The role of diabetes mellitus and BMI in the surgical treatment of ankle fractures

Fractures and dislocations of the foot and ankle in people with diabetes: a literature review

Diabetes (DM) increases fracture risk, and bone quality depends on type diabetes type, duration, and other comorbidities. Diabetes is associated with a 32% increased relative risk (RR) of total fractures and 24% increased RR of ankle fractures compared with patients without DM. Type 2 DM is associated with a 37% increased RR of foot fractures compared with patients without DM. The incidence of ankle fractures in the general population is 169/100,000 per year, while foot fractures occur less frequently, with an incidence of 142/100,000 per year. Biomechanical properties of bone are negatively impacted by stiff collagen, contributing to the increased risk of fragility fractures in patients with DM. Systemic elevation of proinflammatory cytokines, such as tumor necrosis factor-alpha (TNFα), interleukin-1β (IL-1β), and interleukin 6 (IL-6), impact bone healing in patients with DM. Fractures in patients with DM, can be associated with poorly regulated levels of RANKL (receptor activator of nuclear transcription factor kappa-b ligand) leading to prolonged osteoclastogenesis, and net bone resorption. One of the most salient factors in treating fractures and dislocations of the foot and ankle is to recognize the difference between patients with uncomplicated and complicated DM. Complicated diabetes is defined as 'end organ damage', and for the purposes of this review, includes patients with neuropathy, peripheral artery disease (PAD) and/or chronic renal disease. Uncomplicated diabetes is not associated with 'end organ damage'. Foot and ankle fractures in patients with complicated DM pose challenges, and surgery is associated with increased risks of impaired wound healing, delayed fracture healing, malunion, infection, surgical site infection, and revision surgery. While patients with uncomplicated DM can be treated like patients without DM, patients with complicated DM require close follow-up and robust fixation methods should be considered to withstand the anticipated prolonged healing period. The aims of this review are as follows: (1) to review pertinent aspects of DM bone physiology and fracture healing, (2) to review the recent literature on treatment of foot and ankle fractures in patients with complicated DM, and (3) to provide treatment protocols based on the recent published evidence.

Transosseous Fixation of the Distal Tibiofibular Syndesmosis: Comparison of Interosseous Suture and Endobutton Across Age Groups

Background In the ankle, suture bridge fixation for syndesmotic injuries is commonly employed. Initial recommendations for suture bridge constructs advised against using the device in patients with insufficient quantity or quality of bone. Therefore, many surgeons limit its use to younger, more athletic patients and use traditional screw fixation in older, less active patients. The purpose of this study is to compare the outcomes of suture bridge fixation for syndesmotic repair in patients ≥ 60 years old vs patients < 60 years old. Methods A retrospective review of 140 ankle fracture patients from a single institution who received suture bridge fixation between July 13, 2010, and February 2, 2022, was performed. Patient data was obtained from patient records in the electronic health record. Univariate analysis, including chi-square and independent t-tests, was used. Complications included delayed wound healing, infection, hardware loosening, and non-union. Results There were no significant differences in demographics, comorbidities, primary or other procedures, loss of fixation, and neuropathy between groups. There was also no difference within the distribution of the mechanism of injury, affected side, or Weber classification. Finally, the rate of complication and complication type showed no significant differences between patients 60 years and older versus 60 years and younger. Complication rates and types in patients > 60 years versus < 60 years were not significantly different. Conclusion The use of the suture bridge fixation in patients > 60 years may not lead to an increased risk of complications and appears to be safe for use.

Risk factors for wound healing complications after revascularization for MMD with complete Y-shaped incision

Moyamoya disease (MMD) is a chronic occlusive cerebrovascular disease that can be treated with revascularization. Surgery increases the risk of poor wound healing (PWH) due to the impact on the blood supply to the flap. We aimed to analyze risk factors for PWH in MMD with a complete Y-shaped incision. A total of 125 patients with MMD were enrolled in this prospective observational study. The wounds were assessed and measured on the third and seventh days after surgery. The mean age of these patients was 43.3 ± 10.0 years. The ratio of male to female was 1:1.3. 15 (12.0%) patients had incision complications. 5 patients (4.0%) had redness; 2 patients (1.6%) had swelling; 2 patients (1.6%) had fat necrosis; 3 patients (2.4%) had incision infection; and 3 patients (2.4%) had flap necrosis. Student's t test showed significant differences in BMI (P = 0.040) and fever time (P = 0.050). The standard chi-squared test showed significant differences in incision infection (P = 0.010), suture mode (P = 0.047), and cutting off large branch vessels in the flap (P < 0.001). Multivariate logistic regression analysis suggested that incision infection (P = 0.026, OR 12.958), using a skin stapler (P = 0.030, OR 4.335), cutting off large branch vessels in the flap (P = 0.009, OR 5.227), and BMI (P = 0.027, OR 1.204) were risk factors. The area under the curve for risk factors for PWH on a receiver operating characteristic curve was 0.853. Incision infection, using a skin stapler, higher BMI, and cutting off large branch vessels in the flap are risk factors for PWH.

Postoperative short-term mortality between insulin-treated and non-insulin-treated patients with diabetes after non-cardiac surgery: a systematic review and meta-analysis

Background

Diabetes mellitus is an independent risk factor for postoperative complications. It has been reported that insulin-treated diabetes is associated with increased postoperative mortality compared to non-insulin-treated diabetes after cardiac surgery; however, it is unclear whether this finding is applicable to non-cardiac surgery.

Objective

We aimed to assess the effects of insulin-treated and non-insulin-treated diabetes on short-term mortality after non-cardiac surgery.

Methods

Our study was a systematic review and meta-analysis of observational studies. PubMed, CENTRAL, EMBASE, and ISI Web of Science databases were searched from inception to February 22, 2021. Cohort or case-control studies that provided information on postoperative short-term mortality in insulin-treated diabetic and non-insulin-treated diabetic patients were included. We pooled the data with a random-effects model. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to rate the quality of evidence.

Results

Twenty-two cohort studies involving 208,214 participants were included. Our study suggested that insulin-treated diabetic patients was associated with a higher risk of 30-day mortality than non-insulin-treated diabetic patients [19 studies with 197,704 patients, risk ratio (RR) 1.305; 95% confidence interval (CI), 1.127 to 1.511; p < 0.001]. The studies were rated as very low quality. The new pooled result only slightly changed after seven simulated missing studies were added using the trim-and-fill method (RR, 1.260; 95% CI, 1.076-1.476; p = 0.004). Our results also showed no significant difference between insulin-treated diabetes and non-insulin-treated diabetes regarding in-hospital mortality (two studies with 9,032 patients, RR, 0.970; 95% CI, 0.584-1.611; p = 0.905).

Conclusion

Very-low-quality evidence suggests that insulin-treated diabetes was associated with increased 30-day mortality after non-cardiac surgery. However, this finding is non-definitive because of the influence of confounding factors.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021246752, identifier: CRD42021246752.

Comparing the 30-Day Complications Between Smokers and Nonsmokers Undergoing Surgical Fixation of Ankle Fractures

Background:

There have been conflicting reports regarding the effect of smoking on complications after surgical treatment of ankle fractures. This study aimed at identifying the complications for which smokers and subgroups of smokers are at a higher risk compared to nonsmokers when undergoing surgery for fixation of rotational ankle fractures.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program data set from 2008 to 2019 was used to compare the 30-day wound, cardiac, renal, and infectious complications, related readmissions, and return to the operating room between the 2 cohorts.

Results:

Of 33 741 patients included, 25 642 (76.0%) were nonsmokers and 8099 (24.0%) were smokers. Multivariate analysis showed that smokers were at a higher risk for deep wound infection (OR 2.34, 95% CI 1.48-3.69, P < .001), wound dehiscence (OR 2.43, 95% CI 1.56-3.77, P < .001), related return to the operating room (OR 1.69, 95% CI 1.36-2.11, P < .001), and related readmissions (OR 1.67, 95% CI 1.32-2.09, P < .001). Smokers at an increased risk for deep infection included patients between 50 and 59 years (OR 5.75, 95% CI 1.78-18.5, P = .003), who were Black (OR 4.24, 95% CI 1.04-17.23, P = .044), who had body mass index (BMI) 35 to 39.9 (OR 3.73, 95% CI 1.46-9.50, P = .006), or operative times between 60 and 90 minutes (OR 3.64, 95% CI 1.79-7.39, P < .001). Smoker subgroups at a higher risk for wound dehiscence included patients between 50 and 59 years (OR 9.86, 95% CI 3.29-29.53, P < .001), with operative times between 90 and 120 minutes (OR 4.88, 95% CI 1.89-12.58, P < .001), with BMI 30 to 34.9 (OR 3.06, 95% CI 1.45-6.45, P = .003) and who underwent spinal/epidural anesthesia (OR 9.31, 95% CI 2.31-37.58, P = .002).

Conclusion:

Smokers were at an increased risk for deep wound infection, wound dehiscence, related reoperations, and related readmissions after ankle fracture surgery. Certain subgroups were at an even higher risk for these complications.

Level of Evidence:

Level III, retrospective cohort study.

Preoperative diabetes complicates postsurgical recovery but does not amplify readmission risk following pancreatic surgery

BACKGROUND

Diabetes is a significant and prevalent medical condition associated with increased comorbidities, longer hospital length of stay, and higher healthcare costs. We aimed to assess the association between diabetes mellitus and postoperative outcomes following pancreatic surgeries.

METHODS

Records for patients with major elective pancreatic surgeries were retrieved retrospectively from the Nationwide Readmission Database (2010-2014). Association of diabetic status with postoperative complications, in-hospital mortality, length of stay (LOS), readmission rate, and hospital costs were investigated. Logistic regression and decision tree analyses were employed to predict adverse outcomes.

RESULTS

A total of 8,401 patients who had pancreatic surgery were included. They were categorized according to their diabetic diagnosis. Results showed that diabetic patients had a higher risk of postoperative complications compared to non-diabetics (OR: 1.27, 95% CI: 1.08-1.49, P=0.003). Bleeding and renal complications were the most significant. Uncontrolled diabetes significantly required a longer hospital stay (9.17±4.28 vs. 8.03±4.96 days, P=0.001), and incurred higher hospital costs ($34,171.04±$20,846.61 vs. $28,182.21±$24,070.27, P=0.001). After multivariate regression, no association was found with in-hospital mortality or readmission rates; however, diabetic patients' length of stay during readmission was increased at 30- and 90-day readmissions (P=0.004 and 0.007, respectively).

CONCLUSIONS

Among patients who underwent pancreatic surgery, those with diabetes had a higher rate of postoperative complications compared to non-diabetics. Additionally, diabetic patients had higher hospital charges and costs during primary admission. Initial analysis of patients with diabetes showed they had higher rates of 30- and 90-day readmissions, though this did not maintain significance after regression analysis. Exploring the mechanisms underlying this finding would aid in preventing postoperative complications and reducing healthcare costs.

Diabetic ankle fracture complications: a meta-analysis

INTRODUCTION

This meta-analysis aimed to review complication rates following the treatment of an ankle fracture in diabetic patients and to early detect the subgroup of patients at potential risk in order to minimise this complication rate.

METHODS

A search of 3 databases was performed for studies published till March 2018. Twelve studies met the eligibility criteria for further statistical analysis. An odds ratio (OR) with a 95% confidence interval (95% CI) for each complication was calculated between the diabetic and non-diabetic groups.

RESULTS

The overall complication risk after ankle fracture was twice as high in diabetes mellitus (DM) than non-diabetes mellitus (non-DM) patients (OR 1.9, 95%CI: 1.7-2.03). This risk was considerably higher with surgery versus non-surgical treatment (OD 3.7, 95%CI: 2.3-6.2). The risk of infection was 3 times higher in DM than in non-DM patients (OR 3.4, 95%CI: 2.9-9.8). The complication rate was even higher in patients with advanced DM (OR 8.4, 95%CI: 2.9-24.5).

CONCLUSION

This meta-analysis provides evidence that diabetic patients are at a greater risk of complication after an ankle fracture.

The Influence of Obesity on Hospital Admission After Outpatient Foot and Ankle Surgery

We examined the association of body mass index (BMI) with sociodemographic data, medical comorbidities and hospital admission following ambulatory foot and ankle surgery. We conducted an analysis utilizing data from the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2016. Adult patients who underwent ankle surgery defined as ankle arthrodesis, ankle open reduction and internal fixation, and Achilles tendon repair in the outpatient setting. We examined 6 BMI ranges: <20 kg/m² underweight, ≥20 to <25 kg/m² normal weight, ≥25 to <30 kg/m² overweight, ≥30 to <40 kg/m² obese, ≥40 kg/m²to <50 kg/m² severely obese, and ≥50 kg/m² extremely obese. The primary outcome was hospital admission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p value of <.05 as statistically significant. Data extraction yielded 13,454 adult patients who underwent ambulatory ankle surgery. We then performed listwise deletion to exclude cases with missing observations. After excluding 5.4% of the data, the final study population included 12,729 patients. The overall rate of hospital admission was in the population was 18.6% (2,377/12,729). The overall rate of postoperative complications was 0.03% (4/12,729). We found no significant association of BMI with hospital admission following multivariable logistic regression. We recommend that BMI alone should not be solely used to exclude patients from having ankle surgery performed in an outpatient setting, especially since this patient group makes up a significant proportion of orthopedic surgery.

Fibula fractures management

Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.

Diabetic Pilon Factures: Are They as Bad as We Think?

OBJECTIVE

To identify how diabetes impacts the risk of complications requiring further surgery (deep surgical site infection, nonunion, amputation, and arthrodesis) after pilon fracture fixation.

DESIGN

Retrospective cohort study.

SETTING

Level 1 academic trauma center.

PATIENTS

Two hundred seventy-nine pilon fractures (276 patients) were identified. A retrospective review was performed to find patients who presented for open reduction and internal fixation of a tibial pilon fracture (OTA/AO 43). Patient demographics, medical comorbidities, OTA/AO fracture type, and surgical outcomes were reviewed.

INTERVENTION

Patients were stratified into cohorts based on the presence or absence of diabetes at the time of surgery.

MAIN OUTCOME MEASUREMENTS

The complications of interest that proved significant during univariate analyses were then entered into a multivariable logistic regression model using a stepwise method to identify the independent predictors for complications.

RESULTS

There were 43 fractures (15.4%) in patients with diabetes mellitus; 17 (39.5%) of whom were insulin-dependent diabetics. Diabetic patients were significantly more likely to have a higher body mass index (34.81 vs. 29.57, P = 0.002) and be older (55.30 ± 16.3 years vs. 41.70 ± 14.05, P < 0.001) at the time of injury. Patients without diabetes were more likely to sustain an OTA/AO 43-C3 fracture (36.0% vs. 11.6%, P = 0.001). Diabetic patients were 5.5 times more likely to require an arthrodesis [95% confidence interval (CI) = 1.894-16.214; P = 0.001] and 2.7 times more likely to develop a deep infection (95% CI = 1.261-5.630; P = 0.008).

CONCLUSIONS

Overall, diabetic patients in this study were 3.64 times more likely (95% CI = 1.854-7.159; P < 0.001) to experience any complication, despite having less complex fractures.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictive Value of Body Mass Index in Minimally Invasive Mitral Valve Surgery

BACKGROUND

 With this study we aimed to analyze if the separate consideration of body mass index (BMI) could provide any superior predictive values compared with the established risk scores in isolated minimally invasive mitral valve surgery (MIMVS). This might facilitate future therapeutic decision-making, e.g., regarding the question surgery versus transcatheter mitral valve repair (TMVr).

METHODS

 We assessed the relevance of BMI in non-underweight patients who underwent isolated MIMVS. The risk predictive potential of BMI for mortality and several postoperative adverse events was assessed in 429 consecutive patients. This predictive potential was compared with that of European System for Cardiac Outcome Risk Evaluation II (EuroSCORE II) and the Society of Thoracic Surgeons score (STS score) using a comparative receiver operating characteristic curve analysis.

RESULTS

 BMI was a significant numeric predictor of wound healing disorders (p = 0.001) and proved to be significantly superior in case of this postoperative adverse event compared with the EuroSCORE II (p = 0.040) and STS score (p = 0.015). Except for this, the predictive potential of BMI was significantly inferior compared with that of the EuroSCORE II and STS score for several end points, including 30-day (p = 0.029 and p = 0.006) and 1-year (p = 0.012 and p = 0.001) mortality.

CONCLUSION

 Therefore, we suggest that, in the course of decision-making regarding the right treatment modality for non-underweight patients with isolated mitral valve regurgitation, the sole factor of BMI should not be given a predominant weight.

Fatores de risco para infecção de sítio cirúrgico em cirurgias traumato-ortopédicas

Introdução: A Infecção do Sítio Cirúrgico ocupa a terceira posição entre as infecções adquiridas em serviços de saúde, configurando-se como um importante problema de saúde pública, presente em cerca de 15% daquelas encontradas em pacientes hospitalizados, e um dos tipos de cirurgias de maior probabilidade para esse evento são as traumato-ortopédicas. Objetivo: Verificar a associação entre os fatores de risco e a presença de Infecção de Sítio Cirúrgico em cirurgias traumato-ortopédicas. Materiais e métodos: Estudo prospectivo descritivo, quantitativo, realizado entre agosto a outubro de 2017 com 84 pacientes. Os dados referentes ao paciente, ao procedimento e os sinais de Infecções de Sítio Cirúrgico, encontrados no terceiro e décimo dia de pós-operatório, foram coletados por meio de um formulário. Resultados: Das variáveis estudadas, comportaram-se como fatores de risco de Infecção de Sítio Cirúrgico: tabagismo, diabetes e idade acima de 50 anos. A idade foi o principal fator de risco relacionado ao paciente, presente em 31, 36,9% dos casos. Dor, edema e hiperemia foram os sinais de infecção mais prevalentes. Discussão e conclusões: Os fatores de risco relacionados ao paciente possuem maior relevância na associação com infecção do sítio cirúrgico em comparação com os relacionados ao procedimento.

Prevention of postoperative surgical wound complications in ankle and distal tibia fractures: results of Incisional Negative Pressure Wound Therapy

BACKGROUND AND AIM OF THE WORK

complications in surgical wound healing represent the main postoperative complication in ankle and distal tibia fractures. Whereas the use of Incisional Negative Pressure Wound Therapy (INPWT) is recognized to have a role in wound complications prevention in prosthetic surgery, literature about its use in trauma surgery is scarce. The aim of this study was to compare the effectiveness of INWPT with a conventional dressing in order to prevent surgical wound complications in ankle and distal tibia fractures.

METHODS

The study population included patients over 65 years as well as patients under 65 years considered at risk for wound complications (smokers, obese, affected by diabetes), who underwent ORIF for bi/tri-malleolar ankle fractures or distal tibia (pilon) fractures. After surgery, patients were randomized to receive a conventional dressing or INPWT. Complications in surgical wound healing were classified in major (requiring surgical intervention) and minor complications.

RESULTS

65 patients were included in the study. The rate of minor and major complications between the two groups was not significantly different, although a positive trend towards a lower minor complications rate was noted in the INPWT group (12.6% vs 34.7%). No complications or complaints were reported for the INPWT device.

CONCLUSIONS

INPWT proved to be safe, well-tolerated and showed promising results in preventing surgical wound complications in ankle and distal tibia fractures.

Operative Treatment of Ankle Fractures: Predictive Factors Affecting Outcome

Purpose

Surgical management of ankle fractures has been extensively studied in literature but studies investigating validated clinical results are lacking and controversial. The purpose of this study was to evaluate functional and health-related quality of life (HRQL) outcomes after surgically treated ankle fractures and to detect some of their predictors.

Methods

Two hundred sixty-six skeletally mature patients who underwent surgery for an isolated ankle fracture from 2006 to 2017 were retrospectively identified from our hospital records and included in the study. All patients were evaluated at one, three, six and 12 months post-injury with clinical and radiographic examination. Outcome measures recorded at final two years minimum follow-up included patient-reported pain, patient satisfaction, functional (American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score) and quality of life (Short Form (SF) 36 score) status.

Results

Patient satisfaction score was 8.4 out of 10, Visual Analogue Scale mean score was 2.3, complication rate was 36.5% and mean AOFAS ankle-hindfoot score was 87.3. Mean SF36-physical summary score was 77.9 and SF36-mental summary score was 81.1. The injury demonstrated a significant effect on physical function, role-physical, bodily pain and social functioning SF-36 subdomains. Functional outcome was significantly related to occupation, syndesmotic lesion, number of fractured malleoli and delay to surgery. Main predictors of quality of life were age, occupation, cause of injury, syndesmotic lesion, number of fractured malleoli and waiting time to surgery.

Conclusions

Ankle fractures have a considerable impact on functional and quality of life status of patients. Occupation, presence of syndesmotic injury, Pott's classification and surgery delay must be considered as predictors of final outcome.

Effects of Diabetes Mellitus on Functional Outcomes and Complications After Torsional Ankle Fracture

INTRODUCTION

It is well known that patients with diabetes mellitus experience higher complication rates after torsional ankle fracture; however, the functional consequences remain less clear. The goal of this study was to determine the effects of diabetes on complications, secondary operations, and functional outcomes after torsional ankle fracture.

METHODS

Nine hundred seventy-nine adult patients treated surgically for a torsional ankle injury (Orthopaedic Trauma Association 44B, 44C) over 13 years were retrospectively reviewed. Demographic information, comorbidities, injury characteristics, complications, and secondary procedures were recorded. Patient-reported outcome surveys: Foot Function Index (FFI) and Short Musculoskeletal Function Assessment were obtained after minimum of 12 months. Multivariable analysis was done to account for confounding variables.

RESULTS

One hundred thirty-one patients (13.4%) had diabetes. Diabetic patients were older (56.4 versus 43.0 years, P < 0.001), with no difference in sex or race. Body mass index was higher among diabetics (36.0 versus 30.4, P < 0.001) as were most medical comorbidities, including stroke, neuropathy, pulmonary disease, and renal disease (all P < 0.03). There were no differences in rates of dislocations or open injuries. Diabetics experienced more complications (26.0% versus 14.6%, P = 0.001), specifically deep infections (6.9% versus 1.3%, P = 0.001), and had more secondary procedures (18.3% versus 9.1%, P = 0.001), including débridement, arthrodesis, and amputation (all P < 0.02). Diabetes was a significant independent predictor of worse FFI activity limitation scores (P = 0.032), but was not predictive of worse outcomes on any other subscore of the FFI or Short Musculoskeletal Function Assessment.

CONCLUSIONS

Diabetes was associated with more complications and secondary operations. However, functional outcomes including pain and dysfunction were not markedly affected by these clinical outcomes, potentially due to diminished sensory function and less baseline physical activity among diabetic patients.

LEVEL OF EVIDENCE

Prognostic level III.

Current concepts in the management of ankle arthritis

Ankle arthritis is a common condition. It causes a significant socioeconomic burden, and is associated with significant morbidity. Patients with ankle arthritis are either elderly with significant co-morbidities, or young adults who have previously suffered with ankle injuries, resulting in post-traumatic arthritis. There is a wide variation in the management of these patients with ankle arthritis. We therefore present an overview of the current evidence based management of patients with symptomatic ankle arthritis.

Correlation of Soft Tissue Swelling and Timing to Surgery With Acute Wound Complications for Operatively Treated Ankle and Other Lower Extremity Fractures

BACKGROUND

Considerable debate exists regarding how soft-tissue edema should influence timing of surgery for ankle and other lower extremity fractures. Assessment of swelling is subjective, and timing varies among surgeons. However, timing of surgery is one of the few modifiable factors in fracture care. Ultrasonography can objectively measure swelling and help determine optimal timing. The purposes of this study were to determine whether objective measures of swelling, timing to surgery, and patient-specific risk factors correlated with wound complications and to try to create a prediction model for postoperative wound complications based on identified modifiable and nonmodifiable risk factors.

METHODS

Patients with closed ankle and other lower extremity fractures requiring surgery with an uninjured, contralateral extremity were included. Demographic information and sonographic measurements on both lower extremities were obtained pre-operatively. Subjects were followed for 3 months and wound complications were documented. A predictive algorithm of independent risk factors was constructed, determining wound complication risk. Given that patients with ankle fractures made up the majority of the study cohort (75/93 or 80%), a separate statistical analysis was performed on this group. A total of 93 subjects completed the study, with 75/93 sustaining ankle fractures.

RESULTS

Overall wound complication rate was 18.3%. Timing to surgery showed no correlation with wound complications. A heel-pad edema index >1.4 was independently associated with wound complications. Subgroup analysis of ankle fractures demonstrated a 3.4× increase in wound complications with a heel-pad edema index >1.4. Tobacco history and BMI >25 were independent predictors of wound complications. An algorithm was established based on heel-pad edema index, BMI >25, and tobacco history. Patients with none of the 3 factors had a 3% probability of a wound complication. Patients with 1/3, 2/3 and 3/3 factors had a 12-36%, 60-86% and 96% probability of a wound complication, respectively.

CONCLUSIONS

Timing to surgery had no correlation with wound complications. Heel-pad edema index >1.4, BMI >25, and tobacco-use correlated with wound complications. When separately analyzing the cohort that sustained ankle fractures, the heel-pad edema index of >1.4 was still demonstrated to be predictive of wound complications corresponding to a 3.4× increase in wound complication rates (11.1% vs 37.5%). Risk of wound complications significantly increased with each factor. In patients with increased BMI and/or tobacco use, resolution of heel edema may significantly reduce wound complications in lower extremity trauma.

LEVEL OF EVIDENCE

Level II, prognostic, prospective cohort study.

Paradigm shift in geriatric fracture treatment

The number of geriatric patients is increasing. These patients exhibit specific characteristics, which influence the type of fracture care. Many patients have comorbidities, which make them more vulnerable to surgical procedures. The soft tissue envelope around the fracture often is compromised due to pre-existing diseases such as diabetes, chronic venous insufficiency or peripheral vascular disease. Bone mineral density has decreased, which enhances the risk of implant loosening. The goals of treatment differ from those, which are valid for younger adults. Primary goal is preserving independency of the elderly patient in his activities of daily life. Advantages and drawbacks of surgical procedures have to be balanced with those of conservative treatment. Fractures of the lower extremities will more often need surgical treatment than fractures of the upper extremities. Patient´s autonomy is best obtained by creating high stability in the fracture plane, which enables motion and weight-bearing. Second priority is prevention of general and local post-operative complications by the use of less invasive surgical procedures. Restoring anatomy and optimal function are less important goals. The implants, which are used, are inserted through small incisions, placed deep under the skin and use long anatomic or osseous corridors. Intramedullary devices have important advantages. This paradigm shift takes the special challenges and requirements of geriatric patients into account.

Does the time of day in orthopedic trauma surgery affect mortality and complication rates?

Background

Orthopedic trauma surgery has multiple, both patient-based and surgeon-based risk factors. Evaluating and modifying certain patient safety factors could mitigate some of these risks. This study investigates the influence that the time of day of surgery has on mortality and complication rates.

Question/purpose

This study evaluates whether the time of day of orthopedic trauma surgery influences complication or mortality rates.

Patients and methods

A prospective Swiss surgical database developed as a nationwide quality assurance project was reviewed retrospectively. All patients with trauma-coded diagnoses that were surgically treated in Swiss hospitals between 2004 and 2014 were evaluated. Surgery times were stratified into morning, afternoon, evening and night. The primary outcomes were in-hospital mortality and complication rates. Co-factors were sought in bivariate and multivariable analysis.

Results

Of 31,692 patients, 13,969 (44.3%) were operated in the morning, 12,696 (40.3%) in the afternoon, 4,331 (13.7%) in the evening, and 550 (1.7%) at night. Mortality rates were significantly higher in nighttime (2.4%, OR 1.26, p=0.04) and afternoon surgery (1.7%, OR 1.94, p=0.03) vs. surgery in the morning (1.1%). Surgery performed in the afternoon and at night showed significantly increased general complication rates vs. surgery performed in the morning. (OR 1.22, p=0.006 and OR 1.51, p=0.021, respectively).

Conclusion

This study observed higher complication and mortality rates for surgery performed after-hours, which correlates with other recent studies. Surgeon fatigue is a potential contributing factor for these increased risks. Other potential factors include surgeon experience, surgery type, and the potential for more severe or emergent injuries occurring after-hours.

Does the quality of preoperative closed reduction of displaced ankle fractures affect wound complications after surgical fixation?

BACKGROUND

Displaced ankle fractures are initially closed reduced and splinted with the goal of restoring gross ankle alignment. The benefits of an exact closed reduction are unclear and possibly detrimental and unnecessary if multiple attempts are made. The purpose of this study was to determine whether the quality of preoperative closed reduction in patients with operative ankle fractures affects post-operative wound complications.

METHODS

A retrospective analysis was performed of patients with isolated, closed, operative ankle fractures treated at two level 1 trauma centers who had an initial closed reduction performed on presentation. Patient demographics, fracture characteristics, data pertinent to the reduction, and post-operative wound complications were collected. A novel grading system to assess reduction quality was developed, applied, and evaluated for inter- and intra-observer agreement.

RESULTS

161 patients met inclusion criteria for analysis. 17% (27/161) sustained a post-operative wound complication. There was no statistically significant association between wound complications and quality of preoperative closed reduction (p = 0.17) nor with multiple reduction attempts (p = 0.887). However, patients with poor initial reductions had a decreased mean time to surgery (1.4 ± 2.9 versus 4.7 ± 6.3 days, p = 0.03), which may have been protective. Interclass correlation coefficients for inter- and intra-rater reliability of the classification schema was 0.942 and 0.922, respectively, demonstrating excellent agreement.

CONCLUSION

There was no association between preoperative closed reduction quality and incidence of post-surgical wound complications in patients with operative ankle fractures when analyzing the variables assessed in this investigation. While initial ankle reduction is still recommended, multiple attempts to achieve a perfect reduction are likely unnecessary.

Special Considerations in the Management of Diabetic Ankle Fractures

PURPOSE OF REVIEW

Ankle fractures and diabetes mellitus are both increasing in prevalence. Patients with both diabetes and an ankle fracture have been shown to have an increased rate of complications which can be catastrophic. The purposes of this review are to identify factors placing patients at an increased risk and offer guidance on the management of these injuries, in order to reduce potential complications.

RECENT FINDINGS

Non-operative management of unstable ankle fractures in patients with diabetes results in an unacceptably high rate of complications. Operatively managed patients with uncomplicated diabetes seem to fair as well as patients without diabetes. Thus, it is important to recognize patients as either complicated or uncomplicated at the onset of their treatment based on comorbidities. There is limited evidence to guide the management of ankle fractures in patients with diabetes, in particular those deemed complicated. Non-operative management of unstable fractures in diabetic patients should be avoided.