It’s the job of every physician to assess patients for risk factors that predict future outcomes. Doing so helps doctors guide patients in the direction of reducing those risks and preventing future problems. In the case of the orthopedic surgeon, patients undergoing surgery have the additional risk of potential complications during or following the procedure. Once again, awareness of risk factors is important in assuring a successful operation and positive long-term results.
In this study, surgeons from the Department of Orthopedic Surgery at the University of California (Los Angeles) turn their attention to ankle fractures. Specifically, they examined the risks of complication after surgery for severe ankle fractures.
And not just severe ankle fractures but those requiring open reduction and internal fixation (ORIF). Open reduction means the surgeon makes an open incision to treat the fracture. Internal fixation tells us that some type of metal plate, screws, rods, and/or wires were used to hold the bones together.
Knowing the possible risk factors, complications, and risks from those complications is important for every procedure. It’s the first step toward prevention and goes a long way to ensure success. With any surgical procedure, there’s always a risk of infection, delayed wound healing, or blood clots. With severe ankle fractures, there’s the added risk of malunion (fracture heals in poor alignment), nonunion (fracture doesn’t heal at all), or the need for revision surgery.
Revision surgery refers to a second procedure. This could be to revise the original work done. It could be to fuse the ankle, a procedure called arthrodesis. If the first attempt to repair the damage done (using an ORIF) fails and fusion fails or isn’t possible, then an ankle replacement may be needed. If worse comes to worse, it may be necessary to amputate.
The seriousness of possible complications and risks of complications shows us the reason why surgeons pay such close attention to patient risk factors. And statistics have shown that ankle fractures are becoming more common in older adults (third in frequency after hip and wrist fractures).
Since the authors are from California, they could use the California discharge database to collect their data. The discharge database is an electronic bank of information about patients who are hospitalized and released for any reason. By entering in codes that represent ankle fractures and even more specifically, patients who had an ORIF, they were able to find over 50,000 people in a 10-year period of time treated in California for ankle fractures.
The advantage of a study of this type is that the patient population is diverse in age, general health, race/ethnicity, and insurance type. Since only nonfederal hospitals were included, it also allowed for analysis of hospital location, type, and volume as possible risk factors.
They found that patients ranged in age from 18 to 103. The majority of patients were white, female, and younger than 50 years old. The severity of the ankle fracture was defined as a single lateral malleolar fracture, bimalleolar, and trimalleolar fracture. In this study, 16 per cent of the fractures were lateral malleolar, 45 per cent were bimalleolar, and 39 per cent were trimalleolar.
The lateral malleolus is the anklebone along the outside of the ankle (away from the other leg), Bimalleolar means both the medial (inside closest to the other ankle) and lateral bones were broken. A trimalleolar fracture involves the lateral malleolus, medial malleolus and the bottom posterior (backside) tibia. This portion of the tibia is sometimes referred to as the posterior malleolus.
The overall complication rate was extremely low (less than one per cent) — both in the short- and intermediate-term. When broken down into categories, infection was the biggest problem. Other problems included pulmonary embolism (blood clot to the lungs), revision, amputation, and death.
In the short term (90 days to one-year after surgery) there were not more complications with bimalleolar or trimalleolar fractures than with lateral fractures. But within five years, the more severe fractures (trimalleolar) had the highest rate of revision. Patients with diabetes, open fractures, and/or trimalleolar fractures were also more likely to develop arthritis requiring additional surgical procedures.
Rates of complications were higher in cases of open (versus closed) fractures and for older patients. Older adults with complicated diabetes and peripheral vascular disease (PVD; poor circulation) had the most problems. These were the patients who were most likely to end up with infection or amputation. The risk of death as a potential complication was greatest for the patients who were over age 75.
The rates of complications were similar for high-volume versus low-volume hospitals. Location (rural versus urban teaching hospital) did not have a major impact on the results. These kinds of hospital-related factors have been shown in other studies to affect outcomes of hip and knee replacement surgeries. This may be the first study to show that provider volume isn’t always a factor in the success or failure of orthopedic procedures.
The results of this study give surgeons a way to recognize high-risk patients about to undergo an ORIF. Armed with this information, the surgical and postoperative teams can monitor the patient more carefully. Additional preventive measures can be taken to avoid complications. For example, older patients and anyone with medical problems should be considered for blood thinners prior to surgery to prevent blood clots. It may even be necessary to change the surgery plans until the patient’s health status has stabilized. After surgery, patients with diabetes and/or peripheral vascular disease should be assessed carefully for any signs of infection, malunion or nonunion, or other complications.