Background Surgical management of end-stage ankle arthritis consists of either ankle arthrodesis (AA) or total ankle replacement (TAR). The purpose of this study was to evaluate utilization trends in TAR and AA and compare cost and complications. Methods Medicare patients with the diagnosis of ankle arthritis were reviewed. Patients undergoing surgical intervention were split into AA and TAR groups, which were evaluated for trends as well as postoperative complications, revision rates, and procedure cost. Results A total of 673 789 patients were identified with ankle arthritis. A total of 19 120 patients underwent AA and 9059 underwent TAR. While rates of AA remained relatively constant, even decreasing, with 2080 performed in 2005 and 1823 performed in 2014, TAR rates nearly quadrupled. Average cost associated with TAR was $12559.12 compared with $6962.99 for AA ( P < .001). Overall complication rates were 24.9% in the AA group with a 16.5% revision rate compared with 15.1% and 11.0%, respectively, in the TAR group ( P < .001). Patients younger than 65 years had both higher complication and revision rates. Discussion TAR has become an increasingly popular option for the management of end-stage ankle arthritis. In our study, TAR demonstrated both lower revision and complication rates than AA. However, TAR represents a more expensive treatment option. Levels of Evidence: Level III: Retrospective comparative study
The association of nonsteroidal anti-inflammatory drugs (NSAIDs) with non-union in long bone fractures has been controversial. The purpose of this study was to evaluate whether NSAID exposure results in increased risk of non-union in operatively treated long bone fractures. The authors used International Classification of Diseases and Current Procedural Terminology codes to identify patients under a single-payer private insurance with operatively treated humeral shaft, tibial shaft, and subtrochanteric femur fractures from a large database. Patients were divided into cohorts based on NSAID use in the immediate postoperative period, and nonunion rates were compared. A cost analysis and a multivariate analysis were performed. Between 2007 and 2016, a total of 5310 tibial shaft, 3947 humeral shaft, and 8432 subtrochanteric femur fractures underwent operative fixation. Patients used NSAIDs in the first 90 days postoperatively in 900 tibial shaft, 694 humeral shaft, and 967 subtrochanteric femur fractures. In these patients, nonunion rates were 18.8%, 17.4%, and 10.4%, respectively. When no NSAIDs were used, the rates were 11.4%, 10.1%, and 4.6% for each fracture type, respectively ( P <.05). Among patients taking NSAIDs, subtrochanteric femur fractures had a 2.4 times higher risk of nonunion and humeral shaft and tibial shaft fractures both had a 1.7 times higher risk of nonunion ( P <.05). Multivariate analysis showed NSAID use to be an independent risk factor in all 3 types. Cost analysis showed a great increase in economic burden ( P <.05). This study indicated that NSAID exposure was associated with fracture nonunion. [ Orthopedics . 2020;43(4):221–227.]
Background: Treatment of ankle fractures in patients with diabetes is associated with increased complication rates. Ankle arthrodesis is considered a salvage procedure after failed ankle fracture fixation, yet primary ankle arthrodesis has been proposed as a treatment option for patients with significant diabetes-related complications. To date, the characteristics of patients who undergo primary ankle arthrodesis and the associated outcomes have not been described. Methods: A retrospective review was performed of 13 patients with diabetes who underwent primary arthrodesis for traumatic ankle fracture. Patient demographics were characterized in addition to their diabetes complications, Adelaide Fracture in the Diabetic Ankle (AFDA) score, and fracture type. Outcomes assessed included reoperation rates, infection rates, wound complications, nonunion/malunion, amputation, and development of Charcot arthropathy postoperatively. Results: Patients who underwent primary arthrodesis had high rates of diabetes complications, average AFDA scores of 6.4, and high rates of severe injuries, including 38.5% open fractures and 69.2% fracture dislocations. The overall complication rate for primary arthrodesis of ankle fractures in diabetes patients was more than 75% in this cohort. Complications included a 38.5% reoperation rate, 38.5% infection rate, 53.8% wound complication rate, and 23.1% amputation rate. Despite a high nonunion rate at the attempted fusion sites, 89.9% of fractures healed and patients had a stable extremity. Conclusion: This review is the first to characterize the epidemiology and complications of diabetes patients undergoing primary ankle arthrodesis for ankle fractures. In this cohort, patients with multiple diabetic complications and severe injuries underwent primary arthrodesis, which led to an overall high complication rate. Further research is needed to determine the appropriate treatment option for these high-risk patients, and tibiotalocalcaneal stabilization without arthrodesis may be beneficial. Level of Evidence: Level IV, retrospective case series.
Objectives:Controversy exists regarding optimal primary management of Lisfranc injuries. Whether open reduction internal fixation or primary arthrodesis is superior remains unknown. Our retrospective study uses a private payer database to compare cost, complication rate, and hardware removal rate in Lisfranc injuries treated with primary open reduction internal fixation or primary arthrodesis.Methods:Utilizing data mining software created by a private organization, a national insurance database of approximately 23.5 million orthopedic patients was retrospectively queried for subjects who were diagnosed with a Lisfranc injury from 2007-2016 based on international classification of diseases (ICD) codes for tarsometatarsal (TMT) dislocation (PearlDiver, Colorado Springs, CO). Patients with TMT dislocations then progressed on to either non-operative treatment, open reduction internal fixation, or primary arthrodesis. Associated treatment costs based on diagnosis codes were followed after initial diagnosis and t-tests were used to determine statistical significance. Subgroups were then created based on having at least one complication ICD or current procedural terminology (CPT) code after the beginning of treatment, which included: hemorrhage, infection, nonunion, malunion, thromboembolism, wound and hardware complications, or amputation. Additionally, patients undergoing implant removal were identified by CPT code for removal of hardware performed after the index procedure. Complication and hardware removal rates were compared with chi-square test.Results:2205 subjects with a diagnosis of Lisfranc injury were identified in the database. 1248 patients underwent non-operative management, 670 underwent open reduction internal fixation, and 212 underwent primary arthrodesis. The average cost of care associated with primary arthrodesis was greater ($5,005.82) than for open reduction internal fixation ($3,961.97, P=0.045). The overall complication rate was 23.1% (155/670) for open reduction internal fixation and 30.2% (64/212) for primary arthrodesis (P=0.04). Rates of hardware removal independent of complications were 43.6% (292/670) for open reduction internal fixation and 18.4% (39/212) for arthrodesis (P<0.001). Furthermore, 2.5% (17/670) patients in the open reduction internal fixation group progressed to arthrodesis at a mean of 308 days, average cost of care associated with this group of patients was $9,505.12.Conclusion:Primary arthrodesis for the management of acute Lisfranc injuries is both significantly more expensive and has a higher complication rate than open reduction internal fixation. Open reduction internal fixation demonstrated a low rate of progression to arthrodesis, although there was a high rate of hardware removal, which may represent a planned second procedure in the management of a substantial number of patients treated with open reduction internal fixation.
Introduction. Irrigation and debridement of external fixator pin sites is one method utilized by orthopedic surgeons to prevent surgical site infections in patients undergoing definitive internal fixation after temporization in an external fixation device. This study aims to determine if irrigation and debridement of external fixator pin-sites leads to fewer deep surgical site infections, compared to simply scrubbing the external fixator pin sites with a chlorhexidine scrub-brush. Methods. This single center retrospective cohort study was performed at a University Level I Trauma Center. All cases in which a single surgeon removed an external fixator and followed this with definitive open reduction and internal fixation (ORIF) in the same operative setting between October 2007 and October 2018 were reviewed. 313 patients were temporized in 334 external fixators prior to ORIF and were included in the study. Results. 18 of the 179 Irrigation and Debridement cohort (10.0%) and 8 of the 155 Simple Scrubbing cohort (5.2%) resulted in infections that required return to the operating room. We found no statistical difference (p=0.10) or meaningful effect size (Cohen’s d= 0.18) between irrigation and debridement and simple scrubbing of external fixator pin-sites. Conclusions. Given no significant difference was found between debridement of pin sites versus simply scrubbing, the authors propose further studies should focus on the time and resources required for debriding external fixator pin sites.
Category: Diabetes Introduction/Purpose: Diabetes mellitus (DM) poses a risk for increased rate of complications in many orthopaedic procedures, especially in patients undergoing elective arthroplasty procedures. Treatment of end-stage ankle arthritis includes both arthroplasty and arthrodesis. Current literature provides minimal guidance regarding outcomes of total ankle replacement (TAR) or ankle arthrodesis (AA) in diabetic patients. The authors of this study utilized a large database to compare rates of postoperative complications and reoperations of diabetic patients undergoing surgical management of ankle arthritis to rates seen in non-diabetic patients. Methods: Using the PearlDiver Technologies, Inc. database, Medicare patients diagnosed with ankle arthritis using ICD-9 codes were identified from 2005 to 2014. Patients were then sorted as diabetic or non-diabetic. Diabetic patients were then further stratified into Type 1 diabetes (T1DM) and Type 2 diabetes (T2DM). Type 2 diabetics requiring insulin (T2ID) and not requiring insulin (T2NID) were also isolated. Patients were identified who underwent either AA or TAR utilizing ICD-9 procedure and CPT codes. These groups were evaluated for postoperative complications and reoperation rates. Chi-Squared testing was used to determine significance. Multivariate analysis was performed to determine whether diabetes represents an independent risk factor. Results: 1477 diabetic patients underwent TAR and 5399 underwent AA versus 3900 TAR and 7838 AA in nondiabetics. Diabetics undergoing AA experienced complications at 32.2%, reoperations at 30.8%, and revisions at 18.7% versus 13.3%, 22.3%, and 19.2% respectively in patients without diabetes(P<0.05). In diabetics undergoing TAR, the complication rate was 21.6% and reoperation rates were 16.9% versus 12.5% and 13% respectively in their non-diabetic counterparts(P<0.05). Revision rates were similar. Patients with T1DM had more reoperations and complications in both TAR and AA compared to those with T2DM (P<0.05). In both surgical groups, Patients with T2ID had more complications and reoperations than those with T2NID(P<0.05). Multivariate analysis revealed diabetes as an independent risk factor for complication and reoperation in AA but only complication in TAR(P <0.05). Conclusion: Patients with a diagnosis of diabetes mellitus experienced higher complication and total reoperation rates when undergoing either TAR or AA. T1DM appears to impart a greater risk of surgical complication and repeat surgical intervention than does T2DM. However when insulin is required in T2DM, complication and reoperation rates are similar to those of T1DM. Patient selection for surgical management of end-stage ankle arthritis should incorporate diabetic type and insulin dependency when considering surgical intervention.
Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis is a relatively common ailment that affects many people. The method of surgical management of this disease process is usually an ankle arthrodesis (AA) or a total ankle replacement (TAR). Traditionally, AA was viewed as the “gold standard”, however TAR has grown in popularity. Numerous studies have evaluated the risks and benefits of each of these treatments including satisfaction, biomechanics, and cost. The purpose of this study was to compare the cost and rate of complications for patients who underwent either an AA or TAR using a large database. Methods: Using the PearlDiver Technologies, Inc. database, Medicare patients who were diagnosed with ankle arthritis based on ICD-9 codes from 2005 to 2014 were analyzed. Patients were identified who underwent either AA or TAR utilizing ICD-9 procedure and CPT codes. These patient groups were evaluated for postoperative complications and reoperation rates. Subjects and associated costs were followed after the initial procedure. A cost analysis based on diagnosis and procedural codes was then performed on the separate groups, using a t-test to determine statistical significance. Data was analyzed with regards to standard demographic information as well as a metric of overall patient health status, the Charlson Comorbidity Index (CCI). Results: During the study period, 673,789 patients were identified with the diagnosis of ankle arthritis. Of those, 19,120(2.8%) underwent AA and 9,059 (1.3%) underwent TAR. While the yearly rate of AA performed remained stable, TAR was performed at increasing rates. The overall complication rate in the AA group was 24.9% with a 16.5% revision rate compared to 15.1% and 11.2% respectively in the TAR group (P<0.001). Also, the AA group had a higher total reoperation rate. The CCI was found to be significantly lower in the TAR group at 4.5 versus 4.7 in AA patients (P<0.001). Patients younger than 65 years old had both higher complication and reoperation rate. The average one-year cost associated with TAR was $12,566.15 and with AA was $6,967.32 (P<0.001). Conclusion: While TAR was found to be a more expensive treatment option than AA in this large-scale database study, patients in this group had significantly lower complication rates. The reoperation rates were also lower in the TAR group. The CCI was noted to be slightly lower in the arthroplasty group, meaning these patients may have been healthier, representing a selection bias. Also, the patients that had complications were found to have a higher CCI on average. When choosing surgical intervention for end-stage ankle arthritis, patients should be counseled on cost differences and potential complications for TAR and AA.
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