Adverse events, length of stay, and readmission after surgery for tibial plateau fractures

Complications and secondary operations after non-operative and operative treatment of tibial plateau fractures: a population-based study of 562 patients with mean follow-up of 7 years

INTRODUCTION

The incidence of tibial plateau fractures (TPF) is 1% of all fractures and increases with age. Whether non-operatively or operatively treated, complications (infection, malalignment, loss of reduction and delayed union or nonunion) and post-traumatic osteoarthritis are not uncommon, and the risk for complications has generally been assumed to rise with age. This study investigated all post-TPF complications and secondary surgery after non-operative and operative treatment. Secondary aims were to determine the incidence and epidemiology of TPF in the population of the Central Finland region.

MATERIALS AND METHODS

All patients over age 18 years with a TPF, including incidence, etiology, fracture type, and possible complications and reoperations, sustained during the period 1998-2019 were retrospectively identified from hospital records.

RESULTS

The annual mean incidence of TPF was 14.4/100,000, with older women at highest risk. The proportions of non-operative and operatively treated patients who had undergone at least one additional surgical operation were 6% and 26%, respectively. Age and female gender were identified as risk factors for complications and secondary operations. The risk peaked in patients aged 60-65 years, decreasing thereafter. Non-operative treatment showed low risk for both non-union and loss of reduction.

CONCLUSIONS

Older women were at the highest risk for TPF and for subsequent complications and secondary operations after TPF. Secondary operations after operatively treated TPF were not uncommon and patients aged 60-65 years were at highest risk. Given the low rates of complications and re-operations, non-operative treatment may be a safe option in cases of all minimally displaced TPF.

Risk factors of hospitalization costs and length of stay for tibial plateau fractures

PURPOSE

This study aimed to analyze the factors influencing the length of stay (LOS) and the cost of hospital stay in patients with tibial plateau fractures (TPFs).

METHODS

We enrolled 233 patients with TPFs in this retrospective study. The general conditions, hematological indicators, and imaging data of hospitalized patients were collected. The factors influencing the cost and LOS were determined by a multivariate logistic regression model controlling confounding factors. Receiver operating characteristic (ROC) curve is used to determine the sensitivity and specificity of risk factors.

RESULTS

The hospitalization cost of hypoproteinemia was significantly higher than that of the standard group (OR 3.07; 95% CI 1.23-7.69; P = 0.017); Low hemoglobin levels in the male will significantly affect patient hospitalization costs (OR 8.32; 95% CI 2.82-24.57; P = 0.015), will also extend the LOS (OR 3.02; 95% CI 1.15-7.89; P = 0.024). Among Schatzker classification of the tibial plateau, hospitalization costs of type V, VI above fractures were significantly higher than those of class I, II, III, and IV fractures (OR 8.78; 95% CI 3.34-23.09; P < 0.001).

CONCLUSION

In this study, hypoproteinemia and the Schatzker classification appeared to be a useful indicator for predicting hospitalization costs for TPFs patients; Male hemoglobin level appears to be an independent risk factor for hospital cost and LOS.

A High-Fidelity Model to Predict Length-of-Stay in the Neonatal Intensive Care Unit (NICU)

Having an interpretable dynamic length-of-stay (LOS) model can help hospital administrators and clinicians make better decisions and improve the quality of care. The widespread implementation of electronic medical record (EMR) systems has enabled hospitals to collect massive amounts of health data. However, how to integrate this deluge of data into healthcare operations remains unclear. We propose a framework grounded in established clinical knowledge to model patients' lengths-of-stay. In particular, we impose expert knowledge when grouping raw clinical data into medically meaningful variables, which summarize patients' health trajectories. We use dynamic predictive models to output patients' remaining lengths-of-stay (RLOS), future discharges, and census probability distributions based on their health trajectories up to the current stay. Evaluated with large-scale EMR data, the dynamic model significantly improves predictive power over the performance of any model in previous literature and remains medically interpretable.

Morbidity and Mortality After Surgical Management of Tibial Plateau Fractures in Octogenarians

BACKGROUND

Because the geriatric population continues to increase in number, the incidence of geriatric tibial plateau fractures in octogenarians is projected to increase. The functional and physiological status varies within this population. The purpose of this study was to compare the complications after surgical management of tibial plateau fractures in patients aged 65 to 79 years with those in patients aged 80 to 89 years.

METHODS

In this retrospective cohort study, data were collected from the National Surgical Quality Improvement Program database for the years 2006 to 2018. The Current Procedural Terminology codes and International Classification of Diseases codes were used to identify all tibial plateau fractures that were treated with open reduction and internal fixation. Patients were divided into two groups: 65- to 79-year-old group and 80- to 89-year-old group. Primary and secondary outcomes were studied and included the 30-day mortality. Univariate and multivariate analyses were done with a statistical significance set at P < 0.05.

RESULTS

In total, 718 patients with tibial plateau fractures who underwent open reduction and internal fixation were included in this study. Of these, 612 were aged 65 to 79 years, and 106 were aged 80 to 89 years. On multivariate analysis, patients aged 80 to 89 years were at increased risk of postoperative anemia requiring transfusion (odds ratio 2.83; 95% confidence interval 1.37 to 5.84; P = 0.005) and extended length of hospital stay (odds ratio 2.72; 95% confidence interval 1.64 to 4.51; P < 0.001) in comparison with patients aged 65 to 79 years.

CONCLUSION

In appropriately selected octogenarian patients, surgical management of tibial plateau fractures was associated with greater risks of transfusion and longer hospital stay. However, comparisons of the rates of late complications and reoperations remain unknown.

Trends and Complications of Arthroscopic-Assisted Tibial Plateau Fracture Fixation: A Matched Cohort Analysis

Purpose

To determine trends in arthroscopic-assisted tibial plateau fracture fixation (AATPFF), to evaluate trends in the overall rate of tibial plateau fracture fixation, and to compare postoperative complications between AATPFF and traditional tibial plateau fixation.

Methods

A retrospective review of patients undergoing AATPFF and traditional tibial plateau fixation was conducted using the Humana Inc. administrative database from 2007 to 2016. A 1:1 propensity match was utilized to match patients in the 2 study groups based on age, sex, obesity, diabetes, hypertension, chronic obstructive pulmonary disease, depression or anxiety, and smoking history. Postoperative complications were grouped as minor medical complications, major medical complications, surgical complications, emergency department visits, and reoperation. Linear regression analysis was used to assess trends and Pearson's χ² test was used to compare postoperative complications with statistical significance defined as P < .05.

Results

In total, 522 patients underwent AATPFF and 3920 patients underwent traditional tibial plateau fracture fixation. There was a 4-fold increase in the use of AATPFF over the study period (P = .0173). Similarly, there was an increase in the utilization of traditional tibial plateau fracture fixation, although to a lesser extent (1.33-fold). After propensity matching, the traditional fixation group demonstrated significantly higher rates of minor medical complications (8.2% vs 2.7%, P = .0002), major medical complications (9.9% vs 4.6%, P = .0018), surgical complications (13.2% vs 2.7%, P < .0001), and emergency department visits (21.4% vs 13.5%, P < .0001) within 90 days of surgery compared with the AATPFF group. There was no difference in reoperation rates within 90 days between the 2 groups (2.9% vs 3.6%, P = .85).

Conclusions

The incidence of tibial plateau fracture fixation is increasing, however, use of AATPFF is increasing at a faster rate compared to traditional techniques. Furthermore, the addition of knee arthroscopy to fracture fixation does not increase the risk of complication, reoperation, or emergency department visit within 90 days.

Level of Evidence

III, retrospective matched cohort.

Operative Fixation of Hip Fractures in Nonagenarians: Is It Safe?

BACKGROUND

With the shift in hip fracture epidemiology toward older individuals as well as the shift in demographics toward nonagenarians, it is important to understand the outcomes of treatment for these patients.

METHODS

Geriatric patients (≥65 years old) who underwent surgery for hip fracture were identified in the 2005-2017 National Surgical Quality Improvement Program database and stratified into 2 age groups: <90 and ≥90 years old (nonagenarians). Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for complications and 30-day readmissions. Risk factors for serious adverse events (SAEs) and 30-day mortality in nonagenarians were characterized.

RESULTS

This study included 51,327 <90 year olds and 15,798 nonagenarians. Overall rate of SAEs in nonagenarians was 19.89% while in <90 year olds was 14.80%. Multivariate analysis revealed higher risk for blood transfusion (relative risk [RR] = 1.21), death (RR = 1.74), pneumonia (RR = 1.24), and cardiac complications (RR = 1.33) in nonagenarians (all P < .001). Risk factors for SAEs in nonagenarians include American Society of Anesthesiologists ≥3, dependent functional status, admitted from nursing home/chronic/intermediate care, preoperative hypoalbuminemia, and male gender (all P < .05), but not time to surgery (P > .05). In fact, increased time to surgery in nonagenarians was associated with lower risk of 30-day mortality (RR = 0.90, P = .048).

CONCLUSION

Overall complication risk after hip fracture fixation in nonagenarians remains relatively low but higher than their younger counterparts. Interestingly, since time to surgery was not associated with adverse outcomes in nonagenarians, the commonly accepted 48-hour operative window may not be critical to this population. Additional time for preoperative medical optimization in this vulnerable population appears prudent.

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 New Approach to Surgical Management of Tibial Plateau Fractures

Tibial plateau fractures (TPFs) are challenging, requiring complex open reduction and internal fixation (ORIF) and are often associated with complications including surgical site infections (SSIs). In 2007, we introduced a novel management protocol to treat TPFs which consisted of an angiosome- or perforator-sparing (APS) anterolateral approach followed by unrestricted weight bearing and range of motion. The primary aim of this retrospective study was to investigate complication rates and patient outcomes associated with our new management protocol. In total, 79 TPFs treated between 2004 and 2007 through a classic anterolateral surgical approach formed the "Classic Group"; while 66 TPFS treated between 2007 and 2013 formed the "APS Group". Fracture reduction, maintenance of reduction and patient-reported outcomes were assessed. There was a clinically important improvement in the infection incidence with the APS (1.5%) versus the Classic technique (7.6%) (1/66 versus 2/79 for superficial infections; 0/66 versus 4/79 for deep infections). Despite a more aggressive rehabilitation, there was no difference in the fracture reduction over time or the functional outcomes between both groups (p > 0.05). The APS anterolateral approach improved the rate of SSIs after TPFs without compromising fracture reduction and stabilisation. We continue to use this new management approach and early unrestricted weight bearing when treating amenable TPFs.

Prevalence of Deep Surgical Site Infection After Repair of Periarticular Knee Fractures: A Systematic Review and Meta-analysis

IMPORTANCE

Surgical management of periarticular knee fractures can be challenging, and adverse outcomes may be severe. Recent literature indicates that the rate of periarticular knee surgical site infection (SSI) may range from 2% to 88% depending on the fracture site.

OBJECTIVE

To examine the prevalence of deep SSI and the rate of septic arthritis after surgical repair of fractures around the knee.

DATA SOURCES

The electronic databases MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from their inception to July 1, 2018.

STUDY SELECTION

Eligible studies had to specifically report deep SSI rates and include fractures in the distal femur, patella, tibial plateau, or proximal tibia. Risk factors that were associated with increased the risk of deep SSI were also examined.

DATA EXTRACTION AND SYNTHESIS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data were extracted by multiple investigators. Comprehensive Meta-Analysis software was used for the pooling of data, using either random-effects or fixed-effects models, with respect to the degree of statistical heterogeneity present. Data analyses were conducted in October 2019.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall prevalence of deep SSI after periarticular knee fracture repair. The secondary outcomes were the overall prevalence of septic arthritis, risk factors associated with deep SSI, and the most commonly cultured bacteria specimens found periarticular knee infections.

RESULTS

Of 6928 articles screened, 117 articles met inclusion criteria and were included in analysis. Among 11 432 patients included in analysis, 653 patients (5.7%) experienced deep SSIs, most commonly among patients with proximal tibia fractures (56 of 872 patients [6.4%]). Among studies that included information on septic arthritis, 38 of 1567 patients (2.4%) experienced septic arthritis. The 2 most commonly reported bacteria were methicillin-resistant Staphylococcus aureus, found in 67 SSIs, and methicillin-susceptible S aureus, found in 53 SSIs. Sixty-two studies (53.0%) in the sample received a Coleman Methodological Score of poor (<50 points).

CONCLUSIONS AND RELEVANCE

Deep SSIs occurred in nearly 6% of periarticular knee fracture repairs, and 2.4% of SSIs were associated with septic arthritis. Surgeons managing these injuries should be vigilant when wounds are not pristine. Efforts should be made to elevate the quality of research conducted not only in this subject but also in orthopedic surgery as a whole.

Unlike Native Hip Fractures, Delay to Periprosthetic Hip Fracture Stabilization Does Not Significantly Affect Most Short-Term Perioperative Outcomes

BACKGROUND

The incidence of periprosthetic hip fractures is increasing due to higher numbers of total hip arthroplasties being performed. Unlike native hip fractures, the effect of time to surgery of periprosthetic hip fractures is not well established. This study evaluates the effect of time to surgery on perioperative complications for patients with periprosthetic hip fractures.

METHODS

Patients who underwent surgery for periprosthetic hip fracture were identified in the 2005-2016 National Surgical Quality Improvement Program database and stratified into 2 groups: <2 and ≥2 days from hospital admission to surgery. Multivariate regressions were used to compare risk for perioperative complications between the 2 groups. Independent risk factors for postoperative serious adverse events were characterized.

RESULTS

In total, 409 (<2 days from admission to surgery) and 272 (≥2 days from admission to surgery) patients were identified. Multivariate analysis revealed only higher risk of extended postoperative stay for patients who had delays of ≥2 days to surgery compared to those who had <2 days from admission to surgery. Independent risk factors for serious adverse events included increasing age, dependent preoperative functional status, and preoperative congestive heart failure, but not time to surgery.

CONCLUSION

Unlike for native hip fractures, time to surgery for periprosthetic hip fractures does not appear to affect most 30-day perioperative complications. However, it is worth noting that this study was unable to control for all potential confounders and therefore the results may not be generalizable to all types of periprosthetic hip fractures.

Diabetes pharmacotherapy and effects on the musculoskeletal system

Persons with type 1 or type 2 diabetes have a significantly higher fracture risk than age-matched persons without diabetes, attributed to disease-specific deficits in the microarchitecture and material properties of bone tissue. Therefore, independent effects of diabetes drugs on skeletal integrity are vitally important. Studies of incretin-based therapies have shown divergent effects of different agents on fracture risk, including detrimental, beneficial, and neutral effects. The sulfonylurea class of drugs, owing to its hypoglycemic potential, is thought to amplify the risk of fall-related fractures, particularly in the elderly. Other agents such as the biguanides may, in fact, be osteo-anabolic. In contrast, despite similarly expected anabolic properties of insulin, data suggests that insulin pharmacotherapy itself, particularly in type 2 diabetes, may be a risk factor for fracture, negatively associated with determinants of bone quality and bone strength. Finally, sodium-dependent glucose co-transporter 2 inhibitors have been associated with an increased risk of atypical fractures in select populations, and possibly with an increase in lower extremity amputation with specific SGLT2I drugs. The role of skeletal muscle, as a potential mediator and determinant of bone quality, is also a relevant area of exploration. Currently, data regarding the impact of glucose lowering medications on diabetes-related muscle atrophy is more limited, although preclinical studies suggest that various hypoglycemic agents may have either aggravating (sulfonylureas, glinides) or repairing (thiazolidinediones, biguanides, incretins) effects on skeletal muscle atrophy, thereby influencing bone quality. Hence, the therapeutic efficacy of each hypoglycemic agent must also be evaluated in light of its impact, alone or in combination, on musculoskeletal health, when determining an individualized treatment approach. Moreover, the effect of newer medications (potentially seeking expanded clinical indication into the pediatric age range) on the growing skeleton is largely unknown. Herein, we review the available literature regarding effects of diabetes pharmacotherapy, by drug class and/or by clinical indication, on the musculoskeletal health of persons with diabetes.

30-day adverse events, length of stay and re-admissions following surgical management of pelvic/acetabular fractures

INTRODUCTION

Pelvic/acetabular fractures are associated with significant morbidity, mortality and cost to the society. We sought to utilize a national surgical database to assess the incidence and factors associated with prolonged length of stay (LOS), non-home discharge destination, 30-day adverse events and readmissions following surgical fixation of pelvic/acetabular fractures.

MATERIALS & METHODS

The 2011-2016 ACS-NSQIP database files were queried using CPT codes (27215, 27217, 27218, 27226, 27227, 27228) for patients undergoing open reduction/internal fixation (ORIF) for pelvic/acetabular fractures. Patients undergoing additional procedures for associated fractures (vertebral fractures, distal radius/ulna fractures or femoral neck/hip fractures) were excluded from the analysis to ensure that a relevant population of patients with isolated pelvic/acetabular injuries were included in the analysis. A total of 572 patients were included in the final cohort. Severe adverse events (SAE) were defined as: death, ventilator use >48 h, unplanned intubation, stroke, deep venous thrombosis, pulmonary embolism, cardiac arrest, myocardial infarction, acute renal failure, sepsis, septic shock, re-operation, deep SSI and organ/space SSI. Minor adverse events (MAE) included - wound dehiscence, superficial SSI, urinary tract infection (UTI) and progressive renal insufficiency. An extended LOS was defined as >75th centile (>9days).

RESULTS

Factors associated with AAE were partially dependent functional health status pre-operatively (p = 0.020), transfusion ≥1 unit of packed RBCs (p = 0.001), and ASA > II (p < 0.001). Experiencing a SAE was associated with congestive heart failure (CHF) pre-operatively [p = 0.005), total operative time >140 min (p = 0.034) and Hct <36 pre-operatively (p = 0.003). MAE was associated with transfusion≥1 unit of packed RBCs (p = 0.022) and ASA > II (p = 0.007). Patients with an ASA > II (p = 0.001), total operative time>140 min (p < 0.001) and Hct <36 (p = 0.006) were more likely to have a LOS >9 days. Male gender (p = 0.026), prior history of CHF (p = 0.024), LOS >9 days (p = 0.030) and >10% bodyweight loss in last 6 months before the procedure (p = 0.002) were predictors of 30-day mortality.

CONCLUSION

Patients with ASA grade > II, greater co-morbidity burden and prolonged operative times were likely to experience adverse events and have a longer length of stay. Surgeons can utilize this data to risk stratify patients so that appropriate pre-operative and post-operative medical optimization can take place.

Patient-reported quality of life and pain after permissive weight bearing in surgically treated trauma patients with tibial plateau fractures: a retrospective cohort study

INTRODUCTION

A Dutch survey among orthopedic surgeons and trauma surgeons showed that almost 90% of the surgeons do not follow protocols regarding the weight bearing aftercare for tibial plateau fractures. Clinical studies comparing permissive weight bearing (PWB) versus restricted weight bearing (RWB) after surgically treated tibial plateau fractures are not available. The aim of this study was to inventory potential differences in quality of life and pain, and number of complications in patients with surgically treated tibial plateau fractures who followed a PWB regime, relative to those that followed a RWB regime.

MATERIALS AND METHODS

This retrospective cohort study included surgically treated trauma patients with tibial plateau fractures, who underwent rehabilitation according to PWB or RWB between 2005 and 2015. Data such as demographics, patient-reported quality of life and pain, and patient outcome were collected.

RESULTS

This cohort study included 91 patients with a tibial plateau fracture (31 and 60 patients in the PWB and RWB groups respectively). No significant between-group differences in either age or gender were found. However, a significant difference in fracture type was found between groups, (p = 0.04). No significant differences were found in either patient-reported SF-12 or VAS scores between the PWB group and RWB group. Time to full weight bearing was significantly shorter in the PWB than in the RWB group, i.e., 14.7 versus 20.7 weeks, (p = 0.02). No significant differences were found regarding postoperative complications between the PWB and the RWB groups, i.e., 6.5% versus 10.0%, respectively.

CONCLUSION

PWB after surgically treated tibial plateau fractures is safe and is related to a significantly reduced time to full weight bearing with no significant differences in patient-reported quality of life and pain or complication rates.

Tibial Plateau Fractures

Tibial plateau fractures can result from direct trauma or indirect compressive forces. These injuries often result in significant soft tissue disruption, ligamentous disturbance in addition to bone fractures. Diagnostic imaging findings in plain radiographs include fat-fluid level in the suprapatellar bursa, malalignment of the femoral condyles and tibial edges, and increased trabecular density in the lateral epicondyle. Patients in whom a tibial plateau fracture is suspected with negative radiographs should have computerized tomography imaging performed. Most patients will require surgical intervention for fracture fixations. Primary long-term complication includes posttraumatic osteoarthritis because of the traumatic stress forces across the joint.

Longer Operative Time Is Associated With Increased Adverse Events After Anterior Cervical Diskectomy and Fusion: 15-Minute Intervals Matter

Little is known about the impact of operative time, as an independent and interval variable, on general health perioperative outcomes following anterior cervical diskectomy and fusion. Therefore, patients undergoing a 1-level anterior cervical diskectomy and fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program. Operative time (as an interval variable) was tested for association with perioperative outcomes using a multivariate regression that was adjusted for differences in baseline characteristics. A total of 15,241 patients were included. Increased surgical duration was consistently correlated with a rise in any adverse event postoperatively, with each additional 15 minutes of operating time raising the risk for having any adverse event by an average of 10% (99.64% confidence interval, 3%-17%, P<.001). In fact, 15-minute increases in surgical duration were associated with incremental increases in the rates of venous thromboembolism, sepsis, unplanned intubation, extended length of hospital stay, and hospital readmission. Greater operative time, despite controlling for other patient variables, increases the risk for overall postoperative adverse events and multiple individual adverse outcomes. This increased risk may be attributed to anesthetic effects, physiologic stresses, and surgical site issues. Although it is difficult to fully isolate operative time as an independent variable because it may be closely related to the complexity of the surgical pathology being addressed, the current study suggests that surgeons should maximize operative efficiency as possible (potentially using strategies that have been shown to improve operative time in the 15-minute magnitude), without compromising the technical components of the procedure. [Orthopedics. 2018; 41(4):e483-e488.].

Sex Differences in Early Cardiovascular and All-Cause Hospitalization Outcomes After Surviving Firearm Injury

The majority of the burden of firearm injury in the United States is on men as compared to women. There is limited evidence regarding sex differences in short-term hospitalization outcomes after surviving firearm injury. The risk of cardiovascular and all-cause hospital readmission, length of stay (LOS), and costs within 180 days after surviving an index firearm injury was compared between males and females. A claims-based, retrospective, cohort study was performed using Nationwide Readmission Database (2013–2014) to obtain a cohort of patients who survived an index hospitalization of firearm injury. The analysis was performed in August 2017. Cox proportional hazard regression models were used to estimate hazard ratio (HR) and 95% confidence intervals (95% CIs). Among 17,594 males and 2,289 females discharged alive after index firearm injury hospitalization, 14.4% and 13.2% were readmitted within 180 days. Within 180 days, the risk of cardiovascular readmission was 3.3 times greater among males versus females (HR = 3.34, 95% CI [1.18, 9.44]. Risk of all-cause readmission among males was greater at 90 days (HR = 1.40, 95% CI [1.04, 1.87]. Patients surviving a firearm injury have a substantial risk of subsequent hospitalizations. Cardiovascular readmissions are greater among males than females during the first 6 months after injury and may be indicative of a continuing long-term risk of health and patient outcomes that contributes to the overall burden of firearm injury.

Risk factors for complications after primary repair of Achilles tendon ruptures

Purpose

To identify patient characteristics associated with adverse events in Achilles tendon rupture (ATR) surgical repair cases.

Methods

A high risk (HR) cohort group of ATR patients were compared to healthy controls in the ACSNSQIP database with multivariate regression analysis.

Results

Overall, 2% (n = 23) of the group sustained an AE postoperatively, most commonly superficial SSI (0.9%, n = 10). Multivariate analysis did not reveal any patient characteristics to be significantly associated with the occurrence of an AE or superficial SSI.

Conclusions

Obesity, diabetes and a history of smoking did not predispose patients to significantly more AEs in the 30 day postoperative period following ATR repair in this study.

Infection following fractures of the proximal tibia - a systematic review of incidence and outcome

Background

To systematically review all available studies of operatively treated proximal tibia fractures and to report the incidence of superficial or deep infection and subsequent outcomes.

Methods

A systematic review of the literature in Medline, Cochrane, Embase and GoogleScholar was conducted to identify studies with cohorts of patients with infection after surgical treatment of proximal tibia fractures. Studies were included according to predefined inclusion and exclusion criteria. The studies were analysed for methodological deficiencies and quality of outcome reporting based on the Level of Evidence (LOE) and Coleman Methodology Scoring (CMS.)

Results

In total 32 studies were included. There was heterogeneity between the studies, in terms of subject of the studies, outcome criteria, fracture type and classification, surgical techniques and length of follow-up. Therefore, no meta-analysis could be performed. The average CMS was 54.2 (range 36–75). The included studies were 25 case series (LOE IV), 6 were prospective cohort studies (LOE III) and one was a prospective randomized trial (LOE I). 203 (12.3%, range: 2.6–45.0%) infections occurred in the overall population (n = 2063). Those were divided into 129 deep infections and 74 superficial infections. Revision due to infection was reported in 29 studies, microbiological results in 6, respectively. 72 (55,8%) of 129 cases reporting outcome after deep infection had an unsatisfactory outcome with substantial limitations of the affected joint and leg.

Conclusions

Postoperative infections are a challenge, sometimes requiring several revisions and often with a worse outcome. Further studies with structured study protocols should be performed for a better understanding of risk factors to improve treatment outcomes.

Race and Ethnicity Have a Mixed Effect on the Treatment of Tibial Plateau Fractures

OBJECTIVES

To determine whether racial or economic disparities are associated with short-term complications and outcomes in tibial plateau fracture care.

DESIGN

Retrospective cohort study.

SETTING

All New York State hospital admissions from 2000 to 2014, as recorded by the New York Statewide Planning and Research Cooperative System database.

PATIENTS/PARTICIPANTS

Thirteen thousand five hundred eighteen inpatients with isolated tibial plateau fractures (OTA/AO 44), stratified in 4 groups: white, African American, Hispanic, and other.

INTERVENTION

Closed treatment and operative fixation of the tibial plateau.

MAIN OUTCOME MEASUREMENTS

Hospital length of stay (LOS, days), in-hospital complications/mortality, estimated total costs, and 30-day readmission.

RESULTS

There were no significant differences regarding in-hospital mortality, infection, deep vein thrombosis/pulmonary embolism, or wound complications between races, even when controlling for income. There was a higher rate of nonoperatively treated fractures in the racial minority populations. Minority patients had on average 2 days longer LOS compared with whites (P < 0.001), costing on average $4000 more per hospitalization (P < 0.001). Multivariate logistic regression found that neither race nor estimated median family income were independent risk factors for readmission.

CONCLUSIONS

Although nature of initial injury, use of external fixator, comorbidity burden, age, insurance type, and LOS were independent risk factors for readmission, race and estimated median family income were not. In patients who sustained a tibial plateau fracture, race and ethnicity seemed to affect treatment choice, but once treated racial minority groups did not demonstrate worse short-term complications, including increased mortality and postoperative readmission rates.

LEVEL OF EVIDENCE

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

Complications and unplanned outcomes following operative treatment of tibial plateau fractures

INTRODUCTION

The operative management of tibial plateau fractures is challenging and post-operative complications do occur. The purpose of this study was three-fold. 1). To report complications and unplanned outcomes in patients who had sustained tibial plateau fractures and were operatively managed 2). To report predictors of these post-operative events 3). To report if differences in clinical outcomes exist in patients who sustained a post-operative event.

METHODS

Over 11 years, all tibial plateau fractures were prospectively followed. Clinical outcomes were assessed using the validated Short Musculoskeletal Functional Assessment (SMFA) score. Demographics, initial injury characteristics, surgical details and post-operative events were prospectively recorded. Student's t-tests were used for continuous variables and chi-squared analysis was used for categorical variables. Binary logistic regression and multivariate linear regression were conducted for independent predictors of post-operative events and complications and functional outcomes, respectively.

RESULTS

275 patients with 279 tibial plateau fractures were included in our analysis. Ten patients (3.6%) sustained a deep infection. Six patients (2.2%) developed a superficial infection. One patient (0.4%) presented with early implant failure. Two patients (0.7%) developed a fracture nonunion. Eight patients (2.9%) developed a venous thromboembolism. Seventeen patients (6.2%) went on to re-operation for symptomatic implant removal. Nine patients (3.3%) underwent a lysis of adhesions procedure. Univariate analysis demonstrated bicondylar tibial plateau fractures (P<0.001), Moore fracture-dislocations (P=0.005), open fractures (P=0.022), and compartment syndrome (P=0.001) to be associated with post-operative complications and unplanned outcomes. Long-term functional outcomes were worse among patients who developed a post-operative complication or unplanned outcome (P=0.031).

CONCLUSION

Orthopaedic trauma surgeons should be aware of complications and unplanned outcomes following operatively managed tibial plateau fractures, along with having the knowledge of factors that are associated with development of post-operative events.

Risk factors of adverse health outcomes after hospital discharge modifiable by clinical pharmacist interventions: a review with a systematic approach

The present review assessed the evidence on risk factors for the occurrence of adverse health outcomes after discharge (i.e. unplanned readmission or adverse drug event after discharge) that are potentially modifiable by clinical pharmacist interventions. The findings were compared with patient characteristics reported in guidelines that supposedly indicate a high risk of drug-related problems. First, guidelines and risk assessment tools were searched for patient characteristics indicating a high risk of drug-related problems. Second, a systematic PubMed search was conducted to identify risk factors significantly associated with adverse health outcomes after discharge that are potentially modifiable by a clinical pharmacist intervention. After the PubMed search, 37 studies were included, reporting 16 risk factors. Only seven of 34 patient characteristics mentioned in pertinent guidelines corresponded to one of these risk factors. Diabetes mellitus (n = 11), chronic obstructive lung disease (n = 9), obesity (n = 7), smoking (n = 5) and polypharmacy (n = 5) were the risk factors reported most frequently in the studies. Additionally, single studies also found associations of adverse health outcomes with different drug classes {e.g. warfarin [hazard ratio 1.50; odds ratio (OR) 3.52], furosemide [OR 2.25] or high beta-blocker starting doses [OR 3.10]}. Although several modifiable risk factors were found, many patient characteristics supposedly indicating a high risk of drug-related problems were not part of the assessed risk factors in the context of an increased risk of adverse health outcomes after discharge. Therefore, an obligatory set of modifiable patient characteristics should be created and implemented in future studies investigating the risk for adverse health outcomes after discharge.

Functional and Clinical Outcomes of Nonsurgically Managed Tibial Plateau Fractures

INTRODUCTION

This study sought to assess and compare long-term functional and clinical outcomes in patients with tibial plateau fractures that are treated nonsurgically.

METHODS

Over a period of 8 years, 305 consecutive tibial plateau fractures were treated by three surgeons at a single institution and followed prospectively in an Institutional Review Board-approved study. Overall, 41 patients (13%) were treated nonsurgically and 37 were available for follow-up. Indications for nonsurgical management were minimal fracture displacement or preclusion of surgery because of comorbidities. A series of univariate retrospective analyses were used to identify individual risk factors potentially predictive of Short Musculoskeletal Functional Assessment scores.

RESULTS

Thirty-seven patients were included with a mean follow-up of 21 ± 14.9 months. Overall, 59% of patients (n = 22) attained good to excellent functional outcomes. In patients for whom surgery was precluded because of comorbidities, outcome scores were significantly poorer (38.8 ± 23.0 versus 12.7 ± 14.2; P = 0.001). Surgery precluded by a factor other than minimal fracture displacement predicted poor outcome (P = 0.002).

DISCUSSION

Carefully selected patients with minimally displaced tibial plateau fractures can expect good to excellent outcomes when treated nonsurgically.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Predictors of Patient-Reported Function and Pain Outcomes in Operative Ankle Fractures

BACKGROUND

Risk factors associated with short-term functional outcomes in patients with operative ankle fractures have been established. However, no previous studies have reported the association between these risk factors and functional outcomes outside of the first postoperative year. We identified predictors of functional and pain outcomes in patients with operative ankle fractures using the Patient Reported Outcomes Measurement System (PROMIS) physical function (PF) and pain interference (PI) measures.

METHODS

We retrospectively reviewed a multicenter cohort of patients ≥18 years old who underwent operative management of closed ankle fractures from 2001 to 2013 with a minimum of a 2-year follow-up. Patients with pilon variants, Maisonneuve fractures, Charcot arthropathy, prior ankle surgery, and chronic ankle fractures were excluded. Patients meeting inclusion criteria were contacted and evaluated using the PROMIS PF and PI computerized adaptive tests. Patient demographic and injury characteristics were obtained through a retrospective chart review. Univariate and multivariate regression models were developed to determine independent predictors of physical function and pain at follow-up. Included in this study were 142 patients (64 women, 78 men) with a mean age of 52.7 years (SD = 14.7) averaging 6.3 years of follow-up (range 2-14).

RESULTS

Patients had a mean PF of 51.9 (SD = 10.0) and a mean PI of 47.8 (SD = 8.45). Multivariate analysis demonstrated that independent predictors of decreased PF included higher age (B = 0.16, P = .03), higher American Society of Anesthesiologists (ASA) class (B = 10.3, P < .01), and higher body mass index (BMI; B = 0.44, P < .01). Predictors of increased PI included higher ASA class (B = 11.5, P < .01) and lower BMI (B = 0.41, P < .01).

CONCLUSION

At follow-up, increased ASA class, increased BMI, and higher age at time of surgery were independently predictive of decreased physical function. Factors that were associated with increased pain at follow-up include lower BMI and higher ASA class. ASA class had the strongest effect on both physical function and pain.

LEVEL OF EVIDENCE

Level IV, case series.

Shoulder Arthroscopy in Adults 60 or Older: Risk Factors That Correlate With Postoperative Complications in the First 30 Days

PURPOSE

To investigate the 30-day postoperative adverse event (AE) rates of adults 60 years or older after shoulder arthroscopy and identify risk factors for complications in this patient population.

METHODS

Patients aged 60 or more who underwent shoulder arthroscopy were identified in the American College of Surgeons National Surgery Quality Improvement Program database from 2006 to 2013 using 12 Current Procedural Terminology codes related to shoulder arthroscopy. Complications were categorized as severe AEs, minor AEs, and infectious AEs for separate analyses. Pearson's χ² tests were used to identify associations between patient characteristics and AE occurrence and binary logistic regression for multivariate analysis of independent risk factors.

RESULTS

In total, 7,867 patients were included for analysis. Overall, 1.6% (n = 127) of the older adults experienced at least one AE with 1.1% (n = 90) severe AEs, 0.6% (n = 46) minor AEs, and 0.4% (n = 28) infectious complications. Multivariate analysis revealed that age 80 years or older (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.2-2.7, P = .01), body mass index greater than 35 (OR = 1.8, 95% CI = 1.1-2.7, P = .01), functionally dependent status (OR = 2.9, 95% CI = 1.3-6.8, P = .01), American Society of Anesthesiologists class greater than 2 (OR = 1.5, 95% CI = 1.0-2.2, P = .04), congestive heart failure (OR = 6.1, 95% CI = 1.8-21.2, P = .03), disseminated cancer (OR = 7.9, 95% CI = 1.4-43.9, P = .02), and existence of an open wound at the time of surgery (OR = 4.0, 95% CI = 1.1-14.6, P = .03) were independently associated with the occurrence of an AE. Nineteen of the patients included in the study required readmission to the hospital within the 30-day period for an overall readmission rate of 0.2%.

CONCLUSIONS

Patients 60 years or older who underwent shoulder arthroscopy for a variety of indications have a low overall 30-day postoperative complication rate of 1.6%. Although low, this is a higher rate than previously reported for the overall shoulder arthroscopy population. Independent patient characteristics associated with increased risk of AE occurrence included age 80 years or older, body mass index greater than 35, functional dependent status, American Society of Anesthesiologists score of 3 or 4, congestive heart failure, disseminated cancer, and existence of an open wound.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Autograft versus allograft reconstruction of acute tibial plateau fractures: a comparative study of complications and outcome

BACKGROUND

There is no consensus regarding the use of filling agent in the re-elevation of depressed tibial plateau fracture (TPF). Although autograft is considered as the gold standard approach of such reconstructions, its limitation has led to a recent attraction toward allograft substitution. In this study, we compare the complications and outcome of autograft and allograft in TPF reconstruction, in order to address the existing controversy.

MATERIALS AND METHODS

A total of 81 patients with acute TPF were included in this study. Allograft and autograft were applied in 58 and 23 cases, respectively. The mean age of the patients was 40.26 years, and the mean follow-up period of patients was 19.1 months. Clinical and radiological assessment of the outcome was conducted, employing the modified Rasmussen clinical criteria.

RESULTS

A total of three infections were observed in our patients, from which two infections occurred in allograft received patients. Articular surface collapse was seen in two cases, including one allograft and one autograft receiving patient. The mean clinical score was 18.65 and 18.55 in autograft and allograft received patients, respectively (p = 0.09). The mean radiological score was 15.65 and 15.68 in autograft and allograft received patients (p = 0.3).

CONCLUSION

With respect to the comparable complication rate, clinical and radiological outcome of allogenic versus autologous reconstruction of TPF, freeze-dried allograft could be recommended as an appropriate substitute of autograft in this treatment. Nevertheless, the longer follow-up period of the patients could further extend our understanding of the clinical outcome of each component.

Adverse cardiac events in 56,000 orthopaedic trauma patients: Does anatomic area make a difference?

PURPOSE

Postoperative cardiac events in orthopaedic trauma patients constitute severe morbidity and mortality. It is therefore increasingly important to determine patient risk factors that are predictive of postoperative myocardial infarctions and cardiac arrests. This study sought to assess if there is an association between anatomic area and cardiac complications in the orthopaedic trauma patient.

PATIENTS AND METHODS

From 2006-2013, a total of 361,402 orthopaedic patients were identified in the NSQIP database using Current Procedural Terminology (CPT) codes. Of these, 56,336 (15.6%) patients were identified as orthopaedic trauma patients broken down by anatomic region: 11,905 (21.1%) upper extremity patients (UE), 29,009 (51.5%) hip/pelvis patients (HP), and 15,422 (27.4%) lower extremity patients (LE) using CPT codes. Patients were defined as having adverse cardiac events if they developed myocardial infarctions or cardiac arrests within 30days after surgery. Chi-squared analysis was used to determine if there was an association between anatomic area and rates of cardiac events. Multivariate logistical analysis was used with over 40 patient characteristics including age, gender, history of cardiac disease, and anatomic region as independent predictors to determine whether anatomic area significantly predicted the development of cardiac complications.

RESULTS

There were significant differences in baseline demographics among the three groups: HP patients had the greatest average age (77.6 years) compared to 54.8 years for UE patients and 54.1 years in LE patients (p<0.001). HP patients also had the highest average ASA score (3.0) (p<0.001). There was a significant difference in adverse cardiac events based on anatomic area: 0.27% (32/11,905) UE patients developed cardiac complications compared to 2.15% (623/29,009) HP patients and 0.61% (94/15,422) LE patients. After multivariate analysis, HP patients were significantly more likely to develop cardiac complications compared to both UE patients (OR: 6.377, p=0.014) and LE patients (OR: 2.766, p=0.009).

CONCLUSION

There is a significant difference in adverse cardiac events following orthopaedic trauma based on anatomic region. Hip/Pelvis surgery appeared to be a significant risk factor in developing an adverse cardiac event. Further studies should investigate why hip/pelvic patients are at a higher risk of adverse cardiac events.

Do we really know our patient population in database research? A comparison of the femoral shaft fracture patient populations in three commonly used national databases

AIMS

While use of large national clinical databases for orthopaedic trauma research has increased dramatically, there has been little study of the differences in populations contained therein. In this study we aimed to compare populations of patients with femoral shaft fractures across three commonly used national databases, specifically with regard to age and comorbidities.

PATIENTS AND METHODS

Patients were identified in the Nationwide Inpatient Sample (NIS), National Surgical Quality Improvement Program (NSQIP) and National Trauma Data Bank (NTDB).

RESULTS

The distributions of age and Charleston comorbidity index (CCI) reflected a predominantly older population with more comorbidities in NSQIP (mean age 71.5; sd 15.6), mean CCI 4.9; sd 1.9) than in the NTDB (mean age 45.2; sd 21.4), mean CCI = 2.1; sd 2.0). Bimodal distributions in the NIS population showed a more mixed population (mean age 56.9; sd 24.9), mean CCI 3.2; sd 2.3). Differences in age and CCI were all statistically significant (p < 0.001).

CONCLUSION

While these databases have been commonly used for orthopaedic trauma research, differences in the populations they represent are not always readily apparent. Care must be taken to understand fully these differences before performing or evaluating database research, as the outcomes they detail can only be analysed in context.

TAKE HOME MESSAGE

Researchers and those evaluating research should be aware that orthopaedic trauma populations contained in commonly studied national databases may differ substantially based on sampling methods and inclusion criteria.

Comparison of Short-Term Outcomes of Geriatric Distal Femur and Femoral Neck Fractures: Results From the NSQIP Database

Purpose:

To compare and contrast postoperative complications in the geriatric population following open reduction and internal fixation (ORIF) for (DF) fractures relative to femoral neck (FN) fractures.

Methods:

Patients aged 65 years and older in the American College of Surgeons National Surgical Quality Improvement Program database who underwent ORIF for FN fractures or DF fractures from 2005 to 2012 were identified. Differences in rates of any adverse events (AAEs), serious adverse events (SAEs), infectious complications, and mortality between groups were explored using univariate and multivariate analyses.

Results:

The DF cohort had a higher proportion of females (81.95% vs 71.35%, P < .001), were younger (79.41 ± 7.93 vs 82.11 ± 7.26 years old, P < .001), and had a lower age adjusted modified Charlson comorbidity index score (4.22 ± 1.32 vs 4.49 ± 1.35, P = .02). Cases with DF and FN did not differ in AAE (20.05% vs 20.20%, P = .94), SAE (12.03% vs 13.19%, P = .51), infectious complication (4.26% vs 4.22%, P = .97), hospital length of stay (7.32 ± 6.73 days vs 7.02 ± 10.67 days, P = .59), or mortality rates (4.51% vs 5.99%, P = .23). Multivariate analyses revealed that fracture type did not impact AAE (P = .28), SAE (P = .58), infectious complications (P = .83), or mortality (P = .85) rates.

Conclusion:

Postoperative morbidity and mortality of geriatric patients who sustain DF and FN fractures treated operatively were comparable. This information can be used when risk stratifying and prognosticating for elderly patients undergoing these procedures.

Predicting Short-term Morbidity in Patients Undergoing Posterior Spinal Fusion for Neuromuscular Scoliosis

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to determine the incidence and risk factors for short-term morbidity following posterior spinal fusion (PSF) for neuromuscular scoliosis (NMS).

SUMMARY OF BACKGROUND DATA

NMS is a challenging spinal deformity for which PSF is often recommended. There is a lack of information on risk factors for short-term adverse outcomes after PSF for NMS.

METHODS

Patients who underwent PSF for NMS during 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database. Patient characteristics were tested for association with adverse events, infectious complications, extended length of stay (LOS), and readmission using multivariate regression.

RESULTS

Of the 940 NMS patients identified, 133 (14.1%) had an adverse event and 99 (10.5%) had a severe adverse event. American Society of Anesthesiologists (ASA) classification ≥3 was found to be the only independent risk factor for any adverse event (relative risk [RR] 2.2, P = 0.012) and severe adverse events (RR 2.5, P = 0.008). Infectious complications were associated with body mass index (BMI)-for-age ≥95th percentile (RR 2.8, P = 0.005), ASA classification ≥3 (RR 5.9, P = 0.003), and instrumentation to the pelvis (RR 1.8, P = 0.039).A total of 254 patients (27%) spent longer than a week in the hospital postoperatively, and ASA classification ≥3 (RR 2.3, P < 0.001), preoperative seizure disorder (RR 1.4, P = 0.002), previous cardiac surgery (RR 1.6, P = 0.004), operative time ≥470 minutes (RR 1.8, P < 0.001), and ≥13 levels instrumented (RR 1.9, P = 0.001) were associated with extended LOS.Seventy-six patients (8.1%) were readmitted, and BMI-for-age ≥95th percentile (RR 1.8, P = 0.033) was the only risk factor found for readmission.

CONCLUSION

The identified factors associated with poor short-term outcomes after PSF for NMS can be used as benchmark data, be useful for optimizing patient care, and can inform future studies in these patients.

LEVEL OF EVIDENCE

3.

Perioperative adverse events in distal femur fractures treated with intramedullary nail versus plate and screw fixation

BACKGROUND

To compare 30-day outcomes in patients treated for a distal femur (DF) fracture with plate fixation (PF) or intramedullary nail (IMN).

METHODS

Differences in rates of any adverse events (AAE), serious adverse events (SAE), infectious complications, and mortality were explored between groups in the ACS-NSQIP database.

RESULTS

There were 511 PF and 44 IMN patients. The PF group and IMN groups had similar rates of AAEs (p = 0.35), SAEs (p = 0.46), infectious complications (p = 1.00), and mortality (p = 0.39).

CONCLUSIONS

DF fractures treated with IMN have equivalent short-term outcomes compared to those treated with PF.

Balloon tibioplasty for reduction of depressed tibial plateau fractures: Preliminary radiographic and clinical results

PURPOSE

In vitro studies have shown promising results for balloon-guided inflation tibioplasty. It was our hypothesis that this technique may be safe and effective for use in depressed lateral tibial plateau fracture.

METHODS

We performed a prospective study of all patients suffering from a depressed lateral tibial plateau fracture, managed in our institution with inflation tibioplasty and a resorbable calcium phosphate bone substitute injection, between January 2012 and December 2013. Twenty patients, mean age 54.3 ± 12. 8 years, suffering from a depressed lateral tibial plateau fracture (Schatzker type II and III) were included. We then aimed to evaluate at a minimum follow-up of one year: (1) the rate of complications, (2) the clinical outcome (Knee Injury and Osteoarthritis Outcome (KOO) and 12-Item Short Form Health Survey (SF-12) scores); and (3) the radiographic outcome (evaluated by CT-scan).

RESULTS

No peri-operative complications occurred. In one patient, calcium phosphate substitute was found in the infrapatellar fat pad on post-operative radiography with no clinical or radiographic consequences at one year. At one year after surgery, the KOO subscores were: Pain 80 (range 64-93), other symptoms 81.3 (69-93), daily living activities 81.9 (46-99), sport 65.83 (20-100), and quality of life 67.04 (31-100). The SF-12 activity component was 40.4 (28.6-52.2) and SF-12 mental component 47.71 (28 - 67.1). The mean depressed step-off of the lateral joint decreased from 10.7 ± 4.8 mm pre-operatively to 2.7 ± 1.7 mm post-operatively (p < 0.0001).

CONCLUSION

Our observations suggest that the use of balloon-guided inflation tibioplasty with injection of a resorbable bone substitute is safe, and results in a high rate of anatomic reduction and good clinical outcomes in patients with depressed tibial plateau fractures.

LEVEL OF EVIDENCE

Therapeutic Level IV.

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

BACKGROUND

Ankle fractures are common and can be associated with severe morbidity. Risk factors for short-term adverse events and readmission after open reduction and internal fixation (ORIF) of ankle fractures have not been fully characterized.

QUESTIONS/PURPOSES

The purpose of our study was to determine patient rates and risk factors for (1) any adverse event; (2) severe adverse events; (3) infectious complications; and (4) readmission after ORIF of ankle fractures.

METHODS

Patients who underwent ORIF for ankle fracture from 2005 to 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP(®)) database using International Classification of Diseases, 9(th) Revision and Current Procedural Terminology codes. Patients with missing perioperative data were excluded from this study. Patient characteristics were tested for association with any adverse event, severe adverse events, infectious complications, and readmission using bivariate and multivariate logistic regression analyses.

RESULTS

Of the 4412 patients identified, 5% had an adverse event. Any adverse event was associated with insulin-dependent diabetes mellitus (IDDM; odds ratio [OR], 2.05; 95% confidence interval [CI], 1.35-3.1; p = 0.001), age ≥ 60 years (OR, 1.97; 95% CI, 1.22-3.2; p = 0.006), American Society of Anesthesiologists classification ≥ 3 (OR, 1.69; 95% CI, 1.2-2.37; p = 0.002), bimalleolar fracture (OR, 1.6; 95% CI, 1.08-2.37; p = 0.020), hypertension (OR, 1.47; 95% CI, 1.04-2.09; p = 0.031), and dependent functional status (OR, 1.47; 95% CI, 1.02-2.14; p = 0.040) on multivariate analysis. Severe adverse events occurred in 3.56% and were associated with ASA classification ≥ 3 (OR, 2.01; p = 0.001), pulmonary disease (OR, 1.9; p = 0.004), dependent functional status (OR, 1.8; p = 0.005), and hypertension (OR, 1.65; p = 0.021). Infectious complications occurred in 1.75% and were associated with IDDM (OR, 3.51; p < 0.001), dependent functional status (OR, 2.4; p = 0.002), age ≥ 60 years (OR, 2.28; p = 0.028), and bimalleolar fracture (OR, 2.19; p = 0.030). Readmission occurred in 3.17% and was associated with ASA classification ≥ 3 (OR, 2.01; p = 0.017).

CONCLUSIONS

IDDM was associated with an increased rate of adverse events after ankle fracture ORIF, whereas noninsulin-dependent diabetes mellitus was not. IDDM management deserves future study, particularly with respect to glycemic control, a potential confounder that could not be assessed with the ACS-NSQIP registry. Increased ASA class was associated with readmission, and future prospective investigations should evaluate the effectiveness of increasing the discharge threshold, discharging to extended-care facilities, and/or home nursing evaluations in this at-risk population.

LEVEL OF EVIDENCE

Level III, prognostic study.