Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis.

BACKGROUND: Controversy exists regarding optimal primary management of Lisfranc injuries. Whether open reduction internal fixation (ORIF) or primary arthrodesis is superior remains unknown. METHODS: A national insurance database of approximately 23.5 million orthopedic patients was retrospectively queried for subjects who were diagnosed with a Lisfranc injury from 2007 to 2016 based on international classification of diseases (ICD) codes (PearlDiver, Colorado Springs, CO). Patients with lisfranc injuries then progressed to either nonoperative treatment, ORIF, or primary arthrodesis. Associated treatment costs were determined along with complication rate and hardware removal rate. RESULTS: 2205 subjects with a diagnosis of Lisfranc injury were identified in the database. 1248 patients underwent nonoperative management, 670 underwent ORIF, and 212 underwent primary arthrodesis. The average cost of care associated with primary arthrodesis was greater ($5005.82) than for ORIF ($3961.97,P = 0.045). The overall complication rate was 23.1% (155/670) for ORIF and 30.2% (64/212) for primary arthrodesis (P = 0.04). Rates of hardware removal were 43.6% (292/670) for ORIF and 18.4% (39/212) for arthrodesis (P < 0.001). Furthermore, 2.5% (17/670) patients in the ORIF group progressed to arthrodesis at a mean of 308 days, average cost of care associated with this group of patients was $9505.12. DISCUSSION: Primary arthrodesis is both significantly more expensive and has a higher complication rate than ORIF. Open reduction and internal fixation demonstrated a low rate of progression to arthrodesis, although there was a high rate of hardware removal, which may represent a planned second procedure in the management of a substantial number of patients treated with ORIF. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Frostbite vs Burns: Increased Cost of Care and Use of Hospital Resources.

Numerous demographic, socioeconomic, and injury factors influence a burn patient's hospital course. Compared to the typical burn patient, frostbite injury frequently impacts those with high rates of mental illness, substance abuse, and those suffering homelessness. Our aim was to examine differences in the hospital course of frostbite patients compared to those with burns limited to the hands and feet. Patients with frostbite injury and those with isolated hand and/or foot burns were identified in the National Burn Repository. The database was cleaned based on published protocols. Patients were excluded if they had an inhalation injury recorded or unknown. Patients with frostbite injury were significantly older and more likely to be male. Frostbite patients were less frequently covered by commercial insurance (25.3% vs 41.7%). Mean total BSA (TBSA) did not differ between the two groups (frostbite: 2.1 and burn: 1.7, P = .195). The mean intensive care unit (ICU) days and requirement for mechanical ventilation were not significantly different between the two groups, however frostbite patients were significantly more likely to require ICU care (26.5% vs 13.7%, P = .002). Hospital length of stay (LOS) was significantly longer in frostbite patients (8.1 vs 4.0 days, P < .001) and hospital charges were significantly higher in frostbite patients ($43,400 vs $15,600, P < .001). Factors associated with increased hospital charges included mechanism, age, gender, race, TBSA, hospital LOS, ICU, and mechanical ventilation. Factors associated with increased LOS included mechanism, age, gender, race, TBSA, ICU stay, and mechanical ventilation. On multivariate analysis, all factors, except gender, remained independent predictors of increased hospital LOS. A comparison of similarly injured patients treated at burn centers showed frostbite injury as a significant predictor of increased LOS and hospital costs compared to burn-injured patients.

Cost-Effectiveness Analysis of Primary Arthrodesis Versus Open Reduction Internal Fixation for Primarily Ligamentous Lisfranc Injuries.

The purpose of the present study was to determine whether surgical intervention with open reduction internal fixation (ORIF) or primary arthrodesis (PA) for Lisfranc injuries is more cost effective. We conducted a formal cost-effectiveness analysis using a Markov model and decision tree to explore the healthcare costs and health outcomes associated with a scenario of ORIF versus PA for 45 years postoperatively. The outcomes assessed included long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. The costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2017 price base. ORIF was always associated with greater costs compared with PA and was less effective in the long term. When calculating the cost required to gain 1 additional QALY, the PA group cost $1429/QALY and the ORIF group cost $3958/QALY. The group undergoing PA overall spent, on average, $43,192 less than the ORIF group, and PA was overall a more effective technique. Strong dominance compared with ORIF was demonstrated in multiple scenarios, and the model's conclusions were unchanged in the sensitivity analysis even after varying the key assumptions. ORIF failed to show functional or financial benefits. In conclusion, from a healthcare system's standpoint, PA would clearly be the preferred treatment strategy for predominantly ligamentous Lisfranc injuries and dislocations.

Effects of foot complications in patients with Type 2 diabetes mellitus on public healthcare: An analysis based on the Korea National Diabetes Program Cohort.

AIM: Diabetes mellitus (DM) patients are susceptible to foot injury or foot diseases such as diabetic foot and peripheral arterial disease. Although these conditions are considered important, few studies have investigated them in detail. Therefore, we investigated the epidemiology of diabetic foot complications (DFC) with respect to the effects on the public healthcare system. METHODS: We evaluated the incidence, clinical characteristics, health service utilization frequency and medical expenses of DFC in type 2 DM patients in the Korea National Diabetes Program (KNDP), the largest multi-center, prospective cohort in Korea (n=4405). To determine precise outcomes, we used national representative databases, including claims data from the Health Insurance Review & Assessment Service of Korea. RESULTS: During a median follow-up period of 3.30years, 528 patients (12.0%) were newly diagnosed with DFC at an incidence rate of 43.02 cases per 1000 person-years. The patients with DFC were significantly older than patients without DFC, but other clinical characteristics were similar between the two groups. The patients with DFC had more hospital visits (p<0.001), longer duration of hospitalization (p<0.001), and increased expenses (p<0.001) compared to patients without DFC. After multiple adjustments, the differences in number of hospital visits and medical expenses were consistent. In a before and after comparison within the DFC group, all three variables increased significantly after the onset of DFC (p<0.001). CONCLUSIONS: DFC were significantly associated with poor clinical outcomes and caused a substantial burden to the national healthcare system in Korea. Therefore, intervention to prevent DFC is important.

Health care consumption and costs due to foot and ankle injuries in the Netherlands, 1986-2010.

BACKGROUND: Foot and ankle injuries account for a large proportion of Emergency Department attendance. The aim of this study was to assess population-based trends in attendances due to foot and ankle injuries in the Netherlands since 1986, and to provide a detailed analysis of health care costs in these patients. METHODS: Age- and gender-standardized emergency attendance rates and incidence rates for hospital admission were calculated for each year of the study. Injury cases and hospital length of stay were extracted from the National Injury Surveillance System (non-hospitalized patients) and the National Medical Registration (hospitalized patients). Data were grouped into osseous and ligamentous injuries for foot and ankle separately. An incidence-based cost model was applied to calculate associated direct health care costs. RESULTS: Since 1986 the overall emergency attendance rate decreased from 858 to 640 per 100,000 person years. In non-admitted patients (90% of cases), ligamentous injuries approximately halved, whereas osseous injuries increased by 28% (foot) and 25% (ankle). The incidence rate for hospital admission increased by 35%, mainly due to an almost doubling of osseous injuries. Attendance rates showed a peak in adolescents and adults until ~45 years of age in males and (less pronounced) in females. The total number of hospital days decreased to 58,708 days in 2010. Hospital length of stay (HLOS) increased with age and was highest for osseous injuries. HLOS was unaffected by gender, apart for longer stay in elderly females with an osseous ankle injury. Health care costs per case were highest for osseous injuries of the ankle (€ 3,461). Costs were higher for females and increased with age to € 6,023 in elderly males and € 10,949 in elderly females. Main cost determinants were in-hospital care (56% of total costs), rehabilitation/nursing care (15%), and physical therapy (12%). CONCLUSIONS: Since 1986, the emergency attendance rate of foot and ankle injuries in the Netherlands decreased by 25%. Throughout the years, the attendance rate of (relatively simple) ligamentous injuries strongly reduced, whereas osseous injuries nearly doubled. Attendance rates and health care costs were gender- and age-related. Main cost determinants were in-hospital care, rehabilitation/nursing care, and physical therapy.

Fractures of the proximal fifth metatarsal: keeping up with the Joneses.

Fractures of the proximal fifth metatarsal are among the most common fractures of the foot. History, physical examination, and subsequent radiographic work-up can help with the diagnosis of such a fracture. Many fractures of the proximal fifth metatarsal can have an associated prodrome, thereby establishing a level of chronicity to the problem. Identification of the location of the fracture plane within the proximal fifth metatarsal can have prognostic implications in regards to fracture union rate and guide treatment options, due to the particular vascular anatomy of the region. Additional findings on physical exam, such as heel varus, can also impact prognosis and treatment options. Treatments can range from nonoperative to operative modalities, and time to weightbearing can vary. Within the realm of operative treatment, identification of certain parameters can aid in successful reduction and fixation of the fracture and thus impact healing. Careful consideration of the patient's particular constellation of social and professional needs, clinical and radiographic parameters, and acceptance of different options can help guide treatment recommendations in the individual patient.

Cost-effectiveness of the SEN-concept: Specialized Emergency Nurses (SEN) treating ankle/foot injuries.

BACKGROUND: Emergency Departments (EDs) are confronted with progressive overcrowding. As a consequence, the workload for ED physicians increases and waiting times go up with the risk of unnecessary complications and patient dissatisfaction. To cope with these problems, Specialized Emergency Nurses (SENs), regular ED-nurses receiving a short, injury-specific course, were trained to assess and treat minor injuries according to a specific protocol. METHODS: An economic evaluation was conducted alongside a randomized controlled trial comparing House Officers (HOs) and SENs in their assessment of ankle and foot injuries. Cost prices were established for all parts of healthcare utilization involved. Total costs of health care utilization were computed per patient in both groups. Cost-effectiveness was investigated by comparing the difference in total cost between groups with the difference in sensitivity and specificity between groups in diagnosing fractures and severe sprains. Finally, cost-effectiveness ratios were calculated and presented on a cost-effectiveness plane. RESULTS: No significant differences were seen between treatment groups for any of the health care resources assessed. However, the waiting times for both first assessment by a treatment officer and time spent waiting between hearing the diagnosis and final treatment were significantly longer in the HO group. There was no statistically significant difference in costs between groups. The total costs were euro 186 (SD euro 623) for patients in the SEN group and euro 153 (SD euro 529) for patients in the HO group. The difference in total costs was euro 33 (95% CI: - euro 84 to euro 155). The incremental cost-effectiveness ratio was euro 27 for a reduction of one missed diagnosis and euro 18 for a reduction of one false negative. CONCLUSION: Considering the benefits of the SEN-concept in terms of decreased workload for the ED physicians, increased patient satisfaction and decreased waiting times, SENs appear to be a useful solution to the problem of ED crowding.

Consequences and costs of lower extremity injuries.

Lower extremity injuries resulting from motor vehicle crashes are common and have become relatively more important as more drivers with newer occupant restraints survive high-energy crashes. CIREN data provide a greater level of clinical detail based on coding guidelines from the Orthopedic Trauma Association. These detailed data, in conjunction with long-term follow-up data obtained from patient interviews, reveal that the most costly and disabling injuries are those involving articular (joint) surfaces, especially those of the ankle/foot. Patients with such injuries exhibit residual physical and psychosocial problems, even at one year post-trauma.

Soft tissue infections of the extremities in an orthopaedic centre in the UK.

OBJECTIVES: To determine the spectrum, and clinical impact of acute extremity soft tissue infections, encountered in the Orthopaedic service of an inner city hospital in UK. METHODS: Patients requiring admission for an acute limb soft tissue infection to the Orthopaedic unit of the Manchester Royal Infirmary, UK, between July 1996 and 2001 were identified from our database. Infections involving the groin and axilla, those developing within 30 days of a surgical procedure, and patients with chronic soft tissue ulcers or infections were not considered. RESULTS: Of 142 infections the majority were cellulitis (50%) and superficial abscesses (34.5%). Most were secondary to trauma (31.6%), human or animal bites (20%) and intravenous drug abuse (17.6%). Although most patients were young and otherwise healthy, ten developed significant complications: myonecrosis requiring below knee amputation (1), acute carpal tunnel syndrome (1), osteomyelitis (6), extensive skin loss requiring reconstruction (1), deep vein thrombosis (1). Seven hundred and eighty four hospital inpatient days and 143 operative interventions were devoted to these patients. The estimated cost for each episode of soft tissue infection was pound 1011. In 25% of cases earlier referral to a surgical service would have been more appropriate. CONCLUSIONS: Soft tissue infections of the extremities confer significant morbidity and impose an important burden on medical resources.

Epidemiology of foot and ankle injuries in the workplace.

Injuries to the ankle, foot, and toes of injured workers are common. Although the workers' compensation system attempts to collect information about these injuries and report them in a meaningful way, the process is somewhat inconsistent, inaccurate, and provides information relevant to government agencies but not to physician organizations seeking to improve the prevention and treatment of work-related injuries. Several improvements in data collection could greatly increase the system's efficiency and usefulness. The first is to establish a national system of uniform data collection from each State. The second improvement involves standardization of the forms and means that the data are collected from the worker including a system to retrieve information that has been omitted during the initial encounter. The third, and most important, refinement is to change the reporting of the illness to match currently accepted medical diagnosis codes (ICD-9). Using the current system and making these improvements, the United States would be able to collect more meaningful data on work injuries in this country. From that point forward medical interventions could then be created and their effects more meaningfully analyzed. All those involved in the care and treatment of the injured worker must recognize not only the limitations of the collected data but also how this information can be manipulated. For example, whereas the total cost of benefits paid by employers increased during one decade the average cost per covered employee decreased. Employers and insurers can argue that their total costs have consistently risen but only by knowing that the cost per covered employee had decreased during that same time period can that argument be countered. Similarly, implementation of certain safety practices during a given time period may be accompanied by a reduction in the number of injuries. Changes in the laws that altered injury reporting and reduced the coverage for certain injuries, however, may have created a situation where the reported injury rates were reduced by accounting practice, not medical practice. It is also well established that insurance company profits may be linked as much to the general economy and stock market as they are to premiums and claims. It is hoped that this article begins an understanding of the extent of the problem of foot and ankle injuries in the working population. Additional statistical information on specific topics is presented elsewhere in this issue.

Determining foot and ankle impairments by the AMA fifth edition guides.

The fifth edition of the Guides has been criticized for its failure to provide a comprehensive, valid, reliable, unbiased, and evidenced-based system for rating impairments and the way in which workers' compensation systems use the ratings, resulting in inappropriate compensation [8]. The lower extremity chapter utilizes numerous functional and anatomic methods of assessment, as well as diagnosis-based estimates. Though this process of using multiple approaches to measure impairment increases the chances that an underlying physical impairment may be detected, it is time-consuming and may increase rating variability [9]. McCarthy et al studied the correlation between measures of impairment for patients with fractures of the lower extremity. They found that the anatomic approach of evaluation was better correlated than functional and diagnostic methods with measures of task performance based on direct observations as well as the patient's own assessment of activity limitation and disability. Also, muscle strength assessment as described in the Guides was a more sensitive measure of impairment than range of motion [9]. The most elusive part of the foot and ankle evaluation is the inability to capture the added impairment burden caused by pain. The assessment of pain is the most problematic part of any evaluation. Pain is considered and incorporated into the impairment ratings found in the foot and ankle section, as well as the other individual chapters. Chronic pain is often not adequately accounted for, however, and the examiner must evaluate permanent impairment from chronic pain separately. The examiner has the ability to increase the percentage of organ system impairment from 1% to 3% if there is pain-related impairment that increases the burden of illness slightly. If there is significant pain-related impairment, a formal pain assessment is performed. Chapter 18 provides guidance in making these determinations. Impairments for Complex Regional Pain syndrome (CRPS), type 1 (reflex sympathetic dystrophy), and CRPS, type 2 (causalgia) should incorporate the use of a formal pain assessment in addition to the standard methods of assessment. The formal pain evaluation relies mostly on self-reports from the individual and is most heavily weighted for ADL deficits. The physician must make assessments of the individual's pain behavior and credibility for this evaluation. The formal pain assessment classifies the pain-related impairment into categories of mild, moderate, moderately severe, or severe and determines whether this impairment is ratable or not. These categories do not have impairment percentages associated with them. The individual's symptoms or presentation should match known conditions or syndromes in order to be ratable. If not ratable, the examiner should report that the individual has apparent impairment that is not ratable on the basis of current medical knowledge. In the end, pain evaluations are used administratively and, depending on the situation, may be given equal weight with the standard evaluation or may be totally disregarded.

Sprains about the foot and ankle encountered in the workmans' compensation patient.

Soft tissue injury in the workmans' compensation patient population has been previously poorly understood. Injuries that do not show up easily on radiographs are often undertriaged and undertreated. With the advent of improved imaging techniques, an enhanced understanding of soft tissue injuries has evolved over the past few years. Coupled with improved surgical and rehabilitation techniques, severely injured patients are able to experience remarkable recoveries. Many cannot return to previous function. These patients pose challenges to the astute clinician with regards to psychosocial issues relative to secondary gain. In addition, State-to-State variations in the workmans' compensation laws can confuse clinicians. Because of the protections and laws set in place in the United States, these patients can frequently be returned to the workforce as grateful and productive members of society.

Treating work-injured patients in Europe. The Italian experience.

According with to International Labor Office, the European Union gave the directions to improve the life of workers not only by regulating care, but also safety and return to work. Each European country is conforming to this. In Italy, INAIL, an independent body under the control of the Department of Labor and the Ministry of Health, covers the workers for occupational accidents and is funded by an insurance premium, obligatory paid by the employer. INAIL has the medicolegal task of assessment of injuries, supply of prostheses, physical therapy, and various compensation according to the degree of disability and the type of work. The specific treatment of the injured workers is carried out by the SSN, which is in charge of the outpatient treatment and hospitalization; however, INAIL contributes to the costs according to agreements made with each region. Although on one hand the injured worker is fully protected by the regulations, on the other hand, he or she is obliged to abide to the laws of security and to undergo treatment offered. In returning to work, certain factors are taken into account, such as percentage of disability, type of work, and discomfort that disability produces in carrying out work. Should the type or severity of the disability not allow complete return to work, support is given to assess and integrate the reduced working ability of the injured worker with regards to the workplace, even by adapting the latter to solve structural and environmental problems. INAIL, in accordance with the European Council, is committed to the total care of the worker and not only worker meaning "work force." In fact, health care and economic aid are integrated with the safety and rehabilitation of the worker and his or her return to family, social, and working life.

Third-party reimbursement for lower-extremity wound care.

This article describes the treatment of lower-extremity wounds, specifically foot and ankle ulcerations, in the context of reimbursement for treatments rendered. Therefore, such issues as standard of care, documentation, classification of foot wounds, coding, and reimbursement are discussed.

A comparison of standard vs. breakaway bases: an analysis of a preventative intervention for softball and baseball foot and ankle injuries.

More than 40 million individuals participate in organized baseball and softball leagues in the United States every year. Unfortunately, it has also been estimated by the Consumer Product Safety Commission that softball and baseball are the two main sports leading to emergency-room visits in the United States. A previous field study has determined that the utilization of breakaway bases has the potential of preventing 96% of sliding injuries, thereby preventing 1.7 million injuries a year in the United States with a savings of $2 billion a year in health care costs. It is the purpose of this study to analyze and compare the potential attenuating capabilities of various types of bases. We found the force at the ankle upon impact when compared to the standard base revealed all breakaway bases reduced the force of impact to a statistically significant level. The force at the foot upon impact when compared to the standard base revealed all breakaway bases reduced the force at variable levels, with the Rogers bases having the only statistically significant reduction. However, the force delivered to the tibia/fibula was increased with the Stay Down and Mag-Net large bases as compared to the standard stationary base. The moments of inversion/eversion and dorsiflexion/plantar flexion upon impact, when compared to the standard base, revealed all safety bases were reduced to a statistically significant level. We conclude breakaway bases reduce the force of impact and moments to a statistically significant level and confirm previous field studies. Though there is a difference among the breakaway bases themselves, they should be used on all fields.

Injuries of the foot and ankle in occupational medicine: a 1-year study.

With occupational injuries, both the employee and employer are impaired by monetary or physical damages. Administrative and clinical data can assist in identifying risks for these injuries. While musculoskeletal injuries are well known, foot and ankle injuries are not as frequently described as back and hand injuries. Changes in the workplace may then be implemented dependent on the risk factors identified. A retrospective study was completed on all foot and ankle injuries that were reported to the Oakwood Hospital Downriver Center Occupational Medicine Clinics over 1 year. Of 3851 new injuries, 245 (6.4%) were due to foot and ankle injuries. The mean age was 36.7+/-9.2 (mean +/- S.D.) years and 64% men. No seasonal variation was seen. Most commonly the ankle (46.9%) was injured. A diagnosis of sprain was most frequent (40.8%), followed by contusions (26.5%). A twisting mechanism of injury was seen 27.3% of the time. Medical charges ranged from $100 to $6414, although over two thirds of the patients had expenses between $250 and $749. Eleven patients required surgery, costing $9125+/-2321. Most often injured were operators, fabricators, and laborers. Workers were restricted for 20.5+/-21.4 days, although they were allowed light duty most of the time (16.8+/-16.5 days).