journal of clinical orthopaedics and trauma 7 (2016) 80–85
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jcot
Original Article
Increased risk of adverse events in management of femur and tibial shaft fractures with plating: An analysis of NSQIP data Ashley C. Dodd, Christopher G. Salib, Nikita Lakomkin, William T. Obremskey, Manish K. Sethi * The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN 37232, United States
article info
abstract
Article history:
Background: The management of femoral and tibial shaft fractures has long been among the
Received 7 August 2015
simplest in orthopaedic trauma. Little data exist on the predictors of complications associ-
Accepted 10 January 2016
ated with these fractures. The evolving healthcare system is creating a focus on quality
Available online 7 March 2016
metrics and changing payment models. It is critical that traumatologists develop a better understanding of complication rates associated with these injuries so that they may
Keywords:
continue to improve patient care while also reducing overall medical costs.
Femur fracture
Methods: Using the ACS-NSQIP database, we evaluated patient demographics, comorbidities
Tibia fracture
and 30-day complications of femoral and tibial fractures. A bivariate analysis was then used
Intramedullary nailing, Open
to compare rates of minor and major post-operative complications within 30 days. A
reduction internal fixation
multivariate logistic regression was performed, assessing the odds of developing a minor
Complication rates
and/or major complication up to 30 days post-surgery. Results: 2891 patients were identified. For femoral fractures, intramedullary nailing (IMN) demonstrated an overall complication rate of 14.9% (n = 151) whereas open reduction and internal fixation (ORIF) with plating showed an overall complication rate of 15.6% (n = 70). Patients undergoing plating of the femur or tibia were 2 times more likely than the IMN patients to demonstrate postoperative complications. Conclusion: Our study is the first to demonstrate that plating of femoral and tibial fractures doubles the odds of developing a complication. As our healthcare system shifts to bundled payment plans, it is impertinent for the orthopaedic surgeon to understand the risk factors associated with fracture treatments in order to assess the best treatment plan. # 2016 Delhi Orthopedic Association. Published by Elsevier B.V. All rights reserved.
1.
Introduction
Lower extremity long bone fractures, including fractures of the femur and tibia, are common injuries treated by orthopaedic
trauma surgeons. In fact, tibial shaft fractures have been found to be the most common long-bone diaphyseal fractures worldwide.1–3 These long bone fractures often result from high-velocity trauma such as motor vehicle accidents and therefore affect both young and old populations.4–7 Older
* Corresponding author. Tel.: +1 615 936 0112; fax: +1 615 936 2667. E-mail address: [email protected] (M.K. Sethi). http://dx.doi.org/10.1016/j.jcot.2016.01.002 0976-5662/# 2016 Delhi Orthopedic Association. Published by Elsevier B.V. All rights reserved.
journal of clinical orthopaedics and trauma 7 (2016) 80–85
individuals also face an increased risk of long-bone fractures due to a decrease in bone density associated with age and increased risk of falling.5,8,9 Management of long bone fractures varies from conservative methods including casting and bracing to surgical, encompassing open reduction internal fixation (ORIF) with plates or intramedullary nailing (IMN).2,3 Optimal treatment for long-bone fractures is still debated among orthopaedic surgeons and depends on various factors.3 IMN fixation especially has become standard treatment of femoral and tibial shaft fractures resulting in a high rate of union; however, past studies have shown an increased risk of infection for IMN of open fractures when compared to any orthopaedic trauma surgery.10–14 On the contrary, a study by Avilucea et al. found that plating leads to higher rates of nonunion and increases the odds of postoperative complications compared with IMN of open tibial shaft fractures.15 Im and colleagues similarly found that the plating group was associated with a 23% infection rate compared to a rate of 3% for IMN patients.16 As the healthcare system in the United States transitions into bundled payments, understanding the rate and risk factors for postoperative complications associated with lower extremity long bone fractures is essential for the orthopaedic trauma surgeon to not only maintain quality patient care but to also reduce overall medical costs.17,18 In this study, we investigated the (1) rate and (2) risk factors for major and minor postoperative complications within 30 days of plating or IMN for fractures of the femur and tibia. By comparing the rate and risk factors for postoperative complications, orthopaedic surgeons can improve surgical outcomes through accurately assessing benefits and risks associated with plating compared to IMN treatment for lower extremity long bone fractures.
2.
Methods
Utilizing the American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2013, we identified 341,062 orthopaedic patients using a Current Procedural Terminology (CPT) code search. A second CPT code search was used to identify 2891 patients with lower extremity long bone fractures, which constituted as fractures of the femoral and tibial shaft (see Appendix). IMN or plating treatment was evaluated for both fractures. After stratifying by CPT code, patient demographics (including body mass index [BMI], gender, race, smoking status, ASA class), preoperative comorbidities (diabetes, history of chronic obstructive pulmonary disease [COPD], history of congestive heart failure [CHF]) and postoperative complications within 30 days of surgery were collected. Major postoperative complications included: mortality, deep superficial surgical site infection (deep SSI), organ infection, myocardial infarction (MI), deep vein thrombosis (DVT), pulmonary embolism (PE), coma, sepsis and septic shock. Minor postoperative complications included wound dehiscence, superficial surgical site infection [superficial SSI], pneumonia and urinary tract infection. A chi-squared test and Wilcoxon–Mann–Whitney test were performed to evaluate differences in patient demographics, preoperative comorbidities and postoperative complications between the
81
femoral and tibial fractures. Statistical significance was set at p = 0.05. Multiple multivariate logistic regressions were performed to investigate the risk factors for developing a postoperative complication within 30 days of surgery. To compare the risk factors between the four types of procedures (femoral plating, femoral IMN, tibial plating, tibial IMN), a multivariate regression controlling for age, sex, BMI, diabetes, ASA status, active smoking status, hypertension, history of COPD, history of CHF, and dyspnea was performed for each fracture treatment. To further investigate the risk factors for both femoral and tibial fractures, a separate multivariate logistic regression was performed across all patients independent of procedure. Risk factors for minor and major complications were investigated in separate bivariate analyses. Age, BMI, sex, diabetes, smoking status, history of COPD, history of CHF, ASA score, hypertension and type of surgery were included within the analysis.
3.
Results
2891 patients with lower extremity long bone injuries were included within this analysis. As shown in Table 1, the majority of patients underwent IMN, in which 33.5% (n = 1012) of patients had IMN of the femoral shaft and 32.4% (n = 979) had IMN of the tibial shaft. There was a significant difference in patient demographics and preoperative comorbidities between the type of fracture and procedure including gender, race, smoking status, and ASA class. When comparing patients with fractures of the femoral and tibial shaft, independent of surgical treatment, postoperative complications including mortality ( p < 0.001), MI ( p = 0.001), DVT ( p = 0.001) and stroke ( p = 0.039) were found to be significantly higher in patients with femoral fractures (Table 2). Patients with femoral fractures, including those who underwent plating and IMN, were also older in age and majority female ( p < 0.001). They presented with the highest rate of diabetes, history of CHF and an ASA score greater than 3 ( p < 0.0001) compared to tibial shaft fracture patients (Table 1). As shown in Table 2, rate of minor, major and total postoperative complications varied significantly between IMN and plating ( p < 0.001). For tibial and femoral fractures, plating presented with a higher rate of minor and major complications compared to IMN. The rate of postoperative MI was also significantly higher for plating of both fractures (tibia: 0.2%, n = 1; femur: 2.0%, n = 9) when compared to IMN treatment for both fractures (tibia: 0.1%, n = 1; femur: 0.5%, n = 5). Deep SSI was found to be marginally significant, in which plating presented with higher rates of infection ( p = 0.051). The mortality rate was higher in patients with IMN for tibial and femoral fractures; however, the difference was minimal. Table 3 shows the odds of developing any complication for each procedure after controlling for patient demographics and preoperative comorbidities. Each unit increase in ASA score was associated with a 2.53 times increase of developing a postoperative complication after IMN treatment of the femur ( p < 0.001) and a 2.10 times increase after plating of the tibia ( p = 0.046). Age was also found to be a significant risk factor for plating of the femur ( p = 0.019) and IMN of the tibia ( p = 0.011).
82
journal of clinical orthopaedics and trauma 7 (2016) 80–85
Table 1 – Patient demographics and selected clinical characteristics. Characteristic
Femoral fracture IMN
Femoral fracture ORIF
Tibial fracture ORIF
Tibial fracture IMN
p-Value
1012 (33.5%) 68.5 (18.1) 28.1 (7.8)
450 (14.9%) 72.8 (16.4) 28.2 (7.6)
450 (14.9%) 50.8 (16.7) 29.6 (7.6)
979 (32.4%) 48.0 (18.1) 28.3 (7.2)
–
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jcot
Original Article
Increased risk of adverse events in management of femur and tibial shaft fractures with plating: An analysis of NSQIP data Ashley C. Dodd, Christopher G. Salib, Nikita Lakomkin, William T. Obremskey, Manish K. Sethi * The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN 37232, United States
article info
abstract
Article history:
Background: The management of femoral and tibial shaft fractures has long been among the
Received 7 August 2015
simplest in orthopaedic trauma. Little data exist on the predictors of complications associ-
Accepted 10 January 2016
ated with these fractures. The evolving healthcare system is creating a focus on quality
Available online 7 March 2016
metrics and changing payment models. It is critical that traumatologists develop a better understanding of complication rates associated with these injuries so that they may
Keywords:
continue to improve patient care while also reducing overall medical costs.
Femur fracture
Methods: Using the ACS-NSQIP database, we evaluated patient demographics, comorbidities
Tibia fracture
and 30-day complications of femoral and tibial fractures. A bivariate analysis was then used
Intramedullary nailing, Open
to compare rates of minor and major post-operative complications within 30 days. A
reduction internal fixation
multivariate logistic regression was performed, assessing the odds of developing a minor
Complication rates
and/or major complication up to 30 days post-surgery. Results: 2891 patients were identified. For femoral fractures, intramedullary nailing (IMN) demonstrated an overall complication rate of 14.9% (n = 151) whereas open reduction and internal fixation (ORIF) with plating showed an overall complication rate of 15.6% (n = 70). Patients undergoing plating of the femur or tibia were 2 times more likely than the IMN patients to demonstrate postoperative complications. Conclusion: Our study is the first to demonstrate that plating of femoral and tibial fractures doubles the odds of developing a complication. As our healthcare system shifts to bundled payment plans, it is impertinent for the orthopaedic surgeon to understand the risk factors associated with fracture treatments in order to assess the best treatment plan. # 2016 Delhi Orthopedic Association. Published by Elsevier B.V. All rights reserved.
1.
Introduction
Lower extremity long bone fractures, including fractures of the femur and tibia, are common injuries treated by orthopaedic
trauma surgeons. In fact, tibial shaft fractures have been found to be the most common long-bone diaphyseal fractures worldwide.1–3 These long bone fractures often result from high-velocity trauma such as motor vehicle accidents and therefore affect both young and old populations.4–7 Older
* Corresponding author. Tel.: +1 615 936 0112; fax: +1 615 936 2667. E-mail address: [email protected] (M.K. Sethi). http://dx.doi.org/10.1016/j.jcot.2016.01.002 0976-5662/# 2016 Delhi Orthopedic Association. Published by Elsevier B.V. All rights reserved.
journal of clinical orthopaedics and trauma 7 (2016) 80–85
individuals also face an increased risk of long-bone fractures due to a decrease in bone density associated with age and increased risk of falling.5,8,9 Management of long bone fractures varies from conservative methods including casting and bracing to surgical, encompassing open reduction internal fixation (ORIF) with plates or intramedullary nailing (IMN).2,3 Optimal treatment for long-bone fractures is still debated among orthopaedic surgeons and depends on various factors.3 IMN fixation especially has become standard treatment of femoral and tibial shaft fractures resulting in a high rate of union; however, past studies have shown an increased risk of infection for IMN of open fractures when compared to any orthopaedic trauma surgery.10–14 On the contrary, a study by Avilucea et al. found that plating leads to higher rates of nonunion and increases the odds of postoperative complications compared with IMN of open tibial shaft fractures.15 Im and colleagues similarly found that the plating group was associated with a 23% infection rate compared to a rate of 3% for IMN patients.16 As the healthcare system in the United States transitions into bundled payments, understanding the rate and risk factors for postoperative complications associated with lower extremity long bone fractures is essential for the orthopaedic trauma surgeon to not only maintain quality patient care but to also reduce overall medical costs.17,18 In this study, we investigated the (1) rate and (2) risk factors for major and minor postoperative complications within 30 days of plating or IMN for fractures of the femur and tibia. By comparing the rate and risk factors for postoperative complications, orthopaedic surgeons can improve surgical outcomes through accurately assessing benefits and risks associated with plating compared to IMN treatment for lower extremity long bone fractures.
2.
Methods
Utilizing the American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2013, we identified 341,062 orthopaedic patients using a Current Procedural Terminology (CPT) code search. A second CPT code search was used to identify 2891 patients with lower extremity long bone fractures, which constituted as fractures of the femoral and tibial shaft (see Appendix). IMN or plating treatment was evaluated for both fractures. After stratifying by CPT code, patient demographics (including body mass index [BMI], gender, race, smoking status, ASA class), preoperative comorbidities (diabetes, history of chronic obstructive pulmonary disease [COPD], history of congestive heart failure [CHF]) and postoperative complications within 30 days of surgery were collected. Major postoperative complications included: mortality, deep superficial surgical site infection (deep SSI), organ infection, myocardial infarction (MI), deep vein thrombosis (DVT), pulmonary embolism (PE), coma, sepsis and septic shock. Minor postoperative complications included wound dehiscence, superficial surgical site infection [superficial SSI], pneumonia and urinary tract infection. A chi-squared test and Wilcoxon–Mann–Whitney test were performed to evaluate differences in patient demographics, preoperative comorbidities and postoperative complications between the
81
femoral and tibial fractures. Statistical significance was set at p = 0.05. Multiple multivariate logistic regressions were performed to investigate the risk factors for developing a postoperative complication within 30 days of surgery. To compare the risk factors between the four types of procedures (femoral plating, femoral IMN, tibial plating, tibial IMN), a multivariate regression controlling for age, sex, BMI, diabetes, ASA status, active smoking status, hypertension, history of COPD, history of CHF, and dyspnea was performed for each fracture treatment. To further investigate the risk factors for both femoral and tibial fractures, a separate multivariate logistic regression was performed across all patients independent of procedure. Risk factors for minor and major complications were investigated in separate bivariate analyses. Age, BMI, sex, diabetes, smoking status, history of COPD, history of CHF, ASA score, hypertension and type of surgery were included within the analysis.
3.
Results
2891 patients with lower extremity long bone injuries were included within this analysis. As shown in Table 1, the majority of patients underwent IMN, in which 33.5% (n = 1012) of patients had IMN of the femoral shaft and 32.4% (n = 979) had IMN of the tibial shaft. There was a significant difference in patient demographics and preoperative comorbidities between the type of fracture and procedure including gender, race, smoking status, and ASA class. When comparing patients with fractures of the femoral and tibial shaft, independent of surgical treatment, postoperative complications including mortality ( p < 0.001), MI ( p = 0.001), DVT ( p = 0.001) and stroke ( p = 0.039) were found to be significantly higher in patients with femoral fractures (Table 2). Patients with femoral fractures, including those who underwent plating and IMN, were also older in age and majority female ( p < 0.001). They presented with the highest rate of diabetes, history of CHF and an ASA score greater than 3 ( p < 0.0001) compared to tibial shaft fracture patients (Table 1). As shown in Table 2, rate of minor, major and total postoperative complications varied significantly between IMN and plating ( p < 0.001). For tibial and femoral fractures, plating presented with a higher rate of minor and major complications compared to IMN. The rate of postoperative MI was also significantly higher for plating of both fractures (tibia: 0.2%, n = 1; femur: 2.0%, n = 9) when compared to IMN treatment for both fractures (tibia: 0.1%, n = 1; femur: 0.5%, n = 5). Deep SSI was found to be marginally significant, in which plating presented with higher rates of infection ( p = 0.051). The mortality rate was higher in patients with IMN for tibial and femoral fractures; however, the difference was minimal. Table 3 shows the odds of developing any complication for each procedure after controlling for patient demographics and preoperative comorbidities. Each unit increase in ASA score was associated with a 2.53 times increase of developing a postoperative complication after IMN treatment of the femur ( p < 0.001) and a 2.10 times increase after plating of the tibia ( p = 0.046). Age was also found to be a significant risk factor for plating of the femur ( p = 0.019) and IMN of the tibia ( p = 0.011).
82
journal of clinical orthopaedics and trauma 7 (2016) 80–85
Table 1 – Patient demographics and selected clinical characteristics. Characteristic
Femoral fracture IMN
Femoral fracture ORIF
Tibial fracture ORIF
Tibial fracture IMN
p-Value
1012 (33.5%) 68.5 (18.1) 28.1 (7.8)
450 (14.9%) 72.8 (16.4) 28.2 (7.6)
450 (14.9%) 50.8 (16.7) 29.6 (7.6)
979 (32.4%) 48.0 (18.1) 28.3 (7.2)
–
