SLR - May 2019 - Mallory Schweitzer

Surgeon Type and Outcomes After Inpatient Ankle Arthrodesis and Total Ankle Arthroplasty: A Retrospective Cohort Study Using the Nationwide Premier Healthcare Claims Database

Chan JJ, Chan JC, Poeran J, Zubizarreta N, Mazumdar M, Vulcano E. Surgeon Type and Outcomes After Inpatient Ankle Arthrodesis and Total Ankle Arthroplasty: A Retrospective Cohort Study Using the Nationwide Premier Healthcare Claims Database. J Bone Joint Surg. 2019 Jan 16; 101(2):127–135.

Scientific Literature Review

Reviewed By: Mallory Schweitzer, DPM
Residency Program: CHI Franciscan Foot and Ankle Institute, Federal Way, WA

Podiatric Relevance: Both podiatrists and orthopaedic foot and ankle surgeons perform procedures for end-stage ankle arthritis, and in recent years, total ankle arthroplasty (TAA) has become a more popular procedure. The purpose of this study was to evaluate a large cohort of patients undergoing ankle arthrodesis and TAA and to compare outcomes by surgeon type.

Methods: Data from the Nationwide Premier Healthcare Claims Database from 2011 to 2016 was utilized (TAA = 3,674 and arthrodesis = 4,980). Approximately 40 percent of the hospitals included in this database are in the South, with approximately 20 percent located each within the Northeast, West and Midwest. Outcomes by podiatric and orthopaedic surgeons were compared in terms of length of stay, opioid utilization, cost of hospitalization, 30- and 90-day readmission rates and conversion to below-knee amputation.  

Results: Orthopaedic surgeons performed 76.5 percent and podiatrists performed 18.8 percent of total ankle replacements. For ankle arthrodesis, orthopaedic surgeons performed 75.3 percent and podiatrists performed 18.3 percent of these procedures. The authors found that procedures performed by podiatrists had a greater length of stay: +16.6 percent for TAA and +14.2 percent for ankle arthrodesis. There was an increased cost of hospitalization associated with podiatrists performing ankle arthrodesis. Rates of readmission and conversion to below-knee amputation were low regardless of surgeon type for TAA, yet for ankle arthrodesis, there was a higher readmission rate among podiatrists.

Conclusion: This study highlights the negative outcomes of ankle replacement and arthrodesis performed by podiatric surgeons compared to orthopaedic surgeons and downplays the outcomes that were equal and the likely reasons for these findings. The conclusion states that since these procedures are in higher demand, the type of surgeon performing the procedure should be taken into account in terms of resource utilization, implying that facilities should prefer that orthopaedic surgeons perform these procedures because the cost will be lower. The authors fail to mention that in ankle replacements performed by podiatrists, the cost of hospitalization was actually equal to those performed by orthopaedic surgeons, although there was a small increase in length of stay when performed by podiatry. The authors also found that there was a greater cost and length of stay associated with podiatrists performing ankle arthrodesis. Evaluating this further, the authors mention that podiatrists tend to perform ankle fusions on patients who have greater comorbidities and more likely to be obese in smaller community, nonteaching hospitals compared to orthopaedic surgeons. Patients, such as these, generally require more inpatient care for a longer length of time postoperatively, and this likely accounts for some of the increased cost. The authors discuss the differences in training between podiatric and orthopaedic surgeons in the United States at length and cites a study from the United Kingdom, but this comparison is not appropriate. Podiatric surgeons should be aware of research like this and should be prepared to respond in an informed manner to inquiries when compared to orthopaedic surgeons.

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