Abstract
Background
Isolated, closed, femoral shaft fractures are dangerous injuries that commonly occur in the setting of high energy trauma or among older patients with significant comorbidities. Despite their prevalence, relatively little data exists connecting patient independent risk factors to the time to 30-day mortality, unplanned reoperations and unplanned readmissions in these fractures.
Methods
Using National Surgical Quality Improvement Program (NSQIP) database, isolated close femoral shaft fractures were identified using ICD-10 codes. Patient demographics, perioperative course and adverse events were identified. Categorical and binary variables were analyzed among procedure cohorts using Chi2 analysis. Univariate and multivariate analysis were conducted to identify independent risk factors associated with primary outcomes.
Results
Between 2010 and 2019, 1346 closed isolated femoral shaft fracture patients with a mean age of 66.7 were identified, of whom 30.6% and 69.4% were male and female, respectively. Surgical procedures included: 915 (68.0%) intramedullary nail (IMN); 428 (31.8%) open reduction internal fixation (ORIF); and 3 (0.2%) external fixator (Ex-fix). Patients who underwent ORIF reported 3.19 (OR: 3.19; CI: 1.45–7.03; p = 0.004) and 2.12 (OR: 2.12; CI: 1.10–4.09; p = 0.024) increased odds of mortality and unplanned related readmission compared to patients who received IMN. Transfusion, DVT, and PE rates were 34.2%, 1.4%, and 1.1%, respectively. Furthermore, 50% of mortality cases occurred within 6 days of surgery. Patients requiring reintubation reported 61.8 (OR: 61.8; CI: 15.7–242.40; p < 0.001) increased odds of mortality compared to patients not requiring reintubation.
Conclusion
Patients with femoral shaft fractures who require reintubation have increased odds of mortality than those successfully extubated. In addition to precautions prior to extubation, patients with femoral shaft fractures should also be carefully monitored for the development of DVT or PE, and they should be definitively fixed with IMN whenever possible.
Keywords: Femoral shaft fractures, Mortality, Risk factors
1. Introduction
Femoral shaft fractures (FSF) are one of the most commonly treated injuries by orthopedic surgeons, with an estimated annual incidence of 9.5–18.9 per 100,000 patients.1 Male patients between ages 15–35 are reported to sustain high energy direct trauma, most commonly from blunt trauma such as motor vehicle accidents.2 Contrastingly, female patients older than 60 are observed to sustain low-energy injuries such as ground level falls.2,3
Following traumatic injuries, such as FSF, the circulatory system enters a hypercoagulable state to limit hemorrhage.4 A sustained hypercoagulable state increases risk for a venous thromboembolic event: deep vein thrombosis (DVT) or pulmonary embolism (PE).5,6 Yang et al.7 reported the perioperative incidence of DVT to be as high as 5%–58% among patients with an isolated femoral shaft fracture. Furthermore, studies have reported the incidence rate of fatal PE from major orthopedic injuries to range from 0.66% to 7.50%.8 Kim et al.9 reported a 2.2% PE rate among stable femur fracture patients presenting to emergency department.
Additionally, traumatic femoral shaft fractures are associated with perioperative blood loss due to the sustained fracture, use of anticoagulants, comorbidities, and operative fixation. Lieurance et al.10 reported that among 53 isolated femoral shaft fracture patients, 21 (40%) patients required transfusion, with an average of 2.5 units packed red blood cells (pRBC). Comparably, Wertheimer et al.11 observed that 36% of patients with an isolated femur fracture required a blood transfusion.
Although femoral shaft fractures are a prevalent orthopedic long bone fracture, the current literature is sparse in the evaluation of isolated closed FSF patient independent risk factors and time to 30-day mortality, unplanned reoperation and readmission. This is mainly attributed to small cohort size and limited statistical univariate analyses. Therefore, the aim of this study is to use a large administrative claims database to identify (1) risk factors associated with 30-day mortality, unplanned related readmission and reoperation related readmission, related reoperation (2) incidence rates and time to perioperative transfusion, DVT, PE.
2. Methods
2.1. Data source
The National Surgical Quality Improvement Program (NSQIP) database was queried between 2010 and 2019 to identify all patients who sustained a closed isolated femoral shaft fracture using International Classification of Diseases 9th revision and 10th revision (ICD9 and ICD10) codes S72.3* and 821.0*. Patients who sustained open injuries or multiple fractures were excluded from final cohort.
2.2. Data collection
Baseline patient data included: demographics, comorbidities, date of admission, date of operation, as well as preoperative hematocrit (HCT). Categorical independent demographic variables included: age, body mass index (BMI), Race, and American Society of Anesthesiologists (ASA) classification (Table 1). Binary independent comorbidities included: history of bleeding disorder, diabetes mellitus (DM), hypertension, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), myocardial infarction, kidney disease, and dialysis use (Table 1).
Table 1.
Patient demographics, perioperative characteristics, and outcomes by procedure performed for isolated femoral shaft fracture.
| Independent variable | IMN N(%) |
ORIF N(%) |
Ex-Fix N(%) |
P-Value |
|---|---|---|---|---|
| Age Cohort | ||||
| 18-35 | 114 (12.5) | 11 (2.6%) | 0 (0.0%) | <0.001 |
| 36-66 | 257 (28.1) | 74 (17.3%) | 2 (66.7%) | – |
| 67-80 | 285 (31.1) | 131 (30.6%) | 1 (33.3%) | – |
| 81+ | 259 (28.3) | 212 (49.5%) | 0 (0.0%) | – |
| ASA > III | 602 (65.8) | 356 (83.2%) | 1 (33.3%) | <0.001 |
| CHF | 20 (2.2) | 16 (3.7%) | 1 (33.3%) | 0.001 |
| COPD | 72 (7.9) | 51 (11.9%) | 0 (0.0%) | 0.048 |
| Diabetes | 181 (19.8) | 88 (20.6%) | 1 (33.3%) | 0.800 |
| Dialysis | 14 (1.5) | 6 (1.4%) | 0 (0.0%) | 0.96 |
| Functional Status | ||||
| Independent | 741 (82) | 320 (75.5%) | 2 (66.7%) | 0.003 |
| Partially Dependent | 119 (13.2) | 85 (20.1%) | 0 (0.0%) | |
| Totally Dependent | 44 (4.9) | 18 (4.3%) | 1 (33.3%) | |
| Hospital Admission to Initial Operation (Days) | ||||
| 0 | 319 (34.9) | 87 (20.3%) | 1 (33.3%) | <0.001 |
| 1-2 | 551 (60.2) | 288 (67.3%) | 2 (66.7%) | |
| 3+ | 45 (4.9) | 53 (12.4%) | 0 (0.0%) | |
| Gender | ||||
| Male | 303 (33.1) | 108 (25.2) | 1(33.3) | 0.014 |
| Female | 612 (66.9) | 320 (74.8) | 2(66.7) | |
| Preoperative HCT (%) | ||||
| >40.6 | 173 (18.9) | 48 (11.2%) | 0 (0.0%) | |
| 35.2–40.6 | 322 (35.2) | 111 (25.9%) | 1 (33.3%) | |
| 29.4–35.2 | 276 (30.2) | 167 (39.0%) | 1 (33.3%) | |
| <29.40 | 144 (15.7) | 102 (23.8%) | 1 (33.3%) | <0.001 |
| Pulmonary Embolism | 6 (0.7) | 9 (2.1%) | 0 (0.0%) | 0.062 |
| Race | ||||
| White | 648 (70.8) | 359 (83.9%) | 3 (100.0%) | |
| Black/AA | 87 (20.3) | 20 (4.7%) | 0 (0.0%) | |
| Asian | 53 (5.8) | 8 (1.9%) | 0 (0.0%) | 0.370 |
| American Indian/Alaska Native | 4 (0.4) | 2 (0.5%) | 0 (0.0%) | |
| Native Hawaiian/Pacific Islander | 2 (0.2) | 0 (0.0%) | 0 (0.0%) | |
| Unknown | 121 (13.2) | 39 (9.1%) | 0 (0.0%) | |
| Reintubation | 10 (1.1) | 4 (0.9%) | 1 (33.3%) | 0.950 |
| Transfusion | 46 (5.0) | 36 (8.4%) | 0 (0.0%) | 0.008 |
| DVT | 15 (1.6) | 3 (0.7%) | 0 (0.0) | 0.370 |
| Mortality | 15 (1.6) | 20 (4.7%) | 1 (33.3%) | <0.001 |
| Unplanned Related Reoperations | 9 (1.0) | 6 (1.4%) | 0 (0.0%) | <0.001 |
| Unplanned Related Readmissions | 22 (2.4) | 24 (5.6%) | 0 (0.0%) | 0.010 |
Initial operative procedure was identified and categorized into three cohorts using Current Procedural Terminology (CPT) codes: Intramedullary nailing (IMN) - 27506; open reduction internal fixation with plates/screws (ORIF) - 27507; external fixation (Ex-Fix) - 20690, 20692, 20693, 20696, 20697. (Table 1).
Perioperative binary variables and time to event included: transfusion, unplanned intubation/re-intubation, deep vein thrombosis (DVT), pulmonary embolism (PE)]. Primary outcomes were: 30-day unplanned related readmission and reoperation.
2.3. Statistical analysis
Categorical and binary variables were analyzed among procedure cohorts using Chi2 analysis. Univariate logistic regression analysis was initially utilized to identify statistically significant clinically relevant independent risk factors associated with each outcome of interest. These independent risk factors were then included in a multivariable logistic regression analysis for each respective outcome. P-value <0.05 was considered statistically significant. Statistical analyses were performed using [STATA].
3. Results
3.1. Total cohort
Between 2010 and 2019, 1346 patients with closed isolated femoral shaft fractures were identified, of whom 412 (30.6%) were male and 934 (69.4%) were female. The average patient age was 66.7 (IQR: 59.0–80.0) (Table 1). The majority of patients were White [1010 (75.05%)], Black [107 (8.0%)], and Asian [61 (4.5%)]. At baseline, 959 (71.3%) patients reported ASA score ≥ 3. Additionally, 1063 (79.9%), 204 (15.4%), and 63 (4.6%) patients reported full independency, partially dependent, and totally dependent, respectively (Table 1). Table 1 demonstrates cohort comorbidity distributions.
3.2. Perioperative course
Baseline laboratory results reported a mean HCT of 34.8 (IQR:30.7–38.9). Of note, 16.4% of patients reported initial HCT below 29.3 (Table 1). With regards to surgical intervention, 915 (59.9%), 428 (28.0%), and 3 (0.2%) were treated with an intramedullary nail (IMN), open reduction internal fixation (ORIF), or external fixation (Ex-fix), respectively. The mean operative time was 102 min (IQR: 73–139). During the perioperative period, 34.2% of patients received at least one transfusion. The mean time to postoperative transfusion was 1.04 days. The respective cumulative transfusion percentages on postoperative days 0–3 were 39.1% (180/1346), 70.5% (145/1346), 93.1% (104/1346), and 99.3% (458/1346). Of note, 5.3% (46/915) and 8.4% (36/428) of IMN and ORIF patients received transfusion, respectively. Furthermore, 11.1% (15/1346) patients required unplanned reintubation, of which, 20.0% occurred on postoperative day 0.
Thirty-day deep vein thrombosis and pulmonary embolism were 1.3% (18/1346) and 1.1% (15/1346), respectively. The mean time to DVT and PE were 10.7 (IQR: 6–14 days) and 6.6 days (IQR: 3–10 days), respectively. 73.3% of PEs occurred within 6 days of operation, yet only 33.3% of DVTs occurred during the same 6 day period. Only 6.7% (1/15) of patients with PE reported a DVT.
3.3. 30-Day mortality
The reported overall 30-day mortality rate was 2.7% (36/1346), of which 50% occurred by postoperative day 6. Furthermore, 100% of mortality patients were classified as ASA greater than 3 (36/36), of whom 55.5% reported ASA 4 (20/36). Additionally, 80.5% of patients were over the age of 78 (29/36). Univariate analysis demonstrated that patients with total dependent functional status reported 3.8 increased odds of mortality compared to independent functional status (OR: 3.73; CI: 1.37–10.14; p = 0.010). Baseline hematocrit levels less than 29.4 were also associated with increased odds of mortality compared to patients with HCT >40.6% (OR: 4.37; CI: 1.24–15.40; p = 0.022).
Patients who underwent ORIF or Ex-Fix reported a 2.9 (OR: 2.94; CI: 1.49–5.80; p = 0.002) and 30.0 (OR: 30; CI: 2.58–349.07; p = 0.007) increased odds of mortality compared to patients who received IMN. Regarding peri-operative complications, patients who developed a PE, required transfusion or re-intubation reported a 5.9 (OR: 5.87; CI: 1.27–27.03; p = 0.023), 3.9(OR: 3.92; 95% CI: 1.66–9.24; p = 0.002), and 62.1 (OR: 62.01; 95% CI: 20.2–190.8, p = 0.001) increased odds of mortality, respectively.
Multivariate regression analysis reported a 61.8 (OR: 61.8; CI: 15.7–242.40; p < 0.001) and 3.2 (OR: 3.19; CI: 1.45–7.03; p = 0.004) increased odds of mortality among patients requiring re-intubation and ORIF compared to patients without re-intubation and IMN, respectively (Table 2).
Table 2.
This table represents multivariable analysis of independent risk factors associated with 30-day mortality, and unplanned related readmission and reoperation among isolated femoral shaft patients. REF = Reference; ASA = American Society of Anesthesiologists; CHF = Congestive Heart Failure; DVT = Deep Vein Thrombosis; HCT = Hematocrit; IMN = Intramedullary Nail; ORIF = Open Reduction Internal Fixation.
| Independent variable | Mortality |
Readmission |
Reoperation |
||||||
|---|---|---|---|---|---|---|---|---|---|
| OR | 95% CI | P-value | OR | 95% CI | P-value | OR | 95% CI | P-value | |
| ASA ≥ III | - | - | - | 1.75 | 0.68–4.51 | 0.245 | 1.65 | 0.41–6.60 | 0.482 |
| CHF | 2.82 | 0.71–17.28 | 0.139 | 3.67 | 1.16–11.60 | 0.026 | – | – | – |
| Diabetes | 1.42 | 0.87–2.31 | 0.161 | – | – | – | – | – | – |
| Dialysis | – | – | – | 3.07 | 0.72–13.18 | 0.13 | – | – | – |
| DVT | – | – | – | 12.09 | 3.34–43.76 | <0.001 | 12.59 | 2.39–66.24 | 0.003 |
| Functional Status | |||||||||
| Independent | REF | REF | REF | REF | REF | REF | REF | REF | REF |
| Partially Dependent | 1.1 | 0.42–2.90 | 0.843 | 1.22 | 0.54–2.75 | 0.628 | 0.76 | 0.16–3.51 | 0.721 |
| Totally Dependent | 2.72 | 0.80–9.22 | 0.109 | 1.45 | 0.39–5.46 | 0.58 | 0.56 | 0.04–7.60 | 0.662 |
| Hospital Admission to Initial Operation (Days) | |||||||||
| 0 | REF | REF | REF | REF | REF | REF | – | ||
| 2-Jan | 1.49 | 0.53–4.21 | 0.455 | 2.31 | 0.88–6.09 | 0.091 | |||
| 3+ | 1.36 | 0.30–6.09 | 0.69 | 1.69 | 0.40–7.10 | 0.472 | – | – | |
| Preoperative HCT | |||||||||
| >40.6 | REF | REF | REF | REF | REF | REF | – | ||
| 35.2–40.6 | 1.15 | 0.22–6.09 | 0.874 | 4.05 | 0.86–19.15 | 0.078 | – | – | |
| 29.4–35.2 | 2.2 | 0.47–10.29 | 0.319 | 3.14 | 0.66–14.99 | 0.151 | |||
| <29.40 | 3.51 | 0.71–17.28 | 0.123 | 2.16 | 0.40–11.54 | 0.368 | |||
| Procedure | |||||||||
| IMN | REF | REF | REF | REF | REF | REF | REF | REF | REF |
| ORIF | 3.19 | 1.45–7.03 | 0.004 | 2.12 | 1.10–4.09 | 0.024 | 1.37 | 0.46–4.03 | 0.569 |
| External Fixator | 12.94 | 0.29–573.48 | 0.186 | – | – | – | 59.87 | 3.48–1031.44 | 0.005 |
| Pulmonary Embolism | 2.14 | 0.23–19.93 | 0.506 | 14.81 | 4.01–54.69 | <0.001 | 5.13 | 0.54–48.61 | 0.154 |
| Reintubation | 61.8 | 15.7–242.4 | <0.001 | 1.62 | 0.24–10.87 | 0.621 | – | – | – |
| Transfusion | 1.47 | 0.50–4.32 | 0.482 | 3.71 | 1.48–9.32 | 0.005 | 3.54 | 0.85–14.70 | 0.081 |
3.4. Unplanned related readmission
The 30-day unplanned related readmission rate was 1.1% (15/1346) with a mean of 15.6 days (IQR: 10.0–22.0 days) from day of operative procedure. The most common diagnosis at readmission was SSI [0.37% (5/1346)]. Organ Space SSIs, UTIs, and PEs were the second most common [0.30% (4/1346)]. All diagnoses at readmission are listed in Table 3.
Table 3.
Reason for readmission ICD-10 and reoperation CPT codes by procedure; N = Patient count; % = Percent readmitted patients among each primary initial procedure cohort; IMN = Intramedullary Nail; ORIF = Open Reduction Internal Fixation. Of note, no patients with external fixator cohort reported 90-day related readmission, hence not included in the table.
| Reason for 30-Day Readmission and Reoperation | N=Number of Patients (%) | IMN N (%) |
ORIF N (%) |
Ex-Fix N (%) |
|---|---|---|---|---|
| Total Readmission: | 58 (4.3) | 29 (3.2) | 29 (6.8) | 0 (0.0) |
| Transfusion | 1 (3.4) | 1 | 0 | 0 (0.0) |
| C. Dif | 1 (3.4) | 1 | 0 | 0 (0.0) |
| CVA | 1 (3.4) | 1 | 0 | 0 (0.0) |
| Cardiac Arrest | 1 (3.4) | 1 | 0 | 0 (0.0) |
| Organ Space/SSI | 4 (13.8) | 1 | 3 | 0 (0.0) |
| Pneumonia | 2 (6.8) | 1 | 1 | 0 (0.0) |
| Pulmonary Embolism | 4 (13.8) | 1 | 3 | 0 (0.0) |
| Sepsis | 2 (6.8) | 1 | 1 | 0 (0.0) |
| Superficial Incisional SSI | 5 (17.2) | 1 | 4 | 0 (0.0) |
| Urinary Tract Infection | 4 (13.8) | 3 | 1 | 0 (0.0) |
| Vein Thrombosis requiring Therapy | 1 (3.4) | 1 | 0 | 0 (0.0) |
| 32 (55.2) |
16 |
16 |
0 (0.0) |
|
| Total Reoperation: | 21 (1.6) | 13 (1.4) | 7 (1.6) | 1 (33.3) |
| Superficial Wound Debridement (10180, 11042–45) | 7 (33.3) | 3(23.1) | 4 (57.1) | 0 (0.0) |
| Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod, plate) (20680) | 1 (4.8) | 1 (7.7) | 0 (0.0) | 0 (0.0) |
| Treatment of infection (26990, 27301) | 3 (14.3) | 1 (7.7) | 2 (28.6) | 0 (0.0) |
| Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage (27244) | 1 (4.8) | 1 (7.7) | 0 (0.0) | 0 (0.0) |
| Prophylactic treatment (nailing, pinning, plating, or wiring) with or without methylmethacrylate, femur (27495) | 1 (4.8) | 1 (7.7) | 0 (0.0) | 0 (0.0) |
| Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws (27506) | 3 (14.3) | 3 (23.1) | 0 (0.0) | 0 (0.0) |
| Unspecified femur/knee surgery (27599) | 1 (4.8) | 1 (7.7) | 0 (0.0) | 0 (0.0) |
| Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), with internal fixation when performed; of tibia only (27827) | 1 (4.8) | 0 (0.0) | 0 (0.0) | 1 (100.0) |
| Non-orthopedic procedure (31600, 35301, 43239) | 3 (14.3) | 2 (15.4) | 1 (14.3) | 0 (0.0) |
Univariate logistic regression demonstrated an ASA class greater than three (OR: 2.30; CI: 1.02–5.19; p = 0.045), dialysis (OR: 5.27; CI: 1.49–18.65; p = 0.010) and history of CHF (OR: 4.83; CI: 1.79–13.03; p = 0.002) were associated with greater odds of unplanned related readmission, respectively. Surgical intervention 1–2 days after admission reported 2.4 increased odds of unplanned related readmission compared to patients with same day surgical intervention (OR: 2.40; CI: 1.06–5.48; p = 0.036). When comparing surgical fixation ORIF was associated with 2.4 increased odds of readmission when compared to IMN (OR: 2.41; CI: 1.33–4.35; p = 0.003). Perioperative complications that were associated with greater odds of readmission were PE (OR: 15.73; CI: 5.15–48.10; p < 0.001), DVT (OR: 8.75; CI: 2.76–27.71; p < 0.001), reintubation (OR: 4.87; CI: 1.05–22.46; p = 0.042), and the need for transfusion (OR: 3.44; CI: 1.55–7.63; p = 0.002).
Multivariate regression analysis patients undergoing ORIF reported 2.1 increased odds of unplanned related readmission (OR: 2.12; CI: 1.10–4.09); p = 0.024) when compared to IMN. Additionally, DVT and PE during initial hospitalization were associated with 12.1 and 14.8 increased odds of readmission (OR: 12.09; CI: 3.34–43.76; p < 0.001) (OR: 14.81; CI:4.01–54.69; p < 0.001) compared to patients who did not report DVT and PE, respectively. Finally, the need for blood transfusion during hospitalization was associated with a 3.7 (OR: 3.71; CI: 1.48–9.32; p = 0.005) increased odds of unplanned related readmission (Table 2).
3.5. Unplanned related reoperation
Sixty-Two (4.1%) patients underwent an unplanned reoperation related to the index operation within 17.5 days (IQR: 8–26 days) of the index procedure. The most common reason for reoperation was infection [23.1% (3/13)]. Reasons for reoperation are listed in Table 3.
Univariate analysis identified a history of smoking to be associated with greater odds of reoperation (OR: 3.56; CI: 1.28–9.90; p = 0.015). American Indian/Alaska Natives were also associated with greater odds of necessitating a reoperation (OR: 50.00; CI: 8.20–304.93; p < 0.001). The external fixation cohort reported 50.3 increased odds of unplanned related reoperation when compared to IMN (OR: 50.33; CI: 4.18–606.25; p = 0.002). Patients with a DVT and required transfusion were associated with an 11.7 (OR: 11.73; CI: 2.46–55.91; p = 0.002). And 3.5 (OR: 3.61; CI: 1.01–12.91; p = 0.049) increased odds of unplanned related reoperation greater odds of requiring an unplanned related reoperation, respectively. Multivariate regression analysis identified DVT to be independently associated with an increased risk of reoperation (OR: 12.59; CI: 2.39–66.24; p = 0.003). When compared to IMN, patients receiving external fixation were also at increased risk of unplanned reoperation (OR: 59.87; CI: 3.48–1031.44; p = 0.005). No other patient or operative factors were associated with the risk of reoperation. Table 2.
4. Discussion
The aim of this study was to identify patient and perioperative risk factors associated with postoperative 30-day mortality, unplanned related readmission and reoperation rates among patients who sustained isolated, closed femoral shaft fractures. Independent variables associated with postoperative complications included history of CHF, development of a perioperative DVT or PE, required transfusion or reintubation, as well as procedure type, and time to procedure.
Brown et al.12 preformed an 18-month cohort of adult trauma patients admitted to the ICU who required mechanical ventilation and observed that patients who required reintubation reported a mortality rate of 6% compared with 0.4% of patients successfully extubated. Our findings demonstrated that patients requiring reintubation reported 61.8 increased odds of mortality compared to those successfully extubated. The magnitude in reported difference between studies may be attributed to cohort inclusion criteria variability as well as definition of unplanned reintubation. Given these differences, the risk of reintubation remains an independent risk factor for mortality in both patient cohorts. The orthopedic literature remains limited on the risk factors and timing associated with failed trial of extubation. Further research, specifically among blunt polytrauma patients, is required to identify timing of extubation in the potential setting of multiple surgical interventions.
Venous thromboembolic events are also a commonly feared perioperative complication among patients who sustained fracture injuries. Wang et al.13 conducted a retrospective analysis of isolated lower extremity fracture patients who underwent bilateral preoperative and postoperative venous duplex ultrasounds. The reported proximal DVT rates ranged between 0 and 14.5%; highest among femoral shaft fractures. Interestingly, the reported symptomatic PE event was 1.6%. Similarly, our results demonstrated a 1.1% overall PE rate. Of note, 73.3% of PEs occurred within 6 days of operation, yet only 33.3% of DVTs occurred during the same 6 day period. Abelseth et al.5 observed that among lower extremity fractures who underwent surgery, 28% had an occult DVT detected. Furthermore, Wang et al.13 reported that preoperative duplex ultrasound detected between a 30.0% and 43.4% DVT rate among patients who underwent surgery for lower extremity fracture. Our findings in conjunction with previous literature demonstrate that early symptomatic PE may be attributed to occult subclinical preoperative DVT. Further research is required to explore the role of anticoagulation dosing in the preoperative setting among high-risk hypercoagulable patients. Our multivariable logistic regression results demonstrated PE and DVT to also be independent risk factors for 30-day readmission and reoperation, respectively.
With regards to surgical intervention, our study demonstrated that patients who underwent initial ORIF for FSF reported an increased risk of mortality compared to patients who received IMN. Similarly, Dodd et al.14 previously reported that for femoral fractures, ORIF reported a significantly higher rate of postoperative complications compared to IMN (15.6% vs 14.9%). Additionally, external fixation reported increased risk for unplanned related reoperation. This is consistent with prior trials of definitive external fixation of femoral shaft fractures. Reported rates of pin and surgical site infections as well as non-unions frequently warrant reoperation.15,16 In patients with orthopedic trauma, the risk of readmission has previously been described to be the highest in the first 3 months following discharge, with rates as high as 10.3%.17
In our study cohort, of the patients who underwent surgical intervention, fifty percent of mortality cases occurred within 6 days of operation, of whom 100% of mortality patients reported an ASA greater than 3, and 80.5% of patients were over the age of 78. This data is supported by Bommireddy et al.18 who reported that among 53 femoral shaft fracture patients with a mean age of 78.7 years, 30-day mortality rate was 13.2%. These findings demonstrate that elderly patients who sustain a femoral shaft fracture require managed care analogous to recent Hip Fracture Pathway initiatives.19
Although this study has many strengths and contributes to a paucity of literature, a few limitations must be addressed. This is a retrospective NSQIP database analysis and subject to the inherent bias of retrospective study design and available data variables. The use of anticoagulation therapies in the setting of lower extremity injuries significantly contributes to the risk of VTE events; however, this data is not available in the present NSQIP population.20 It is important to recognize that presenting fracture patterns are amenable to various modes of definitive fixation; therefore, it is possible that some patients in the ORIF cohort did not present with a fracture pattern amenable to IMN. The results of this study suggest that among fracture patterns that can either be treated with ORIF or IMN, IMN fixation may decrease risk of 30-day mortality. Additionally, among patients receiving an IMN, NSQIP does not distinguish between reamed and unreamed IMN which can also have an impact on outcomes. What allows this study to still be generalized and contribute to the published literature is the both the unique evaluation and large sample size of NSQIP.
5. Conclusion
This study highlights that patients who require reintubation have strikingly higher odds of mortality than patients successfully extubated. In addition to precaution regarding extubation, patients with femoral shaft fractures should also be carefully monitored for a hypercoagulable state to mitigate their risk of complications associated with DVT or PE. Although not always possible, the risks associated with ORIF and external fixation indicate patients should be fixed with IMN whenever possible. Studies with greater access to patient data will be essential in further elucidating these risk factors for future femoral shaft fracture patients and their surgeons.
Funding sources
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Institutional ethical committee approval
Not applicable.
Authors contribution
Eric H. Tischler, DO, MPH: Conceptualization, Methodology, Formal Analysis, Writing – Original Draft, Writing – Review & Editing. Jake R. McDermott, BA: Methodology, Formal Analysis, Writing – Original Draft, Writing – Review & Editing. Adam J. Wolfert, MD: Conceptualization, Methodology, Writing – Original Draft, Writing – Review & Editing. Benjamin Krasnyasnskiy, BS, BA: Methodology, Formal Analysis, Writing – Review & Editing. Ishaq Ibrahim, MD: Conceptualization, Writing – Review & Editing, Supervision. Aden Malik, MD: Conceptualization, Writing – Review & Editing, Supervision. Jonathan M. Gross, MD: Conceptualization, Writing – Review & Editing, Supervision. Nishant Suneja, MD: Conceptualization, Writing – Review & Editing, Supervision.
Declaration of competing interest
None.
Acknowledgements
None.
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