Efficacy of Post-Operative X-Rays after Operatively Treated Ankle Fractures: What is their Role?

Category: Ankle; Trauma Introduction/Purpose: Ankle fractures are extremely common orthopaedic injuries that frequently require surgical fixation. In the post-operative setting these fractures are routinely monitored with radiographs. However, the utility of routine post-operative imaging in clinically asymptomatic patients is unclear. This study sought to examine how frequently post-operative radiographs result in management changing decisions for operatively treated ankle fractures. We further sought to identify whether the indication for the study would play a role in the clinical utility of the examination. Methods: This was a retrospective study conducted at a single level 1 trauma center. A detailed review of the hospital’s electronic health record was performed. All patients with operatively treated ankle fractures over a two-year period were identified. Patients required at least one post-operative xray for inclusion. Xrays were divided into surveillance xrays and clinically correlated xrays. Surveillance xrays were those obtained in otherwise asymptomatic patients ordered as part of standard clinic workflow. Clinically indicated xrays were defined as any xrays taken outside of the standard workflow or those in which there was a documented concern noted by the patient or provider. To quantify the cost associated with xrays, we performed a cost analysis. A multivariate logistic regression was then performed using patient demographic variables, fracture characteristics (open vs closed, comminution, syndesmotic injury), and whether the study was performed with a clinical concern or as part of standard asymptomatic follow-up screening. Results: A total of 193 patients with 438 xrays met inclusion criteria. Overall, five asymptomatic radiographs were determined to have changed management (1.3% of all asymptomatic xrays), while 18 clinically correlated xrays were determined to have resulted in a change in management or clinical decision making(38.3%). The difference between number of management changing studies between asymptomatic vs clinically driven xrays was significant (p < 0.001). The elimination of all asymptomatic xrays over the study period would have resulted in a savings of 21,825.62 USD per year. In the logistic regression, the only factor found to be significant in predicting a change in management was the presence of a documented clinical concern voiced by the patient (p < 0001). Conclusion: Screening radiographs in clinically asymptomatic patients with operatively managed ankle fractures have a low likelihood (Approx. 1%) of changing management. Such imaging represents costs to the healthcare system, increased time for patients during clinic visits, and radiation exposure. Such studies remain commonplace because of the concern for missed or delayed diagnosis. Future surveillance protocols must strike a careful balance between minimizing unnecessary studies, maximizing early complication detection, and being personalized towards individual patient level factors so as to optimize care and efficiency for both patient and health system.