Large Individual Bilateral Differences in Tibial Torsion Impact Accurate Contralateral Templating and the Evaluation of Rotational Malalignment.

OBJECTIVE: To determine individual bilateral differences (IBDs) in tibial torsion in a diverse population. METHODS: Computed tomography scans of uninjured bilateral tibiae were used to determine tibial torsion and IBDs in torsion using 4 measurement methods. Age, sex, and self-identified race/ethnicity were also recorded for each subject. Mean tibial torsion and IBDs in torsion were compared in the overall cohort and when stratified by sex and race/ethnicity. Simple and multiple linear regression models were used to correlate demographic variables with tibial torsion and IBDs in torsion. RESULTS: One hundred ninety-five patients were evaluated. The mean tibial torsion was 27.5 ± 8.3 degrees (range -3 to 47.5 degrees). The mean IBD in torsion was 5.3 ± 4.0 degrees (range 0-23.5 degrees, P < 0.001). 12.3% of patients had IBDs in torsion of ≥10 degrees. In the regression analysis, patients who identified as White had greater average torsion by 4.4 degrees compared with Hispanic/Latinx patients (P = 0.001), whereas age and sex were not significantly associated with absolute torsion. Demographics were not associated with significant differences in IBDs in torsion. CONCLUSIONS: Tibial torsion varies considerably and individual side-to-side differences are common. Race/ethnicity was associated with differences in the magnitude of tibial torsion, but no factors were associated with bilateral differences in torsion. The results of this study may be clinically significant in the context of using the uninjured contralateral limb to help establish rotational alignment during medullary nail stabilization of diaphyseal tibia fractures. In addition, these findings should be considered in the evaluation of tibia rotational malalignment. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Factors Associated With Distal Femoral Osteotomy Survivorship: Data From the California Office of Statewide Health Planning and Development (OSHPD) Registry.

BACKGROUND: Malalignment of the lower extremity can lead to early functional impairment and degenerative changes. Distal femoral osteotomy (DFO) can be performed with arthroscopic surgery to correct lower extremity malalignment while addressing intra-articular abnormalities or to help patients with knee osteoarthritis (OA) changes due to alignment deformities. PURPOSE: To examine survivorship after DFO and identify the predictors for failure. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data from the California Office of Statewide Health Planning and Development, a statewide discharge database, were utilized to identify patients between the ages of 18 and 40 years who underwent DFO from 2000 to 2014. Patients with a history of lower extremity trauma, infectious arthritis, rheumatological disease, skeletal dysplasia, congenital deformities, malignancy, or concurrent arthroplasty were excluded. Failure was defined as conversion to total or unicompartmental knee arthroplasty, and the identified cohort was stratified based on whether they went on to fail. Age, sex, race, diagnoses, concurrent procedures, and comorbidities were recorded for each admission. Statistically significant differences between patients who required arthroplasty and those who did not were identified using the Student t test for continuous variables and a chi-square test for categorical variables. Kaplan-Meier survivorship curves were constructed to estimate 5- and 10-year survival rates. A Cox proportional hazards model was used to analyze the risk for conversion to arthroplasty. RESULTS: A total of 420 procedures were included for analysis. Overall, 53 knees were converted to arthroplasty. The mean follow-up time was 4.8 years (range, 0.0-14.7 years). The 5-year survivorship was 90.2% (range, 85.7%-93.4%), and the 10-year survivorship was 73.2% (range, 64.7%-79.9%). The mean time to failure was 5.9 years (range, 0.4-13.9 years). Survivorship significantly decreased with increasing age (P = .004). Hypertension and a primary diagnosis of osteoarthrosis were significant risk factors for conversion to arthroplasty (odds ratio [OR], 3.12 [95% CI, 1.38-7.03]; P = .006, and OR, 2.42 [95% CI, 1.02-5.77]; P = .045, respectively), along with a primary diagnosis of traumatic arthropathy (OR, 10.19 [95% CI, 1.71-60.65]; P = .01) and a comorbid diagnosis of asthma (OR, 2.88 [95% CI, 1.23-6.78]; P = .02). Patients with Medicaid were less likely (OR, 0.11 [95% CI, 0.01-0.88]; P = .04) to undergo arthroplasty compared with patients with private insurance, while patients with workers' compensation were 3.1 times more likely (OR, 3.08 [95% CI, 1.21-7.82]; P = .02). CONCLUSION: Older age was an independent risk factor for conversion to arthroplasty after DFO in patients ≥18 years but ≤60 years. Hypertension, asthma, and a diagnosis of osteoarthrosis or traumatic arthropathy at the time of surgery were predictors associated with failure, reinforcing the need for careful patient selection. The high survivorship rate of DFO in this analysis supports this procedure as a reasonable alternative to arthroplasty in younger patients with valgus deformities about the knee and symptomatic unicompartmental OA.

High Tibial Osteotomy Survivorship: A Population-Based Study.

BACKGROUND: High tibial osteotomy (HTO) was developed to treat early medial compartment osteoarthritis in varus knees. PURPOSE: To evaluate the midterm and long-term outcomes of HTO in a large population-based cohort of patients. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Data from the California Office of Statewide Health Planning and Development were used to identify patients undergoing HTO from 2000 to 2014. Patients with infectious arthritis, rheumatological disease, congenital deformities, malignancy, concurrent arthroplasty, or skeletal trauma were excluded. Demographic information was assessed for every patient. Failure was defined as conversion to total or unicompartmental knee arthroplasty. Differences between patients requiring arthroplasty and those who did not were identified using univariate analysis. Multivariate analysis was performed, and Kaplan-Meier survivorship estimates for 5- and 10-year survival were computed. RESULTS: A total of 1576 procedures were identified between 2000 and 2014; of these, 358 procedures were converted to arthroplasty within 10 years. Patients who went on to arthroplasty after HTO were older (48.23 ± 6.76 vs 42.66 ± 9.80 years, respectively; P < .001), had a higher incidence of hypertension (25.42% vs 17.82%, respectively; P = .001), and had a higher likelihood of having ≥1 comorbidity (38.0% vs 31.4%, respectively; P = .044). Patients were 8% more likely to require arthroplasty for each additional year in age (relative risk [RR], 1.08). Female patients were also at an increased risk of conversion to arthroplasty compared with male patients (RR, 1.38). Survivorship at 5 and 10 years was 80% and 56%, respectively, and the median time to failure was 5.1 years. CONCLUSION: HTO may provide long-term survival in select patients. Careful consideration should be given to patient age, sex, and osteoarthritis of the knee when selecting patients for this procedure.

The Utility of Plain Films for Nonoperative Fifth Metacarpal Fractures: Are Follow-up Radiographs Necessary?

BACKGROUND: Fifth metacarpal fractures are often treated nonoperatively with serial radiographs; however, the utility of these radiographs in altering clinical management has not been investigated. We hypothesize that follow-up plain films will not alter clinical management and are therefore unnecessary for most patients. METHODS: Between 2007 and 2014, patients with a fifth metacarpal fracture at our level I trauma center were retrospectively reviewed. Patients with inadequate documentation or imaging, ipsilateral upper extremity injuries, or who underwent initial surgical fixation were excluded. Initial and postreduction radiographs were reviewed by 4 board-certified attending hand surgeons and 2 hand fellows who indicated their preferred management. At a later date, blinded to their initial management, the reviewers assessed follow-up films taken at least 2 weeks later and indicated their preferred management. RESULTS: In total, 60 patients met inclusion criteria, and of those, 30 were randomly selected. There were 9 base, 7 shaft, and 14 neck fractures. Initially, reviewers opted for nonoperative management in 72.2% of base, 71.4% of shaft, and 91.7% of neck fractures. After reviewing follow-up films, reviewers changed from nonoperative to operative management in 0.0% of base, 9.5% of shaft, and 1.2% of neck fractures. CONCLUSIONS: Follow-up radiographs may not be indicated for most fifth metacarpal base and neck fractures. Follow-up radiographs may change management in select fifth metacarpal shaft fractures as these fractures may displace. Follow-up radiographs should be performed at the discretion of the treating surgeon on an as-needed basis for fractures at risk for displacement.

Predictors of Nerve Injury After Gunshot Wounds to the Upper Extremity.

BACKGROUND: The purpose of this study is to examine the incidence of nerve injury, clinical variables associated with nerve palsy, and predictive factors of nerve laceration after gunshot wounds to the upper extremity. METHODS: Forty-one patients from a level I trauma center with gunshot wounds to the upper extremity who underwent surgical exploration between 2007 and 2014 were identified retrospectively. Patients with proximal ipsilateral injuries, inadequate documentation, imaging, or with a pre-existing neurologic deficit were excluded. Patient demographics, clinical sensory and motor examination, the presence of retained bullet fragments, fracture, vascular injury, and compartment syndrome were recorded. Univariate analysis was performed to determine significant predictors of intraoperative nerve laceration. Significance was set at P < .05. RESULTS: Fifty-nine nerves were explored in 41 patients. There were higher frequencies of fractures, retained fragments, vascular injury, and compartment syndrome in patients with nerve palsies, although none were associated with nerve laceration. Patients with palsies on presentation were significantly more likely to have a nerve laceration found intraoperatively. CONCLUSIONS: Gunshot wounds to the upper extremity with focal nerve deficits remain a difficult problem for orthopedic surgeons. The present study provides evidence that may help guide operative decision making in treatment of these injuries.

So You Think You Don't Plunge? An Assessment of Far Cortex Drill Tip Plunging Based on Level of Training.

INTRODUCTION: Drill bit tip plunging past the far cortex places critical anatomical structures at risk. This study measured plunging past the far cortex based on level of training. The time required for screw placement when a depth gauge was used to measure bone tunnel depth was compared to the time required for screw placement when bone tunnel depth was measured in real time. MATERIALS AND METHODS: Thirty orthopedic surgery staff with 1-37 years of experience applied 10-hole plates to cadaveric limbs. Procedures were performed using two different drilling systems. Time and plunge depth were recorded. RESULTS: Penetration past the far cortex ranged from an average of 11.9 mm in the novice group to an average of 6.1 mm in the experienced group (P <0.001). The time required to drill and place a screw decreased by an average of 14 seconds per screw when depth gauge use was eliminated. CONCLUSIONS: Penetration past the far cortex occurred at all levels of training, but decreased with increased levels of experience. Real time measurement of bone tunnel length decreased total drilling time. The time saved with real time measurement decreased with increased level of experience.

Surgical Approach and Anesthetic Modality for Carpal Tunnel Release: A Nationwide Database Study With Health Care Cost Implications.

Background: Carpal tunnel release (CTR) is commonly performed for carpal tunnel syndrome once conservative treatment has failed. Operative technique and anesthetic modality vary by surgeon preference and patient factors. However, CTR practices and anesthetic trends have, to date, not been described on a nationwide scale in the United States. Methods: The PearlDiver Patient Records Database was used to search Current Procedural Terminology codes for elective CTR from 2007 to 2011. Anesthetic modality (eg, general and regional anesthesia vs local anesthesia) and surgical approach (eg, endoscopic vs open) were recorded for this patient population. Cost analysis, patient demographics, regional variation, and annual changes in CTR surgery were evaluated. Results: We identified 86 687 patients who underwent carpal tunnel surgery during this 5-year time period. In this patient sample, 80.5% of CTR procedures were performed using general or regional anesthesia, compared with 19.5% of procedures performed using local anesthesia; 83.9% of all CTR were performed in an open fashion, and 16.1% were performed using an endoscopic technique. Endoscopic surgery was on average $794 more expensive than open surgery, and general or regional anesthesia was $654 more costly than local anesthesia. Conclusions: In the United States, open CTR under local anesthesia is the most cost-effective way to perform a CTR. However, only a small fraction of elective CTR procedures are performed with this technique, representing a potential area for significant health care cost savings. In addition, regional and age variations exist in procedure and anesthetic type utilized.

Distal Radius Fractures Do Not Displace following Splint or Cast Removal in the Acute, Postreduction Period: A Prospective, Observational Study.

Background Displacement of distal radius fractures has been previously described in the literature; however, little is known about fracture displacement following splint or cast removal at the initial clinic visit following reduction and immobilization. Purpose The purpose of this study was to evaluate risk factors for fracture displacement following splint or cast removal and physical examination in the acute postinjury period. Methods All patients with a closed distal radius fracture who presented to our orthopedic hand clinic within 3 weeks of injury were prospectively enrolled in our study. Standard wrist radiographs were obtained prior to splint or cast removal. A second wrist series was obtained following physical exam and application of immobilization at the end of the clinic visit. Radiographic parameters for displacement were measured by two independent reviewers and included dorsal angulation, radial inclination, articular step-off, radial height, and ulnar variance. Displacement was assessed using predefined, radiographic criteria for displacement. Results A total of 64 consecutive patients were enrolled over a period of 12 weeks. Of these, 37.5% were classified as operative according to American Academy of Orthopaedic Surgeons guidelines and 37.5% met LaFontaine instability criteria. For each fracture, none of the five measurements exceeded the predefined clinically or statistically significant criteria for displacement. Conclusion Splint removal in the acute postinjury period did not result in distal radius fracture displacement. Clinicians should feel comfortable removing splints and examining underlying soft tissue in the acute setting for patients with distal radius fractures after closed reduction. Level of Evidence Level II, prospective comparative study.

Risk Factors for 30-Day Readmission Following Shoulder Arthroscopy.

PURPOSE: The purpose of this study was to evaluate a large population of shoulder arthroscopy cases in order to provide insight into the risk factors associated with readmission following this common orthopaedic procedure. METHODS: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using current procedural terminology (CPT) billing codes to identify all patients older than 18 years of age who underwent shoulder arthroscopy between 2011 and 2013. Univariate and multivariate analyses were conducted to identify factors associated with 30-day readmission. RESULTS: We identified 15,015 patients who had undergone shoulder arthroscopy, with a 30-day readmission rate of 0.98%. The most common reason for readmission was pulmonary embolism (0.09%). On multivariate analysis, operative time > 1.5 hours (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.29 to 2.50), age 40 to 65 years (OR, 3.80; 95% CI, 1.37 to 10.59), age > 65 years (OR, 3.91; 95% CI, 1.35 to 11.35), American Society of Anesthesiologists (ASA) class 3 (OR, 4.53; 95% CI, 1.90 to 10.78), ASA class 4 (OR, 7.73; 95% CI, 2.91 to 27.25), chronic obstructive pulmonary disease (COPD; OR, 2.65; 95% CI, 1.54 to 4.55), and chronic steroid use (OR, 2.96; 95% CI, 1.46 to 6.01) were identified as independent risk factors for readmission. CONCLUSIONS: Operative time > 1.5 hours, age > 40 years, ASA classes 3 or 4, COPD, and chronic steroid use are independent risk factors for readmission following elective arthroscopic shoulder surgery, although the readmission rate following these procedures is low. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Utility of Postoperative Imaging in Radial Shaft Fractures.

BACKGROUND: Postoperatively, radial shaft fractures are often followed clinically with serial radiographs to assess for fracture healing. Currently, there is no standard of care regarding postoperative imaging for these injuries. The purpose of this study is to determine whether imaging influences management decisions. METHODS: Patients who presented to a level I trauma center between 2009 and 2014 with an operatively treated radial shaft fracture were retrospectively screened for inclusion in our study. Patients with ipsilateral ulna or radius fractures, or with inadequate imaging or inadequate follow-up, were excluded. Four blinded, board-certified, orthopedic surgeons reviewed the postoperative films twice for each patient and stated whether the imaging would influence management decisions. Images were separated into 3 groups based on time from surgery: 0 to 4 weeks, 4 to 8 weeks, and greater than 8 weeks. The number of times imaging influenced these hypothetical management decisions was recorded. Interobserver and intraobserver agreements were calculated using Fleiss's and Cohen's kappa coefficients, respectively. RESULTS: One hundred eighteen patients underwent operative fixation for an isolated radial shaft fracture, of whom 38 met inclusion criteria. Imaging from 0 to 4 weeks, 4 to 8 weeks, and greater than 8 weeks postoperatively resulted in a change of management in 0%, 32%, and 16% of patients, respectively. After 4 weeks, changes were primarily for immobilization and activity-level modification. Intraobserver and interobserver agreement kappa coefficients were 0.761 and 0.563, respectively. CONCLUSIONS: Films obtained within 4 weeks of surgery for radial shaft fractures are unlikely to change postoperative management and may not be warranted during routine postoperative follow-up.

Surgical management of midshaft clavicle nonunions is associated with a higher rate of short-term complications compared with acute fractures.

BACKGROUND: Little is known about the perioperative complication rates of the surgical management of midshaft clavicle nonunions. The purpose of the current study was to report on the perioperative complication rates after surgical management of nonunions and to compare them with complication rates of acute fractures using a population cohort. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients who had undergone open reduction-internal fixation of midshaft clavicle fractures between 2007 and 2013. Patients were stratified by operative indication: acute fracture or nonunion. Patient characteristics and 30-day complication rates were compared between the 2 groups using univariate and multivariate analyses. RESULTS: A total of 1215 patients were included in our analysis. Of these, 1006 (82.8%) were acute midshaft clavicle fractures and 209 (17.2%) were midshaft nonunions. Patients undergoing surgical fixation for nonunion had a higher rate of total complications compared with the acute fracture group (5.26% vs. 2.28%; P = .034). On multivariate analysis, patients with a nonunion were at a >2-fold increased risk of any postsurgical complication (odds ratio, 2.29 [95% confidence interval, 1.05-5.00]; P = .037) and >3-fold increased risk of a wound complication (odds ratio, 3.22 [95% confidence interval, 1.02-10.20]; P = .046) compared with acute fractures. CONCLUSION: On the basis of these findings, patients undergoing surgical fixation for a midshaft clavicle nonunion are at an increased risk of short-term complications compared with acute fractures. This study provides additional information to consider in making management decisions for these common injuries.

Antibiotic related acute kidney injury in patients treated for open fractures.

OBJECTIVE: Antibiotic administration during the treatment of open fractures has been shown to reduce infection rates and is considered a critical step in the management of these injuries. The purpose of this study was to determine if aminoglycoside administration during the treatment of open fractures leads to acute kidney injury. METHODS: Patient records at a level I trauma centre were reviewed for adult patients who presented in 2014 with open fractures were screened for inclusion. Patients were excluded with fractures of the phalanges, metatarsals, and metacarpals, with isolated traumatic arthrotomies, or pre-existing renal dysfunction. Charts were reviewed for patient age, gender, race, past medical history, medication history, injury severity score, intravenous dye studies and fracture type. Patients were divided into those given cefazolin (Group A) and cefazolin with gentamicin (Group B). Laboratory values were used to determine which patients developed kidney dysfunction as measured using the RIFLE criteria. Wilcoxon-Mann-Whitney test and Chi-square were used to compare interval and categorical variables, respectively. Significance was set at P<0.05. RESULTS: One-hundred and fifty-nine patients met inclusion criteria. Forty-one (25%) patients were given cefazolin alone and 113 (68%) patients were given cefazolin with gentamicin. Ten (18%) patients with Gustilo-Anderson type III fractures were given cefazolin alone and 67 (67%) patients with types I or II fractures were given a cefazolin with gentamicin. Baseline characteristics and risk factors for renal dysfunction did not vary between groups. Two (4.8%) patients in Group A and 5 (4%) patients in Group B developed acute kidney injury (P=0.599). CONCLUSIONS: Gentamicin use during the treatment of open fractures does not lead to increased rates of renal dysfunction when used in patients with normal baseline renal function.

Complication rate and implant survival for reverse shoulder arthroplasty versus total shoulder arthroplasty: results during the initial 2 years.

BACKGROUND: The use of reverse total shoulder arthroplasty (RTSA) has significantly increased in recent years. However, there is large variance in reported complication rates and sparse data on implant survival. This study used a statewide patient database to investigate complication rates and implant survival for RTSA. METHODS: All patients undergoing RTSA or total shoulder arthroplasty (TSA) from 2011 to 2013 were identified within a statewide database. The complication and revision rates at 30 days, 90 days, 1 year, and 2 years postoperatively were determined. Potential risk factors for complications were analyzed with logistic regression, and Kaplan-Meier survival curves were used to compare implant failure. RESULTS: During the 3-year period, 10,844 procedures (6,658 TSA; 4,186 RTSA) were found within the database. The all-cause complication rate at 90 days and 2 years postoperatively was significantly higher for RTSA (P < .001). RTSA patients had a significantly increased risk of infection (P < .05) and dislocation (P < .001) in the early and midterm postoperative course. Workers' compensation, male sex, preoperative anemia, and those aged younger than 65 years had a significantly higher risk for complications (P < .001). Although RTSA initially had a higher rate of implant failure than TSA during the early postoperative period, this rate equalized at approximately the 1-year mark. CONCLUSION: RTSA patients had significantly higher complication rates compared with TSA patients, with identifiable risk factors for all-cause complications postoperatively and equivalent accepted implant failure at 2 years. LEVEL OF EVIDENCE: Level III; Cross Sectional Design; Large Database Analysis.

Preoperative risk factors for discharge to a postacute care facility after shoulder arthroplasty.

BACKGROUND: Shoulder arthroplasty procedures are becoming increasingly prevalent in the United States due to expanding indications and an aging population. Most patients are discharged home, but a subset of patients is discharged to a postacute care (PAC) facility. The purpose of this study was to identify the risk factors for discharge to a PAC facility after shoulder arthroplasty. METHODS: The Nationwide Inpatient Sample discharge records from 2011 to 2012 were analyzed for patients who underwent a total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). Patient and hospital characteristics were identified. Univariate and multivariate analysis were used to determine the statistically significant risk factors for discharge to a PAC facility while controlling for covariates. RESULTS: In 2011 and 2012, 103,798 patients underwent shoulder arthroplasty procedures: 58,937 TSAs and 44,893 RTSAs were identified. RTSA patients were 1.3 times as likely to be discharged to a PAC facility as TSA patients (P = .001). Medicare patients were 2 times as likely to be discharged to a PAC facility than those with private insurance (P < .001). In addition, women and patients presenting with a fracture, older age, or an increasing number of medical comorbidities were more likely to be discharged to a PAC facility (P < .001). CONCLUSION: The risk factors identified in our study can be used to stratify patients at high risk for postoperative discharge to PAC, allowing for greater improvement in overall care and the facilitation of postoperative discharge planning.

Trends in the surgical treatment of lumbar spine disease in the United States.

BACKGROUND CONTEXT: There is a lack of agreement among spine surgeons as to the best surgical treatment modality for many degenerative lumbar diseases. Although there are many studies examining trends in spinal surgery, specific studies reporting the variations in surgical treatment in the United States for these diseases are lacking. PURPOSE: The aim of this study was to analyze trends in lumbar spinal fusion methods for common lumbar pathologies in the United States. STUDY DESIGN/SETTING: National insurance database review: 2004-2009. PATIENT SAMPLE: Data is taken from United Healthcare and represents more than 25 million patients. OUTCOME MEASURES: No outcomes were measured in this study. METHODS: Using a private insurance database, we identified patients who underwent one of five types of instrumented single-level lumbar spinal fusion for the 10 most common primary diagnoses. Surgery rates were reviewed from 2004 to 2009 and were stratified according to patient age, patient gender, and region in the United States. Poisson regression analysis was performed to determine regional and demographic differences in treatment modality. The authors received no funds in support of this work. RESULTS: A total of 23,986 patients met our search criteria. Of the five fusion types, posterior lumbar interbody fusion (PLIF) with posterolateral fusion (PLF) was the most common (45%), followed by PLF (19%), anterior lumbar interbody fusion (ALIF, 16%), PLIF (10%), and ALIF with PLF (9%). There was a significant increase in PLIF with PLF (p<.0001), PLIF (p<.0001), PLF (p=.012), ALIF (p<.0001), and ALIF with PLF (p<.0001) from 2004 to 2009. After controlling for gender, there were significant differences between regions for all fusion types (p<.0001). The likelihood of a posterior fusion increased with age. Anterior fusions were more common in the 30- to 49-year-old age range than in patents older than 50. For patients in age groups older than 30, there was an increased number who underwent a circumferential fusion or an ALIF (p<.022). Fusion types were significantly different between genders (p<.026). Both genders had an overall increase in the number of fusions (p<.001) over the time period studied. CONCLUSIONS: There are large differences in the United States for surgical treatment methods for lumbar spine pathology. These differences are likely multifactorial, with both patient and surgeon traits playing a role. Illustrating these differences will hopefully lead to outcomes research to determine the indications, efficacy, and appropriateness of these surgical methods, an important step on the path toward standardization of care.

Comparison of practice patterns in total ankle replacement and ankle fusion in the United States.

BACKGROUND: Although tibiotalar fusion has historically been considered the gold standard treatment for end-stage arthritis of the ankle, the performance of total ankle replacement appears to be gaining favor as improved outcomes have been observed with new implant designs and surgical techniques. The purpose of this study was to compare trends and demographics in the performance of ankle fusion and total ankle replacement in the United States. METHODS: The Current Procedural Terminology (CPT) codes of patients undergoing ankle fusion and total ankle replacement were searched using the PearlDiver Patient Record Database, a national database of orthopaedic patients. The CPT codes for open ankle arthrodesis (27870), arthroscopic ankle arthrodesis (29899), and total ankle replacement (27700, 27702) were searched for the years 2004 to 2009 to identify relative changes in the performance of ankle fusion and replacement over time. RESULTS: The performance of ankle fusion was unchanged during the 6-year study period. In contrast, an increase in total ankle replacement was observed, from 0.63 cases per 10 000 patients searched in 2004 to 0.99 cases per 10 000 patients in 2009 (P < .05). Both ankle fusion and total ankle replacement were performed most commonly in patients aged 60 to 69 years (P < .05). Although an even gender distribution was observed in patients undergoing total ankle replacement, open and arthroscopic fusion were more commonly performed in males (P < .05). With regard to regional distribution, open and arthroscopic fusion were most commonly performed in the western region of the United States, whereas total ankle replacement was performed most frequently in the Midwest (P < .001). CONCLUSIONS: In the population studied, the performance of total ankle replacement increased 57% from 2004 to 2009 and was performed equally in male and female patients when compared to ankle fusion, which was more often performed in males and was unchanged with time. LEVEL OF EVIDENCE: Level IV, cross-sectional study.