Table 1 Incidence of medical complications after open reduction and internal fixation among patients with alcohol use disorder (AUD) compared with without AUD. OR, odds ratio.
Courtesy of Arie Monas


Published 3/11/2024
Terry Stanton

Alcohol Use Disorder Associated with Poor Outcomes after Bimalleolar Ankle Fractures

Research conducted at Maimonides Medical Center on patients who underwent open reduction and internal fixation (ORIF) for bimalleolar ankle fractures revealed that individuals diagnosed with alcohol use disorder (AUD) experienced more complications within 90 days post-surgery and incurred higher healthcare expenses compared to those without AUD.

The study, presented as a poster during the AAOS 2023 Annual Meeting in Las Vegas, analyzed a nationwide administrative claims database from 2010 to 2020, consisting of 64,563 patients, 8,177 of whom had AUD (versus 56,386 without AUD in the comparison group). The study compared the two groups for demographic data, 90-day medical complications, and the costs of care for the day of surgery and total 90-day episode. The 90-day medical complications included acute kidney injury, cerebrovascular accident, deep vein thrombosis, myocardial infarction, pneumonia, pulmonary embolism, respiratory failure, surgical site infection, transfusion of blood products, urinary tract infection, and venous thromboembolism (Table 1). The costs were measured using reimbursements.

Ninety-day complications
The study found a statistically significant increase in the number of patients with AUD undergoing ORIF for bimalleolar ankle fractures from 2010 (n = 1,206) to 2020 (n = 2,232) and demonstrated that these patients had significantly higher odds of developing 90-day postoperative complications than the comparison group (59.35 versus 18.77 percent). AUD was linked to higher rates of cerebrovascular accidents, respiratory failure, pneumonia, and transfusions of blood products, among other complications. The study group patients also had significantly higher day-of-surgery and total global 90-day episode-of-care costs. However, the higher incidence of 90-day readmissions in AUD patients (9.14 versus 5.56 percent) failed to reach statistical significance.

The study also found that patients with AUD in the age group of 50 to 54 years were the largest cohort among AUD patients, making up 14.33 percent of the group, followed by 55 to 59 years (14.12 percent), 45 to 49 years (10.92 percent), and 60 to 64 years (10.36 percent). There were significant differences in age among AUD patients compared with the comparison group (P <0.0001).>

Differences in sex and the prevalence of certain comorbid conditions were also observed. The prevalence of males was higher among the AUD group (47 percent) than in the comparison group (28 percent). This difference was significant (P <0.0001).>

Arie Monas, medical student at the State University of New York Downstate College of Medicine and the presenting author of the study, explained the significance of the findings. “AUD is one of the most prevalent mental health conditions in the United States,” he told AAOS Now. “While previous studies have investigated the impact of AUD on various orthopaedic procedures, there is limited research on the impact of AUD on patients with bimalleolar ankle fractures undergoing ORIF.”

With the rising incidence of ankle fractures, the increasing number of ORIF procedures being performed nationwide, and the high prevalence of AUD, he said, “Further research is needed to examine the relationship between AUD and postoperative outcomes following ORIF of bimalleolar fractures.”

Among the key findings of the study, the researcher stated that “Patients with AUD are more likely to experience complications and incur higher healthcare costs in the 90 days following ORIF of bimalleolar ankle fractures.” This information can help orthopaedic surgeons minimize healthcare costs and enhance postsurgical outcomes by being proactive in identifying and managing potential complications prior to the procedure, Monas said.

Alcohol use and surgical outcomes
Orthopaedic surgeons are well aware that excessive alcohol consumption can harm bone health and negatively impact surgical outcomes. The study conducted at Maimonides highlights the harmful effects of alcohol on complications and costs after ORIF of bimalleolar ankle fractures. The author emphasizes the importance of advising patients to limit alcohol intake for optimal bone health, especially before an orthopaedic procedure. By reducing alcohol consumption, both surgeons and patients can minimize the likelihood of complications and lower healthcare costs.

The presenter said that this study represents a significant step forward in understanding the impact of AUD on outcomes following ORIF of bimalleolar ankle fractures and that it “opens new avenues for research and that the effects of other substance abuse disorders on outcomes of ankle fracture surgery and other orthopedic procedures deserve further investigation.”

The author summarized the limitations of the study by stating that although the study utilized a large sample size to achieve a high level of statistical power, there are some limitations. The study is retrospective in nature, which can introduce inherent limitations. Furthermore, although certain variables were found to be statistically significant (e.g., costs), this may not necessarily reflect clinical significance due to the ease of determining statistical significance in large database studies. Despite these limitations, Monas said, “this study provides valuable insights into the impact of AUD on outcomes in patients undergoing ORIF of bimalleolar ankle fractures and can help improve care for orthopaedic patients who have AUD.”

Mr. Monas’ coauthors of “How Does Alcohol Use Disorder Impact Outcomes and Costs following Open Reduction and Internal Fixation for Bimalleolar Ankle Fractures?” are Derrick Chatad, MS; Ariel Nicolas Rodriguez, MD; Aaron Lam, MD; Rushabh Vakharia, MD; Amr Atef Abdelgawad, MD, MBA, PhD; and Afshin Razi, MD, FAAOS.

Terry Stanton is the former senior medical writer for AAOS Now.