Agonizing and Expensive: A Review of Institutional Costs of Ankle Fusion Nonunions

Orthopedics. 2020 Jul 1;43(4):e219-e224. doi: 10.3928/01477447-20200404-01. Epub 2020 Apr 12.


Nonunion after ankle arthrodesis requiring revision is a challenging operative complication, and bone graft substitutes are costly. This study sought to summarize all institutional expenditures related to the revision of an ankle fusion nonunion, presuming that cost and skin-to-skin time would exceed those of the index surgery. The electronic records from 2 foot and ankle centers were reviewed, leading to a list of patients with 2 or more entries for tibiotalar fusions being generated. A total of 24 cases were found to match the criteria. Demographic factors and skin-to-skin time of the remaining patients were compiled. This cohort included 24 patients (6 female and 18 male) with a mean age of 64 years and body mass index of 30.4 kg/m2. Supplemental clinic visits and investigations were included either after computed tomography to assess union or 365 days after index surgery. Total cost of the revision was calculated from billing codes, length of operation, and period of hospitalization. Postrevision outpatient fees were included as well. The revisions were performed open in all cases, and 21 patients received autograft and/or bone substitute. Mean postoperative hospitalization was 3 days. The additional costs (in US dollars) associated with nonunion were $1061 for imaging, $627 for prerevision visits, $3026 for the revision, $3432 for the hospital stay, and $1754 for postrevision follow-up. The total mean amount was $9683, equivalent to 9 nights of acute inpatient stay. Mean index skin-to-skin time was 114 minutes, being 126 minutes for revisions (P=.26). Additional care related to ankle fusion nonunion represents a financial burden equivalent to 9 nights of acute inpatient stay. The use of an orthobiologic would need to be less than $436 to be cost saving. Revision surgery is not significantly longer intraoperatively than index surgery. [Orthopedics. 2020;43(4):e219-e224.].

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Aged
  • Ankle / surgery
  • Ankle Joint / surgery*
  • Arthrodesis / economics*
  • Bone Substitutes*
  • Bone Transplantation / economics
  • Case-Control Studies
  • Cohort Studies
  • Cost-Benefit Analysis
  • Electronic Health Records
  • Female
  • Foot
  • Humans
  • Length of Stay / economics
  • Male
  • Middle Aged
  • Reoperation / economics*
  • Retrospective Studies
  • Transplantation, Autologous
  • Young Adult


  • Bone Substitutes