Surgical Fixation Of Ankle Fractures Research Articles

Immediate Unprotected Weightbearing vs 2 Weeks Nonweightbearing After Open Reduction Internal Fixation of Ankle Fractures.

Postoperative care protocols for ankle fracture surgery remain controversial with variability among care providers. This prospective controlled trial compared 12-week postoperative outcomes for immediate unprotected weightbearing (IMWB) vs nonweightbearing (NWB) for 2 weeks in a splint followed by weightbearing as tolerated (WBAT) in a boot after surgical fixation of selected low-energy ankle fractures without superior articular involvement. Eighty-seven patients undergoing surgical fixation of ankle fractures at a single level 1 trauma center were recruited according to specific criteria and enrolled by presentation date. The first 43 eligible patients were allocated to the control group, with NWB in a splint for 2 weeks followed by WBAT in a walker boot. The next 44 patients recruited were allocated to the IMWB group. The primary outcome was the Olerud-Molander score (OMAS). Secondary outcome measures included the Euroquol-5D (EQ5D) score and Work Productivity and Activity Impairment: Specific Health Problem (WPAI:SHP) scores, ankle range of motion (ROM), wound complications, time to return to work, radiograph measurements, and fracture reduction loss. In this perioperative-focused study, we collected data on patients until 12 weeks postoperation. The IMWB group had 5 superficial wound complications vs 1 in the control group. At 12 weeks, we found no difference in OMAS, EQ5D, WPAI:SHP scores, ROM, time to return to work, or radiographic measurements. In this short-term and relatively small prospective trial, we found more wound complications among patients treated with immediate unprotected weightbearing compared with patients treated with 2 weeks of NWB followed by protected weightbearing. Given the low incidence and small sample size, we do not know if these observed findings are generalizable. However, we also found no difference in functional outcomes at 12 weeks postoperation between these 2 groups. In light of that, we do not recommend IMWB after open reduction internal fixation of low-energy ankle fractures with plate and/or screw fixation. Level II, prospective controlled trial.

9 Surgical fixation of ankle fractures with bioresorbable magnesium implants (ZX00): 2.5 year long term results of a first-in-man study with an HR-pQCT assessment of the implantation site

9 Surgical fixation of ankle fractures with bioresorbable magnesium implants (ZX00): 2.5 year long term results of a first-in-man study with an HR-pQCT assessment of the implantation site

Surgical fixation of ankle fractures with bioresorbable magnesium implants: A first-in-human HR-pQCT assessment of the implantation site

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Comparing the 30-Day Complications Between Smokers and Nonsmokers Undergoing Surgical Fixation of Ankle Fractures.

Background:There have been conflicting reports regarding the effect of smoking on complications after surgical treatment of ankle fractures. This study aimed at identifying the complications for which smokers and subgroups of smokers are at a higher risk compared to nonsmokers when undergoing surgery for fixation of rotational ankle fractures.Methods:The American College of Surgeons National Surgical Quality Improvement Program data set from 2008 to 2019 was used to compare the 30-day wound, cardiac, renal, and infectious complications, related readmissions, and return to the operating room between the 2 cohorts.Results:Of 33 741 patients included, 25 642 (76.0%) were nonsmokers and 8099 (24.0%) were smokers. Multivariate analysis showed that smokers were at a higher risk for deep wound infection (OR 2.34, 95% CI 1.48-3.69, P < .001), wound dehiscence (OR 2.43, 95% CI 1.56-3.77, P < .001), related return to the operating room (OR 1.69, 95% CI 1.36-2.11, P < .001), and related readmissions (OR 1.67, 95% CI 1.32-2.09, P < .001). Smokers at an increased risk for deep infection included patients between 50 and 59 years (OR 5.75, 95% CI 1.78-18.5, P = .003), who were Black (OR 4.24, 95% CI 1.04-17.23, P = .044), who had body mass index (BMI) 35 to 39.9 (OR 3.73, 95% CI 1.46-9.50, P = .006), or operative times between 60 and 90 minutes (OR 3.64, 95% CI 1.79-7.39, P < .001). Smoker subgroups at a higher risk for wound dehiscence included patients between 50 and 59 years (OR 9.86, 95% CI 3.29-29.53, P < .001), with operative times between 90 and 120 minutes (OR 4.88, 95% CI 1.89-12.58, P < .001), with BMI 30 to 34.9 (OR 3.06, 95% CI 1.45-6.45, P = .003) and who underwent spinal/epidural anesthesia (OR 9.31, 95% CI 2.31-37.58, P = .002).Conclusion:Smokers were at an increased risk for deep wound infection, wound dehiscence, related reoperations, and related readmissions after ankle fracture surgery. Certain subgroups were at an even higher risk for these complications.Level of Evidence:Level III, retrospective cohort study.

Bioresorbable Magnesium Implants for first in Human surgical fixation of Ankle Fractures: Clinical follow-up and HR-pQCT Assessment of the Implantation Site

Bioresorbable Magnesium Implants for first in Human surgical fixation of Ankle Fractures: Clinical follow-up and HR-pQCT Assessment of the Implantation Site

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

The purpose of this study was to investigate whether decision-making regarding implant selection affects the reimbursement margins for the surgical fixation of ankle fractures. All ankle fractures treated between 2010 and 2017 within a single-insurer database were identified via Current Procedural Terminology codes by review of electronic medical record. Implant cost was determined via the implant record cross-referenced with the single contract institutional charge master database. The Time-Driven Activity-Based Costing (TDABC) technique was used to determine the costs of care during all activities throughout the 1-year episode of care. Statistical analysis consisted of multiple linear regression and goodness-of-fit analyses. In all, 249 patients met inclusion criteria. Implant costs ranged from $173 to $3944, averaging $1342 ± $751. The TDABC-estimated cost of care ranged from $1416 to $9185, averaging $3869 ± $1384. Finally, the total reimbursed cost of care ranged between $1335 and $65 645, averaging $13 954 ± $9445. The implant costs occupied an estimated 34.7% of the TDABC-estimated cost of care per surgical encounter. Implant cost, as a percentage of the overall TDABC, was estimated as 36.2% in the inpatient setting and 33% in the outpatient setting, which was the second highest percentage behind surgical costs in both settings. We found a significant increase in net revenue of $1.93 for each dollar saved on implants in the outpatient setting, whereas the increase in net revenue per dollar saved of $1.03 approached significance in the inpatient setting. There is a direct relationship between intraoperative decision-making, as evidenced by implant choices, and the revenue generated by surgical fixation of ankle fractures. Intraoperative decision-making that is cognitive of implant cost can facilitate adoption of institutional cost containment measures and prompt increased healthcare value. Level III: Retrospective cohort study.

Treatment of perioperative swelling by rest, ice, compression, and elevation (RICE) without and with additional application of negative pressure (RICE+) in patients with a unilateral ankle fracture: study protocol for a monocentric, evaluator-blinded randomized controlled pilot trial

BackgroundEdema is commonly seen after surgical fixation of ankle fractures. Rest, ice, compression, and elevation (RICE) is an established combination to prevent swelling but hardly able to stimulate lymphatic resorption. Recently, an epicutaneously applied negative pressure suction apparatus (LymphaTouch®) has been introduced to stimulate lymphatic flow. While postoperative recovery, soft tissue, and osseous healing as well as functional outcome are probably linked to the amount of postoperative swelling, estimates on this relative to prevention (RICE) or prevention + stimulated resorption (RICE+) of fluid are scarce.Methods and analysisThis is a single-center, evaluator-blinded randomized pilot trial to investigate postoperative swelling in adults requiring surgical fixation of a closed unilateral ankle fracture. A total of 50 patients will be recruited and randomly assigned to RICE or RICE+ prior to surgery. All patients will undergo evaluator-blinded measurements of the ankle volume the day before surgery and subsequently from the evening of the 2nd postoperative day every 24 h until discharge. RICE will be initiated right after surgery and continued until discharge from the hospital in all patients. Additional application of negative pressure therapy (RICE+) will be initiated on the morning of the 2nd postoperative day and repeated every 24 h until the time of discharge from the hospital. Outcome measures are (i) the relative amount and the time course of the postoperative swelling, (ii) the demand for analgesic therapy (type and amount) together with the perception of pain, (iii) the rate of complications, and (iv) mobility of the ankle joint and the recovery of walking abilities during a 12-weeks follow-up period. Serum and urine samples taken prior to sugery and during postoperative recovery will allow to evaluate the ratio of naturally occurring stable calcium isotopes (δ44/42Ca) as a marker of skeletal calcium accrual.Ethics and disseminationThe protocol was approved by the institutional Ethics Committee (Rostock University Medical Center, Rostock, Germany) in accordance with the Declaration of Helsinki (approval number: A 2020-0092). The results of this study will be actively disseminated through scientific publications and conference presentations.Trial registrationDRKS, DRKS00023739. Registered on 14 December 2020

Utilization of a Standardized Care Pathway to Decrease Costs of Ankle Fracture Management.

Ankle fractures are the most common fracture of the foot and ankle treated at trauma hospitals in the United States, costing millions of dollars yearly. The purpose of this study was to determine whether a standardized care pathway led to a difference in the direct and indirect costs of surgical fixation of ankle fractures at one Level I Trauma Center and tertiary care medical center. We analyzed cost, volume, length of stay, and collections for surgical treatment of ankle fractures in inpatient and outpatient settings by the orthopaedics and podiatry departments during fiscal years 2016 to 2018. Based on these data, we compared projected costs and collections across a 5-year period with the procedure being done by a single department (orthopaedics only and podiatry only). Total costs per case fell by 18% in the orthopaedics department and 8% in the podiatry department over the 3-year period. The podiatry department spent an average of $1,296 (46%) more per case than the orthopaedics department, driven by increased average supply costs. Both departments had significantly decreased direct costs (P = 0.0039 orthopaedics and P = 0.033 podiatry) in the outpatient setting. The orthopaedics department also had significantly lower average supply costs than the podiatry department (P = 0.045) and significantly decreased total costs in the outpatient setting (P = 0.0084). The orthopaedics department performed a higher volume of cases at a lower cost per case than the podiatry department. These savings were driven by a standardized ankle fracture treatment pathway that we propose decreased direct and supply costs. Our results suggest that surgical treatment of ankle fracture cases using a standardized care pathway is economically advantageous because of limiting variations in care and creating manageable workflows.

Complications After Surgical Treatment of Geriatric Ankle Fractures

The incidence of geriatric ankle fractures is rising and the potential for complications is high in this population. Little is known about factors associated with increased postoperative complications after surgical fixation of ankle fractures in older-age patients. The purpose of this retrospective cohort study was to assess the epidemiology and risk factors for complications after surgically treated ankle fractures in geriatric patients. All patients who were 65 years or older and had a surgically treated ankle fracture were included. Pilon fractures, patients who were initially treated conservatively or who had less than 1 month of follow-up were excluded. Postoperative complications, demographic-, fracture- and surgical data of 282 patients were recorded from two level 2 trauma centers between 2012 and 2017. A total of 87 (30.9%) patients developed a complication, of which wound related complications were most frequently reported. Superficial and deep wound infections were observed in 27 (9.6%) and 18 (6.4%) patients, respectively. Multivariate regression analysis demonstrated increased age to be an independent predictive variable for the occurrence of postoperative complications (odds ratio 1.04; 95% confidence interval 1.00-1.09), while cast immobilization for more than 2 weeks was a protective factor for the development of wound related complications (odds ratio 0.34; 95% confidence interval 0.17-0.66). In conclusion, the incidence of postoperative complications among geriatric patients after surgical treatment of ankle fractures is high and patients should be informed accordingly.

Arthroscopically Assisted Internal Fixation of Foot and Ankle Fractures: A Systematic Review.

Background:Patients undergoing fixation for foot and ankle fractures may experience poor outcomes despite achieving apparent anatomic reduction. Adjunct arthroscopy to identify missed concomitant injuries and subtle displacements has been proposed as a vehicle to enhance functional results for these patients. The purpose of this review is to provide an overview of the literature regarding arthroscopically assisted open reduction and internal fixation (AAORIF) methods for commonly encountered foot and ankle injuries including pilon, ankle, and calcaneus fractures published to date.Methods:A systematic review of the literature was performed using the PubMed database to access all studies reporting on arthroscopically assisted internal fixation methods for pilon, ankle, and calcaneus fractures. Relevant publications were analyzed for details on their respective study designs, the operative technique used, clinical outcomes, outcome instruments used, and reported complications.Results:A total of 32 studies were included in this review. Two studies on pilon fractures, a randomized controlled trial (RCT) and case series with a total of 243 patients, met inclusion criteria. Postoperative articular reductions, bone union, and Mazur scores were found to be significantly better for those using adjunct arthroscopy when compared to those with no arthroscopy use. Patient-reported outcomes were overall reported as excellent for most patients, with no difference in patient-reported outcomes reported in the RCT. For ankle fractures, a total of 17 studies comprising of 2 systematic reviews, 1 meta-analysis, 2 RCTs, 5 retrospective comparative studies, 6 case series, and 1 case-control study met inclusion criteria for this review. Results were mixed, though the overall consensus was that arthroscopy use may help to better visualize concomitant intra-articular injuries and is generally considered safe with at least comparable outcomes to conventional methods. For the calcaneus, 13 studies met the criteria. Two studies were review papers, 8 were case series, and 3 were retrospective comparative studies. A total of 308 patients with 316 fractures formed the basis of analysis. In general, the studies found comparable functional outcomes between with or without arthroscopy use, but found that anatomical reductions were significantly improved with the use of arthroscopy.Conclusions:Arthroscopy shows promise as a valuable adjunct tool for internal fixation of foot and ankle fractures, though definitive conclusions as to its clinical significance have yet to be drawn because of limited evidence. Potential advantages related to the direct visualization of the fracture site and minimally invasive nature of arthroscopy were suggested throughout studies examined in this review. The presence of intra-articular pathology may lead to unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with an otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions with arthroscopy, therefore, has the potential to improve patient outcomes. To date, however, available literature has not shown that significant improvements in anatomical reductions and treatment of these intra-articular injuries provide any improvement in outcomes over standard fixation methods. Few prospective randomized controlled studies have been performed comparing these 2 operative techniques, rendering any suggestion that AAORIF improves clinical outcomes over traditional open fixation difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct prior to advocating for its routine use in patients.

Hypoalbuminemia is an Independent Predictor of 30-Day Postoperative Complications Following Surgical Fixation of Ankle Fractures

Category:Basic Sciences/Biologics; Trauma; OtherIntroduction/Purpose:Malnutrition is known to be negatively associated with outcomes after multiple orthopedic procedures. We hypothesized that admission albumin levels, as a maker for malnutrition, would correlate with postoperative outcomes. The purpose of this study is to investigate this relationship following surgery for ankle fracture.Methods:This is a retrospective cohort study of the ACS-NSQIP database. Patients undergoing operative fixation of an ankle fracture were identified. 6,138 patients with albumin available for analysis were identified. Baseline patient information, preoperative serum albumin levels, 30-day postoperative complications, readmission, reoperation, and length of stay data were then collected. Poisson regression with robust error variance was performed to assess the effect of preoperative serum albumin level on postoperative outcomes.Results:6,138 patients with albumin available for analysis were identified in the database. The mean albumin level was 3.86 g/dl and 20.3% of patients with available albumin levels were hypoalbuminemic. Multivariate analysis revealed that albumin level <3.5 g/dl is an independent risk factor for complication (RR 1.42, 95% CI 1.13-1.78, p=0.002) and readmission (RR 1.54, 95% CI 1.13- 2.08, p =0.006). Additionally, when analyzed as a continuous variable, albumin level was negatively correlated with risk of mortality (RR 0.37, 95% CI 0.19-0.72, p=0.003). Patients with hypoalbuminemia also had significantly longer length of stays (4.5 v. 2.1 days, p<0.001).Conclusion:While complication rates after fixation of ankle fractures remain low, hypoalbuminemia is a predictor of postoperative course. Malnutrition, therefore, may help inform the decision between surgical and conservative management of patients with ankle fractures potentially amenable to non-operative management. Additionally, hypoalbuminemia should trigger heightened awareness and prophylactic therapy where appropriate.

Safety and Outcomes of Early Fixation in Patients who Suffered an Ankle Fracture

Category:AnkleIntroduction/Purpose:Ankle fractures are a common injury in the United States leading to increased ER visits and healthcare costs. Additionally, these injuries normally lead to prolonged immobilization that can make it difficult for patients to return to work and normal activities. By optimizing fracture healing and decreasing the amount of time to union patients can avoid the frustration of prolonged immobilization and return to daily activities more quickly. It is believed that early surgical fixation of ankle fractures can lead to wound complications while late fixation can lead to issues with reduction during surgical intervention. This study was undertaken to determine if there is a difference in wound complication and time to union between early and late fracture fixation.Methods:From July of 2008 to June of 2018, a retrospective chart review of 321 patients who underwent ankle fracture corrected with ORIF was performed at a single institution. Patients with pilon fractures, poly trauma, open fractures, or less than 3 months of follow up time were excluded from our study. After exclusion were made there was 232 patients remaining. All patients were then stratified by time to surgery after injury and injury classification. The cohorts were surgery within 2 days with 31 patients, surgery within 7 days with 69 patients, and patients that had surgery after 8 days (132). The patients were also stratified according to the Lauge-Hansen classification. The cohorts were PA, PER, SA, and SER.Results:The average time to union for patients who were operated on within 2 days of injury was 108.48 days, 106.52 days for patients operated on between 3-7 days, and 97.59 days for patients operated on after 7 days. Wound complications were highest in the cohort operated on within 2 days at 9.6%. Patients operated on between 3 and 7 days had the lowest rate of wound complications at 2.8%/. Patients with an SER Lauge-Hansen classification has the fastest time to union at 94.04 days and individuals with an SA had the longest at 139.30 days. Wound frequency for patients with a classification of PA had the highest wound complications at 20%.Conclusion:There has been little research done on how time to surgery affects wound complications and healing time in ankle fracture fixation. Patients that received surgery after 7 days achieved union the fastest. We saw that wound complication rate was greatest in the cohort that had surgery within 2 days of injury. Injury classification did factor into union time and wound complications. Overall, there was not a significant difference in wound complication between early fixation and delayed fixation.

Audit changes practice-a simple education intervention can lead to better outcome in ankle fracture surgery

BackgroundUnstable ankle fractures are common, and majority requires open reduction and internal fixation (ORIF). There is emerging evidence that the rate of malreduction has remained high despite advances in surgical techniques and implants. Malreduced ankle is a prominent cause of post-traumatic ankle arthritis leading to poor patient reported outcome. The aim of this study was to investigate the quality of anatomical reduction and surgical fixation of ankle fractures and the impact of simple education intervention on the quality of reduction of these fractures. MethodologyAn audit cycle was completed in two phases; retrospective review (phase 1) of 114 cases operated prior to an education intervention using infographic posters and then a prospective (phase 2) review of 96 consecutive cases operated after the education intervention. Data including age, fracture morphology, time to surgery, and the quality of reduction were assessed. The quality of anatomical reduction was evaluated using radiological parameters described by Pettrone. Paediatric, Weber A, pathological and open fractures were excluded. Education interventions included regional teaching and dissemination of infographic posters. Mann- Whitney U test and Chi-squared test were used to compare continuous and categorical data between phase 1 and 2 respectively. P value < 0.05 was considered significant. ResultsPhase one cohort showed malreduced fixation in 25% of cases. Inadequate restoration of fibular length was the most common type of malreduction. After implementation of education intervention, malreduction rate reduced to 9.4% in phase 2 (p = 0.015). There were no significant differences between age, gender, and time to surgery between phase one and two. ConclusionThis study demonstrates that simple education intervention can lead to better understanding of fixation and decrease the rate of malreduction of these fractures. We recommend that using Pettrone’s radiological criteria in correction of corresponding anatomy of ankle fracture is a useful tool to avoid malreduction.

Refining Risk-Adjustment of 90-Day Costs Following Surgical Fixation of Ankle Fractures: An Analysis of Medicare Beneficiaries

As the current healthcare model transitions from fee-for-service to value-based payments, identifying cost-drivers of 90-day payments following surgical procedures will be a key factor in risk-adjusting prospective bundled payments and ensuring success of these alternative payment models. The 5% Medicare Standard Analytical Files data set for 2005–2014 was used to identify patients undergoing open reduction and internal fixation (ORIF) for isolated unimalleolar, bimalleolar, and trimalleolar ankle fractures. All acute care and post–acute care payments starting from day 0 of surgery to day 90 postoperatively were used to calculate 90-day costs. Patients with missing data were excluded. Multivariate linear regression modeling was used to derive marginal cost impact of patient-level (age, sex, and comorbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy, and syndesmotic fixation), and state-level factors on 90-day costs after surgery. A total of 6499 patients were included in the study. The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 ± $1060. Individuals aged <65 or ≥70 years had significantly higher costs. Procedure-level factors associated with significant marginal cost increases were inpatient surgery (+$5577), trimalleolar fracture (+$1082), and syndesmotic fixation (+$2822). The top 5 comorbidities with the largest marginal cost increases were chronic kidney disease (+$8897), malnutrition (+$7908), obesity (+$5362), cerebrovascular disease/stroke (+$4159), and anemia (+$3087). Higher costs were seen in Nevada (+$6371), Massachusetts (+$4497), Oklahoma (+$4002), New Jersey (+$3802), and Maryland (+$3043) compared with Michigan. With the use of a national administrative claims database, the study identifies numerous patient-level, procedure-level, and state-level factors that significantly contribute to the cost variation seen in 90-day payments after ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in patients with fractures.

Role of Hypoalbuminemia as an Independent Predictor of 30-Day Postoperative Complications Following Surgical Fixation of Ankle Fractures

Malnutrition is known to be negatively associated with outcomes after multiple orthopedic procedures. We hypothesized that admission albumin levels, as a marker for malnutrition, would correlate with postoperative outcomes. The purpose of this study was to investigate this relationship following surgery for ankle fracture. This is a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients undergoing operative fixation of an ankle fracture were identified. A total of 6138 patients with albumin available for analysis were identified. Baseline patient information, preoperative serum albumin levels, 30-day postoperative complications, readmission, reoperation, and length of stay data were then collected. Poisson regression with robust error variance was performed to assess the effect of preoperative serum albumin level on postoperative outcomes. The mean albumin level was 3.86 g/dL and 20.3% (1246/6138) of patients with available albumin levels were hypoalbuminemic. Multivariate analysis revealed that an albumin level <3.5 g/dL was an independent risk factor for complications (relative risk [RR], 1.42; 95% confidence interval [CI], 1.13-1.78; P = .002) and readmission (RR, 1.54; 95% CI, 1.13-2.08; P = .006). Additionally, when analyzed as a continuous variable, albumin level was negatively correlated with risk of mortality (RR, 0.37; 95% CI, 0.19-0.72; P = .003). Patients with hypoalbuminemia also had significantly longer lengths of stay (4.5 vs 2.1 days; P < .001). While complication rates after fixation of ankle fractures remain low, hypoalbuminemia was a predictor of postoperative course. Malnutrition, therefore, may help inform the decision between surgical and conservative management of patients with ankle fractures potentially amenable to nonoperative management. Additionally, hypoalbuminemia should trigger heightened awareness and prophylactic therapy where appropriate. Level III, comparative study.

Refining Risk-Adjustment of 90-day Costs Following Surgical Fixation of Ankle Fractures: Implications for a Bundled Payment Model

Category:TraumaIntroduction/Purpose:Current literature revolving around understanding cost-determinants of 90-day payments following ankle fractures is limited to single-institution studies. As the current healthcare model transitions from fee-for-service to value- based payments, risk-adjustment of 90-day payments will be a key factor driving success of these bundled payment models. The current study, utilizes a national Medicare database, to understand patient-level, procedure-level and state-level variation in 90-day payments following open reduction internal fixation (ORIF) of isolated ankle fractures.Methods:The 2005-2014 5% Medicare SAF (Standard Analytical Files) database was queries using Current Procedural Terminology codes to identify patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (27766, 27769, 27792), bi-malleolar (27814) and tri-malleolar (27822, 27823) ankle fractures. Patients with polytrauma or those undergoing a concurrent surgical fixation of the upper extremity, hip, femur, knee or tibia were removed from the study to capture a relevant cohort of isolated ankle fracture patients. All payments starting from day 0 of surgery up to day 90 post-operatively were used to calculate 90-day costs. Patients with missing data were excluded. Multi-variate linear regression modeling was used to derive marginal cost-impact of patient-level (age, gender, co-morbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy and syndesmotic fixation) and state-level factors on 90-day costs following surgery.Results:Following application of inclusion/exclusion criteria, a total of 6,499 patients were included in the study. The risk- adjusted 90-day price of a non-geriatric (age<65) female patient undergoing outpatient ORIF for a closed uni-malleolar ankle fracture was $8,915 ± $1,054. Individuals aged 65-69 vs. <65 had significantly lower costs (-$1,967). Procedure-level factors associated with significant marginal cost-increases were inpatient surgery (+$5,577), tri-malleolar fracture (+$1,082) and syndesmotic fixation (+$2,822). The top 5 co-morbidities with largest marginal cost-increases were chronic kidney disease (+$8,897), malnutrition (+$7,908), obesity (+$5,362), cerebrovascular disease/stroke (+$4,159) and anemia (+$3,087). Significant state-level variation in 90-day costs was seen with Nevada (+$6,371), Massachusetts (+$4,497), Oklahoma (+$4,002), New Jersey (+$3,802) and Maryland (+$3,043) having the highest marginal cost-increase and Idaho (-$6,025) having the lowest.Conclusion:Using a national administrative claims database, the study identifies numerous patient-level, procedure-level and state-level factors that significantly contribute to the cost-variation seen in 90-day payments following ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in fracture patients.

Safety and Cost-Efficacy of Surgical Fixation of Isolated Ankle Fractures in a Free-Standing Ambulatory Surgical Center (ASC) vs. Hospital-Owned Outpatient Facility (HOPD)

Category:Ankle, TraumaIntroduction/Purpose:Free-standing Ambulatory Surgical Centers (ASCs) typically provide uncomplicated surgical procedures in a non-hospital setting, and function as ‘focused factories’ that replicate the delivery of quality care while achieving lower costs as compared to hospital-owned outpatient facilities (HOPD). Despite an increasing interest towards outpatient foot and ankle surgery, few studies have compared the safety and cost-savings associated with surgical fixation of isolated ankle fractures in a free-standing ASC vs. a HOPD.Methods:The 2007-2014 Humana Administrative Claims (HAC) database was queried using Current Procedural Terminology codes to identify patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (27766, 27769, 27792), bi-malleolar (27814) and tri-malleolar (27822, 27823) ankle fractures. Patients with polytrauma or those undergoing a concurrent surgical fixation of the upper extremity, hip, femur, knee or tibia were removed from the study to capture a relevant cohort of isolated ankle fracture patients. Location of surgery was identified using Service Location codes 22 (HOPD) and 24 (ASC). Propensity- score matching and multi-variate regression analyses were used to compare differences in 90-day complications, ED-visits and readmissions between the two groups. A 90-day cost comparison was also carried out to assess savings associated with surgery in an ASC vs. HOPD.Results:A total of 4,832 (80.1%) ankle fractures treated in a HOPD and 1,198 (19.9%) in a free-standing ASC were included in the study. Following propensity-score matching to account for differences in baseline demographics and clinical characteristics, each group consisted of 1,138 patients. Following multi-variate analyses, undergoing surgery in a free-standing ASC vs. a HOPD was not associated with a higher rate of 90-day complications (0.73 [95% CI 0.54 -1.00]; p=0.05), ED visits (OR 0.86 [95% CI 0.64- 1.16]; p=0.331) and readmissions (0.79 [95% CI 0.53 -1.18]; p=0.251). Furthermore, undergoing surgery in a free-standing ASC was associated with nearly $2500 cost-savings/case over the 90-day episode of care (ASC = $8,058 vs. HOPD = $10,619; p<0.001).Conclusion:Using national administrative claims of Commercial insurance beneficiaries, the results of the study show that performing surgical fixation of ankle fractures in a free-standing ASC is a safe and cost-effective option in a carefully selected patient population.

The rationale behind surgical approaches to ankle fractures

Ankle fractures and fracture dislocations are one of the commonest injuries seen by orthopaedic surgeons. Decisions around the surgical fixation of ankle fractures require an understanding of the bony and ligamentous anatomy of the joint as well as an appreciation of the normal ankle joint biomechanics. The operative treatment of these injuries aims to hold the joint securely in an anatomically reduced position throughout the period of healing, and allow initiation of joint motion as soon as possible. If these treatment goals are met, a good outcome is a reasonable expectation, given the proviso that disruption of any articular surface can result in permanent damage. However the functional outcome of fractures involving a posterior malleolar fragment is often not satisfactory and recent debate has surrounded ankle fracture fixation, with the posterior malleolus in particular being subject to increased scrutiny for its contribution towards long-term ankle stability. With the advent of excellent results from the use of open reduction and rigid internal fixation, the gold standard of treatment for displaced ankle fractures has become surgical fixation. This article explores the evidence behind commonly used surgical approaches to ankle fracture fixation and the rationale behind their use.

Consideration of Medial Anatomical Structures at Risk when Placing Quadricortical Syndesmotic Fixation

Category: Trauma Introduction/Purpose: Surgical fixation of ankle fractures with syndesmotic instability using quadricortical fixation through the fibula and tibia is commonly performed to maintain mortise congruency. Quadricortical fixation can be achieved by screws or suture buttons however both involve unprotected drilling and placement of hardware through the medial distal tibia which places anatomic structures at iatrogenic risk. These structures may include the anterior tibialis tendon, the saphenous neurovascular bundle (SNVB) and posteriorly, the posterior tibialis tendon (PTT). This study aims to radiographically map the anatomic course of these structures at risk on a lateral radiograph as would be used intraoperatively during syndesmotic fixation. Methods: Eighteen fresh-frozen cadaveric feet were dissected with preservation of all soft tissue and neurovascular structures over the medial distal tibia. While preserving fascial and tendinous sheath attachments, the SNVB and the PTT were identified and marked with metal wiring. Standardized and calibrated lateral radiographs were obtained to determine the anatomic course of these structures. Lateral radiographs of the distal tibia and fibula were analyzed by a grid system comprised of 1 cm row-increments moving cranially from the ankle joint up to 5 cm and by 3 evenly distributed parallel columnar zones from anterior to posterior (see Figure). The anterior boundary of the columnar zone was placed at the anterior tibial shaft and the posterior boundary was placed at the posterior malleolus of the tibia. The position of respective metal wires placed within the SNVB and the anterior portion of the PTT were charted according to this grid system and results compiled. Results: The SNVB was located in zone 1 or 2 (or anterior to zone 1) in 97.3% of specimens (107/110). The SNVB traversed from proximal-posterior to distal-anterior. For the 16 specimens that crossed a columnar zone, the most common crossover was from zone 2 to zone 1 at 3-4 cm above the ankle joint which occurred in 43.8% (7 of 16) specimens. The PPT was found in zone 3 in all specimens (n=18) with only one specimen demonstrating crossover of a columnar zone into zone 2 at its most distal extent (0-1 cm). The PTT was noted to pass behind (radiographically overlap) with the tibia in 83.3% (15 of 18) of specimens between 1 and 3 cm above the ankle joint. Conclusion: Inappropriate placement of quadricortical syndesmotic fixation may place structures on the medial ankle at risk given blind drilling and hardware placement. The SNVB is at considerable risk along the anterior course of the distal tibial while the PTT is only at risk in zone 3 at the distal extent of the tibia when a true lateral radiograph is obtained. This grid system allows a simple intra-operative check to guide safer placement of quadricortical syndesmotic fixation.

Risk Stratification for Ankle Fracture Complications in Diabetic Patients

Category: Diabetes Introduction/Purpose: While diabetes is a well-known risk factor for morbidity following surgical fixation of ankle fractures, it is likely that increased risk is related to specific diabetes-associated comorbidities. Compared to patients with uncomplicated diabetes, patients with complicated diabetes have higher risks of infection, overall complications, and a higher likelihood of needing revision surgery/arthrodesis. This suggests that the presence and severity of specific risk factors may help predict post-operative risks for diabetic ankle fracture patients and help guide treatment decisions. To date, no study has identified specific diabetes-associated factors and comorbidities which can pose an increased risk of complications for diabetic ankle fracture patients. We hypothesized that patients with diabetes-related comorbidities will suffer significantly more major complications following surgery for unstable ankle fractures compared to uncomplicated diabetics. Methods: We retrospectively reviewed all patients with diabetes treated surgically for ankle fracture at a University medical center over a 12-year period, examining patient and fracture characteristics, treatment method, and clinical and laboratory factors associated with complications. Outcome variables include time to union, wound complication, infection, hardware failure, and need for additional surgery following injury. The primary outcome was major complication, defined as the presence of one or more of the following: deep infection (as evidenced by hardware removal or I&amp;D), amputation, malunion or non-union, skin graft, or wound complication (as evidenced by infection or dehiscence). Bivariate analyses and logistic regression were used to examine the relationships between specific complications and various clinical and demographic factors. A p-value of &lt; 0.05 denotes statistical significance. Results: A total of 61 patients met inclusion criteria. Patient characteristics are depicted in Table 1. Bivariate analyses showed that when compared to diabetic patients without complications, patients who experienced major complications had a significantly higher rate of renal disease (p = 0.032) and retinopathy (p = 0.020), and significantly more hospital readmissions (p &lt; 0.001). Factors associated with complications were determined by a logistic regression model. Age, sex, race, tobacco use and HgbA1C were not associated with increased risk of major complications. However, for each 1-unit increase in the Charlson Comorbidity Index (CCI) Score, there was a 40.6% increase in the likelihood of major complication among diabetic patients with ankle fractures (p = 0.025). Conclusion: Patients with diabetes-related comorbidities have a significantly higher risk of experiencing major complications following treatment of unstable ankle fractures. In this cohort, renal disease, retinopathy and higher CCI were found to be significantly associated with major complications. Interestingly, neuropathy, smoking, and HgA1C were not independent predictors of major complications in this cohort. These data will inform a multi-center prospective registry of patients with diabetes and ankle fractures, and ultimately the development of a risk tool to help guide clinical decision-making and post-operative care for diabetic patients at risk of major complication, re-admission, or re-operation following treatment for ankle fractures.