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Kavanagh AM, Schumann J, Burgess BJ. Intramedullary Nail Fixation for the Treatment of Symptomatic Fibular Nonunion: A Case Series. Foot Ankle Spec 2023:19386400231193620. [PMID: 37608750 DOI: 10.1177/19386400231193620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Ankle fractures are a relatively common injury in the lower extremity. They can be treated with conservative management if they are nondisplaced and only involve the fibula. Nonunions at the fracture site, however, are a potential complicating factor during treatment. There is growing literature supporting the use of intramedullary fixation for fracture care. Not only does it have the advantages of using smaller incisions to preserve periosteum while providing improved biomechanical outcomes, but intramedullary reaming can help stimulate cells to promote bone healing. Few articles discuss the use and success of intramedullary reaming in revision surgery of the distal fibula. We present 3 cases of computed tomography-confirmed fibular nonunion following conservative fracture care, which underwent revision surgery with fibular nail fixation technique. These cases illustrate clinical and image findings as well as highlight the surgical technique used for each patient. At follow-up, all patients were asymptomatic and radiographs confirmed healing of the previous nonunion site. These cases are examples of successful revision for fibular fracture nonunion using intramedullary nail fixation.Level of Evidence: Level IV: Case series.
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Affiliation(s)
- Amber M Kavanagh
- Division of Hinsdale Orthopaedics, Illinois Bone & Joint Institute, Joliet, Illinois
| | - Jaclyn Schumann
- Division of Hinsdale Orthopaedics, Illinois Bone & Joint Institute, Joliet, Illinois
| | - Brian J Burgess
- Division of Hinsdale Orthopaedics, Illinois Bone & Joint Institute, Joliet, Illinois
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2
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Bernstein DN, Ramirez G, Thirukumaran CP, Samuel Flemister A, Oh IC, Ketz JP, Baumhauer JF. Clinical Improvement Following Operative Management of Ankle Fractures Among Patients With and Without Moderate to High Depressive Symptoms: An Analysis Using PROMIS. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114221151077. [PMID: 36741681 PMCID: PMC9893091 DOI: 10.1177/24730114221151077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Understanding the recovery trajectory following operative management of ankle fractures can help surgeons guide patient expectations. Further, it is beneficial to consider the impact of mental health on the recovery trajectory. Our study aimed to address the paucity of literature focused on understanding the recovery trajectory following surgery for ankle fractures, including in patients with depressive symptoms. Methods From February 2015 to March 2020, patients with isolated ankle fractures were asked to complete Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression questionnaires as part of routine care at presentation and follow-up time points. Linear mixed effects regression models were used to evaluate the patient recovery pattern, comparing the preoperative time point to <3 months, 3-6 months, and >6 months across all patients. Additional models that included the presence of depression symptoms as a covariate were then used. Results A total of 153 patients met inclusion criteria. By 3-6 months, PROMIS PF (β: 9.95, 95% CI: 7.97-11.94, P < .001), PI (β: -10.30, 95% CI: -11.87 to -8.72, P < .001), and Depression (β: -5.60, 95% CI: -7.01 to -4.20, P < .001) improved relative to the preoperative time point. This level of recovery was sustained thereafter. When incorporating depressive symptoms into our model as a covariate, the moderate to high depressive symptoms were associated with significantly and clinically important worse PROMIS PF (β: -4.00, 95% CI: -7.00 to -1.00, P = .01) and PI (β: 3.16, 95% CI: -0.55 to 5.76, P = .02) scores. Conclusion Following ankle fracture surgery, all patients tend to clinically improve by 3-6 months postoperatively and then continue to appreciate this clinical improvement. Although patients with moderate to high depressive symptoms also clinically improve following the same trajectory, they tend to do so to a lesser level than those who have low depressive symptoms. Level of Evidence Level III, case-control study.
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Affiliation(s)
- David N. Bernstein
- Harvard Combined Orthopaedic Residency Program (HCORP), Massachusetts General Hospital, Boston, MA, USA
| | - Gabriel Ramirez
- Harvard Combined Orthopaedic Residency Program (HCORP), Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY, USA
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Caroline P. Thirukumaran
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY, USA
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - A. Samuel Flemister
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY, USA
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Irvin C. Oh
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - John P. Ketz
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY, USA
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Judith F. Baumhauer
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, NY, USA
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Judith F. Baumhauer, MD, MPH, Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA.
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Barfield M, Jackson JB, Gonzalez T. A cost analysis of ankle fractures treated by orthopedic surgeons with or without foot and ankle fellowship training at ambulatory surgery centers and hospitals. SAGE Open Med 2022; 10:20503121221128690. [PMID: 36226230 PMCID: PMC9549085 DOI: 10.1177/20503121221128690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 09/08/2022] [Indexed: 11/07/2022] Open
Abstract
Introduction Ankle fractures are commonly treated by orthopedic surgeons. Fellowship versus non-fellowship training often adds a different perspective, use of specialty-specific implants, comfort with outpatient procedures, and may contribute to cost differences between surgeons. To assess the impact of fellowship training on the value of care provided, the difference in cost of ankle fracture open reduction internal fixation procedures between foot and ankle trained orthopedic surgeons and non-foot and ankle trained orthopedic surgeons over the past 10 years was retrospectively evaluated. We additionally evaluated the cost differences of ankle fracture open reduction internal fixations between hospitals, hospital-owned ambulatory surgery centers, and physician-owned ambulatory surgery centers. The study also assessed the costs effects of inpatient versus outpatient procedures and ankle open reduction internal fixation procedure volume of the surgeon observed within the timeframe of the study. Methods Patient data was collected from electronic medical records and billing documents for patients who underwent an ankle open reduction internal fixation procedure performed by an orthopedic surgeon in our hospital system and local hospital-owned ambulatory surgery centers between the years 2010 and 2020. Data were also collected from a physician-owned ambulatory surgery center for patients who underwent an ankle open reduction internal fixation procedure performed by an orthopedic surgeon between the years 2015 and 2020. Statistical analyses were performed to observe potential cost differences among all variables. Results Procedures performed by fellowship-trained orthopedic surgeons were significantly less costly than those performed by non-foot and ankle trained orthopedic surgeons when performed at ambulatory surgery centers but not at hospitals. Procedures performed at ambulatory surgery centers were found to be significantly less costly than those performed at hospitals. In addition, it was noted that procedures performed at hospital-owned ambulatory surgery centers were less costly than physician-owned ambulatory surgery centers. It was also found that procedure cost decreased with an increase in surgeon volume. Conclusion An ankle fracture open reduction internal fixation performed by a foot and ankle trained orthopedic surgeon in a hospital-owned ambulatory surgery center is the lowest cost option available, and an increase in volume of open reduction internal fixations is associated with a further decrease in cost when within our hospital system between the years 2010 and 2020.
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Affiliation(s)
- Matthew Barfield
- School of Medicine Columbia, University
of South Carolina, Columbia, SC, USA,Matthew Barfield, School of Medicine
Columbia, University of South Carolina, 6311 Garners Ferry Rd., Columbia, SC
29209, USA.
| | - J Benjamin Jackson
- Department of Orthopedic Surgery,
Prisma Health Midlands, Columbia, SC, USA,Department of Orthopaedic Surgery,
University of South Carolina, Columbia, SC, USA
| | - Tyler Gonzalez
- Department of Orthopedic Surgery,
Prisma Health Midlands, Columbia, SC, USA,Department of Orthopaedic Surgery,
University of South Carolina, Columbia, SC, USA
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4
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Stowers JM, Black AT, Kavanagh AM, Mata KDL, Bohm A, Katchis SD, Weiner LS, Spielfogel W, Rahnama A. Predicting Nonunions in Ankle Fractures Using Quantitative Tibial Hounsfield Samples From Preoperative Computed Tomography: A Multicenter Matched Case Control Study. J Foot Ankle Surg 2022; 61:562-566. [PMID: 34819267 DOI: 10.1053/j.jfas.2021.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 07/12/2021] [Accepted: 10/05/2021] [Indexed: 02/06/2023]
Abstract
The aim of this study is to use tibial Hounsfield unit measurements from preoperative computed tomography scans of ankle fractures to predict delayed union and nonunion. We hypothesize that patients with lower Hounsfield unit averages, an indirect measure of lower bone mineral density, in the distal tibia are more likely to develop delayed union and nonunion complications after ankle fracture surgery. Patient data from January 2010 to January 2020 were retrospectively analyzed from 2 institutions. Exposure cases of delayed union or nonunion that had preoperative computed tomography were compared to 5 controls matched for sex, age, and classification. 3 measurements were taken from the tibia on axial computed tomography and averaged to create a summative measure for overall bone health. Statistical analysis was used to analyze the relationship between the groups. 19 exposure patients were compared to 95 control patients. There were 16 females and 3 males in the exposure group aged from 30 to 88 years. Average follow-up was 1.6 years. The average exposure and control Hounsfield measurements were 186 (161-210) and 258 (248-269), respectively. Significant differences were found for all measured averages. This is the first study to our knowledge relating preoperative tibial Hounsfield measurements to healing rates of ankle fractures. Measurements taken from any of the 3 sites or the average could be an indicator of overall bone health. Using this technique on preoperative imaging will help surgeons adjust their perioperative planning for patients at higher risk for delayed union and nonunion.
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Affiliation(s)
- Jered M Stowers
- ACFAS Surgical Fellow, Foot and Ankle Institute Fellowship, Indianapolis, IN.
| | - Alexandra T Black
- ACFAS Surgical Fellow, Foot and Ankle Specialists of Central Ohio Foot and Ankle Surgery Fellowship, Columbus, OH
| | - Amber M Kavanagh
- Resident Physician, Department of Plastics Surgery, Medstar Georgetown University Hospital, Washington, DC
| | - Karla De La Mata
- Resident Physician, Department of Podiatric Surgery, Northwell Lenox Hill Hospital, New York, NY
| | - Andrew Bohm
- Biostatistician, Department of Orthopedics, Lenox Hill Hospital Northwell Health, New York, NY
| | - Stuart D Katchis
- Section Chief Foot and Ankle, Department of Orthopedics, Lenox Hill Hospital Northwell, New York, NY
| | - Lon S Weiner
- Program Director, Department of Orthopedics, Lenox Hill Hospital Northwell, New York, NY
| | - William Spielfogel
- Chief of Podiatry, Department of Orthopedics, Lenox Hill Hospital Northwell, New York, NY
| | - Ali Rahnama
- Fellowship Trained Foot and Ankle Surgeon Assistant Professor, Georgetown University, School of Medicine, Washington, DC
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5
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[Translated article] Position statement relating ankle fractures in major outpatient surgery. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022. [DOI: 10.1016/j.recot.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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6
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Documento de posicionamiento respecto a las fracturas de tobillo en cirugía mayor ambulatoria. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:229-234. [DOI: 10.1016/j.recot.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 10/18/2022] Open
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Burton BN, Carter D, Dalstrom DJ, Said ET, Gabriel RA. The Influence of Obesity on Hospital Admission After Outpatient Foot and Ankle Surgery. J Foot Ankle Surg 2021; 60:738-741. [PMID: 33814311 DOI: 10.1053/j.jfas.2020.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/13/2020] [Accepted: 09/25/2020] [Indexed: 02/03/2023]
Abstract
We examined the association of body mass index (BMI) with sociodemographic data, medical comorbidities and hospital admission following ambulatory foot and ankle surgery. We conducted an analysis utilizing data from the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2016. Adult patients who underwent ankle surgery defined as ankle arthrodesis, ankle open reduction and internal fixation, and Achilles tendon repair in the outpatient setting. We examined 6 BMI ranges: <20 kg/m2 underweight, ≥20 to <25 kg/m2 normal weight, ≥25 to <30 kg/m2 overweight, ≥30 to <40 kg/m2 obese, ≥40 kg/m2to <50 kg/m2 severely obese, and ≥50 kg/m2 extremely obese. The primary outcome was hospital admission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p value of <.05 as statistically significant. Data extraction yielded 13,454 adult patients who underwent ambulatory ankle surgery. We then performed listwise deletion to exclude cases with missing observations. After excluding 5.4% of the data, the final study population included 12,729 patients. The overall rate of hospital admission was in the population was 18.6% (2,377/12,729). The overall rate of postoperative complications was 0.03% (4/12,729). We found no significant association of BMI with hospital admission following multivariable logistic regression. We recommend that BMI alone should not be solely used to exclude patients from having ankle surgery performed in an outpatient setting, especially since this patient group makes up a significant proportion of orthopedic surgery.
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Affiliation(s)
- Brittany N Burton
- Anesthesiology Resident, Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA.
| | - Devon Carter
- Medical Student, Charles R. Drew/University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA
| | - David J Dalstrom
- Associate Clinical Professor, Department of Orthopedic Surgery, University of California, San Diego, La Jolla, CA
| | - Engy T Said
- Associate Clinical Professor, Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA
| | - Rodney A Gabriel
- Associate Clinical Professor, Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA; Associate Clinical Professor, School of Medicine, University of California, San Diego, La Jolla, CA
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8
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Womble TN, Comadoll SM, Dugan AJ, Davenport DL, Ali SZ, Srinath A, Matuszewski PE, Aneja A. Is supplemental regional anesthesia associated with more complications and readmissions after ankle fracture surgery in the inpatient and outpatient setting? Foot Ankle Surg 2021; 27:581-587. [PMID: 32917527 DOI: 10.1016/j.fas.2020.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/14/2020] [Accepted: 07/31/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is concern that regional anesthesia is associated with increased risk of complications, including return to the hospital for uncontrolled pain once the regional anesthetic wears off. METHODS Retrospective database review of patients who underwent open reduction and internal fixation of a closed ankle fracture from 2014-16 who received general anesthesia alone (GA) or general anesthesia plus regional anesthesia (RA). RESULTS 9459 patients met inclusion criteria. Patients in the RA group had significantly longer operative duration in both inpatient (GAI=71min vs RAI=79min, p=0.002) and outpatient setting (GAO=66min vs RAI=72min, p<0.001), lower overall LOS (GA=1.7 days vs RA=1.1 days, p<0.001), and higher readmission rate for pain (RAO=4 [0.3%] vs GAO=1 [0.0%], p=0.007). CONCLUSIONS Patients who received supplemental regional anesthesia had shorter hospital LOS, increased operative time, and increased readmission rates for rebound pain. However, the small number of patients needing readmission are not clinically significant demonstrating that regional anesthesia is safe, effective and readmission for rebound pain should not be a concern. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Tanner N Womble
- School of Medicine, University of Kentucky, Lexington, KY, USA
| | - Shea M Comadoll
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Adam J Dugan
- Department of Biostatistics, University of Kentucky College of Public Health, Lexington, KY, USA
| | - Daniel L Davenport
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Syed Z Ali
- Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Arjun Srinath
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Paul E Matuszewski
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA.
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9
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Shields CN, Solasz S, Gonzalez LJ, Tong Y, Konda SR, Egol KA. Outpatient lower extremity fracture surgery: should we be concerned? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:719-723. [PMID: 34101006 DOI: 10.1007/s00590-021-03029-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 04/09/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE With rising healthcare costs and insurance push against non-emergent hospital admission, lower extremity fracture treatment is shifting toward outpatient procedures over inpatient hospitalizations. This study compares outcomes for fractures treated as inpatient versus outpatient. METHODS We conducted a retrospective review of lower extremity fracture patients. We collected demographics, injury information, hospital course, and complication data. Length of stay was categorized as "inpatient" and "outpatient" based a 24-h hospital stay cutoff. Data analysis included differences between cohorts with regards to readmissions and complications. RESULTS We identified 229 patients who met inclusion criteria. Inpatient versus outpatient status was predictive of in-hospital complications; however, inpatient versus outpatient status did not predict 1-year readmission. CONCLUSION Outpatient surgery is safe and effective. As the population increases and ages, low-risk surgeries should be considered for outpatient rather than inpatient stays to lower costs, save resources, and reduce complications.
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Affiliation(s)
- Charlotte N Shields
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Medical Center, 301 E 17th Street, New York, NY, 10003, USA
| | - Sara Solasz
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Medical Center, 301 E 17th Street, New York, NY, 10003, USA
| | - Leah J Gonzalez
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Medical Center, 301 E 17th Street, New York, NY, 10003, USA
| | - Yixuan Tong
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Medical Center, 301 E 17th Street, New York, NY, 10003, USA
| | | | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Medical Center, 301 E 17th Street, New York, NY, 10003, USA. .,Jamaica Hospital Medical Center, Queens, NY, USA.
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10
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Reider L, Pollak A, Wolff JL, Magaziner J, Levy JF. National trends in extremity fracture hospitalizations among older adults between 2003 and 2017. J Am Geriatr Soc 2021; 69:2556-2565. [PMID: 34062611 DOI: 10.1111/jgs.17281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Fractures in late life are highly consequential for health, services use, and spending. Little is known about trends in extremity fracture hospitalizations among older adults in the United States. DESIGN Retrospective longitudinal cohort study. SETTING The 2003-2017 National Inpatient Sample (NIS), a representative sample of U.S. community hospitals. PARTICIPANTS Hospitalized adults aged 65 and older with a diagnosis of upper or lower extremity fracture. MEASUREMENTS Incidence of extremity fracture hospitalization and mortality, using NIS discharge and trend weights, and population denominators derived from the U.S. Census Bureau. Incidence was reported separately for men and women by age, fracture diagnosis, and injury mechanism. Weighted linear regression was used to test for significant trends over time. RESULTS Incidence of extremity fracture hospitalizations declined in both women (15.7%, p trend < 0.001) and men (3.2%, p trend < 0.001) between 2003 and 2017. This trend was primarily attributed to a decline in low energy femur fractures which accounted for 65% of all fracture hospitalizations. Among older adults with an extremity fracture hospitalization, mortality declined from 5.1% in 2003 to 3.3% in 2017 in men, and from 2.6% to 1.9% in women (p trend < 0.001). High energy fractures were due to falls (53%), motor vehicle accidents (34%), and other high impact injuries (13%). Overall, 12% of extremity fracture hospitalizations were attributed to high-energy injuries: increases were observed among men ages 65-74 (20%; p trend < 0.001) and 75-84 (10%; p trend = 0.013), but not among women of any age. CONCLUSION Observed declines in the incidence of extremity fracture hospitalizations and related mortality are encouraging. However, increasing incidence of fracture hospitalization from high energy injuries among men suggests that older adults with complex injuries will be seen with more prevalence in the future.
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Affiliation(s)
- Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andrew Pollak
- School of Medicine, Department of Orthopaedics, University of Maryland, Baltimore, Maryland, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jay Magaziner
- School of Medicine, Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland, USA
| | - Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Malik AT, Quatman CE, Ly TV, Phieffer LS, Khan SN. Refining Risk-Adjustment of 90-Day Costs Following Surgical Fixation of Ankle Fractures: An Analysis of Medicare Beneficiaries. J Foot Ankle Surg 2020; 59:5-8. [PMID: 31882148 DOI: 10.1053/j.jfas.2019.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/10/2019] [Accepted: 05/12/2019] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Azeem Tariq Malik
- Research Fellow, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Carmen E Quatman
- Assistant Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Thuan V Ly
- Associate Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Laura S Phieffer
- Associate Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Safdar N Khan
- Associate Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
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12
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Simske NM, Audet MA, Kim CY, Vallier HA. Open ankle fractures are associated with complications and reoperations. OTA Int 2019; 2:e042. [PMID: 33937670 PMCID: PMC7997115 DOI: 10.1097/oi9.0000000000000042] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 06/22/2019] [Indexed: 01/14/2023]
Abstract
Objectives: To assess clinical and functional outcomes after open versus closed ankle fracture. Design: Retrospective comparative study. Location: Level 1 Trauma Center. Patients/Participants: 1303 patients treated for ankle fractures (Weber B and C) between 2003 and 2015. One hundred sixty-five patients (12.7%) presented with open fracture and 1138 (87.3%) with closed fracture. Intervention: Surgical or conservative management of ankle fracture. Main Outcome Measure: Rates of complications and reoperations. Patient-reported functional outcomes were assessed with the Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA), after a minimum of 12 months. Results: Mean age was 46 years and 49% of patients were male. Higher mean age was associated with open injuries (51 vs 45 years, P < 0.001), and fractures were increasingly open with aging. Open fractures were associated with high-energy mechanisms: 44% following motor vehicle or motorcycle collisions, although the majority of open fractures in patients >65 years occurred after ground-level fall. Complications occurred more often after open fracture (33% vs 11%) and necessitated more secondary procedures (19% vs. 7%), both P < 0.001. Multivariate regression analysis identified open fracture as a predictor of complications and of worse scores on the activity categories of both the FFI and SMFA. Conclusion: Open fractures occurred more often after high energy mechanisms, and were generally more complex than closed fractures. Advanced age was common among open fracture patients, likely contributing to higher complication and secondary procedure rates. Greater morbidity after open ankle fractures was associated with minor differences on activity functions of the FFI and SMFA. Level of Evidence: Level 3, prognostic
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Affiliation(s)
- Natasha M Simske
- MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
| | - Megan A Audet
- MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
| | - Chang-Yeon Kim
- MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
| | - Heather A Vallier
- MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
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