scholarly journals Effect of Hypoalbuminemia on Perioperative Complications and Hospital Outcomes in Ankle Fracture Fixation

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0000
Author(s):  
Collin Barber ◽  
Andrew Chung ◽  
Clifford Jones ◽  
George Russell ◽  
Sean Karr
Keyword(s):  
Length Of Stay ◽  
Serum Albumin ◽  
Fracture Fixation ◽  
Ankle Fracture ◽  
Preoperative Diagnosis ◽  
Perioperative Complications ◽  
Ankle Fractures ◽  
Operative Outcomes ◽  
Surgical Fixation ◽  
Operative Fixation

Category: Trauma Introduction/Purpose: Pre-operative serum albumin levels have routinely been utilized to assess nutritional status. Malnutrition, as defined by serum albumin levels < 3.5 g/dL, has been associated with worse post-operative outcomes in multiple surgical settings. The effect of hypo-albuminemia on 30-day post-operative outcomes after operative fixation of ankle fractures has not been well delineated. Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, 1,526 patients who had undergone surgical fixation of ankle fractures were identified using Current Procedural Terminology (CPT) codes. Perioperative complications and length of hospital stay were compared between patients with and without hypoalbuminemia (serum albumin concentration <3.5 g/dL) with adjustment for patient and procedural factors. Complications were divided into major and minor. Major complications included death, myocardial infarction, sepsis, and return to operating room. Results: Preoperative diagnosis of hypoalbuminemia was present in 324 patients (21%). Multivariate analysis confirmed hypoalbuminemia as an independent risk factor for major complications following surgical fixation of ankle fractures (2.3% vs 7.7%; odds ratio [OR], 2.35; 95% confidence interval [CI], 1.29 to 4.27; p=0.05). Patients with a preoperative diagnosis of hypoalbuminemia had an increased length of stay (p<0.001) and increased risk of rehospitalization (1.9% vs 7.1%; OR 4.072; 2.03 to 8.19, p<0.001) compared to those with normal albumin levels. Conclusion: The presence of hypoalbuminemia upon admission for ankle fracture fixation increases risk of major perioperative complications as well as hospital length of stay. Nutritional optimization of malnourished patients is important in patients undergoing operative fixation of ankle fractures.

scholarly journals Does the quality of preoperative closed reduction of displaced ankle fractures affect wound complications after surgical fixation?

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0018
Author(s):  
Bonnie Chien ◽  
Kristen Stupay ◽  
Christopher Miller ◽  
Jeremy Smith ◽  
Jorge Briceno ◽  
...  
Keyword(s):  
Classification System ◽  
Closed Reduction ◽  
Ankle Fracture ◽  
Ankle Fractures ◽  
Wound Complications ◽  
Complication Rates ◽  
Ankle Osteoarthritis ◽  
Surgical Fixation

Category: Trauma Introduction/Purpose: Prompt reduction and stabilization of displaced ankle fractures is important to protect soft tissues, restore potential neurovascular deficits and prevent cartilage injury. Many of these injuries do eventually require surgical fixation. The purpose of this study is to determine whether the initial quality of ankle closed reduction based on radiographic criteria would affect outcomes such as ankle osteoarthritis and complications after surgery. Furthermore, we sought to develop a classification system for the quality of closed reduction that would be easy to use and provide interrater reliability. Methods: A retrospective analysis of patients who sustained isolated, closed ankle fractures with at least 3 months follow up postoperatively at two level 1 trauma centers was performed. Patient demographics and history, ankle fracture characteristics and reduction information as well as surgical outcomes and complications were collected. A grading classification for the quality of the initial closed reduction before surgery was developed based on standard AP or mortise and lateral ankle x-rays. The factors considered for rating the reduction included the degree of talar shift on the AP/mortise view, malleoli displacement, as well the relationship of a central plumb line to the center of the talar dome on the lateral x-ray. For ankle osteoarthritis, the Takakura classification was utilized. Three reviewers (1 resident, 2 attendings) independently reviewed and rated all imaging. Results: 161 patients were analyzed. 65% female, average age 50, average 4 days between injury and surgery, mean follow up of 12 months (3-58 months), and 17% wound complications. Psychiatric history was the single comorbidity significantly associated with complications (p=0.009). There was no difference in wound or infection complication rates based on initial closed reduction quality (p=0.17). Neither number nor quality of reductions correlated with increased osteoarthritis (p=0.19, 0.39 respectively). Worst graded reductions had shorter time to surgery, mean 1.4 vs 4.7 days for best reductions (p=0.03), suggesting a protective factor that may account for no association between reduction quality and wound complications. Interclass correlation coefficients for multiple observers showed very high consistency for grading of reduction quality based on the classification system (ICC >0.85, p<0.001). Conclusion: It is often emphasized that a displaced ankle fracture should be as perfectly reduced as possible, understandably for grossly dislocated ankle fracture dislocations potentially compromising skin and neurovascular structures. At the same time, this original study demonstrated contrary to common assumption that the initial quality of ankle closed reduction does not appear to affect the severity of ankle osteoarthritis or the rate of surgical complications. This study also developed a highly reproducible ankle reduction classification system. It opens the opportunity for future prospective application and analysis of this classification’s ultimate clinical utility.

scholarly journals Cost Benefit with Early Operative Fixation of Unstable Ankle Fractures

2006 ◽  
Vol 88 (4) ◽  
pp. 405-407 ◽  
Author(s):  
P Pietzik ◽  
I Qureshi ◽  
J Langdon ◽  
S Molloy ◽  
M Solan
Keyword(s):  
Length Of Stay ◽  
Hospital Stay ◽  
Complication Rate ◽  
Retrospective Review ◽  
Fast Track ◽  
Surgical Intervention ◽  
Length Of Hospital Stay ◽  
Ankle Fractures ◽  
Track System ◽  
Operative Fixation

INTRODUCTION Ankle fractures are common and many require surgical intervention. It has been well documented that a delay in fracture fixation results in increased length of hospital stay and increased complication rate. Initial delay can also allow swelling or blistering to develop which may necessitate a further delay in operative fixation for up to 1 week. The aim of the current study was to review the length of hospital in-patient stay for operative ankle fractures over the previous 12-month period at our hospital and compare this to the length of hospital stay following the introduction of a fast-track system for the fixation of these fractures (all fractures fixed within 48 h). PATIENTS AND METHODS A retrospective review of all ankle fractures managed by open reduction and internal fixation over a 12-month period was undertaken. A protocol was then agreed to openly reduce and fix these fractures at the earliest possible opportunity over the next 6-month period. We then collected the data on all ankle fractures that needed open reduction and internal fixation over this 6-month period. The pre-protocol and post-protocol groups were then compared for total hospital length of stay and complication rate. RESULTS In the 12-month retrospective review, there were 83 ankle fractures that required surgical intervention. Sixty-two of these had surgery within 48 h (mean length of stay, 5.4 days), and 21 had surgery after 48 h (mean length of stay, 9.5 days). There were 39 ankle fractures in the post-protocol group who all had surgery within 48 h (mean length of stay, 5 days). There was no increase in complication rate after implementation of the fast-track system. CONCLUSIONS This study shows that early operative intervention for ankle fractures reduces the length of hospital stay. Intensive physiotherapy and co-ordinated discharge planning are also essential ingredients for early discharge. Early operative fixation for unstable ankle fractures has substantial cost-saving implications with no increase in complication rate.

scholarly journals Refining Risk-Adjustment of 90-day Costs Following Surgical Fixation of Ankle Fractures: Implications for a Bundled Payment Model

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0028
Author(s):  
Azeem Tariq Malik ◽  
Carmen E Quatman ◽  
Thuan V. Ly ◽  
Laura Phieffer ◽  
Safdar N Khan
Keyword(s):  
Risk Adjustment ◽  
Ankle Fracture ◽  
Marginal Cost ◽  
State Level ◽  
Open Reduction Internal Fixation ◽  
Ankle Fractures ◽  
Fee For Service ◽  
Bundled Payment ◽  
Patient Level ◽  
Surgical Fixation

Category: Trauma Introduction/Purpose: Current literature revolving around understanding cost-determinants of 90-day payments following ankle fractures is limited to single-institution studies. As the current healthcare model transitions from fee-for-service to value- based payments, risk-adjustment of 90-day payments will be a key factor driving success of these bundled payment models. The current study, utilizes a national Medicare database, to understand patient-level, procedure-level and state-level variation in 90-day payments following open reduction internal fixation (ORIF) of isolated ankle fractures. Methods: The 2005-2014 5% Medicare SAF (Standard Analytical Files) database was queries using Current Procedural Terminology codes to identify patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (27766, 27769, 27792), bi-malleolar (27814) and tri-malleolar (27822, 27823) ankle fractures. Patients with polytrauma or those undergoing a concurrent surgical fixation of the upper extremity, hip, femur, knee or tibia were removed from the study to capture a relevant cohort of isolated ankle fracture patients. All payments starting from day 0 of surgery up to day 90 post-operatively were used to calculate 90-day costs. Patients with missing data were excluded. Multi-variate linear regression modeling was used to derive marginal cost-impact of patient-level (age, gender, co-morbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy and syndesmotic fixation) and state-level factors on 90-day costs following surgery. Results: Following application of inclusion/exclusion criteria, a total of 6,499 patients were included in the study. The risk- adjusted 90-day price of a non-geriatric (age<65) female patient undergoing outpatient ORIF for a closed uni-malleolar ankle fracture was $8,915 ± $1,054. Individuals aged 65-69 vs. <65 had significantly lower costs (-$1,967). Procedure-level factors associated with significant marginal cost-increases were inpatient surgery (+$5,577), tri-malleolar fracture (+$1,082) and syndesmotic fixation (+$2,822). The top 5 co-morbidities with largest marginal cost-increases were chronic kidney disease (+$8,897), malnutrition (+$7,908), obesity (+$5,362), cerebrovascular disease/stroke (+$4,159) and anemia (+$3,087). Significant state-level variation in 90-day costs was seen with Nevada (+$6,371), Massachusetts (+$4,497), Oklahoma (+$4,002), New Jersey (+$3,802) and Maryland (+$3,043) having the highest marginal cost-increase and Idaho (-$6,025) having the lowest. Conclusion: Using a national administrative claims database, the study identifies numerous patient-level, procedure-level and state-level factors that significantly contribute to the cost-variation seen in 90-day payments following ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in fracture patients.

scholarly journals Lower Complication Rate Following Ankle Fracture Fixation by Orthopaedic Surgeons Versus Podiatrists

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0000
Author(s):  
Jeremy Chan ◽  
Jeremy Truntzer ◽  
Michael Gardner ◽  
Julius Bishop
Keyword(s):  
Postoperative Complications ◽  
Operative Treatment ◽  
Fracture Fixation ◽  
Ankle Fracture ◽  
Ankle Fractures ◽  
Scope Of Practice ◽  
Complication Rates ◽  
Orthopaedic Surgeons ◽  
Irrigation And Debridement ◽  
Lower Complication

Category: Ankle, Trauma Introduction/Purpose: Although the scope of practice for orthopaedic surgeons and podiatrists have considerable overlap in many foot and ankle pathologies, there are significant differences between the training for each surgical specialty that may affect patient outcomes. The purpose of this study was to evaluate complication rates following fixation of ankle fractures based on provider type. Our hypothesis was that patients with ankle fractures treated by orthopaedic surgeons would have lower complication rates compared to patients treated by podiatrists. Methods: This was a retrospective cohort study of data extracted from the Humana Claims database for 15,067 patients who underwent ankle fracture fixation between 2007 and 2015. Procedure type was identified by Current Procedural Terminology (CPT) codes. Patient data was subcategorized by surgeon type (orthopaedic surgeon versus podiatrist) and whether the patient underwent operative treatment for a single malleolus fracture (CPT 27766, 27792) versus a bimalleolar or a trimalleolar fracture (CPT 27814, 27822, 27823). The primary outcome was postoperative complications within 3 months including malunion, infection, or deep vein thrombosis (DVT). Secondary outcomes included reoperation rates for implant removal or irrigation and debridement. Complications were identified by International Classification of Disease-9 (ICD-9) codes and reoperations were identified by CPT codes. Chi-squared tests were used to determine differences in complication rates between surgeon types. The Charlson comorbidity index (CCI) was used to compare populations based on medical risk factors for complications. Results: 14,222 patients with ankle fractures were treated by orthopaedic surgeons and 845 patients were treated by podiatrists. Operative treatment by orthopaedists was associated with lower DVT (p<0.02) and malunion (p<0.02) rates among all types of ankle fractures. There were no differences in complications for patients with single malleolar fractures, although higher rates of implant removal (p<0.01) were noted in patients treated by orthopaedic surgeons. For bimalleolar or trimalleolar fractures, treatment by an orthopaedic surgeon was associated with lower DVT (p<0.03) and malunion (p<0.04) rates. No differences were observed in rates of infection or need for irrigation and debridement based on surgeon type (Table 1). Patients treated by orthopaedic surgeons versus podiatrists were also noted to have a similar median CCI at 2.0 and 2.5, respectively. Conclusion: Operative treatment of ankle fractures by orthopaedic surgeons is associated with lower rates of certain postoperative complications compared with podiatrists. Malunion, in particular, is a surgeon related variable that has a significant impact on functional outcome in unstable ankle fracture patients. The specific reasons for the difference in malunion rates is likely multifactorial, and unable to be answered using this dataset, but warrants further investigation. Our findings have important implications for patients who must choose a surgeon to manage their operative ankle fracture, as well as policy makers who determine scope of practice in orthopaedic surgeons and podiatrists alike.

scholarly journals The Costs of Operative Fixation for Ankle Fractures

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0003
Author(s):  
Geoffrey Phillips ◽  
Drew Stal ◽  
Rachel Chernet ◽  
Zohair Saquib
Keyword(s):  
Length Of Stay ◽  
Direct Cost ◽  
Ankle Fracture ◽  
Outpatient Setting ◽  
Ankle Fractures ◽  
Total Direct Cost ◽  
Patient Demographics ◽  
The Mean ◽  
Trauma Surgeons ◽  
Fracture Surgery

Category: Ankle Introduction/Purpose: One of the emerging trends in contemporary healthcare is the shift in surgical resources to the outpatient setting coupled with institutional focus of reducing inpatient length of stay to facilitate cost containment. Through a multi-center retrospective review of operatively treated ankle fractures, we sought to calculate the actual financial cost of each procedure as well as to compare the economics of performing outpatient versus inpatient surgery. Additionally, we sought to determine whether the surgery location (inpatient and outpatient) was associated with specific patient demographics, medical co- morbidities, or surgeon practice patterns. Methods: A multi-center retrospective comparative study of 240 surgically treated ankle fractures over a two-year period was performed. Two tertiary care hospitals and their affiliated ambulatory surgery centers were included in the study. Patient selection was based on Current Procedural Terminology codes while exclusion criteria included pediatric patient, open trauma, distal tibia pilon fracture, or history of prior ankle fracture. The total direct cost of each surgery was calculated including categorized charges for room and board, pharmacy, rehabilitation, radiology, surgical implant materials, and surgeon professional fees. Patient age, medical co-morbidities, presence of poly-trauma, ordering of ankle CT-scan, and fellowship training of the orthopaedic surgeon were also evaluated in the study. The chi-square test or Fisher’s exact test was used to compare inpatients and outpatients for each variable. Results: 142 inpatient and 98 outpatient ankle fracture surgeries were performed. Median length of stay was 5 days for inpatients and the mean total direct cost was $11,466 for each inpatient case with room and board charges averaging $2,694. The mean total direct cost for each outpatient procedure was $3,111. Regarding patient demographics, statistically significant higher percentages were recorded among inpatients in the following groups: age 65 years or older (p < 0.0003), hypertension (p < 0.0230), presence of poly-trauma (p < 0.0149) and ordering of ankle CT-scan (p < 0.0001). 84% of ankle fracture surgeries performed by foot and ankle surgeons were outpatient procedures while 71% of ankle fracture surgeries performed by orthopaedic trauma surgeons were inpatient procedures. Conclusion: Our data shows that with 5 day median length of stay for the hospitalized patient group, the average total cost for inpatient ankle fracture surgery was nearly four times higher and $8,000 more than the total cost for outpatient ankle fracture surgery. Increased patient age and other specific medical co-morbidities were statistically linked with inpatient admission. In this multi-center study, foot and ankle surgeons were more likely than trauma surgeons to perform outpatient ankle fracture surgery. Healthcare institutions may realize substantial practice management cost savings by shifting ankle fracture surgery to the outpatient setting.

Effect of Obesity on Perioperative Complications, Hospital Costs, and Length of Stay in Patients With Open Ankle Fractures

2019 ◽  
Vol 27 (11) ◽  
pp. e529-e534 ◽  
Author(s):  
Joseph A. Gil ◽  
Wesley Durand ◽  
Joseph P. Johnson ◽  
Avi D. Goodman ◽  
Alan H. Daniels
Keyword(s):  
Length Of Stay ◽  
Perioperative Complications ◽  
Hospital Costs ◽  
Ankle Fractures

scholarly journals Arthroscopic Findings During Routine Ankle ORIF: What is Being Missed?

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0026
Author(s):  
Shain Howard ◽  
Victor C. Hoang ◽  
Troy S. Watson ◽  
Candice L. Brady ◽  
Adam Eudy
Keyword(s):  
Fracture Fixation ◽  
Ankle Fracture ◽  
External Rotation ◽  
Ankle Arthroscopy ◽  
Ankle Fractures ◽  
Osteochondral Lesions ◽  
Fracture Type ◽  
Syndesmotic Injury ◽  
Patient Reported ◽  
Articular Pathology

Category: Ankle; Arthroscopy; Trauma Introduction/Purpose: Ankle fractures are among the most common operatively treated injuries by orthopedic surgeons. However, up to 20% of patients will have continued pain and poor patient reported outcomes despite good/excellent radiographic results. Ankle fractures typically occur with varying degrees of intra-articular and soft tissue injury which can include ligamentous injury, loose bodies, and chondral lesions. The aim of study is to document intra-articular findings with ankle arthroscopy prior to ankle open reduction internal fixation (ORIF) and to contribute to the growing body of literature that shows this to be a safe adjunct to fracture fixation. Methods: IRB approval was obtained prior to chart review. This is a retrospective review of ankle fractures that were treated with arthroscopy and ORIF by a single surgeon. Between August 2016 and July 2018 Operative reports, office notes, and images were reviewed to identify intra-articular pathology and fracture type. Analysis was performed with regard to fracture type, presence and location of osteochondral lesions, presence of loose-body, syndesmotic injury, and deltoid injury. Results: Fifty-seven ankle fractures were identified that met inclusion criteria. 84.2% of the fractures had intra-articular pathology, most commonly a syndesmotic injury followed by loose joint body and osteochondral defect. Conclusion: Arthroscopic evaluation during ankle fracture ORIF, particularly pronation external rotation and supination external rotation patterns give a more detailed examination of associated pathology. Arthroscopy at the time of ankle fracture fixation is a safe adjunct and should be considered a potential compliment to routine ORIF of ankle fractures.

scholarly journals Early Weightbearing After Operatively Treated Trimalleolar Ankle Fractures with Large Posterior Malleolar Fragments

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0047
Author(s):  
Jason Tartaglione ◽  
Sorawut Thamyongkit ◽  
Pooyan Abbasi ◽  
Brent Parks ◽  
Erik Hasenboehler ◽  
...  
Keyword(s):  
Ankle Fracture ◽  
Ankle Fractures ◽  
Malleolar Fracture ◽  
Fracture Displacement ◽  
Posterior Malleolar Fracture ◽  
Average Motion ◽  
Significant Difference ◽  
Surgical Fixation ◽  
Group 2 ◽  
Group 1

Category: Trauma Introduction/Purpose: No consensus exists regarding postoperative rehabilitation protocols after surgical fixation of unstable trimalleolar ankle fractures with large posterior malleolar fragments. Additionally, no consensus exists regarding type of fixation of large posterior malleolar fragments in these fractures. It is unclear whether clinical results with early weightbearing differ between large posterior malleolar fragments fixed with either screws alone or a plate and screws construct. We evaluated fracture displacement with simulated early weightbearing in a cadaveric model. Methods: Sixteen fresh-frozen lower extremities were assigned to Group 1, trimalleolar ankle fracture with a large posterior malleolar fragment fixed with screws (n=8) or Group 2, trimalleolar ankle fracture with a large posterior malleolar fragment fixed with a plate and screws construct (n=8). Both Groups were tested with an axial compressive load at 3.2 Hz from 100 to 1,000 N and internal/external torque at 1.6 Hz at 0.5 Nm for 250,000 cycles to simulate 5 weeks of full weightbearing. Displacement was measured by differential variable reluctance transducer. Results: The average motion at all fracture sites in both groups was less than 1 mm. Group 1 displacement of the medial, lateral, and posterior malleolar fracture was 0.30 ± 0.27 mm, 0.12 ± 0.11 mm, and 0.87 ± 0.68 mm respectively. Group 2 displacement of the medial, lateral, and posterior malleolar fracture was 0.78 ± 1.52 mm, 0.12 ± 0.16 mm, and 0.87 ± 1.20 mm respectively. There was no significant difference between the average motion at all fractures sites between Group 1 and Group 2 (P > 0.05). There was no statistical correlation between fracture displacement and bone mineral density. Conclusion: This study supports early weightbearing after surgical fixation of unstable trimalleolar ankle fractures regardless of type of fixation of the posterior malleolus. Further investigation of early weightbearing protocols after surgical fixation of unstable trimalleolar ankle fractures are needed to help guide future treatment.

scholarly journals Safety and Outcomes of Early Fixation in Patients who Suffered an Ankle Fracture

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0043
Author(s):  
Ashish Shah ◽  
Jacob Hawkins ◽  
Bradley Alexander ◽  
Abhinav Agarwal ◽  
Benjamin B. Cage ◽  
...  
Keyword(s):  
Fracture Fixation ◽  
Ankle Fracture ◽  
Wound Complication ◽  
The United States ◽  
Ankle Fractures ◽  
Wound Complications ◽  
Time To Surgery ◽  
Prolonged Immobilization ◽  
Early Fixation ◽  
Injury Classification

Category: Ankle Introduction/Purpose: Ankle fractures are a common injury in the United States leading to increased ER visits and healthcare costs. Additionally, these injuries normally lead to prolonged immobilization that can make it difficult for patients to return to work and normal activities. By optimizing fracture healing and decreasing the amount of time to union patients can avoid the frustration of prolonged immobilization and return to daily activities more quickly. It is believed that early surgical fixation of ankle fractures can lead to wound complications while late fixation can lead to issues with reduction during surgical intervention. This study was undertaken to determine if there is a difference in wound complication and time to union between early and late fracture fixation. Methods: From July of 2008 to June of 2018, a retrospective chart review of 321 patients who underwent ankle fracture corrected with ORIF was performed at a single institution. Patients with pilon fractures, poly trauma, open fractures, or less than 3 months of follow up time were excluded from our study. After exclusion were made there was 232 patients remaining. All patients were then stratified by time to surgery after injury and injury classification. The cohorts were surgery within 2 days with 31 patients, surgery within 7 days with 69 patients, and patients that had surgery after 8 days (132). The patients were also stratified according to the Lauge-Hansen classification. The cohorts were PA, PER, SA, and SER. Results: The average time to union for patients who were operated on within 2 days of injury was 108.48 days, 106.52 days for patients operated on between 3-7 days, and 97.59 days for patients operated on after 7 days. Wound complications were highest in the cohort operated on within 2 days at 9.6%. Patients operated on between 3 and 7 days had the lowest rate of wound complications at 2.8%/. Patients with an SER Lauge-Hansen classification has the fastest time to union at 94.04 days and individuals with an SA had the longest at 139.30 days. Wound frequency for patients with a classification of PA had the highest wound complications at 20%. Conclusion: There has been little research done on how time to surgery affects wound complications and healing time in ankle fracture fixation. Patients that received surgery after 7 days achieved union the fastest. We saw that wound complication rate was greatest in the cohort that had surgery within 2 days of injury. Injury classification did factor into union time and wound complications. Overall, there was not a significant difference in wound complication between early fixation and delayed fixation. [Table: see text]

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