- Email: [email protected]
Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis
G Model JINJ 7871 No. of Pages 4
Injury, Int. J. Care Injured xxx (2018) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis Brandon Barnds* , William Tucker, Brandon Morris, Armin Tarakemeh, John Paul Schroeppel, Scott Mullen, Bryan G. Vopat The University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 2 October 2018
Background: Controversy exists regarding optimal primary management of Lisfranc injuries. Whether open reduction internal fixation (ORIF) or primary arthrodesis is superior remains unknown. Methods: A national insurance database of approximately 23.5 million orthopedic patients was retrospectively queried for subjects who were diagnosed with a Lisfranc injury from 2007 to 2016 based on international classification of diseases (ICD) codes (PearlDiver, Colorado Springs, CO). Patients with lisfranc injuries then progressed to either nonoperative treatment, ORIF, or primary arthrodesis. Associated treatment costs were determined along with complication rate and hardware removal rate. Results: 2205 subjects with a diagnosis of Lisfranc injury were identified in the database. 1248 patients underwent nonoperative management, 670 underwent ORIF, and 212 underwent primary arthrodesis. The average cost of care associated with primary arthrodesis was greater ($5005.82) than for ORIF ($3961.97,P = 0.045). The overall complication rate was 23.1% (155/670) for ORIF and 30.2% (64/212) for primary arthrodesis (P = 0.04). Rates of hardware removal were 43.6% (292/670) for ORIF and 18.4% (39/ 212) for arthrodesis (P < 0.001). Furthermore, 2.5% (17/670) patients in the ORIF group progressed to arthrodesis at a mean of 308 days, average cost of care associated with this group of patients was $9505.12. Discussion: Primary arthrodesis is both significantly more expensive and has a higher complication rate than ORIF. Open reduction and internal fixation demonstrated a low rate of progression to arthrodesis, although there was a high rate of hardware removal, which may represent a planned second procedure in the management of a substantial number of patients treated with ORIF. Level of evidence: :Level III Retrospective Cohort Study. © 2018 Published by Elsevier Ltd.
Keywords: Lisfranc Tarsometatarsal Midfoot dislocation Tarsometatarsal fusion Tarsometatarsal arthrodesis Lisfranc fusion Lisfranc arthrodesis
Introduction Lisfranc injuries involving the tarsometatarsal joint of the midfoot are relatively uncommon orthopedic injuries, making up 0.2% of all fractures with an overall incidence of 1 in 55,000 annually [1]. The Lisfranc joint is composed of the tarsometatarsal joints making up the junction of the forefoot and midfoot including the medial, intermediate, and lateral cuneiforms, along with cuboid and the 1 st through 5th metatarsals [2]. Further, the mortise made up of the medial aspect of the 2nd metatarsal base against the medial cuneiform along with the Lisfranc ligament from the medial cuneiform to the 2nd MT base confers significant stability to the Lisfranc joint, and the
* Corresponding author. E-mail address: [email protected] (B. Barnds).
shallower this mortise, the less inherently stable the joint [2– 5]. These injuries are characterized by disruption of the tarsometatarsal joints by purely ligamentous, purely osseous, or a combination of the two mechanisms, resulting in instability of the forefoot-midfoot junction and associated pain, disability, and development of posttraumatic osteoarthritis [5,6]. This problem is associated with both direct and indirect forces, seen with a range of mechanisms including high energy trauma, sporting injuries, and low energy trauma affecting osteoporotic or insensate individuals [4]. Lisfranc injuries appropriately diagnosed and treated are associated with adequate functional outcomes in low demand patients, whereas higher demand subjects including professional football players can experience a noticeable effect on their athletic performance in the short term and in some cases, throughout their career. [7–9] Appropriately managed Lisfranc injuries can result in a majority of patients returning to their prior level of employment
https://doi.org/10.1016/j.injury.2018.10.002 0020-1383/© 2018 Published by Elsevier Ltd.
Please cite this article in press as: B. Barnds, et al., Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis, Injury (2018), https://doi.org/10.1016/j.injury.2018.10.002
G Model JINJ 7871 No. of Pages 4
2
B. Barnds et al. / Injury, Int. J. Care Injured xxx (2018) xxx–xxx
and functional status [7]. These injuries have a significant effect on push-off strength and balance [8]. Due to the significant complications and effect on long term function of these injuries, there must be a high index of suspicion to prevent a missed diagnosis [10]. Missed injuries or a significant delay in treatment more often result in significantly worse outcomes [11]. Overall subjects with Lisfranc instability have better outcomes when managed with operative versus nonoperative management [12]. Patients with non-displaced stable injuries or with significant comorbidities and low functional status can be managed nonoperatively with non-weight bearing restrictions in a protective orthosis for at least 6–16 weeks [5,10]. Variability in the optimal treatment exists between attempting primary reduction and fixation versus primary arthrodesis; studies have found that primary arthrodesis may result in better clinical outcomes for certain injuries, especially purely ligamentous types [13–15]. Further, in those cases requiring operative intervention, results are superior with formal open reduction techniques compared to closed reduction and percutaneous fixation [16]. The purpose of this study was to use a private payer database to compare cost, complication rate, and hardware removal rate in Lisfranc injuries treated with primary open reduction internal fixation or primary arthrodesis. Materials and methods This study was conducted using the PearlDiver Health Insurance Database (PearlDiver, Colorado Springs, CO). Specifically, this study utilized the Humana Insurance Database of over 23.5 million orthopedic patients from 2007 to 2016. Patients with a history of a lisfranc injury were isolated using a customized PearlDiver code and their associated demographics, outcomes, and cost of care were obtained. Utilizing International Classification of Diseases (ICD) Ninth and Tenth Revisions codes, patients with a diagnosis of tarsometatarsal dislocations (Lisfranc injury) were queried and further classified into groups based on Current Procedural Terminology (CPT) codes (Supplemental Table 1). The nonoperative group consisted of those patients with a diagnosis of Lisfranc injury having never undergone a procedure including closed reduction with percutaneous fixation, arthrodesis or open reduction and internal fixation. The open reduction internal fixation group was defined by having a diagnosis of Lisfranc injury and procedure code for open treatment of TMT joint dislocation who had never had an arthrodesis. Patients in this group were followed for progression to arthrodesis. Patients undergoing primary arthrodesis were identified by having a diagnosis of Lisfranc injury and procedure code for midtarsal or TMT arthrodesis who did not have fixation before the arthrodesis. A cost analysis was performed on the groups using a PearlDiver code to sum the cost reimbursed to all billing entities for all charges associated with the Lisfranc injury ICD codes listed as the primary diagnosis. This included all encounters or procedures in which these ICD codes were listed, performed in all healthcare settings (inpatient, outpatient, physical therapy, etc.). For the subgroup of patients initially undergoing ORIF who progressed to arthrodesis, the average time between arthrodesis and original ORIF surgery was recorded. Subgroups were then created based on having at least one complication ICD or CPT code after the beginning of treatment, which included: hemorrhage, infection, nonunion, malunion, thromboembolism, wound and hardware complications, or amputation. Additionally, patients undergoing implant removal were identified by CPT code for removal of hardware performed after the index procedure. This was not included as a complication since this is routinely done by after open reduction internal fixation.
A t-test was used to assess significance of the cost between the fusion group and the open reduction internal fixation group. Chisquare analysis was utilized to determine significance between complication rates between the different groups. A p value < 0.05 was considered significant. Results Initial database query resulted in 2205 subjects with a diagnosis of Lisfranc injury. Of these subjects, 1248 underwent nonoperative management, 670 underwent open reduction internal fixation, and 212 underwent primary arthrodesis (Supplemental Table 2). The average cost of care associated with primary arthrodesis was greater ($5005.82) than for open reduction internal fixation ($3961.97, P = 0.045). The overall complication rate was 23.1% (155/670) for open reduction internal fixation and 30.2% (64/212) for primary arthrodesis (P = 0.04). The most common complications within each operative group were included in Table 2, exact numbers of subjects with each complication were included where possible. Due to database constraints protecting patient confidentiality, the exact number of subjects could not be specified if there were fewer than 11 subjects per group. Rates of hardware removal independent of complications were 43.6% (292/670) for open reduction internal fixation and 18.4% (39/212) for arthrodesis (P < 0.001). The average cost of patients in the open reduction and internal fixation not requiring hardware removal was $3688.83 versus $4311.04 in the patients requiring hardware removal (P = 0.1242). Furthermore, 2.5% (17/670) patients in the open reduction internal fixation group progressed to arthrodesis at a mean of 308 days, average cost of care associated with this group of patients was $9505.12. Further, amongst patients undergoing ORIF, there was no significant difference in cost between those requiring hardware removal and not requiring hardware removal (P = 0.1242). Discussion There were 2205 subjects in this database with a diagnosis of Lisfranc injury. Approximately 30.4% (670/2205) of patients diagnosed with a Lisfranc injury were managed with primary ORIF versus 9.6% (212/2205) who were managed with primary arthrodesis in this study population. Primary arthrodesis for the management of acute Lisfranc injuries is significantly more expensive than primary ORIF ($5005.82 versus $3961.97, P = 0.045). Primary arthrodesis also has a higher complication rate than open reduction internal fixation (30.2% versus 23.1%, P = 0.04). Open reduction internal fixation demonstrated a low rate of progression to arthrodesis (2.5%), although there was a significantly greater rate of hardware removal than ORIF (43.6% versus 18.4%, P < 0.001). This high hardware removal rate may represent a planned second procedure in the management of a substantial number of patients treated with open reduction internal fixation. Furthermore, amongst patients undergoing ORIF, there was no significant difference in cost between those requiring hardware removal and not requiring hardware removal (P = 0.1242). The current study corroborated data from previous work suggesting that primary ORIF had a low progression to secondary arthrodesis yet a higher rate of hardware removal. This is the first study of its kind to use a large insurance database to perform a cost analysis on primary arthrodesis versus ORIF for Lisfranc injuries, demonstrating a significantly increased cost with arthrodesis. This study was unable to assess subjective outcomes in this population but another large retrospective study by Ferriere showed no significant difference in outcomes of patients with Lisfranc injuries treated with primary ORIF versus arthrodesis [7]. There was a significantly greater complication rate observed in the primary
Please cite this article in press as: B. Barnds, et al., Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis, Injury (2018), https://doi.org/10.1016/j.injury.2018.10.002
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arthrodesis group, the first finding of its kind in a large database study. Overall, this study adds to the body of literature suggesting that careful patient selection must be undertaken in this injury population to minimize cost, complications, and rate of secondary procedures. Studies by McHale et al. analyzing high-demand NFL athletes with Lisfranc injuries found that the majority of these patients are managed operatively (63.4%), of those, 76.9% underwent ORIF, 19.2% underwent suspensory fixation and only 3.8% underwent primary arthrodesis [8]. Although there was a greater percentage of patients undergoing operative management in the NFL population, the rate of ORIF amongst those patients being treated operatively in the Humana population was very similar at 76.0%. Similar to the current study, there was a high rate of hardware removal at 53.8% [8]. Players with appropriate management preventing joint displacement >2 mm started in more professional games and were drafted sooner than those with less displacement. Regardless of management, these injuries had a significant effect on return to play, although 92.9% of players returned, this occurred 11.1 months after injury and they missed 8.5 games on average; there was a decrease in performance measures though this was not significant. [9]. These high demand patients seem to perform reasonably well with ORIF after a prolonged recovery period [8, 9]. The increased cost associated with primary arthrodesis may be attributable to increased implant cost and biologic arthrodesis supplementation products. There may also be a trend towards selecting patients who have worse comorbidities for primary arthrodesis, thus increasing the global cost of their care. Some authors suggest performing primary arthrodesis in all patients with peripheral neuropathy and purely ligamentous injuries, especially those with charcot arthropathy, due to the reduced proprioceptive and protective ability to prevent displacement through ORIF fixation. [15,17] In another study by Rammelt assessing the efficacy of secondary fusion for failed ORIF procedures, patients requiring secondary fusion had worse outcomes than those patients undergoing ORIF who did not require subsequent fusion, they also found the highest risk of ORIF failure in cases of malreduction, therefore, closed reduction is discouraged [18]. Therefore, one must appropriately select patients undergoing ORIF versus arthrodesis, as the results of secondary fusion are less optimal, but still a reasonable salvage procedure when necessary. There was a significantly higher rate of hardware removal in patients undergoing ORIF, likely attributable to a planned second procedure in a majority of patients to remove temporary joint spanning fixation. Hardware removal is specifically recommended in patients undergoing tarsometatarsal joint spanning fixation, especially of the 4th and 5th TMT joints which often require removal of hardware at 8–12 weeks to prevent long-term lateral column stiffness [10]. In a review article by Sheibani et al comparing ORIF versus fusion, it was determined that patients undergoing primary fusion had higher American orthopedic foot and ankle scores (AOFAS) and a significantly decreased rate of reoperation and nonunion rate than patients initially treated with ORIF [13]. The current study population found similar trends in reoperation rate though outcome scores were not able to be assessed given the constraints of the lack of subjective data in this database study. Although these hardware removal surgeries are typically simple procedures with minimal incisions and risk of complications, there is increased risk associated with a second anesthetic event. This is a non-negligible aspect of treating patients with ORIF given the high hardware removal rate (43.6%), more than double that of the primary arthrodesis group, although there was not a significant increase in cost associated with hardware removal. Care should be taken in patient, injury pattern, and ORIF method selection to minimize the hardware removal rate.
3
Ferriere et al determined that approximately 72% of Lisfranc injuries managed operatively developed degenerative OA, of the 26% who were malreduced, all developed OA; only 54% of patients developed symptomatic OA at 2–24 years after the injury [7]. Ferriere et al found that only 6.5% of Lisfranc injuries managed operatively required secondary fusion and the most significant risk factors for development of OA were failure to obtain an anatomic reduction and smoking [7]. This study also found a low rate of progression to secondary arthrodesis in the primary ORIF group (2.5%) occurring at 308 days after initial diagnosis, though this study only has a maximum 9 years of follow up and may be missing some patients developing late symptomatic OA requiring secondary arthrodesis. This data would suggest that although there is a high rate of post-traumatic OA, a majority of patients are either asymptomatic and/or not symptomatic enough to warrant secondary arthrodesis after primary ORIF. This study is limited in the retrospective nature and lack of subjective outcome measures, therefore no conclusions can be made about the activity and pain related outcome measures of these two interventions. Further, this study relies upon accurate provider coding and billing information, and the use of a single payer database. Patients may have also changed insurance companies resulting in loss to follow up. As the database and years of follow up grows, this will need to be reassessed to determine ongoing trends, especially in the rate of progression to secondary arthrodesis. The long-term need for arthrodesis due to arthritis after ORIF is limited by the maximum amount of follow up only being 9 years. Conclusions Primary arthrodesis for the management of acute Lisfranc injuries is both significantly more expensive and has a higher complication rate than open reduction internal fixation. Open reduction internal fixation demonstrated a low rate of progression to arthrodesis, although there was a high rate of hardware removal, which may represent a planned second procedure in the management of a substantial number of patients treated with open reduction internal fixation. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.injury.2018.10.002. References [1] Desmond E.A., Chou LB. Current concepts review: Lisfranc injuries. Foot Ankle Int 2006;27(8):653–60. [2] Hatem SF. Imaging of lisfranc injury and midfoot sprain. Radiol Clin North Am 2008;46(6)1045–60 vi.. [3] Peicha G, Labovitz J, Seibert FJ, Grechenig W, Weiglein A, Preidler KW, et al. The anatomy of the joint as a risk factor for Lisfranc dislocation and fracturedislocation. An anatomical and radiological case control study. J Bone Joint Surg Br 2002;84(7):981–5. [4] Wiley JJ. The mechanism of tarso-metatarsal joint injuries. J Bone Joint Surg Br 1971;53(3):474–82. [5] Eleftheriou KI, Rosenfeld PF, Calder JD. Lisfranc injuries: an update. Knee Surg Sports Traumatol Arthrosc 2013;21(6):1434–46. [6] Welck MJ, Zinchenko R, Rudge B. Lisfranc injuries. Injury 2015;46(4):536–41. [7] Dubois-Ferriere V, Lubbeke A, Chowdhary A, Stern R, Dominguez D, Assal M. Clinical outcomes and development of symptomatic osteoarthritis 2 to 24 years after surgical treatment of tarsometatarsal joint complex injuries. J Bone Joint Surg Am 2016;98(9):713–20. [8] McHale KJ, Vopat BG, Beaulieu-Jones BR, Sanchez G, Whalen JM, McDonald LS, et al. Epidemiology and outcomes of Lisfranc injuries identified at the national football league scouting combine. Am J Sports Med 2017;45(8):1901–8. [9] McHale KJ, Rozell JC, Milby AH, Carey JL, Sennett BJ. Outcomes of Lisfranc injuries in the national football league. Am J Sports Med 2016;44(7):1810–7.
Please cite this article in press as: B. Barnds, et al., Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis, Injury (2018), https://doi.org/10.1016/j.injury.2018.10.002
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[10] Weatherford BM, Anderson JG, Bohay DR. Management of tarsometatarsal joint injuries. J Am Acad Orthop Surg 2017;25(7):469–79. [11] Calder JD, Whitehouse SL, Saxby TS. Results of isolated Lisfranc injuries and the effect of compensation claims. J Bone Joint Surg Br 2004;86(4):527–30. [12] Brinsden MD, Smith SR, Loxdale PH. Lisfranc injury–surgical fixation facilities an early return to work. J R Nav Med Serv 2001;87(2):116–9. [13] Sheibani-Rad S, Coetzee JC, Giveans MR, DiGiovanni C. Arthrodesis versus ORIF for lisfranc fractures. Orthopedics 2012;35(6):e868–73. [14] Weatherford BM, Bohay DR, Anderson JG. Open reduction and internal fixation versus primary arthrodesis for lisfranc injuries. Foot Ankle Clin 2017;22(1):1– 14.
[15] Coetzee JC, Ly TV. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. Surgical technique. J Bone Joint Surg Am 2007;89(Suppl 2)122–7 Pt.1. [16] English TA. Dislocations of the metatarsal bone and adjacent toe. J Bone Joint Surg Br 1964;46:700–4. [17] Stone NC, Daniels TR. Midfoot and hindfoot arthrodeses in diabetic Charcot arthropathy. Can J Surg 2000;43(6):449–55. [18] Rammelt S, Schneiders W, Schikore H, Holch M, Heineck J, Zwipp H. Primary open reduction and fixation compared with delayed corrective arthrodesis in the treatment of tarsometatarsal (Lisfranc) fracture dislocation. J Bone Joint Surg Br 2008;90(11):1499–506.
Please cite this article in press as: B. Barnds, et al., Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis, Injury (2018), https://doi.org/10.1016/j.injury.2018.10.002
Injury, Int. J. Care Injured xxx (2018) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis Brandon Barnds* , William Tucker, Brandon Morris, Armin Tarakemeh, John Paul Schroeppel, Scott Mullen, Bryan G. Vopat The University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 2 October 2018
Background: Controversy exists regarding optimal primary management of Lisfranc injuries. Whether open reduction internal fixation (ORIF) or primary arthrodesis is superior remains unknown. Methods: A national insurance database of approximately 23.5 million orthopedic patients was retrospectively queried for subjects who were diagnosed with a Lisfranc injury from 2007 to 2016 based on international classification of diseases (ICD) codes (PearlDiver, Colorado Springs, CO). Patients with lisfranc injuries then progressed to either nonoperative treatment, ORIF, or primary arthrodesis. Associated treatment costs were determined along with complication rate and hardware removal rate. Results: 2205 subjects with a diagnosis of Lisfranc injury were identified in the database. 1248 patients underwent nonoperative management, 670 underwent ORIF, and 212 underwent primary arthrodesis. The average cost of care associated with primary arthrodesis was greater ($5005.82) than for ORIF ($3961.97,P = 0.045). The overall complication rate was 23.1% (155/670) for ORIF and 30.2% (64/212) for primary arthrodesis (P = 0.04). Rates of hardware removal were 43.6% (292/670) for ORIF and 18.4% (39/ 212) for arthrodesis (P < 0.001). Furthermore, 2.5% (17/670) patients in the ORIF group progressed to arthrodesis at a mean of 308 days, average cost of care associated with this group of patients was $9505.12. Discussion: Primary arthrodesis is both significantly more expensive and has a higher complication rate than ORIF. Open reduction and internal fixation demonstrated a low rate of progression to arthrodesis, although there was a high rate of hardware removal, which may represent a planned second procedure in the management of a substantial number of patients treated with ORIF. Level of evidence: :Level III Retrospective Cohort Study. © 2018 Published by Elsevier Ltd.
Keywords: Lisfranc Tarsometatarsal Midfoot dislocation Tarsometatarsal fusion Tarsometatarsal arthrodesis Lisfranc fusion Lisfranc arthrodesis
Introduction Lisfranc injuries involving the tarsometatarsal joint of the midfoot are relatively uncommon orthopedic injuries, making up 0.2% of all fractures with an overall incidence of 1 in 55,000 annually [1]. The Lisfranc joint is composed of the tarsometatarsal joints making up the junction of the forefoot and midfoot including the medial, intermediate, and lateral cuneiforms, along with cuboid and the 1 st through 5th metatarsals [2]. Further, the mortise made up of the medial aspect of the 2nd metatarsal base against the medial cuneiform along with the Lisfranc ligament from the medial cuneiform to the 2nd MT base confers significant stability to the Lisfranc joint, and the
* Corresponding author. E-mail address: [email protected] (B. Barnds).
shallower this mortise, the less inherently stable the joint [2– 5]. These injuries are characterized by disruption of the tarsometatarsal joints by purely ligamentous, purely osseous, or a combination of the two mechanisms, resulting in instability of the forefoot-midfoot junction and associated pain, disability, and development of posttraumatic osteoarthritis [5,6]. This problem is associated with both direct and indirect forces, seen with a range of mechanisms including high energy trauma, sporting injuries, and low energy trauma affecting osteoporotic or insensate individuals [4]. Lisfranc injuries appropriately diagnosed and treated are associated with adequate functional outcomes in low demand patients, whereas higher demand subjects including professional football players can experience a noticeable effect on their athletic performance in the short term and in some cases, throughout their career. [7–9] Appropriately managed Lisfranc injuries can result in a majority of patients returning to their prior level of employment
https://doi.org/10.1016/j.injury.2018.10.002 0020-1383/© 2018 Published by Elsevier Ltd.
Please cite this article in press as: B. Barnds, et al., Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis, Injury (2018), https://doi.org/10.1016/j.injury.2018.10.002
G Model JINJ 7871 No. of Pages 4
2
B. Barnds et al. / Injury, Int. J. Care Injured xxx (2018) xxx–xxx
and functional status [7]. These injuries have a significant effect on push-off strength and balance [8]. Due to the significant complications and effect on long term function of these injuries, there must be a high index of suspicion to prevent a missed diagnosis [10]. Missed injuries or a significant delay in treatment more often result in significantly worse outcomes [11]. Overall subjects with Lisfranc instability have better outcomes when managed with operative versus nonoperative management [12]. Patients with non-displaced stable injuries or with significant comorbidities and low functional status can be managed nonoperatively with non-weight bearing restrictions in a protective orthosis for at least 6–16 weeks [5,10]. Variability in the optimal treatment exists between attempting primary reduction and fixation versus primary arthrodesis; studies have found that primary arthrodesis may result in better clinical outcomes for certain injuries, especially purely ligamentous types [13–15]. Further, in those cases requiring operative intervention, results are superior with formal open reduction techniques compared to closed reduction and percutaneous fixation [16]. The purpose of this study was to use a private payer database to compare cost, complication rate, and hardware removal rate in Lisfranc injuries treated with primary open reduction internal fixation or primary arthrodesis. Materials and methods This study was conducted using the PearlDiver Health Insurance Database (PearlDiver, Colorado Springs, CO). Specifically, this study utilized the Humana Insurance Database of over 23.5 million orthopedic patients from 2007 to 2016. Patients with a history of a lisfranc injury were isolated using a customized PearlDiver code and their associated demographics, outcomes, and cost of care were obtained. Utilizing International Classification of Diseases (ICD) Ninth and Tenth Revisions codes, patients with a diagnosis of tarsometatarsal dislocations (Lisfranc injury) were queried and further classified into groups based on Current Procedural Terminology (CPT) codes (Supplemental Table 1). The nonoperative group consisted of those patients with a diagnosis of Lisfranc injury having never undergone a procedure including closed reduction with percutaneous fixation, arthrodesis or open reduction and internal fixation. The open reduction internal fixation group was defined by having a diagnosis of Lisfranc injury and procedure code for open treatment of TMT joint dislocation who had never had an arthrodesis. Patients in this group were followed for progression to arthrodesis. Patients undergoing primary arthrodesis were identified by having a diagnosis of Lisfranc injury and procedure code for midtarsal or TMT arthrodesis who did not have fixation before the arthrodesis. A cost analysis was performed on the groups using a PearlDiver code to sum the cost reimbursed to all billing entities for all charges associated with the Lisfranc injury ICD codes listed as the primary diagnosis. This included all encounters or procedures in which these ICD codes were listed, performed in all healthcare settings (inpatient, outpatient, physical therapy, etc.). For the subgroup of patients initially undergoing ORIF who progressed to arthrodesis, the average time between arthrodesis and original ORIF surgery was recorded. Subgroups were then created based on having at least one complication ICD or CPT code after the beginning of treatment, which included: hemorrhage, infection, nonunion, malunion, thromboembolism, wound and hardware complications, or amputation. Additionally, patients undergoing implant removal were identified by CPT code for removal of hardware performed after the index procedure. This was not included as a complication since this is routinely done by after open reduction internal fixation.
A t-test was used to assess significance of the cost between the fusion group and the open reduction internal fixation group. Chisquare analysis was utilized to determine significance between complication rates between the different groups. A p value < 0.05 was considered significant. Results Initial database query resulted in 2205 subjects with a diagnosis of Lisfranc injury. Of these subjects, 1248 underwent nonoperative management, 670 underwent open reduction internal fixation, and 212 underwent primary arthrodesis (Supplemental Table 2). The average cost of care associated with primary arthrodesis was greater ($5005.82) than for open reduction internal fixation ($3961.97, P = 0.045). The overall complication rate was 23.1% (155/670) for open reduction internal fixation and 30.2% (64/212) for primary arthrodesis (P = 0.04). The most common complications within each operative group were included in Table 2, exact numbers of subjects with each complication were included where possible. Due to database constraints protecting patient confidentiality, the exact number of subjects could not be specified if there were fewer than 11 subjects per group. Rates of hardware removal independent of complications were 43.6% (292/670) for open reduction internal fixation and 18.4% (39/212) for arthrodesis (P < 0.001). The average cost of patients in the open reduction and internal fixation not requiring hardware removal was $3688.83 versus $4311.04 in the patients requiring hardware removal (P = 0.1242). Furthermore, 2.5% (17/670) patients in the open reduction internal fixation group progressed to arthrodesis at a mean of 308 days, average cost of care associated with this group of patients was $9505.12. Further, amongst patients undergoing ORIF, there was no significant difference in cost between those requiring hardware removal and not requiring hardware removal (P = 0.1242). Discussion There were 2205 subjects in this database with a diagnosis of Lisfranc injury. Approximately 30.4% (670/2205) of patients diagnosed with a Lisfranc injury were managed with primary ORIF versus 9.6% (212/2205) who were managed with primary arthrodesis in this study population. Primary arthrodesis for the management of acute Lisfranc injuries is significantly more expensive than primary ORIF ($5005.82 versus $3961.97, P = 0.045). Primary arthrodesis also has a higher complication rate than open reduction internal fixation (30.2% versus 23.1%, P = 0.04). Open reduction internal fixation demonstrated a low rate of progression to arthrodesis (2.5%), although there was a significantly greater rate of hardware removal than ORIF (43.6% versus 18.4%, P < 0.001). This high hardware removal rate may represent a planned second procedure in the management of a substantial number of patients treated with open reduction internal fixation. Furthermore, amongst patients undergoing ORIF, there was no significant difference in cost between those requiring hardware removal and not requiring hardware removal (P = 0.1242). The current study corroborated data from previous work suggesting that primary ORIF had a low progression to secondary arthrodesis yet a higher rate of hardware removal. This is the first study of its kind to use a large insurance database to perform a cost analysis on primary arthrodesis versus ORIF for Lisfranc injuries, demonstrating a significantly increased cost with arthrodesis. This study was unable to assess subjective outcomes in this population but another large retrospective study by Ferriere showed no significant difference in outcomes of patients with Lisfranc injuries treated with primary ORIF versus arthrodesis [7]. There was a significantly greater complication rate observed in the primary
Please cite this article in press as: B. Barnds, et al., Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis, Injury (2018), https://doi.org/10.1016/j.injury.2018.10.002
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arthrodesis group, the first finding of its kind in a large database study. Overall, this study adds to the body of literature suggesting that careful patient selection must be undertaken in this injury population to minimize cost, complications, and rate of secondary procedures. Studies by McHale et al. analyzing high-demand NFL athletes with Lisfranc injuries found that the majority of these patients are managed operatively (63.4%), of those, 76.9% underwent ORIF, 19.2% underwent suspensory fixation and only 3.8% underwent primary arthrodesis [8]. Although there was a greater percentage of patients undergoing operative management in the NFL population, the rate of ORIF amongst those patients being treated operatively in the Humana population was very similar at 76.0%. Similar to the current study, there was a high rate of hardware removal at 53.8% [8]. Players with appropriate management preventing joint displacement >2 mm started in more professional games and were drafted sooner than those with less displacement. Regardless of management, these injuries had a significant effect on return to play, although 92.9% of players returned, this occurred 11.1 months after injury and they missed 8.5 games on average; there was a decrease in performance measures though this was not significant. [9]. These high demand patients seem to perform reasonably well with ORIF after a prolonged recovery period [8, 9]. The increased cost associated with primary arthrodesis may be attributable to increased implant cost and biologic arthrodesis supplementation products. There may also be a trend towards selecting patients who have worse comorbidities for primary arthrodesis, thus increasing the global cost of their care. Some authors suggest performing primary arthrodesis in all patients with peripheral neuropathy and purely ligamentous injuries, especially those with charcot arthropathy, due to the reduced proprioceptive and protective ability to prevent displacement through ORIF fixation. [15,17] In another study by Rammelt assessing the efficacy of secondary fusion for failed ORIF procedures, patients requiring secondary fusion had worse outcomes than those patients undergoing ORIF who did not require subsequent fusion, they also found the highest risk of ORIF failure in cases of malreduction, therefore, closed reduction is discouraged [18]. Therefore, one must appropriately select patients undergoing ORIF versus arthrodesis, as the results of secondary fusion are less optimal, but still a reasonable salvage procedure when necessary. There was a significantly higher rate of hardware removal in patients undergoing ORIF, likely attributable to a planned second procedure in a majority of patients to remove temporary joint spanning fixation. Hardware removal is specifically recommended in patients undergoing tarsometatarsal joint spanning fixation, especially of the 4th and 5th TMT joints which often require removal of hardware at 8–12 weeks to prevent long-term lateral column stiffness [10]. In a review article by Sheibani et al comparing ORIF versus fusion, it was determined that patients undergoing primary fusion had higher American orthopedic foot and ankle scores (AOFAS) and a significantly decreased rate of reoperation and nonunion rate than patients initially treated with ORIF [13]. The current study population found similar trends in reoperation rate though outcome scores were not able to be assessed given the constraints of the lack of subjective data in this database study. Although these hardware removal surgeries are typically simple procedures with minimal incisions and risk of complications, there is increased risk associated with a second anesthetic event. This is a non-negligible aspect of treating patients with ORIF given the high hardware removal rate (43.6%), more than double that of the primary arthrodesis group, although there was not a significant increase in cost associated with hardware removal. Care should be taken in patient, injury pattern, and ORIF method selection to minimize the hardware removal rate.
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Ferriere et al determined that approximately 72% of Lisfranc injuries managed operatively developed degenerative OA, of the 26% who were malreduced, all developed OA; only 54% of patients developed symptomatic OA at 2–24 years after the injury [7]. Ferriere et al found that only 6.5% of Lisfranc injuries managed operatively required secondary fusion and the most significant risk factors for development of OA were failure to obtain an anatomic reduction and smoking [7]. This study also found a low rate of progression to secondary arthrodesis in the primary ORIF group (2.5%) occurring at 308 days after initial diagnosis, though this study only has a maximum 9 years of follow up and may be missing some patients developing late symptomatic OA requiring secondary arthrodesis. This data would suggest that although there is a high rate of post-traumatic OA, a majority of patients are either asymptomatic and/or not symptomatic enough to warrant secondary arthrodesis after primary ORIF. This study is limited in the retrospective nature and lack of subjective outcome measures, therefore no conclusions can be made about the activity and pain related outcome measures of these two interventions. Further, this study relies upon accurate provider coding and billing information, and the use of a single payer database. Patients may have also changed insurance companies resulting in loss to follow up. As the database and years of follow up grows, this will need to be reassessed to determine ongoing trends, especially in the rate of progression to secondary arthrodesis. The long-term need for arthrodesis due to arthritis after ORIF is limited by the maximum amount of follow up only being 9 years. Conclusions Primary arthrodesis for the management of acute Lisfranc injuries is both significantly more expensive and has a higher complication rate than open reduction internal fixation. Open reduction internal fixation demonstrated a low rate of progression to arthrodesis, although there was a high rate of hardware removal, which may represent a planned second procedure in the management of a substantial number of patients treated with open reduction internal fixation. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.injury.2018.10.002. References [1] Desmond E.A., Chou LB. Current concepts review: Lisfranc injuries. Foot Ankle Int 2006;27(8):653–60. [2] Hatem SF. Imaging of lisfranc injury and midfoot sprain. Radiol Clin North Am 2008;46(6)1045–60 vi.. [3] Peicha G, Labovitz J, Seibert FJ, Grechenig W, Weiglein A, Preidler KW, et al. The anatomy of the joint as a risk factor for Lisfranc dislocation and fracturedislocation. An anatomical and radiological case control study. J Bone Joint Surg Br 2002;84(7):981–5. [4] Wiley JJ. The mechanism of tarso-metatarsal joint injuries. J Bone Joint Surg Br 1971;53(3):474–82. [5] Eleftheriou KI, Rosenfeld PF, Calder JD. Lisfranc injuries: an update. Knee Surg Sports Traumatol Arthrosc 2013;21(6):1434–46. [6] Welck MJ, Zinchenko R, Rudge B. Lisfranc injuries. Injury 2015;46(4):536–41. [7] Dubois-Ferriere V, Lubbeke A, Chowdhary A, Stern R, Dominguez D, Assal M. Clinical outcomes and development of symptomatic osteoarthritis 2 to 24 years after surgical treatment of tarsometatarsal joint complex injuries. J Bone Joint Surg Am 2016;98(9):713–20. [8] McHale KJ, Vopat BG, Beaulieu-Jones BR, Sanchez G, Whalen JM, McDonald LS, et al. Epidemiology and outcomes of Lisfranc injuries identified at the national football league scouting combine. Am J Sports Med 2017;45(8):1901–8. [9] McHale KJ, Rozell JC, Milby AH, Carey JL, Sennett BJ. Outcomes of Lisfranc injuries in the national football league. Am J Sports Med 2016;44(7):1810–7.
Please cite this article in press as: B. Barnds, et al., Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis, Injury (2018), https://doi.org/10.1016/j.injury.2018.10.002
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[10] Weatherford BM, Anderson JG, Bohay DR. Management of tarsometatarsal joint injuries. J Am Acad Orthop Surg 2017;25(7):469–79. [11] Calder JD, Whitehouse SL, Saxby TS. Results of isolated Lisfranc injuries and the effect of compensation claims. J Bone Joint Surg Br 2004;86(4):527–30. [12] Brinsden MD, Smith SR, Loxdale PH. Lisfranc injury–surgical fixation facilities an early return to work. J R Nav Med Serv 2001;87(2):116–9. [13] Sheibani-Rad S, Coetzee JC, Giveans MR, DiGiovanni C. Arthrodesis versus ORIF for lisfranc fractures. Orthopedics 2012;35(6):e868–73. [14] Weatherford BM, Bohay DR, Anderson JG. Open reduction and internal fixation versus primary arthrodesis for lisfranc injuries. Foot Ankle Clin 2017;22(1):1– 14.
[15] Coetzee JC, Ly TV. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. Surgical technique. J Bone Joint Surg Am 2007;89(Suppl 2)122–7 Pt.1. [16] English TA. Dislocations of the metatarsal bone and adjacent toe. J Bone Joint Surg Br 1964;46:700–4. [17] Stone NC, Daniels TR. Midfoot and hindfoot arthrodeses in diabetic Charcot arthropathy. Can J Surg 2000;43(6):449–55. [18] Rammelt S, Schneiders W, Schikore H, Holch M, Heineck J, Zwipp H. Primary open reduction and fixation compared with delayed corrective arthrodesis in the treatment of tarsometatarsal (Lisfranc) fracture dislocation. J Bone Joint Surg Br 2008;90(11):1499–506.
Please cite this article in press as: B. Barnds, et al., Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis, Injury (2018), https://doi.org/10.1016/j.injury.2018.10.002