Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.
J Bone Joint Surg Am. 2019 Oct 2;101(19):1768-1774. doi: 10.2106/JBJS.19.00203.
As orthopaedic surgery moves toward bundled payments, there is growing interest in identifying patients at high risk of early postoperative adverse events. The purpose of this study was to develop and validate a risk-stratification system for the occurrence of early adverse events among patients treated with open reduction and internal fixation (ORIF) for a closed fracture of the ankle.
Patients undergoing ORIF for a closed ankle fracture during the period of 2006 to 2017, as documented by the American College of Surgeons National Surgical Quality Improvement Program, were identified. For the 60% of patients randomly selected as the development cohort, multivariate Cox proportional hazards modeling was used to identify factors that were independently associated with the occurrence of adverse events (including events such as reoperation, surgical site infection, and pulmonary embolism). On the basis of these results, a nomogram analysis was used to generate a point-based risk-stratification system. To evaluate the validity of the point-based system, the system was applied to the remaining 40% of patients constituting the validation cohort and tested for its ability to predict adverse events.
Of the 7,582 patients in the development cohort, 455 developed an adverse event (estimated adverse event risk of 6%). On the basis of Cox proportional-hazards regression, patients were assigned points for each of the following significant risk factors: +1 point for age of 40 to 59 years, +3 points for age of 60 to 79 years, +5 points for age of ≥80 years, +1 point for female sex, +2 points for chronic obstructive pulmonary disease (COPD), +2 points for insulin-dependent diabetes, +3 points for anemia, and +4 points for end-stage renal disease. The validation cohort included 5,263 patients. Among this second cohort, the risk-stratification system predicted the risk of early adverse events (p < 0.001; Harrell C = 0.697).
The occurrence of early adverse events following ORIF for closed ankle fractures was associated with greater age, female sex, COPD, insulin-dependent diabetes, anemia, and end-stage renal disease. We present and validate a simple point-based risk-stratification system to predict the risk of early adverse events.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
随着矫形外科手术向捆绑式支付方式发展，人们越来越关注识别术后早期不良事件风险较高的患者。本研究的目的是开发和验证一种用于预测接受切开复位内固定术（ORIF）治疗的闭合性踝关节骨折患者发生早期不良事件的风险分层系统。
在美国外科医师学会国家外科质量改进计划的记录中，确定了 2006 年至 2017 年间接受 ORIF 治疗的闭合性踝关节骨折患者。在随机抽取的 60%患者中，采用多变量 Cox 比例风险模型确定与不良事件发生相关的独立因素（包括再次手术、手术部位感染和肺栓塞等事件）。基于这些结果，采用列线图分析生成基于点数的风险分层系统。为了评估基于点数的系统的有效性，将该系统应用于构成验证队列的剩余 40%患者中，并测试其预测不良事件的能力。
在发展队列的 7582 名患者中，有 455 名患者发生了不良事件（估计不良事件风险为 6%）。基于 Cox 比例风险回归，为以下每个显著风险因素分配 1 分：年龄 40 至 59 岁加 1 分，年龄 60 至 79 岁加 3 分，年龄≥80 岁加 5 分，女性加 1 分，慢性阻塞性肺疾病（COPD）加 2 分，胰岛素依赖型糖尿病加 2 分，贫血加 3 分，终末期肾病加 4 分。验证队列包括 5263 名患者。在第二队列中，风险分层系统预测了早期不良事件的风险（p < 0.001；Harrell C = 0.697）。
接受切开复位内固定术治疗的闭合性踝关节骨折后早期不良事件的发生与年龄较大、女性、COPD、胰岛素依赖型糖尿病、贫血和终末期肾病有关。我们提出并验证了一种简单的基于点数的风险分层系统，以预测早期不良事件的风险。
治疗性 IV 级。请参阅作者说明以获取完整的证据水平描述。
