SLR - December 2017 - Heather H. Schaefbauer

Rate of and Risk Factors for Intermediate-Term Reoperation After Ankle Fracture Fixation: A Population-Based Cohort Study

Reference: Pincus D, Veljkovic A, Zochowski T, et al. Rate of and Risk Factors for Intermediate-Term Reoperation After Ankle Fracture Fixation: A Population-Based Cohort Study. Journal of Orthopaedic Trauma. 2017; 31:315–320. 

Scientific Literature Review

Reviewed By: Heather H. Schaefbauer, DPM
Residency Program: HealthPartners Institute/Regions Hospital, St. Paul, MN

Podiatric Relevance: Open reduction internal fixation (ORIF) is currently considered the gold standard in the treatment of unstable rotational ankle fractures due to improved clinical and radiograph outcomes when compared to cast treatment. Recent evidence, however, has demonstrated that for a certain subset of older-aged individuals, ORIF may be less favorable compared to casting when it comes to early patient-reported outcomes. This recent literature does not account for rates of reoperation and is limited by its short-term follow-up. This article investigates intermediate-term (one to two years) reoperation rates after ankle ORIF and looks at individual factors that may influence these rates.

Methods: The rate of reoperation after ankle ORIF along with patient, provider and surgical factors were investigated in a large population-based cohort. Data from several health administrative databases was obtained at 202 different hospitals in Ontario, Canada. Inclusion criteria included all adult patients 16 years of age and older undergoing ankle ORIF between January 1, 1994 and December 1, 2011. Exclusion criteria included non-Ontario residents, patients less than 16 years of age and those with bilateral or tibial plafond fractures. Reoperation rates were assessed by looking at those who underwent implant removal in isolation, repeat ORIF, irrigation and debridement (I&D) and lower-extremity amputation. Several patient, provider and surgical factors thought to impact reoperation after ankle ORIF were also investigated. All analyses were performed utilizing SAS software.

Results: A total of 45,444 patients who underwent isolated ankle ORIF were included in the investigation. The mean age was 48 years, and 41.2 percent were male. A total of 8,906 patients (19.6 percent) underwent intermediate-term reoperation. Repeat ORIF was performed in 200 (0.5 percent) patients with single-malleolus fracture and in 216 (0.5 percent) patients with multiple malleolus fractures. The vast majority (8,232 cases or 92.4 percent) of all reoperations were isolated implant removal. Implant removal was more common in females and in those with a higher socioeconomic status. I&D for infection occurred in 207 (0.5 percent) patients and was highest among patients with open fractures or diabetes. Amputation was performed in 48 (0.1 percent) cases and was highest among male patients and in those with diabetes.

Conclusions: Intermediate-term reoperation after ankle ORIF was common and was performed in 8,906 cases (19.6 percent). The vast majority, however, was implant removal in isolation. Reoperation for all other reasons was rare even among the highest risk patients. Diabetes and open fracture/fracture-dislocation were the most common risk factors among those who underwent reoperation. The authors conclude that based on these findings, operative treatment of ankle fractures should not preclude any patient, provider or injury group considered in this study, including those of an older age. 

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