The Influence of Opioid Use Disorder on Open Reduction and Internal Fixation Following Ankle Fracture.

BACKGROUND: Ankle fractures are common and may require open reduction and internal fixation (ORIF). Literature is scarce evaluating the associations of opioid use disorder (OUD) with ORIF postoperative outcomes. This study investigates whether OUD patients have increased (1) costs of care, (2) emergency room visits, and (3) readmission rates. METHODS: ORIF patients with a 90-day history of OUD were identified using an administrative claims database. OUD patients were matched (1:4) to controls by age, sex, and medical comorbidities. The Welch t-test determined the significance of cost of care. Logistic regression yielded odds ratios (ORs) for emergency room visits and 90-day readmission rates. RESULTS: A total of 2183 patients underwent ORIF (n = 485 with OUD vs n = 1698 without OUD). OUD patients incurred significantly higher costs of care compared with controls ($5921.59 vs $5128.22, P < .0001). OUD patients had a higher incidence and odds of emergency room visits compared with controls (3.50% vs 0.64%; OR = 5.57, 95% CI = 2.59-11.97, P < .0001). The 90-day readmission rates were not significantly different between patients with and without OUD (8.65% vs 7.30%; OR = 1.20, 95% CI = 0.83-1.73, P = .320). CONCLUSION: OUD patients have greater costs of care and odds of emergency room visits within 90 days following ORIF.Levels of Evidence: Level III: Retrospective cohort study.

Estimates of Direct and Indirect Costs of Ankle Fractures: A Prospective Analysis.

BACKGROUND: The quantification of the costs of ankle fractures and their associated treatments has garnered increased attention in orthopaedics through cost-effectiveness analysis. The purpose of this study was to prospectively assess the direct and indirect costs of ankle fractures in operatively and nonoperatively treated patients. METHODS: A prospective, observational, single-center study was performed. Adult patients presenting for an initial consult for an ankle fracture were enrolled and were followed until recurring indirect costs amounted to zero. Patients completed a cost form at every visit that assessed time away from work and the money spent in the last week on transportation, household chores, and self-care due to an ankle fracture. Direct cost data were obtained directly from the hospital billing department. RESULTS: Sixty patients were included in this study. With regard to patient characteristics, the mean patient age was 46.5 years, 55% of patients were female, 10% of patients had diabetes, and 17% of patients were active smokers. Weber A fractures composed 12% of fractures, Weber B fractures composed 72% of fractures, and Weber C fractures composed 18% of fractures. Operatively treated patients (n = 37) had significantly higher total costs and direct costs compared with nonoperatively treated patients (p < 0.01). In all patients, losses from missed work accounted for the largest portion of total and indirect costs, with a mean percentage of 35.8% of the total cost. The mean period preceding return to work of the 39 employed patients was 11.2 weeks. Longer periods of return to work were significantly associated with surgical fixation and having less than a college-level education (p < 0.05). The mean time for recurring observed costs to cease was 19.1 weeks. CONCLUSIONS: In patients treated operatively and nonoperatively, the largest discrete cost component was a specific indirect cost. Indirect costs accounted for a mean of 41.3% of the total cost. Although the majority of the direct costs of ankle fractures are accrued in the period immediately following the injury, indirect cost components will regularly be incurred for nearly 5 months and often longer. To capture the full economic impact of these injuries, future research should include detailed reporting on an intervention's impact on the indirect costs of ankle fractures. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England.

BACKGROUND: Evidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contact-casting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients. METHODS: Patients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence. RESULTS: Over the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0-19.5% < 60 years; 15.2-17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved. CONCLUSIONS: Despite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contact-casting, in line with recent evidence.

Risk Factors for Short-Term Complication After Open Reduction and Internal Fixation of Ankle Fractures: Analysis of a Large Insurance Claims Database.

Although fractures of the ankle are common injuries treated by surgical podiatrists and orthopaedic surgeons specializing in foot and ankle surgery, postoperative complications can occur, often imposing an economic burden on the patient. As health care in the United States moves toward value-based care, cost reduction has primarily focused on reducing complications and unplanned episodes of care. We used a large modern database of insurance claims to examine patterns of complications after open reduction internal fixation of ankle fractures, identifying diabetes mellitus and history of myocardial infarction as risk factors for postoperative infection within 30 days of surgery. Lateral malleolar repair was less likely to lead to infection, or need for repeated surgery, than was medial malleolar fracture repair. Diabetes mellitus, neuropathy, and chronic obstructive pulmonary disease were associated with development of postoperative cellulitis. Patients with a history of cerebrovascular accident were more likely to return to the emergency department or to have a pulmonary embolism. Male sex, presence of lupus, and increased age were associated with repeat surgery.

Reduced incidence and economic cost of hardware removal after ankle fracture surgery: a 20-year nationwide registry study.

Background and purpose - Open reduction and internal fixation (ORIF) is a treatment method for unstable ankle fractures. During recent years, scientific evidence has shed light on surgical indications as well as on hardware removal. We assessed the incidence and trends of hardware removal procedures following ORIF of ankle fractures.Patients and methods - The study covered all patients 18 years of age and older who had an ankle fracture treated with ORIF in Finland between the years 1997 and 2016. Patient data were obtained from the Finnish National Hospital Discharge Register.Results - 68,865 patients had an ankle fracture treated with ORIF in Finland during the 20-year study period between 1997 and 2016. A hardware removal procedure was performed on 27% of patients (n = 18,648). The incidence of hardware removal procedures after ankle fracture decreased from 31 (95% CI 29-32) per 100,000 person-years in the highest year 2001 (n = 1,247) to 13 (CI 12-14) per 100,000 person-years in 2016 (n = 593). Moreover, the proportion and number of removal operations performed within the first 3 months also decreased. The costs of removal procedures decreased from approximately €994,000 in 2001 to €472,600 in 2016.Interpretation - Removal of hardware after ankle surgery (ORIF) is a common operation with substantial costs. However, the incidence and cost of removals decreased during the study period, with a particular decrease in hardware removal operations within 3 months.

Refining Risk-Adjustment of 90-Day Costs Following Surgical Fixation of Ankle Fractures: An Analysis of Medicare Beneficiaries.

As the current healthcare model transitions from fee-for-service to value-based payments, identifying cost-drivers of 90-day payments following surgical procedures will be a key factor in risk-adjusting prospective bundled payments and ensuring success of these alternative payment models. The 5% Medicare Standard Analytical Files data set for 2005-2014 was used to identify patients undergoing open reduction and internal fixation (ORIF) for isolated unimalleolar, bimalleolar, and trimalleolar ankle fractures. All acute care and post-acute care payments starting from day 0 of surgery to day 90 postoperatively were used to calculate 90-day costs. Patients with missing data were excluded. Multivariate linear regression modeling was used to derive marginal cost impact of patient-level (age, sex, and comorbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy, and syndesmotic fixation), and state-level factors on 90-day costs after surgery. A total of 6499 patients were included in the study. The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 ± $1060. Individuals aged <65 or ≥70 years had significantly higher costs. Procedure-level factors associated with significant marginal cost increases were inpatient surgery (+$5577), trimalleolar fracture (+$1082), and syndesmotic fixation (+$2822). The top 5 comorbidities with the largest marginal cost increases were chronic kidney disease (+$8897), malnutrition (+$7908), obesity (+$5362), cerebrovascular disease/stroke (+$4159), and anemia (+$3087). Higher costs were seen in Nevada (+$6371), Massachusetts (+$4497), Oklahoma (+$4002), New Jersey (+$3802), and Maryland (+$3043) compared with Michigan. With the use of a national administrative claims database, the study identifies numerous patient-level, procedure-level, and state-level factors that significantly contribute to the cost variation seen in 90-day payments after ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in patients with fractures.

Patient-Level Value Analysis: An Innovative Approach to Optimize Care Delivery.

BACKGROUND: An increasing emphasis has been placed on developing value-based care delivery systems in orthopaedics to combat rising health care costs. The goal of these systems is to both measure and improve the provisional value of care. Patient-level value analysis creates a mechanism to quantify and optimize value within a procedure, in contrast to traditional methods, which only measures value. The purpose of this study was to develop a patient-level value analysis model and determine the efficacy of this model to improve value in orthopaedic care. METHODS: Patients treated operatively for isolated closed ankle fractures at a single level 1 trauma center were prospectively identified. Short musculoskeletal function assessment was collected at the time of the initial clinical presentation and 6 months postoperatively. The cost of care was determined using time-driven activity-based costing, which included personnel, supplies, length of stay, implants, pharmacy, and radiology. Value was defined as each patient's change in the outcome score divided by their cost as determined by time-driven activity-based costing. A multiple linear regression was performed to determine which aspects of care significantly predicted value. RESULTS: Forty-nine patients met inclusion/exclusion criteria. The multiple linear regression indicated treatment by physician D (ß = -0.135, P = 0.04) and inpatient stay (ß = -0.468, P < 0.01) were predictors of lesser value and represent areas for potential care pathway and value improvement. CONCLUSIONS: Patient-level value analysis represents a paradigm shift in the quantification of value. We recommend surgeons, practices, and health care systems begin implementing a system to quantify and optimize the value of care provided. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Operative Ankle Fractures.

OBJECTIVES: To investigate the ability of a validated geriatric trauma risk prediction tool to stratify hospital quality metrics and inpatient cost for middle-aged and geriatric patients admitted from the emergency department for operative treatment of an ankle fracture. DESIGN: Prospective cohort study. SETTING: Single Academic Medical Center. PATIENTS: Patients 55 years of age and older who sustained a rotational ankle fracture and who were treated operatively during their index hospitalization. INTERVENTION: Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle Aged (STTGMA), using patient demographics, injury severity, and functional status. Patients were stratified into groups based on scores to create a minimal-, low-, moderate-, and high-risk cohort. MAIN OUTCOME MEASUREMENTS: Length of stay, complications, need for intensive care unit-/step-down unit-level care, discharge location, and index admission costs. RESULTS: Fifty ankle fracture patients met inclusion criteria. The mean length of stay was 7.8 ± 5.2 days with a significant difference among the 4 risk groups (4.6-day difference between low and high risk). 73.1% of minimal-risk patients were discharged home compared with 0% of high-risk patients. There was no difference in complication rate or in need for intensive care unit-level care between groups. However, high-risk patients had a mean total inpatient cost 2 times greater than that of minimal-risk patients. CONCLUSION: The Score for Trauma Triage in Geriatric and Middle-Aged tool is able to meaningfully stratify older patients with ankle fracture who require operative fixation regarding hospital quality metrics and cost. This information may allow for efficient targeted reductions in costs while optimizing outcomes. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The health economics of ankle and foot sprains and fractures: A systematic review of English-language published papers. Part 1: Overview and critical appraisal.

BACKGROUND: Ankle and foot sprains and fractures are common injuries affecting many individuals, often requiring considerable and costly medical interventions. The objectives of this systematic review are to collect, assess, and critically appraise the published literature on the health economics of ankle and foot injury (sprain and fracture) treatment. METHODS: A systematic literature review of Ovid MEDLINE, EMBASE, Cochrane DSR, ACP Journal Club, AMED, Ovid Healthstar, and CINAHL was conducted for English-language studies on the costs of treating ankle and foot sprains and fractures published from January 1980 to December 2014. Two reviewers assessed the articles for study quality and abstracted data. RESULTS: The literature search identified 2047 studies of which 32 were analyzed. A majority of the studies were published in the last decade. A number of the studies did not report full economic information, including the sources of the direct and indirect costs, as suggested in the guidelines. The perspective used in the analysis was missing in numerous studies, as was the follow-up time period of participants. Only five of the studies undertook a sensitivity analysis which is required whenever there are uncertainties regarding cost data. CONCLUSION: This systematic review found that publications do not consistently report on the components of health economics methodology, which in turn limits the quality of information. Future studies undertaking economic evaluations should ensure that their methods are transparent and understandable so as to yield accurate interpretation for assistance in forthcoming economic evaluations and policy decision-making.

The health economics of ankle and foot sprains and fractures: A systematic review of English-language published papers. Part 2: The direct and indirect costs of injury.

BACKGROUND: Ankle and foot sprains and fractures are prevalent injuries, which may result in substantial physical and economic consequences for the patient and place a financial burden on the health care system. Therefore, the objectives of this paper are to examine the direct and indirect costs of treating ankle and foot injuries (sprains, dislocations, fractures), as well as to provide an overview of the outcomes of full economic analyses of different treatment strategies. METHODS: A systematic review was carried out among seven databases to identify English language publications on the health economics of ankle and foot injury treatment published between 1980 and 2014. The direct and indirect costs were abstracted by two independent reviewers. All costs were adjusted for inflation and reported in 2016 US dollars (USD). RESULTS: Among 2047 identified studies, 32 were selected for analysis. The direct costs of ankle sprain management ranged from $292 to $2268 per patient (2016 USD), depending on the injury severity and treatment strategy. The direct costs of managing ankle fractures were higher ($1908-$19,555). Foot fracture treatment had similar direct costs ranging from $998 to $21,801. The economic evaluations were conducted from the societal or payer's perspectives. CONCLUSION: The costs of treating ankle and foot sprains and fractures varied among the studies, mostly due to differences in injury type and study characteristics, which impacted the ability of directly comparing the financial burden of treatment. Nonetheless, the review showed that the costs experienced by the patient and the health care system increased with injury complexity.

Cost Comparison of Surgically Treated Ankle Fractures Managed in an Inpatient Versus Outpatient Setting.

INTRODUCTION: Although choices physicians make profoundly affect the cost of health care, few surgeons know relative costs associated with the setting in which care is provided. Without valid cost information, surgeons cannot understand how their choices affect the total cost of care. METHODS: Actual costs for all isolated, surgically treated ankle fractures at a level I trauma hospital and affiliated outpatient surgery center were determined using a validated episode of care costing system and analyzed using multivariate regression analysis in this retrospective cohort study. RESULTS: One hundred forty-eight patients (ie, 61 inpatients and 87 outpatients) with isolated, surgically treated ankle fractures were included. After controlling for confounding variables, outpatient care was associated with 31.6% lower costs compared with inpatient care. Obese patients had 21.6% higher costs compared with patients who were not obese. No difference was noted in revision surgery, readmission, or return visits to the emergency department for patients treated on an inpatient or outpatient basis. CONCLUSION: Where medically/socially appropriate, this analysis suggests that ankle fracture surgery should be provided in an outpatient surgical facility to provide the greatest value to the patient and society. LEVEL OF EVIDENCE: Level III.

The Effect of Insurance Type on Patient Access to Ankle Fracture Care Under the Affordable Care Act.

The purpose of this study is to assess the effect of insurance type (Medicaid, Medicare, private insurance) on the ability for patients with operative ankle fractures to access orthopedic traumatologists. The research team called 245 board-certified orthopedic surgeons specializing in orthopedic trauma within 8 representative states. The caller requested an appointment for their fictitious mother in order to be evaluated for an ankle fracture which was previously evaluated by her primary care physician and believed to require surgery. Each office was called 3 times to assess the response for each insurance type. For each call, information was documented regarding whether the patient was able to receive an appointment and the barriers the patient confronted to receive an appointment. Overall, 35.7% of offices scheduled an appointment for a patient with Medicaid, in comparison to 81.4%and 88.6% for Medicare and BlueCross, respectively (P < .0001). Medicaid patients confronted more barriers for receiving appointments. There was no statistically significant difference in access for Medicaid patients in states that had expanded Medicaid eligibility vs states that had not expanded Medicaid. Medicaid reimbursement for open reduction and internal fixation of an ankle fracture did not significantly correlate with appointment success rates or wait times. Despite the passage of the Affordable Care Act, patients with Medicaid have reduced access to orthopedic surgeons and more complex barriers to receiving appointments. A more robust strategy for increasing care-access for patients with Medicaid would be more equitable.

Time-Driven Activity-Based Costing in Fracture Care: Is This a More Accurate Way to Prepare for Alternative Payment Models?

OBJECTIVES: To use surgical treatment of isolated ankle fractures as a model to compare time-driven activity-based costing (TDABC) and our institution's traditional cost accounting (TCA) method to measure true cost expenditure around a specific episode of care. METHODS: Level I trauma center ankle fractures treated between 2012 and 2016 were identified through a registry. Inclusion criteria were age greater than 18 years and same-day ankle fracture operation. Exclusion criteria were pilon fractures, vascular injuries, soft-tissue coverage, and external fixation. Time for each phase of care was determined through repeated observations. The TCA method at our institution uses all hospital costs and allocates them to surgeries using a relative value method. RESULTS: A total of 35 patients met the inclusion/exclusion criteria, 18 were men and 17 were women. Age at time of surgery was 47 ± 15 years. Time from injury to surgery was 10 ± 4 days. Operative time was 86 ± 30 minutes, Post-anesthesia care unit (PACU) time was 87 ± 27 minutes, and secondary recovery time was 100 ± 56 minutes. Average cost was significantly lower for the TDABC method ($2792 ± 734) than the TCA method ($5782 ± 1348) (P < 0.001). There was no difference between methods for implant cost ($882 ± 507 for Traditional Accounting (TA) and $957 ± 651 for TDABC, P = 0.593). TCA produced a significantly greater cost (P < 0.01) in every other category. CONCLUSIONS: As orthopaedics transitions to alternative payment models, accurate costing will become critical to maintaining a successful practice. TDABC may provide a better estimate of the cost of the resources necessary to treat a patient.

Cost Determinants in the 90-Day Management of Isolated Ankle Fractures at a Large Urban Academic Hospital.

OBJECTIVES: To determine the independent risk factors associated with increasing costs and unplanned hospital readmissions in the 90-day episode of care (EOC) for isolated operative ankle fractures at our institution. DESIGN: Retrospective cohort study. SETTING: Level I Trauma Center. PATIENTS: Two hundred ninety-nine patients undergoing open reduction internal fixation for the treatment of an acute, isolated ankle fracture between 2010 and 2015. INTERVENTION: None. MAIN OUTCOME MEASURES: Independent risk factors for increasing 90-day EOC costs and unplanned hospital readmission rates. RESULTS: Orthopaedic (64.9%) and podiatry (35.1%) patients were included. The mean index admission cost was $14,048.65 ± $5,797.48. Outpatient cases were significantly cheaper compared to inpatient cases ($10,164.22 ± $3,899.61 vs. $15,942.55 ± $5,630.85, respectively, P < 0.001). Unplanned readmission rates were 5.4% (16/299) and 6.7% (20/299) at 30 and 90 days, respectively, and were often (13/20, 65.0%) due to surgical site infections. Independent risk factors for unplanned hospital readmissions included treatment by the podiatry service (P = 0.024) and an American Society of Anesthesiologists score of ≥3 (P = 0.017). Risk factors for increasing total postdischarge costs included treatment by the podiatry service (P = 0.011) and male gender (P = 0.046). CONCLUSIONS: Isolated operative ankle fractures are a prime target for EOC cost containment strategy protocols. Our institutional cost analysis study suggests that independent financial clinical risk factors in this treatment cohort includes podiatry as the treating surgical service and patients with an American Society of Anesthesiologists score ≥3, with the former also independently increasing total postdischarge costs in the 90-day EOC. Outpatient procedures were associated with about a one-third reduction in total costs compared to the inpatient subgroup.

Costs and Radiographic Outcomes of Rotational Ankle Fractures Treated by Orthopaedic Surgeons With or Without Trauma Fellowship Training.

INTRODUCTION: We evaluated the radiographic outcomes and surgical costs of surgically treated rotational ankle fractures in our health system between providers who had completed a trauma fellowship and those who had not. METHODS: We grouped patients into those treated by trauma-trained orthopaedic surgeons (TTOS) and non-trauma-trained orthopaedic surgeons (NTTOS). We graded the quality of fracture reductions and calculated implant-related costs of treatment. RESULTS: A total of 208 fractures met the inclusion criteria, with 119 in the TTOS group and 89 in the NTTOS group. Five patients lost reduction during the follow-up period. The adequacy of fracture reduction at final follow-up did not differ (P = 0.29). The median surgical cost was $2,940 for the NTTOS group and $1,233 for the TTOS group (P < 0.001). DISCUSSION: We found no notable differences in radiographic outcomes between the TTOS and NTTOS groups. Cost analysis demonstrated markedly higher implant-related costs for the NTTOS group, with the median surgical cost being more than twice that for the TTOS group. LEVEL OF EVIDENCE: Level III.

Economic Analysis of Anatomic Plating Versus Tubular Plating for the Treatment of Fibula Fractures.

Ankle fractures are among the most common injuries requiring operative management. Implant choices include one-third tubular plates and anatomically precontoured plates. Although cadaveric studies have not revealed biomechanical differences between various plate constructs, there are substantial cost differences. This study sought to characterize the economic implications of implant choice. A retrospective review was undertaken of 201 consecutive patients with operatively treated OTA type 44B and 44C ankles. A Nationwide Inpatient Sample query was performed to estimate the incidence of ankle fractures requiring fibular plating, and a Monte Carlo simulation was conducted with the estimated at-risk US population for associated plate-specific costs. The authors estimated an annual incidence of operatively treated ankle fractures in the United States of 59,029. The average cost was $90.86 (95% confidence interval, $90.84-$90.87) for a one-third tubular plate vs $746.97 (95% confidence interval, $746.55-$747.39) for an anatomic plate. Across the United States, use of only one-third tubular plating over anatomic plating would result in statistically significant savings of $38,729,517 (95% confidence interval, $38,704,773-$38,754,261; P<.0001). General use of one-third tubular plating instead of anatomic plating whenever possible for fibula fractures could result in cost savings of up to nearly $40 million annually in the United States. Unless clinically justifiable on a per-case basis, or until the advent of studies showing substantial clinical benefit, there currently is no reason for the increased expense from widespread use of anatomic plating for fractures amenable to one-third tubular plating. [Orthopedics. 2018; 41(2):e252-e256.].

Implant Failure Rates and Cost Analysis of Contoured Locking Versus Conventional Plate Fixation of Distal Fibula Fractures.

The authors analyzed 330 consecutive Weber B distal fibula fractures that occurred during a 3-year period and were treated with either a contoured locking plate or a conventional one-third tubular plate to compare the cost and failure rates of the 2 constructs. The primary outcomes were failure of the distal fibular implant and loss of reduction. Secondary outcomes were surgical wound infection requiring surgical debridement and/or removal of the fibular implant, and removal of the fibular plate for persistent implant-related symptoms. No failure of the fibular plates or distal fibular fixation occurred in either group. A total of 5 patients required surgical revision of syndesmotic fixation within 4 weeks of the index surgery. Of these patients, 1 was in the contoured locking plate group and 4 were in the one-third tubular plate group (P=.610). The rate of deep infection requiring surgical debridement and/or implant removal was 6.2% in the contoured locking plate group and 1.4% in the one-third tubular plate group (P=.017). The rate of lateral implant removal for either infection or symptomatic implant was 9.3% in the contoured locking plate group and 2.3% in the one-third tubular plate group (P=.005). A typical contoured locking plate construct costs $800 more than a comparable one-third tubular plate construct. Based on a calculated estimate of 60,000 locking plates used annually in the United States, this difference translates to a potential avoided annual cost of $50 million nationally. This study demonstrates that it is possible to treat Weber B distal fibula fractures with one-third tubular plates at a substantially lower cost than that of contoured locking plates without increasing complications. [Orthopedics. 2017; 40(6):e1024-e1029.].

Standardised virtual fracture clinic management of radiographically stable Weber B ankle fractures is safe, cost effective and reproducible.

BACKGROUND: Virtual clinics have been shown to be safe and cost-effective in many specialties, yet barriers exist to their implementation in orthopaedics. Ankle fractures are common and therefore represent a significant clinical workload. The aim of this study was to evaluate the management of radiographically stable Weber B ankle fractures using a standardised treatment protocol in a virtual fracture clinic setting, to assess clinical outcomes, any complications and its cost effectiveness. METHODS: All patients referred to the VFC with an actual or suspected stable Weber B ankle fracture between September 2013 and September 2015 were identified. The primary outcome measure was successful fracture union. Any complications were noted and a cost analysis comparing the VFC and traditional fracture clinic models was undertaken. RESULTS: 314 patients referred with a radiographically stable Weber B ankle fracture were identified. Follow up was complete for 98.4% (309/314) of patients. The union rate was 99.4% (307/309) in patients where follow up was completed. 3.5% (11/309) of patients were underwent acute surgical intervention. Of these patients, 6 were identified as having an unstable injury on weight bearing radiographs at 2 weeks and underwent ORIF, 4 were identified as having an unstable injury on EUA and underwent ORIF and 1 had an EUA with no fixation. 2 patients required ORIF for radiographically confirmed non-union. A cost saving analysis comparing the traditional fracture clinic model and VFC model revealed a saving of £237 per patient (32% reduction) with a VFC model. This represents an estimated saving of almost £40,000 per year for the management of this injury alone in our institution. CONCLUSION: Our study supports the use of a virtual fracture clinic model that is standardised, initiated in ED, and is both safe and cost-effective in the management of radiographically stable Weber B ankle fractures. LEVEL OF EVIDENCE: Level III-Retrospective Cohort Study.

Sanders II/III Calcaneus Fractures in Laborers: A Cost-Effectiveness Analysis and Call for Effectiveness Research.

OBJECTIVE: This study compares the cost and cost-effectiveness of treatments options for Sanders II/III displaced intra-articular calcaneus fractures (DIACFs) in laborers. METHODS: Literature on Sanders type II and III fractures was reviewed to determine complication rates and utility values for each treatment option. Costs were calculated using Medicare reimbursement and implant prices from our institution. Monte Carlo simulations were used to analyze a decision tree to determine the cost and cost-effectiveness of each treatment from a societal perspective. Sensitivity analysis was performed on all variables. RESULTS: Minimally invasive open reduction internal fixation (ORIF) (sinus tarsi approach with 4 screws alone) was least expensive ($23,329), followed by nonoperative care ($24,530) and traditional ORIF using extensile lateral approach ($27,963) (P < 0.001); this result was most sensitive to time out of work. Available cost-effectiveness data were limited, but our analysis suggests that minimally invasive ORIF is a dominant strategy, and traditional ORIF is superior to nonoperative care (incremental cost-effectiveness ratio $57,217/quality-adjusted life year). CONCLUSIONS: Our findings suggest that minimally invasive ORIF (sinus tarsi approach) is the least expensive option for managing Sanders II/III displaced intra-articular calcaneus fractures, followed by nonoperative care. Our cost-effectiveness results favor operative management but are highly sensitive to utility values and are weakened by scarce utility data. We therefore cannot currently recommend a treatment course based on value, and our primary conclusion must be that more extensive effectiveness research (ie, health-related quality of life data, not just functional outcomes) is desperately needed to elucidate the value of treatment options in this field. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Influence of Medical Insurance Under the Affordable Care Act on Access to Pain Management of the Trauma Patient.

BACKGROUND AND OBJECTIVES: The Affordable Care Act intended to "extend affordable coverage" and "ensure access" for vulnerable patient populations. This investigation examined whether the type of insurance (Medicaid, Medicare, Blue Cross, cash pay) carried by trauma patients influences access to pain management specialty care. METHODS: Investigators phoned 443 board-certified pain specialists, securing office visits with 235 pain physicians from 8 different states. Appointments for pain management were for a patient who sustained an ankle fracture requiring surgery and experiencing difficulty weaning off opioids. Offices were phoned 4 times assessing responses to the 4 different payment methodologies. RESULTS: Fifty-three percent of pain specialists contacted (235 of 443) were willing to see new patients to manage pain medication. Within the 53% of positive responses, 7.2% of physicians scheduled appointments for Medicaid patients, compared with 26.8% for cash-paying patients, 39.6% for those with Medicare, and 41.3% with Blue Cross (P < 0.0001). There were no differences in appointment access between states that had expanded Medicaid eligibility for low-income adults versus states that had not expanded Medicaid eligibility. Neither Medicaid nor Medicare reimbursement levels for new patient visits correlated with ability to schedule an appointment or influenced wait times. CONCLUSIONS: Access to pain specialists for management of pain medication in the postoperative trauma patient proved challenging. Despite the Affordable Care Act, Medicaid patients still experienced curtailed access to pain specialists and confronted the highest incidence of barriers to receiving appointments.