title: Morbidity and readmission after open reduction and internal fixation of ankle fractures are associated with preoperative patient characteristics.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Level III, prognostic study.
authors.affiliation: Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA.
authors.forename: Bryce A
authors.initials: BA
authors.lastname: Basques
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Miller
authors.forename: Nicholas S
authors.initials: NS
authors.lastname: Golinvaux
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Bohl
authors.forename: Jonathan N
authors.initials: JN
authors.lastname: Grauer
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D064386:Ankle Fractures / Q000150:complications / Q000601:surgery*; D016208:Databases, Factual; D003922:Diabetes Mellitus, Type 1 / Q000150:complications; D003924:Diabetes Mellitus, Type 2 / Q000150:complications; D005260:Female; D005593:Fracture Fixation, Internal / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission; D011183:Postoperative Complications / Q000209:etiology*; D011446:Prospective Studies; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D055815:Young Adult