The surgeon who treats your ankle fracture is more important than previously recognized

PR Newswire

ROSEMONT, Ill., Aug. 15, 2019 /PRNewswire/ -- A wrong twist, rotation or roll could cause a broken ankle, also known as an ankle fracture, among people of all ages. One or more broken bones in an ankle joint can lead to instability and an active, older population of "baby boomers" have been seeing an increase in the number and severity of broken ankles. Among Medicare patients, ankle fractures are the third most common extremity fracture, costing more than half a billion dollars per year. Yet, according to new research published in the August 15 issue of the Journal of the American Academy of Orthopaedic Surgeons, the surgeon who treats your fracture may be more important to the healing process than previously recognized. The study authors at Stanford Health Care's Department of Orthopaedic Surgery reviewed 11,745 records from an insurance claims database of patients between the ages of 20-80 treated for ankle fractures by orthopaedic surgeons^i,ii and podiatristsⁱⁱⁱ between 2007 and 2015.

The study specifically looked at several short-term complications after ankle fracture surgery:

the rate of fractures healing in a poor or incorrect position (malunion) within a year;
the rate of fractures that did not heal (nonunion) within a year; and,
the rate of infection, blood clots or repeat surgery for removal of unhealthy wound tissue within 90 days.

The study authors found a large difference in the rates of malunion and nonunion after comparing ankle fracture surgery outcomes by different surgeon types. Review of the insurance claims database revealed that "patients who had ankle fracture surgeries performed by podiatrists had a 50 percent increase in the rate of malunion or nonunion compared to surgery done by orthopaedic surgeons," says lead researcher and orthopaedic surgeon Jeremy Chan, MD. "These differences were even higher in more complex ankle fracture patterns."

Even though this study analyzed all types of orthopaedic surgeons, including those with subspecialized training in the foot and ankle trauma care as well as general orthopaedic surgeons, it was not designed to look at the causes for the differences, or long-term complications. Dr. Chan indicated that a range of factors could potentially influence the rates of fracture healing, which may include some surgeon-related factors (e.g., differences in surgical training between orthopaedic surgeons and podiatrists; volume of ankle fracture surgeries performed by individual surgeons). "This is important because ankle fractures that heal in a poor position or do not heal lead to future problems for patients such as continued pain, as well as the development of ankle arthritis long-term."

Study highlights

There were no statistical differences in complications observed in patients with unimalleolar fractures—a fracture in one of the three components (i.e., medial, lateral, and posterior malleolus -- the bony components on each side of the ankle) that make up an ankle joint.
In patients with fractures in bimalleolar or trimalleolar fractures—two or three ankle joint components, respectively—treatment by a podiatrist was associated with higher malunion/nonunion rates.
Patients treated by orthopaedic surgeons versus podiatrists had similar comorbidity profiles (long-term or chronic conditions).
Despite higher malunion/nonunion rates, there is an increasing number of ankle fracture surgeries being performed by podiatrists over the past decade, whereas the number of ankle fracture surgeries being performed by orthopaedic surgeons is decreasing. However, over 90 percent of ankle fractures in this study sample were still treated by orthopaedic surgeons.

Given the potential risks associated with a poorly treated ankle fracture, "patients with ankle fractures undergoing surgery should consider choosing a physician with lower complication rates, and someone who routinely treats ankle fractures for the best outcome," says Dr. Chan.

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Disclosure
Dr. Michael J. Gardner or an immediate family member has received IP royalties from Synthes; is a member of a speakers' bureau or has made paid presentations on behalf of KCI; serves as a paid consultant to Biocomposites, BoneSupport AB, Conventus, Globus Medical, KCI, Pacira Pharmaceuticals, SI-Bone, StabilizOrtho, and Synthes; has stock or stock options held in Conventus, Imagen Technologies; has received research or institutional support from Medtronic, SmartDevices, SMV Medical, Synthes, and Zimmer Biomet; and serves as a board member, owner, officer, or committee member of the American Orthopaedic Association, Orthopaedic Research Society, and Orthopaedic Trauma Association. Dr. Julius A. Bishop or an immediate family member has received IP royalties from Globus Medical and Innomed; serves as a paid consultant to DePuy, Globus Medical, and KCI; has received research or institutional support from Conventus; and serves as a board member, owner, officer, or committee member of the Western Orthopaedic Association. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Jeremy Y. Chan and Dr. Jeremy N. Truntzer.

ⁱ Orthopaedic surgeons are medical doctors who have completed a total of approximately 14 years of formal education, with extensive training in the proper diagnosis and both non-surgical and surgical treatment of injuries and disease of the musculoskeletal system. Board-certified orthopaedic surgeons must maintain their certification with continuous, life-long learning and demonstrating their expertise on a regular basis via an oral or written examination. Orthopaedics. (June 2017). Retrieved from OrthoInfo: https://orthoinfo.org/en/treatment/orthopaedics/

ⁱⁱ Foot and ankle orthopaedic surgeons additionally complete a one- or two-year fellowship focused on foot and ankle care. About Us. (n.d.). Retrieved from American Orthopaedic Foot & Ankle Society: https://www.aofas.org/about-us

ⁱⁱⁱ A podiatrist is a Doctor of Podiatric Medicine (DPM), known also as a podiatric physician or surgeon, qualified by their education and training to diagnose and treat conditions affecting the foot, ankle and related structures of the leg. Becoming a Podiatric Physician. (n.d.). Retrieved from American Association o f Colleges of Podiatric Medicine: https://www.aacpm.org/becoming-a-podiatric-physician/

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