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Abstract

Category: Ankle Arthritis Introduction/Purpose: Ankle arthrodesis is the most favored surgical treatment for several tibiotalar pathologies. Nonunion requiring revision occurs in 5.7% - 6.5% of patients. Nonunion is a challenging surgical complication and bone graft substitutes are costly. This study aimed to summarize all institutional expenditures related to ankle fusion nonunion needing revision, presuming that cost and skin-to-skin time would exceed that of the index surgery. Methods: Reviewing electronic charts from a foot and ankle center, a patient list with two or more entries for tibiocalcaneal, pantalar and tibiotalar fusions was generated. Out of 44 cases found, 21 patients had bilateral surgery and were excluded. Three had TAR or surgery in the periphery as index surgery; four had revision not for nonunion.Demographic factors and skin-to-skin time of the 16 remaining patients were compiled. Supplemental clinic visits and investigations were included either after CT to assess union, or 365 days post-index procedure in the absence of CT. Total cost of the revision was calculated from surgical billing codes, length of operation, and period of hospitalization. Post-revision outpatient fees were all included. This cohort included 16 patients (6F: 10 M) with an average age of 60 years (52 - 67) and BMI of 33 (29 - 38). 14 revisions were performed open; 13 patients received bone graft. Results: Average hospitalization post-operatively was 5.5 days (1.87 - 9.28). The additional cost associated with nonunion were $1,538 (CAD) for imaging, $737 for pre-revision visits, $12,483 for the revision and hospital stay, and $1,990 for post-revision follow-up. The total average amount was $14,982, equivalent to 10 nights of acute inpatient stay. Index average skin to skin time was 2:00:50 and for revisions 2:18:20, for a p-value of 0.26. The cost of nonunion per 100 primary procedures is therefore $85,397 to $97,383. If an intervention reduces the incidence of nonunion by 50% the cost saved would be $486 per procedure. As grafting or bone graft substitutes cost over $1,000, grafting should be limited to at risk patients. Conclusion: Additional care related to ankle fusion nonunion represents a financial burden equivalent to 10 nights of acute inpatient stay. Revision surgery is not significantly longer intraoperatively than index surgery. Bone graft and/or substitute should only be considered if it’s cost is less than $486 CAD at our institution.
AOFAS Annual Meeting 2018 1
Institutional Costs Associated with Ankle Fusion Nonunion
Oliver Gagné, MD, Murray Penner, MD, FRCSC, Kevin Wing, MD, FRCSC, Alastair Younger, MBChB, ChM, FRCSC, Andrea
Veljkovic, MD, MPH, FRCSC
Category: Ankle Arthritis
Keywords: Ankle, Fusion, Cost, Nonunion, Revision
Introduction/Purpose: Ankle arthrodesis is the most favored surgical treatment for several tibiotalar pathologies. Nonunion
requiring revision occurs in 5.7% - 6.5% of patients. Nonunion is a challenging surgical complication and bone graft substitutes are
costly. This study aimed to summarize all institutional expenditures related to ankle fusion nonunion needing revision, presuming
that cost and skin-to-skin time would exceed that of the index surgery.
Methods: Reviewing electronic charts from a foot and ankle center, a patient list with two or more entries for tibiocalcaneal,
pantalar and tibiotalar fusions was generated. Out of 44 cases found, 21 patients had bilateral surgery and were excluded. Three
had TAR or surgery in the periphery as index surgery; four had revision not for nonunion.Demographic factors and skin-to-skin
time of the 16 remaining patients were compiled. Supplemental clinic visits and investigations were included either after CT to
assess union, or 365 days post-index procedure in the absence of CT. Total cost of the revision was calculated from surgical billing
codes, length of operation, and period of hospitalization. Post-revision outpatient fees were all included. This cohort included 16
patients (6F : 10M) with an average age of 60 years (52 - 67) and BMI of 33 (29 - 38). 14 revisions were performed open; 13
patients received bone graft.
Results: Average hospitalization post-operatively was 5.5 days (1.87 - 9.28). The additional cost associated with nonunion were
$1,538 (CAD) for imaging, $737 for pre-revision visits, $12,483 for the revision and hospital stay, and $1,990 for post-revision
follow-up. The total average amount was $14,982, equivalent to 10 nights of acute inpatient stay. Index average skin to skin time
was 2:00:50 and for revisions 2:18:20, for a p-value of 0.26. The cost of nonunion per 100 primary procedures is therefore
$85,397 to $97,383. If an intervention reduces the incidence of nonunion by 50% the cost saved would be $486 per procedure.
As grafting or bone graft substitutes cost over $1,000, grafting should be limited to at risk patients.
Conclusion: Additional care related to ankle fusion nonunion represents a financial burden equivalent to 10 nights of acute
inpatient stay. Revision surgery is not significantly longer intraoperatively than index surgery. Bone graft and/or substitute should
only be considered if it's cost is less than $486 CAD at our institution.
Foot & Ankle Orthopaedics, 3(3)
DOI: 10.1177/2473011418S00225
©The Author(s) 2018
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Article
Background Nonunion rates in hind or midfoot arthrodesis have been reported as high as 41%. The most notable and readily modifiable risk factor that has been identified is smoking. In 2018, 14.4% of the UK population were active smokers. We examined the effect of smoking status on union rates for a large cohort of patients undergoing hind- or midfoot arthrodesis. Methods In total, 381 consecutive primary joint arthrodeses were identified from a single surgeon’s logbook (analysis performed on a per joint basis, with a triple fusion reported as 3 separate joints). Patients were divided based on self-reported smoking status. Primary outcome was clinical union. Delayed union, infection, and the need for ultrasound bone stimulation were secondary outcomes. Results Smoking prevalence was 14.0%, and 32.2% were ex-smokers. Groups were comparable for sex, diabetes, and body mass index. Smokers were younger and had fewer comorbidities. Nonunion rates were higher in smokers (relative risk, 5.81; 95% CI, 2.54-13.29; P < .001) with no statistically significant difference between ex-smokers and nonsmokers. Smokers had higher rates of infection ( P = .05) and bone stimulator use ( P < .001). Among smokers, there was a trend toward slower union with heavier smoking ( P = .004). Conclusion This large retrospective cohort study confirmed previous evidence that smoking has a considerable negative effect on union in arthrodesis. The 5.81 relative risk in a modifiable risk factor is extremely high. Arthrodesis surgery should be undertaken with extreme caution in smokers. Our study shows that after cessation of smoking, the risk returns to normal, but we were unable to quantify the time frame. Level of Evidence Level III, retrospective cohort study.
Article
Full-text available
A recent survey of orthopaedic surgeons asking about risk factors for nonunion following foot and ankle arthrodesis revealed that patient age is considered to be a relatively low risk factor, despite the potential for autologous graft quality to deteriorate with increasing age. The purpose of the current study was to evaluate the impact of patient age and graft type on fusion rates following hindfoot and ankle arthrodesis. Methods: In this study, we analyzed data from a previously published clinical trial, comparing fusion success in 397 subjects who underwent hindfoot or ankle arthrodesis (597 joints) supplemented with either autograft or an osteoinductive autograft alternative, recombinant human platelet-derived growth factor-BB homodimer carried in beta-tricalcium phosphate (rhPDGF-BB/β-TCP). The odds of fusion success were compared among subjects older or younger than age thresholds of 55, 60, 65, 70, and 75 years. The odds of fusion success were also compared between autograft and rhPDGF-BB/β-TCP among subjects older than each age threshold. Results: In the autograft group, the joints of subjects who were younger than the age thresholds of 60 and 65 years had >2 times the odds of successful fusion compared with those of older subjects. There was no significant difference in the odds of fusion success between the older and younger subjects at the age threshold of 55 years. In the rhPDGF-BB/β-TCP group, there was no significant difference in the odds of successful fusion between older and younger subjects at any age threshold. When the odds of fusion success were compared between the 2 graft materials in subjects who were older than each age threshold, rhPDGF-BB/β-TCP had approximately 2 times the odds of fusion success compared with autograft for all thresholds, except 55 years. Conclusions: The presented evidence suggests that age is an identifiable and concerning risk factor for hindfoot and ankle arthrodesis nonunion, a finding in contrast to the wider perception in the surgeon community. Notably, patients ≥60 years of age had significantly lower odds of fusion success with the use of autograft. The data reveal that use of rhPDGF-BB/β-TCP as an alternative bone-healing adjunct may help mitigate the risk of nonunion when these procedures are performed in the elderly population. Level of evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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