JAAOS - 2026-04-21 - Journal Article
The Influence of Peripheral Artery Disease on Postoperative Complications Following Open Reduction and Internal Fixation for Ankle Fractures.
Sontam TR, Tummala S, Mittal MM, Wukich DK
Topics
Key Takeaway
PAD patients undergoing ankle ORIF face a 10.5-fold increased risk of below-knee amputation and 3.07-fold increased risk of nonunion at 2 years compared to propensity-matched controls.
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Summary
This study used the TriNetX database to compare 90-day and 2-year postoperative complications after ankle ORIF in PAD versus non-PAD patients, matched 1:1 for demographics and comorbidities. At 90 days, PAD patients had significantly higher rates of SSI (5.5% vs 2.0%), wound disruption (10.2% vs 3.9%), and acute osteomyelitis (3.1% vs 0.6%). At 2 years, PAD conferred RR 3.07 for nonunion, RR 8.42 for chronic osteomyelitis, and RR 10.5 for below-knee amputation.
Key Limitation
PAD severity (ABI, Rutherford classification, revascularization status) is not captured, preventing any dose-response analysis or identification of a PAD threshold below which ORIF risk is acceptable.
Original Abstract
BACKGROUND
Peripheral artery disease (PAD) has been associated with an increased risk of wound complications and surgical site infection following open reduction and internal fixation (ORIF) for ankle fractures. However, longer-term outcomes, including fracture healing, remain poorly characterized. This study evaluates the association between PAD and short- and long-term postoperative complications following ankle ORIF.
METHODS
The TriNetX Research Network was queried to identify patients who underwent isolated unimalleolar, bimalleolar, trimalleolar, or syndesmotic ORIF for ankle fractures. Patients were classified as having PAD if they had a documented diagnosis within 6 months before surgery, whereas patients without PAD served as controls. PAD and non-PAD cohorts were 1:1 propensity score matched for demographics and medical comorbidities. Postoperative complications were assessed at 90 days and 2 years.
RESULTS
After propensity matching, 2,159 patients were included in each cohort. At 90 days, patients with PAD had markedly higher rates of surgical site infection (5.5% vs 2.0%), wound disruption (10.2% vs 3.9%), lower extremity cellulitis (7.6% vs 2.1%), and acute osteomyelitis of the ankle or foot (3.1% vs 0.6%) (all P < 0.001). At 2 years, PAD was associated with increased risks of nonunion (RR 3.07, 95% CI, 1.69 to 5.60), chronic osteomyelitis (RR 8.42, 95% CI, 4.64 to 15.27), implant infection (RR 3.19, 95% CI, 2.47 to 4.11), implant removal (RR 1.54, 95% CI, 1.32 to 1.81), and below-knee amputation (RR 10.5, 95% CI, 5.50 to 20.03) (all P ≤ 0.0001).
CONCLUSIONS
PAD is associated with markedly increased short- and long-term complications following ankle ORIF, including a sustained risk of impaired fracture healing. These findings underscore the importance of long-term risk stratification in patients with PAD undergoing ankle fracture fixation.