Morbidity and readmission after open reduction and internal fixation of ankle fractures are associated with preoperative patient characteristics

Predictors of first-year postoperative complications after fixation of low-energy ankle fractures: A single-center, retrospective cohort study of 663 consecutive fractures

INTRODUCTION

Rotational ankle fractures are common, have diverse personalities and affect both robust and fragile patients. Postoperative complications are frequent, creating a sizeable economic burden. The primary purpose of this study was to expand current knowledge on predictors of postoperative complications after low-energy ankle fracture fixation.

MATERIALS AND METHODS

A retrospective single-center cohort study was completed of patients undergoing internal fixation OF low-energy ankle fractures. The primary outcome was first-year postoperative complications, classified as major (surgical) or minor (non-surgical). Data on patients, their injuries, and treatments were collected. To identify potential predictors of outcomes, logistic regression methods were used, with a backward-stepwise method used for model fitting.

RESULTS

In total, 663 patients of median age 59 years were analyzed. We found a high rate of complications (28.4%), with wound-healing issues and infections predominant. Overall, 14.8% had minor complications, while 13.6% required an unplanned reoperation. On multivariable analysis, the most consistent predictors of complications were older age (OR=1.02 per year), longer operating time (3.32 per hour), and smoking (2.91).

CONCLUSIONS

Older patients and smokers who sustain fractures requiring more complex surgery are at higher risk of postoperative complications.

Predictors of first-year postoperative complications after fixation of low-energy ankle fractures: A single-center, retrospective cohort study of 663 consecutive fractures

INTRODUCTION

Rotational ankle fractures are common, have diverse personalities and affect both robust and fragile patients. Postoperative complications are frequent, creating a sizeable economic burden. The primary purpose of this study was to expand current knowledge on predictors of postoperative complications after low-energy ankle fracture fixation.

MATERIALS AND METHODS

A retrospective single-center cohort study was completed of patients undergoing internal fixation OF low-energy ankle fractures. The primary outcome was first-year postoperative complications, classified as major (surgical) or minor (non-surgical). Data on patients, their injuries, and treatments were collected. To identify potential predictors of outcomes, logistic regression methods were used, with a backward-stepwise method used for model fitting.

RESULTS

In total, 663 patients of median age 59 years were analysed. We found a high rate of complications (28.4%), with wound-healing issues and infections predominant. Overall, 14.8% had minor complications, while 13.6% required an unplanned reoperation. On multivariable analysis, the most consistent predictors of complications were older age (OR: 1.02 per year), longer operating time (3.32 per hour), and smoking (2.91).

CONCLUSIONS

Older patients and smokers who sustain fractures requiring more complex surgery are at higher risk of postoperative complications.

-A machine learning model to predict surgical site infection after surgery of lower extremity fractures

PURPOSE

This study aimed to develop machine learning algorithms for identifying predictive factors associated with the risk of postoperative surgical site infection in patients with lower extremity fractures.

METHODS

A machine learning analysis was conducted on a dataset comprising 1,579 patients who underwent surgical fixation for lower extremity fractures to create a predictive model for risk stratification of postoperative surgical site infection. We evaluated different clinical and demographic variables to train four machine learning models (neural networks, boosted generalised linear model, naïve bayes, and penalised discriminant analysis). Performance was measured by the area under the curve score, Youdon's index and Brier score. A multivariate adaptive regression splines (MARS) was used to optimise predictor selection.

RESULTS

The final model consisted of five predictors. (1) Operating room time, (2) ankle region, (3) open injury, (4) body mass index, and (5) age. The best-performing machine learning algorithm demonstrated a promising predictive performance, with an area under the ROC curve, Youdon's index, and Brier score of 77.8%, 62.5%, and 5.1%-5.6%, respectively.

CONCLUSION

The proposed predictive model not only assists surgeons in determining high-risk factors for surgical site infections but also empowers patients to closely monitor these factors and take proactive measures to prevent complications. Furthermore, by considering the identified predictors, this model can serve as a reference for implementing preventive measures and reducing postoperative complications, ultimately enhancing patient outcomes. However, further investigations involving larger datasets and external validations are required to confirm the reliability and applicability of our model.

Predicting Risk of 30-day Postoperative Morbidity Using the Pathologic Fracture Mortality Index

INTRODUCTION

The purpose of this study was to evaluate the ability of the Pathologic Fracture Mortality Index (PFMI) to predict the risk of 30-day morbidity after pathologic fracture fixation and compare its efficacy with those of the American Society of Anesthesiologists (ASA) physical status, modified Charlson Comorbidity Index (mCCI), and modified frailty index (mFI-5).

METHODS

Cohorts of 1,723 patients in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2020 and 159 patients from a tertiary cancer referral center who underwent fixation for impending or completed pathologic fractures of long bones were retrospectively analyzed. National Surgical Quality Improvement Program morbidity variables were categorized into medical, surgical, utilization, and all-cause. PFMI, ASA, mCCI, and mFI-5 scores were calculated for each patient. Area under the curve (AUC) was used to compare efficacies.

RESULTS

AUCs predicting all-cause morbidity were 0.62, 0.54, and 0.56 for the PFMI, ASA, and mFI-5, respectively. The PFMI outperformed the ASA and mFI-5 in predicting all-cause ( P < 0.01), medical ( P = 0.01), and utilization ( P < 0.01) morbidities. In the 2005 to 2012 subset, the PFMI outperformed the ASA, mFI-5, and mCCI in predicting all-cause ( P = 0.01), medical ( P = 0.03), and surgical ( P = 0.05) morbidities but performed similarly to utilization morbidity ( P = 0.19). In our institutional cohort, the AUC for the PFMI in morbidity stratification was 0.68. The PFMI was associated with all-cause (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.12 to 1.51; P < 0.001), medical (OR, 1.19; 95% CI, 1.03 to 1.40; P = 0.046), and utilization (OR, 1.32; 95% CI, 1.14 to 1.52; P < 0.001) morbidities but not significantly associated with surgical morbidity (OR, 1.21; 95% CI, 0.98 to 1.49; P = 0.08) in this cohort.

DISCUSSION

The PFMI is an advancement in postoperative morbidity risk stratification of patients with pathologic fracture from metastatic disease.

LEVEL OF EVIDENCE

III.

Adverse Events After Ankle Fracture Open Reduction Internal Fixation Among Patients With and Without Documented Cannabis and Tobacco Use

BACKGROUND

Ankle fractures are common orthopaedic injuries that may be indicated for open reduction internal fixation (ORIF). Although the negative impact of tobacco use on perioperative outcomes of ankle fracture ORIF has been described, the potential impact of cannabis use on related outcomes is not as well established.

METHODS

Retrospective database study of adult patients undergoing ankle ORIF for closed, isolated, ankle fractures from the 2010-2021 Q1 PearlDiver M151 data set. Subcohorts without and with cannabis and/or tobacco use were identified based on coding and matched based on patient age, sex, and Elixhauser Comorbidity Index (ECI) scores to yield groups of nonusers, tobacco users, tobacco and cannabis users, and cannabis users. Ninety-day adverse events were assessed between matched subcohorts with multivariable logistic regression controlling for age, sex, and ECI.

RESULTS

A total of 149 289 patients met study inclusion criteria for whom tobacco only use was documented for 14 989 (10.0%), tobacco and cannabis use for 2726 (1.8%), and cannabis only use for 867 (0.6%). Matching yielded 823 for each group. On multivariable analyses, isolated tobacco users were at higher odds of 90-day urinary tract infections (UTIs) (odds ratio [OR] 2.64), minor adverse events (OR 2.33), all-cause adverse events (OR 2.17), readmissions (OR 1.85), and severe adverse events (OR 1.84). Tobacco and cannabis comorbid users were at a marginally higher odds of 90-day UTI (OR 2.82), minor adverse events (OR 2.51), readmissions (OR 2.39), and any adverse events (OR 2.22). Cannabis only users were not at greater odds of 90-day adverse events relative to nonusers.

CONCLUSION

Patients with tobacco use (alone or with cannabis) were at greater odds of 90-day adverse events following ankle fracture ORIF, but cannabis only users were not.

LEVEL OF EVIDENCE

Level III, Retrospective database study.

Risks of Immunosuppressive Therapy in Patients Undergoing Open Reduction Internal Fixation for Ankle Fractures

Chronic steroid and immunosuppressant use have been shown to increase the risk for postoperative complications in orthopedic surgery. Further understanding of the risks of immunosuppression is necessary to aid in risk stratification and patient counseling. However, these risks have not yet been explored in ankle fracture patients. Thus, the purpose of this study is to determine whether patients taking immunosuppressives are at an increased risk for morbidity and mortality following open reduction and internal fixation (ORIF) of ankle fractures. Patients undergoing operative treatment for ankle fractures from 2006 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were categorized based on their use of immunosuppressive medications. Postoperative outcomes assessed included superficial surgical site infections, deep surgical site infections, organ space infections, wound dehiscence, pneumonia, unplanned intubation, pulmonary embolism, urinary tract infection, renal failure, blood transfusion requirement, deep vein thrombosis, sepsis, cardiac arrest, extended length of hospital stay, readmission, reoperation, and mortality. Univariate and multivariate analyses were performed. In total, 10,331 patients underwent operative treatment for ankle fracture. Total 10,153 patients (98.3%) were not taking immunosuppressants and 178 (1.7%) were taking these medications. In multivariate analysis, patients taking immunosuppressants were at increased risk of pulmonary embolism (odds ratio [OR] 4.382; p = .041) and hospital readmission (OR 2.131; p = .021). Use of immunosuppressive medications is an independent risk factor for pulmonary embolism and readmission following ORIF for ankle fractures. Notably, no association with wound complications, infections, or sepsis was identified.

Republication of "Most Readmissions Following Ankle Fracture Surgery Are Unrelated to Surgical Site Issues: An Analysis of 5056 Cases"

Background

Ankle fracture surgeries are generally safe and effective procedures; however, as quality-based reimbursement models are increasingly affected by postoperative readmission, we aimed to determine the causes and risk factors for readmission following ankle fracture surgery.

Methods

Ankle fracture cases were identified from the prospectively collected American College of Surgeons National Surgical Quality Improvement Program from 2013 to 2014. Demographics, comorbidities, and fracture characteristics were collected. Rates of 30-day adverse events and readmissions were determined as well as the causes for readmission. Multivariable logistic regression analyses were performed to identify risk factors associated with having any adverse events and being readmitted within 30 days of surgery.

Results

There were 5056 patients included; 167 (3.3%) were open fractures. The rate of any postoperative adverse event was 5.2%. There were 116 unplanned readmissions, with a readmission rate of 2.3%. Of the 116 unplanned readmissions, 49 (42.2%) were for reasons related to the surgery or surgical site, with the most common causes being deep surgical site/hardware infections (12.9%), superficial site infections (11.2%), and wound disruption (6.9%). Most readmissions were for reasons unrelated to the surgical site (51.7%), including cardiac disorders (8.6%), pulmonary disorders (7.8%), and neurological/psychiatric disorders (6.9%). The cause of readmission was unknown for 6% of readmissions. With multivariable logistic regression, the strongest risk factors for readmission were a history of pulmonary disease (odds ratio [OR], 2.29), American Society of Anesthesiologists (ASA) class ≥3 (OR, 2.28), and open fractures (OR, 2.04) (all P < .05).

Conclusion

In this cohort of 5056 ankle fracture cases, 2.3% of patients were readmitted within 30 days, with at least 51.7% of all unplanned readmissions due to causes unrelated to the surgery or surgical site. Predictors of readmission included a history of pulmonary disease, higher ASA class, and open fractures. Based on these findings, we advocate close medical follow-up with nonorthopaedic providers after discharge for high-risk patients.

Level of Evidence

Level III.

Does the type of anesthesia (regional vs. general) represent an independent predictor for in-hospital complications in operatively treated malleolar fractures? A retrospective analysis of 5262 patients

PURPOSE

The impact of the type of anesthesia (regional vs. general anesthesia) on in-hospital complications in ankle fractures has not been thoroughly studied yet. Identifying factors that place patients at risk for complications following ankle fractures may help reduce their occurrence. The primary goal of this study was (1) to describe the cohort of patients and (2) to evaluate independent risk factors for complications during hospitalization.

METHODS

We analyzed patients from 2005 to 2019 with an operatively treated isolated fracture of the medial or lateral malleolus using a prospective national quality measurement database. Patients were selected based on international classifications (ICD) and national procedural codes (CHOP). Uni- and multivariate analysis were applied.

RESULTS

In total, we analyzed 5262 patients who suffered a fracture of the malleolus; 3003 patients (57%) had regional and 2259 (43%) general anesthesia. Patients with regional anesthesia were significantly older (51 vs. 46 years), but healthier (23 vs. 28% comorbidities) than patients who received general anesthesia. The in-hospital complication rate was not significantly lower in regional anesthesia (2.2% vs 3.0%). The type of anesthesia was not an independent predictor for complications while controlling for confounders.

CONCLUSION

Type of anesthesia was not an independent predictor of complications; however, higher ASA class, age over 70 years, fracture of the medial versus lateral malleolus, longer preoperative stay, and duration of surgery were significant predictors of complications. Patient and procedure characteristics, as well as changes in medical care and epidemiological changes along with patient requests, influenced the choice of the type of anesthesia.

The impact of surgical weight loss procedures on the risk of metachronous colorectal neoplasia: the differential effect of surgery type, sex, and anatomic location

Patients with prior colorectal polyps are at high risk for metachronous colorectal neoplasia, especially in the presence of obesity. We assessed the impact of 2 common bariatric surgeries, vertical sleeve gastrectomy and roux-n-Y gastric bypass, on the risk of colorectal neoplasia recurrence. This nationally representative analysis included 1183 postbariatric adults and 3193 propensity score-matched controls, who all had prior colonoscopy with polyps and polypectomy. Colorectal polyps reoccurred in 63.8% of bariatric surgery patients and 71.7% of controls at a mean follow-up of 53.1 months from prior colonoscopy. There was a reduced odds of colorectal polyp recurrence after bariatric surgery compared with controls (odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.58 to 0.83). This effect was most pronounced in men (OR = 0.58, 95% CI = 0.42 to 0.79), and post roux-n-Y gastric bypass (OR = 0.57, 95% CI = 0.41 to 0.79). However, the risk of rectal polyps or colorectal cancer remained consistent between groups. This study is the first to our knowledge to show a reduction in risk of polyp recurrence following bariatric surgery.

Enterobacter cloacae Infection After Surgical Treatment of Ankle Fractures, a Multicenter Observational Study

BACKGROUND

Infection is one of the challenging complications after open reduction and internal fixation for ankle fractures. Previously published case series conclude that Staphylococcus aureus is the most frequent causative microorganism. An unexpected increase in Enterobacter cloacae infections after this surgery was observed in a preliminary analysis of data at the promoting center of the study. In traumatology, its incidence has been reported in chronic osteomyelitis, prosthetic infections, septic osteoarthritis, open fractures in children and adults, and fractures other than the ankle. Because of this unexpected finding, we decided to perform this study to analyze the demographic and microbiological variables of acute osteosynthesis infection after ankle fracture and determine the distinctive features of the patients with E cloacae infection.

METHODS

We performed a retrospective multicenter study including 4 university hospitals. All patients diagnosed with acute osteosynthesis infection after ankle fracture fixation between January 2015 and December 2018 were included. We analyzed demographic data, type of fracture, surgical technique, and microorganisms responsible for the infection. We performed a descriptive statistical analysis of the variables. Univariate and multivariate regression analysis were performed to compare patients with E cloacae infection to patients with infection caused by other microorganisms.

RESULTS

A total of 65 patients were included. A predominance of polymicrobial infections (24.62%), followed by infections caused by S aureus (23.07%) and E cloacae (23.07%) was observed. When E cloacae isolated in polymicrobial infections were added, the incidence of E cloacae as a causative microorganism increased to 32.3%. Patients with E cloacae infection were older (64/53, P = .008) and had a higher requirement of negative-pressure therapy after surgical debridement (71%/40%, P = .017).

CONCLUSION

A high incidence of E cloacae infections was observed. Patients with E cloacae infection were generally older and required a higher use of negative-pressure therapy after debridement.

LEVEL OF EVIDENCE

Level V, mechanism-based reasoningr.

Ankle Fractures in Diabetic Patients: A Critical Analysis

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Patients with diabetes are at higher risk for complications after surgical fixation of unstable fractures due to impaired neurovascular functioning and wound-healing capabilities.

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Patients with uncontrolled diabetes have higher rates of complications when compared with patients with controlled diabetes.

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Despite higher rates of complications, operative fixation of unstable ankle fractures in diabetic patients reliably leads to a functional lower extremity with an overall lower rate of complications than nonoperative management.

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Operatively and nonoperatively managed ankle fractures in patients with diabetes should remain non-weight-bearing for an extended period of time.

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Discussion of risk of poor outcomes including deep infection, loss of reduction, return to the operating room, and risk of arthrodesis or amputation should be explicitly discussed with patients and families when managing unstable ankle fractures in diabetic patients.

Are Foot & Ankle Surgeons Being Adequately Compensated for Ankle Fractures? - An Analysis of Relative Value Units

The current relative value units (RVU)-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs bi-malleolar vs tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation for uni-malleolar versus bi-malleolar versus tri-malleolar ankle fractures. The 2012 to 2017 American College of Surgeons - National Surgical Quality Improvement Program files were queried using current Procedural Terminology (CPT) codes for patients undergoing open reduction internal fixation for uni-malleolar (CPT-27766,CPT-27769,CPT-27792), bi-malleolar (CPT-27814), and tri-malleolar (CPT-27822,CPT-27823) ankle fractures. A total of 7830 (37.2%) uni-malleolar, 7826 (37.2%) bi-malleolar and 5391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs, Mean RVU/minute and Reimbursement rate ($/min) and Mean Reimbursement/case for each fracture type were calculated and compared using Kruskal-Wallis tests. The mean total RVU for each fracture type was as follows: (1) Uni-malleolar: 9.99, (2) Bi-malleolar = 11.71 and 3) Tri-malleolar = 12.87 (p < .001). A statistically significant difference was noted in mean operative time (uni-malleolar = 63.2 vs bi-malleolar = 78.6 vs tri-malleolar = 95.5; p < .001) between the 3 groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar = $7.21/min vs bi-malleolar = $6.75/min vs tri-malleolar = $6.10; p < .001). The average reimbursement/case was $358, $420, and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Foot & ankle surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.

Thirty-Day Morbidity and Mortality in Patients With COPD Following Open Reduction and Internal Fixation for Rotational Ankle Fractures

Prior orthopedic literature has found patients with chronic obstructive pulmonary disease (COPD) to be at an increased risk for postoperative morbidity and mortality. Thus, the purpose of this study is to identify whether there are any differences in risk for 30-day morbidity or mortality following ORIF for ankle fractures between adult patients with COPD and without COPD. Patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database from 2006 to 2018. Patients were divided into 2 cohorts: non-COPD and COPD patients. In this analysis, demographics data, medical comorbidities, and thirty-day postoperative outcomes were analyzed between the 2 cohorts. Bivariate and multivariate analyses were performed. Of 10,346 total patients who underwent operative treatment for ankle fracture, 9986 patients (96.5%) did not have a history of COPD whereas 360 (3.5%) had COPD. Following adjustment to control for demographic and comorbidity data, relative to patients without COPD, those with COPD had an increased risk of pneumonia (odds ratio [OR] 4.601; p = .001), unplanned intubation (OR 3.085; p = .043), and hospital readmission (OR 1.828; p = .020). Patients with COPD did not have a statistically significant difference with regards to mortality (OR 2.729; p = .080). Adult patients with COPD are at an increased risk for pneumonia, unplanned intubation, and hospital readmission within 30 days following ORIF of ankle fractures compared to patients without COPD. Despite these risks, this is a relatively safe procedure for these patients and the presence of COPD alone should not serve as a barrier to surgery.

Efficacy of hook-type locking plate and partially threaded cancellous lag screw in the treatment of displaced medial malleolar fractures in elderly patients

INTRODUCTION

Traditionally, partially threaded cancellous lag screws (PTCS) are used for most medial malleolar fractures but are often challenging to execute in elderly patients because of the high risk of postoperative complications. Limited literature explores whether hook-type locking compression plates (LCPs) reliably offer better outcomes than PTCS in elderly patients. We aimed to compare the midterm radiologic and clinical outcomes between hook-type LCP and PTCS for medial malleolar fractures in an elderly population.

METHODS

We included 258 patients, aged 65 years and above, treated with either a hook-type locking plate (hook LCP group: 121 patients) or PTCS (screw group: 137 patients), and with follow-ups of at least 36 months in this retrospective study. Radiographic assessments included the union rate and interval to fracture union. Clinical assessment included the postoperative complications and revision procedures.

RESULTS

Although a significantly higher rate of comminuted fractures was observed in the hook LCP group than in the screw group (p < .001), no significant difference in the union rate was observed between the two groups (hook LCP group: 93.4% vs. screw group: 89.8%, p = .151), and a significantly shorter interval to union was observed in the hook LCP group (10.2 ± 7.0 vs. 12.3 ± 6.7 weeks, p = .015). There was a trend toward a lower rate of complications, including revision procedures, in the hook LCP group than in the screw group (19.9% vs. 28.5%, p = .107 and 6.6% vs. 13.8%, p = .074).

CONCLUSION

Hook-type LCP may be an alternative option for treating medial malleolar fractures with comminution in elderly patients.

Clinical outcomes in the surgical management of ankle fractures: A systematic review and meta-analysis of fibular intramedullary nail fixation vs. open reduction and internal fixation in randomized controlled trials

BACKGROUND

What level I evidence exists to support the use of FNF for surgical management of ankle fractures in high risk patients? The purpose of this study was to compare clinical outcomes following fibular intramedullary nail fixation (FNF) and open reduction and internal fixation (ORIF) of ankle fractures.

METHODS

A systematic review of the current literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Certainty of evidence reported according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Our primary hypothesis was that patients undergoing FNF procedures to manage an ankle fracture would have significantly higher patient reported outcome scores (PROs) than patients undergoing ORIF. Primary study outcome measures were validated PROs. Secondary outcome measures included complication rate, secondary surgery rate, and bony union.

RESULTS

The primary outcome analysis revealed no evidence of a significant effect difference on Olerud and Molander Ankle Score (OMAS) PRO and no evidence of statistical heterogeneity. Secondary outcome analysis revealed a significant 0.30 (0.12-0.74 95CI) relative risk reduction for complications in FNF (P = 0.008). No evidence of an effect difference for bony union. The GRADE certainty of the evidence was rated as low for bone union. No evidence of reporting bias was appreciated. Sensitivity analyses did not significantly alter effect estimates.

CONCLUSION

This systematic review and meta-analysis restricted to evidence derived from RCTs revealed that the quality of evidence is reasonably strong and likely sufficient to conclude: (1) there is likely no clinically important difference between FNF and ORIF up to 12 months post-operatively, as defined by OMS (moderate certainty); (2) surgeons may reasonably expect reduced complications in 14 out of every 100 patients treated with FNF (moderate certainty); (3) there is likely no difference in bony union (low certainty). Future studies should investigate more patient-centered outcomes and if short-term findings are durable over time if these findings apply to lower risk populations.

LEVEL OF EVIDENCE

Systematic review and meta-analysis of level I evidence.

An Evaluation of Basic Demographic Characteristics in Foot and Ankle Surgery From the American College of Surgeons National Surgical Quality Improvement Program

It has become increasingly prevalent in the foot and ankle surgical literature to evaluate outcomes and trends obtained from large databases. The objective of this investigation was to provide a broad descriptive analysis and compare basic demographic characteristics relating to foot and ankle surgery within the American College of Surgeons National Surgical Quality Improvement Program database. The 16 Current Procedural Terminology® (CPT) codes available within this database pertaining to foot and ankle surgery were studied. Several CPT codes were observed to be more frequently associated with male gender: 27650 (Achilles tendon repair), 27698 (Lateral ankle reconstruction), 27702 (Total ankle arthroplasty), 27766 (ORIF medial malleolus fracture), 27792 (ORIF lateral malleolus fracture), and 28805 (Metatarsal amputation). Several other CPT codes were observed to be more frequently associated with female gender: 27658 (Primary peroneal tendon repair), 27814 (ORIF bimalleolar fracture), 27822 (ORIF trimalleolar ankle fracture without posterior lip fracture), and 27823 (ORIF trimalleolar ankle fracture with posterior lip fracture). The elective case designation was observed to be more frequently associated with male gender (65.4 vs 58.7%; p < .001). These data have potential use in the development and interpretation of quality improvement/performance improvement protocols at individual health care delivery centers, as well as the interpretation of other published investigations utilizing this database.

High-risk ankle fractures in high-risk older patients: to fix or nail?

INTRODUCTION

Optimal treatment of high-risk ankle fractures in older, comorbid patients is unknown. Results of open reduction internal fixation (ORIF) versus tibiotalocalcaneal (TTC) fusion nailing for the treatment of high-risk geriatric ankle fractures were investigated.

MATERIALS AND METHODS

Results of ORIF versus TTC fusion nailing were evaluated via retrospective case-control cohort study of 60 patients over age 50 with an open ankle fracture or one with at least 50% talar subluxation and at least 1 high-risk comorbidity: diabetes mellitus (DM), peripheral vascular disease, immunosuppression, active smoking, or a BMI > 35. The primary outcome was reoperation rate within 1-year post-surgery. Secondary outcomes include infection, peri-implant fracture, malunion/nonunion, mortality, length of stay, disposition, and hospital acquired complications.

RESULTS

Mean age was 71 (ORIF) and 68 (TTC). 12/47 (25.5%) ORIF cases were open fractures versus 4/14 (28.6%) with TTC. There were no significant differences between ORIF and TTC in 1-year reoperation rates (17% vs 21.4%), infection rates (12.8% vs 14.3%), or union rates (76.% vs 85.7%), respectively. One TTC patient sustained a peri-implant fracture treated nonoperatively. There were no significant differences in medical risk factors between groups other than a higher rate of DM in the TTC group, 42.6% vs 78.6%, p = 0.02. Incomplete functional outcome data in this challenging patient cohort precluded drawing conclusions.

CONCLUSION

ORIF and TTC fusion nailing result in comparable and acceptable reoperation, infection, and union rates in treating high-risk ankle fractures in patients over 50 with at least 1 major comorbidity for increased complications; further study is warranted.

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.

Male sex, Gustillo-Anderson type III open fracture and definitive external fixation are risk factors for a return to the or following the surgical management of geriatric low energy open ankle fractures

INTRODUCTION

Open ankle fractures in geriatric (age > 60 years) patients are a source of significant morbidity and mortality. Surgical management includes plate and screw fixation (ORIF), retrograde hindfoot nail (HFN), definitive external fixation (ex-fix) and below knee amputation. However, each modality poses unique challenges for this population. We sought to identify predictors of unplanned OR and short-term mortality after geriatric open ankle fractures managed by our service.

MATERIALS AND METHODS

In an IRB-approved protocol, we evaluated patients over 60 years of age managed for a low energy open ankle/distal tibia pilon fracture by trauma fellowship-trained surgeons from a single academic department that covers two level I trauma centers. Our primary outcome was an unplanned return to the OR. Secondary outcomes were a 90-day "event", defined as an all-cause hospital readmission or mortality, and 1-year mortality. Differences with a p-value < 0.1 measured on univariate analysis were evaluated using a multivariable logistic regression to identify independent outcome predictors.

RESULTS

A total of 113 (60 ORIF, 36 HFN, 11 ex-fix, 6 amputations) were performed. Cohort mean age was 75.2 ± 9.8 years, and 31 patients (27.4%) were male. Mean age-adjusted charlson comorbidity index was 5.5 ± 2.0. Significant independent predictors of an unplanned return to the OR were male sex (OR 4.4, 95% CI 1.3 to 15.4), Gustilo Type III open fracture (OR 4.9, 95% CI 1.5 to 17.5) and ex-fix (OR 15.6, 95% CI 2.7 to 126.3). Independent predictors of a 90-day "event" were walker/minimal ambulation (OR 3.5, 95% CI 1.3 to 10.4), surgical site infection (OR 4.8, 95% CI 1.8 to 13.8) and reduced BMI (OR 0.9, 95% CI 0.9 - 0.99), while independent predictors of 1-year mortality were age (OR 1.1, 95% CI 1.003 to 1.2), ACCI (OR 1.4, 95% CI 1.02 to 2.0) and walker/minimal ambulator (OR 7.5, 95% CI 1.7 to 53) CONCLUSIONS: Host factors, particularly pre-operative mobility, were most predictive of 90-day event and 1-year mortality. Only definitive external fixation was found to influence patient morbidity as a significant predictor of unplanned OR. However, no surgical modality had any influence on short-term readmission or survival.

COVID-positive ankle fracture patients are at increased odds of perioperative surgical complications following open reduction internal fixation surgery

INTRODUCTION

Ankle fractures have continued to occur through the COVID pandemic and, regardless of patient COVID status, often need operative intervention for optimizing long-term outcomes. For healthcare optimization, patient counseling, and care planning, understanding if COVID-positive patients undergoing ankle fracture surgery are at increased risk for perioperative adverse outcomes is of interest.

METHODS

The COVID-19 Research Database contains recent United States aggregated insurance claims. Patients who underwent ankle fracture surgery from April 1st, 2020 to June 15th, 2020 were identified. COVID status was identified by ICD coding. Demographics, comorbidities, and postoperative complications were extracted based on administrative data. COVID-positive versus negative patients were compared with univariate analyses. Propensity-score matching was done on the basis of age, sex, and comorbidities. Multivariate regression was then performed to identify risk factors independently associated with the occurrence of 30-day postoperative adverse events.

RESULTS

In total, 9,835 patients undergoing ankle fracture surgery were identified, of which 57 (0.58%) were COVID-positive. COVID-positive ankle fracture patients demonstrated a higher prevalence of comorbidities, including: chronic kidney disease, diabetes, hypertension, and obesity (p<0.05 for each). After propensity matching and controlling for all preoperative variables, multivariate analysis found that COVID-positive patients were at increased risk of any adverse event (odds ratio [OR] = 3.89, p = 0.002), a serious adverse event (OR = 5.48, p = 0.002), and a minor adverse event (OR = 3.10, p = 0.021).

DISCUSSION

COVID-positive patients will continue to present with ankle fractures requiring operative intervention. Even after propensity matching and controlling for patient factors, COVID-positive patients were found to be at increased risk of 30-day perioperative adverse events. Not only do treatment teams need to be protected from the transmission of COVID in such situations, but the increased incidence of perioperative adverse events needs to be considered.

Outcomes of orthopaedic trauma surgery in COVID-19 positive patients

Objectives:

To investigate outcomes for operative orthopaedic trauma in patients who tested positive for coronavirus disease 2019 (COVID-19) during the height of the COVID-19 pandemic in New York.

Design:

Retrospective case series.

Setting:

Urban Level-1 academic trauma center.

Patients/participants:

Thirteen patients diagnosed with COVID-19 who underwent surgical management for orthopaedic trauma between January 21, 2020 and May 11, 2020.

Intervention:

Does not apply to this study.

Main outcome measurements:

Complications including death, coma lasting more than 24 hours, prolonged mechanical ventilation, unplanned intubation, blood transfusion, postoperative pneumonia, cerebrovascular event, thromboembolic event, myocardial infarction, urinary tract infection, acute renal failure, septic shock, return to the operating room, wound dehiscence, surgical site infection, graft/prosthesis/flap failure, and peripheral nerve injury.

Results:

Two (18%) patients had symptoms of COVID-19 (cough, shortness of breath, fevers, chills, nausea/vomiting, diarrhea, abdominal cramps/pains) on admission. Average length of stay (standard deviation) was 6.6 (4.31) days. Average time to follow up was 29 (10.77) days. Three (27%) patients developed pneumonia postoperatively and 1 (9%) underwent unplanned intubation. One (9%) patient was intubated for greater than 48 hours. Two (18%) patients developed postoperative deep venous thromboembolism. Three (27%) patients developed acute renal failure postoperatively. Six (55%) patients underwent blood transfusion intraoperatively or postoperatively. Two (18%) patients died postoperatively.

Conclusion:

In this small series surgical management in Coronavirus-19 positive patients with skeletal injuries was successfully accomplished with patient anticoagulation, hematologic, and pulmonary status in mind. Therapeutic anticoagulation and patient hematologic status were optimized prior to the operating room to minimize development of venous thromboembolism and avoid blood transfusion.

Level of evidence:

Level IV prognostic

Insulin Dependence Increases the Risk of 30-Day Postoperative Complications Following Ankle Fracture Surgery in Patients With Diabetes Mellitus

Patients with diabetes mellitus that undergo ankle fracture surgery have higher rates of postoperative complications compared to patients without diabetes mellitus. We evaluated the rate of complications in insulin-dependent diabetes mellitus patients, non-insulin-dependent diabetes mellitus patients, and patients without diabetes in the 30-day postoperative period following ankle fracture surgery. We also analyzed hospital length of stay, unplanned readmission, unplanned reoperation, and death. Patients who underwent operative management for ankle fractures between 2012 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program® database using Current Procedural Terminology codes. Multiple logistic regression was implemented. Adjusted odds ratios were calculated along with the 95% confidence interval. A total of 19,547 patients undergoing ankle surgery were identified from 2012 to 2016. Of these patients, 989 (5.06%) had insulin-dependent diabetes mellitus, 1256 (6.43%) had noninsulin-dependent diabetes mellitus, and 17,302 (88.51%) did not have diabetes mellitus. Compared to patients without diabetes, patients with insulin-dependent diabetes mellitus had significantly greater adjusted odds of superficial surgical site infections, deep surgical site infections, osteomyelitis, wound dehiscence, pneumonia, unplanned intubation, mechanical ventilation, urinary tract infection, cardiac arrest, bleeding requiring transfusion, sepsis, hospital length of stay, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery. We demonstrate that insulin-dependent diabetes mellitus is a strong predictor of 30-day postoperative complications, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery.

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.

Investigation of the Effect of Bone Mineral Density on the Postoperative Outcome of Ankle Fractures in Elderly Patients

BACKGROUND

The association between ankle fractures in elderly patients and low bone mineral density (BMD) has recently been recognized, but the effect of BMD on the postoperative outcome of these fractures is unknown. The aim of this study was to investigate the effect of BMD on the postoperative outcome of ankle fractures in elderly patients to evaluate the need for BMD screening.

METHODS

We retrospectively reviewed 48 patients aged 65 years or older who had ankle fractures and underwent dual-energy x-ray absorptiometry to assess BMD after surgical treatment of the fracture. Postoperative outcomes were assessed using the Olerud-Molander Ankle Score (OMAS), visual analog scale (VAS) score for pain, Kellgren and Lawrence (K&L) grading scale score, and quality of fracture reduction. The correlation between the BMD and the outcome measures at 12 months after surgery was analyzed using the Pearson correlation coefficient.

RESULTS

The mean absolute value of BMD was 0.6 ± 0.1 g/cm² (T-score, -1.5 ± 1.2) at the femoral neck and 0.8 ± 0.2 g/cm² (T-score, -1.2 ± 1.5) at the lumbar spine. Osteoporosis was present in 33% of female patients and in 11% of male patients. At 12 months after surgery, the OMAS was 70 ± 17 and the VAS score for pain was 18 ± 17. Of the patients, 20, 21, 5, 1, and 1 had K&L grades of 0, 1, 2, 3, and 4, respectively. None of the clinical and radiographic outcome measures were correlated with the BMD values of the patients.

CONCLUSION

The postoperative outcome of the ankle fractures in elderly patients at 12 months after surgery showed no correlation with femoral neck or lumbar spine BMD at the time of fracture.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Is supplemental regional anesthesia associated with more complications and readmissions after ankle fracture surgery in the inpatient and outpatient setting?

BACKGROUND

There is concern that regional anesthesia is associated with increased risk of complications, including return to the hospital for uncontrolled pain once the regional anesthetic wears off.

METHODS

Retrospective database review of patients who underwent open reduction and internal fixation of a closed ankle fracture from 2014-16 who received general anesthesia alone (GA) or general anesthesia plus regional anesthesia (RA).

RESULTS

9459 patients met inclusion criteria. Patients in the RA group had significantly longer operative duration in both inpatient (GAI=71min vs RAI=79min, p=0.002) and outpatient setting (GAO=66min vs RAI=72min, p<0.001), lower overall LOS (GA=1.7 days vs RA=1.1 days, p<0.001), and higher readmission rate for pain (RAO=4 [0.3%] vs GAO=1 [0.0%], p=0.007).

CONCLUSIONS

Patients who received supplemental regional anesthesia had shorter hospital LOS, increased operative time, and increased readmission rates for rebound pain. However, the small number of patients needing readmission are not clinically significant demonstrating that regional anesthesia is safe, effective and readmission for rebound pain should not be a concern.

LEVEL OF EVIDENCE

III.

Rising Incidence of Colorectal Cancer in Young Adults Corresponds With Increasing Surgical Resections in Obese Patients

Strong evidence links obesity to esophageal cancer (EC), gastric cancer (GC), colorectal cancer (CRC), and pancreatic cancer (PC). However, national-level studies testing the link between obesity and recent temporal trends in the incidence of these cancers are lacking.

Timing of Early Complications Following Open Reduction and Internal Fixation of Closed Ankle Fractures

Introduction: There is increasing interest in the early identification and treatment of adverse medical events following orthopaedic procedures. The purpose of this study is to characterize the timing of 8 early adverse events following open reduction and internal fixation of closed fractures of the ankle. Methods: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program. A total of 17 318 patients undergoing open reduction and internal fixation of closed ankle fractures were identified. 48.4% of patients were discharged on the day of surgery. For each of 8 different early adverse events, the median postoperative day of diagnosis, interquartile range for day of diagnosis, and middle 80% for day of diagnosis were determined. Timing was compared between unimalleolar and bi-/trimalleolar fractures and between inpatient and outpatient procedures. Results: The median day of diagnosis (and interquartile range; middle 80%) for myocardial infarction was 2 (1-5; 0-17), pneumonia 3 (2-7; 1-19), acute kidney injury 6.5 (2-18; 2-20), urinary tract infection 7 (2-14; 0-24), pulmonary embolism 10 (3-21; 0-27), sepsis 15 (4-22; 1-28), deep vein thrombosis 17 (10-22; 3-27), and surgical site infection 19 (14-25; 8-28). Patients with bi-/trimalleolar fractures had earlier occurrence of myocardial infarction (day 2 vs 10), urinary tract infection (day 6.5 vs 9.5), and sepsis (day 10 vs 20.5). Inpatients had later occurrence of acute kidney injury (day 7 vs 3), but earlier occurrence of urinary tract infection (day 6 vs 15). Conclusions: These precisely described time periods for occurrence of specific adverse events enable heightened awareness among orthopaedic surgeons during the first month following open reduction and internal fixation of the ankle. Orthopaedic surgeons should have the lowest threshold for testing for each adverse event during the time period of greatest risk.Levels of Evidence: Therapeutic, Level III: Retrospective cohort study.

Peri-incisional perfusion does not differ between running versus interrupted Allgöwer-Donati suture technique in ankle fracture surgery: a pilot randomized controlled trial of wound perfusion

Objectives:

To compare peri-incisional perfusion, perfusion impairment and wound closure time between the conventional interrupted Allgöwer-Donati (IAD) technique and a modified running Allgöwer-Donati (RAD) technique in ankle fracture surgery.

Design:

Prospective, randomized controlled clinical trial.

Setting:

Level I and II trauma centers.

Patients:

Twenty-five healthy adults with ankle fractures (AO/OTA 44-A, 44-B, or 44-C) between November 2017 and December 2018. (Of 26 patients enrolled in this study, 1 was lost to follow-up.)

Intervention:

Participants were randomized into the IAD or the RAD group (13 patients each). All participants were followed for at least 3 months after surgery to assess for wound complications.

Main Outcome Measurements:

Skin perfusion was assessed immediately after wound closure with laser-assisted indocyanine green angiography. Wound closure time, mean incision perfusion, and mean perfusion impairment were measured and compared with analysis of variance. Alpha = 0.05.

Results:

The RAD technique was significantly faster in terms of mean (± standard deviation) wound closure time (6.2 ± 1.4 minutes) compared with the IAD technique (7.3 ± 1.4 minutes) (P = 0.047). We found no differences in mean incision perfusion and mean perfusion impairment (all, P > 0.05).

Conclusion:

The IAD and RAD techniques resulted in similar peri-incisional perfusion and perfusion impairment. Closure time was significantly shorter for the RAD technique compared with the IAD technique.

Level of Evidence:

I

Current concepts and challenges in managing ankle fractures in the presence of diabetes: A systematic review of the literature

BACKGROUND

Ankle fractures in diabetic patients are known to have an increased morbidity. This systematic review aims to evaluate the current evidence in terms of risk profile and inform treatment options.

METHODS

Following the methodology of the Cochrane collaboration, an extensive literature search was conducted. Outcomes included, complications, operative and non-operative management and early weight-bearing.

RESULTS

A total of 40 studies were included. Complication rates were higher in diabetic patients and more so in poorly controlled diabetes, IDDM, or "complicated" diabetes. Supplementary fixation was associated with lower complication rates. Regarding early weight-bearing, similar results to non-diabetics in the stable fracture pattern were found providing there was no evidence of neuropathy.

CONCLUSION

Diabetes, especially complicated diabetes, presents an increased risk of complications. However non operative management of diabetic ankle fractures do poorly, and with the use of 'ORIF plus' techniques there is no increase in complications from early fixation. The use of external fixation for definitive fixation should be minimised as it is associated with high complication rates.

Risk Factors for Short-Term Complication After Open Reduction and Internal Fixation of Ankle Fractures: Analysis of a Large Insurance Claims Database

Although fractures of the ankle are common injuries treated by surgical podiatrists and orthopaedic surgeons specializing in foot and ankle surgery, postoperative complications can occur, often imposing an economic burden on the patient. As health care in the United States moves toward value-based care, cost reduction has primarily focused on reducing complications and unplanned episodes of care. We used a large modern database of insurance claims to examine patterns of complications after open reduction internal fixation of ankle fractures, identifying diabetes mellitus and history of myocardial infarction as risk factors for postoperative infection within 30 days of surgery. Lateral malleolar repair was less likely to lead to infection, or need for repeated surgery, than was medial malleolar fracture repair. Diabetes mellitus, neuropathy, and chronic obstructive pulmonary disease were associated with development of postoperative cellulitis. Patients with a history of cerebrovascular accident were more likely to return to the emergency department or to have a pulmonary embolism. Male sex, presence of lupus, and increased age were associated with repeat surgery.

Predicting Length of Stay and Readmissions After an Ankle Fracture Using a Risk Stratification Tool (STTGMA)

OBJECTIVES

To determine the usefulness of a validated trauma triage score to stratify short-term outcomes including hospital length of stay (LOS), in-hospital complications, discharge location, and rate of readmission after an ankle fracture.

DESIGN

Retrospective cohort.

SETTING

Level 1 trauma center.

PATIENTS

Four hundred fifteen patients, age ≥55 with 431 ankle fractures.

INTERVENTION

Closed or open reduction.

MAIN OUTCOME MEASUREMENTS

Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA).

RESULTS

Of the 415 patients, 38% were male, 72% were white, and the mean age was 66 years. The mean LOS was 4.4 days, and this increased from 2.6 days in the minimal-risk group to 11.8 days in the high-risk group (P < 0.001). Similarly, 74% of minimal-risk patients were discharged home versus 13% of high-risk patients (P < 0.001). There were 19 readmissions (4.6%) within 30 days, ranging from 1.5% to 10% depending on the risk cohort (P = 0.006). Seventy-three patients (18%) experienced an in-hospital complication. On multiple linear regression, moderate- and high-risk STTGMA stratification was predictive of a longer hospital LOS, and moderate-risk STTGMA stratification was predictive of subsequent readmission after injury.

CONCLUSIONS

Calculation of the STTGMA score is helpful for stratifying patients according to hospital LOS and readmission rates, which have substantial bearing on resource utilization and cost of care. The STTGMA tool may allow for effective identification of patients to potentially ameliorate these common issues and to inform payers and policymakers regarding patients at risk for greater costs of care.

LEVEL OF EVIDENCE

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

Factors affecting emergency department visits, readmissions, and reoperations within 30 days of ankle fracture surgery- an institutional retrospective study

INTRODUCTION

With the U.S. healthcare system focused on value of care, providers and hospitals are increasingly measured by factors that increase patient care and decrease healthcare cost. Early postoperative adverse events not only increase healthcare cost, but also illuminate areas of potential improvement in patient care. This large single institution study aims to delineate factors that may influence emergency department visits, admissions, and reoperations within 30 days of ankle fracture surgery.

METHODS

This retrospective review of patients at a Level 1 trauma center evaluated 30-day outcomes after ankle fracture surgery over a 4-year period (2015-2018). A total of 596 patients were included in final analysis. The primary outcome measures assessed were emergency department (ED) visits within 30 days, unplanned readmissions within 30 days and unplanned return to the operating room (OR) within 30 days. Patient and injury characteristics were investigated as potential factors related to these 30-day outcomes. Multiple linear regression was used for outcomes.

RESULTS

Forty-three (7.2%) patients visited the ED within thirty days, 30 (5.0%) patients were readmitted within thirty days, and 10 (1.7%) patients requiring reoperation within thirty days. Sex, insurance status, several comorbidities, smoking status, and fracture type/location were not found to be significantly related to 30-day events. Age less than 45 was a significant risk factor for returning to the ED within 30 days (RR 2.1, p = 0.016). Open fractures were more likely to require unplanned reoperation than closed fractures (RR 5.7, p<0.01). Fifty-four percent of ED visits were for postoperative pain, while 37% of ED visits and 60% of readmissions within 30 days were for issues unrelated to the ankle fracture.

CONCLUSIONS

Age less than 45 years old was a risk factor for early ED visits, highlighting a potential "at-risk" population after ankle fracture surgery. Furthermore, many of the ED visits (37%) and readmissions (60%) were unrelated to the ankle fracture suggesting unnecessary healthcare utilization may be avoided with protocols that increase emphasis on reconditioning and optimization of comorbidities.

Comorbidities Associated With Poor Outcomes Following Operative Hammertoe Correction in a Geriatric Population

Background:

Although complications following hammertoe correction surgery are rare, older patients with comorbid conditions are often considered poorer operative candidates compared with younger, healthier patients because of a suspected increased risk of adverse outcomes. The aim of this study was to determine if the presence of multiple comorbidities was associated with increased complications or unsuccessful patient-reported outcomes following operative hammertoe correction in geriatric patients.

Methods:

Prospectively collected data was reviewed on 78 patients aged 60 years or older who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, and postoperative complications were recorded. Patient-reported outcomes were assessed using preoperative and postoperative visual analog scale for pain and Short Form Health Survey Physical and Mental Component Summary with 1 year of follow-up. Patients were divided into 2 groups based on number of comorbidities (0 or 1 vs > 2) and then compared. The average age of patients was 69.4 years and the prevalence of comorbidities in the study population was as follows: 11.5% smokers, 25.6% on blood thinners, 15.4% with rheumatoid arthritis, 7.7% with diabetes mellitus, 2.6% with peripheral arterial disease, 6.4% with chronic obstructive pulmonary disease, 11.5% with coronary artery disease, and 23.1% with osteoporosis.

Results:

Fifty-three patients (67.9%) had 0 or 1 comorbidity and 25 (32.1%) had 2 or more comorbidities. Compared to the 0 or 1 comorbidity group, the presence of multiple comorbidities was associated with an adjusted odds ratio (OR) for superficial wound infection of 4.18 (P = .045) and deformity recurrence requiring surgery OR of 23.15 (P = .032). Patient-reported outcomes were similar between comorbidity groups.

Conclusions:

This study further informs foot and ankle specialists to maintain increased surveillance for postoperative complications and unsuccessful outcomes in patients with multiple comorbidities. Although geriatric patients still report significant improvements in both pain and function, patients with underlying medical conditions should be counseled about their increased risks when pursuing operative hammertoe correction.

Level of Evidence:

Level III, retrospective comparative series.

Ankle fractures in diabetic patients

Surgical complications are more common in patients with complicated diabetes (presence of inner organ failure, neuropathy).

Of all patients undergoing ankle fracture fixation, approximately 13% are diabetic and 2% have complicated diabetes mellitus.

Non-operative management of ankle fractures in patients with complicated diabetes results in an even higher rate of complications.

Insufficient stability of ankle fractures (treated operatively, or non-operatively) can trigger Charcot neuroarthropathy, and result in bone loss, deformity, ulceration, and the need for amputation.

Rigid fixation is recommended. Hindfoot arthrodesis (as primary procedure or after failed ankle fracture management) can salvage the limb in approximately 80% of patients.

Early protected weight bearing can be allowed, provided rigid fixation without deformity has been achieved.

Cite this article: EFORT Open Rev 2020;5:457-463. DOI: 10.1302/2058-5241.5.200025

Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England

BACKGROUND

Evidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contact-casting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients.

METHODS

Patients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence.

RESULTS

Over the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0-19.5% < 60 years; 15.2-17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved.

CONCLUSIONS

Despite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contact-casting, in line with recent evidence.

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.

Outpatient surgery in patients with ankle fractures minimises hospital admissions and utilisation of healthcare resources

Purpose

The recent outbreak of the novel coronavirus (SARS-CoV-2) has emphasised the need to minimise hospital admissions and utilisation of healthcare resources. The purpose of this study was to examine the outcomes of an outpatient surgery protocol for acute closed ankle fractures.

Methods

In this retrospective study, 262 patients underwent outpatient surgery for their closed ankle fractures at our level-1 trauma centre. A total of 196 patients met our inclusion criteria and were ultimately included in the final analysis. Our primary outcomes’ measures included post-operative admission to the emergency department within 30 days after surgery and unplanned hospital readmission within 30 days after surgery. Our secondary outcome measure included the incidence of surgical site infection (SSI) within 12 weeks after surgery.

Results

Thirty-two patients (16.3%) had an unplanned emergency department visit within 30 days of fracture fixation and two patients (1.0%) required hospital readmission within 30 days of their surgery. Sixteen patients (8.2%) developed SSI, which included 11 (5.6%) superficial and five (2.6%) deep infections.

Conclusion

Strategic outpatient management of acute closed ankle fractures is associated with acceptable rates of unplanned emergency department visits, hospital readmissions, and SSIs. In the context of the recent SARS-CoV-2 outbreak, outpatient management of these injuries may aide in the mitigation of nosocomial infections and the preservation of finite healthcare resources.

Operative Incision and Drainage for Perirectal Abscesses: What Are Risk Factors for Prolonged Length of Stay, Reoperation, and Readmission?

BACKGROUND

Perirectal abscess is a common problem. Despite a seemingly simple disease to manage, clinical outcomes of perirectal abscesses can vary significantly given the wide array of patients who are susceptible to this disease.

OBJECTIVE

Our aims were to evaluate the outcomes after operative incision and drainage for perirectal abscess and to examine factors associated with length of stay, reoperations, and readmissions.

DESIGN

This was a retrospective analysis of the National Surgical Quality Improvement Program database.

SETTINGS

The study was conducted with hospitals participating in the surgical database.

PATIENTS

Adult patients undergoing outpatient perirectal abscess procedures from 2011 through 2016 were included.

MAIN OUTCOME MEASURES

Study outcomes were length of stay, reoperation, and readmission.

RESULTS

We identified 2358 patients undergoing incision and drainage for perirectal abscesses. Approximately 35% of patients required hospital stay. Reoperations occurred in 3.4%, with median time to reoperation of 15.5 days. The majority of reoperations (79.7%) were performed for additional incision and drainage. Readmissions rate was 3.0%, with median time to readmission of 10.5 days. Common indications for readmissions included recurrent/persistent abscess (41.4%) and fever/sepsis (8.6%). Risk factors for hospitalization in multivariable analysis were preoperative sepsis, bleeding disorder, and non-Hispanic black and Hispanic races. For reoperations, risk factors included morbid obesity, preoperative sepsis, and dependent functional status. Lastly, for readmissions, female sex, steroid/immunosuppression, and dependent functional status were significant risk factors.

LIMITATIONS

The study was limited by its retrospective analysis and potential selection bias in decisions on hospital stay, reoperation, and readmission.

CONCLUSIONS

Suboptimal outcomes after outpatient operative incision and drainage for perirectal abscesses are not uncommon in the United States. In the era of value-based care, additional work is needed to optimize use outcomes for high-risk patients undergoing perirectal incision and drainage. Strategies to prevent inadequate drainage at the time of the initial operative incision and drainage (ie, use of imaging modalities and thorough examination under anesthesia) are warranted to improve patient outcomes. See Video Abstract at http://links.lww.com/DCR/B229. INCISIÓN Y DRENAJE QUIRÚRGICOS DE ABSCESOS PERIRRECTALES: CUALES SON LOS FACTORES DE RIESGO PARA UNA ESTADÍA PROLONGADA, REINTERVENCIÓN Y READMISION?: Los abscesos perirrectales son un problema frecuente. A pesar que parecen ser una afección aparentemente simple de manejar, los resultados clínicos de la incisión y drenaje quirúrgicos pueden variar significativamente dada la amplia variedad de pacientes susceptibles de sufrir esta afección.Evaluar los resultados después de la incisión y el drenaje quirúrgicos de un absceso perirrectal y analizar los factores asociados con la duración de la hospitalización, la reoperación y la readmisión.Análisis retrospectivo de la base de datos del Programa Americano de Mejora de la Calidad Quirúrgica.Hospitales que participan en la base de datos quirúrgica.Pacientes adultos sometidos a incisión y drenaje quirúrgico ambulatorio de un absceso perirrectal desde 2011 hasta 2016.Los resultados del estudio fueron la duración de la hospitalización, la reoperación y el reingreso.Fueron estudiados 2,358 pacientes sometidos a incisión y drenaje por abscesos perirrectales. Aproximadamente el 35% de los pacientes requirieron hospitalización. Las reoperaciones ocurrieron en 3.4% con una mediana de tiempo de reoperación de 15.5 días. La mayoría de las reoperaciones (79.7%) se realizaron para una incisión y drenaje adicionales. La tasa de reingreso fue del 3.0% con una mediana de tiempo de reingreso de 10.5 días. Las indicaciones comunes para los reingresos incluyeron abscesos recurrentes / persistentes (41.4%) y fiebre / sepsis (8.6%). Los factores de riesgo para la hospitalización en el análisis multivariable fueron sepsis preoperatoria, trastorno hemorrágico, raza negra no hispánica y raza hispana. Para las reoperaciones, los factores de riesgo incluyeron obesidad mórbida, sepsis preoperatoria y estado funcional dependiente. Por último, para los reingresos, el sexo femenino, uso de corticoides / inmunosupresores y un estadío funcional dependiente fueron factores de riesgo significativos.Análisis retrospectivo y posible sesgo de selección en las decisiones sobre hospitalización, reoperación y reingreso.Un resultado poco satisfactorio después de la incisión quirúrgica el drenaje de abscesos perirrectales ambulatoriamente no son infrecuentes en los Estados Unidos. En la era de la atención basada en los resultados, se necesita mucho más trabajo para optimizar los mismos en pacientes de alto riesgo sometidos a incisión y drenaje perirrectales. Las estrategias para prevenir el drenaje inadecuado en el momento de la incisión quirúrgica inicial y el drenaje (es decir, el uso de modalidades de imágenes, un examen completo bajo anestesia) son una garantía para mejorar los resultados en estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B229.

Refining Risk-Adjustment of 90-Day Costs Following Surgical Fixation of Ankle Fractures: An Analysis of Medicare Beneficiaries

As the current healthcare model transitions from fee-for-service to value-based payments, identifying cost-drivers of 90-day payments following surgical procedures will be a key factor in risk-adjusting prospective bundled payments and ensuring success of these alternative payment models. The 5% Medicare Standard Analytical Files data set for 2005-2014 was used to identify patients undergoing open reduction and internal fixation (ORIF) for isolated unimalleolar, bimalleolar, and trimalleolar ankle fractures. All acute care and post-acute care payments starting from day 0 of surgery to day 90 postoperatively were used to calculate 90-day costs. Patients with missing data were excluded. Multivariate linear regression modeling was used to derive marginal cost impact of patient-level (age, sex, and comorbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy, and syndesmotic fixation), and state-level factors on 90-day costs after surgery. A total of 6499 patients were included in the study. The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 ± $1060. Individuals aged <65 or ≥70 years had significantly higher costs. Procedure-level factors associated with significant marginal cost increases were inpatient surgery (+$5577), trimalleolar fracture (+$1082), and syndesmotic fixation (+$2822). The top 5 comorbidities with the largest marginal cost increases were chronic kidney disease (+$8897), malnutrition (+$7908), obesity (+$5362), cerebrovascular disease/stroke (+$4159), and anemia (+$3087). Higher costs were seen in Nevada (+$6371), Massachusetts (+$4497), Oklahoma (+$4002), New Jersey (+$3802), and Maryland (+$3043) compared with Michigan. With the use of a national administrative claims database, the study identifies numerous patient-level, procedure-level, and state-level factors that significantly contribute to the cost variation seen in 90-day payments after ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in patients with fractures.

The safety of foot and ankle procedures at an ambulatory surgery center

Background

This study evaluates the safety of foot and ankle outpatient surgeries at a freestanding ambulatory surgery centers.

Methods

A total of 1352 cases were evaluated for adverse events in a retrospective review of all foot and ankle cases performed over a 5-year period at a single center.

Results

The rate of adverse events was 2.3%, with 31 identified over the 5-year period (23 infections, 5 symptomatic thromboembolisms, 3 postoperative hospital transfers).

Discussion

The rate of postoperative adverse events in outpatient foot and ankle procedures is low. These surgeries can be performed safely in an outpatient setting at an ASC.

Level of evidence

Level IV, Case Series.

The Impact of Metabolic Syndrome on 30-Day Outcomes Following ORIF for Ankle Fractures

Introduction: Metabolic syndrome (MetS) is associated with significant postoperative morbidity. Despite an increasing prevalence of MetS in the US population, its impact on postoperative outcomes following ankle fractures remains limited. Materials and Methods: The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program database was queried for patients undergoing open reduction with internal fixation (ORIF) for ankle fractures using Current Procedural Terminology codes: 27766, 27769, 27792, 27814, 27822, and 27823. The study cohort was divided into 2 groups: MetS versus No MetS. MetS was identified using a predefined criteria as the coexistence of (1) diabetes mellitus, (2) hypertension, and (3) body mass index ≥30 kg/m2. Results: A total of 1013 (6.7%) MetS underwent ORIF for ankle fractures. Following adjustment for baseline differences, MetS was an independent predictor of experiencing any 30-day complication (odds ratio [OR] = 1.35; P = .020), wound complications (OR = 1.67; P = .024), renal complications (OR = 3.54; P = .022), 30-day readmissions (OR = 1.66; P = .001), 30-day unplanned reoperations (OR = 1.69; P = .009) and decreased odds of home discharge (OR = 0.66; P < .001). Conclusion: Patients with MetS undergoing ORIF for ankle fractures are at an increased risk of experiencing adverse 30-day complications, readmissions, and reoperations. Providers should understand the need of appropriate postoperative surveillance in this high-risk group to minimize the risk of poor outcomes. Level of Evidence: Level III.

The synergistic effect of preoperative opioid use and many associated preoperative predictors of poor outcome in the trauma patient population

OBJECTIVE

The purpose of this study is to investigate if preoperative opioid use is associated with other predictors of poor outcome and the effect of these factors on complications. We hypothesized that preoperative opioid use (POU) is associated with increased rates of postoperative complications.

DESIGN

Retrospective case control study.

SETTING

Academic level-1 trauma center.

PATIENTS/PARTICIPANTS

Patients with long bone, lower extremity fractures requiring operative fixation.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

Postoperative hospital admissions, emergency room (ER) visits, and reoperations.

RESULTS

399 patients (opioid naïve [ON] 80.2%, Age 38, 95% CI 35.9-39.6) were reviewed. Patients who had POU were older (P = 0.004), had higher BMI (P = 0.03), proportion of females (P < 0.001), tobacco use (P < 0.001), proportion of American Society of Anesthesiologist (ASA) class ≥ 3 (P < 0.001), and rates of substance use disorder (SUD) (P < 0.001). POU was associated with prolonged opiate use at 6 months (60.8%), 1 year (43.0%), higher rates of postoperative readmissions (18.1%), ER visits (17.2%), reoperations (17.5%), and complications (Odds Ratio [OR]: 2.4, P < 0.01). The risk of complication increased synergistically with the addition of other predictors: less than a high school education (OR: 4.6, P = 0.001); ASA class ≥3 (OR: 5.6, P < 0.001). All three factors combined also increased risk of complication synergistically (OR: 9.1, P = 0.003).

CONCLUSIONS

Our study demonstrates that many predictors of poor outcome frequently accompany POU. POU combined with many of these predictors synergistically increases the risk of complication. Outcomes-based payment models should reflect this expected rate of readmissions, ER visits and complications in this group. Patients with POU should be targeted with multi-disciplinary interventions aimed to modify these risk factors.

A Dashboard Prototype for Tracking the Impact of Diabetes on Hospital Readmissions Using a National Administrative Database

Background

Over the past several decades, diabetes mellitus has contributed to a significant disease burden in the general population. Evidence suggests that patients with a coexisting diabetes diagnosis consume more hospital resources, and have higher readmission rates compared to those who do not. Against the backdrop of bundled-payment programs, healthcare systems cannot underestimate the importance of monitoring patient health information at the population level.

Methods

Using the data from the Centers for Medicare and Medicaid Services (CMS) administrative claims database, we created a dashboard prototype to enable hospitals to examine the impact of diabetes on their all-cause readmission rates and financial implications if diabetes was present at the index hospitalization. The technical design involved loading the relevant 10th revision of International Classification of Diseases (ICD-10) codes provided by the medical team and flagging diabetes patients at the claim. These patients were then tagged for readmissions within the same database. The odds ratios were determined based on data from two groups: those with diabetes at index hospitalization which include type 1 only, type 2 only, and type 1 and type 2 diabetes, plus those without diabetes at index hospitalization.

Results

The dashboard presents summary data of diabetes readmissions quality metrics at a national level. Users can visualize summary data of each state and compare odds ratios for readmissions as well as raw hospitalization data at their facility. Dashboard users can also view data classified by a diagnosis-related group (DRG) system. In addition to a “national” data view, for users who inquire about data specific to demographic regions, the DRG view can be further stratified at the state level or county level. At the DRG level, users can view data about the cost per readmissions for all index hospitalization with and without diabetes.

Conclusions

The dashboard prototype offers users a virtual interface which displays visual data for quick interpretation, monitors changes at a population level, and enables administrators to benchmark facility data against local and national trends. This is an important step in using data analytics to drive population level decision making to ultimately improve medical systems.

Do surgical site complications after ankle fracture surgery reduce with Aquacel Extra Ag®?

INTRODUCTION

Ankle fractures account for up to 10% of total fractures. Most of them require surgical fixation, which involves an important risk of wound complications. The aim of this study was to determine whether a silver-impregnated occlusive surgical dressing (Aquacel Ag Extra^®) was effective in reducing the rates of wound complications after ankle fracture open reduction and internal fixation compared to standard sterile dressing.

METHODS

We prospectively reviewed 233 patients who underwent ankle fracture open reduction and internal fixation. Surgeons switched from using a standard dressing to an Aquacel Ag Extra^® from July 2017 to February 2018, without other major changes in perioperative management. We compared skin complications between both groups after 3 months' follow-up.

RESULTS

The statistical analysis showed that there is no difference in the prevalence of skin complications between both groups.

CONCLUSIONS

The theoretical advantages of silver impregnated dressings need further prospective randomized controlled studies to assess the appropriate indications for their use in orthopaedic surgery.

Machine Learning Accurately Predicts Short-Term Outcomes Following Open Reduction and Internal Fixation of Ankle Fractures

Ankle fractures are common orthopedic injuries with favorable outcomes when managed with open reduction and internal fixation (ORIF). Several patient-related risk factors may contribute to poor short-term outcomes, and machine learning may be a valuable tool for predicting outcomes. The objective of this study was to evaluate machine-learning algorithms for accurately predicting short-term outcomes after ORIF for ankle fractures. The Nationwide Inpatient Sample and Nationwide Readmissions Database were queried for adult patients ≥18 years old who underwent ORIF of an ankle fracture during 2013 or 2014. Morbidity and mortality, length of stay >3 days, and 30-day all-cause readmission were the outcomes of interest. Two machine-learning models were created to identify patient and hospital characteristics associated with the 3 outcomes. The machine learning models were evaluated using confusion matrices and receiver operating characteristic area under the curve values. A total of 16,501 cases were drawn from the Nationwide Inpatient Sample and used to assess morbidity and mortality and length of stay >3 days, and 33,504 cases were drawn from the Nationwide Readmissions Database to assess 30-day readmission. Older age, Medicaid, Medicare, deficiency anemia, congestive heart failure, chronic lung disease, diabetes, hypertension, and renal failure were the variables associated with a statistically significant increased risk of developing all 3 adverse events. Logistic regression and gradient boosting had similar area under the curve values for each outcome, but gradient boosting was more accurate and more specific for predicting each outcome. Our results suggest that several comorbidities may be associated with adverse short-term outcomes after ORIF of ankle fractures, and that machine learning can accurately predict these outcomes.

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.

Increased Rates of Readmission, Reoperation, and Mortality Following Open Reduction and Internal Fixation of Ankle Fractures Are Associated With Diabetes Mellitus

The purpose of this study was to compare the rates of readmission, reoperation, and mortality in patients with and without diabetes mellitus during the 30-day postoperative period after ankle fracture surgery. Patients who underwent operative management for ankle fractures between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program^® database by using Current Procedural Terminology codes for ankle fracture surgery. A total of 17,464 patients undergoing ankle fracture surgery were identified. Of these patients, 2044 (11.7%) had diabetes and 15,420 (88.3%) did not have diabetes. We excluded patients older than 90 years or with inadequate perioperative data. Patients with diabetes had significantly higher rates of readmission (2.84% vs 1.05%, p < .0001), significantly higher rates of unplanned reoperation (2.3% vs 0.74%, p < .0001), and significantly higher rates of mortality (0.7% vs 0.2%, p < .0001) compared with patients without diabetes. Additionally, patients with diabetes had significantly greater age-adjusted odds ratios (ORs) of unplanned readmission (OR 2.40, 95% confidence interval [CI] 1.74 to 3.31, p < .0001), unplanned reoperation (OR 2.56, 95% CI 1.44 to 3.27, p < .0001), and mortality (OR 2.01, 95% CI 1.08 to 3.62, p = .0432) than did patients without diabetes after ankle surgery. In this large-scale retrospective study, we demonstrated that the presence of diabetes significantly increases the risk of unplanned readmission, unplanned reoperation, and mortality during the 30-day postoperative period after ankle fracture surgery.

Unstable Ankle Fracture Fixation Using Locked Fibular Intramedullary Nail in High-Risk Patients

Open reduction internal fixation is the gold standard for unstable ankle fracture fixation; however, complications in patients with multiple medical comorbidities are common. Intramedullary nail fixation of the fibula can help to mitigate these difficulties. A retrospective chart review was performed on all patients who underwent fixation for unstable ankle fracture between January 2015 and March 2016 at our level I trauma center. Comorbidities in the patient sample included were one or several of diabetes, renal disease, hypertension, advanced age with osteoporosis, hemorrhagic blisters, and alcoholism. The primary outcomes studied were wound complications, infections, and hardware failure or failure of fixation. Eighteen patients with a mean age of 61 years underwent fibular intramedullary nail fixation, all of whom were considered at high risk for postoperative complications. Patients presented with Weber B or C fracture patterns. All patients had syndesmotic fixation through the nail by one or two 3.5-mm tricortical screws. A medial malleolus was added if needed for stability. The average follow-up time was 291.1 (range 9 to 14 months) days. The prescribed range of time to weightbearing was 2 to 6 weeks. All patients maintained reduction of the fracture and had no wound complications. No syndesmotic screws broke postoperatively, although most patients to failed comply with the postoperative non-weightbearing restrictions. Intramedullary nailing of the fibula with syndesmotic intranail fixation is minimally invasive, quick, and provides adequate fixation strength. It offers a viable treatment option for patients at high risk for complications or who are suspected to have difficulty with follow-up or compliance.