Abstract
Research Type:
Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies
Introduction/Purpose:
Osteoporosis, a common comorbid condition seen in the elderly population, is characterized by decreased bone mineralization and density leading to increased risk of fractures and falls. Although not a direct cause of postoperative morbidity, increased bone frailty can often compromise surgical recovery. There have been several studies investigating osteoporosis’ risk on sustaining ankle fractures, however, very limited research into its effect on postoperative morbidity itself. Our study aims to evaluate the effects of preoperative diagnoses of osteoporosis on the surgical outcomes in patients following ankle open reduction and internal fixation (ORIF), comparing patients with treated osteoporosis, untreated osteoporosis, and those without osteoporosis.
Methods:
The TriNetX database (2005-2025) identified patients aged 65-90 who underwent ankle fracture ORIF. Patients were divided into three cohorts: C1 (osteoporosis diagnosis with treatment, n=1,374), C2 (osteoporosis diagnosis without treatment, n=2,173), and a control group without osteoporosis (n=2,173). Treatment included bisphosphonates, raloxifene, or teriparatide. Propensity score matching (1:1) based on demographics and comorbidities resulted in matched cohorts: C1 and control (n=1,374 each), C2 and control (n=2,173 each). C1 (91.6% female) had a mean age of 73.7 years, BMI of 28.3 kg/m², and a mean follow-up of 738.1 days, with controls having a mean follow-up of 649.3 days. C2 (84% female) had a mean age of 73.6 years, BMI of 29.8 kg/m², and a mean follow-up of 662.2 days, with controls having similar demographics and a mean follow-up of 649.3 days. Both groups had BMI ranges of 18.5-40 and follow-up ranges of 730-1095 days.
Results:
At 6 months postoperatively, C1 showed a statistically significant increased risk of deep vein thrombosis (DVT) (risk difference [RD]: 0.015; 95% Confidence Interval [CI]: 0.003, 0.026; p = 0.011) and superficial peroneal neuropathy (RD: 0.007; 95% CI: 0.003, 0.012; p = 0.002), whereas C2 exhibited slightly increased emergency department utilization (RD: 0.019; 95% CI: -0.000, 0.038; p = 0.050). At 2 years postoperatively, C1 demonstrated a slightly increased risk for deep wound infection (RD: 0.007; 95% CI: 0.003, 0.012; p = 0.002) and a slightly decreased risk of nonunion or malunion (RD: -0.007; 95% CI: -0.012, -0.003; p = 0.002). Similarly, C2 also showed a reduction in the risk of nonunion or malunion (RD: -0.005; 95% CI: -0.007, -0.002; p = 0.002).
Conclusion:
Osteoporosis is associated with an increased risk of postoperative complications in patients undergoing ankle fracture ORIF. While treatment may modify certain risks, it does not uniformly improve outcomes. Notably, both treated and untreated osteoporosis cohorts demonstrated a lower risk of nonunion or malunion, suggesting that factors beyond osteoporosis treatment may influence fracture healing. Further research is needed to better understand the impact of osteoporosis and its treatment on outcomes following ankle fracture ORIF.