One of the emerging trends in contemporary healthcare is the shift in surgical resources to the outpatient setting coupled with institutional focus of reducing inpatient length of stay to facilitate cost containment. Through a multi-center retrospective review of operatively treated ankle fractures, we sought to calculate the actual financial cost of each procedure as well as to compare the economics of performing outpatient versus inpatient surgery. Additionally, we sought to determine whether the surgery location (inpatient and outpatient) was associated with specific patient demographics, medical comorbidities, or surgeon practice patterns. Methods: A multi-center retrospective comparative study of 240 surgically treated ankle fractures over a two-year period was performed. Two tertiary care hospitals and their affiliated ambulatory surgery centers were included in the study. Patient selection was based on Current Procedural Terminology codes while exclusion criteria included pediatric patient, open trauma, distal tibia pilon fracture, or history of prior ankle fracture. The total direct cost of each surgery was calculated including categorized charges for room and board, pharmacy, rehabilitation, radiology, surgical implant materials, and surgeon professional fees. Patient age, medical co-morbidities, presence of poly-trauma, ordering of ankle CT-scan, and fellowship training of the orthopaedic surgeon were also evaluated in the study. The chi-square test or Fisher's exact test was used to compare inpatients and outpatients for each variable. Results: 142 inpatient and 98 outpatient ankle fracture surgeries were performed. Median length of stay was 5 days for inpatients and the mean total direct cost was $11,466 for each inpatient case with room and board charges averaging $2,694. The mean total direct cost for each outpatient procedure was $3,111. Regarding patient demographics, statistically significant higher percentages were recorded among inpatients in the following groups: age 65 years or older (p < 0.0003), hypertension (p < 0.0230), presence of poly-trauma (p < 0.0149) and ordering of ankle CT-scan (p < 0.0001). 84% of ankle fracture surgeries performed by foot and ankle surgeons were outpatient procedures while 71% of ankle fracture surgeries performed by orthopaedic trauma surgeons were inpatient procedures. Conclusion: Our data shows that with 5 day median length of stay for the hospitalized patient group, the average total cost for inpatient ankle fracture surgery was nearly four times higher and $8,000 more than the total cost for outpatient ankle fracture surgery. Increased patient age and other specific medical co-morbidities were statistically linked with inpatient admission. In this multi-center study, foot and ankle surgeons were more likely than trauma surgeons to perform outpatient ankle fracture surgery. Healthcare institutions may realize substantial practice management cost savings by shifting ankle fracture surgery to the outpatient setting.
Introduction/Purpose: Roughly 15% of ankle sprains and 23% of ankle fractures involve disruption of the syndesmotic ligaments. It has been shown that patients who require syndesmotic stabilization have worse subjective outcomes than those who do not require fixation. Recent studies have demonstrated that both Weber B and Weber C distal fibula ankle fractures can have concomitant syndesmotic injury necessitating trans-syndesmotic fixation. Significant controversy exists regarding the proper syndesmotic fixation strategy in regards to size, number and type of screws, and number of engaged cortices. The goal of our study was to establish the current practice in syndesmotic fixation in surgically-treated ankle fractures at our institution, through a retrospective review, based on fracture pattern and surgeon subspecialty training.
Category: Ankle Introduction/Purpose: One of the emerging trends in contemporary healthcare is the shift in surgical resources to the outpatient setting coupled with reductions in the inpatient length of stay. Through a multi-center retrospective review of surgically treated ankle fractures, we sought to determine whether the selection for outpatient surgery or inpatient admission was dependent upon specific patient demographics, associated medical co-morbidities, or surgeon practice management. Methods: A multi-center retrospective cohort study of 240 surgically treated ankle fractures over a two-year period was performed. Two tertiary care hospitals and their affiliated ambulatory surgery centers were included in the study. Patient selection criteria was based on CPT codes while exclusion criteria included pediatric patient, open trauma, pilon fracture, or history of prior ankle fracture. Patient age, presence of poly-trauma, medical co-morbidities (syncope, hypertension, diabetes, as well as coronary artery, pulmonary, renal or hepatic disease), and ordering of CT-scan were evaluated in the study. Surgeons were divided into three groups according to fellowship training: foot and ankle (Group 1), trauma (Group 2, and general / other (Group 3). There were 2 foot and ankle fellowship trained orthopedists, 5 trauma fellowship trained orthopedists, and 9 generalists whose fellowships included sports, hand, and spine. Results: 142 inpatient surgeries were performed with 5 days median length of stay and 98 surgeries were performed in the outpatient ambulatory care setting. The chi-square test or Fisher's exact test was used to compare inpatients and outpatients for each variable. Statistically significant higher percentages were recorded among inpatients in the following categories: age 65+ years (p < 0.0003), hypertension (p < 0.0230), presence of poly-trauma (p < 0.0149), and ordering of CT-scan (p < 0.0001). The majority of ankle fracture surgeries performed by Group 1 surgeons (84%) and Group 3 surgeons (61%) were outpatient cases compared with only 29% for Group 2 surgeons. There were no statistically significant differences in demographics and medical risk factors among patients in the three groups. Conclusion: Our data shows that age (65+ years-old) and specific medical co-morbidities are statistically linked with inpatient admission for ankle fracture surgery. In this multi-center review, trauma fellowship trained surgeons on-call were more likely to hospitalize their patients in preparation for surgery. With a 5 day median length of stay for these inpatient admissions, the health care institution may realize substantial practice management cost savings by shifting cases to the outpatient setting using the ambulatory care model of foot and ankle fellowship trained surgeons.
Introduction/Purpose: Ankle fractures are a common orthopedic injury in the United States with annual incidence up to 187 per 100,000 persons. Approximately 23% of ankle fractures also involve injury to the syndesmotic ligaments and intraoperative assessment of syndesmotic instability represents a critical aspect of ankle fracture surgery. Recent studies have demonstrated that both Weber B and Weber C distal fibula ankle fractures can have concomitant syndesmotic injury necessitating trans-syndesmotic fixation. Through retrospective review of surgically treated ankle fracture cases, we sought to assess whether there were differences in the rates of intraoperative detection and surgical management of syndesmotic injuries based upon surgeon fellowship training and subspecialty experience. Methods:A multi-center retrospective cohort study of 219 surgically treated ankle fractures over a two year period was performed. Patient selection criteria was based on CPT codes while exclusion criteria included open trauma, pilon fracture, history of prior ankle fracture or pediatric patients. All preoperative radiographs were reviewed for Danis-Weber classification. All post-operative radiographs as well as operative reports were reviewed to confirm surgeon detection of syndesmotic injury and type of trans-syndesmotic fixation utilized. Surgeons were divided into three groups according to fellowship training: foot and ankle (Group 1), trauma (Group 2), and general / other (Group 3). There were 2 foot and ankle fellowship trained orthopedists, 5 trauma fellowship trained orthopedists, and 9 generalists whose fellowships included sports, hand, and spine. Patient demographics and medical risk factors were also recorded in the study.
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