VCOM Carolinas Research Day 2023

Clinical Studies

Assessing Closed Traumatic Trimalleolar Fractures: Immediate Surgical Repair versus Delayed Surgical Management in a Rural Setting

*Brandon Welborn, OMS-III, *Mackenzie Pargeon, OMS-III, Lynn Campbell, DO, FACOEP, FACEP Edward Via College of Osteopathic Medicine, Spartanburg, SC and Spartanburg Regional Healthcare System

Abstract # CLIN-11



Results cont.

Context : Closed trimalleolar fractures are severe ankle injuries, are considered unstable and account for about 7% of all ankle injuries. 3-5 The injury can have detrimental consequences for patients if not treated adequately. While delayed surgical treatment is an option, closed trimalleolar fractures normally require immediate surgery since a delay in treatment can put the patient at risk of permanent damage from malunion, loss of mobility, or significant morbidity from complications. 6 Surgical fixation for the management of medial and lateral fractures is well defined, however, the management of posterior and trimalleolar fractures does not have a defined treatment route. 10 Objective: The objective of this study is to determine if immediate surgical repair or delayed surgical treatment of closed trimalleolar fractures has a better clinical outcome. In order to assess outcomes, we looked at readmission rates within 30 days of initial presentation as well as the presence of complications after treatment. Patient charts were analyzed for any factors that might have played a role in the treatment decision. Demographic factors, patient comorbidities, and whether patients were seen in the Emergency Department (ED) before or after COVID-19 restrictions were placed were examined. • Retrospective chart review of Spartanburg Regional Healthcare System (SRHS) from the dates of 01/01/2017-12/31/2021 were used. A convenience sample of 314 patients were obtained. All identifying factors were removed. • Inclusion criteria : Patients between the ages of 18 and 90 with the ICD-10 Codes for Trimalleolar Fractures were pulled using electronic medical records. • Exclusion criteria : Subjects with history of prior ankle injury or hardware in the involved ankle if documented were excluded. • Factors including race, gender, comorbidities and insurance status were analyzed. • Comorbidities listed in the patient chart were evaluated and analyzed. Complications from management such as deep vein thrombosis/pulmonary emboli, wound infections, recurring pain, delayed healing, nonunion and malunion were examine . • Patients were then separated into three groupings: age, treatment type and timing in relation to COVID-19 restrictions. The data was analyzed using the Fisher’s Exact Test with left and right tail test and the Wilcoxon/Kruskal-Wallis Test. Mutlivariable factors using Wald Test was done. P-values were then Methods Introduction or Methods Females overall were more likely to have trimalleolar fractures (shown in graph 1). Patients who had immediate surgical treatment had a higher pain scale, a higher body mass index (BMI), were in the 51-90 age group, more likely to have insurance and were less likely to have readmission rates (Table 1 and 2). The 18-50 age group were more likely to have delayed surgery. Those in the delayed group were also noted to have a lower pain scale, have a lower BMI but were more likely to be readmitted within 30 days (table 2). The majority of patients across all data sets had at least one comorbidity documented however, those that were treated immediately had more comorbidities prior to treatment. Before the COVID-19 pandemic, more patients were referred from outpatient settings. After hospital restrictions were established, there were more patients being admitted or had initial management in the Emergency Department. There were more emergency room visits in the younger age group overall. obtained and reported with the results if significant. • Confidence Interval: 95% with p-value of <0.05. Results

The majority of patients across all data sets had at least one comorbidity documented. A greater percentage of patients with osteoporosis, obesity, depression, long term steroid use, cancer, CKD/ESRD, rheumatoid arthritis, osteoarthritis, anemia, lung disease, hypothyroidism, hyponatremia, hypertension, and heart failure underwent immediate surgical treatment. Patients in both age groups were more likely to undergo immediate surgical treatment. The majority of patients within the delayed management group were discharged home, and patients treated immediately were largely discharged to a home health agency or skilled nursing facility. Most of the patients in this study were women. Although immediate surgical treatment was largely the route taken for all ages, younger patients were more likely to undergo delayed surgical management, and they were also more likely to have readmissions. Delayed surgical management led to more readmissions, and the immediate surgical treatment were the only ones to have complications however, with our 95% confidence level it was found not to be significant. Factors including race, insurance status, and overall comorbid status were not statistically significant contributors to management choice. COVID-19 restrictions did not play a role in management choice. Discussion: Although the sample size was adequate and representative of our study population, this study is limited in its generalization to a larger, more urban population. Other limitations within the study do not account for complications or readmissions outside of the SRHS. So, complications may have existed but were not reported in our specific system, therefore, potentially missing some issues. In future studies, it would be good to broaden the study parameters to include more hospitals, a larger sample size as well as expand the time frame past 30 days of readmission. The results showed most patients were female and the underlying reason for this could be further explored. It was also found that patients in the 50 and under group had a higher percentage of readmissions. Studying the cause of this issue in this population would be of benefit.



Figure 1. Gender of patients in age group & the Immediate vs Delayed Surgical Groups

Indicator Number



p-Value Power




Mean= 59.57 Median= 61 Range= 71

Mean= 50.7 Median= 53 Range= 59 Mode= 64 SD=16.313

<.0001 Wilcoxon/Kruskal-Wallis Test

Mode= 65 SD=15.67

Insurance No Yes

0.0134 Right Tail Test Fisher’s Exact Test

15 (7.04%) 198 (92.96%)

16 (16%) 84 (84%)

Table 1. Comparison of those patients who underwent Immediate surgical repair vs Delayed

Delayed Surgical Group

Immediate Surgical Group


Mean Pain Score




Body Mass Index (BMI) mean


Readmission within 30 days



Complications, yes or no



References eferences

Table 2. Immediate vs Delayed Surgical Group: Mean Pain Scores, Percent of Readmissions & Percent with Complications with a p-value of is 0.96.


Age 18-50

Age 51-90


Insurance No Yes Immediate/ Delayed Immediate Delayed

0.0004 Right Tail Test Fisher’s Exact Test

19 (19%) 81 (81%)

12 (5.63%) 201 (94.37%)

0.0006 Right Tail Test Fisher’s Exact Test


55 (55%) 45 (45%)

158 (74.18%) 55 (25.82%)

Readmissions Immediate Delayed

• Angela Wilson, BS, MBA who did the Statistical Analysis. • Dorothy Williams, Senior Date Quality Analyst at SRHS. • This project was approved by the Spartanburg Regional Healthcare System IRB Committee on June 29, 2022. Protocol number: 1888901-1.

4 11

8 6

0.0232 Wald Test

Table 3. Age Group break down on Insurance, Treatment Plan and Readmission


2 0 2 3 R e s e a r c h R e c o g n i t i o n D a y

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