In the JournalsPerspective

Fewer malunions, nonunions found after ankle fracture surgery by orthopedists vs podiatrists

Jeremy Y. Chan

Published results showed ankle fractures surgically treated by orthopedic surgeons had lower rates of malunion and nonunion than when treated by podiatrists.

Jeremy Y. Chan, MD, Julius A. Bishop, MD, and colleagues categorized 11,745 patients who underwent ankle fracture fixation based on whether they were treated by an orthopedic surgeon or a podiatrist. Researchers used ICD-9 codes to identify complications, including malunion or nonunion, infection, deep vein thrombosis and rates of irrigation and debridement, and CPT codes to identify revision surgeries. Using the Charlson Comorbidity Index, researchers compared risk factors for complications.

Results showed orthopedic surgeons treated 11,115 patients and podiatrists treated 630 patients. Researchers found a decrease in the percentage of ankle fractures surgically treated by orthopedic surgeons (96.5% to 93%) and an increase in ankle fractures surgically treated by podiatrists from 2007 to 2015 (3.5% to 7%).

Across all types of ankle fractures, patients treated by podiatrists had a malunion or nonunion rate of 7.3% compared with 4.6% among patients treated by orthopedic surgeons, according to results. Although results showed no differences in complications among patients with unimalleolar fractures, researchers found patients with bimalleolar or trimalleolar fractures had higher malunion or nonunion rates when treated by a podiatrist. Researchers noted similar comorbidity profiles among patients treated by orthopedic surgeons vs. podiatrists.

“Despite an increasing number of ankle fracture surgeries being performed by podiatrists in the past decade, our study found that patients who underwent ankle fracture surgery by a podiatric provider were associated with a higher rate of malunion and nonunion compared to surgeries performed by orthopedic surgeons,” Chan told Healio.com/Orthopedics. “Given the known risks of poor functional outcome with persistent tibiotalar instability, these findings may have implications for patients who must choose a surgeon to surgically manage their ankle fracture as well as policymakers who determine scope of practice providers from different educational backgrounds.” – by Casey Tingle

 

Disclosures: Chan reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Jeremy Y. Chan

Published results showed ankle fractures surgically treated by orthopedic surgeons had lower rates of malunion and nonunion than when treated by podiatrists.

Jeremy Y. Chan, MD, Julius A. Bishop, MD, and colleagues categorized 11,745 patients who underwent ankle fracture fixation based on whether they were treated by an orthopedic surgeon or a podiatrist. Researchers used ICD-9 codes to identify complications, including malunion or nonunion, infection, deep vein thrombosis and rates of irrigation and debridement, and CPT codes to identify revision surgeries. Using the Charlson Comorbidity Index, researchers compared risk factors for complications.

Results showed orthopedic surgeons treated 11,115 patients and podiatrists treated 630 patients. Researchers found a decrease in the percentage of ankle fractures surgically treated by orthopedic surgeons (96.5% to 93%) and an increase in ankle fractures surgically treated by podiatrists from 2007 to 2015 (3.5% to 7%).

Across all types of ankle fractures, patients treated by podiatrists had a malunion or nonunion rate of 7.3% compared with 4.6% among patients treated by orthopedic surgeons, according to results. Although results showed no differences in complications among patients with unimalleolar fractures, researchers found patients with bimalleolar or trimalleolar fractures had higher malunion or nonunion rates when treated by a podiatrist. Researchers noted similar comorbidity profiles among patients treated by orthopedic surgeons vs. podiatrists.

“Despite an increasing number of ankle fracture surgeries being performed by podiatrists in the past decade, our study found that patients who underwent ankle fracture surgery by a podiatric provider were associated with a higher rate of malunion and nonunion compared to surgeries performed by orthopedic surgeons,” Chan told Healio.com/Orthopedics. “Given the known risks of poor functional outcome with persistent tibiotalar instability, these findings may have implications for patients who must choose a surgeon to surgically manage their ankle fracture as well as policymakers who determine scope of practice providers from different educational backgrounds.” – by Casey Tingle

 

Disclosures: Chan reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Matthew A. Varacallo

    Matthew A. Varacallo

    Jeremy Y. Chan, MD, and colleagues provide level 3 evidence from an insurance claims database encompassing more than 11,000 patients from 2007 to 2015. A retrospective cohort analysis was performed on adult patients treated for operative ankle fractures by either podiatrists or orthopedic surgeons.

    First, we must understand the impetus for this study. The authors do a great job summarizing this in the introductory section of their paper. In fact, a deeper dive into the background reveals important companion studies coming from Drexel University: Andre M. Jakoi, MD, and colleagues initially called attention to a drastic increase in ER podiatric consultations for ankle fractures from 2007 to 2011 at a level 1 trauma center in Philadelphia. My colleagues and I then followed up with an institutional cost and outcomes analysis from the same trauma center to expand off of the increasing podiatric consultation footprint in a July 2018 paper in the Journal of Orthopedic Trauma titled, “Cost determinants in the 90-day management of isolated ankle fractures at a large urban academic hospital.” 

    In this 5-year study, it was found that the independent risk factors for increasing costs of care, postoperative complications and hospital readmissions included treatment by the podiatry service, as opposed to the orthopedic surgery team.

    The findings of the study by Chan and colleagues corroborate results seen by me and my colleagues in terms of operative ankle fracture management by orthopedics vs. podiatry, albeit manifested a little differently in terms of lower rates of malunion/nonunion.   

    While one could certainly argue that large, “big data” database studies are inherently limited by several factors, in the context of this study, the relative comparison between treatment services mitigates these inherent limitations. I personally was able to reconcile this study with prior research at the institutional level, effectively bridging and confirming outcomes and results on both the “big data” and “little data” (institutional) scales. 

    I commend the authors for adding to the growing body of literature; this study further confirms the growing concern of the increasing consultation and surgical footprint of podiatrists in the management of isolated operative ankle fractures. Isolated extremity trauma may very well be the next target of bundled payment initiatives, and as podiatry continues to encroach into these areas, the health care system is further warned to heed the results of these aforementioned studies.

     

    References:

    Jakoi AM, et al. Orthopedics. 2014;doi:10.3928/01477447-20140528-58.

    Varacallo MA, et al. J Orthop Trauma. 2018;doi:10.1097/BOT.0000000000001186.

    • Matthew A. Varacallo, MD
    • Attending orthopedic surgeon
      Penn Highlands Healthcare System
      DuBois, Pennsylvania

    Disclosures: Varacallo reports no relevant financial disclosures.

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