Ankle Fracture Surgery Appropriate for Elderly Patients

May 31, 2007
Jill Stein

Internal Medicine World Report, April 2007, Volume 0, Issue 0

From the American Academy of Orthopedic SurgeonsMortality Rate Greater with Conservative Therapy

SAN DIEGO—Although elderly persons who sustain a broken ankle are often referred for nonsurgical treatment out of concern about an increased risk of complications with surgery, such precautions may be unfounded.

New findings reported at the American Academy of Orthopedic Surgeons annual meeting document low complication rates with both surgical and nonoperative treatment of ankle fractures in this age-group.

Kenneth Koval, MD, director of the Orthopaedic Trauma Division at Dartmouth–Hitchcock Medical Center, Lebanon, NH, and colleagues used the US Medicare database to compare complication rates in surgically treated and conservatively treated ankle fractures in the elderly.

Although ankle fractures are among the most common fractures in older patients, the optimal treatment has not been determined, Dr Koval noted.

Overall, 33,704 patients who had sustained an ankle fracture between 1998 and 2001 were evaluated. Their mean age was 76 years; about one fourth had diabetes or peripheral vascular disease. All were assessed at 30 days, 6 months, and at 1 and 2 years after treatment.

After controlling for the effects of age, gender, race, Charlson comorbidity index, presence of diabetes or peripheral vascular disease, and fracture type, patients treated conservatively had significantly greater mortality rates (P <.05) than those treated surgically at all evaluation points, except for the earliest time period of 30 days.

However, the surgery group did have significantly greater rehospitalization rates at all time periods (P <.05).

&#8220;Although the apparent protective effect of surgical intervention on mortality may result from selection bias in choosing operative treatment for healthier individuals, it is important to recognize that the difference in mortality persisted after adjusting for potential confounders like patient age and number of comorbidities,&#8221; Dr Koval said.

The medical and surgical complication rates at virtually every assessment point were ≤2% for all patients, regardless of treatment. Fewer than 1% required additional procedures, such as revision internal fixation, ankle arthroplasty, ankle arthrodesis, and lower extremity amputation.

Dr Koval cautioned that the study&#8217;s retrospective database design should be taken into account when interpreting the results, since users cannot independently corroborate the accuracy of the data, its standardization, or its input. In addition, the Medicare database lacks clinical information on medications, the severity of associated comorbidities, lifestyle factors, patient body composition, and radiographic information such as fracture displacement. Without such information, it is difficult to fully evaluate whether specific interventions are appropriate and to control for all patient variables, he added.

Nevertheless, Dr Koval said that these results suggest that concern about operative complications should not be a deterrent to the surgical treatment of ankle fractures in older adults.