Early mortality after tibial plateau fracture fixation linked with age, injury type

Issue: December 2012

MINNEAPOLIS — A recently presented study cites high energy injury and after-hours surgery as top risk factors of reoperation following tibial plateau fracture fixation and showed an 11% increase in 90-day mortality for each year patients were older than 48 years.

Perspective from Michael J. Gardner, MD

“We showed this independent association of higher morbidity with after-hours surgery,” David Wasserstein, MD, of the University of Toronto, Canada, said during his presentation at the Orthopaedic Trauma Association 2012 Annual Meeting. “If you had a higher energy injury, you had a higher rate of reoperation. But, overall, reoperation rates were relatively low and the finding of advanced age was a significant risk factor for early mortality. This has some practical and clinical relevance.”

Retrospective database study

Wasserstein and colleagues used physician billing codes from administrative data in Ontario to identify 8,400 patients who underwent surgical fixation for tibial plateau fracture between 1996 and 2009. Patients had a mean age of 48 years and a 1-year mean follow-up.

“The nature of the codes allowed us to look at some aspects of the injuries, as well as the surgery, but not all,” Wasserstein said. “For example, we could identify which fractures were bicondylar.”

The researchers found 25% of the fractures were bicondylar and 5% were open fractures. Overall, an arthroscopy was performed in 8% of the surgeries.

Mortality, morbidity

The study revealed that 12% of the cases underwent hardware removal, 8% of surgeries were revised and 3% had deep infection.

The top predictors of revision were markers of high energy injury, such as bicondylar or open fractures, and surgery performed after 5 p.m. or after midnight. Factors that increased odds of reoperation for deep infection included, bicondylar or open fracture and male gender. Surgery performed after midnight also increased the odds of hardware removal.

Overall, the 90-day mortality rate was 0.85%. Risk factors for mortality also included markers of high energy injury: open fractures, bicondylar fractures, associated shaft fractures and performing fixation at an academic hospital, including all level 1 trauma centers. Older age was a risk factor for mortality, increasing 11% for each year that patients were older than 48 years. The 90-day mortality rate for octogenarians was 8.2%, Wasserstein said.

Limitations

The use of administrative data and the retrospective study design could allow for recall bias and cause accuracy concerns, Wasserstein said.

“The resolution of the data set is not optimal to look at things like fixation used, fracture subtypes, grade of open injury or the length of time from injury to surgery and how those factors influenced reoperation,” he said. “But, if you compare our study to the current literature, it is easily the largest cohort study from a general population. It gives the unique ability to look at a certain provider factors, such as volume and academic hospital status. Of course, in Ontario, the health care system is public, so everyone is being captured within the data set.” – by Renee Blisard Buddle

Reference:

Wasserstein D. Paper #80. Presented at: Orthopaedic Trauma Association Annual Meeting; Oct. 3-6, 2012; Minneapolis.

For more information:

David Wasserstein, MD, can be reached at the Department of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, 600 University Ave., Toronto, ON M5G 1X5, Canada; email: david.wasserstein@utoronto.ca.
Disclosure: This study was funded by a resident research grant from the Orthopaedic Trauma Association.

Perspective

Michael J. Gardner, MD

The authors have used an extremely large population database to analyze risk factors for complications following surgical treatment of tibial plateau fractures. One of their most notable findings was the relatively high 90-day mortality rate (8.2%) in elderly patients with these injuries. One caveat to this finding is that, in contradistinction to geriatric hip fractures, there are likely more high energy mechanisms associated with tibial plateau fractures that may have contributed to mortality. Nevertheless, one cannot ignore the implication that a period of restricted weight-bearing and recumbency in this population may also contribute to the mortality rate. This underscores the importance of designing and validating fixation strategies or other surgical interventions that safely allow for early weight-bearing. Another important finding is the increased complication rate in patients who undergo after-hours surgery. While the authors have acknowledged the potential confounders in using a retrospective dataset to interpret these data, this does highlight the importance of prioritizing working-hour resources to optimize patient outcomes.

Michael J. Gardner, MD

Orthopaedic Trauma Service

Assistant Professor

Department of Orthopaedic Surgery

Washington University School of Medicine

Chesterfield, Mo.

Disclosures: Gardner has no relevant financial disclosures.