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.

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.