Peripheral nerve block use in ankle arthroplasty and ankle arthrodesis: utilization patterns and impact on outcomes.

PURPOSE: Ankle arthrodesis and total ankle arthroplasty (TAA) are often associated with significant postoperative pain. While this may be mitigated by the use of peripheral nerve blocks (PNB), large-scale data are lacking. Using national data, we aimed to evaluate PNB utilization pattern and its impact on outcomes. METHODS: This retrospective cohort study utilized data from the nationwide database (2006-2016) on TAA (n = 5,290) and ankle arthrodesis (n = 14,709) procedures. PNB use was defined from billing; outcomes included opioid utilization, length and cost of stay, discharge to a skilled nurse facility, and opioid-related complications. Mixed-effects models estimated the association between PNB use and outcomes, separate by procedure type and inpatient/outpatient setting. We report odds ratios and 95% confidence intervals (CI). RESULTS: Overall, PNB was utilized in 8.7% of TAA and 9.9% of ankle arthrodesis procedures, with increased utilization from 2006 to 2016 of 2.6% to 11.3% and 5.2% to 12.0%, respectively. After adjustment for relevant covariates, PNB use was significantly associated with decreased total opioid utilization specifically in the inpatient setting in TAA ( - 16.9% CI  - 23.9%;  - 9.1%) and ankle arthrodesis procedures ( - 18.9% CI  - 24.4;  - 13.0%), this was particularly driven by a decrease in opioid utilization on the day of surgery. No clinically relevant effects were observed for other outcomes. CONCLUSION: PNB utilization is associated with substantial reductions in opioid utilization, particularly in the inpatient setting. Our study is in support of a wider use of this analgesic technique, which may translate into more benefits in terms of clinical outcomes and resource utilization. LEVEL OF EVIDENCE: III.

Economic impact of Comorbidities in Total Ankle Arthroplasty and Ankle Arthrodesis.

BACKGROUND: The 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 limited. The goal of this study is to study the comorbidity burden for TAA and ankle arthrodesis. HYPOTHESIS: Comorbidity burden is associated with higher resource utilization for both TAA and ankle arthrodesis. PATIENTS AND 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 (DCCI) groups. Outcomes were cost of hospitalization, length of stay (LOS), total opioid utilization, discharge to a skilled nursing facility (SNF), and 30-day readmission. Mixed-effects models estimated associations between DCCI and outcomes. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI). RESULTS: In the TAA group, 67.9% of patients were in DCCI category 0 while 22.4%, 6.6%, and 3.1% were in the 1, 2, and >2 DCCI categories, respectively. This was 61.3%, 18.1%, 9.8% and 10.9% in the ankle arthrodesis group. The most common comorbidities were obesity, diabetes mellitus, and chronic pulmonary disease. Particularly in the ankle arthrodesis group, the proportion of patients with comorbidities has increased over time. After adjustment for relevant covariates, patients in the DCCI group >2 (compared to '0') were associated with stepwise effects of up to 77.1% (CI 70.9%; 83.6%) longer length of stay and up to 48.5% (CI 44.0%; 53.2%) higher cost of hospitalization. DISCUSSIONS: Comorbidity burden is increasing among patients undergoing ankle arthrodesis where it is associated with significantly increased resource utilization. Our data demonstrate the potential impact of patient selection, which may be crucial in optimizing preoperative status. LEVEL OF EVIDENCE: III.

Opioid Consumption and Time to Return to Work After Percutaneous Osteotomy in Foot Surgery.

Surgeries involving the foot and ankle are painful procedures, with many patients unwilling to discontinue prescribed narcotics at 3 months postoperatively. Percutaneous techniques allow for smaller incisions and minimal soft tissue disruption. Fifty consecutive patients underwent outpatient percutaneous foot surgery. Data were collected on pain medication taken and time to return to work. A mean of 3.3 tablets of oxycodone were consumed during the first 2 weeks. No patient was taking narcotics after 2 weeks. Mean time to return to work was 18.9 days. Percutaneous foot and ankle surgery led to a significant reduction in narcotic consumption. [Orthopedics. 2020;43(4):e334-e337.].

Surgeon Type and Outcomes After Inpatient Ankle Arthrodesis and Total Ankle Arthroplasty: A Retrospective Cohort Study Using the Nationwide Premier Healthcare Claims Database.

BACKGROUND: Two main treatments for end-stage ankle arthritis are ankle arthrodesis and total ankle arthroplasty (TAA). While both procedures can be performed either by a foot and ankle orthopaedic surgeon or a podiatrist (when within a particular state's scope of practice), studies comparing the surgical outcomes of the 2 surgeon types are lacking. Therefore, in this study, we compared outcomes by surgeon type for TAA and for ankle arthrodesis. METHODS: This retrospective cohort study utilized data from the nationwide Premier Healthcare claims database (2011 to 2016) regarding TAA (n = 3,674) and ankle arthrodesis (n = 4,980) procedures. Multivariable models estimated associations between surgeon type (podiatrist versus orthopaedic foot and ankle surgeon) and opioid utilization (in oral morphine equivalents [OMEs]), length of stay, and cost of hospitalization. We report percent change (compared with reference) and 95% confidence intervals (CIs). RESULTS: Overall, 76.5% (n = 2,812) and 18.8% (n = 690) of TAA procedures were performed by orthopaedic foot and ankle surgeons and podiatrists, respectively; surgeon type was unknown for 4.7% (n = 172). For ankle arthrodesis, 75.3% (n = 3,752) and 18.3% (n = 912) of the procedures were performed by orthopaedic foot and ankle surgeons and podiatrists, respectively; surgeon type was unknown for 6.3% (n = 316). The proportion of TAA and ankle arthrodesis procedures performed by podiatrists increased over time, from 12.8% and 13.6% in 2011 to 24.6% and 26.0% in 2016, respectively. When adjusting for relevant covariates, procedures performed by podiatrists (compared with orthopaedic foot and ankle surgeons) were associated with increased length of stay: for TAA, +16.7% (95% CI, 7.6% to 26.5%; median, 2 days in both groups) and for ankle arthrodesis, +14.2% (95% CI, 7.9% to 20.9%; median, 3 compared with 2 days) (p < 0.05 for both). In addition, ankle arthrodesis performed by podiatrists was associated with increased cost of hospitalization: +28.5% (95% CI, 22.1% to 35.2%; median, $19,236 compared with $13,433) (p < 0.05). Differences in opioid utilization were nonsignificant in the main analysis: +10.9% (95% CI, -3.1% to 26.8%; median, 345 compared with 250 OMEs) and +2.8% (95% CI, -5.9% to 12.4%; median, 351 compared with 315 OMEs) for TAA and ankle arthrodesis, respectively. CONCLUSIONS: An increasing trend in the proportion of procedures performed by podiatrists was coupled with apparent increases in length of stay and cost compared with procedures performed by orthopaedic foot and ankle surgeons. Given the increasing demand for these procedures, factors associated with resource utilization, such as type of surgeon, may be increasingly important on the population level. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.