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.

Abstract

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. 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 ($/hr). 1:1 propensity score matching was done based on age, sex, American Society of Anesthesiologists class, and inpatient versus outpatient status. Analysis of covariance was subsequently used to adjust for preoperative comorbidities and postoperative complications affecting compensation metrics. Among 17,833 cases, 779 patients per group were identified after propensity score matching. Surgical time (minutes) increased significantly with complexity (unimalleolar: 64.1 ± 35.5; syndesmosis: 64.2 ± 37.9; bimalleolar: 83.5 ± 43.6; trimalleolar: 105.0 ± 53.6; P < 0.001). Although trimalleolar ankle fractures generated the highest total wRVUs (11.7), wRVU/hr decreased as complexity increased (unimalleolar: 10.7 ± 6.3; syndesmosis: 11.3 ± 6.9; bimalleolar: 9.9 ± 5.4; trimalleolar: 8.7 ± 5.5; P = 0.006). Hourly reimbursement rate ($/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). 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 III.