Octogenarian and Nonagenarians Are at a Higher Risk for Experiencing Adverse 30-Day Outcomes Following ORIF of Ankle Fractures

Open ankle fractures in the elderly: predisposing factors and the associated mortality

The purpose of this study was to investigate the independent effect of open ankle fractures on postoperative mortality and to identify factors leading to open ankle fractures in the elderly population. This is a retrospective case-control study of 1,045 patients aged 65 years and older, with ankle fractures undergoing surgical fixation between 2010 and 2020 at three medical centers (Levels 1-2). A logistic regression analysis was used to identify risk factors for open fractures. Propensity score matching and survival analysis were used to measure the hazard of mortality attributable to open versus closed ankle fractures. There were 128 (12.2%) patients with open ankle fractures. Patients with open ankle fractures were more likely to be older, to be active smokers (OR = 1.7, p = 0.049), and tended to have a higher number of medical comorbidities including hypertension (OR = 2, p = 0.006) and chronic kidney disease (OR = 2.9, p = 0.005). Open ankle fractures were, independently of comorbid conditions and age, associated with higher risk of mortality (HR = 1.7, p = 0.03).

Risk factors and nomogram predictive model of surgical site infection in closed pilon fractures

OBJECTIVES

In this study, we try to investigate the risk factors of postoperative surgical site infection (SSI) in closed pilon fractures and establish a nomogram prediction model.

METHODS

From January 2012 to June 2021, 516 closed pilon fracture patients were included in this study. Of these, 387 patients were randomly assigned to the training group and 129 patients were assigned to the validation group (3:1). By univariate and multivariate Cox analysis, we identified independent risk factors for postoperative SSI after Pilon fracture. We established a nomogram model and used receiver operating characteristic (ROC) and calibration chart to evaluate its discriminant and calibration.

RESULTS

SSI occurred in 71 patients in the training group and 23 patients in the validation group. Ultimately, age, preoperative blood sugar, operative time, Tscherne classification and fracture classification were identified as independent risk factors for SSI. The AUC values for SSI of the training and validation group were 0.898 and 0.880, and the P value of the Hosmer-Lemeshow test was 0.125. We established a nomogram prediction model based on age, preoperative blood sugar, operative time, Tscherne classification and fracture classification.

CONCLUSION

Our nomogram model had good discrimination and calibration power, so it could be used to predict SSI risk in patients with pilon fracture.

Can CT-based assessment of lateral malleolus anatomy indicate when and how to perform an intramedullary fixation in distal fibula fractures? An analysis of 150 ankles

PURPOSE

The primary aim was to analyse the lateral malleolus morphology with a focus on the shape of the distal fibula for IM fixation of the fibula in infra- and transsyndesmotic fracture patterns. The secondary aim was to propose a treatment algorithm according to the lateral malleolar anatomy.

METHODS

77 healthy, skeletally mature volunteers underwent CT scanning of the ankle. The fibula medullary canal and its cortical thickness were quantitatively analysed at 4 different levels measured from the fibular tip (1.5 cm, 3.0 cm, 4.5 cm, and 6.0 cm). A geometric classification was proposed, and a decision algorithm was developed. Statistical significance was set at a p-value < 0.05.

RESULTS

The smallest diameter of the medullary canal of the fibula was at 6.0 cm from the tip of the fibula, in 98.2% of the ankles. The distal fibula can be classified into triangular and rectangular type, according to the cortical thickness index (p < 0.0001). In 16.7% ankles, the internal diameter of the fibula at 6.0 cm was equal or narrower than 3.5 mm (p < 0.05).

CONCLUSION

The shape of the distal fibula as evaluated by CT-guided analysis allows for IM osteosynthesis of the lateral malleolus in 83% of individuals. In our study, the smallest diameter of the medullary canal of the fibula was located 6.0 cm from the tip of the lateral malleolus. Coronal CT evaluation is advantageous in indicating which type of IM implant should be used safely for infra- and transsyndesmotic fracture patterns, potentially reducing intraoperative risks.

Association of Bleeding Disorders and Risk of Complications Following Open Reduction and Internal Fixation of the Ankle

BACKGROUND

Open reduction and internal fixation (ORIF) of the ankle is a common procedure performed to correct ankle fractures in many different patient populations. Diabetes, peripheral vascular disease, and osteoporosis have been identified as risk factors for postoperative complications following surgery for ankle fractures. To date, there have not been any studies evaluating postoperative outcomes in patients with bleeding disorders undergoing operative treatment for ankle fractures. The aim of this study was to determine the postoperative complication rate following ORIF of the ankle in patients with a bleeding disorder vs those without a bleeding disorder.

METHODS

From 2006 to 2018, patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database. Two patient cohorts were defined: patients with a bleeding disorder and patients without a bleeding disorder. Patients who underwent either inpatient or outpatient ORIF of the ankle were included in this study. In this analysis, demographics, medical comorbidities, and postoperative complications variables were assessed between the 2 cohorts. Bivariate and multivariate analyses were performed.

RESULTS

Of 10 306 patients undergoing operative treatment for ankle fracture, 9909 patients (96.1%) had no bleeding disorder whereas 397 patients (3.9%) had a bleeding disorder. Following adjustment on multivariate analysis, compared to patients who did not have a bleeding disorder, those with a bleeding disorder had an increased risk of any postoperative complications (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.05-2.08, P = .024), requirement for postoperative blood transfusion (OR 2.86, 95% CI 1.53-5.36, P = .001), and extended length of hospital stay greater than 5 days (OR 1.46, 95% CI 1.10-1.93, P = .010).

CONCLUSION

Patients with bleeding disorders are associated with increased risk of postoperative complications following ORIF for ankle fractures. Determining patient risk factors and creating optimal preoperative and perioperative management plans in patients with bleeding disorders undergoing ORIF can be beneficial in reducing postoperative complications, improving patient outcomes, and reducing overall morbidity.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Extended length of stay and postoperative complications in octogenarians with hypertension following revision total knee arthroplasty

BACKGROUND

Prior studies have shown hypertensive patients to be at an increased risk of postoperative complications following various surgeries, including revision total knee arthroplasty (rTKA). However, whether these risks are compounded in octogenarian patients has not yet been well explored. The purpose of this study was to analyze whether hypertensive octogenarians, aged 80 to 89, undergoing rTKA are at an increased risk of postoperative complications relative to the younger hypertensive geriatric population aged 65 to 79.

METHODS

A national database was used to collect data for all hypertensive patients who underwent rTKA from 2006 to 2018. Patients were stratified into an aged 65 to 79 cohort and an aged 80 to 89 cohort. Demographics, medical comorbidities, and postoperative complications were compared between the two cohorts. Bivariate and multivariate analyses were performed.

RESULTS

Of the 6,599 hypertensive patients who underwent rTKA, 5,477 (83.0%) patients were in the aged 65 to 79 group and 1,122 (17.0%) patients were in the aged 80 to 89 group. Following adjustment to control for demographic and comorbidity data, relative to patients in the 65 to 79 age group, hypertensive patients who were 80-89 years old had an increased risk of unplanned reintubation (OR 3.52; p = 0.008), urinary tract infection (OR 2.08; p = 0.011), postoperative transfusion (OR 1.90; p < 0.001), myocardial infarction (OR 2.55; p = 0.017), and extended length of hospital stay (OR 1.77; p < 0.001).

CONCLUSION

Hypertensive octogenarian patients undergoing rTKA have an increased risk of an extended length of stay and other postoperative complications relative to their younger hypertensive geriatric counterparts. Orthopaedic surgeons should consider a multi-disciplinary approach to managing hypertension in these octogenarian patients prior to surgery to minimize this risk. However, even with this risk, an octogenarian age should not be used independently in evaluating if a hypertensive geriatric patient is a safe rTKA candidate.