Are Foot & Ankle Surgeons being adequately compensated for Ankle Fractures? – An Analysis of Relative Value Units

Published:November 24, 2022DOI:


      The current RVU-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs. bi-malleolar vs. tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation (ORIF) for uni-malleolar vs. bi-malleolar vs. tri-malleolar ankle fractures. The 2012-2017 American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) files were queried using CPT codes for patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (CPT-27766,CPT-27769,CPT-27792), bi-malleolar (CPT-27814) and tri-malleolar (CPT-27822,CPT-27823) ankle fractures. A total of 7,830 (37.2%) uni-malleolar, 7,826 (37.2%) bi-malleolar and 5,391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs, Mean RVU/minute and Reimbursement rate ($/min) and Mean Reimbursement/case for each fracture type were calculated and compared using Kruskal-Wallis tests. The mean total RVU for each fracture type was as follows:- 1) Uni-malleolar: 9.99, 2) Bi-malleolar=11.71 and 3) Tri-malleolar=12.87 (p<0.001). A statistically significant difference was noted in mean operative time (uni-malleolar=63.2 vs. bi-malleolar=78.6 vs. tri-malleolar=95.5; p<0.001) between the three groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar=$7.21/min vs. bi-malleolar=$6.75/min vs. tri-malleolar=$6.10; p<0.001). The average reimbursement/case was $358, $420 and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Foot & ankle surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.

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        • Baadh A
        • Peterkin Y
        • Wegener M
        • et al.
        The Relative Value Unit: History, Current Use, and Controversies.
        Curr Probl Diagn Radiol. 2016; 45: 128-132
        • Shah DR
        • Bold RJ
        • Yang AD
        • et al.
        Relative value units poorly correlate with measures of surgical effort and complexity.
        J Surg Res. 2014; 190: 465-470
        • Schwartz DA
        • Hui X
        • Velopulos CG
        • et al.
        Does relative value unit-based compensation shortchange the acute care surgeon?.
        J Trauma Acute Care Surg. 2014; 76 (discussion 92-84): 84-92
        • Nguyen KT
        • Gart MS
        • Smetona JT
        • et al.
        The relationship between relative value units and outcomes: a multivariate analysis of plastic surgery procedures.
        Eplasty. 2012; 12: e60
        • Peterson J
        • Sodhi N
        • Khlopas A
        • et al.
        A Comparison of Relative Value Units in Primary Versus Revision Total Knee Arthroplasty.
        J Arthroplasty. 2018; 33: S39-S42
        • Sodhi N
        • Piuzzi NS
        • Khlopas A
        • et al.
        Are We Appropriately Compensated by Relative Value Units for Primary vs Revision Total Hip Arthroplasty?.
        J Arthroplasty. 2018; 33: 340-344
        • Isaacson MJ
        • Bunn KJ
        • Noble PC
        • et al.
        Quantifying and Predicting Surgeon Work Input in Primary vs Revision Total Hip Arthroplasty.
        J Arthroplasty. 2016; 31: 1188-1193
        • Tokarski AT
        • Deirmengian CA
        • Lichstein PM
        • et al.
        Medicare fails to compensate additional surgical time and effort associated with revision arthroplasty.
        J Arthroplasty. 2015; 30: 535-538
        • Sodhi N
        • Dalton SE
        • Gold PA
        • et al.
        A comparison of relative value units in revision hip versus revision knee arthroplasty.
        J Orthop. 2019; 16: 45-48
        • Orr RD
        • Sodhi N
        • Dalton SE
        • et al.
        What provides a better value for your time? The use of relative value units to compare posterior segmental instrumentation of vertebral segments.
        Spine J. 2018; 18: 1727-1732
        • Smith EL
        • Tybor DJ
        • Daniell HD
        • et al.
        The 22-Modifier in Reimbursement for Orthopedic Procedures: Hip Arthroplasty and Obesity Are Worth the Effort.
        J Arthroplasty. 2018; 33: 2047-2049
        • Basques BA
        • Miller CP
        • Golinvaux NS
        • et al.
        Morbidity and readmission after open reduction and internal fixation of ankle fractures are associated with preoperative patient characteristics.
        Clin Orthop Relat Res. 2015; 473: 1133-1139
        • SooHoo NF
        • Krenek L
        • Eagan MJ
        • et al.
        Complication rates following open reduction and internal fixation of ankle fractures.
        J Bone Joint Surg Am. 2009; 91: 1042-1049