Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Bruce J. Sangeorzan, MD*,
Harborview Medical Center, Seattle, Washington
Posted May 2009
In this month's Journal, SooHoo et al. report on short-term and intermediate-term complications of ankle
fractures that required readmission to a hospital. The authors identified more
than 57,000 patients who had been treated as inpatients for ankle fracture in
California hospitals during an eleven-year period. From this group, they examined
the rates of infection, reoperation, and pulmonary embolism. Data were available
for 30,728 patients at a follow-up of five years. The data from this subgroup
were queried, specifically with regard to the prevalence of reoperation for the
performance of ankle fusion or ankle arthroplasty. The overall rate of
short-term complications was low, with a wound infection rate of 1.44%, a pulmonary
embolism rate of 0.34%, and a surgical revision rate of 0.82%. A mortality rate
of 1.07% was surprisingly high. Not surprisingly, patients with severe medical
comorbidities were the patients most likely to have complications.
The investigators used a method that is not commonly used in
orthopaedics but that is often used in health-sciences research—mining data in
a registry for very large numbers of a common illness or treatment and
comparing rates of complications among different groups. The concept is simple;
the methods are complex. This method is not often employed in orthopaedic
studies because it obscures much detail and does not assess factors that
technically oriented surgeons often think are important, such as surgical
technique, implant strength, and treatment or rehabilitation strategies. Also,
this methodology does not help determine which treatment is best or who
requires treatment, and it does not discriminate between problem fractures and
simple fractures. Lastly, it is dependent upon the coding accuracy of clerical
support staff who may be unfamiliar with patient-care issues.
What it does do, however, is provide data from a completely
disinterested investigator mining a completely objective, if imperfect, data
source. It provides reliable quantitative data that, in this case, support our
qualitative observations. The California discharge data are compiled by California's
Office of Statewide Health Planning and Development (OSHPD). The mission
statement of the OSHPD is "to promote healthcare accessibility through
leadership in analyzing California's healthcare infrastructure,… providing
information about healthcare outcomes…"1 Like other
government agencies that are struggling with the cost of providing medical care
to a population that is older and has more treatable illnesses than at any time
in history, the OSHPD is looking for the treatments that are most cost-effective.
That should be good for orthopaedics. It is unlikely that there are many
treatments that are more cost-effective than open reduction and internal fixation
of an ankle fracture, or total hip replacement, or intramedullary repair of a
fracture of the femoral shaft. However, this database cannot differentiate
between good and suboptimal techniques or between an anatomic reduction and a
suboptimal one.
What should the readership of JBJS take from this study? It
is worth reading in detail, including the appendices, because it includes
information of value. Such information includes the facts, for instance, that a
seventy-five-year-old patient with complicated diabetes and an open ankle
fracture can be advised that there is a strong likelihood of complications, that
the data for complicated diabetes show a worrisome trend for the future, and
that a patient without diabetes can be advised that there is less than a 1%
chance of end-stage ankle arthritis in the five years after the fracture. In
addition, the authors' finding that patients who underwent surgery for ankle
fracture had a one-in-three-hundred chance of sustaining a pulmonary embolism
raises the question of whether prophylactic therapy, with its attendant
morbidity, is justified.
It is worthwhile for surgeons to pay attention to the data that
is being collected with regard to their patients, and to ensure, for instance,
that a diagnosis of diabetes and peripheral neuropathy is documented. Failure
to code comorbidities may make the treatment seem excessive in comparison with the
expected complication rate.
It is important that orthopaedic surgeons conduct the kind
of research done by SooHoo et al. so that the collected data will reflect the
factors that we observe to be important. For a young orthopaedic surgeon who
wants to contribute to orthopaedic research in the future, a background in
biostatistics and epidemiology may be more helpful than a background in
biomechanics, genetics, or biochemistry.
Overall, the data reviewed by SooHoo et al. support our
general belief that treatment of ankle fractures is safe and effective. The
importance of understanding how the outside world looks at the care we provide is
an equally worthwhile message of this manuscript.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
Reference
1. Equitable Healthcare Accessibility for California. Office of Statewide Health Planning and Development. http://www.oshpd.ca.gov/General_Info/Mission_and_Values.html#heading. Accessed 2009 Apr 23.
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