Unicompartmental Knee Arthroplasty: More Conversions, Fewer Complications Than Proximal Tibial Osteotomy in a Young Population.

BACKGROUND: Patients with isolated medial compartment osteoarthritis requiring surgical intervention generally have two surgical options: unicompartmental knee arthroplasty (UKA) and proximal tibial osteotomy (PTO). Outcomes of reoperation rates and survivorship are important for counseling patients on treatment options. METHODS: A retrospective, comparative cohort study was performed for a consecutive series of patients in the Military Health System who underwent either UKA or PTO between 2003 and 2018. All patients were between 18 and 55 years old and diagnosed with isolated medial compartmental arthritis. Cases with concurrent meniscal or cartilage procedures were included, while cases with concurrent ligament reconstruction were excluded. A minimum 2-year follow-up was required. The primary outcome was conversion to total knee arthroplasty, and the secondary outcome was reoperation for any reason. RESULTS: A total of 383 procedures were performed for isolated medial compartment arthritis in 303 patients (UKA 270, PTO 113). A multivariate analysis showed that PTO was associated with decreased risk of conversion to TKA compared to UKA (P = .0364). However, the reoperation due to complications was significantly higher in the PTO group (21.2% vs 2.2%; P ≤ .01). The 5-year conversion rate was 13.7% for UKA and 3.5% for PTO (P = .0033) with an average time to conversion of 3.1 years for UKA and 2.9 years for PTO (P = .7805). CONCLUSIONS: In young patients with isolated medial compartment arthritis, conversion rates to TKA are higher with UKA compared to PTO. However, overall reoperation rate is higher with PTO, secondary to complications and revision procedures. Overall survivorship is acceptable for both procedures.

Variation in Implant Selection for Ankle Fractures: Identifying Cost Drivers.

BACKGROUND: Implant selection is the first opportunity for surgeons to control costs of fracture fixation. The current literature has demonstrated surgeons' poor understanding of implant costs. Our study evaluated implant cost variability for surgically treated ankle fractures and distal tibia fractures. Our hypothesis was that significant cost variation exists among providers. The goal was to identify cost drivers and determine whether specialty training is linked to implant selection. METHODS: A retrospective 2010-2017 chart review was performed for 1281 patients at a Level I trauma center. Patients were excluded for skeletal immaturity, open fractures, polytrauma, and concurrent surgeries. Variables were assessed included age, sex, body mass index, OTA/AO classification, Weber classification, 1-year reoperation status, surgeon specialty, and use of syndesmotic screws, locking plates, and cannulated screws. Construct cost was determined by using electronic medical record implant model numbers cross-referenced with the chargemaster database. Statistical analysis involved intergroup comparative tests, regression analysis, and goodness-of-fit analyses. RESULTS: Implant cost was different among OTA patterns (P < 0.01), highest among 43C ($3771) and lowest with 44A ($819). Construct costs of OTA 43 fractures varied from $2568 to 3771, whereas OTA 44 ranged from $819 to $1474. Costs were comparable across Weber patterns (P = 0.15), with Weber B having the highest ($1494). Costs were highest among reconstructive, podiatry, and spine surgeons, with mean costs of $1804, $1404, and $1396, respectively. Traumatologist constructs had the lowest overall price ($987). A total of 433 (33.8%) procedures used locking plates with 512 (40.0%) using at least one cannulated screw. Locking plates averaged a larger total implant cost ($1947) than nonlocking plates ($1313) but had a comparable reoperation rate (18.5% vs. 17.7%, P = 0.81). Use of a cannulated screw presented a higher total cost ($2008 vs. $1435) with comparable reoperation rates (17.4% vs. 18.8%, P = 0.72). A total of 401 (31.5%) patients received syndesmotic fixation and a significantly higher reoperation rate (17.0% vs. 11.0%, P < 0.01). Overall, 199 patients underwent elective hardware removal, 23 were infected, 7 required revision, and 3 were identified with a nonunion. CONCLUSIONS: Our study demonstrated significant variability in implant costs for ankle fracture fixation and identified the key cost drivers as locking plates and cannulated screws. Surgical management of ankle fractures could be an ideal setting to pilot economic alignment between physicians and hospitals to drive value. LEVEL OF EVIDENCE: Level III. Retrospective Cohort.

Acute Treatment of Open Foot and Ankle Fractures Using a Bioartificial Dermal Regeneration Template and Split-Thickness Skin Grafting: A Report of 2 Cases.

CASE: Two patients with open foot and ankle fractures were treated with aggressive irrigation and debridement and acute placement of a dermal regeneration template (DRT) followed by split-thickness skin grafting. Patient 1 was an 82-year-old female with a type IIIB open ankle fracture complexed with 2 significant regions of soft tissue loss. Patient 2 was a 54-year-old male with type IIIB open metatarsal fractures. Both patients healed without complication. CONCLUSIONS: Complex open fractures in lower extremities can be managed with acute DRT application. This may be a more cost-effective solution compared to free flaps.