Are current DRG-based bundled payment models for lumbar fusions risk-adjusting adequately? An analysis of Medicare beneficiaries

BACKGROUND CONTEXTCurrent bundled payment programs in spine surgery, such as the bundled payment for care improvement rely on the use of diagnosis-related groups (DRG) to define payments. However, these DRGs may not be adequate enough to appropriately capture the large amount of variation seen in spine procedures. For example, DRG 459 (spinal fusion except cervical with major comorbidity or complication) and DRG 460 (spinal fusion except cervical without major comorbidity or complication) do not differentiate between the type of fusion (anterior or posterior), the levels/extent of fusion, the use of interbody/graft/BMP, indication of surgery (primary vs. revision) or even if the surgery was being performed for a vertebral fracture.PURPOSEWe carried out a comprehensive analysis to report the factors responsible for cost-variation in a bundled payment model for spinal fusions.STUDY DESIGNRetrospective review of a 5% national sample of Medicare claims from 2008 to 2014 (SAF5).OUTCOME MEASURESTo understand the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day costs for patients undergoing spinal fusions under DRG 459 and 460.METHODSThe 2008 to 2014 Medicare 5% standard analytical files (SAF) were used to retrieve patients undergoing spinal fusions under DRG 459 and DRG 460 only. Patients with missing gender, age, and/or state-level data were excluded. Only those patients who had complete data, with regard to payments/costs/reimbursements, starting from day 0 of surgery up to 90 days postoperatively were included to prevent erroneous collection. Multivariate linear regression models were built to assess the independent marginal cost impact (decrease/increase) of each patient-level, state-level, and procedure-level characteristics on the average 90-day cost while controlling for other covariates.RESULTSA total of 21,367 patients (DRG-460=20,154; DRG-459=1,213) were included in the study. The average 90-day cost for all lumbar fusions was $31,716±$18,124, with the individual 90-day payments being $54,607±$30,643 (DRG-459) and $30,338±$16,074 (DRG-460). Increasing age was associated with significant marginal increases in 90-day payments (70–74 years: +$2,387, 75–79 years: +$3,389, 80–84 years: +$2,872, ≥85: +$1,627). With regards to procedure-level factors—undergoing an anterior fusion (+$3,118), >3 level fusion (+$5,648) vs. 1 to 3 level fusion, use of interbody device (+$581), intraoperative neuromonitoring (+$1,413), concurrent decompression (+$768) and undergoing surgery for thoracolumbar fracture (+$6,169) were associated with higher 90-day costs. Most individual comorbidities were associated with higher 90-day costs, with malnutrition (+$12,264), CVA/stroke (+$5,886), Alzheimer's (+$4,968), Parkinson's disease (+$4,415), and coagulopathy (+$3,810) having the highest marginal 90-day cost-increases. The top five states with the highest marginal cost-increase, in comparison to Michigan (reference), were Maryland (+$12,657), Alaska (+$11,292), California (+$10,040), Massachusetts (+$8,800), and the District of Columbia (+$8,315).CONCLUSIONSUnder the proposed DRG-based bundled payment model, providers would be reimbursed the same amount for lumbar fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion (1–3 level vs. >3 level), use of adjunct procedures (decompressions) and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated costs. When defining and developing future bundled payments for spinal fusions, health-policy makers should strive to account for the individual patient-level, state-level, and procedure-level variation seen within DRGs to prevent the creation of a financial dis-incentive in taking care of sicker patients and/or performing more extensive complex spinal fusions.     

Refining risk adjustment for bundled payment models in cervical fusions—an analysis of Medicare beneficiaries

BACKGROUND CONTEXTThe current Bundled Payment for Care Improvement model relies on the use of “Diagnosis Related Groups” (DRGs) to risk-adjust reimbursements associated with a 90-day episode of care. Three distinct DRG groups exist for defining payments associated with cervical fusions: (1) DRG-471 (cervical fusions with major comorbidity/complications), (2) DRG-472 (with comorbidity/complications), and (3) DRG-473 (without major comorbidity/complications). However, this DRG system may not be entirely suitable in controlling the large amounts of cost variation seen among cervical fusions. For instance, these DRGs do not account for area/location of surgery (upper cervical vs. lower cervical), type of surgery (primary vs. revision), surgical approach (anterior vs. posterior), extent of fusion (1–3 level vs. >3 level), and cause/indication of surgery (fracture vs. degenerative pathology).PURPOSETo understand factors responsible for cost variation in a 90-day episode of care following cervical fusions.STUDY DESIGNRetrospective study of a 5% national sample of Medicare claims from 2008 to 2014 5% Standard Analytical Files (SAF5).OUTCOME MEASURESTo calculate the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day reimbursements for patients undergoing cervical fusions under DRG-471, DRG-472, and DRG-473.METHODSThe 2008 to 2014 Medicare SAF5 was queried using DRG codes 471, 472, and 473 to identify patients receiving a cervical fusion. Patients undergoing noncervical fusions (thoracolumbar), surgery for deformity/malignancy, and/or combined anterior-posterior fusions were excluded. Patients with missing data and/or those who died within 90 days of the postoperative follow-up period were excluded. Multivariate linear regression modeling was performed to assess the independent marginal cost impact of DRG, gender, age, state, procedure-level factors (including cause/indication of surgery), and comorbidities on total 90-day reimbursement.RESULTSFollowing application of inclusion/exclusion criteria, a total of 12,419 cervical fusions were included. The average 90-day reimbursement for each DRG group was as follows: (1) DRG-471=$54,314±$32,643, (2) DRG-472=$28,535±$17,271, and (3) DRG-473=$18,492±$10,706. The risk-adjusted 90-day reimbursement of a nongeriatric (age <65) female, with no major comorbidities, undergoing a primary 1- to 3-level anterior cervical fusion for degenerative cervical spine disease was $14,924±$753. Male gender (+$922) and age 70 to 84 (+$1,007 to +$2,431) was associated with significant marginal increases in 90-day reimbursements. Undergoing upper cervical surgery (−$1,678) had a negative marginal cost impact. Among other procedure-level factors, posterior approach (+$3,164), >3 level fusion (+$2,561), interbody (+$667), use of intra-operative neuromonitoring (+$1,018), concurrent decompression/laminectomy (+$1,657), and undergoing fusion for cervical fracture (+$3,530) were associated higher 90-day reimbursements. Severe individual comorbidities were associated with higher 90-day reimbursements, with malnutrition (+$15,536), CVA/stroke (+$6,982), drug abuse/dependence (+$5,059), hypercoagulopathy (+$5,436), and chronic kidney disease (+$4,925) having the highest marginal cost impacts. Significant state-level variation was noted, with Maryland (+$8,790), Alaska (+$6,410), Massachusetts (+$6,389), California (+$5,603), and New Mexico (+$5,530) having the highest reimbursements and Puerto Rico (−$7,492) and Iowa (−$3,393) having the lowest reimbursements, as compared with Michigan.CONCLUSIONSThe current cervical fusion bundled payment model fails to employ a robust risk adjustment of prices resulting in the large amount of cost variation seen within 90-day reimbursements. Under the proposed DRG-based risk adjustment model, providers would be reimbursed the same amount for cervical fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion, use of adjunct procedures (decompressions), and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Our findings suggest that defining payments based on DRG codes only is an imperfect way of employing bundled payments for spinal fusions and will only end up creating major financial disincentives and barriers to access of care in the healthcare system.     

Ankle fractures: High implant cost is not associated with better patient reported outcomes

IntroductionAnkle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries.Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture.MethodsAll ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost.ResultsThere was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [−411.8, −54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [−74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48).ConclusionsThe utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.     

Outpatient Versus Inpatient Surgical Fixation of Isolated Ankle Fractures: An Analysis of 90-Day Complications,Readmissions, and Costs

Despite increasing interest toward managing isolated ankle fractures in an outpatient setting, evidence of its safety remains largely limited. The 2007 to 2014 Humana Administrative Claims database was queried to identify patients undergoing open reduction internal fixation for unimalleolar, bimalleolar, or trimalleolar isolated closed ankle fractures. Two cohorts (outpatient versus inpatient) were then matched on the basis of age, sex, race, region, fracture type (uni-/bi-/trimalleolar) and Elixhauser Comorbidity Index to control for selection bias. Multivariate regression analyses were performed to report independent impact of outpatient-treated ankle fracture surgery on 90-day complications, readmission, and emergency department visit rates. Independent-samples t test was used to compare global 90-day costs between cohorts. A total of 5317 inpatient-treated and 6941 outpatient-treated closed ankle fractures were included in the final cohort. After matching and multivariate analyses, patients with outpatient ankle fractures, compared with patients with inpatient ankle fractures, had statistically lower rates of pneumonia (2.3% versus 4.0%; p < .001), myocardial infarction (0.9% versus 1.8%; p = .005), acute renal failure (2.2% versus 5.3%; p < .001), urinary tract infections (7.4% versus 12.3%; p < .001), and pressure ulcers (0.9% versus 2.0%; p = .001). Outpatient ankle fractures also had lower rates of 90-day readmissions (9.7% versus 14.1%; p < .001) and emergency department visits (13.8% versus 16.2%; p = .028). Last, overall 90-day costs for outpatient ankle fractures were nearly $9000 lower than costs for inpatient ankle fractures ($12,923 versus $21,866; p < .001). Based on our findings, it appears that outpatient treatment of ankle fractures can be deemed safe and feasible in a select cohort of patients.     

Functional outcome 3–6 years after operative treatment of closed Weber B ankle fractures with or without syndesmotic fixation

BackgroundTo compare the long-term functional outcomes of patients surgically treated for Weber B ankle fractures with or without syndesmotic fixation.MethodsIn total, 959 adult patients with previous treatment with open reduction and internal fixation (ORIF) for closed ankle fractures were eligible for inclusion in a cross-sectional postal survey 3–6 years after surgery; 645 had Weber B fractures. The survey assessed functional outcomes with three validated ankle questionnaires.ResultsIn total 365 (57%) patients responded at a median of 4.2 years after the trauma. After adjusting for age, sex, education, smoking status, body mass index, diabetes, physical status before surgery, fracture classification, and duration of surgery, patients with a syndesmotic fixation had no different OMAS score (p = 0.98), LEFS score (p = 0.61), and SEFAS score (p = 0.98) than those without a syndesmotic fixation. Trimalleolar fracture was associated with worse functional outcomes than unimalleolar on two of the scales, the OMAS (p = 0.028) and LEFS (p = 0.046).ConclusionsIn multivariable analysis, patients with a syndesmotic fixation had no worse long-term functional outcomes than those without syndesmotic fixation.     

Operative costs associated with arthroscopic assisted open reduction and internal fixation of acute ankle fractures

BackgroundAnkle fractures are a common orthopedic injury that frequently involves associated cartilage lesions, soft tissue damage, and a significant inflammatory burden. Despite studies revealing intra-articular pathology in up to 79% of ankle fractures, only 1% of open reduction and internal fixation (ORIF) procedures undergo arthroscopic evaluation. The primary purpose of this study was to determine the cost effectiveness of ankle arthroscopy performed at time of ORIF for ankle fracture.MethodsAn IRB approved retrospective review of patients who sustained ankle fractures and underwent ORIF with and without concomitant arthroscopic surgery between 2015 and 2020 were investigated. Patient demographics, fracture characteristics, outcomes, and cost data were collected and analyzed.ResultsThere were 567 total ORIF and 28 ORIF and scope included for cost analysis purposes. Total surgical costs averaged $6,537.62 and $6,886.46 for the ORIF only and ORIF and scope procedures respectively. Total direct costs, including operating room time, for the same procedures were found to average $6,212.34 and $7,312.10 for the ORIF only and ORIF and scope procedures respectively. The cost difference between the ORIF only and with arthroscopy was not statistically significant (p = 0.1174). Twelve of the 28 arthroscopic patients (42.86%) had grade 3 or full thickness chondral lesions, and 11/28 (39.28%) arthroscopic patients were found to have grade 1–2 cartilage changes.ConclusionIn the acute treatment of ankle fractures, concurrent arthroscopic evaluation does not add a significant cost to the procedure and may result in improved short and long term benefits for the patient. With improved arthroscopic efficiency, the cost differential can be further reduced.LOEIV.     

后外侧入路切开复位内固定治疗三踝骨折

目的评价采用后外侧入路切开复位内固定治疗三踝骨折的价值。方法自2009-03—2012—06采用后外侧入路切开复位内固定治疗三踝骨折23例,处理外踝骨折时钢板放置于腓骨后侧或外侧,对后踝骨折行钢板或螺钉固定。观察术后切口及骨折愈合情况,术后3、12个月采用AOFAS踝一后足评分标准评价踝关节功能。结果术后3个月23例均获得随访,术后12个月2例失访。术后7d2例外侧和内侧切口周围同时出现张力性水泡．2例外侧切口周围出现张力性水泡,未出现切口感染。1例出现足背外侧麻木,术后3个月复诊时症状消失。术后3个月X线片显示23例骨折线均模糊,AOFAS评分：优12例,良8例,可2例,差1例,优良率86．96％。术后12个月X线片显示骨折线均消失,AOFAS评分：优17例,良2例,可2例,优良率90．48％。结论采用后外侧入路行切开复位内固定术治疗三踝骨折可以一次性复位固定外踝和后踝骨折,联合内侧切口可以一个体位下完成三踝骨折的治疗,对软组织破坏少,骨折可获得解剖复位,术后踝关节功能恢复佳、并发症少。     

骨折间隙直视下复位固定后踝移位骨折

[目的]介绍骨折断端间隙直视法下三踝骨折中后踝移位骨折复位固定的手术技术与临床效果。[方法]选择2014年1月~2017年12月手足外科收治的三踝骨折中后踝移位骨折患者42例,采用骨折断端间隙直视法复位固定后踝骨折,采用骨骼肌肉功能评分(SMFA)评定患者术后恢复情况。[结果]所有患者均达到骨性愈合,术后未出现需要进行翻修手术或感染的病例,踝关节背伸跖屈功能良好。患者骨骼肌肉功能评分(SMFA)功能障碍指数平均为(8.01±1.73)分,SMFA困扰指数平均为(2.22±1.31)分。所有患者术后平均3个月进行正常的日常生活活动。[结论]对于三踝骨折中后踝移位骨折的治疗,采用后外侧入路骨折断端直视下复位固定方法可能是一种更好的选择。     

Comparing Different Surgical Techniques for Addressing the Posterior Malleolus in Supination External Rotation Ankle Fractures and the Need for Syndesmotic Screw Fixation

Trimalleolar ankle fractures are unstable injuries with possible syndesmotic disruption. Recent data have described inherent morbidity associated with screw fixation of the syndesmosis, including the potential for malreduction, hardware irritation, and post-traumatic arthritis. The posterior malleolus is an important soft tissue attachment for the posterior inferior syndesmosis ligament. We hypothesized that fixation of a sizable posterior malleolar (PM) fracture in supination external rotation type IV (SER IV) ankle fractures would act to stabilize the syndesmosis and minimize or eliminate the need for trans-syndesmotic fixation. A retrospective review of trimalleolar ankle fractures surgically treated from October 2006 to April of 2011 was performed. A total of 143 trimalleolar ankle fractures were identified, and 97 were classified as SER IV. Of the 97 patients, 74 (76.3%) had a sizable PM fragment. Syndesmotic fixation was required in 7 of 34 (20%) and 27 of 40 (68%), respectively, when the PM was fixed versus not fixed (p = .0002). When the PM was indirectly reduced using an anterior to posterior screw, 7 of 15 patients (46.7%) required syndesmotic fixation compared with none of 19 patients when the PM fragment was fixated with direct posterior lateral plate fixation (p = .0012). Fixation of the PM fracture in SER IV ankle fractures can restore syndesmotic stability and, thus, lower the rate of syndesmotic fixation. We found that fixation of a sizable PM fragment in SER IV or equivalent injuries through posterolateral plating can eliminate the need for syndesmotic screw fixation.     

Arthroscopically Assisted Treatment of Complex Ankle Fractures: Intra-articular Findings and 1-Year Follow-Up

Especially after complex ankle fractures, patients regularly suffer from residual symptoms, presumably due to occult intra-articular injuries. The aim of this study was to evaluate the intra-articular lesions, identify fractures specifically at risk for these, and assess the results after arthroscopically assisted open reduction and internal fixation of complex ankle fractures after 1 year. The primary outcome was the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. Secondary outcome parameters were the Olerud and Molander Ankle Score (OMAS), Tegner activity scale, arthroscopic findings, functional assessment, and complications. Thirty-two patients (56% female) were enrolled. Chondral lesions were detected in 91%. Full-thickness lesions treated by microfracturing were observed in 0% of unimalleolar, 43% of bimalleolar, and 40% of trimalleolar fractures. After 1 year, the median (interquartile range) AOFAS was 94 (9) and OMAS was 90 (10) for all patients. When analyzing factors possibly influencing the outcome, age, sex, smoking, grading for surgical procedures according to the American Society of Anesthesiologists, fracture type (uni-, bi-, or trimalleolar), severity of chondral lesions graded according to the International Cartilage Repair Society (grade <4 versus grade 4), and syndesmotic instability had no significant influence on the outcome. The only variable significantly influencing the AOFAS (p = .004) and OMAS (p < .001) was body mass index (BMI; r_s = –0.522 and –0.606, respectively), with a higher BMI resulting in inferior outcome scores. Complications were observed in 3 patients, 2 with superficial skin necrosis at the posterolateral incision and 1 nonunion of the medial malleolus. Taken together, these data show that intra-articular injuries were common in ankle fractures. Bi- and trimalleolar fractures were particularly at risk for full-thickness lesions. A higher BMI tended to result in inferior outcome scores. Arthroscopically assisted open reduction and internal fixation led to good to excellent results in all but 1 patient.     

The Operative Treatment of Ankle Fractures: A 10-Year Retrospective Study of 1529 Patients

Ankle fractures are the second most common fracture of the lower limb and account for nearly 10% of all fractures. They range from simple to complex injuries and approximately 40% require surgical intervention. The aim of our study was to provide an up-to-date reference of the epidemiology, fracture, and fixation characteristics of operatively treated ankle fractures. We also sought to determine the number of patients undergoing further surgery through revision, implant removal, or ankle fusion. A retrospective observational study was conducted of 1529 consecutive patients that underwent operative intervention for an unstable ankle fracture between 2007 and 2017. Fractures of the distal tibia and pilon injuries were excluded. The mean age of patients was 41.8 years with 50.7% male. Unimalleolar fixation was performed in 60.1%, while bimalleolar and trimalleolar fixation was performed in 31.2% and 5%, respectively. Isolated syndesmotic fixation was performed in 3.8%. A posterior malleolus fracture was present in 28.6%, of which 31.6% underwent fixation. A further procedure was performed in 234 (15.3%) patients. Revision open reduction internal fixation was required in 1.4% and 0.8% underwent future ankle fusion. Treatment of ankle fractures makes up a sizeable part of orthopedic trauma practice with more than 1 in 7 patients requiring a second procedure. More complex fractures were predominantly seen in older females, while patients who suffered trimalleolar fractures have an increased likelihood of requiring future ankle fusion or revision. Despite this the rate of ankle fusion was <1%.     

Early Protected Weightbearing After Open Reduction Internal Fixation of Ankle Fractures With Trans-syndesmotic Screws

Traditional postoperative care after open reduction internal fixation (ORIF) of unstable ankle fractures with syndesmotic instability includes non-weightbearing for 6 to 8 weeks. However, prolonged non-weightbearing may be detrimental. The goal of this case series was to assess the outcomes of early protected weightbearing after operative treatment of acute ankle fractures with syndesmotic instability requiring screw stabilization. Fifty-eight consecutive patients, treated from January 2006 to January 2013, met the inclusion criteria with a minimum follow up of 1 year. Electronic medical records and radiographs were reviewed for patient and surgical characteristics, postoperative complications, and maintenance of reduction. Patients initiated walking at an average of 10 days (range 1 to 15) postoperatively. Surgical treatment consisted of operative reduction with standard fixation devices and 1 or 2 trans-syndesmotic screws that purchased 4 cortices. All 58 patients maintained correction after surgery when allowed to weightbear early in the postoperative recovery. Five complications (8.6%) occurred in the 58 patients, which included 3 superficial infections (5.2%) and 2 cases (3.4%) of neuritis. The maintenance of reduction and low complication rate in this study support the option of early protected weightbearing after ankle fracture ORIF with trans-syndesmotic fixation.     

The role of arthroscopy in the management of fractures about the ankle

Anatomic restoration of the joint is the goal of management in fractures about the ankle. Open reduction and internal fixation (ORIF) is the standard of care for unstable ankle fractures; however, arthroscopic management has been proposed. The use of arthroscopic reduction and internal fixation (ARIF) is surgeon-dependent. Reported indications for ARIF include transchondral talar dome fracture, talar fracture, low-grade fracture of the distal tibia, syndesmotic disruption, malleolar fracture, and chronic pain following definitive management of fracture about the ankle. Among the potential benefits are less extensive exposure, preservation of blood supply, and improved visualization of the pathology. Although arthroscopy is increasingly used in the setting of trauma, the effectiveness of ARIF compared with ORIF for management of fractures of the distal tibia, malleolus, displaced talar neck, and talar body has yet to be determined. Most of these fractures are effectively managed with open procedures.     

Incidence and severity of malreduction of the tibiofibular syndesmosis following surgical treatement of displaced ankle fractures and impact on the function –Clinical study and MRI evaluation

PurposeTo compare tibiofibular reduction quality in different types of operatively treated ankle fractures and the impact on clinical and functional outcome at mid-term follow-up.Patients and methodsOne hundred patients with an acute ankle fracture who had undergone open reduction and internal fixation were included. Eighty-eight patients who suffered from ligamentous ankle injury with neither fracture nor syndesmotic lesions served as a control group. Tibiofibular alignment was measured on MR images in all 188 patients. In case of tibiofibular malreduction tibiotalar positioning was determined as well. Clinical and functional outcome was assessed using the AOFAS hindfoot score as well as the SF-36.ResultsNo tibiofibular malreduction was found in type Weber B fractures, irrespective of syndesmotic instability followed by syndesmotic screw placement, as compared to the control group. A significant tibiofibular malreduction was detected in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic screw, in comparison to the control group. Tibiotalar displacement could not be detected. Clinical and functional outcome analysis revealed no significant differences between the treatment groups.ConclusionThree-dimensional imaging may improve tibiofibular malreduction visualization in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic transfixation. The clinical impact of improving tibiofibular positioning remains highly questionable since there was no correlation between tibiofibular alignment and the clinical outcome at mid-term follow-up.     

Cost description of inpatient treatment for ankle fracture

Background

The study estimated the hospital costs associated with the surgical fixation of ankle fractures by either open reduction internal fixation (ORIF) or external fixation.

Method

A retrospective review of the clinical records of all 264 patients admitted with an ankle fracture requiring surgical stabilisation between 1 March 2007 and 29 February 2008. Patient records were examined for a minimum of 6 months after primary admission. A mean cost per patient was calculated based on patient-level hospital resource use. This included all procedures received during both their primary hospitalisation and subsequent re-admissions.

Results

Approximately equal numbers of males and females (mean age 46.2 years) were admitted, and males were significantly younger than females. The mean length of stay was 10.8 days (SD 9.1); however, ORIF (which was performed in the vast majority of cases, 94.7%) was associated with a much shorter mean length of stay compared with external fixation (10.4 days; SD 8.9 vs. 17.4 days; SD 10.2). The mean total hospital cost per patient including was £4730.28 (SD £2340.73) with a higher mean cost for those who received external fixation as the primary procedure (£9453.92; SD £3391.84) compared with ORIF (£4465.76; SD £1965.10). Patients with severe health problems had significantly higher costs than fit and healthy patients (£5982.65; SD £28 77.74 vs. £4375.00; SD £1957.65).

Conclusions

The results highlight the considerable hospital costs associated with the surgical fixation of an ankle fracture, thus providing valuable information for resource planners. Future research should broaden the perspective of the economic analysis to include rehabilitation costs and assess the cost-effectiveness of potential cost-saving strategies.     

Open reduction and internal fixation of the posterior malleolus fragment via the posterolateral approach is radiologically superior to ‘A to P’ screw fixation

PurposeFunctional outcome in trimalleolar fractures is largely correlated to the reduction of the posterior fragment. Until recently, fixation was mainly performed for large fragments, by percutaneous anterior to posterior (‘A to P’) screw placement after closed reduction. Nowadays, ORIF via a posterolateral approach seems to gain in popularity. The aim of this study was to compare the postoperative photographs of operated trimalleolar fractures after either fracture treatment method, for fracture diastasis and step-off.Material and methodsAll consecutive patients with trimalleolar fractures, including posterior fragments of >5% of the articular surface and operated between 2007–2013 were analysed on size of posterior fragment, post-operative gap and step-off by three observers. The patients were divided into three groups; A to P screw fixation, ORIF via the posterolateral approach and no posterior fragment fixation at all.Results180 patients with trimalleolar ankle fractures were included for analyses. Twenty five posterior fragments were fixated percutaneously from anterior to posterior (group 1) and 51 underwent open reduction and internal fixation through a posterolateral approach (group 2). 104 patients underwent no posterior malleolus fixation (group 3). The average size of posterior fragment was 34% in group 1, 27% in group 2 and 16% in group 3. A postoperative step-off >1 mm was found in 40% (group 1), 9% (group 2) or 34% respectively (group 3).ConclusionsFixation of the posterior malleolus through an open posterolateral approach leads to better radiological results as compared to percutaneous ‘A to P’ screw fixation or no fixation at all.     

Open reduction and internal fixation of the posterior malleolus fragment frequently restores syndesmotic stability

Aim

Comparison of unfixed, CRIF, and ORIF of the posterior malleolus fragment (PMF) regarding the frequency of trans-syndesmotic fixation and quality of reduction in trimalleolar (equivalent) fractures.

Cost analysis of ankle syndesmosis internal fixation

BackgroundUnstable ankle syndesmosis injuries are common, and the optimal surgical fixation is controversial. The two main options for stabilization of syndesmotic injuries are suture button fixation and screw fixation. Suture button fixation has a higher initial cost, but may have a lower hardware removal rate. The purpose of this study was to compare the costs of syndesmotic fixation.MethodsA cost analysis was performed at a single university-affiliated hospital. Variables included the number of suture buttons, the number and type of syndesmosis screws used, and the frequency of hardware removal and operative time required for hardware removal. There were four clinical scenarios evaluated: (A) one suture button versus one cortical screw; (B) two suture buttons versus two cortical screws; (C) one suture button versus one locking screw; (D) two suture buttons versus two locking screws. Suture button removal rate was assumed to be 0% in the analysis.ResultsCost equivalence was achieved at an 18 to 53% syndesmotic screw removal rate depending on the fixation construct used and the amount of time required for hardware removal. When the syndesmosis screws were removed 100% of the time, suture button fixation was more economical by $85,000–$194,656 per 100 ankles. When hardware was never removed, suture button fixation was more expensive by $169,844–$295,500 per 100 ankles.ConclusionThis study demonstrates that the costs associated with syndesmosis fixation are more dependent on the rate of hardware removal than the type of hardware utilized. Routine removal of syndesmosis screws is clearly less economical than suture button fixation.     

Reoperation Rates and Costs of Radial Head Arthroplasty Versus Open Reduction and Internal Fixation of Radial Head and Neck Fractures: A Retrospective Database Study

Background: We conducted a retrospective study to compare reoperation/conversion rates and costs between open reduction and internal fixation (ORIF) and radial head arthroplasty (RHA) in patients with radial head/neck fractures. Methods: We examined the Humana Orthopedic data sets using the PearlDiver Application from January 2007 to June 2016 to identify patients with radial head and neck fractures with and without a concurrent elbow dislocation. Time to revision surgery, odds ratios, and survival curves for reoperations/conversions were calculated comparing ORIF and RHA. Results: A total of 7520 patients were identified who had undergone either ORIF or RHA. Overall, ORIF patients were less likely to undergo a conversion procedure (2.76% vs 7.03%) but more likely to undergo any reoperation (21.36% vs 17.63%) with a higher average cost ($19 688.46 vs $11 626.64). Patients who underwent ORIF without a concurrent elbow dislocation were also less likely to undergo a conversion procedure (2.12% vs 7.24%) but more likely to undergo any reoperation (20.22% vs 16.99%) with a higher average cost ($19 420.21 vs $11 123.61). Patients who underwent ORIF with a concurrent elbow dislocation were more likely to undergo both a conversion procedure (15.86% vs 6.39%) and any reoperation (44.98% vs 19.63%) with a higher average cost per patient ($24 999.62 vs $13 192.00). The average time to reoperation/conversion surgery was less than a year for all patient groups. Conclusions: Overall reoperation rates are high in patients undergoing operative treatment of radial head and neck fractures. RHA is less expensive and has fewer reoperations/conversions in short-term follow-up when compared with ORIF in radial head/neck fracture dislocations of the elbow.