Basques Bryce A, Miller Christopher P, Golinvaux Nicholas S, Bohl Daniel D, Grauer Jonathan N
Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA.
Clin Orthop Relat Res. 2015 Mar;473(3):1133-9. doi: 10.1007/s11999-014-4005-z. Epub 2014 Oct 22.
Ankle fractures are common and can be associated with severe morbidity. Risk factors for short-term adverse events and readmission after open reduction and internal fixation (ORIF) of ankle fractures have not been fully characterized.
QUESTIONS/PURPOSES: The purpose of our study was to determine patient rates and risk factors for (1) any adverse event; (2) severe adverse events; (3) infectious complications; and (4) readmission after ORIF of ankle fractures.
Patients who underwent ORIF for ankle fracture from 2005 to 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP(®)) database using International Classification of Diseases, 9(th) Revision and Current Procedural Terminology codes. Patients with missing perioperative data were excluded from this study. Patient characteristics were tested for association with any adverse event, severe adverse events, infectious complications, and readmission using bivariate and multivariate logistic regression analyses.
Of the 4412 patients identified, 5% had an adverse event. Any adverse event was associated with insulin-dependent diabetes mellitus (IDDM; odds ratio [OR], 2.05; 95% confidence interval [CI], 1.35-3.1; p = 0.001), age ≥ 60 years (OR, 1.97; 95% CI, 1.22-3.2; p = 0.006), American Society of Anesthesiologists classification ≥ 3 (OR, 1.69; 95% CI, 1.2-2.37; p = 0.002), bimalleolar fracture (OR, 1.6; 95% CI, 1.08-2.37; p = 0.020), hypertension (OR, 1.47; 95% CI, 1.04-2.09; p = 0.031), and dependent functional status (OR, 1.47; 95% CI, 1.02-2.14; p = 0.040) on multivariate analysis. Severe adverse events occurred in 3.56% and were associated with ASA classification ≥ 3 (OR, 2.01; p = 0.001), pulmonary disease (OR, 1.9; p = 0.004), dependent functional status (OR, 1.8; p = 0.005), and hypertension (OR, 1.65; p = 0.021). Infectious complications occurred in 1.75% and were associated with IDDM (OR, 3.51; p < 0.001), dependent functional status (OR, 2.4; p = 0.002), age ≥ 60 years (OR, 2.28; p = 0.028), and bimalleolar fracture (OR, 2.19; p = 0.030). Readmission occurred in 3.17% and was associated with ASA classification ≥ 3 (OR, 2.01; p = 0.017).
IDDM was associated with an increased rate of adverse events after ankle fracture ORIF, whereas noninsulin-dependent diabetes mellitus was not. IDDM management deserves future study, particularly with respect to glycemic control, a potential confounder that could not be assessed with the ACS-NSQIP registry. Increased ASA class was associated with readmission, and future prospective investigations should evaluate the effectiveness of increasing the discharge threshold, discharging to extended-care facilities, and/or home nursing evaluations in this at-risk population.
Level III, prognostic study.
踝关节骨折很常见，且可能伴有严重的发病率。踝关节骨折切开复位内固定术（ORIF）后短期不良事件和再入院的危险因素尚未完全明确。
问题/目的：我们研究的目的是确定踝关节骨折ORIF后（1）任何不良事件；（2）严重不良事件；（3）感染性并发症；以及（4）再入院的患者发生率和危险因素。
利用国际疾病分类第9版和当前手术操作术语编码，在美国外科医师学会国家外科质量改进计划（ACS-NSQIP(®)）数据库中识别2005年至2012年接受踝关节骨折ORIF的患者。围手术期数据缺失的患者被排除在本研究之外。使用双变量和多变量逻辑回归分析测试患者特征与任何不良事件、严重不良事件、感染性并发症和再入院的相关性。
在识别出的4412例患者中，5%发生了不良事件。多变量分析显示，任何不良事件与胰岛素依赖型糖尿病（IDDM；优势比[OR]，2.05；95%置信区间[CI]，1.35 - 3.1；p = 0.001）、年龄≥60岁（OR，1.97；95%CI，1.22 - 3.2；p = 0.006）、美国麻醉医师协会分级≥3（OR，1.69；95%CI，1.2 - 2.37；p = 0.002）、双踝骨折（OR，1.6；95%CI，1.08 - 2.37；p = 0.020）、高血压（OR，1.47；95%CI，1.04 - 2.09；p = 0.031）以及依赖性功能状态（OR，1.47；95%CI，1.02 - 2.14；p = 0.040）相关。严重不良事件发生率为3.56%，与美国麻醉医师协会分级≥3（OR，2.01；p = 0.001）、肺部疾病（OR，1.9；p = 0.004）、依赖性功能状态（OR，1.8；p = 0.005）和高血压（OR，1.65；p = 0.021）相关。感染性并发症发生率为1.75%，与IDDM（OR，3.51；p < 0.001）、依赖性功能状态（OR，2.4；p = 0.002）、年龄≥60岁（OR，2.28；p = 0.028）和双踝骨折（OR，2.19；p = 0.030）相关。再入院发生率为3.17%，与美国麻醉医师协会分级≥3（OR，2.01；p = 0.017）相关。
IDDM与踝关节骨折ORIF后不良事件发生率增加相关，而非胰岛素依赖型糖尿病则不然。IDDM的管理值得未来研究，特别是关于血糖控制，这是一个无法通过ACS-NSQIP登记处评估的潜在混杂因素。美国麻醉医师协会分级增加与再入院相关，未来的前瞻性研究应评估提高出院阈值、转至长期护理机构和/或对该高危人群进行家庭护理评估的有效性。
III级，预后研究。
