Economic impact of syndesmosis hardware removal

Ankle syndesmosis injuries are commonly seen with 5-10% of sprains and 10% of ankle fractures involving injury to the ankle syndesmosis. Anatomic reduction has been shown to be the most important predictor of clinical outcomes. Optimal surgical management has been a subject of debate in the literature. The method of fixation, number of screws, screw size, and number of cortices are all controversial. Postoperative hardware removal has also been widely debated in the literature. Some surgeons advocate for elective hardware removal prior to resuming full weightbearing. Returning to the operating room for elective hardware removal results in increased cost to the patient, potential for infection or complication(s), and missed work days for the patient. Suture button devices and bioabsorbable screw fixation present other options, but cortical screw fixation remains the gold standard. This retrospective review was designed to evaluate the economic impact of a second operative procedure for elective removal of 3.5mm cortical syndesmosis screws. Two hundred and two patients with ICD-9 code for "open treatment of distal tibiofibular joint (syndesmosis) disruption" were identified. The medical records were reviewed for those who underwent elective syndesmosis hardware removal. The primary outcome measurements included total hospital billing charges and total hospital billing collection. Secondary outcome measurements included average individual patient operative costs and average operating room time. Fifty-six patients were included in the study. Our institution billed a total of $188,271 (USD) and collected $106,284 (55%). The average individual patient operating room cost was $3579. The average operating room time was 67.9 min. To the best of our knowledge, no study has previously provided cost associated with syndesmosis hardware removal. Our study shows elective syndesmosis hardware removal places substantial economic burden on both the patient and the healthcare system.