Epidemiology & management of complex ankle fractures in the United Kingdom: A multicentre cohort study.

BACKGROUND: Patient factors are known to contribute to decision making and treatment of ankle fractures. The presence of poor baseline mobility, diabetes, neuropathy, alcoholism, cognitive impairment, inflammatory arthritis or polytrauma can result in a higher risk of failure or complications. Limited evidence is available on the optimum management for this challenging cohort of patients herein described as complex ankle fractures. This UK multicentre study assessed and evaluated the epidemiology of ankle fractures complicated by significant comorbidity and patient factors and use of specialist surgical techniques such as hindfoot nails (HFN) / tibiotalarcalcaneal (TCC) nails and enhanced open reduction and internal fixation (ORIF). PATIENTS AND METHODS: A UK-wide collaborative study was performed of adult distal AO43/AO44 fractures, associated with 1 or more of the patient factors listed above. Primary outcomes included patient demographics, comorbidities, surgical technique and implants. Secondary outcomes included surgical complications and early post-operative weight bearing instructions. Statistical analysis was performed to assess patient and fracture characteristics on outcome, including propensity matching. RESULTS: One-thousand three hundred and sixty patients, with at least one of the above complex factors, from 56 centres were included with a mean age of 53.1 years. 90.2% (1227) patients underwent primary fixation which included 78.9% (1073) standard open reduction internal fixations (ORIF), 3.25% (43) extended ORIF and 8.1% (111) primary HFN / TCC. Overall wound complications and thromboembolic events were similar in the hindfoot nail group and the ORIF group (11.7% vs 10.7%). Wound complications were greater in diabetic patients versus non-diabetic patients independent of fixation method (15.8% vs 9.0%). After propensity matching for comorbidities and fracture type, overall complications were lower in the hindfoot nail (11.8%) and extended ORIF groups (16.7%), than the standard ORIF group (18.6%). CONCLUSION: Only a minority of complex ankle fractures are treated with specialised techniques (HFN/TCC or extended ORIF). Though more commonly used in older and frail patients their perceived advantages are often negated by a reluctance to bear weight early. These techniques demonstrated a better complication profile to standard ORIF but hindfoot nail with joint preparation for fusion was associated with more complications than hindfoot nail for fixation. LEVEL OF EVIDENCE: III.

Incidence, costs and post-operative complications following ankle fracture - A US claims database analysis.

BACKGROUND: The epidemiology and payer costs for ankle fractures are not well documented. This study evaluated: (1) the incidence of ankle fracture and ankle surgery following fracture in the US population; and (2) the clinical presentation of patients presenting with ankle fractures requiring surgery, their complication rates, and payer costs. METHODS: Patients in the IBM® MarketScan® Commercial and Medicare Supplemental databases with an inpatient/outpatient diagnosis of ankle fracture from 2016 to 2019 were stratified by age group and gender, and rates of fracture per 10,000 enrollees were estimated. Surgically-treated patients between January 2016 - October 2021 were further analyzed. One-year post-surgical outcomes evaluated complication rates (e.g., infection, residual pain), reoperations, and 1-year payments. Standard descriptive statistics were calculated for all variables and outcomes. Generalized linear models were designed to estimate payments for surgical care and incremental payments associated with postoperative complications. RESULTS: Fracture cases affected 0.14% of the population; 23.4% of fractures required surgery. Pediatric and elderly patients were at increased risk. From 3 weeks to 12 months following index ankle surgery, 5.5% (5.3% - 5.7%) of commercially insured and 5.9% (5.1% - 6.8%) of Medicare patients required a new surgery. Infection was observed in 4.4% (4.2% - 4.6%) commercially insured and 9.8% (8.8% - 10.9%) Medicare patients, and residual pain 3 months post-surgery was observed in 29.5% (28.7% - 30.3%) commercially-insured and 39.3% (36.0% - 42.6%) Medicare patients. Commercial payments for index surgery ranged from $9,821 (95% CI: $9,697 - $9,945) in the ambulatory surgical center to $28,169 (95% CI: $27,780 - $28,559) in the hospital inpatient setting, and from $16,775 (95% CI: $16,668 - $16,882) in patients with closed fractures, to $41,206 (95% CI: $38,795 - $43,617) in patients with Gustilo III fractures. Incremental commercial payments for pain and infection averaged $5,200 (95% CI: $4,261 - $6,139) and $27,510 (95% CI: $21,759 - $33,261), respectively. CONCLUSION: Ankle fracture has a high incidence and complication rate. Residual pain affects more than one-third of all patients. Ankle fracture thus presents a significant societal impact in terms of patient outcomes and payer burden.

Does the Covid-19 pandemic affect ankle fracture incidence? Moderate decrease in Sweden.

Background and purpose - While many other countries implemented strict regulations and restrictions for their citizens during the 1st wave of the Covid-19 pandemic, Sweden maintained a more restrained approach. The Swedish Public Health Agency emphasized individual responsibility and pushed for behavioral changes. With strict lockdown a 77% decrease in ankle fracture incidence has been reported. We investigated whether there was a change in the incidence of ankle fractures seen at 7 selected hospitals during the Covid-19 pandemic 2020.Patients and methods - Data on all ankle fractures treated at 7 selected departments during March 15 through June 15, 2020, and for the same period in the preceding 3 years (2017-2019), was retrieved from the Swedish Fracture Register. The number of fractures during the whole period and subsequent 30-day periods were compared between 2020 and 2017-2019, including subgroup analyses of age and sex.Results - The monthly rate of ankle fractures was reduced by 14% in 2020 (139 fractures) compared with 2017-2019 (161 fractures). Women had a 16% decrease and patients aged > 70 years had a 29% decrease. During the 1st 30-day period, a 26% decrease in fractures was seen.Interpretation - During the 1st wave of the Covid-19 pandemic, a moderate decline in the number of ankle fractures was seen. Women and patients aged > 70 years displayed the greatest reduction. The greatest reduction in incidence of fractures was seen during the 1st 30-day period. This indicates greater adherence to government recommendations regarding social distancing in these subgroups and during the 1st month of the pandemic. Changes in ankle fracture incidence may be a measure of lockdown extent.

Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England.

BACKGROUND: Evidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contact-casting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients. METHODS: Patients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence. RESULTS: Over the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0-19.5% < 60 years; 15.2-17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved. CONCLUSIONS: Despite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contact-casting, in line with recent evidence.

Mortality and Morbidity of Surgical Management of Geriatric Ankle Fractures.

INTRODUCTION: The incidence of geriatric ankle fractures is rising. With the substantial variation in the physiologic and functional status within this age group, our null hypothesis was that mortality and complications of open reduction and internal fixation (ORIF) between patients who are aged 65 to 79 are equivalent to ORIF in patients who are aged 80 to 89. METHODS: Patients with ankle fracture were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Patients treated with ORIF were identified using the Current Procedural Terminology codes. Patients were divided into two age cohorts: 65 to 79 years of age and 80 to 89 years of age. The primary outcome studied was 30-day mortality. Secondary outcomes included 30-day readmission, revision surgery, surgical site infection, sepsis, wound dehiscence, pulmonary embolism, deep vein thrombosis, blood transfusion, urinary tract infection, pneumonia, stroke, myocardial infarction, renal insufficiency or failure, and length of hospital stay. RESULTS: Our cohort included 2,353 ankle fractures: 1,877 were among 65 to 79 years of age and 476 were among 80 or older. Thirty-day mortality was 3.2-fold higher in the 80 to 89 years of age group compared with the 65 to 79 years of age group (1.47% versus 0.48%, P = 0.019). However, after controlling for the ASA class, 80 to 89 years of age patients no longer had a significantly higher mortality (P = 0.0647). Similarly, revision surgery rate (3.36% versus 1.81%, P = 0.036), transfusion requirement (2.94% versus 1.49%, P = 0.033), urinary tract infection (1.89% versus 0.75%, P = 0.023), and hospital length of stay (4.9 versus 2.9 days, P < 0.0001) were all significantly higher in the 80 to 90 years of age group compared with the 65 to 79 years old group. However, after controlling for the ASA class, 80 to 89 years old patients no longer had a rate of complications in comparison to the 65 to 79 years old age group. DISCUSSION: After controlling for comorbidities (ie, the ASA class), no increased risk is observed for the 30-day mortality or complication rate between geriatric ankle fracture in the 65 to 79 years old and the 80 to 99 years old age groups. LEVEL OF EVIDENCE: Prognostic level III, retrospective study.

Machine Learning Accurately Predicts Short-Term Outcomes Following Open Reduction and Internal Fixation of Ankle Fractures.

Ankle fractures are common orthopedic injuries with favorable outcomes when managed with open reduction and internal fixation (ORIF). Several patient-related risk factors may contribute to poor short-term outcomes, and machine learning may be a valuable tool for predicting outcomes. The objective of this study was to evaluate machine-learning algorithms for accurately predicting short-term outcomes after ORIF for ankle fractures. The Nationwide Inpatient Sample and Nationwide Readmissions Database were queried for adult patients ≥18 years old who underwent ORIF of an ankle fracture during 2013 or 2014. Morbidity and mortality, length of stay >3 days, and 30-day all-cause readmission were the outcomes of interest. Two machine-learning models were created to identify patient and hospital characteristics associated with the 3 outcomes. The machine learning models were evaluated using confusion matrices and receiver operating characteristic area under the curve values. A total of 16,501 cases were drawn from the Nationwide Inpatient Sample and used to assess morbidity and mortality and length of stay >3 days, and 33,504 cases were drawn from the Nationwide Readmissions Database to assess 30-day readmission. Older age, Medicaid, Medicare, deficiency anemia, congestive heart failure, chronic lung disease, diabetes, hypertension, and renal failure were the variables associated with a statistically significant increased risk of developing all 3 adverse events. Logistic regression and gradient boosting had similar area under the curve values for each outcome, but gradient boosting was more accurate and more specific for predicting each outcome. Our results suggest that several comorbidities may be associated with adverse short-term outcomes after ORIF of ankle fractures, and that machine learning can accurately predict these outcomes.

Demographic and socioeconomic factors influencing the incidence of ankle fractures, a national population-based survey of 512187 individuals.

This study aimed to investigate the population-based incidence rate of ankle fracture and associated risk factors in China. All the data on ankle fractures were available from the China National Fracture Survey (CNFS) conducted between January and May in 2015. All eligible household members were sampled from 8 provinces, 24 urban cities and 24 rural counties in China, using stratified random sampling and the probability proportional to size method. Questionnaires were sent to every participant for data collection and quality control was accomplished by our quality control team members. A total of 512187 valid questionnaires were collected and relevant data were abstracted and analyzed. One hundred and ninety patients sustained 193 ankle fractures in 2014, indicating the incidence rate was 37.1 (95% CI, 31.8-42.4)/100,000 person-year. Alcohol consumption, living alone and average sleep time <7 h/d were identified as independent risk factors for ankle fracture in both males and females. Previous history of fracture was identified as significant risk factor of ankle fracture in females but not in males. Therefore, specific public health policies focusing on decreasing alcohol consumption and encouraging individuals to obtain sufficient sleep should be implemented. Individuals living alone should focus more on healthcare, especially in those with previous fracture.

Sanders II/III Calcaneus Fractures in Laborers: A Cost-Effectiveness Analysis and Call for Effectiveness Research.

OBJECTIVE: This study compares the cost and cost-effectiveness of treatments options for Sanders II/III displaced intra-articular calcaneus fractures (DIACFs) in laborers. METHODS: Literature on Sanders type II and III fractures was reviewed to determine complication rates and utility values for each treatment option. Costs were calculated using Medicare reimbursement and implant prices from our institution. Monte Carlo simulations were used to analyze a decision tree to determine the cost and cost-effectiveness of each treatment from a societal perspective. Sensitivity analysis was performed on all variables. RESULTS: Minimally invasive open reduction internal fixation (ORIF) (sinus tarsi approach with 4 screws alone) was least expensive ($23,329), followed by nonoperative care ($24,530) and traditional ORIF using extensile lateral approach ($27,963) (P < 0.001); this result was most sensitive to time out of work. Available cost-effectiveness data were limited, but our analysis suggests that minimally invasive ORIF is a dominant strategy, and traditional ORIF is superior to nonoperative care (incremental cost-effectiveness ratio $57,217/quality-adjusted life year). CONCLUSIONS: Our findings suggest that minimally invasive ORIF (sinus tarsi approach) is the least expensive option for managing Sanders II/III displaced intra-articular calcaneus fractures, followed by nonoperative care. Our cost-effectiveness results favor operative management but are highly sensitive to utility values and are weakened by scarce utility data. We therefore cannot currently recommend a treatment course based on value, and our primary conclusion must be that more extensive effectiveness research (ie, health-related quality of life data, not just functional outcomes) is desperately needed to elucidate the value of treatment options in this field. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Wide Variation of Surgical Cost in the Treatment of Periarticular Lower Extremity Injuries Between 6 Fellowship-Trained Trauma Surgeons.

OBJECTIVES: We hypothesized that negligible surgical material cost variation exists between traumatolgists for treatment of bimalleolar ankle and bicondylar tibial plateau fractures. DESIGN: Retrospective medical record review. SETTING: Academic level 1 Trauma Center; 2-year period. PATIENTS/PARTICIPANTS: Current Procedure Terminology codes for open treatment of bimalleolar ankle and bicondylar tibial plateau fractures identified patients. Patients who had operative treatment of other injuries under the same anesthetic session were excluded. Only definitive treatment procedures were analyzed. INTERVENTION: We analyzed the intraoperative material costs of these procedures and compared them between surgeons. This analysis was done with a newly developed proprietary program designed for inventory and cost analysis. MAIN OUTCOME MEASUREMENTS: Mean and median total case material costs were compared using one-way analysis of variance. Individual items that significantly increased costs were identified. RESULTS: We identified 88 bimalleolar ankle and 46 bicondylar tibial plateau fractures treated by 6 surgeons. The mean intraoperative material cost per bimalleolar ankle fracture was $1099. The least expensive surgeon's mean case cost was $613, which was significantly less than the most expensive surgeon's $2243 (P = 0.009). The median cost range was $598-$784. The top quartile of cases resulted in 57% of overall material cost for ankle fractures. The mean intraoperative material cost per bicondylar tibial plateau fracture was $3219 (range $1839-$4088, P = 0.064). The range of median costs ($1826-$3989) was significantly wider than for ankle fractures. Bone void fillers, locking plates, adjunctive external fixators, mini-fragment locking plates, cannulated screws, single-use taps, guidewires, and drill bits all substantially increased costs. CONCLUSION: This study demonstrated variation in intraoperative material cost between 6 traumatologists resulting from practice variations despite similar specialty training. The cost differences resulting from practice variation reveal potential savings through increased standardization of surgical care for similar injuries. We identified high-cost items, which could lead to cost savings if used only when they will have clinical benefit.

Computed Tomography Assessment of Peroneal Tendon Displacement and Posteromedial Structure Entrapment in Pilon Fractures.

OBJECTIVES: To determine the proportion of (1) peroneal tendon displacement (PTD) and posteromedial structure entrapment (PMSE) cases in a sample of pilon fractures, (2) missed diagnoses of PTD and PMSE on computed tomography (CT) by radiologists and attending orthopaedic trauma surgeons, and PTD and PMSE cases by (3) OTA/AO classification, and (4) fibular fracture. DESIGN: Retrospective cohort review. SETTING: Regional level 1 Trauma Center. PATIENTS/PARTICIPANTS: Two hundred patients treated between July 2008 and November 2014. INTERVENTION: Axial and reconstructed CT images were used in bone and soft tissue windows to identify PTD and PMSE. MAIN OUTCOME MEASUREMENTS: Medical charts were reviewed to identify OTA/AO fracture classification, the presence of concomitant fibular fracture, whether radiologist CT interpretation noted PTD or PMSE, and whether attending orthopaedic trauma surgeons' operative notes mentioned recognition of and management of PTD or PMSE. RESULTS: From the retrospective review of CT, PTD was identified in 11.0% and PMSE in 19.0% of all pilon fractures. Of the 22 patients with PTD, 59.1% sustained a concomitant fibular fracture and 90.9% sustained a 43-C fracture. Patients with PTD sustained more 43-C fractures (90.9% vs. 62.9%) but significantly fewer fibular fractures (59.1% vs. 80.3%; P = 0.023) than patients without PTD. Of the 38 patients with PMSE, 81.6% sustained a fibular fracture and 86.8% sustained a 43-C fracture. PMSE was more common in patients with 43-C fractures (86.8% vs. 61.1%). The final preoperative radiologist CT interpretation commented on PTD and PMSE in 50.0% of cases. CONCLUSIONS: Higher energy pilon fractures (43-C) are associated with higher incidence of PMSE and PTD. Concomitant fibula fracture may play a protective role in PTD in the setting of pilon fractures. Both attending radiologists and attending orthopaedic trauma surgeons frequently fail to recognize the diagnoses of PTD and PMSE. LEVEL OF EVIDENCE: Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of Diabetes Mellitus on Surgical Quality Measures After Ankle Fracture Surgery: Implications for "Value-Based" Compensation and "Pay for Performance".

OBJECTIVES: To evaluate the impact of diabetes mellitus (DM) and associated complications on cost, length of stay, and inpatient mortality after open reduction internal fixation (ORIF) of an ankle fracture, and the implications of these variables during a time of health care payment reform. DESIGN: Retrospective study. SETTING: The Statewide Planning and Research Cooperative System database, which includes all admissions to New York State hospitals from 2000 to 2011. PATIENTS/PARTICIPANTS: A total of 58,748 patients were identified as having undergone the primary procedure of ORIF of the ankle (ICD-9-CM procedure code 79.36). INTERVENTION: ORIF of the ankle. MAIN OUTCOME MEASURE: Cost, length of stay, and inpatient mortality. RESULTS: Of the 58,748 patients evaluated, 7501 (12.8%) had DM. Mean length of stay and total hospital charges were significantly greater for the DM cohort compared to the without DM cohort (P < 0.01). Patients with DM had greater Charlson Comorbidity Index scores and greater in-hospital mortality than patients without DM (both P < 0.01). Of the patients with diabetes, 1098/7501 had complicated diabetes mellitus (C-DM). Patients with C-DM stayed 2.4 days longer and were $6895 more costly than those with diabetes alone (both P < 0.01). Patients with C-DM also had a significantly higher in-hospital mortality rate than those with diabetes alone. CONCLUSIONS: Patients with diabetes admitted to the hospital for ankle ORIF have more expensive hospital stays and higher in-hospital mortality rates than patients without diabetes. The presence of diabetic complications further increases these risks. These data will help provide risk-adjustment for future health care payment reform initiatives. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Operative versus nonoperative treatment of geriatric ankle fractures: a Medicare Part A claims database analysis.

BACKGROUND: The incidence of ankle fractures is increasing in the geriatric population, and several studies suggest them to be the third most common extremity fracture in this age group. Previous work has reflected relatively low complication rates during operative treatment. Little is known, however, about the association between these injuries and overall mortality, nor whether operative intervention has any effect on mortality. We hypothesized that geriatric ankle fractures would be correlated with an elevated mortality rate and that operative intervention would be associated with a reduced mortality when compared to nonoperative management. METHODS: Following Institutional Review Board approval we retrospectively assessed all relevant 2008 part A inpatient claims from the Medicare database. We queried diagnosis codes for ankle fractures, and then excluded any patients whose age was less then 65 or had an admission related to an ankle fracture during the previous year. Operative patients were then identified by their ICD-9 procedure codes occurring within 30 days of their initial diagnosis code; all other patients were presumed to be treated without operative intervention, thereby creating 2 groups for comparison. We then analyzed this database for specific variables including overall mortality, length of stay, age distribution, and other demographical characteristics. Groups were compared with Elixhauser and Deyo-Charlson scores to determine the level of comorbidities in each group. Multivariate logistic regression analysis was used to determine if operative intervention had a protective effect. RESULTS: In all, 19 648 patients with an ankle fracture were identified. Of those, 15 193 underwent operative intervention (77.3% ) and 4455 were treated nonoperatively (22.7% ). The mean ages for nonoperative and operative intervention were 80.9 and 76.5, respectively (P < .0001). The average length of stay for nonoperative management was 4.5 days, while operative intervention resulted in a length of stay of 4.6 days (P = .43). One-year mortality was 21.5% for the nonoperative group and 9.1% for the operative group (P < .0001). The mean Elixhauser score for the nonoperative group was 2.5 and 2.2 for the operative group (P < .0001). The mean Deyo-Charlson score was 1.3 and 1.0 for the nonoperative and operative groups, respectively (P < .0001). Multivariate logistic regression analysis demonstrated an odds ratio of 0.534 of death within 1 year for patients undergoing operative intervention as compared to nonoperative intervention (95% CI 0.483-0.591, P < .0001). CONCLUSION: The incidence of geriatric ankle fractures continue to increase as our population continues to grow older. A significantly larger number of those patients were treated with operative intervention, at a ratio of approximately 3:1 versus nonoperative management. Despite a relatively low overall reported complication rate with treatment of these injuries, they are associated with substantially increased 1-year mortality in both patient groups. Compared to the operative group, the nonoperative cohort demonstrated a 2-fold elevated mortality rate, although this may be related to them being an arguably more frail population as suggested by both comorbidity indexes. In spite of the difference in comorbidities, logistic regression analysis demonstrated operative intervention to have a protective effect. LEVEL OF EVIDENCE: Level III, comparative series.