SLR - May 2020 - Zachary J. Lubek

Timing of Early Complications Following Open Reduction and Internal Fixation of Closed Ankle Fractures 

Reference: Bohl D, Idarraga A, Lee S, Hamid K, Lin J, Holmes G. Timing of Early Complications Following Open Reduction and Internal Fixation of Closed Ankle Fractures. Foot Ankle Spec. 2020 Mar 2: 1938640020908428. doi: 10.1177/1938640020908428

Scientific Literature Review

Reviewed By: Zachary J. Lubek, DPM 
Residency Program: Regions/HealthPartners Institute – St. Paul, MN 
Podiatric Relevance: Ankle fractures are a common condition treated by foot and ankle specialists, and having a focused timeframe of anticipating specific adverse events can bring heightened awareness following open reduction and internal fixation (ORIF) of uni-/bi-/trimalleolar ankle fractures. This study seeks to characterize the timing of  eight early adverse events, and encourages podiatric surgeons to have a low threshold for testing for each of described adverse events during the time period of greatest risk. 

Methods: A level III retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients undergoing inpatient and outpatient surgeries and monitor for postoperative events within 30 days after surgery. Patients for the study were identified using specific procedural, ICD-9, and ICD-10 codes and analyzed for the following adverse events: myocardial infarction (MI), pneumonia, acute kidney injury (AKI), urinary tract infection (UTI), pulmonary embolism (PE), sepsis, deep vein thrombosis (DVT) and surgical site infection (SSI). For each event it was sought to determine the median postoperative day of diagnosis, inpatient vs. outpatient, and association with uni-malleolar vs. bi-, tri-trimalleolar fractures with adjustments for age, sex and comorbidities.

Results: A total of 17,318 patients who underwent ORIF of closed ankle fracture were included. Of these, 37.1 percent were isolated fibula fractures and 62.9 percent were bi- or trimalleolar. Outpatient procedures constituted 48.4 percent of cases while 51.6 percent were inpatient procedures. The median day of diagnosis for MI was day two, pneumonia day three, AKI day 6.5, UTI day seven, PE day 10, sepsis day 15, DVT day 17 and SSI day 19. Patients with bi-/trimalleolar fractures suffered from MI, UTI, and sepsis earlier than patients with isolated fibular fractures, with no significant difference in timing for the other five adverse events. Patients undergoing inpatient surgery suffered from AKI later and UTI earlier than those who underwent outpatient surgery.  The above associations held up when adjusted for patient demographics and comorbidities.

Conclusions: The authors concluded that their findings should help reduce the threshold for perioperative testing/internal medicine consults for specific adverse events given the isolated time periods. Further, they suggest that the present data does not follow the common clinical dictum as learned by foot and ankle surgical trainees (ie. “wind, water, wound, walk, wonder”) when applied to ankle fracture ORIF. Each median timeframe was longer that this dictum, most notably surgical site infections found at 19 days vs. 5-7. This research should also be applied pragmatically to aid with patient counseling with regard to each complication and adjust previously adhered to timeline assumptions.  The study also has substantial research implications, demonstrating that duration of follow up for database studies can be critical for determining the conclusion of future studies, and assessing adverse events past 30 days may avoid missing a large portion of postoperative events occurring at or after that timeframe. While this study does have limitations, the characterized data would be beneficial for all podiatric surgeons to review when considering complications following ankle fracture ORIF.

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