SLR - April 2018 - Jenna M. Lohre

Open Treatment of Ankle Fracture as Inpatient Increases Risk of Complication

Reference: Shen MS, Dodd AC, Lakomkin N, Mousavi I, Bulka C, Jahangir AA, Sethi MK. Open Treatment of Ankle Fracture as Inpatient Increases Risk of Complication. J Orthop Traumatol. 2017 Oct 26; 18:431–438.

Scientific Literature Review

Reviewed By: Jenna M. Lohre, DPM
Residency Program: Temple University Hospital, Philadelphia, PA

Podiatric Relevance: The National Trauma Data Bank demonstrated in a recent study that ankle fractures account for 55.7 percent of the total fractures to the foot and ankle region. Additionally, podiatric and orthopaedic surgeons alike are seeing a rise in the incidence of ankle fractures among the aging population. Postoperative complications associated with ankle fracture surgery have demonstrated to be very costly, yet few studies have been done on factors that may be predictors of these complications. Since ankle fractures are frequently treated in both the inpatient and outpatient setting, the authors aimed to demonstrate if postoperative complications were higher among those ankle fractures that were treated in the inpatient setting.

Methods: This was a retrospective comparative study of 7,383 patients with operatively treated ankle fractures between the years of 2006 and 2013. The data was collected using a CPT code search of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were further divided into admission status; 3,885 underwent inpatient and 3,498 underwent outpatient surgery. Additionally, patient demographics, such as age, sex, BMI, ASA status, preoperative comorbidities, smoking status, operative characteristics, etc., were collected for each patient. Postoperative complications were also evaluated and divided into major and minor categories. The authors used a propensity score matched model to allow comparison of inpatient and outpatient cohorts with similar health profiles so that the increased rate of preoperative comorbidities among the inpatient group would not alter the results. Finally, bivariate analysis and a multinomial logistic regression model were used to evaluate the rates and odds of major and minor postoperative complications within 30 days after surgery.

Results:
After propensity score matching, 2,630 (36 percent) outpatients were matched to 2,630 (36 percent) inpatients. Comparison of these cohorts demonstrated no significant differences in patient demographics, including age, gender, BMI, ASA class or smoking habits, nor did they differ in their level of health prior to surgery. In regards to the initial hypothesis, the authors demonstrated that there was a significant difference in complication rates between the inpatient and outpatient groups. The inpatient cohort had a significantly higher rate of postoperative complications compared to the outpatient cohort. Overall, inpatients were almost twice as likely to develop a complication and specifically were 2.14 times more likely to develop a major complication.

Conclusions: The authors concluded that inpatient surgery for ankle fractures may lead to a higher risk of both major and minor complications compared to outpatient treatment. Ultimately, postoperative complications were significantly more prevalent among the inpatient groups. Ankle fractures are one of the most common injuries to the lower extremity, and podiatric surgeons are often faced with the decision to admit a patient postoperatively. However, this study demonstrated that inpatient ankle fracture treatment is associated with a higher risk of postoperative major and minor complications. 

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