isolated ankle fracture at a Canadian Level-1 trauma center was conducted. Episode-of-care costs were generated using an activity-based costing framework. The median global episode-of-care cost for ankle fracture surgeries performed at the studied institution was $3,487 CAD [IQR 880] ($2,685 USD [IQR 616]). Patients aged 60 to 90 years had a significantly higher median EOCC than younger patients (p = .01). Supination-adduction injuries had a significantly higher median EOCC than other injury patterns (p = .01). The median EOCC for patients who underwent surgery within 10 days of their injury ($3,347 CAD [582], $2,577 USD [448]) was significantly lower than the cost for patients who had their surgery delayed 10 days or more after the injury ($3,634 CAD [776], $2,798 USD [598]) (p = .03). Patient sex, anesthesia type, ASA score and surgeon's fellowship training did not affect the EOCC. This study provides valuable data on predictors of EOCC in the surgical management of ankle fractures. Delaying simple ankle fracture cases due to operating time constraints can increase the total cost and burden of these fractures on the healthcare system. In addition, this study provides a framework for future episode-of-care cost analysis studies in orthopedic surgery.

Determining the Causal Effect of Statins on Reducing the Incidence of Venous Thromboembolism after Ankle Fractures

Category: Ankle; Other Introduction/Purpose: It can be challenging to decide when to give preventative medication for venous thromboembolism (VTE). It is challenging to identify VTE in its early phases, and surgeons disagree on when prophylaxis should be given and when to suspect VTE. Additionally, patients who are not at a high risk of VTE are advised not to take prophylaxis due to the potential risk of bleeding adverse events and the evidence does not fully support providing prophylaxis in isolated foot and ankle procedures (BAE). The effectiveness of prevention, particularly in isolated foot and ankle fractures, is debatable, and research into how patients react to statins is necessary. By utilizing causal inference techniques, this research simulates a randomized control trial (RCT) from observational data. Methods: Out of a total of 1,175 patients, 238 had confirmed VTE 180 days after the incidence of ankle fracture (Case group, n=238). The inclusion criteria were 1- ankle fracture diagnosed by a physician and confirmed radiologically via X-ray or CT scan; 2- Age of 18 years or older; 3- Symptomatic VTE confirmed by a clinician and through radiologic (Duplex ultrasound, CT angiography, and/or angiography). To infer causal effects, we took the three following steps: first, the causal diagram must be created. Second, the set of variables necessary for causal inference must be identified. Third, the average treatment effect should be estimated for different treatment regimens. Results: Table 1 shows the incidence of VTE among patients who had VTE chemoprophylaxis. A non-significant 2.9% increase in VTE incidence was found, 95% CI [-1%, 7%]. The results state that, if a patient is already taking Statins, the incidence of VTE is reduced by 1%, 95% CI [-4.2%, 2.8%] as compared to patients who are not taking the drug which is not statistically significant. This indicates that there is no significant difference between administering VTE prophylaxis or not, in patients that are already consuming Statins. On the contrary, for patients in the sample that are not already taking Statins, the VTE incidence increases by 6%, 95% CI [1.6%, 10%] compared to no treatment administration which is significant since the confidence interval does not contain 0. Conclusion: Our findings provide more evidence that VTE prophylaxis may not, on average, be successful in lowering the incidence of VTE after ankle fracture, particularly in individuals who do not take Statins. To put it another way, doctors may decide not to give extra prophylaxis to avoid VTE in isolated ankle fractures if a patient is on Statins. Here, we established the causal inference methodology that can help us reproduce the results of an expensive RCT.

Clinical Improvement Following Operative Management of Ankle Fractures Among Patients With and Without Moderate to High Depressive Symptoms: An Analysis Using PROMIS.

Understanding the recovery trajectory following operative management of ankle fractures can help surgeons guide patient expectations. Further, it is beneficial to consider the impact of mental health on the recovery trajectory. Our study aimed to address the paucity of literature focused on understanding the recovery trajectory following surgery for ankle fractures, including in patients with depressive symptoms. From February 2015 to March 2020, patients with isolated ankle fractures were asked to complete Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression questionnaires as part of routine care at presentation and follow-up time points. Linear mixed effects regression models were used to evaluate the patient recovery pattern, comparing the preoperative time point to <3 months, 3-6 months, and >6 months across all patients. Additional models that included the presence of depression symptoms as a covariate were then used. A total of 153 patients met inclusion criteria. By 3-6 months, PROMIS PF (β: 9.95, 95% CI: 7.97-11.94, P < .001), PI (β: -10.30, 95% CI: -11.87 to -8.72, P < .001), and Depression (β: -5.60, 95% CI: -7.01 to -4.20, P < .001) improved relative to the preoperative time point. This level of recovery was sustained thereafter. When incorporating depressive symptoms into our model as a covariate, the moderate to high depressive symptoms were associated with significantly and clinically important worse PROMIS PF (β: -4.00, 95% CI: -7.00 to -1.00, P = .01) and PI (β: 3.16, 95% CI: -0.55 to 5.76, P = .02) scores. Following ankle fracture surgery, all patients tend to clinically improve by 3-6 months postoperatively and then continue to appreciate this clinical improvement. Although patients with moderate to high depressive symptoms also clinically improve following the same trajectory, they tend to do so to a lesser level than those who have low depressive symptoms. Level III, case-control study.

Ankle fracture follow up using the Chertsey Outcome score for Trauma. Floor and ceiling effect of the scale

BackgroundPatient reported outcome measures (PROMs) are increasingly used by orthopaedic surgeons in order to measure their results. The Chertsey Outcome Score for Trauma (COST) is a recently validated PROM, which treats trauma as pathology, is not site or pathology specific. It measures the rehabilitation of the patients after an injury, using the pre-injury status as the default state of the patients. The aim of the present study was to focus on a narrow group of patients with similar ankle fracture injuries, investigate if there is any floor or ceiling effect of the scale and examine its use during the ankle fracture at the immediate post-injury rehabilitation period. Materials and methodsAll patients who had isolated ankle fractures treated either operatively or conservatively between March 2018 and December 2019, were included in the study. A COST and a FADI questionnaire was completed prior to their follow-up at 2, 6 and 12 weeks post injury/operation. Demographic data were also collected. ResultsA total of 527 COST questionnaires from 314 different patients (aged 51.4 ± 18.4 years) were included in the study. The average COST score was 40.28 ± 18 and the average FADI score was 60.1 ± 21.8. The VAS score reached 3.57 ± 2.2. There was no significant floor and ceiling effect for the COST score. The COST score had good correlation with the FADI score (Spearman’s Rho=0.69) and good internal consistency (Cronbach’s Alpha=0.85). ConclusionNo significant floor or ceiling effect was identified for the COST score, during the short and medium term follow up period following an ankle fracture, treated with either conservative or operative management. The scale was found to be valid and with good internal consistency.

Cost and safety of inpatient versus outpatient open reduction internal fixation of isolated ankle fractures.

Background:As health care shifts to value-based models, one strategy within orthopedics has been to transition appropriate cases to outpatient or ambulatory settings to reduce costs; however, there are limited data on the efficacy and safety of this practice for isolated ankle fractures. The purpose of this study was to compare the cost and safety associated with inpatient versus outpatient ankle open reduction internal fixation (ORIF).Methods:All patients who underwent ORIF of isolated closed ankle fractures at 2 affiliated hospitals between April 2016 and March 2017 were identified retrospectively. Demographic characteristics, including age, gender, comorbidities and injuryspecific variables, were collected. We grouped patients based on whether they underwent ankle ORIF as an inpatient or outpatient. We determined case costing for all patients and analyzed it using multivariate regression analysis.Results:A total of 196 patients (125 inpatient, 71 outpatient) were included for analysis. Inpatients had a significantly longer mean length of stay than outpatients (54.3 h [standard deviation (SD) 36.3 h] v. 7.5 h [SD 1.7 h], p < 0.001). The average cost was significantly higher for the inpatient cohort than the outpatient cohort ($4137 [SD $2285] v. $1834 [SD $421], p < 0.001). There were more unimalleolar ankle fractures in the outpatient group than in the inpatient group (42 [59.2%] v. 41 [32.8%], p < 0.001). Outpatients waited longer for surgery than inpatients (9.6 d [SD 5.6 d] v. 2.0 d [SD 3.3 d], p < 0.001). Fourteen patients (11.2%) in the inpatient group presented to the emergency department or were readmitted to hospital within 30 days of discharge, compared to 5 (7.0%) in the outpatient group (p = 0.3).Conclusion:In the treatment of isolated closed ankle fractures, outpatient surgery was associated with a significant reduction in length of hospital stay and overall case cost compared to inpatient surgery, with no significant difference in readmission or reoperation rates. In medically appropriate patients, isolated ankle ORIF can be performed safely in an ambulatory setting and is associated with significant cost savings.

Short-term results of gait analysis with the Heidelberg foot measurement method and functional outcome after operative treatment of ankle fractures

BackgroundAnkle fractures are common fractures in trauma surgery. Several studies have compared gait patterns between affected patients and control groups. However, no one used the Heidelberg Foot Measurement Method in combination with statistical parametric mapping of the entire gait cycle in this patient cohort. We sought to identify possible mobility deficits in the tibio-talar joint and medial arch in patients after ankle fractures as a sign of stiffness and pain that could result in a pathological gait pattern. We focused on the tibio-talar flexion as it is the main movement in the tibio-talar joint. Moreover, we examined the healing progress over time.MethodsFourteen patients with isolated ankle fractures were included prospectively. A gait analysis using the Heidelberg Foot Measurement Method was performed 9 and 26 weeks after surgery to analyse the tibio-talar dorsal flexion, the foot tibia dorsal flexion, the subtalar inversion and the medial arch as well as the cadence, the walking speed and the ground reaction force. The American Orthopedic Foot & Ankle Society ankle hindfoot score was used to obtain clinical data. Results were compared to those from 20 healthy participants. Furthermore, correlations between the American Orthopedic Foot & Ankle Society hindfoot score and the results of the gait analysis were evaluated.ResultsStatistical parametric mapping showed significant differences for the Foot Tibia Dorsal Flexion for patients after 9 weeks (53–75%: p = 0.001) and patients after 26 weeks (58–70%: p = 0.011) compared to healthy participants, respectively. Furthermore, significant differences regarding the tibio-talar dorsal flexion for patients 9 weeks after surgery (15–40%: p < 0.001; 56,5–70%: p = 0.007; 82–88%: p = 0.033; 97–98,5%: p = 0.048) as well as patients after 26 weeks (62,5–65%: p = 0.049) compared to healthy participants, respectively. There were no significant differences looking at the medial arch and the subtalar inversion. Moreover, significant differences regarding the ground reaction force were found for patients after 9 weeks (0–17%: p < 0.001; 21–37%: p < 0.001; 41–54%: p < 0.001; 60–64%: p = 0.013) as well as patients after 26 weeks (0–1,5%: p = 0.046; 5–15%: p < 0.001; 27–33%: p = 0.001; 45–49%: p = 0.005; 57–59%: p = 0.049) compared to healthy participants, respectively. In total, the range of motion in the tibio-talar joint and the medial arch was reduced in affected patients compared to healthy participants. Patients showed significant increase of the range of motion between 9 and 26 weeks.ConclusionsThis study shows, that patients affected by ankle fractures show limited mobility in the tibio-talar joint and the medial arch when compared to healthy participants. Even though the limitation of motion remains at least over a period of 26 weeks, a significant increase can be recognized over time. Furthermore, if we look at the absolute values, the patients’ values tend to get closer to those of the control group.Trial registrationThis study is registered at the German Clinical Trials Register (DRKS00023379).

State-Wide COVID-19 Lockdowns Did Not Adversely Affect the Management of Acute Ankle Fractures

Category:Ankle; Trauma; OtherIntroduction/Purpose:The novel coronavirus (COVID-19) pandemic has presented a unique challenge to orthopaedic trauma and operative fracture management throughout the United States. Various public health and safety measures imposed during the lockdown lead to cancelation or rescheduling of non-emergent or non-urgent surgery cases. In order to provide appropriate standard of care, certain operative cases were deemed urgent and managed on an inpatient basis. This change in practice had an impact on the management of acute ankle fractures which has previously reported excellent results and cost-savings with outpatient operative management. The goal of this study is to determine the impact of the COVID-19 lockdown and barriers to care in treating isolated operative ankle fractures in the inpatient setting.Methods:The current IRB approved study is a retrospective review of adult patients presenting to University of Cincinnati (UC) with isolated, operative ankle fractures. The study period consisted of patients who presented during the months of January 1st - July 1st 2020 to coincide with pre-, intra and post- COVID lockdown in Southwestern Ohio. Of note, the official mandated lockdown within the state of Ohio was March 23rd - May 1st with phased business re-openings after May 1st. Similarly, hospital operations including operative capacity was restricted until a return to full capacity on June 29, 2020. A total of 464 patient records were reviewed (159, 176, 129 ankle fractures for the respective years 2018-2020). A review of the data from years 2018, 2019 were analyzed for statistical comparison. Polytraumatized patients, open fractures and those with bilateral injuries were excluded.Results:The final cohort included 190 ankles (52, 71, 67, for 2018, 2019, 2020 respectively). This comprised of 71 males (38%), 119 females (62%). The average age of patients were 48+-19, 51+-18, 48+-20, respectively. There were no significant differences in BMI, smoking and diabetic status. There was a total of eight isolated ankle fractures during the immediate lockdown period of 2020, all managed with inpatient surgery. This was compared to the previous year 2019 (7/16 treated with inpatient management), versus 2018 (4/5 inpatient). Overall, among allcomers, 2020 had the lowest amount of acute fractures treated as outpatient, elective cases (34%) versus 45% -2019, 58%- 2018; however, this was not statistically significant. The length of stay for inpatients, time until surgical management, time to physical therapy clearance, postoperative follow up with index surgeon or midlevel providers were not significantly different among the 2020 cohort during and immediately after the state-wide lockdown.Conclusion:Little has been published about the effect of the coronavirus lockdown on acute fracture management. In this study of acute ankle fractures, strategic practice changes to predominantly inpatient management did not adversely affect patient care. However, there are disadvantages to inpatient versus outpatient management such as: (1) resource allocation (such as hospital beds during a pandemic) and (2) associated costs to both patients and hospital. Future efforts will be made to elucidate the cost analysis within our hospital system (not available at the time of this submission).

Venous thromboembolism in patients with surgically treated ankle fractures.

In patients with rotational ankle fracture, we compare the rate of venous thromboembolism development between patients who received chemoprophylaxis vs those patients that received none. Retrospective cohort study. Level I trauma center. Between 2014 and 2018, we identified 483 patients with rotational ankle fracture that had no VTE risk factors, were under 70years of age, and had an isolated injury. Chemoprophylaxis vs no chemoprophylaxis after open reduction internal fixation of a rotational ankle fracture. Development of VTE was the primary outcome. Secondary outcomes included wound problems, infection, hematoma, or non-union. There were 313 patients that received no prophylaxis and 170 patients that received chemoprophylaxis after operative fixation of an isolated ankle fracture. Demographics including age, gender, body mass index, and ASA class were similar between groups. The rate of DVT/PE was 3.5% in those without DVT prophylaxis, and 4.1% in those on DVT prophylaxis with no significant differences found (p = 0.8). There was no significant difference in wound complication (no VTE prophylaxis-3.7% vs VTE prophylaxis-2.5%, p = 0.7) or infection rates (no VTE prophylaxis-3.8% vs VTE prophylaxis 4.1%, p = 1.0) between groups. No difference was detected in the rate of symptomatic DVT or PE in patients based on chemoprophylaxis. Our results support the conclusion that the use of chemoprophylaxis may remain surgeon preference and based on patient risk factors for VTE development. Level III-retrospective cohort study.

Short-term outcome of isolated lateral malleolar fracture treatment is independent of hospital trauma volume or teaching status: a nationwide retrospective cohort study

IntroductionIn light of current discussions about centralisation and teaching in medicine, we wanted to investigate the differences in in-hospital outcomes after surgical treatment of isolated ankle fractures, taking into account high-volume centres (HVCs) and low-volume centres (LVCs) and teaching procedures.MethodsA retrospective analysis of malleolar fractures recorded in a National Quality Assurance Database (AQC) from the period 01-01-1998 to 31-12-2018 was carried out. Inclusion criteria were isolated, and operatively treated lateral malleolar fractures (ICD-10 Code S82.6 and corresponding procedure codes). Variables were sought in bivariate and multivariate analyses. A total of 6760 cases were included. By dividing the total cases arbitrarily in half, 12 HVCs (n = 3327, 49%) and 56 LVCs (n = 3433, 51%) were identified.ResultsPatients in HVCs were younger (48 vs. 50 years old), had more comorbidities (26% vs. 19%) and had more open fractures (0.48% vs. 0.15%). Open reduction and internal fixation was the most common operative treatment at HVCs and LVCs (95% vs. 98%). A more frequent use of external fixation (2.5% vs. 0.55%) was reported at HVCs. There was no difference in mortality between treatment at HVCs and LVCs. A longer hospitalisation of 7.2 ± 5 days at HVCs vs. 6.3 ± 4.8 days at LVCs was observed. In addition, a higher rate of complications of 3.2% was found at HVCs compared to 1.9% at LVCs. The frequency of teaching operations was significantly higher at HVCs (30% vs. 26%). Teaching status had no influence on mortality or complications but was associated with a prolonged length of stay and operating time.ConclusionWe found significant differences between HVCs and LVCs in terms of in-hospital outcomes for ankle fractures. These differences could be explained due to a more severely ill patient population and more complex (also open) fracture patterns with resulting use of external fixation and longer duration of surgery. However, structural and organisational differences, such as an extended preoperative stays at HVCs and a higher teaching rate, were also apparent. No difference in mortality could be detected.

Lack of Surgeon Standardization on Implant Selection in Ankle Fracture Fixation May Increase Costs and Decrease Contribution Margin.

Surgical standardization has been shown to decrease costs without impacting quality; however, there is limited literature on this subject regarding ankle fracture fixation. Methods. Between October 5, 2015 and September 27, 2017, a total of 168 patients with isolated ankle fractures who underwent open reduction, internal fixation (ORIF) were analyzed. Financial data were analyzed across ankle fracture classification type, implant characteristics, and surgeons. Bivariate analyses were conducted. One-way analysis of variance was used to compare hardware costs across all 5 surgeons. Linear regression analysis was used to determine if hardware cost differed by surgeon when accounting for fracture type. The mean contribution margin was $4853 (SD $6446). There was a significant difference in implant costs by surgeon (range, lowest-cost surgeon: $471 [SD $283] to $1609 [SD $819]; P < .001). There was no difference in the use of a suture button or locking plate by fracture type (P = .13); however, the cost of the implant was significantly higher if a suture button or locking plate was used ($1014 [SD $666] vs $338 [SD $176]; P < .001). There was an association between surgeon 3 (β = 200.32 [95% CI 6.18-394.47]; P = .043) and surgeon 4 (β = 1131.07 [95% CI 906.84-1355.30]; P < .001) and higher hardware costs. Even for the same ankle fracture type, a wide variation in implant costs exists. The lack of standardization among surgeons accounted for a nearly 3.5-fold difference, on average, between the lowest- and highest-cost surgeons, negatively affecting contribution margin. Level IV.

Operative Treatment of Ankle Fractures: Predictive Factors Affecting Outcome.

PurposeSurgical management of ankle fractures has been extensively studied in literature but studies investigating validated clinical results are lacking and controversial. The purpose of this study was to evaluate functional and health-related quality of life (HRQL) outcomes after surgically treated ankle fractures and to detect some of their predictors.MethodsTwo hundred sixty-six skeletally mature patients who underwent surgery for an isolated ankle fracture from 2006 to 2017 were retrospectively identified from our hospital records and included in the study. All patients were evaluated at one, three, six and 12 months post-injury with clinical and radiographic examination. Outcome measures recorded at final two years minimum follow-up included patient-reported pain, patient satisfaction, functional (American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score) and quality of life (Short Form (SF) 36 score) status.ResultsPatient satisfaction score was 8.4 out of 10, Visual Analogue Scale mean score was 2.3, complication rate was 36.5% and mean AOFAS ankle-hindfoot score was 87.3. Mean SF36-physical summary score was 77.9 and SF36-mental summary score was 81.1. The injury demonstrated a significant effect on physical function, role-physical, bodily pain and social functioning SF-36 subdomains. Functional outcome was significantly related to occupation, syndesmotic lesion, number of fractured malleoli and delay to surgery. Main predictors of quality of life were age, occupation, cause of injury, syndesmotic lesion, number of fractured malleoli and waiting time to surgery.ConclusionsAnkle fractures have a considerable impact on functional and quality of life status of patients. Occupation, presence of syndesmotic injury, Pott's classification and surgery delay must be considered as predictors of final outcome.

Can Reducing Implant Costs Increase Revenue for Surgically Treated Ankle Fractures: Time Driven Activity Based Costing for 1 year Episode of Care

Category:Ankle; Trauma; OtherIntroduction/Purpose:Implant selection may provide an opportunity to reduce costs and improve value in healthcare, but most orthopaedic surgeons are unfamiliar with the cost of surgical implants. Large variation has been reported in the overall cost of the surgical treatment of ankle fractures, largely due to variations in implant selection. The purpose of this study is to evaluate the relationship between implant selection and the Reimbursed Cost of Care (RCC) over the total cost-of-care over the entire care episode.Methods:A single payer database was queried for isolated ankle fractures from 2010-2017. Patient characteristics, implant cost, RCC and total cost of care for one-year episodes were collected. Total cost of care was determined via Time Driven Activity Based Costing (TDABC). Analysis consisted of multivariable linear regression and goodness-of-fit tests. The relative proportion of the implant cost to the RCC was defined as Ic/RCC.Results:Construct costs (Inpatient: $1563.30 vs Outpatient: $1143.00; p<0.01)TDABC cost of care (Inpatient: $3670.90 vs Outpatient: $2941.90; p<0.01)RCC (Inpatient: $17350.00 vs Outpatient: $10895.80; p<0.01) were all significantly lower for the outpatient setting. Construct costs constituted an estimated 38.8% of the total TDABC cost and 14.5% of the RCC. The difference between RCC and implant costs presented a significant negative trend with the total construct costs for outpatient procedures (B=-$1.54; p=0.03), but non-significant for inpatient (B=-$0.37;p=0.79).Conclusion:This study investigated the effect of implant cost on the total cost of care in surgically treated ankle fractures. We found an overall higher reimbursed cost of care (RCC) in the outpatient setting and a higher TDABC cost of care in the inpatient setting, reinforcing the trend towards outpatient surgical management. Implant selection proved not only a significant portion of the overall cost of care, but a driver of overall revenue.

Effect of Opioid Limiting Legislation on Postoperative Opioid Utilization in Patients Treated for Ankle Fractures.

Background:The state of Ohio implemented legislation in August of 2017 limiting the quantity of opioids a provider could prescribe. The purpose of this study was to identify if implementation of legislation affected opioid and nonopioid utilization in patients operatively treated for ankle fractures in the initial 90-day postoperative period after controlling for injury severity and preoperative narcotic usage.Methods:A retrospective review of 144 patients treated for isolated ankle fractures in a pre-law group (January 2017–July 2017; n = 73) and post-law group (January 2018–July 2018; n = 71) was completed using electronic medical records and a legal prescriber database. Total number of opioid prescriptions, pills, milligrams of morphine equivalents (MMEs), and nonopioid prescriptions were recorded. Multiple regression analysis was run to identify predictors of opioid prescribing after controlling for law group, demographic, preoperative narcotic use, and injury severity characteristics.Results:Mean MME prescribed per patient significantly decreased from 817.2 MME pre-law to 380.9 post-law (P < .01). Mean number of opioid pills prescribed per patient decreased from 99.1 in the pre-law group and 55.3 in the post law group (P < .001), respectively. Multiple linear regression analysis to predict the mean number of opioid pills prescribed was statistically significant (R 2 = 0.33; P < .001), with law group adding significantly to the prediction (P < .001). The multiple linear regression analysis to predict MME per patient was found to be statistically significant (R 2 = 0.31; P < .001), with the law group contributing significantly (P < .001).Conclusion:The Ohio prescriber law successfully contributed to the decreased number of opioid pills and MME prescribed in the initial 90-day postoperative period after controlling for injury severity and preoperative narcotic usage. Policies on opioid prescriptions may serve as an important public health tool in the fight against the opioid epidemic.Level of Evidence:Level III, retrospective comparative series.

Independent Risk Factors for Impaired Early Outcome after Isolated Ankle Fracture - A Multivariate Analysis and Prognostic Models.

Ankle fractures are common operative indications in orthopedic surgery. Their incidence is increasing. To identify independent risk factors and to develop prognostic models for the prediction of prolonged length of hospital stay (LOS) and the onset of postoperative complications. This is a single-center, retrospective, observational study analyzing data of 154 consecutive, isolated, surgically treated ankle fractures. Multivariate binary logistic regression analysis was applied to identify significant independent risk factors. The validity and clinical applicability of the developed prognostic models was assessed with ROC-curve analysis (ROC: Receiver Operating Characteristic). Internal validation of prognostic models was performed with randomized backwards bootstrapping. The median LOS was 7 days. 50 patients (33%) had a longer LOS. 13% of operated patients had a postoperative complication (n = 20). Independent preoperative risk factors for prolonged length of stay were leukocytosis (p = 0.020; OR: 1.211), an increased CRP-level (p = 0.005; OR: 1.901), as well as a bi- (p = 0.002; OR: 15.197) or trimalleolar (p = 0.001; OR: 10.678) fracture type. Immediate operative therapy was an independent beneficial factor (p < 0.001; OR: 0.070). The onset of complications was associated significantly with diabetes mellitus (p = 0.004; OR: 9.903) and an elevated ASA score (p = 0,004; OR: 3.574). The developed prognostic models for the prediction of prolonged LOS (AUROC: 0.736) and postoperative complications (AUROC: 0.724) had a good clinical validity and were internally validated. The current data pronounce the importance of preoperative laboratory works. Furthermore, co-morbidities play a major role in the prognosis of outcome. The developed prognostic models are able to reliably predict the outcome and enable the preoperative identification of high-risk patients.

Overlapping Surgery for Ankle Fractures: Is It Safe?

To determine whether the practice of overlapping surgery influenced patient safety after open reduction internal fixation (ORIF) for ankle fractures. Retrospective case-control. Level 1 Academic Midwest trauma center. All patients who underwent ankle fracture ORIF by a single surgeon were eligible for our study, with 478 total patients. Cases that were overlapping were compared against cases that were not overlapping. Cases were defined as overlapping if there was greater than 30 minutes of overlap between procedural times. Patient complications were recorded up to a year from the index surgery. Unexpected return to surgery. There were 478 ankle fracture ORIF patients, 238 with at least 3 months follow-up; 124 (52%) in the overlapping group and 114 (48%) in the nonoverlapping group. There was no difference in the rate of unexpected return to surgery (P = 0.76), infection (P = 0.52), readmission (P = 0.96), painful implant (P = 0.62), malunion (P = 0.27), nonunion (P = 0.52), or arthritis (P = 0.39) between the overlapping and nonoverlapping groups. There were 467 isolated ankle fractures used for time analysis. Average procedure time was 26 minutes longer for the overlapping group than the nonoverlapping group (P < 0.01). Overlapping surgery causes increased operative time for ankle ORIF, but there was no apparent increased risk to the patients for short-term complications. The need for graduated resident responsibility required by ACGME guidelines need to be weighed against the decreased efficiency of operating room time. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Minimum Clinically Important Difference in Short Musculoskeletal Function Assessment: What Change Matters in Ankle Fractures.

Accurate interpretation of the clinical significance of patient-reported outcome (PRO) research requires determination of the threshold where a difference in PRO score represents a clinical benefit to patients, termed the minimum clinically important difference (MCID). The Short Musculoskeletal Function Assessment (SMFA) is one of the most commonly utilized PRO tools in orthopaedics. However, to date, no MCID has been determined. The purpose of this study was to define the MCID for the SMFA. A prospectively collected ankle fracture outcomes registry was reviewed between 2014 and 2016. Inclusion criteria were isolated ankle fracture, treatment with open reduction and internal fixation, and 6-week follow-up with completed SMFA. Two commonly utilized methods to determine the MCID, the anchor and distribution methods, were performed in this study. Overall, 105 patients met inclusion/exclusion criteria. Utilizing both the overall health anchor and the mental and emotional health anchor, the MCID was 7.3 (n = 17 and n = 19, respectively). The distribution method MCID was 7.0 (n = 105). Our study found the MCID values for the SMFA to converge around a value of 7 for the 3 analyses. This indicates that a threshold of 7 should be applied to studies utilizing the SMFA to determine the clinical significance of the results.