Wonyong Lee

Background: Diabetes mellitus (DM) is a well-established risk factor for complications after surgical fixation of ankle fractures. Elevated hemoglobin A1c (HbA1c) has been associated with worse outcomes; however, it remains unclear whether HbA1c alone predicts perioperative risk independent of a formal DM diagnosis and treatment status. This study evaluated whether elevated preoperative HbA1c (≥8.0%) in patients without a documented diagnosis or pharmacologic treatment of DM is associated with increased early postoperative complications compared with patients with established DM. Methods: The American College of Surgeons National Surgical Quality Improvement Program database (2021 to 2024) was queried for patients undergoing open reduction and internal fixation of ankle fractures. Patients were stratified into four cohorts based on diabetes diagnosis/treatment status and glycemic control: (1) undiagnosed/untreated, HbA1c < 8.0%; (2) undiagnosed/untreated, HbA1c ≥ 8.0%; (3) diagnosed/treated, HbA1c < 8.0%; and (4) diagnosed/treated, HbA1c ≥ 8.0%. Propensity score matching (1:1) on age and sex yielded 388 matched patients (n = 97 per group). Primary outcomes were 30-day mortality, readmission, and revision surgery. Secondary outcomes included surgical site infection, organ-space infection, and medical complications. Multivariable logistic regression adjusted for residual differences in body mass index and comorbidities. Results: Thirty-day mortality was rare (0.8%) and did not differ between groups ( P = 0.381). Significant differences were observed in revision surgery ( P = 0.006), superficial surgical site infection ( P = 0.003), and organ space infection ( P = 0.019). Patients with diagnosed/treated uncontrolled DM had higher odds of these complications compared with those with elevated HbA1c but no documented DM diagnosis or treatment (undiagnosed/untreated uncontrolled) (all P < 0.05). Conclusion: Patients with poorly controlled established diabetes had higher rates of early postoperative complications after ankle fracture open reduction and internal fixation compared with those with elevated HbA1c but no earlier diabetes diagnosis or treatment. Assessment of the presence and treatment status of diabetes may provide more meaningful perioperative risk stratification than HbA1c level alone. Level of Evidence: Level III, retrospective cohort study.

Background: Unimalleolar, bimalleolar, and trimalleolar ankle fractures and syndesmosis injuries represent a spectrum of increasing instability and surgical complexity. Although the work Relative Value Unit (wRVU) system is designed to account for surgical time and technical complexity, previous studies suggest a mismatch between procedural complexity and proportional reimbursement rate. Our study aims to evaluate whether current wRVU allocation across ankle fracture types adequately reflects procedural complexity and to assess whether more complex cases are relatively undercompensated. Methods: The national surgical quality improvement program (NSQIP) database (2021 to 2024) was queried for patients undergoing open reduction and internal fixation for ankle fractures and syndesmosis injuries, using current procedural terminology (CPT) codes. Cases involving tibial shaft or pilon fractures or multiple CPT codes were excluded. Compensation metrics included surgical time, total wRVUs, wRVUs per hour (wRVU/hr), and hourly reimbursement rate ($/hr). 1:1 propensity score matching was done based on age, sex, American Society of Anesthesiologists class, and inpatient versus outpatient status. Analysis of covariance was subsequently used to adjust for preoperative comorbidities and postoperative complications affecting compensation metrics. Results: Among 17,833 cases, 779 patients per group were identified after propensity score matching. Surgical time (minutes) increased significantly with complexity (unimalleolar: 64.1 ± 35.5; syndesmosis: 64.2 ± 37.9; bimalleolar: 83.5 ± 43.6; trimalleolar: 105.0 ± 53.6; P < 0.001). Although trimalleolar ankle fractures generated the highest total wRVUs (11.7), wRVU/hr decreased as complexity increased (unimalleolar: 10.7 ± 6.3; syndesmosis: 11.3 ± 6.9; bimalleolar: 9.9 ± 5.4; trimalleolar: 8.7 ± 5.5; P = 0.006). Hourly reimbursement rate ($/hr) followed a similar inverse pattern (unimalleolar: 361.9 ± 214.2; syndesmosis: 382.0 ± 234.4; bimalleolar: 335.4 ± 182.6; trimalleolar: 296.1 ± 188.7; P = 0.006). Conclusion: Our study suggests that the current compensation structure for ankle fracture and syndesmosis fixation procedures may not adequately reflect the surgical time and effort required for more complex injuries. Additional evaluation of wRVU allocation for ankle fracture and syndesmosis injury management may be necessary to ensure that compensation more accurately aligns with physician time and effort. Level of Evidence: Level III.

Background: The prognostic value of initial tendon gap distance following acute Achilles tendon rupture (ATR) remains unclear. The present systematic review and meta-analysis aimed to investigate the effect of tendon gap distance on clinical outcomes following nonsurgical management of acute ATR. Methods: Our review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and used PubMed, EMBASE, and Cochrane Library databases for studies investigating the influence of tendon gap distance on functional outcomes following nonsurgical management of acute ATR. Data investigated included patient demographics, functional scores, including the Achilles Tendon Rupture Score (ATRS), gap size, and rupture location. The association between tendon gap distance and functional outcomes was investigated. Additional analyses examined secondary associations among age, sex, and rupture location and functional outcomes. Results: A total of eight studies comprising 288 patients with acute ATRs were included in our review. Of these, four studies met criteria for quantitative synthesis and were included in the meta-analysis. With a cutoff of 10-mm gap distance, the pooled analysis demonstrated a markedly lower ATRS in patients with a larger gap size (>10 mm versus ≤10 mm; Cohen d = −0.39; 95% CI = −0.76 to −0.02; P = 0.04). Secondary analyses revealed lower ATRS in patients older than 50 years (d = −0.70; P < 0.001) and female patients (d = −0.58; P = 0.01), whereas rupture location had no notable effect ( P = 0.85). Conclusion: Our review demonstrated that a larger initial tendon gap is associated with lower functional outcomes following nonsurgical management of acute ATR, particularly with a cutoff of 10 mm. Furthermore, factors such as age and sex may also influence clinical outcomes. However, the result should be interpreted with caution due to heterogeneity across studies. Level of Evidence: Level 3, systematic review and meta-analysis.

Background: Lower extremity amputation (LEA) is performed by diverse specialties, including orthopaedic surgery and vascular surgery; whether outcomes differ by specialty remains uncertain. This study compared early postoperative outcomes after LEA performed by orthopaedic and vascular surgeons. Methods: Patients who underwent LEA surgeries were identified within the National Surgical Quality Improvement Program database. National Surgical Quality Improvement Program was queried for above-knee amputation, below-knee amputation, and foot amputations performed by orthopaedic or vascular surgeons. Patients were matched in a 1:1 ratio using propensity scores using a mixed exact/caliper approach. Primary outcomes were 30-day mortality, readmission, and revision surgery; secondary outcomes included cardiac, pulmonary, wound-related issues, and discharge disposition. Results: A total of 26,925 LEA cases were identified. After propensity matching, 3,580 cases remained: orthopaedic surgery 1790 versus vascular surgery 1790, including 3,180 matched below-knee amputation, 806 matched above-knee amputation, and 334 matched foot amputations. Final cohorts had a similar distribution of demographic variables, indicating appropriate matching. Mortality of 4.0% versus 4.0%, readmission of 10.7% versus 11.7%, and revision surgery of 7.6 versus 8.3% were equivalent between orthopaedics and vascular surgery, respectively. The vascular cohort demonstrated higher rates of any postoperative complication: the sum of secondary outcomes (77.9% vs 70.4%; P < 0.001), driven primarily by increased non–home discharge (69.7% vs 60.8%) and transfusion within 72 hours (19.5% vs 16.3%). When non–home discharge was removed, there was no difference in early postoperative complication (32.2% vs 35.5%; P = 0.382). By contrast, the orthopaedic group had slightly higher rates of organ/space infection (4.1% vs 2.2%; P = 0.001) and postoperative pneumonia (3.8% vs 2.5%; P = 0.029), consistent with the higher proportion of contaminated/dirty wounds: 44.4% versus 36.0% and longer surgical duration: 79.5 ± 43.5 versus 68.3 ± 46.1 observed in this group. Conclusions: The present analysis represents the first matched comparison of LEA outcomes by surgical specialty. When baseline patient risk is balanced, orthopaedic and vascular surgeons achieve comparable 30-day major outcomes: mortality, readmission, and revision surgery following LEA. Residual differences in complication profiles appear driven by clinical context, such as wound class, transfusion exposure, and rehabilitation needs, rather than by specialty itself. Level of Evidence: Level III.

Background: Many orthopaedic foot and ankle (FA) procedures require substantial technical expertise, yet the adequacy of their compensation remains largely unexplored. This study evaluates whether orthopaedic FA surgeries are fairly compensated compared with other orthopaedic procedures. Methods: Orthopaedic procedures recorded in the National Surgical Quality Improvement Program (2020 to 2022) were identified using Current Procedural Terminology (CPT) codes, and they were classified as FA or non-FA. Compensation adequacy for FA procedures was assessed by comparing work relative value unit (wRVU), operative time (OT), wRVU per hour (wRVU/hr), and reimbursement rate ($/hr) to non-FA procedures. Patients' demographics, preoperative comorbidities, and postoperative complications were compared between the groups. 1:1 propensity score matching was performed on age, sex, case setting: inpatient versus outpatient, and whether the case was emergent or elective. Analysis of covariance was performed to control the effect of preoperative comorbidities and postoperative complications. Results: Twenty FA CPT codes accounted for 24,773 procedures, whereas 137 non-FA CPT codes accounted for 471,759 procedures. In the propensity score–matched cohorts: 8,899 patients were present in each group. OT was significantly longer in FA procedures than non-FA procedures: 96.55 vs. 86.90 minutes, P < 0.001, yet demonstrated significantly lower wRVUs: 11.35 vs. 14.40, P < 0.001. FA procedures generated significantly lower 8.77 wRVU/hr compared with 13.51 wRVU/hr for non-FA procedures, P < 0.001, translating to $382.25/hr vs. $487.65/hr in reimbursement rate. All findings persisted after analysis of covariance adjusting for the rates of preoperative comorbidities and postoperative complications. Conclusion: Compared with non-FA procedures, FA procedures generate significantly lower wRVU/hr and reimbursement rates ($/hr), despite requiring substantially longer OT. This highlights a systemic undervaluation of FA procedures and supports the need to reevaluate wRVU allocation to better reflect the demands of orthopaedic FA surgery. Level of Evidence: Level III

Background: This study aims to evaluate whether obesity affects early postoperative outcomes or reimbursement metrics following surgical intervention for Achilles tendinopathy. Methods: A retrospective analysis was done using the National Surgical Quality Improvement Program database (2013 to 2022). Patients undergoing secondary Achilles reconstruction were identified through Current Procedural Terminology and International Classification of Diseases 9th/10th codes and were categorized as obese (body mass index ≥ 30) or nonobese (body mass index < 30). Demographic variables, comorbidities, 30-day postoperative complications, including mortality, readmission, revision surgery, wound complications, thromboembolic events, respiratory complications, infectious complications, renal complications, cardiac complications, and transfusion. The number of concurrent procedures and work relative value unit (wRVU)–based compensation metrics were compared between the two groups. An analysis of covariance was done to adjust the effect of patient demographics, preoperative comorbidities, and perioperative complications on the valuation of compensation metrics. Results: Six hundred eighty-eight patients met inclusion criteria: 505 (73.4%) were obese and 183 (26.6%) were nonobese. Obese patients had markedly higher rates of comorbidities, including diabetes and hypertension. No notable differences were found between the two groups in any of the early postoperative complication rates we investigated. The number of concurrent procedures per case was markedly higher in the obese group: 1.2 vs. 1.0, P = 0.015. Regarding compensation metrics, wRVU/hr, and reimbursement ($/hr) were comparable between the groups after analysis of covariance: 14.6 wRVU/hr and 473.82 $/hr for the obese group versus 13.5 and 435.2 for the nonobese group, P = 0.131, respectively. Conclusion: Our findings suggest that secondary reconstruction for Achilles tendinopathy can be done safely in obese patients without increasing short-term postoperative complication rates. Compensation metrics remained comparable between the obese and nonobese groups, indicating that the increased preoperative burden and surgical demands in obese patients may not be matched by a proportional increase in reimbursement. Level of Evidence: Level III

Background: Total ankle arthroplasty (TAA) is among the most technically demanding joint arthroplasties; however, the adequacy of its compensation has not been thoroughly examined. Work relative value units (wRVUs), a key metric for physician reimbursement, are assigned based on the complexity and time associated with clinical activities. This study aims to evaluate whether TAA is adequately compensated compared with total knee arthroplasty (TKA), total hip arthroplasty (THA), and total shoulder arthroplasty (TSA), using the National Surgical Quality Improvement Program (NSQIP) database. Methods: Arthroplasty procedures, including TAA, TKA, THA, and TSA, were identified using Current Procedural Terminology codes within the NSQIP database from 2020 to 2022. A 1:1 propensity score matching was done using the TAA group as the reference, matched across groups by age (±1 year) and sex. The adequacy of TAA compensation was assessed based on wRVUs, surgical time (OT), wRVUs per hour (wRVU/hour), and reimbursement rates ($/hour), in comparison to other joint arthroplasties. Postoperative complications within 30 days were evaluated to compare procedural risk profiles. Results: After propensity score matching, 511 cases were identified per group. TAA was associated with a markedly longer surgical time compared with other joint arthroplasties (TKA, THA, TSA): 135.69 versus 91.66, 97.82, and 96.77 minutes, respectively ( P < 0.001). In addition, TAA demonstrated a markedly lower mean wRVU/hour (7.17 versus 13.84, 13.13, and 15.86, respectively; P < 0.001) and reimbursement rate (231.77 versus 447.81, 424.73, and 513.12 $/hour, respectively; P < 0.001). These trends remained consistent after adjusting for preoperative comorbidities and postoperative complication rates. Conclusions: Despite requiring markedly longer OT, TAA was associated with substantially lower wRVU/hour and reimbursement rate. Our results suggest that the current wRVU scale may inadequately compensate for TAA, particularly in comparison to other joint arthroplasty procedures. These findings highlight the potential need to reevaluate wRVU allocation for TAA to ensure more equitable and appropriate compensation. Level of Evidence: Level III.

Background: Total ankle arthroplasty (TAA) has been increasingly used to treat end-stage of ankle arthritis, leading to a corresponding rise in revision TAA (rTAA). Given the greater complexity of rTAA procedures, assessing whether early postoperative complications differ from primary TAA and whether current reimbursement models appropriately account for this complexity remains essential. Methods: Using the National Surgical Quality Improvement Program database from 2013 to 2022 and current procedural terminology codes, patients undergoing TAA or rTAA were identified. Demographics, comorbidities, and 30-day early postoperative complications were compared. Compensation metrics included surgical time, work relative value units (wRVU) per hour (wRVU/hr), and reimbursement rate ($/hr). Statistical analyses included chi square tests, unpaired t -tests, and analysis of covariance adjusting for age and postoperative complication rates. Results: A total of 2,418 TAA and 276 rTAA cases were identified. No statistically notable differences were noted in 30-day mortality, readmission, or revision surgery rates. Secondary complications were similar between groups, except for cardiac arrest, which was higher in the rTAA cohort (0.36% vs. 0%, P = 0.003), although the absolute incidence was low. rTAA was associated with more concomitant procedures (1.10 vs. 0.79, P = 0.001), longer surgical time (166.78 vs. 151.45 minutes, P = 0.003), and higher mean wRVU (20.98 vs. 17.04, P < 0.001), wRVU/hr (9.63 vs. 7.57, P < 0.001), and reimbursement rate/hr ($311.65/hr vs. $244.78/hr, P < 0.001). Conclusion: No notable differences were found in early postoperative outcomes between TAA and rTAA, indicating comparable early postoperative safety. rTAA procedures received appropriately higher compensation metrics, aligning with their greater surgical demands. These findings support the adequacy of current reimbursement models for rTAA in accounting for the increased complexity and surgical time associated with rTAA compared with primary TAA. Level of Evidence: Level III

Background: Ankle, distal radius, and proximal femur fractures are among the top three most common fractures. Despite the high prevalence and cost of these fractures, the relative valuation of these common fractures within the current US healthcare system has not been evaluated. This study aims to evaluate whether ankle fracture fixation is adequately compensated for in the hospital setting compared with distal radius and proximal femur fractures, using the National Surgical Quality Improvement Program database. Methods: Ankle, distal radius, and proximal femur fracture fixations were identified within the National Surgical Quality Improvement Program database from 2020 to 2022 using Current Procedural Terminology codes. The relative valuation between the three fracture fixations was assessed using operative time, work relative value units (wRVUs), wRVU per hour (wRVU/hr), and reimbursement rates ($/hr). A propensity score–matched analysis was performed including age (±2 years) and sex with the ankle fracture group as a reference. Two matched cohorts were constructed: ankle and (1) proximal femur fracture and (2) distal radius fracture. Covariance analysis including postoperative complications and preoperative comorbidities were performed to adjust for their effect on the valuation of compensation metrics. Results: A total of 15,507 ankle fractures, 51,955 proximal hip fractures, and 11,874 distal radius fractures were included. Compared with other fractures, ankle fracture fixation had a significantly longer operative time (89.16 minutes for ankle vs. 65.32 for proximal hip vs. 71.21 for distal radius; respectively, P < 0.001), lower mean wRVU (10.29 vs. 17.94 vs. 11.55, P < 0.001), wRVU/hr (10.37 vs. 21.66 vs. 11.393, P < 0.001), and reimbursement rate (335.32 vs. 700.75 vs. 385.94, P < 0.001). These trends persisted after adjusting for the rates of preoperative comorbidities and postoperative complication as in propensity score–matched analysis. Conclusion: Our findings suggest that ankle fracture fixation is undervalued in the current wRVU system, pointing to the need to reevaluate wRVU allocation more accurately for the surgical treatment in ankle fracture. Level of Evidence: Level III

Background Ankle fractures are among the most prevalent injuries in the general population, and the timing of surgical fixation may influence postoperative wound complications. This systematic review and meta-analysis investigated the impact of surgical timing on postoperative wound complications, specifically investigating the significance of a 24-hour cutoff point. Materials and methods The comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, Web of Science, and Cochrane databases. Research evaluating and comparing clinical outcomes following ankle fracture treatment between early versus delayed surgical fixation groups, specifically using a 24-hour cutoff point, were reviewed. Evaluated data for the meta-analysis included total wound complications: divided into major and minor wound complications, length of stay, and other complications such as fixation failure. Results A total of eight studies were included in this systematic review and meta-analysis. In total, 1,183 patients were analyzed, with 572 in the early fixation group and 611 in the delayed fixation group. Compared to the delayed fixation group, the early fixation group significantly reduced total wound complications and length of stay, with a relative ratio of 0.37 (95% CI, 0.22 to 0.60) and − 0.88 (95% CI, -1.07 to -0.70), respectively. When analyzed as separate groups of major and minor wound complications, there was a trend showing lower rate of major and minor wound complication in the early fixation group than the delayed fixation group, but without reaching statistically significant differences. Conclusions Based on our review, early surgical intervention within the first 24 h may be considered to minimize the risk of postoperative wound complications and reduce the length of stay in ankle fractures. Level of evidence Level 3.