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The management of femoral and tibial shaft fractures has long been among the simplest in orthopaedic trauma. Little data exist on the predictors of complications associated with these fractures. The evolving healthcare system is creating a focus on quality 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 continue to improve patient care while also reducing overall medical costs.
Using the ACS-NSQIP database, we evaluated patient demographics, comorbidities and 30-day complications of femoral and tibial fractures. A bivariate analysis was then used to compare rates of minor and major post-operative complications within 30 days. A multivariate logistic regression was performed, assessing the odds of developing a minor and/or major complication up to 30 days post-surgery.
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.
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.
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, 2, 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, 5, 6, 7 Older 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, 11, 12, 13, 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.
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 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.
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).
The significant risk factors for 30-day postoperative complications were found to be age (OR: 1.02, 95% CI: 1.01–1.03, p < 0.001) and ASA score (OR: 2.05, 95% CI: 1.64–2.56, p < 0.001) (Table 4). After controlling for all confounding variables, plating of the tibia and femur were each associated with a 2-fold increase of developing a postoperative complication compared to IMN. Plating of the femur or tibia was also associated with higher odds of major postoperative complications compared to IMN.
Our study shows that lower extremity long bone fractures are associated with a number of major and minor complications. Compared to IMN for tibia and femur fractures, plating has a significantly higher rate of minor and major complications within 30 days following surgery. Our study found that plating of a tibial or femoral fracture approximately doubles the risk of developing any postoperative complication. Significant risk factors associated with postoperative complications for plating of the femur were: hypertension and age, whereas the significant risk factor for complications due to plating of the tibia was ASA score.
Patients with femoral fractures had a higher rate of comorbidities such as COPD, CHF and diabetes compared to patients with tibial fractures. Therefore, the majority of patients with femur fractures had an ASA score greater than 3 (54%), which was higher than the ASA score for most patients with tibial shaft fractures. Since the femur is the strongest bone in the body and fractures often result from high-energy impaction, patients frequently present with associated injuries and need multiple surgical interventions, leading to a higher ASA score.19, 20 Orthopaedic surgeons must account for the increased risk of complications for femoral fractures when assessing patients for surgery.
IMN is currently the method most used by surgeons to treat long bone fractures since it is less invasive by nature, has potential for earlier weight-bearing, and has shown to have a lower rate of postoperative complications.15, 21, 22, 23, 24, 25, 26 It has even been found to have union rates for femur fractures approaching 97.0%.11 Previous literature has also shown that compared to IMN, plating is associated with higher rates of postoperative complications. The recent study by Avilucea et al. found that plating of open distal tibial shaft fractures leads to higher rates of nonunion and significantly increases the odds of postoperative complications compared with IMN.15 However, this study investigated only open tibial fractures, whereas our study evaluated open and closed fractures of the tibia and femur. Im et al. prospectively investigated open and closed tibial shaft fractures and found infection rates to be higher in the plating cohort.16 Similarly, our study found a higher rate of deep SSI for plating of the femur and tibia when compared to IMN for each fracture type. Other studies, however, have found that the type of fixation does not impact postoperative outcomes. Vallier et al., for instance, found statistically similar rates of infection between the plating and IMN group for tibial shaft fractures, but this study used a small sample size.26 Minhas et al. used the ACS-NSQIP database to compare plating and IMN, but found no difference in postoperative complications for closed extra-articular tibial fractures.21 However, they only evaluated closed fractures of the tibia rather than all lower extremity long bone fractures. Unlike previous literature comparing plating and IMN, the results from this study are unique in that postoperative complications for both femoral and tibial fractures demonstrated that plating was a risk factor. Therefore, although technically demanding, IMN fixation of long bone fractures may be less risky than plating and should be considered based on the patient's type of fracture and preoperative health profile.
Independent of fracture type and fixation, risk factors for developing any postoperative complication were found to be age (OR: 1.022, 95% CI: 1.01–1.03, p < 0.001) and ASA score (OR: 2.05, 95% CI: 1.64–2.56, p < 0.001) for all patients with lower extremity long bone fractures. Advanced age has been shown to be a risk factor for postoperative complications such as nonunion as well as a risk factor for developing a long bone fracture.5, 8, 9, 27 ASA score was significantly predictive of postoperative complications, in which each unit increase was associated with a 2-fold increase in developing a postoperative complication. Knowing the risk factors for postoperative complications of lower extremity long bone fractures, surgeons will be able to better risk stratify patients based on fracture type and be able to better prevent acute postoperative complications.
After further classifying patients by fracture type, our results demonstrated that femoral fractures had a higher rate of complications. For all postoperative complications, femoral shaft fractures presented with a complication rate of 14.9–15.6%, whereas tibial shaft fractures presented with a complication rate of only 5.8%. The rates of major postoperative complications were also higher for femoral shaft fractures. Mortality, for example, occurred in 3.8–4.8% of patients with femur fractures but only 0.4–0.5% of patients with fractures of the tibia.
Our study should be evaluated within the context of its limitations. Using the NSQIP database, we were limited by the number of patients and the risk factors that could be evaluated. Our study did not investigate orthopaedic postoperative complications such as nonunion, malunion and hardware which are commonly associated with surgical fixation of lower extremity long bone fractures.15, 22, 23, 24, 25, 26 Social factors such as addiction and homelessness have also shown to affect outcomes of bone healing,11 and were not evaluated in this study. Due to the nature of the database, our study was only able to evaluate complications within 30 days following surgery. We could not specify the mechanism of injury or if the fracture patterns involved the proximal, middle or distal third of the tibial or femoral shaft, and we could not determine the grade of compounding of the fracture. The patient cohorts included closed and open fractures, which may have influenced the rate of infection and other postoperative complications.
To the best of our knowledge, this study is the first to compare the rate and risk factors for postoperative complications for lower extremity long bone fractures by type of fixation and fracture region. The results demonstrate that diaphyseal femur and tibia fractures are not without risk and are significantly impacted by type of surgical treatment. As our healthcare system begins to focus more on quality measures, orthopaedic surgeons must use knowledge of associated risk factors and complications to properly assess the best surgical intervention for each patient.
This study was performed in accordance with the relevant regulations of the US Health Insurance Portability and Accountability Act (HIPPA) and the ethical standards of the 1964 Declaration of Helsinki. The protocol was approved by the Vanderbilt Institution Review Board.
Author William Obremskey has done expert testimony in legal matters. The institution of one or more authors (WTO) has received a grant from the Department of Defense. The remaining authors certify that he or she has no commercial associations that might pose a conflict of interest in connection with the submitted article.
|27506||Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary nail, with or without cerclage and/or locking screws.|
|27507||Open treatment of femoral shaft fracture with plate/screws, with our without cerclage.|
|27758||Open treatment of tibial shaft fracture (with or without fibular fracture) with plate/screws, with or without cerclage.|
|27759||Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage.|