Study Asserts Higher Costs And Longer Hospital Stays When DPMs Perform Ankle Arthroplasty And Ankle Arthrodesis Procedures

A controversial study maintains that when podiatrists perform ankle arthroplasties and ankle arthrodeses, patients experience longer hospitalization and higher costs in comparison to when the surgeries are performed by orthopedic surgeons.

The study, published in the American edition of the Journal of Bone and Joint Surgery, compared the outcomes of podiatric surgeons and orthopedic surgeons for 3,674 total ankle arthroplasty procedures and 4,980 ankle arthrodesis procedures. Podiatrists performed 18.8 percent of arthroplasties in the study and orthopedic surgeons performed 76.5 percent. In the arthrodesis group, podiatrists performed 18.3 percent of surgeries while orthopedists performed 75.3 percent.

After adjusting for relevant covariates, the study notes that in comparison to orthopedic surgeries, those who had arthroplasties performed by podiatrists had a 116 percent greater length of hospital stay while those who had an arthrodesis had a 114 percent greater hospital stay. The authors add that ankle arthrodesis performed by podiatrists was associated with an increased cost of hospitalization of 128.5 percent in comparison to ankle arthrodesis procedures performed by orthopedic surgeons.

“The authors of this study misrepresented the results, selectively reported the data and failed to disclose their conflicts of interest,” says Lee C. Rogers, DPM, who says the study is “attempting to cast podiatrists in a negative light.”  

Dr. Rogers asserts that the study does not mention surgical outcome, only cost and hospital stay. He says only 10 percent of podiatrist-performed surgeries were excluded from the study while more than 50 percent of orthopedist-performed surgeries were excluded. Dr. Rogers adds that the study also excluded all outpatient cases, which he says are cheaper and are more likely to be performed by a podiatrist.   

“There may be actual differences in the cost of procedures performed by orthopedic surgeons and podiatrists, but this study is clearly biased with flaws in the methodology so one cannot draw any reliable conclusions (from this study),” says Dr. Rogers, the Medical Director of the Amputation Prevention Centers of America in White Plains, NY.

Mark Prissel, DPM, notes the study’s statistical analyses support its conclusion for both ankle arthrodesis and total ankle arthroplasty having longer hospitalization time for podiatrists. However, he says podiatrists operated on patients who were relatively more medically comorbid than the patients orthopedic surgeons treated.

“Rather than focusing on the logical expectation that the relatively ‘sicker’ patients will require relatively longer hospitalization, the authors elected to rapidly pivot the narrative to the educational and surgical training path of the podiatrist, and inappropriately compare the U.S.-trained surgical podiatrists to the more non-surgical United Kingdom podiatrists,” says Dr. Prissel, who is private practice at the Orthopedic Foot and Ankle Center in Westerville, Ohio.

Jeffrey E. McAlister, DPM, FACFAS, points out that the authors found an increased length of stay for ankle arthrodesis patients treated by podiatrists but did not say why. He agrees that one of the factors for a longer hospital stay is that the podiatric population tends to be “sicker,” as the study authors note.

“In this study, the bias and confounding factors supersede the clinical value of the identified results,” says Dr. Prissel.

“The authors attempt to undermine the capabilities of well-trained podiatric surgeons in an unspoken attempt to disallow podiatric surgeons from performing a total ankle arthroplasty,” says Dr. McAlister, who is in private practice at Arcadia Orthopedics and Sports Medicine in Phoenix. “We all need to focus on collaborative efforts, not combative efforts.”

Can Increased Plantar Temperatures Indicate DFU Risk?

By Brian McCurdy, Managing Editor

A new study in press in the Journal of the American Podiatric Medical Association notes temperatures are higher in the plantar surface of the foot in those with a history of diabetic neuropathic ulcers.

The study focused on nine patients with diabetic neuropathy and history of an ulcer, 14 with diabetic neuropathy (no ulcer history) and 14 patients without diabetic neuropathy. Researchers used infrared cameras to record the plantar barefoot temperatures, recording mean temperatures in the hallux, medial forefoot, central forefoot and lateral forefoot. The study found mean temperatures to be higher than 30.0°C in those with neuropathy, both with and without ulcer history, in comparison to patients without neuropathy, who had temperatures below 30.0°C. Between those with an ulcer history and those without neuropathy, researchers noted mean temperature differences ranging from 3.2°C in the medial forefoot to 4.9°C in the hallux.

Temperature monitoring “is an important topic and may prove to be a great tool in the prevention of diabetic foot ulcers,” notes Alexander Reyzelman, DPM.

Tissue trauma, repetitive stress, bony deformity and repetitive stress may contribute to higher plantar temperatures, according to Dr. Reyzelman, an Associate Professor at the California School of Podiatric Medicine at Samuel Merritt University and the Co-Director of the University of California San Francisco (UCSF) Center for Limb Preservation. He says monitoring temperatures is effective when evaluating the progression of Charcot feet.

Currently, Dr. Reyzelman notes only handheld temperature measuring devices are available and adds that temperature monitoring is “not a well utilized modality at this time.” Citing the use of a Podimetrics Mat (Podimetrics) with temperature sensors embedded in it, Dr. Reyzelman says patients can step on the mat and get a temperature reading. He also notes the utility of temperature monitoring with Smart Socks (Siren).

Study Assesses Impact Of Arthroscopy On ORIF For Ankle Fractures

By Brian McCurdy, Managing Editor

Ankle fracture fixation with concurrent arthroscopy does not lead to a higher rate of reoperation, according to a recent study.

The study, published in the Journal of Foot and Ankle Surgery, included 32,307 patients who had open reduction and internal fixation (ORIF) for ankle fractures, 248 of whom also had ankle arthroscopy. The study noted 7.7 percent of those who had arthroscopy had reoperation in comparison with 8.6 percent in those who did not have arthroscopy, which the authors noted was not a significant difference. The study notes reoperations included repeat ankle fracture fixation, arthroscopy, osteochondral autograft transfers and ankle arthrodesis.

The biggest advantages of arthroscopic treatment for an acute ankle fracture are assessing and treating the articular surface of the ankle joint, notes Jason George DeVries, DPM. While one should routinely inspect the joint when applying ankle fracture fixation, he notes only a limited view is possible while arthroscopy can allow the surgeon to inspect the entire articular surface. Arthroscopy’s disadvantages are related to its increased operative time, the need for more equipment in the operating room and more potential complications, according to Dr. DeVries, a fellowship-trained surgeon who is in private practice in Green Bay, Wis.

As Dr. DeVries says, there are no common specific complications related to arthroscopic inspection of the acute ankle fracture although there are risks common to all arthroscopic procedures such as potential nerve injury from the portals, wound problems or draining portals as well as iatrogenic damage to the articular surface. He notes a potentially higher risk for compartment syndrome in the setting of an acute fracture. Dr. DeVries says the joint damage may allow for extravasation of fluid into the leg compartments. While he notes this is not a common finding, Dr. DeVries says there may be a greater risk of this with syndesmotic disruption.

Dr. DeVries will add arthroscopic inspection to ankle ORIF in several situations. First, if there is radiographic concern for an osteochondral defect that will be difficult to assess during the open approach, he will arthroscopically treat the lesion. Second, for patients with significant articular disruption along the tibia, such as a pilon fracture, he will assess the reduction arthroscopically. Similarly, in the case of a triplane fracture in a patient with open growth plates, Dr. DeVries will typically inspect the joint arthroscopically. Third, he is more apt to consider arthroscopy when utilizing ORIF in a younger patient population as potential articular damage may have a greater long-term effect.