JAAOS - 2026-05-26 - Journal Article
A Proposed Preoperative Risk Score for Predicting Surgical Site Complications After Ankle Fracture Fixation in Frail Elderly Patients.
Williamson TK, Verlinsky L, McDonald C, Atkison C, Michaeli D, Martin C, Karia R, Hand T
Topics
Key Takeaway
A novel FAIR score combining age, revised risk analysis index, and geriatric nutritional risk index predicts 30-day SSI or wound dehiscence after ankle fracture ORIF with an AUC of 0.814, versus AUC ≤0.517 for any individual index alone.
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Summary
This study asked whether a composite frailty-based score could predict surgical site complications after ankle fracture ORIF in elderly patients better than existing individual indices. Using a national database and backstep logistic regression, the authors derived the FAIR score from age, revised risk analysis index, and geriatric nutritional risk index. The FAIR score demonstrated good discriminatory accuracy (AUC 0.814) for SSI/wound dehiscence, with an OR of 3.2 (95% CI 1.9–5.4) for infection/wound complications, while the overall 30-day complication rate was 2.4%.
Key Limitation
The FAIR score was derived and tested within the same national database without external validation, making its generalizability and calibration in independent institutional cohorts unknown.
Original Abstract
BACKGROUND
Open reduction and internal fixation (ORIF) of geriatric ankle fractures is associated with infection and wound-related complications, especially in patients with decreased functionality and increased comorbidity. The purpose of this study was to propose a risk-related score to anticipate the development of surgical site infection (SSI) and/or wound complications after ORIF of surgical ankle fractures among frail, elderly patients.
METHODS
A national database was queried for elderly patients undergoing ORIF for lateral malleolar, bimalleolar, and trimalleolar ankle fractures. Risk indices included age, the revised risk analysis index, and the geriatric nutritional risk index. Outcomes included 30-day SSI, wound dehiscence, and readmission. Established weights were generated for predictive variables (comorbidities, preoperative values) through backstep logistic regression to yield a frail ankle infection risk (FAIR) score for wound and infectious complications. Multivariable analysis assessed associations of indices with outcomes through odds ratio (OR) and confidence interval (CI). Discriminatory accuracy was quantified by receiver operating characteristic curve analysis.
RESULTS
A total of 3,383 patients underwent ankle fracture ORIF. 2.4% of patients developed SSI or wound dehiscence. The regression model generated the FAIR score, which demonstrated association with any complication (OR: 2.1; 95% CI, 1.4 to 3.1) and infection-related or wound-related complications (OR: 3.2; 95% CI, 1.9 to 5.4). The FAIR score had good discrimination for wound and infectious complications (area under the curve [AUC] = 0.814), whereas the geriatric nutritional risk index (AUC: 0.500), age (AUC: 0.506), and the revised risk analysis index (AUC: 0.517) demonstrated poor discrimination.
CONCLUSIONS
ORIF for ankle fractures is associated with increased rates of wound-related and infection-related perioperative complications among frail patients with predisposing factors. This score may provide additional understanding of the factors associated with complications and expose additional areas for perioperative optimization to include surgical techniques in this patient population.
LEVEL OF EVIDENCE
III.