Utilization of Arthroscopy During Ankle Fracture Fixation Among Early Career Surgeons: An Evaluation of the American Board of Orthopaedic Surgery Part II Oral Examination Database

Abstract

Background

Rotational ankle fractures are common injuries associated with high rates of intra-articular injury. Traditional ankle fracture open reduction and internal fixation (ORIF) techniques provide limited capacity for evaluation of intra-articular pathology. Ankle arthroscopy represents a minimally invasive technique to directly visualize the articular cartilage and syndesmosis while aiding with reduction and allowing joint debridement, loose body removal, and treatment of chondral injuries. The purpose of this study was to evaluate temporal trends in concomitant ankle arthroscopy during ankle fracture ORIF surgery amongst early-career orthopaedic surgeons while examining the influence of subspecialty fellowship training on utilization.

Methods

The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination database was queried to identify all candidates performing at least one ankle fracture ORIF from examination years 2010 to 2019. All ORIF cases were examined to identify those that carried a concomitant CPT code for ankle arthroscopy. Concomitant ankle arthroscopy cases were categorized by candidates self-reported fellowship training status and examination year. Descriptive statistics were performed to report relevant data and linear regression analyses were utilized to assess temporal trends in concomitant ankle arthroscopy with ORIF for ankle fractures. Statistical significance was defined as p<0.05.

Results

During the study period, there were 36,113 cases of ankle fracture ORIF performed of which 388 cases (1.1%) were performed with concomitant ankle arthroscopy. Ankle fracture ORIF was most frequently performed by trauma fellowship trained ABOS Part II candidates (n=8,888; 24.6%), followed by sports medicine (n=7,493; 20.8%) and foot and ankle (n=6,563; 18.2%). Arthroscopy was most frequently utilized by foot and ankle fellowship trained surgeons (293/6,270 cases; 4.5%) followed by sports medicine (29/7,464 cases; 0.4%) and trauma (4/8,884 cases; 0.1%). With respect to arthroscopic cases, 293 cases (75.5%) were performed by foot and ankle fellowship trained surgeons, 29 (7.5%) sports medicine, and 4 (1.0%) trauma. Ankle arthroscopy utilization significantly increased from 3.65 cases per 1,000 ankle fractures in 2010 to 13.91 cases per 1,000 ankle fractures in 2019 (p=0.010). Specifically, foot and ankle fellowship trained surgeons demonstrated a significant increase in arthroscopy utilization during ankle fracture ORIF over time (p<0.001; OR: 1.101; CI: 1.054-1.151).

Conclusion

Ankle arthroscopy utilization during ankle fracture ORIF has increased over the past decade. Foot and ankle fellowship trained surgeons contribute most significantly to this trend.

Level of Evidence: IV

Introduction

Unstable rotational ankle fractures represent the fourth most common surgically managed fracture pattern and occur at a rate of 187 per 100,000 person-years.^1-3 The standard of care for these injuries is open reduction and internal fixation (ORIF) with generally favorable outcomes reported; however, unsatisfactory results still occur.^4-7 A 10-year follow-up study demonstrated good to excellent outcomes in only 52% of cases with other studies reporting high rates of stiffness and persistent pain after ORIF.^8,9 Poor outcomes of appropriately managed ankle fractures may be due to unrecognized chondral or ligamentous injury.

Previous studies have estimated the rate of associated cartilage injury following rotational ankle fractures to be as high as 63-79%, potentially contributing to poor postoperative outcomes.^10-13 Standard ankle fracture ORIF techniques provide limited capacity to evaluate the articular surface.¹⁴ Ankle arthroscopy presents a minimally-invasive technique to directly visualize the articular cartilage and syndesmosis and allows for assistance in reduction, joint debridement, loose body removal, and treatment of appropriate chondral injuries. The current literature is scarce regarding the utilization and outcomes of arthroscopic-assisted ankle fracture fixation. However, a recent meta-analysis suggests the addition of ankle arthroscopy yields superior functional outcomes compared to traditional approaches using only open techniques.¹⁵

Practice patterns of young orthopaedic surgeons are often reflective of national trends in terms of procedure utilization in the academic setting and volume over time.^16-19 A current understanding of the utilization of arthroscopic-assisted ankle fracture fixation is warranted given the high rate of intra-articular injury and its impact on postoperative outcomes. Furthermore, the evaluation of early-career surgeons can determine the influence of fellowship training status on procedure selection and utilization.^16,17,20 Orthopaedic surgeons trained in sports medicine, foot and ankle, trauma, and other subspecialties perform arthroscopy at variable rates, and the influence of fellowship training on the treatment of ankle fractures is currently unknown.¹⁸ Identification of these trends and influences has implications for practice design as well as training of both residents and fellows.¹⁷ The purpose of this study was to evaluate temporal trends in ankle arthroscopy utilization during ankle fracture ORIF amongst early-career orthopaedic surgeons while examining the influence of subspecialty fellowship training on concomitant ankle arthroscopy utilization during ankle fracture ORIF.

Methods

The American Board of Orthopaedic Surgery (ABOS) grants board certification pending satisfactory completion of both Part I (computer-based multiple choice) and Part II oral case based board examinations. Following 22 months of clinical practice, candidates for the ABOS Part II Oral Examination collect and submit all surgical cases from a six-month time period (35 case minimum). Information regarding these submitted cases is compiled in an electronic database maintained by the ABOS and is available for research purposes. Part II Oral Examination surgical case-specific information includes Current Procedural Terminology (CPT) codes, International Classification of Disease Ninth and Tenth Revisions (ICD-9, ICD-10) codes, year of surgery, and surgeon reported postoperative complications. Patient demographics including gender and age are also recorded. Patient reported outcome data is not collected in the ABOS Part II Oral Examination database. The current study was deemed exempt from Institutional Review Board (IRB) approval given the de-identified nature of the data.

The ABOS Part II Oral Examination database was queried to identify all candidates who performed at least one ankle fracture ORIF (Current Procedural Terminology [CPT] codes 27766, 27769. 27784, 27792, 27814, 27822, 27823, 27829, 27846, 27848) from examination years 2010 to 2019. All ORIF cases were examined to identify those that carried a concomitant CPT code for ankle arthroscopy (CPT codes 29891, 29892, 29894, 29895, 29897, 29898, 29899). Concomitant ankle arthroscopy cases were categorized by candidates self-reported fellowship training status and examination year. Fellowship training status was stratified as foot and ankle, sports medicine, trauma, multiple fellowships, other, and no fellowship.

Statistical Analysis

Descriptive statistics were performed to report relevant data and linear regression analyses were utilized to assess temporal trends in concomitant ankle arthroscopy utilization with ORIF. Odds ratios (OR) and 95% Wald Confidence Intervals (CI) were reported, where appropriate. Statistical significance was defined as p<0.05.

Results

Over the study period, there were 36,113 cases of ankle fracture ORIF of which 388 cases (1.1%) were performed with concomitant ankle arthroscopy. Patients who underwent concomitant ankle arthroscopy were significantly younger (36.2+15.9 vs. 45.6+19.2 years, p<0.001) while there was no difference in patient sex between the two groups (49.0% vs. 46.7% male, p=0.373). Ankle fracture ORIF was most frequently performed by trauma fellowship trained candidates (n=8,888; 24.6%), followed by sports medicine (n=7,493; 20.8%) and foot and ankle (n=6,563; 18.2%) (Table 1). Over the study period, the number of ankle fracture ORIF cases performed significantly increased for foot and ankle fellowship trained candidates (p=0.009). Conversely, ankle fracture ORIF cases decreased in the sports medicine group (p=0.040) and did not change in the Trauma group (p=0.354).

Table 1.

Total Ankle Fracture Open Reduction Internal Fixation Cases Stratified by Fellowship Training

Fellowship	Ankle Fracture ORIF cases
	n	%
Trauma	8,888	24.6%
Sports	7,493	20.8%
Foot and Ankle	6,563	18.2%
None	3,845	10.7%
Multiple	2,482	6.9%
Other	6,842	19.0%

When considering only ankle fracture ORIF cases with concomitant arthroscopy, 293 cases (75.5%) were performed by foot and ankle fellowship trained surgeons, 29 (7.5%) sports medicine, and 4 (1.0%) trauma (Table 2). Ankle arthroscopy utilization significantly increased from 3.65 cases per 1,000 ankle fracture ORIF cases in 2010 to 13.91 cases per 1,000 ankle fracture ORIF cases in 2019 (p=0.010) (Figure 1). Over the study period, candidates that completed a foot and ankle fellowship performed more ankle arthroscopies during ankle fracture ORIF over time (p<0.001; OR: 1.101; CI: 1.054-1.151). No such trends were noted for candidates trained in sports medicine (p=0.409; OR: 1.055; CI: 0.9291.198), trauma (p=0.908; OR: 0.979; CI: 0.686-1.398), multiple fellowships (p=0.510; OR: 1.035; CI: 0.934-1.147), no fellowship (p=0.911; OR: 1.014; CI: 0.794-1.295), and other (p=0.298; OR: 1.215; CI: 0.842-1.755). During ankle fracture ORIF, foot and ankle fellowship trained surgeons utilized concomitant ankle arthroscopy most frequently at 4.5%, while sports medicine and trauma fellowship trained surgeons only utilized concomitant ankle arthroscopy during 0.4% and 0.1% of ORIF cases, respectively (Table 3).

Table 2.

Annual Cases of Concurrent Ankle Arthroscopy with Open Reduction Internal Fixation for Ankle Fracture by Fellowship Training

Year	Foot and Ankle	Sports Medicine	Trauma	No Fellowship	Multiple Fellowships	Other	Total
2010	2	2	0	0	3	0	7
2011	12	3	0	2	3	0	20
2012	28	4	1	2	8	1	44
2013	24	2	0	0	3	0	29
2014	23	2	1	1	2	0	29
2015	38	6	1	1	7	0	53
2016	33	3	0	0	2	1	39
2017	30	1	1	0	9	0	41
2018	68	0	0	1	9	2	80
2019	35	6	0	1	4	0	46
Total	293	29	4	8	50	4	388

Figure 1:

Temporal Trend in Concurrent Ankle Arthroscopy with Open Reduction Internal Fixation for Ankle Fractures.

Table 3.

Proportion of Concomitant Ankle Arthroscopy During Open Reduction Internal Fixation Stratified by Fellowship Training

Fellowship	Total Arthroscopy Cases (n)	Total ORIF Cases (n)	Rate of Concomitant Arthroscopy (%)
Foot and Ankle	293	6,270	4.5%
Sports Medicine	29	7,464	0.4%
Trauma	4	8,884	0.1%
Multiple	50	2,432	2.0%
None	8	3,837	0.2%
Other	4	6,838	0.1%

Discussion

Although the overall rate of concomitant ankle arthroscopy was low in the study cohort (1.1%), utilization of ankle arthroscopy during ankle fracture ORIF increased ten-fold over the study period among ABOS Part II examinees. While ABOS Part II Oral Examination examinees that completed a fellowship in trauma performed the most ankle ORIF cases overall, they exhibited the lowest arthroscopy utilization rate of 0.1%. Trainees with fellowship experience in foot and ankle performed the most ankle ORIF cases with concomitant arthroscopy and were primarily responsible for the increased utilization of ankle arthroscopy observed over the study period.

Postoperative outcomes following traditional ankle fracture ORIF have generally been favorable.^4-7 However, a significant number of patients experience a poor outcome even if anatomic reduction of the ankle fracture is achieved.^21-23 Unrecognized articular cartilage injury has been implicated in cases of unsatisfactory postoperative results, as these injuries have been associated with the development of posttraumatic arthritis regardless of bony reduction. Lantz et al. demonstrated that patients with ankle fractures and concomitant cartilage injury at the time of ORIF experienced poorer results than patients without chondral pathology.²⁴ Furthermore, Thomas et al. performed ankle arthroscopy in patients with persistent issues following ankle fracture ORIF and identified chondral lesions in 90% of cases.²⁵ Previous studies have estimated the rate of associated cartilage injury from 63-79% in the setting of ankle fracture, leading many authors to advocate for direct visualization of the articular surface via arthroscopy at the time of ORIF.^7-10,26-28

Ankle arthroscopy also represents a potential therapeutic tool as it allows for assisted articular reduction, joint debridement, loose body removal, and treatment appropriate chondral injuries. A large database study of ankle fracture ORIF cases performed with concomitant arthroscopy found that 22.4% of all patients that underwent ankle arthroscopy at the time of ankle fracture ORIF had osteochondral lesions addressed with microfracture.²⁹ Other studies in the literature have reported favorable outcomes following ankle fracture ORIF with concomitant ankle arthroscopy. Turhan et al. retrospectively compared 21 patients managed with ankle ORIF with concomitant arthroscopy to 26 patients with traditional ORIF alone and found superior Olerud-Molander scores in the arthroscopy group.³⁰ Additionally, in a study by Takao et al., 62 patients with ankle fractures were randomized to either traditional ankle ORIF or ORIF with ankle arthroscopy.²⁸ At a mean of 40-month follow-up, the arthroscopy group exhibited significantly improved American Orthopaedic Foot and Ankle Society (AOFAS) scores.²⁸ Lastly, a meta-analysis of the existing literature demonstrated improved functional outcomes with the use of ankle arthroscopy prior to ankle fracture fixation compared to ORIF alone.¹⁵

The current study of 36,113 cases of ankle fracture ORIF demonstrated an overall concomitant arthroscopy rate of 1.1% among ABOS Part II Oral Examination examinees over the past decade. Similarly, Ackerman et al. performed a study utilizing the PearlDiver Patient Record Database from 2005-2011 of 32,307 ankle fractures and found a 1.0% rate of concomitant ankle arthroscopy.²⁹ Although the overall rate of concurrent ankle arthroscopy was low in the study cohort, ankle arthroscopy utilization during ankle fracture ORIF increased ten-fold over the study period. The previously mentioned study by Ackerman et al. also demonstrated a significant increase in the utilization of arthroscopy with ankle fracture ORIF from 2007-2011, although prior fellowship subspecialty training of the treating surgeons was not assessed.²⁹

The increased utilization of concomitant ankle arthroscopy in the current study was primarily due to ABOS Part II Oral Examination examinees with foot and ankle fellowship training experience. These candidates performed 75% of the concomitant ankle arthroscopies during ankle fracture ORIF observed in the ABOS Part II Oral Examination database. Furthermore, concomitant arthroscopic case volume for candidates with trauma and sports medicine fellowship training experiences, as well as those that had completed multiple fellowships or had received no subspecialty training, remained unchanged over time. ABOS Part II Oral Examination candidates with trauma fellowship training experience performed the most ankle fracture ORIF procedures yet had the lowest rate of concomitant ankle arthroscopy utilization at 0.1%. In contrast, examinees with foot and ankle fellowship training performed the third most ankle fracture ORIF cases with the highest rate of concomitant ankle arthroscopy utilization at 4.5%. A possible explanation for this discrepancy is decreased exposure to arthroscopic procedures in a trauma fellowship compared when compared with foot and ankle or sports medicine fellowship leading to decreased familiarity early in practice. Further work is needed to evaluate the effect of arthroscopic case exposure in training with arthroscopy case volume once in practice.

Limitations

The present study has multiple limitations. First, the study design is a retrospective review of prospectively collected data. Inherent to any database study, there is a risk of inaccurate coding or reporting of procedural data. Also, fellowship training status is self-reported within the ABOS Part II Oral Examination database by the candidates and is not cross-referenced with actual training certificates. The ABOS Part II Oral Examination database does not contain patient reported or functional outcomes. Additionally, the extent of exposure to ankle arthroscopy during residency and fellowship training for each individual candidate is unknown. Next, there is variability within a physician’s practice over time. The relatively short reporting interval of six months required by the ABOS may not consistently represent cases from select practices. This is particularly important to consider during the 6-month ABOS Part II Oral Examination board collection period, which is a monitored period of a surgeon’s practice where individual cases are individually scrutinized which may influence treatment decisions. Ankle fracture pattern and characteristics, including injury pattern or degree of comminution, are not included in the ABOS Part II Oral Examination database. Additionally, surgical indications are not recorded in the database. Lastly, the data represents a group of surgeons during a unique period of their careers. The knowledge that treatment decisions or postoperative complications are being evaluated may lead to case volumes not indicative of standard practice.

Conclusion

Ankle arthroscopy utilization during ankle fracture ORIF has increased over the past decade. Foot and ankle fellowship trained surgeons contribute most significantly to this trend.