Equivalence in osteoporosis workup and management after femoral neck fracture fixation and vertebral compression fracture cement augmentation: A single-center retrospective study highlighting persistent Underdiagnosis and Undertreatment.

Background: The purpose of this study was to evaluate pre- and post-fracture medical management of osteoporosis among patients who underwent surgical fixation of femoral neck fractures (FNF) and vertebral compression fractures (VCF), and to investigate if there is a difference in treatment, management, and subsequent fractures between FNF and VCF patients. Methods: Patients who underwent surgical fixation of FNF or VCF were retrospectively reviewed at a minimum 1 year follow up. Patients were excluded if their fracture was caused by high energy trauma or malignancy, <50 years-old, deceased, or lost to follow up. Patient demographics such as age, sex, BMI, American Society of Anesthesiology Physical Status Classification System and Charleston Comorbidity index were recorded. Management of osteoporosis, including medication regimen and dual-energy X-ray absorptiometry (DEXA) scans were assessed preoperatively and at minimum one year follow up. Subsequent fractures were also recorded. Results: In the analysis of 370 patients (74.7% FNF, 25.2% VCF), demographics showed a predominantly female population (mean age 78.1). Preoperatively, 21.6% were diagnosed with osteoporosis, consistent between FNF and VCF. Postoperatively, there were no significant differences in new osteoporosis diagnoses, bisphosphonate use, or subsequent fractures. VCF patients, however, were more likely to receive denosumab and post-operative DEXA scans (p < 0.05). Within a year, 6.2% experienced subsequent fractures, with no significant FNF-VCF difference. Only 12.7% received appropriate post-operative osteoporosis treatment, 27.1% had DEXA scans, and 25% had a recorded osteoporosis diagnosis. Multivariable analysis highlighted pre-fracture osteoporosis diagnosis as the sole predictor for post-operative DEXA scans and anti-osteoporotic medication (p < 0.001). Conclusions: This study suggests that factors beyond the type of fragility fracture may influence subsequent fracture risk and anti-osteoporotic medication administration in elderly patients. These findings underscore the importance of a comprehensive approach to fracture risk assessment and treatment decisions in this population. Level of evidence: III.

Value of Acid-Fast Bacilli and Fungal Cultures in Foot and Ankle Surgery in a US Hospital System.

BACKGROUND: Acid-fast bacilli(AFB) and fungi are generally slow-growing, difficult to culture, and rarely the cause of infection. The goal of this study was to evaluate the value of routinely obtaining AFB and fungal cultures in foot and ankle surgery at a US hospital. METHODS: A retrospective review was conducted to determine the number of positive AFB and fungal cultures out of the total number of foot and ankle samples tested. Between 2014 and 2019, patients who underwent surgery for a foot and ankle infection for soft tissue infection, septic arthritis, infectious postoperative complications were identified. Charts were reviewed to identify the results of the microbiological tests performed. To determine the value of running AFB and fungal cultures, the costs of each were provided by the microbiology lab at our institution. RESULTS: Of the 322 patient charts reviewed, there were 434 AFB and 525 fungal cultures performed. None of these cultures were indicated to be positive for AFB (0%), and 22 (4.19%) were positive for fungi. The total labor and material costs were calculated to be $38 767. The AFB cultures cost $23 967, the positive fungal cultures cost $2371, and the negative fungal cultures cost $36 395.36. CONCLUSION: This 322-case series of surgically managed foot and ankle infections showed 0% and 4.1% positivity rates of AFB and fungal cultures, respectively. Additionally, only 20% of cases with positive cultures were identified as pathologic requiring antifungal treatment. Further analysis is needed to determine best practices for obtaining vs declining to culture for AFB or fungal species, including assessing patient outcomes in the series of culture-positive(fungal-only) cases. Our results suggest that in our clinical setting of a US hospital system, routine fungal and AFB cultures may not be necessary but should be considered for chronic/recalcitrant infections, immunocompromised patients, and those with high surgeon suspicion. LEVEL OF EVIDENCE: Level IV, case series.

Tobacco smoking is associated with more pain and worse functional outcomes after torsional ankle fracture.

OBJECTIVE: The purpose of this study was to assess the impact of current and remote tobacco smoking on clinical and functional outcomes after torsional ankle fracture. METHODS: Nine hundred thirty-five patients treated surgically for torsional ankle fracture over 9 years were reviewed. Tobacco smoking status at the time of injury was defined as current (48.3%), former (11.7%), and nonsmoker (40.0%). Complications, unplanned secondary procedures, pain medication use, and functional outcome scores, as measured by Foot Function Index and Short Musculoskeletal Function Assessment (SMFA) surveys. RESULTS: Mean age was 44.8 years, with 50.3% male. More than 6 months following injury current smokers were more likely than former smokers and nonsmokers to report ankle pain (67.8% vs 45.8% vs 47.5%) and to use prescription pain medicines (23.0% vs 10.4% vs 6.3%), all P < .05. Multiple logistic regression found current tobacco use to be an independent predictor for prescription pain medication use, and worse scores for the Foot Function Index, SMFA Dysfunction, and SMFA Bothersome scores, all P < .05. Complications occurred in 15.5% of all patients, and 10.7% underwent unplanned secondary operations. Tobacco smoking was not associated with more complications or secondary procedures. CONCLUSION: Current smokers are more likely to use prescription pain medications several months after injury and have worse patient-reported functional outcome scores after surgical treatment of torsional ankle fractures than former smokers and nonsmokers.

Determinants of functional outcome following ankle fracture.

OBJECTIVES: To assess the patient and injury characteristics that impact functional outcomes after ankle fracture. DESIGN: Retrospective study. SETTING: Urban level I trauma center. PATIENTS/PARTICIPANTS: One thousand patients underwent fixation of ankle fracture (AO/OTA 44) between 2006 and 2015. Four hundred sixteen completed functional outcome surveys by telephone or mail at a mean of 5.9 years after injury. INTERVENTION: Open reduction internal fixation. MAIN OUTCOME MEASURE: Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA). RESULTS: Mean age was 46.7 years, with 46.2% male. Higher (worse) FFI scores were seen in tobacco users (38.9 vs 30.1), recreational drug users (45.9 vs 32.7), and the morbidly obese (52.0 vs 30.6), all P < .005. Higher (worse) SMFA dysfunction and bothersome scores were also seen in these groups, and in females and alcohol users. Multiple regression analysis identified female gender, obesity, tobacco and alcohol use, complications, secondary procedures, and multiple additional injuries as independent predictors of higher scores (all P < .04). Fracture patterns, open fracture, and development of arthritis had no impact on FFI or SMFA scores. CONCLUSION: Patient characteristics, not under surgeon-control, such as female sex, obesity, and substance use, appear to contribute to patient-reported functional outcome scores more than injury characteristics. LEVEL OF EVIDENCE: Level 3, prognostic.

Potential Benefits of Limited Clinical and Radiographic Follow-up After Surgical Treatment of Ankle Fractures.

INTRODUCTION: Ankle fractures are one of the most prevalent musculoskeletal injuries, with a significant number requiring surgical treatment. Postoperative complications requiring additional interventions frequently occur during the early postoperative period. We hypothesize that there is a limited need for routine clinical and radiographic follow-up once the fracture is deemed healed. METHODS: IRB approval was obtained at four academic trauma centers. A retrospective chart review was done to identify adults with healed unimalleolar and bimalleolar ankle fractures treated surgically with at least 12 months of follow-up. Based on postoperative radiographs, changes in fracture alignment and implant position from radiographic union to final follow-up were documented. The average reimbursement for a final follow-up clinic visit and a set of ankle radiographs were estimated. RESULTS: A total of 140 patients met inclusion criteria. The mean age at injury was 49.5 years, and 67.9% of patients were female. The mean time to healing was 82.2 days (±33.5 days). After radiographic healing, one patient had radiographic changes but was asymptomatic and full weight bearing at their final follow-up. On average, our institution was reimbursed $46 to $49 for a follow-up clinic visit and $364 to $497 for a set of ankle radiographs. CONCLUSION: Given the average time to healing, there is limited utility in routine radiographic and clinical follow-up beyond 16 weeks in asymptomatic patients. In our series, this would result in a savings of $950 to $1,200 per patient. However, after ankle fractures were deemed healed, 0.7% patients had radiographic evidence of a change in implant position. Documenting this change did not modify the immediate course of fracture treatment. Surgeons will need to balance the need for routine follow-up with the potential economic benefits in reducing costs to the healthcare system.

Supination Adduction Ankle Fractures Are Associated With Arthritis and Poor Outcomes.

OBJECTIVE: To compare complications and functional outcomes between supination adduction type II (SAD) injuries and torsional ankle injuries (TAI). DESIGN: Retrospective cohort. SETTING: Level 1 trauma center. PATIENTS AND METHODS: Patients (n = 1531) treated for ankle fractures (OTA/AO 43B or 44) over 16 years were identified. The most recent 200 consecutive adult patients treated for TAI (OTA/AO 44, not SAD) served as controls. MAIN OUTCOME MEASURES: Complications, unplanned secondary procedures, and patient-reported functional outcome scores, as measured by the Foot Function Index and Short Musculoskeletal Function Assessment. RESULTS: Sixty-five patients with SAD injuries (4.2%) were included. They were younger (43.2 vs. 47.7 years, P = 0.08) and more commonly involved in a motorized collision, (58.5% vs. 29.0%) and more often multiply injured: other orthopaedic injuries (66.2% vs. 31.0%) and other nonorthopaedic injuries (40.0% vs. 7.5%, all P < 0.001 vs. TAI). Overall complication and unplanned secondary procedure rates were not different between groups. Those with a SAD injury had more posttraumatic arthrosis (80.0% vs. 40.9%, P = 0.004), but no differences were noted in infection, wound healing, malunion, or nonunion. The mean functional outcome scores were worse for SAD patients over 6 years after injury among all the Foot Function Index and Short Musculoskeletal Function Assessment categories; however, these differences were not significant. CONCLUSIONS: SAD injuries represented 4.2% of all ankle fractures, occurring in younger patients through higher-energy mechanisms and more often associated with polytrauma. Despite 80% of SAD patients developing posttraumatic arthrosis, secondary procedures were not more common, and functional outcomes after a SAD injury were not different from TAI. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effects of Diabetes Mellitus on Functional Outcomes and Complications After Torsional Ankle Fracture.

INTRODUCTION: It is well known that patients with diabetes mellitus experience higher complication rates after torsional ankle fracture; however, the functional consequences remain less clear. The goal of this study was to determine the effects of diabetes on complications, secondary operations, and functional outcomes after torsional ankle fracture. METHODS: Nine hundred seventy-nine adult patients treated surgically for a torsional ankle injury (Orthopaedic Trauma Association 44B, 44C) over 13 years were retrospectively reviewed. Demographic information, comorbidities, injury characteristics, complications, and secondary procedures were recorded. Patient-reported outcome surveys: Foot Function Index (FFI) and Short Musculoskeletal Function Assessment were obtained after minimum of 12 months. Multivariable analysis was done to account for confounding variables. RESULTS: One hundred thirty-one patients (13.4%) had diabetes. Diabetic patients were older (56.4 versus 43.0 years, P < 0.001), with no difference in sex or race. Body mass index was higher among diabetics (36.0 versus 30.4, P < 0.001) as were most medical comorbidities, including stroke, neuropathy, pulmonary disease, and renal disease (all P < 0.03). There were no differences in rates of dislocations or open injuries. Diabetics experienced more complications (26.0% versus 14.6%, P = 0.001), specifically deep infections (6.9% versus 1.3%, P = 0.001), and had more secondary procedures (18.3% versus 9.1%, P = 0.001), including débridement, arthrodesis, and amputation (all P < 0.02). Diabetes was a significant independent predictor of worse FFI activity limitation scores (P = 0.032), but was not predictive of worse outcomes on any other subscore of the FFI or Short Musculoskeletal Function Assessment. CONCLUSIONS: Diabetes was associated with more complications and secondary operations. However, functional outcomes including pain and dysfunction were not markedly affected by these clinical outcomes, potentially due to diminished sensory function and less baseline physical activity among diabetic patients. LEVEL OF EVIDENCE: Prognostic level III.

The effect of obesity on post-operative complications and functional outcomes after surgical treatment of torsional ankle fracture: A matched cohort study.

BACKGROUND: Obesity is a growing public health concern. While diabetes mellitus is associated with obesity and is a risk for infection and other complications, effects of obesity on outcomes remains less clear. The purpose was to determine effect of obesity on complications, secondary operations, and functional outcomes after surgical treatment of ankle fracture. METHODS: 955 adult patients treated surgically for torsional ankle injury were reviewed. Obese patients (body mass index (BMI) ≥30), and patients without obesity were matched for age, sex, race, diabetes, and fracture pattern. Patient reported outcomes, measured by Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA), were obtained after 12 months. RESULTS: 632 patients (316 obese [mean BMI 36.7] and 316 non-obese [mean BMI 25.5]) with mean age 44.6 years were analyzed. Each group was 52.5% female, and 6.6% had diabetes mellitus. 75.6% of fractures in each group were AO/OTA type 44B and 24.4% were 44C. Non-obese patients were more likely tobacco users (63.3% vs 40.2%, p<0.001). Obese patients trended toward more dislocations (41.8% vs 35.4%, p=0.10), with similar rate of open fracture. Obese patients trended toward more complications (28.5% vs 22.5%. p=0.08) and wound healing problems (4.7% vs 2.2%, p=0.08) with similar rates of secondary procedures. Total FFI scores were higher (worse) for obese patients (35.4 vs 28.5, p=0.03); subcategory scores for disability and activity limitation were worse (p=0.03 and p=0.04, respectively), and obesity was associated with worse SMFA bothersome (31.0 vs 23.6, p=0.02) and mobility scores (41.8 vs 32.5, p=0.008), with a trend towards worse SMFA dysfunction scores in obese patients (29.7 vs 24.7, p=0.06). CONCLUSIONS: Obesity is associated with worse functional outcomes by FFI and SMFA surveys. Contributions of baseline limitations to these poor scores in obese patients remain unclear. Injury characteristics were similar between obese and non-obese patients, though obese patients may be more prone to dislocations. A trend was noted for obese patients to experience more complications and wound healing issues, although rates of secondary operations were no different. LEVEL OF EVIDENCE: III.

Factors associating with surgical site infection following operative management of malleolar fractures at an urban level 1 trauma center.

OBJECTIVES: To identify comorbidities and injury characteristics associated with surgical site infection (SSI) following internal fixation of malleolar fractures in an urban level 1 trauma setting. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seven-hundred seventy-six consecutive patients with operatively managed malleolar fractures from 2006 to 2016. INTERVENTION: Open reduction internal fixation. MAIN OUTCOME MEASUREMENTS: Superficial SSI (erythema and drainage treated with oral antibiotics and wound care) or deep SSI (treated with surgical debridement and antibiotics). RESULTS: Fifty-six (7.2%) patients developed SSI, with 17 (30%) of these being deep infections. An a-priori power analysis of n = 325 (α=0.05, ß=0.2) was tabulated for differences in univariate analysis. Univariate analysis identified categorical associations (P < .05) between SSI and diabetes mellitus, drug abuse, open fracture, and renal disease but not tobacco abuse, body mass index, or neuropathy. Multivariate logistic regression identified categorical associations between diabetes (OR = 2.2, 95% CI: 1.1-4.3), drug abuse (OR = 3.9, 95% CI: 1.2-12.7), open fracture (OR = 4.1, 95% CI: 1.3-12.8), and renal disease (OR = 2.7, 95% CI: 1.4-5.0) and any (superficial or deep) SSI. A separate multivariate logistic regression analysis found categorical associations between deep SSI requiring reoperation and diabetes (OR = 4.4, 95% CI: 1.6-12.2) and open fracture (OR = 4.1, 95% CI: 1.3-12.8). Furthermore, American society of anesthesiologists classification (ASA) Class 4 patients were (OR = 9.2, 95% CI: 2.0-41.79) more likely to experience an SSI than ASA Class 1 patients. CONCLUSIONS: Factors associated with SSI following malleolar fracture surgery in a single urban level 1 trauma center included diabetes, drug abuse, renal disease, and open fracture. The presence of diabetes or open type fractures were associated with deep SSI requiring reoperation. LEVEL OF EVIDENCE: Level 3 prognostic: retrospective cohort study.

Ankle fractures in patients over age 55 years: Predictors of functional outcome.

OBJECTIVES: To identify predictors of functional outcomes following treatment of ankle fracture in patients 55 years or older. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Four hundred twenty-nine patients with torsional ankle fractures (44A-C): 233 patients (54%) were ages 55 to 64, 25% were between the ages 65 and 74; 21% were 75 years or older. INTERVENTION: Operative or nonoperative management of ankle fracture. MAIN OUTCOME MEASURE: Early complications were assessed for all patients after minimum of 6 months, and functional outcome scores as assessed by the Foot Function Index (FFI; n = 166, 39%) and Short Musculoskeletal Function Assessment (SMFA; n = 168, 39%) after median 57 months follow-up. RESULTS: Surgical management was elected in 67% of patients. Nonoperative management became more common with advancing age and was associated with fewer unplanned operations (12% vs 3%, P < .01) and complications (21% vs 13%, P = .07). African American race was associated with worse pain on the FFI (P = .002) and BMI was associated with worse (higher) scores on all categories of the FFI and SMFA (all P < .05). Diabetes, neuropathy, and mental illness were also predictive of worse scores on various categories of both surveys. Assistive device use or nonambulatory status at the time of injury was associated with worse disability/dysfunction, activity, and mobility scores on both the FFI and SMFA (all P > 15, P < .05). Sex, Hispanic ethnicity, tobacco use, open fracture, dislocation, fracture pattern, and operative management were not independent predictors in this regression model. CONCLUSIONS: Baseline health and ambulatory capacity at injury were more predictive of outcomes following ankle fracture than were fracture characteristics or type of treatment.

Mental illness is associated with more pain and worse functional outcomes after ankle fracture.

Objectives: To assess clinical and functional outcomes after ankle fracture in patients with preexisting mental illness. Design: Retrospective study. Setting: Level 1 trauma center. Patients/Participants: One thousand three hundred seventy-eight adult patients treated for ankle fractures; 228 (17%) had preexisting mental illness. Intervention: Open reduction internal fixation. Main outcome measure: Rates of complications and reoperations. Functional outcomes were assessed via Foot Function Index (n = 530) and Short Musculoskeletal Function Assessment (n = 530). Results: Depression was the most common mental illness (63%), followed by anxiety (23%). Mental illness was associated with older age, female sex, and preexisting medical comorbidities, including diabetes and obesity. Mental illness was not associated with specific fracture patterns or open injury. Complications occurred no more often in patients with mental illness, but secondary operations (13% vs 7%) were more likely, particularly implant removals (8% vs 4%), both P < .05. Functional outcomes were worse in mentally ill patients as measured by the Foot Function Index (39 vs 30, P = .006) and Short Musculoskeletal Function Assessment Mobility: 45 vs 35, Bothersome: 35 vs 26 and Dysfunction: 35 vs 26, all P < .01. Conclusion: Secondary operations were nearly 50% more frequent in patients with mental illness, and functional outcome scores were significantly worse, suggesting that mental illness, unrelated to injury and treatment parameters, has major influence on outcomes. In the future, strategies to identify and treat mental illness prior to and after treatment could improve functional outcomes following ankle fracture.

Open ankle fractures are associated with complications and reoperations.

OBJECTIVES: To assess clinical and functional outcomes after open versus closed ankle fracture. DESIGN: Retrospective comparative study. LOCATION: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: 1303 patients treated for ankle fractures (Weber B and C) between 2003 and 2015. One hundred sixty-five patients (12.7%) presented with open fracture and 1138 (87.3%) with closed fracture. INTERVENTION: Surgical or conservative management of ankle fracture. MAIN OUTCOME MEASURE: Rates of complications and reoperations. Patient-reported functional outcomes were assessed with the Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA), after a minimum of 12 months. RESULTS: Mean age was 46 years and 49% of patients were male. Higher mean age was associated with open injuries (51 vs 45 years, P < 0.001), and fractures were increasingly open with aging. Open fractures were associated with high-energy mechanisms: 44% following motor vehicle or motorcycle collisions, although the majority of open fractures in patients >65 years occurred after ground-level fall. Complications occurred more often after open fracture (33% vs 11%) and necessitated more secondary procedures (19% vs. 7%), both P < 0.001. Multivariate regression analysis identified open fracture as a predictor of complications and of worse scores on the activity categories of both the FFI and SMFA. CONCLUSION: Open fractures occurred more often after high energy mechanisms, and were generally more complex than closed fractures. Advanced age was common among open fracture patients, likely contributing to higher complication and secondary procedure rates. Greater morbidity after open ankle fractures was associated with minor differences on activity functions of the FFI and SMFA.Level of Evidence: Level 3, prognostic.