SLR - December 2019 - Elizabeth F. Neubauer
Reference: Okelana AB, McMillan LJ, Kibble K, Parikh HR, Gorman C, Schaefbauer H, Cunningham BP. Variation in Implant Selection for Ankle Fractures: Identifying Cost Drivers. J Orthop Trauma. 2019. 2019 Nov; 33(11) S26-S31.Scientific Literature Review
Reviewed By: Elizabeth F. Neubauer, DPM, MSHA
Residency Program: Regions Hospital / HealthPartners Institute – St. Paul, Minnesota
Podiatric Relevance: Surgeons performing open reduction and internal fixation (ORIF) of ankle fractures can influence the type of fixation utilized but most are unaware of the cost variation between implant types. There is also little or no incentive to reduce implant costs. This study compares implant costs between ankle fracture types and surgeon specialties in an attempt to improve surgeon knowledge on the topic thereby improving cost-saving strategies while maintaining a high quality of care.
Methods: Electronic Medical Records of patients undergoing ankle ORIF at a single level 1 trauma center over an eight-year period (2010-2017) were retrospectively reviewed (n=1241). Age, sex, BMI, OTA/AO fracture classification, Weber classification, one-year reoperation rates, surgeon specialty, and type of fixation were statistically analyzed.
Results: Implant costs were highest among surgeons with specialty training – adult joint reconstruction ($1804), foot and ankle ($1357), and podiatric medicine ($1404) – and lowest among trauma surgeons ($987). Mean implant costs were highest in tri-malleolar ankle fractures ($1749) compared to isolated distal fibula fractures ($1205). Key drivers of cost include the use of locking plates ($1947), at least one cannulated screws ($2008) and a tightrope ($1701). Reoperation rates were similar between locking and non-locking plates (18.5 percent vs. 17.7 percent) and between cannulated vs. solid screws 17.4 percent vs 18.8 percent). While there are still indications for locking plates (comminution, osteopenia, neuropathy), the use of one-third tubular plates may save $38 to $50 million without compromise to patient outcomes. Previously published studies have shown no significant difference in stability between pre-contoured plates and pre-fabricated plates and there is no evidence to suggest worse outcomes when non-locking plates were used in the fixation of tibial plateau fractures.
Conclusions: Anecdotal evidence and training have been highly influential in implant selection by orthopaedic physicians, more so than implant cost or fracture classification. The authors show that there is a need to educate orthopaedic residents and physicians about the costs and indications of different fixation constructs because orthopaedic surgeons are among the highest users of medical devices and technology. Furthermore, there may be a need to offer incentives for cost efficiency based on the rising costs of healthcare in the United States. The authors demonstrate that there is an opportunity to increase value either by improving patient care while keeping costs constant or decreasing costs while maintaining quality of care. Addressing changes in the operative management of this common injury will likely influence other areas of trauma and reconstruction.