title: Operative versus nonoperative treatment of geriatric ankle fractures: a Medicare Part A claims database analysis.
abstract: 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).
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Level III, comparative series.
authors.affiliation: Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta GA, USA jason.bariteau@gmail.com.
authors.forename: Jason T
authors.initials: JT
authors.lastname: Bariteau
authors.affiliation: Department of Orthopaedic Surgery, Brown University, Providence, RI, USA.
authors.forename: Raymond Y
authors.initials: RY
authors.lastname: Hsu
authors.affiliation: Center for Gerontology and Health Care Research and the Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence RI, USA.
authors.forename: Vincent
authors.initials: V
authors.lastname: Mor
authors.affiliation: Center for Gerontology and Health Care Research and the Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence RI, USA.
authors.forename: Yoojin
authors.initials: Y
authors.lastname: Lee
authors.affiliation: Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Christopher W
authors.initials: CW
authors.lastname: DiGiovanni
authors.affiliation: Department of Orthopaedic Surgery, Brown University, Providence, RI, USA.
authors.forename: Roman
authors.initials: R
authors.lastname: Hayda
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D064386:Ankle Fractures / Q000453:epidemiology / Q000628:therapy*; D016208:Databases, Factual; D005260:Female; D005592:Fracture Fixation / Q000706:statistics & numerical data*; D006333:Heart Failure / Q000401:mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D016344:Medicare Part A; D009026:Mortality; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000401:mortality; D009735:Nursing Homes; D010351:Patient Discharge; D010359:Patient Readmission / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology; D020246:Venous Thrombosis / Q000401:mortality
keywords: outcome studies; trauma