Abstract: Predictors of Adverse Outcomes in the Management of Mandibular Fractures: An Analysis of 953 Cases

Abstract

PURPOSE: Mandibular fractures are the most common isolated facial fractures in the United States and often require surgical treatment with open reduction and internal fixation to prevent infection and promote adequate bone healing. Various clinical risk factors have been associated with increased rates of postoperative complications, including smoking, substance abuse, and surgical approach. However, national outcomes reports are limited, and data are conflicting. Using a national multi-institutional database, we sought to analyze 30-day outcomes after mandibular fracture repair and determine risk factors for complications, readmission, and reoperation. METHODS: Retrospective review of the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was performed to identify patients undergoing surgical treatment of mandibular fractures between 2010 and 2015. Case distribution was based on available CPT codes and included open treatment of mandible fracture with external fixation (21454), open treatment of mandible fracture with and without interdental fixation (21462, 21461), and open treatment of complex fractures involving multiple approaches (21470). Preoperative demographic data and postoperative outcomes were analyzed. Primary outcomes included: wound complications (superficial surgical site infection (SSI), deep SSI, and wound dehiscence), overall complications (wound complications and/or medical complications), as well as 30-day readmission and reoperation rates. For risk factors significant on univariate analysis, multivariate analysis was performed to control for confounders. RESULTS: Review of the database identified 953 eligible patients who underwent surgical treatment of mandibular fractures. Mean age was 34.5 years and 84% of the cohort was male. Fifty percent of patients were active smokers. Wound complications occurred in 38 patients (4.0%) and the overall complication rate was 7.9%. The 30-day reoperation and readmission rates were 2.2% and 3.3%, respectively. Multivariate analysis demonstrated age to be a significant risk factor for 30-day readmission (OR = 1.06, p=0.01) and reoperation (OR = 1.05, p=0.01), as well as overall complications (OR = 1.03, p=0.02). Additionally, active smoking was a significant risk factor for 30-day reoperation (OR = 4.86, p=0.03). The odds of readmission for smokers was more than 3 times higher than non-smokers (OR=3.25; 95% CI 0.93–11.43); however, this approached but failed to reach our threshold for statistical significance (p=0.07). CONCLUSION: Our analysis demonstrates that surgical treatment of mandibular fractures can be performed safely and with low rates of wound and overall complications. However, increased age is an independent risk factor for readmission, reoperation, and overall complications. Active smoking was also found to be an independent risk factor for reoperation, with active smokers nearly five times as likely to undergo additional surgery. This is a particularly important finding given that over half of all mandibular fracture patients in our nationwide study were active tobacco users, highlighting the importance of patient education and smoking cessation in the perioperative period within this population.