JAAOS - 2026-08-19 - Journal Article
Comparative Analysis of Work Relative Value Units by Procedural Complexity in the Surgical Treatment of Ankle Fractures and Syndesmosis Injury: A Propensity Score-matched Study.
Reddy S, Chen L, Lee W
Topics
Key Takeaway
Trimalleolar ankle fracture ORIF generates the lowest hourly reimbursement ($296.1/hr) despite the longest operative time (105.0 min), while unimalleolar fixation yields the highest wRVU/hr (10.7) and $/hr ($361.9), demonstrating an inverse relationship between surgical complexity and proportional compensation.
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Summary
This study queried NSQIP (2021–2024) to determine whether wRVU allocation for ankle fracture ORIF and syndesmosis fixation proportionally reflects operative complexity. After propensity score matching and ANCOVA adjustment, surgical time increased significantly with fracture complexity (unimalleolar 64.1 min vs. trimalleolar 105.0 min, P<0.001), but wRVU/hr decreased inversely (10.7 vs. 8.7, P=0.006) and hourly reimbursement followed the same pattern ($361.9 vs. $296.1, P=0.006). Total wRVUs were highest for trimalleolar fractures (11.7), but this did not compensate for the disproportionate increase in operative time.
Key Limitation
NSQIP does not capture surgeon-level variables such as training level, assistant availability, or case complexity beyond fracture pattern, meaning operative time differences may reflect institutional or surgeon efficiency rather than inherent procedural complexity.
Original Abstract
BACKGROUND
Unimalleolar, bimalleolar, and trimalleolar ankle fractures and syndesmosis injuries represent a spectrum of increasing instability and surgical complexity. Although the work Relative Value Unit (wRVU) system is designed to account for surgical time and technical complexity, previous studies suggest a mismatch between procedural complexity and proportional reimbursement rate. Our study aims to evaluate whether current wRVU allocation across ankle fracture types adequately reflects procedural complexity and to assess whether more complex cases are relatively undercompensated.
METHODS
The national surgical quality improvement program (NSQIP) database (2021 to 2024) was queried for patients undergoing open reduction and internal fixation for ankle fractures and syndesmosis injuries, using current procedural terminology (CPT) codes. Cases involving tibial shaft or pilon fractures or multiple CPT codes were excluded. Compensation metrics included surgical time, total wRVUs, wRVUs per hour (wRVU/hr), and hourly reimbursement rate ($/hr). 1:1 propensity score matching was done based on age, sex, American Society of Anesthesiologists class, and inpatient versus outpatient status. Analysis of covariance was subsequently used to adjust for preoperative comorbidities and postoperative complications affecting compensation metrics.
RESULTS
Among 17,833 cases, 779 patients per group were identified after propensity score matching. Surgical time (minutes) increased significantly with complexity (unimalleolar: 64.1 ± 35.5; syndesmosis: 64.2 ± 37.9; bimalleolar: 83.5 ± 43.6; trimalleolar: 105.0 ± 53.6; P < 0.001). Although trimalleolar ankle fractures generated the highest total wRVUs (11.7), wRVU/hr decreased as complexity increased (unimalleolar: 10.7 ± 6.3; syndesmosis: 11.3 ± 6.9; bimalleolar: 9.9 ± 5.4; trimalleolar: 8.7 ± 5.5; P = 0.006). Hourly reimbursement rate ($/hr) followed a similar inverse pattern (unimalleolar: 361.9 ± 214.2; syndesmosis: 382.0 ± 234.4; bimalleolar: 335.4 ± 182.6; trimalleolar: 296.1 ± 188.7; P = 0.006).
CONCLUSION
Our study suggests that the current compensation structure for ankle fracture and syndesmosis fixation procedures may not adequately reflect the surgical time and effort required for more complex injuries. Additional evaluation of wRVU allocation for ankle fracture and syndesmosis injury management may be necessary to ensure that compensation more accurately aligns with physician time and effort.
LEVEL OF EVIDENCE
Level III.