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Category: Trauma; Ankle; Sports; Other Introduction/Purpose: Increasing overlap exists between surgical care provided by orthopedic foot and ankle surgeons and podiatrists. Use of either specialty depends on numerous factors including perceived costs. Unfortunately, large scale cost comparisons between the two are lacking. Such data is increasingly important given the current climate of payment reform and cost containment in healthcare. Using national Medicare claims data, we therefore aimed to compare per-case Medicare payments between orthopedic foot and ankle surgeons and podiatrists for ankle fracture fixation. We additionally aimed to describe any differences between groups that may drive differences in payments. Methods: This IRB-exempt retrospective study included patients undergoing either unimalleolar, bimalleolar, or trimalleolar ankle fracture repair as recorded in the national Medicare Limited Data Set (2013-2019). Type of surgeon (orthopedic foot and ankle surgeon or podiatric surgeon) was determined using publicly available healthcare provider taxonomy information available from the Washington Publishing Company ( www.wpc-edi.com ) and maintained by the National Uniform Claim Committee ( www.nucc.org ); crosswalks between Medicare Specialty Code and Provider Taxonomy are publicly available. The primary outcome was total Medicare payments specific to the procedure, as a surrogate for cost (inflation-adjusted to 2019 US dollars). Additionally, patient demographics and hospital characteristics were compared between groups to determine if any specific factors associated with costs may influence group differences. Univariable tests (chi-squared and t-tests; non-parametric tests where appropriate) assessed significance of group differences. Results: Overall, 16,927 unimalleolar; 17,244 bimalleolar; and 11,717 trimalleolar fracture repairs were included. Of these, orthopedic surgeons performed more procedures than podiatrists (86.7% vs 13.3% for uni-; 92.4% and 7.6% for bi-; 92.2% and 7.8% for trimalleolar fracture repairs respectively). The mean and median age (71.6 - 72.7 [70-71] years) as well as the mean and median Charlson-Deyo Comorbidity Index (0.6 - 0.7 [0]) did not significantly differ between patients treated by an orthopedic surgeon or podiatrist (p = 0.157 and p = 0.890 respectively). Regionally, podiatrists saw patients more often in the West and Midwest whereas providers in the South were more often orthopedic surgeons (p < 0.001). Median procedure-specific Medicare payments for all three categories of ankle fracture repairs were significantly lower for orthopedic surgeons compared to podiatrists: $4,156 vs $4,300 for uni-, $4,205 vs $4,379 for bi-, and $4,396 vs $4,525 for trimalleolar, respectively (all p < 0.001). Conclusion: In this analysis comparing Medicare payments between orthopedic foot and ankle surgeons and podiatrists we found that ankle fracture fixation procedures performed by the orthopedic surgeons were less expensive and that cost differences do not appear to be driven by patient characteristics. Additionally, we were able to discern geographic differences regarding practice location of both surgeon types. These data will inform future discussions on how to optimize costs of foot and ankle surgical care.

Background: Closed wound drainage has been extensively studied in the hip and knee arthroplasty literature with equivocal results on its clinical benefits. Although also used in orthopaedic surgeries like ankle arthrodesis and ankle arthroplasty, large-scale data are currently lacking on utilization patterns and real-world effectiveness. We, therefore, aimed to address this research gap in this distinct surgical cohort using national claims data. Methods: Using the Premier Healthcare claims database from 2006 to 2016, ankle arthrodesis (n=10,085) and ankle arthroplasty (n=4,977) procedures were included. The main effect was drain use, defined by detailed billing descriptions. Outcomes included blood transfusion, 90-day readmission, and length and cost of hospitalization. Mixed-effects models measured associations between drain use and outcomes. Odds ratios (OR, or % change), 95% CIs, and P values are reported. Results: Overall, drains were used in 11% (n=1,074) and 15% (n=755) of ankle arthrodesis and ankle arthroplasty procedures, respectively. Drain use dramatically decreased over the years in both surgery types: from 14% to 6% and 24% to 7% between 2006 and 2016, for arthrodesis and ankle arthroplasty procedures, respectively. After adjustment for relevant covariates, drain use was associated with increased odds of blood transfusion in ankle arthrodesis surgery (OR 1.4, CI 1.1-1.8, P = .0168), whereas differences that were statistically but not clinically significant were seen in cost and length of stay. In total ankle arthroplasty, no statistically significant associations were observed between drain use and the selected outcomes. Conclusion: This is the first national study on drain use in ankle surgery. We found a decrease in use over time. Drain use was associated with higher odds of blood transfusion in ankle arthrodesis patients. Although this negative effect may be mitigated by the rapidly decreasing use of drains, future studies are needed to discern drivers of drain use in this distinct surgical population. Level of Evidence: Level III, retrospective cohort study

Category: Ankle, Ankle Arthritis, Diabetes Introduction/Purpose: Demand for total ankle arthroplasty (TAA) and ankle arthrodesis surgery is increasing. Findings from other orthopaedic populations suggest an increasing comorbidity burden among those planned for surgery, however, data on TAA and ankle arthrodesis is lacking. Methods: This retrospective cohort study utilized data from the nationwide Premier Healthcare Database (2006-2016) which contains inpatient claims on N=10,085 ankle arthrodesis and N=4,977 TAA procedures. Patients were categorized into Deyo Charlson comorbidity index groups with higher scores representing higher comorbidity burden: 0, 1, 2, =3. Outcomes were cost of hospitalization, length of stay (LOS), total opioid utilization (in oral morphine equivalents), discharge to a skilled nursing facility (SNF) and 30-day readmission. Mixed-effects models estimated associations between Deyo-Charlson comorbidity index and outcomes. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI). Results: In the TAA group, 64.4% of patients were in Deyo-Charlson category 0 while 24.1%, 7.6%, and 3.9% were in the 1, 2, and =3 Deyo-Charlson categories, respectively; this was 50.3%, 23.2%, 12.4% and 14.1% in the ankle arthrodesis group. The most common comorbidities were obesity, diabetes mellitus and chronic pulmonary disease. After adjustment for relevant covariates, patients in the Deyo-Charlson group =3 (compared to ‘0’) were associated with stepwise effects of 77.1% (CI 70.9%;83.6%) longer LOS and 48.5% (CI 44.0%;53.2%) higher cost of hospitalization with higher odds for admission to a SNF (OR=3.12 CI 2.64;3.70), all P

Category: Ankle, Ankle Arthritis Introduction/Purpose: Ankle arthrodesis (AA) and total ankle arthroplasty (TAA) are often associated with significant postoperative pain; this may be mitigated by the use of peripheral nerve blocks (PNB). While smaller studies suggest PNB to be an effective pain management option in foot and ankle procedures, large scale comparative effectiveness data in ankle arthrodesis and TAA is lacking. Therefore, the purpose of this national study was to evaluate PNB utilization patterns and its impact on outcomes such as opioid utilization. Methods: This retrospective cohort study utilized data from the nationwide Premier Perspective claims database (2006-2016) on AA (n=10,049) and TAA (n=4,977) procedures. Mixed-effects models estimated associations between PNB use (defined from inpatient billing) and opioid utilization (during the total hospitalization period and specified by each day), hospitalization costs, length of stay (LOS), admission to skilled nurse facility (SNF), opioid-related complications, and 90-day readmission. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI). Results: Overall, PNB was utilized in 8.6% of TAA and 8.5% of AA. Both procedures demonstrate increased utilization of PNB from 2006 to 2016 (2.7% to 11.7% and 5.5% to 11.7% for TAA and AA, respectively). In general, PNBs were utilized less in non- teaching and smaller hospitals and among surgeries performed by a podiatrist (compared to orthopaedic surgeon). After adjustment for relevant covariates, PNB use was significantly associated with decreased opioid utilization during the total hospitalization period for both TAA (-15.7%, CI 22.8; 7.9%) and AA (-16.0%, CI 21.9%; 9.7%); this was particularly driven by a decrease in opioid utilization on the day of surgery. PNB use was not associated with reductions in LOS, cost of hospitalization, discharge to SNF, complications, 90-day readmission. Conclusion: In this first national study on PNB use in ankle procedures we found an overall low use of PNB while an increasing trend in utilization was observed. Importantly, PNB use was associated with significant opioid-sparing effects (especially on the day of surgery), while no effects were seen for other outcomes. Given the current low utilization rate, increased use of this analgesic technique may translate into more benefits in terms of clinical outcomes and resource utilization.

Background: Monthly incidence of elbow ulnar collateral ligament (UCL) injuries and surgeries is relatively unknown. Defining seasonal peaks of UCL injuries and surgeries may identify opportunities for injury-prevention strategies. The purpose of this study is to analyze seasonal and monthly variations in UCL injuries and surgeries across the United States with emphasis on the timing of baseball season. Methods: The Truven Health MarketScan database (2013-2015) was queried for patients younger than 40 years with a diagnosis code of elbow UCL sprain and a procedural code for UCL repair or reconstruction. Differences in patient characteristics were evaluated using chi-square and Mann-Whitney U-tests. Negative binomial regression models were calculated for UCL injuries and surgeries to assess monthly trends. Results: UCL injuries were sustained by 13,894 patients, with 1404 (10.1%) patients having undergone surgery. The median age at first diagnosis was 17 years, and the median age of patients requiring surgery decreased from 20 to 18 years from 2013 to 2015 (P = .75). Most UCL injuries (n = 3785) and surgeries (n = 438) occurred during the spring season (March 21-June 20), and spring injuries were most likely to result in surgical management (11.6%). During the baseball season (March to September), the number of UCL injuries peaked in April/May, then declined, except for a second peak in September/October (incidence rate ratio 0.97; confidence interval 0.95, 0.99; P = .01). The number of UCL surgeries steadily increased from March (n = 116) to June (n = 152), followed by a gradual decline (incidence rate ratio 1.00; confidence interval 0.96, 1.04; P = .99). Conclusion: Athletes frequently experienced UCL injuries and surgeries in the early months (April-June) of the baseball season. More emphasis should be paid to rehabilitative strategies at the beginning of a baseball season to help mitigate injury risk.

Background: Perianchor cyst formation (PCF) can occur after arthroscopic rotator cuff repair with poly-L-lactic acid (PLLA) anchors; however, little is known about PCF after all-suture anchor (ASA) use. Methods: We reviewed patients who underwent double-row arthroscopic rotator cuff repair from 2012 to 2017 with ASAs implanted in the medial row and PLLA anchors in the lateral row. We evaluated PCF (graded on magnetic resonance imaging) and compared physical examination and functional surveys between patients with PCF (WC) and without PCF (WoC) at long-term follow-up. Results: Among twenty-two patients (23 shoulders), 93% of PLLA anchors (vs. 79% ASA) displayed a grade 0 PCF, P = .100. No PLLA anchors had a grade 3 or 4 PCF, compared to 11% of ASAs, P = .158. At a mean postoperative follow-up time of 113 weeks, there was no significant difference between WC and WoC cohorts with regard to range of motion, rotator cuff strength, American Shoulder and Elbow Surgeons survey scores, or retear rates. However, the WoC cohort had a significantly higher University of California at Los Angeles shoulder survey score at final follow-up (34.3 WoC vs. 30.9 WC, P = .024). Conclusion: No difference was found in PCF between ASAs and PLLA anchors. At long-term follow-up, WoC patients had significantly improved functional outcome scores, based on the University of California at Los Angeles survey, but equivalent range of motion and rotator cuff strength examinations compared with WC patients.