Variations in Gender and Ethnicity Among Unstable Ankle Fractures and Postoperative Outcomes

Category:

Trauma; Ankle

Introduction/Purpose:

Ankle fractures are one of the most common conditions treated by orthopaedic surgeons. Many of these injuries are unstable and require surgical open reduction and internal fixation (ORIF) for optimal treatment. While much has been published regarding surgical management and post-operative outcomes of unstable ankle fractures, there are scant epidemiological studies regarding this subject. The purpose of this study is to evaluate the epidemiology of unstable ankle fractures and post-surgical outcomes at an academic hospital and tertiary care center in an urban setting with particular attention paid to gender and ethnicity in this patient population.

Methods:

Patients that incurred unstable ankle fractures and received surgical ORIF as treatment between January 2011 and August 2020 were reviewed retrospectively and included in this study. Patients' gender, ethnicity, age, body mass index (BMI), medical co-morbidities, smoking status, surgical diagnoses, and procedures were recorded. Exclusion criteria included ankle fractures that were (1) open, (2) treated nonsurgically, (3) seen initially at or after 4 weeks from the time of injury, and (4) in skeletally immature patients. Post-surgical complications and the need for further surgical treatment was documented. Data analysis was performed using the Statistical Package for the Social Sciences (IBM SPSS, Version 24.0. Armonk, NY: IBM Corp). Chi- square analysis was used to identify factors associated with varying incident fracture types and postoperative complications. Logistic regression, reported as an odds ratio, was used to confirm and characterize associations of significance. A p-value less than 0.05 was considered statistically significant.

Results:

304 eligible patients had ankle fractures that received ORIF. 65% and 35% of patients were female and male respectively. 50.0%, 24.0%, 17.8%, and 3.3% of patients were Black, Latino, White, and Asian respectively. 46.4%, 28.3%, and 25.3% of patients had a unimalleolar, bimalleolar, and trimalleolar fracture respectively. Men had 42.4% and 47.3% decreased odds of medial and posterior malleolar fracture respectively with 96% increased odds of syndesmotic injury compared to women. Black patients had 150% increased odds of syndesmotic injury compared to other ethnicities. Rate of post-operative complications was 11.5%, where painful implants to necessitate surgical removal as treatment was the most common post-surgical adverse event. Black and Latino patients had a 75.6% and 69.7% decreased odds of having complications respectively compared to White patients.

Conclusion:

This study provides valuable information upon unstable ankle fractures and post-surgical outcomes with regard to differences in gender and ethnicity. Women were at higher odds for having a medial and posterior malleolar fracture and lower odds for having syndesmotic injury than men. White/Caucasian patients were at higher odds for post-surgical complications than those from other ethnicities. Further study in larger populations may be needed to confirm these findings.

The Optimized Oxford Hip Skeletal Maturity System Proves Resilient to Rotational Variation

BACKGROUND

The recently described optimized Oxford skeletal maturity system utilizes anteroposterior (AP) hip radiographs to accurately, rapidly, and reliably estimate skeletal maturity. However, in the real-world setting, significant positional variation in AP hip radiographs may influence the accuracy of optimized Oxford skeletal age estimates. We sought to evaluate the consistency of skeletal age estimations using the optimized Oxford system between differently rotated radiographs.

METHODS

Thirty normal computerized tomography scans of males (15 children, 9 to 15 y) and females (15 children, 8 to 14 y) were obtained retrospectively, converted into 3D reconstructions, and then used to produce simulated hip radiographs in five different rotational positions. The optimized Oxford system was applied to the 150 simulated AP hip radiographs (5 differently rotated views of 30 hips) to produce a skeletal age estimate for each.

RESULTS

Rotational position did not have a statistically significant effect on the skeletal age (P=0.84) using 1-way repeated measures analysis of variance. Of the 5 radiographic parameters in the optimized Oxford system, only greater trochanter height showed significant rotational variation after Greenhouse-Geisser correction (F2.58, 74.68=5.98, P<0.001). However, post hoc analyses showed that the greater trochanter height obtained at the most centered position was not different from the other 4 rotational positions (P>0.05 for all).

CONCLUSION

The optimized Oxford skeletal maturity system is resilient to rotational variation. Mildly to moderately rotated radiographs obtained in the modern clinical setting can be used for skeletal age estimation by this method, broadening the clinical usage of this system.

LEVEL OF EVIDENCE

Level III-diagnostic study.

Skeletal Maturity Using Knee X-rays: Understanding the Resilience of 7 Radiographic Parameters to Rotational Position

BACKGROUND

Recently, a skeletal maturity system using knee radiographs, named the modified Roche-Wainer-Thissen (RWT) system, has been developed using 7 discrete radiographic parameters. While the system has been shown to significantly outperform the Greulich and Pyle atlas, the effect of rotational variation of the knee radiograph on skeletal maturity determinations has not been studied.

METHODS

Normal knee computed tomography scans of 12 male children ages 10 to 16 years and 8 female children ages 8 to 14 years were obtained retrospectively, converted into 3-dimensional reconstructions, and then used to simulate knee radiographs in 5 different rotational positions. Images were graded using the modified RWT system, and 1-way repeated measures analysis of variance was used to compare skeletal age in the patella centered view versus the other positions. We next retrospectively found 85 pediatric patients with both bilateral standing anteroposterior hip to ankles and separate knee radiograph within 6 months of each other. The skeletal maturity values from the 2 different radiographs were compared in 39 males between the ages of 10 and 16 years and 46 females between 8 and 14 years of age using paired t test and Wilcoxon-signed rank test.

RESULTS

On the computed tomography scan-based images, there was no statistically significant effect of rotational position on the modified RWT score using repeat measures analysis of variance (P=0.210). Only the width ratio of the tibial epiphysis and metaphysis and the width ratio of the fibular epiphysis and metaphysis were statistically different between rotational positions (P<0.05). Comparing clinical full length versus knee radiographs, we found a small difference of 0.069 years which trended towards a statistically significant difference (P=0.009).

CONCLUSIONS

This retrospective study supports the resilience of the RWT model to rotational variation, reassuring clinicians that bone age estimation can be performed in a slightly rotated knee x-ray within a reasonable margin of error. These results can minimize the number of radiographs needed to assess skeletal maturity limiting radiation exposure and expedite clinical flow.

LEVEL OF EVIDENCE

Level-III-diagnostic study.

Patient-Reported Complications after Intravitreal Injection and Their Predictive Factors

Purpose

The intravitreal injection (IVI) of pharmacologic agents is the most commonly performed ocular procedure and is associated with a host of complications. Most IVI-related complications data are derived from randomized controlled clinical trials, which report a high adverse event rate. The nature of these protocol-driven trials limit their applicability to the diverse circumstances seen in routine clinical practice. The goal of this study was to determine the prevalence of patient-reported IVI-related complications, their risk factors, and the manner in which patients sought treatment at a tertiary eye care center.

Design

Retrospective, institutional review board–approved study.

Participants

Forty-four thousand seven hundred thirty-four injections in 5318 unique patients at the Cleveland Clinic Cole Eye Institute from 2012 through 2016.

Methods

Intravitreal injection.

Main Outcome Measures

Complication occurrence within 15 days of injection.

Results

From 2012 through 2016, a total of 44734 injections were performed in 5318 unique patients. Overall, complication rates were low, representing 1.9% of all injections, with 1031 unique complications in 685 patients (12.9%). The most common minor complications, or those not requiring intervention, were irritation (n = 312) and subconjunctival hemorrhage (n = 284). The most common serious complications, or those requiring intervention, were corneal abrasion (n = 46) and iritis (n = 31). Most complications (66%) were managed adequately by a telephone or Epic (Epic Systems Corp., Verona, WI) electronic message encounter only. Importantly, no injection protocol parameter, such as type of anesthesia, preparation, or post-injection medication, increased the risk of a complication. However, a patient’s gender, age, number of previous injections, and provider strongly influenced the risk of patient-reported complications.

Conclusions

Overall, complication rates seen in routine clinical practice were low compared with clinical trial reporting. Providers should feel confident in the safety and administration of IVI during times when follow-up office visits and resources may be limited. When performing an IVI, factors such as a patient’s gender, age, number of previous injections, and provider must be taken into account to ensure the best possible outcomes.