Open Reduction And Internal Fixation Of Ankle Fractures Research Articles

Predicting surgical site infections after open reduction and internal fixation for ankle fractures

IntroductionSurgical site infections (SSI) are one of the more severe complications following ankle surgery. It is associated with worse outcomes and re-admissions. Therefore, identification of risk factors is essential. The aim of this study was to identify risk factors for SSI in patients undergoing surgery for ankle fractures.Materials and methodsA retrospective study was performed in a large cohort (n = 929) of patients who underwent open reduction and internal fixation (ORIF) of ankle fractures between 2015 and 2020 in the Netherlands. The primary outcome variables included rate of SSI (superficial or deep) and deep SSI. Prediction factors were categorized as patient-related, injury-related and treatment-related.ResultsThe incidence rate was 9.36% for SSI and 3.55% for deep SSI. Univariate analysis showed significant associations for higher age (p < 0.001), DM (p = 0.018), ASA 2 and 3 (p = 0.013 and p < 0.001), bi- and trimalleolar fractures (p = 0.021 and p = 0.013), open fractures (p = 0.004) and small size plate compared to screw fixation (p = 0.027). The only independent significant risk factor for SSI in multivariate analysis was open fracture. For deep SSI the significant risk factors were DM (p = 0.039), ASA 3 and 4 (p = 0.001 and p = 0.005) and open fracture (p = 0.002). After multivariate analysis, the independent significant risk factors were open fracture and ASA 3 and 4.ConclusionsHigher age, DM, ASA 2 and 3, bi- and trimalleolar fractures, open fractures and standard plate-size implant placement were identified as significant risk factors for SSI. Open fracture was the only significant independent risk factor for SSI after ORIF of ankle fractures. In deep SSI, there were different risk factors. DM, ASA 3 and 4, and open fractures were significantly associated. Although, open fracture and ASA 3 and 4 were the significant independent risk factors.

Perioperative Antibiotic Choice Does Not Affect Wound Complications in the Operative Treatment of Ankle Fractures.

Background and aims Ankle injuries are one of the most common lower extremity traumas reported, with nearly half needing surgical intervention. For those who undergo surgicaltreatment, surgical site infection (SSI) is not a rare complication. Cefazolin is therecommended preoperative surgical chemoprophylaxis for surgical site infection.This exploratory study sought to evaluate the efficacy of cefazolin prophylaxis atthe time of primary open reduction and internal fixation (ORIF) for ankle fracturescompared to the efficacy of non-cefazolin chemoprophylaxis with respect towound complications. Methods A single-center retrospective study of adult patients who underwent open reduction and internal fixation (ORIF) of a closed ankle fracture between January 1, 2012, and April 11, 2023, was conducted at Good Samaritan University Hospital. Patients were compared based on the perioperative antibiotic received per our hospital's guidelines: cefazolin (given by weight: 2 g < 120 kg and 3 g ≥ 120 kg) or a non-cefazolin alternative for a reported cefazolin or penicillin allergy (clindamycin 900 mg and/or vancomycin 1 g < 80 kg or 1.5 g ≥ 80 kg). Group 1 consisted of 132 patients who underwent ORIF of the ankle after having received cefazolin. Group 2 consisted of 19 patients who underwent ORIF of the ankle after having received a non-cefazolin antibiotic. The outcomes measured were postoperative infection, infection requiring surgery, and dehiscence. Associations between the American Society of Anesthesiologists (ASA) physical classification score, body mass index (BMI), and ankle fracture classification and our primary outcomes were also reviewed. Results Of the 151 patients, 22 patients were reported to have complications. Complications were defined as postoperative infection, infection requiring surgery, and dehiscence. There was no statistically significant difference in these complication rates (infection, p = 0.9; infection requiring surgery, p = 0.6; and dehiscence, p = 0.5) between the cefazolin and non-cefazolin cohorts. The average follow-up time after surgery in both groups was eight months. Conclusions There were no significant differences in complication rates between the cefazolin and non-cefazolin cohorts. In turn, prophylactic antibiotic type, among those reported in this study, does not appear to be a prominent influence on the rate of wound complications in ORIF of ankle fractures. The sample size of this study, however, is a major limitation. These results can help guide a larger study of the efficacy of antibiotic chemoprophylaxis choice in ankle ORIF surgeries.

5-Item Modified Frailty Index Score is Associated with Increased Postoperative Complications Following Ankle Fracture ORIF

Category: Trauma; Ankle Introduction/Purpose: Ankle fractures are among the most common injuries in orthopaedics and often require surgical management to obtain a stable mortice. It is essential to quantify preoperative risk for patients undergoing ankle fracture repair, but a consensus regarding an optimal risk stratification model does not currently exist. The 5-factor modified frailty index (mFI-5) has been found to be an independent predictor of postoperative complications following numerous orthopaedic procedures, but its efficacy has not been evaluated in patients undergoing ankle fracture open reduction and internal fixation (ORIF). This study aims to analyze the effect of preoperative mFI-5 on 30-day complication, readmission, reoperation, and mortality rates following ankle fracture procedures. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2005-2019 to identify 44,755 patients undergoing ankle fracture ORIF using Current Procedural Terminology (CPT) codes 27766, 27792, 27814, 27822, and 27823. Patients were stratified into groups based on preoperative mFI-5 scores, which incorporate the presence of chronic obstructive pulmonary disease, pneumonia, congestive heart failure, non-independent functional status, and diabetes into a composite risk index. Demographics, hospital length of stay (LOS), and 30-day complication, surgical site infection (SSI), Clavien-Dindo grade IV (CDIV) complication, readmission, reoperation, and mortality rates were compared between groups. The cohort was predominantly male (59.0%) and the mean age was 49.52 (range, 16-89) years. Preoperative mFI-5 was also used as a categorical variable when analyzing postoperative outcomes. Results: A total of 44,838 patients met criteria for inclusion, with the majority of patients having an mFI-5 score of 0 (mFI-5:0=65.1%, mFI-5:1=27.0%, mFI-5:2=6.5%, mFI-5:3=1.1%, mFI-5:4=0.2%). The mFI-5 score was a predictor of serious medical complications (myocardial infarction, sepsis, pulmonary embolism, postoperative dialysis, prolonged ventilator requirement, SSI, blood transfusion, DVT/thrombophlebitis, and pneumonia), adverse discharge to a facility, readmission, and reoperation. (Table 1) Mortality was strongly predicted by mFI-5 with the risk more than tripling for each point increase in mFI-5 score (odds ratio (OR)=3.639, 95% CI= 3.038-4.360). Lastly, LOS was also found to increase with mFI-5 with the average length of stay increasing by 1.44 days per increase in mFI-5 score. Conclusion: Our results indicate that mFI-5 score is useful as a predictive measure for postoperative complications, adverse discharge, readmission, reoperation, mortality, and length of stay for patients undergoing ankle ORIF. The variables considered by mFI-5 are easily obtained through a patient history, making this scale a practical measure to identify patients at increased risk for postoperative outcomes.

Differences in Intraoperative Fluoroscopic Radiation Exposure during Ankle Fracture ORIF between Orthopaedic Surgery and Podiatry

Category: Ankle; Trauma Introduction/Purpose: Operative ankle fractures pose a unique situation as both podiatrists and orthopaedic surgeons manage these injuries. Intraoperative fluoroscopy is routinely used, however, excessive radiation can be harmful to both the patient and surgical team. The primary aim of this study is to determine if there is a difference in the amount of intraoperative radiation exposure during ankle fracture open reduction and internal fixation (ORIF) when performed by orthopaedic surgeons versus podiatrists. Methods: This is a retrospective review of patients who underwent ankle fracture ORIF at an urban level I trauma center between January 1st, 2018 and April 1st, 2023. The electronic health record was queried using International Classification of Diseases nine and 10 codes associated with ankle fractures. Patients greater than 18 years of age with an ankle fracture managed operatively were included. Subjects were then stratified by procedure. Mean total radiation dose (mRad) and mean total fluoroscopic time (seconds) were then compared between those performed by orthopaedic surgeons and podiatrists. Results: Of the 333 included procedures, 186 were performed by orthopaedic surgeons and 147 were performed by podiatrists. Using multiple linear regression analysis to control for age, sex, race, ethnicity, and body mass index, patients undergoing isolated malleolus ORIF with syndesmosis repair performed by orthopaedic surgery were found to have a significantly lower mean fluoroscopic time compared those performed by podiatry (68.4s versus 104.8.s; p = 0.0280). Additionally, trimalleolar ORIF with syndesmotic repair performed by orthopaedic surgery had a significantly lower mean total radiation dose compared to those performed by podiatry (244.6 mRad v 565.6 mRad; p = 0.0090). Conclusion: Patients and surgical teams are exposed to significantly less radiation in isolated malleolar and trimalleolar fracture ORIF with syndesmosis repair when performed by an orthopaedic surgeon as compared to those performed by a podiatrist.

Cannabis Use and Postoperative Risks: A Comprehensive Analysis of Medical Complications Within 90 Days Following Ankle Fracture Fixation

Category: Ankle; Trauma Introduction/Purpose: As medical and recreational cannabis use continues to increase in prevalence across the United States, it is important to understand how cannabis can impact health. Though prior studies have shown that cannabis use can result in delayed bone healing, there is a paucity of literature examining the relationship between cannabis use and postoperative medical outcomes following fracture fixation. Therefore, the purpose of this study was to investigate the relationship between cannabis use and the incidence of medical complications within 90 days of surgical fixation of ankle fractures. Methods: A retrospective review of a national insurance claims database was performed from 2010 to 2022. Patients who underwent open reduction and internal fixation (ORIF) procedures for medial malleolus fractures, lateral malleolus fractures, distal fibula fractures, bimalleolar fractures, and trimalleolar fractures were identified using CPT codes. Of those patients, those with established diagnoses of cannabis use disorder, cannabis dependency, or cannabis addiction were identified using ICD-9 and -10 codes. This cannabis cohort was matched 1:4 on the basis of age, sex, and Charlson Comorbidity Index (CCI) to a control cohort without a history of cannabis use to remove potential confounding upon comparison. Demographic and comorbidity profiles, as well as medical and surgical post-operative outcomes were compared using Chi-square tests. Results: Out of 788,702 patients undergoing ankle fracture open reduction and internal fixation (ORIF) during the study period, 46,105 had documented cannabis use. Cannabis cohort, compared to controls, exhibited significant differences: younger age (mean 38.8 vs. 52.7 years; p&lt; 0.001), lower comorbidity-burden (mean CCI 1.58 vs. 1.68; p&lt; 0.001), and a higher proportion of male patients (51.1% vs. 33.2%; p&lt; 0.001). Following age, CCI, and sex matching, patients with cannabis use histories showed a significantly increased incidence of medical complications within 90 days post ankle fracture ORIF. Cannabis users displayed elevated rates of various complications compared to matched controls, including pneumonia, deep venous thrombosis, pulmonary embolism, myocardial infarction, stroke, surgical site infection, cardiac arrest, acute kidney injury, urinary tract infection, sepsis, and hypoglycemia (all p&lt; 0.001). Conclusion: Cannabis use is associated with increased incidences of many serious medical complications within 90 days of ankle fracture fixation procedures. These results underscore the importance of eliciting cannabis use history during preoperative patient evaluations so that physicians and patients can be better informed about the increased postoperative risks they may face, and so tailored perioperative care can be appropriately implemented. Further, these results emphasize the need for further research on the molecular mechanisms of cannabis to explain interactions that may predispose heavy cannabis users to this profile of adverse surgical outcomes.

Differences in Intraoperative Fluoroscopic Radiation Exposure During Ankle Fracture Open Reduction and Internal Fixation Between Orthopaedic Surgery and Podiatry.

Surgical ankle fractures pose a unique situation because both podiatrists and orthopaedic surgeons manage these injuries. Intraoperative fluoroscopy is routinely used; however, excessive radiation can be harmful to both the patient and the surgical team. The primary goal of this study was to determine whether there is a difference in the amount of intraoperative radiation exposure during ankle fracture open reduction and internal fixation (ORIF) when performed by orthopaedic surgeons versus podiatrists. This is a retrospective review of patients who underwent ankle fracture ORIF at an urban level I trauma center between January 1st, 2018, and April 1st, 2023. The electronic health record was queried using International Classification of Diseases nine and 10 codes associated with ankle fractures. Patients aged older than 18 years with an ankle fracture managed surgically were included. Subjects were then stratified by procedure. The mean total radiation dose (mRad) and mean total fluoroscopic time (seconds) were then compared between those performed by orthopaedic surgeons and podiatrists. Of the 333 included procedures, 186 were done by orthopaedic surgeons and 147 were done by podiatrists. Using multiple linear regression analysis to control for age, sex, race, ethnicity, and body mass index, patients undergoing isolated malleolus ORIF with syndesmosis repair performed by orthopaedic surgery were found to have a significantly lower mean fluoroscopic time compared with those performed by podiatry (68.4 s versus 104.8 s; P = 0.028). In addition, trimalleolar ORIF with syndesmotic repair performed by orthopaedic surgery had a significantly lower mean total radiation dose compared with those performed by podiatry (244.6 mRad v 565.6 mRad; P = 0.009). Patients and surgical teams are exposed to markedly less radiation in isolated malleolar and trimalleolar fracture ORIF with syndesmosis repair when performed by an orthopaedic surgeon as compared with those performed by a podiatrist.

To cast or not to cast? Postoperative care of ankle fractures: a meta-analysis of randomized controlled trials.

Postoperative care of ankle fractures treated with open reduction and internal fixation (ORIF) is a debated topic. A meta-analysis of Randomized Controlled Trials was conducted with the aim of comparing early mobilization and weightbearing to traditional postoperative protocols. A systematic search of electronic databases was conducted according to the PRISMA guidelines. Only randomized clinical trials were included. Data about clinical outcome, time to return to work and complications were extracted and summarized. Meta-analyses were performed. Twenty studies for a total of 1328 patients were included. Early mobilization was compared to immobilization in 724 patients: the two groups did not significantly differ in terms of short- and long-term clinical outcome (p = 0.08 and p = 0.41, respectively). However, early mobilization resulted to be significantly associated with faster return to work (p = 0.047). Early weightbearing was compared to nonweightbearing in 1088 patients. While the clinical difference between the two groups was not significant at short term (p = 0.08), it was significant at long term (p = 0.002). No other significant differences, in particular regarding complications, were highlighted between different groups. Early motion, early weightbearing and traditional postoperative protocols are all safe strategies after ORIF for unstable ankle fractures. Early mobilization is significantly associated with faster return to work and early weightbearing improves long term clinical outcome.Level of evidence: I.

Ankle fracture open reduction and internal fixation in patients with cerebral palsy.

To examine patients with cerebral palsy (CP) undergoing open reduction and internal fixation (ORIF) for ankle fractures. This was a retrospective study of adult patients undergoing ankle fracture ORIF for closed, isolated ankle fractures identified in between 2010 and 2021 in the Q1 PearlDiver M151 database. Patients with CP were identified with International Classification of Diseases (ICD)-9 and ICD-10 codes, and were matched to those without 1:10 on age, sex, and Elixhauser comorbidity index (ECI). Ninety-day adverse events were assessed with multivariable logistic regression. A total of 148 993 patients with isolated ankle fracture ORIF were identified, of whom 407 (0.27%) had CP. After matching, 3863 without CP were compared to 389 with CP. Patients with CP were at increased odds of: 90-day urinary tract infection (odds ratios [OR] 6.26), pneumonia (OR 3.50), minor adverse events (OR 3.46), sepsis (OR 3.30), any adverse events (OR 3.04), emergency department visits (OR 2.28), serious adverse events (OR 1.77), and prolonged length of stay more than 4 days (OR 22.44) (p < 0.001 for all). Patients with CP undergoing ORIF for isolated, closed ankle fractures are at increased odds of several 90-day adverse events and prolonged length of stay compared to matched patients without CP.

Comparison of Patient Demographics and Risk of Surgical Site Infections Following Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures: A Nationwide Analysis of a Private Payor

Surgical site infections (SSIs) are a notable complication following open reduction and internal fixation (ORIF) for ankle fractures. The purpose of this study was to (1) compare baseline demographics of patients who did and did not develop SSIs within 90 days following ORIF for trimalleolar ankle fractures and (2) identify risk factors associated with SSIs in this setting. A retrospective analysis from 2010 to 2020 was completed using a national administrative database. The study group consisted of patients who underwent ORIF for trimalleolar ankle fractures and developed SSIs within 90 days postoperatively. Patients without SSIs served as the comparison cohort. Baseline demographics of the two cohorts were compared utilizing Pearson's Chi-Square Analyses. A multivariate binomial logistic regression model determined the association of various comorbidities on developing SSIs in this setting. Out of a total sample of 22,118 patients, 1000 individuals (4.52%) developed SSIs. The study revealed that the SSI cohort exhibited a greater burden of comorbidities, as evidenced by significant differences in various individual comorbidities and average Elixhauser-Comorbidity Indices scores. The most strongly associated risk factors for the development of SSIs following ORIF for trimalleolar ankle fractures were peripheral vascular disease (OR: 1.53, p < .0001), diabetes mellitus (OR: 1.26, p = .0010), iron deficiency anemia (OR: 1.24, p = .0010), male sex (OR: 1.22, p = .0010), and tobacco use (OR: 1.15, p = .0010). This study identified several patient risk factors that were associated with developing SSIs after ORIF for trimalleolar ankle fractures, recognizing potential patient-directed interventions that may reduce the rate of SSIs in this setting.

Wound complication risk factors following open reduction and internal fixation of ankle fractures.

This study was designed to identify risk factors for wound complications including surgical site infection (SSI) and wound healing issues following open reduction and internal fixation (ORIF) of ankle fractures. A retrospective analysis of individuals with ankle fractures treated with ORIF was undertaken. Study subjects were divided into a wound complications (WC) group and a no wound complication (NWC) group. The WC group was further divided into an SSI group and wound healing issues group. Twenty-one potential risk factors associated with wound complications after ORIF were tracked. Uni- and multivariate binary logistical regression analyses were used to identify risk factors associated with wound complications, ISS and wound healing issues. In total, 613 individuals, who had undergone surgery for ankle fractures formed the study cohort. The incidence of postoperative wound complications was 10.3% (63 cases), including 5.2% of SSI (32 cases) and 5.1% of wound healing issues (31 cases). The independent risk factors for wound complications were age 65 years or older, preoperative serum albumin level below 35 g/L, peripheral neuropathy, open fracture, fewer than seven cases per year in surgical volume, and attending surgeon level. The independent risk factors for SSI were age 65 years or older, preoperative serum albumin level below 35 g/L, open fracture and fewer than seven cases per year in surgical volume. The independent risk factors for wound healing issues were preoperative serum albumin level below 35 g/L, peripheral neuropathy, open fracture and attending surgeon level. Herein we found both factors inherent to the injury and individual and those pertaining to the surgical team affected the frequency of wound complications after ORIF of ankle fractures. Specifically, advanced age and low surgical volume were associated with a greater risk of SSI. Peripheral neuropathy and the low expertise level on the part of the surgeon were associated with a greater risk of wound healing issues. Hypoproteinaemia and open fracture were both associated with a greater risk of both SSI and wound healing issues.

How Does Alcohol Use Disorder Impact Morbidity, Readmission Rates, and HealthCare Expenditures Following Open Reduction and Internal Fixation of Bimalleolar Fractures?

Category: Ankle; Trauma Introduction/Purpose: Bimalleolar ankle fractures are a common injury that can be treated with open reduction and internal fixation (ORIF). However, there is a paucity of literature evaluating the impact of patients with alcohol use disorder (AUD) on postoperative complications following ORIF of bimalleolar ankle fractures. Therefore, the purpose of this study is to investigate whether patients with AUD undergoing ORIF of bimalleolar ankle fractures have higher odds of (1) morbidity; (2) readmissions; and (3) costs of care. Methods: A retrospective query of the PearlDiver nationwide claims database was performed between January 2010 and October 2020. Baseline demographics were analyzed using Pearson’s Chi-Square Analyses. Multivariate binomial logistic regression was utilized to calculate the effect of AUD on 90-day medical complications. Costs of care were compared using Welch’s t-tests. A P value less than 0.001 was considered to be statistically significant. Results: The query yielded 64,563 patients within the study (AUD = 8,177; control = 56,386). Patients who have AUD were found to have significantly higher incidence and odds of developing 90-day medical complications (59.35% vs. 18.77; OR: 2.30; 95% CI: 2.16 to 2.46; p &lt; 0.0001). AUD patients were found to have higher incidences of 90-day readmissions (9.14% vs. 5.56; OR: 0.95; 95% CI: 0.86 to 1.05; p=0.361); however, this failed to reach statistical significance. Patients with AUD also incurred significantly higher day of surgery costs ($4,433.33 vs. $3,979.85, p&lt; 0.0001) and 90-day episode of care costs ($8,523.40 vs. $6,976.95, p&lt; 0.0001). Conclusion: AUD patients have higher odds of 90-day postoperative complications and costs of care following ORIF of bimalleolar ankle fractures. The findings of this study can be used by orthopaedic surgeons to reduce healthcare costs as well as improve postsurgical outcomes by educating patients who have AUD on the potential complications that they may encounter after their procedure.

Prospective Randomized Controlled Trial Between Fibula Intramedullary Nail Fixation vs Open Reduction and Internal Fixation for the Surgical Management of Unstable Ankle Fractures

Category: Ankle; Trauma Introduction/Purpose: The fundamental concept of open reduction and internal fixation (ORIF) of unstable ankle fractures was anatomical reduction and firm fixation that allow early mobilization and rehabilitation. On the other hand, ORIF of ankle fractures is associated with complications including wound dehiscence, necrosis and infection, prominent hardware and failure. Closed reduction and intramedullary fixation (CRIF) using fibula nail was emerged as additional surgical option for unstable ankle fractures especially in elderly and medical high-risk patients. We hypothesized that fibula nailing for unstable ankle fractures would have similar functional outcomes to standard ORIF. The purpose of this study is to perform a prospective randomized study to compare clinical outcomes, bone union, and postoperative complications between ORIF and CRIF using fibula nail. Methods: A total of 59 patients (32 men, 27 women) with the mean age of 50.2 years were prospectively randomized to undergo standard ORIF or fibular nailing for unstable ankle fractures: those who underwent ORIF (31 patients 14 men, 17 women) and those who underwent CRIF using fibula nail (29 patients; 18 men and 11women). Exclusion criteria of fracture characteristics were open fracture and highly comminuted fibula fractures. Functional scoring including VAS, AOFAS and FAOS were evaluated at minimum postoperative 2 years follow up. In addition, union period, reduction status of fracture and ankle mortise at postoperative CT scan, complications including wound problem and posttraumatic arthritis were evaluated. Results: The VAS, AOFAS, and all FAOS subscales were not significantly different between two group at 2 years postoperatively (all, p&gt;0.05). Significantly fewer infections and wound complication occurred in the fibula nail group. (p &lt; 0.05; ORIF group (12.9%), fibula nail group (0%)). Postoperative at fracture site of fibula was high in fibula nail group (p &lt; 0.05; ORIF group (0%), fibula nail group (13.7%)), but there were no significant differences in the status of mortise and the rate of posttraumatic arthritis (all, p&gt;0.05). Conclusion: We concluded that the fibula nail allows acceptable reduction and secure fixation of unstable ankle fracture, with low soft tissue complication rate than ORIF. Considering the property closed reduction, the fibula nail would be an excellent treatment option for patients with unstable ankle fractures when indications is well selected

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.

Ninety-Day Emergency Department Visits After Ankle Fracture Surgery.

Emergency department (ED) visits after orthopaedic procedures such as ankle fracture open reduction and internal fixation (ORIF) have received less attention than other outcomes. This study analyzed 90-day ED visits after ankle fracture surgery in a national database to better characterize the incidence, timing, risk factors, and reasons. Ankle fractures undergoing ORIF were extracted from the PearlDiver M91Ortho 2010 to 2020Q3 data set. Patients were excluded for age younger than 18 years, presence of concomitant fractures, and <90 days of database follow-up. Patient age, sex, Elixhauser Comorbidity Index score, region of the country, and insurance plan were analyzed as predictors for 90-day ED utilization using multivariate logistic regression. Incidence of readmissions and incidence, timing, risk factors, and reasons for ED visits were determined. Of 87,662 ankle fracture ORIF patients identified, ED visits were noted within 90 days of surgery for 10,087 (11.5%) while 4,030 (4.6%) were readmitted. One ED visit was noted for 6,102 patients, two visits for 2,654, three visits for 787, and more than three visits for 544. The greatest weekly incidence of ED visits was observed in weeks 1 and 2, with 2.9% and 3.1% of the entire cohort visiting in each week respectively. Factors independently associated with 90-day ED utilization included younger age (odds ratio [OR] 1.21 per decade decrease, P < 0.001), greater Elixhauser Comorbidity Index score (OR 1.40 per two-point increase, P < 0.001), and Medicaid insurance (OR 1.92, P < 0.001). In the first two postoperative weeks, 71% of ED visits were attributed to issues directly involving the surgical site while in subsequent weeks, most visits did not involve the surgical site (65%). Many patients visit the ED after ankle fracture surgery. The greatest ED utilization was during the first two postoperative weeks, and reasons for visits were defined. These findings have implications for optimizing care pathways and targeting resource allocation.

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

Category: Ankle; Other Introduction/Purpose: 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 versus 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 two cohorts. Bivariate and multivariate analyses were performed. Results: Of 10,306 patients undergoing operative treatment for ankle fracture, 9,909 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 (OR 1.479; p=0.024), requirement for postoperative blood transfusion (OR 2.863; p=0.001), and extended length of hospital stay greater than 5 days (OR 1.455; p=0.010) (Table 1). Conclusion: Patients with bleeding disorders are at an increased risk of postoperative complications following ORIF for ankle fractures. Our study found that patients with bleeding disorders had greater odds of postoperative complications following ORIF of the ankle. 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 cost.

Cost Efficiency of Ankle Fracture ORIF at an Ambulatory Surgical Center vs Hospital

Category: Ankle; Trauma Introduction/Purpose: Ankle fracture open reduction and internal fixation (ORIF) is one of the most commonly performed orthopaedic surgeries, which can be performed at a variety of surgical locations. However, there is very little data exploring the cost and efficiency of ankle fracture ORIF in different operative settings. Time-Driven Activity Based Costing (TDABC) is a novel accounting method used to accurately assign costs for various procedures by creating a process map of all personnel interactions as a patient moves through a care event. Further, it has been shown to more accurately allocate costs, as compared to traditional accounting systems. Our purpose is to evaluate cost and efficiency differences in ankle fracture ORIF at an outpatient ambulatory surgery center (ASC) versus a hospital setting. Methods: A prospective cohort study was performed at a single academic medical center involving four orthopaedic surgeons. Patients were enrolled with uni-, bi-, or tri-malleolar displaced ankle fractures undergoing ORIF. According to TD-ABC methodology, a process map was created for each peri-operative platform and hand-timed data was collected at each location (ASC=5, hospital=5) by a single observer. In addition, retrospective cost data was obtained from 181 surgical cases using our institution's existing cost accounting system (ASC=34, hospital=147). Average event times and care costs were calculated for both locations, and a process map outlining the steps of care was created for each surgical site, according to TDABC methodology. Data were analyzed to investigate the effects of surgical site on labor cost, efficiency, and provider time. Results: Overall, total direct cost was similar between locations (ASC=$10,837.43, hospital=$9,377.80; p=.114), although there were significantly higher direct costs in the hospital: perioperative/anesthesia (ASC=$2,532.61, hospital=$4,594.20; p&lt;.001), pharmacy (ASC=$112.18, hospital=$349.74; p&lt;.001), radiology (ASC=$17.67, hospital=$227.98; p&lt;.001), and therapy (ASC=$28.23, hospital=$130.91; p&lt;.001). However, medical supply costs, including implant costs, were significantly higher at the ASC (ASC=$7,835.14, hospital=$2,459.60; p&lt;.001). Preoperatively, nurse assessment of the patient was significantly quicker in the hospital (ASC=14.65 min, hospital=5.10 min; p=.030), while patient transport to the operating room was significantly quicker in the ASC (ASC=1.20 min, hospital=2.60 min; p=.014). Case duration was significantly longer in the ASC (ASC=138.60 min, hospital=56.60 min; p=.005), which may have been influenced by case complexity, as there were more tri-malleolar fractures (n=2) and concomitate ankle arthroscopies (n=3) in that cohort. Conclusion: Overall, direct costs appear to be lower at the ASC than the main hospital, although efficiency of care delivery seems similar. Generally, there were small differences in the care continuum between the main hospital and ASC, though areas where improvement could be obtained include preoperative nurse assessment of the patient and efficacy of regional nerve block administration. Going forward, larger studies will be needed to further investigate these results.

Evaluating the Association of Anesthesia Type with Postoperative Complications in Patients Undergoing Ankle Fracture Repair

Category: Ankle Introduction/Purpose: General and neuraxial anesthesia are both successful anesthesia techniques used in many orthopaedic procedures. Neuraxial anesthesia involves local anesthetics placed around the central nervous system (CNS) and spinal anesthesia is a subtype where the anesthetic is injected into intrathecal space. General anesthesia is usually recommended in ambulatory surgeries for its rapid onset of action. However, current literature shows contradicting complication profiles between these two anesthesia types. The purpose of this study was to compare the complications and length of hospital stay between patients who underwent general anesthesia versus neuraxial anesthesia during the repair of ankle fractures. Methods: Patients undergoing open reduction and internal fixation (ORIF) for ankle fracture from 2014 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were stratified into 2 cohorts: general anesthesia and neuraxial anesthesia. In this analysis, demographics data, comorbidities, and postoperative complications were collected and compared between the two cohorts. Bivariate analyses and multivariable logistical regression were performed. Results: Of 3,585 patients who underwent operative treatment for ankle fracture, 3,315 patients (92.5%) had general anesthesia and 270 (7.5%) had neuraxial anesthesia. Compared to patients who had general anesthesia, those who had neuraxial anesthesia were more likely to be older (58.0 vs 49.6 years old; p&lt;0.001), Caucasian (80.0% vs 71.9%; p=0.001), and have an ASA classification of III (38.1% vs 25.0%; p&lt;0.001). On bivariate analyses, patients who had neuraxial anesthesia were more likely to develop pulmonary complications (p=0.173) or extended length of stay more than 5 days (p=0.342) compared to the general anesthesia group. Following adjustment on multivariate analyses, the neuraxial anesthesia cohort no longer had increased likelihood of pulmonary complications or extended length of stay compared to the general anesthesia group. Conclusion: Prior studies have shown that neuraxial anesthesia methods are as effective as general anesthesia with fewer short- term outcomes. When compared to patients who underwent general anesthesia during ORIF for ankle fracture, neuraxial anesthesia patients experienced no significant increases in postoperative complications or extended length of hospital stay. In terms of the variables we explored in the NSQIP database, healthy ankle fracture patients could also benefit from neuraxial anesthetic methods, and they should be considered for this anesthetic type regardless of their lack of comorbidities that would make them high risk for general anesthesia.

Sleep Apnea and Postoperative Medical Complications and Health Care Expenditures Following Open Reduction and Internal Fixation of Bimalleolar Ankle Fractures.

Sleep Apnea (SA) is a common sleep disorder that increases postoperative morbidity. There is limited research on how SA influences outcomes following operative fixation of ankle fractures. Therefore, the aim of this study was to determine whether patients who undergo surgical fixation for bimalleolar ankle fractures have higher rates of medical complications and health care expenditures. A retrospective review from January 1, 2005 to March 31, 2014 was conducted using the parts A and B Medicare Data from PearlDiver database. Patients with and without SA on the day of the primary open reduction and internal fixation (ORIF) of their bimalleolar ankle fractures were queried using the International Classification of Diseases, Ninth Revision codes. Welch'st-tests were used to compare costs of care. A multivariate binomial logistic regression model was used to calculate the odds ratio (OR) of adverse events. A P-value <.001 was considered statistically significant. There were 20 560 patients (SA = 3150; comparison cohort = 17 410) who underwent ORIF for bimalleolar ankle fractures during the study period. Sleep apnea patients were found to have significantly higher rates and odds of 90-day medical complications (21.42% vs 7.47%, OR: 3.11, P < .0001) and 90-day costs of care ($7213.12 vs $5415.79, P < .0001). This research demonstrates an increased risk of postoperative medical complications and health care costs among patients with SA undergoing ORIF for bimalleolar ankle fractures. Therapeutic, Level IV: Retrospective.

Utilization of Arthroscopy During Ankle Fracture Fixation among Early Career Surgeons: An Evaluation of the American Board of Orthopedic Surgery Part II Database

Category:Ankle; Arthroscopy; TraumaIntroduction/Purpose:Rotational ankle fractures are common injuries associated with high rates of intra-articular injury. Traditional ankle fracture open reduction and internal fixation (ORIF) techniques provide limited capacity for evaluation of intra- articular pathology. Ankle arthroscopy represents a minimally invasive technique to directly visualize the articular cartilage and syndesmosis while aiding with reduction and allowing joint debridement, loose body removal, and treatment of chondral injuries. The purpose of this study was to evaluate temporal trends in concomitant ankle arthroscopy during ankle fracture ORIF surgery amongst early-career orthopaedic surgeons while examining the influence of subspecialty fellowship training on utilization.Methods:The American Board of Orthopedic Surgery (ABOS) Part II database was queried to identify all candidates performing at least one ankle fracture ORIF (Current Procedural Terminology [CPT] codes 27766, 27769. 27784, 27792, 27814, 27822, 27823, 27829, 27846, 27848) from examination years 2010 to 2019. All ORIF cases were examined to identify those that carried a concomitant CPT code for ankle arthroscopy (CPT codes 29891, 29892, 29894, 29895, 29897, 29898, 29899). Concomitant ankle arthroscopy cases were categorized by candidates self-reported fellowship training status and examination year. Descriptive statistics were performed to report relevant data and linear regression analyses were utilized to assess temporal trends in concomitant ankle arthroscopy with ORIF for ankle fractures. Statistical significance was defined as p<0.05.Results:There were 36,113 cases of ankle fracture ORIF performed of which 388 cases (1.1%) were performed with concomitant ankle arthroscopy. Ankle fracture ORIF was most frequently performed by trauma fellowship trained Part II candidates (n=8,888; 24.6%), followed by sports medicine (n=7,493; 20.8%) and foot and ankle (n=6,563; 18.2%). Arthroscopy was most frequently utilized by foot and ankle fellowship trained surgeon (293/ 6,270 cases; 4.5%) followed by sports medicine (29/7,464 cases; 0.4%) and trauma (4/8,884 cases; 0.1%). With respect to total arthroscopic cases, 75.5% were performed by foot and ankle fellowship trained surgeons while only 1.0% was performed by trauma trained candidates. Ankle arthroscopy utilization significantly increased from 3.65 cases per 1,000 ankle fractures in 2010 to 13.91 cases per 1,000 ankle fractures in 2019 (p=0.010). Specifically, foot and ankle fellowship trained surgeons demonstrated a significant increase in arthroscopy utilization during ankle fracture ORIF over time (p<0.001; OR: 1.101; CI: 1.054-1.151).Conclusion:Ankle arthroscopy utilization during ankle fracture ORIF has increased ten-fold over the past decade. Foot and ankle fellowship trained surgeons contribute most significantly to this trend.

Recovery Position vs Prone Position in the Surgical Treatment of Trimalleolar Ankle Fractures Using Posterolateral and Medial Approach

Category:TraumaIntroduction/Purpose:Posterolateral (PL) and medial approaches have been increasingly used for open reduction and internal fixation (ORIF) of trimalleolar ankle fractures. Traditionally this procedure is performed on the prone position. Nevertheless, this position itself has been related to general complications as brachial plexus injury and postoperative visual loss. Moreover, the prone position can provide difficult access for medial malleolar reduction. Recovery position was recently described as an alternative but its results have not been evaluated yet. This study aimed to compare the results using recovery position (RP) versus prone position in the surgical treatment of trimalleolar fractures.Methods:A retrospective analytic study was conducted in a Level 1 trauma center, analyzing patients who underwent ORIF for trimalleolar ankle fractures using posterolateral and medial approaches over 3 years. 58 ankles were divided according to the position used in the surgical fixation: Group 1 positioned in RP (27 ankles), and group 2 positioned in prone (31 ankles). Demographics, surgical time, hospital stay, quality of reduction, surgical site complications and re- interventions were compared between both groups. Statistical analysis was performed with Shapiro-Wilks test to assess normality in distribution, Chi-square test, and t-student test for group differences in parametric variables as Fisher's exact test and Mann-Whitney U test in non- parametric variables with a p-value set at 0.05.Results:Median age was 47 years old (IQR 40-58). Both groups were similar regarding age (p=0.794), gender (p=0.902), and posterior malleolus Haraguchi (p=0.064) and Bartonicek-Rammelt (p=0.055) classifications. Surgical median time was 115 (IQR 100-130) and 100 (IQR 75-129) minutes for RP and prone groups respectively (p=0,085), Both groups showed similar rates of lateral, posterior and medial malleolus insufficient reduction (Table attached). Median hospital stay was 4 (IQR 2-9 and 2-7 for RP and prone respectively) days for both (p=0,86) (Table attached). Surgical site complications and re-interventions were similar between both groups (p=0.349 and p=1.0 respectively).Conclusion:The RP showed similar results than the prone position while providing an accessible simultaneous approach to the posterolateral and medial regions of the ankle.