Department of Orthopaedic Surgery, Sports Medicine, and Rehabilitation, Wright State University, 30 East Apple Street, Suite 2200, Dayton, OH 45409. E-mail address for M.J. Cavo:
Department of Surgery, Boonshoft School of Medicine, Wright State University, 128 East Apple Street, Dayton, OH 45409.
J Bone Joint Surg Am. 2015 Jun 17;97(12):987-94. doi: 10.2106/JBJS.N.00789.
Although obesity is widely accepted as a risk factor for surgical complications following orthopaedic surgery, the literature is unclear with regard to the effect of obesity on outcomes of ankle fracture surgery, particularly in the setting of competing risks from diabetes. We hypothesized that obesity would be independently associated with more frequent complications, longer hospital length of stay, and higher costs of care among patients with and without diabetes.
With use of data from 2001 to 2010 from the Nationwide Inpatient Sample, we identified all adult patients who underwent surgical treatment for a primary diagnosis of an isolated ankle fracture or dislocation. We then divided patients into four groups according to the presence or absence of diabetes or obesity: Group A included patients with neither diagnosis; Group B, obesity alone; Group C, diabetes alone; and Group D, both diagnoses. Multivariable regression models were constructed to determine the association between diagnostic group and in-hospital complications, hospital length of stay, and imputed costs of care, while controlling for other conditions.
The final sample included 148,483 patients (78.4% in Group A, 5.0% in Group B, 13.6% in Group C, and 3.0% in Group D). The median age was 53.0 years, and most patients (62.2%) were female and had a closed bimalleolar or trimalleolar fracture (62.2%). In the unadjusted analysis, the frequency of in-hospital complications (2.6%, 4.2%, 5.3%, and 6.5% in Groups A, B, C, and D, respectively; p < 0.001), length of stay (3.0, 3.6, 4.4, and 4.8 days, respectively; p < 0.001), and costs of care ($9686, $10,555, $11,616, and $12,804, respectively, in 2010 U.S. dollars; p < 0.001) increased across groups. Patients with obesity alone (Group B) (adjusted odds ratio [OR] = 1.4; 95% confidence interval [CI] = 1.3 to 1.6), diabetes alone (Group C) (OR = 1.1; 95% CI = 1.0 to 1.2), and both diagnoses (Group D) (OR = 1.4; 95% CI = 1.2 to 1.5) had more frequent in-hospital complications than those with neither diagnosis.
We found that patients with concurrent diagnoses of diabetes and obesity had higher health-care utilization and costs than those with neither diagnosis or with obesity alone or diabetes alone. The delay in the diagnosis of diabetes may somewhat obscure the true effect.
尽管肥胖被广泛认为是骨科手术后发生手术并发症的一个危险因素，但关于肥胖对踝关节骨折手术结果的影响，文献并不明确，尤其是在糖尿病存在竞争风险的情况下。我们假设肥胖与糖尿病患者和非糖尿病患者的并发症更频繁、住院时间更长、治疗费用更高有关。
我们利用 2001 年至 2010 年全国住院患者样本中的数据，确定了所有接受手术治疗的原发性踝关节骨折或脱位的成年患者。然后，我们根据是否存在糖尿病或肥胖将患者分为四组：A 组包括无上述两种诊断的患者；B 组为单纯肥胖；C 组为单纯糖尿病；D 组为两种诊断均有。建立多变量回归模型，以确定诊断组与院内并发症、住院时间和估计的治疗费用之间的关联，同时控制其他情况。
最终样本包括 148483 名患者（A 组占 78.4%，B 组占 5.0%，C 组占 13.6%，D 组占 3.0%）。患者的中位年龄为 53.0 岁，大多数患者（62.2%）为女性，且患有闭合性双踝或三踝骨折（62.2%）。在未调整的分析中，院内并发症的发生率（A、B、C 和 D 组分别为 2.6%、4.2%、5.3%和 6.5%；p<0.001）、住院时间（3.0、3.6、4.4 和 4.8 天；p<0.001）和治疗费用（2010 年以美元计，分别为 9686 美元、10555 美元、11616 美元和 12804 美元；p<0.001）均随组间变化而增加。单纯肥胖（B 组）（调整后比值比[OR] = 1.4；95%置信区间[CI] = 1.3 至 1.6）、单纯糖尿病（C 组）（OR = 1.1；95%CI = 1.0 至 1.2）和两种诊断（D 组）（OR = 1.4；95%CI = 1.2 至 1.5）的院内并发症发生率均高于无上述两种诊断的患者。
我们发现，同时患有糖尿病和肥胖症的患者的医疗保健利用率和费用高于无上述两种诊断或仅有肥胖症或糖尿病的患者。糖尿病诊断的延迟可能会在一定程度上掩盖真正的影响。
