Comparing Fixation Used for Calcaneal Displacement Osteotomies: A look at removal rates and cost

Transcription

1 Comparing Fixation Used for Calcaneal Displacement Osteotomies: A look at removal rates and cost Douglas E. Lucas, DO 1 G. Alex Simpson, DO 1 Terrence M. Philbin, DO 2 Advanced Orthopedic Foot & Ankle Fellowship Orthopedic Foot & Ankle Center, Columbus 1. Orthopedic Surgery Resident, Ohio University/Doctor s Hospital, Columbus, OH 2. Attending Physician, Orthopedic Foot and Ankle Center, Westerville, OH

2 Disclosure Comparing Fixation Used for Calcaneal Displacement Osteotomies: A Look at Removal Rates and Cost Douglas E Lucas, DO Our disclosures are in the Final AOFAS Program Book. I have a potential conflict with this presentation due to: Consultant relationship, OrthoHelix (TMP)

3 Introduction Calcaneal Displacement Osteotomies Very common hindfoot procedure Can be Varus or Valgus producing Powerful effects Historically good clinical outcomes Requires internal fixation Reliable union rates

4 Introduction Traditional techniques utilize headed compression screw(s) placed through separate incision in posterior, inferior calcaneus Hardware prominence requiring removal is reported in literature at 11-47% Implant innovation has attempted to decrease these rates Headless compression screws Limited amount of capable compression Still utilize separate posterior incision Lateral locked plate Provides no compression across osteotomy Documented delayed union rates Lateral locked compression plate (LLCP) Compresses across osteotomy site Placed through same incision as osteotomy Headed compression screw and lateral locked compression plate

5 Introduction and Purpose Purpose To evaluate removal rates of headed compression screws versus a lateral locked compression plate in a single practice To perform a crude cost comparison between implants when removal rates are considered Harris Axial view of lateral locked compression plate

6 Methods and Materials Ohio Health IRB Approval Reviewed records from the Orthopedic Foot and Ankle Center 4 surgeons (Including senior author) June, 2010 January, 2012 Minimum 12 months f/u Variables Gathered Epidemiologic data Duration of Follow-up Time to Radiographic Healing Frequency of Hardware Removal Cost analysis Cost of Screws (averaged) Cost of LLCP device (total) Cost of outpatient removal of hardware in hospital setting Statistics OpenEpi Cohorts were compared with two sample independent t-test, Fisher and mid-p exact tests. Lateral Locked Compression Plate

7 Results LLCP group vs. Compression Screw group LLCP Screw P value Odds Ratio 95% Confidence Interval # In Group Mean Age (years) ± ± Mean BMI ± ± Mean Time to Healing (days) ± ± Hardware Removal 1/63 (1.6%) 32/165 (19.4%) <0.05 * Duration Follow-Up Days (Non-Revision Patients) ± ± 156 <0.05 * Duration Follow-Up Days (Including Revision Patients) ± ± 210 <0.05 * * Statistically Significant Table 1: Data for group comparison

8 Cost analysis Implant Lateral Locked Compression Plate Cost Comparison Cost Compression Screw $ LLCP $ LLCP Complete $1, Implant Removal $10, Screw + Removal $11, Patients with Compression Screw fixation and 20% rate of removal 100 Patients with LLCP fixation with 2% rate of removal $243, $139, Overall decreased cost with LLCP fixation per 100 patients $104, Overall decreased cost with LLCP per patient $1, Cost of LLCP fixation compared to compression screw fixation Cost of compression screw fixation compared to LLCP fixation 139,433.04/243,452.4 = 55% 243,452.4/139, = 1.75 (x more costly) Table 2: Cost comparison

9 Discussion Literature review Konan et al showed lateral plates are 2x as strong as a single screw in load to failure Abbasian et al showed removal rates for headed, headless and lateral locked plates as 47%, 11% and 6% respectively Schepers et al demonstrated a 22.4% complication rate with simple hardware removal in the lower extremity Conclusion Lateral locked compression plates provide enough strength for equal time to union Patients fixed with screws require more visits over a longer period of time and subsequently utilize more resources The increased cost of the implant is well off set by the cost of hardware removal at rates seen in these cohorts With increased burden placed on the surgeon to control costs, justification of more expensive implants is crucial

10 References 1. Dwyer F. Osteotomy of the calcaneum for pes cavus. Journal of Bone and Joint Surgery-British Volume. 1959;41(1):80. Available at: Accessed March 1, Gleich A. Beitrag zur Operation Plattfussbehandlung. Arch Klin Chir. 1893;46: Krackow KA, Hales D, Jones L. Preoperative planning and surgical technique for performing a Dwyer calcaneal osteotomy. Journal of Pediatric Orthopaedics. 1985;5(2):214 hyhen. Available at: Accessed March 1, Joseph TN, Myerson MS. Correction of multiplanar hindfoot deformity with osteotomy, arthrodesis, and internal fixation. Instructional course lectures. 2005;54: Maskill MP, Maskill JD, Pomeroy GC. Surgical management and treatment algorithm for the subtle cavovarus foot. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2010;31(12): doi: /fai Coughlin M, Mann R, Saltzman C. Surgery of the Foot and Ankle.; 2007: Fortin P, Guettler J. Idiopathic cavovarus and lateral ankle instability: recognition and treatment implications relating to ankle arthritis. Orthopaedic Foot and Ankle Available at: Accessed March 1, Mosier-Laclair S, Pomeroy G, Manoli A. Operative treatment of the difficult stage 2 adult acquired flatfoot deformity. Foot and Ankle Clinics of North. 2001;6(1): Available at: Accessed March 1, Abbasian A, Zaidi R, Guha A, Goldberg A, Cullen N, Singh D. Comparison of three different fixation methods of calcaneal osteotomies. Foot & ankle international. / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2013;34(3): doi: / Wacker JT, Hennessy MS, Saxby TS. Calcaneal osteotomy and transfer of the tendon of flexor digitorum longus for stage-ii dysfunction of tibialis posterior. Three- to five-year results. The Journal of bone and joint surgery. British volume. 2002;84(1): Tellisi N, Lobo M, O Malley M, Kennedy JG, Elliott AJ, Deland JT. Functional outcome after surgical reconstruction of posterior tibial tendon insufficiency in patients under 50 years. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2008;29(12): doi: /fai Niki H, Hirano T, Okada H, Beppu M. Outcome of Medial Displacement Calcaneal Osteotomy for Correction of Adult-Acquired Flatfoot. Foot & Ankle International. 2012;33(10): doi: /fai Kou J, Balasubramaniam M. Functional Results of Posterior Tibial Tendon Reconstruction, Calcaneal Ostetomy, and Gastrocnemius Recession. Foot and Ankle. 2012;33(7): doi: /fai Guyton GP, Jeng C, Krieger LE, Mann R a. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for posterior tibial tendon dysfunction: a middle-term clinical follow-up. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2001;22(8): Available at: Konan S, Meswania J, Blunn GW, Madhav RT, Oddy MJ. Mechanical Stability of a Locked Step-Plate Versus Single Compression Screw Fixation for Medial Displacement Calcaneal Osteotomy. Foot & Ankle International. 2012;33(08): doi: /fai Schepers T, Van Lieshout EMM, De Vries MR, Van der Elst M. Complications of Syndesmotic Screw Removal. Foot & Ankle International. 2011;32(11): doi: /fai