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.]

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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.