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Open Access 01-12-2022 | Obesity | Research

The effect of BMI on long-term outcomes after operatively treated ankle fractures: a study with up to 16 years of follow-up

Authors: Diogo Vieira Cardoso, Joris Paccaud, Victor Dubois-Ferrière, Christophe Barea, Didier Hannouche, Andrea Veljkovic, Anne Lübbeke

Published in: BMC Musculoskeletal Disorders | Issue 1/2022

Abstract

Background

Ankle fractures are a common injury and the main cause of post-traumatic ankle arthritis. The prevalence of obesity is increasing worldwide, and this population is known to have poorer short and midterm outcomes after ankle fractures. Our objective is to assess long-term patient-reported outcomes in patients with operatively treated ankle fractures, and the effect of BMI on these results using the new and validated patient-reported outcome questionnaire, the Manchester Oxford foot and ankle questionnaire (MOXFQ).

Methods

We performed a retrospective review of all ankle fractures treated operatively in a ten-year period from 2002–2012. The MOXFQ and SF-12 were sent to all patients and were obtained, on average, 11.1 years after surgery (range 5.3–16.2 years).

Results

Two thousand fifty-five ankle fractures were reviewed, of which 478 (34%) patients completed the questionnaires. The mean age was 48.1 ± 15.5 years, 52% were men and the mean BMI was 26.1 ± 4.5 kg/m2. Of the 478, 47% were of normal weight, 36% were overweight, and 17% were obese. Overall, 2.1% were type A, 69.9% B, and 24.9% type C fractures. There were no significant differences in the type of fracture between the BMI groups. Comparing obese and non-obese patients, there were large differences in MOXFQ pain (33 ± 29 vs. 18.7 ± 22.1, effect size 0.55), and function scores (27.3 ± 29 vs. 12.5 ± 21.1, effect size 0.58). No differences in complications and reoperations rates were observed. The BMI value at surgery correlated more strongly with the MOXFQ pain score than the BMI at follow-up (Spearman’s Rho 0.283 vs. 0.185, respectively).

Conclusion

These findings reveal that obese patients have significant worse long-term outcomes, namely increased pain, poorer function, and greater impairment in everyday life after an operatively treated ankle fracture. Moreover, pain and function linearly declined with increasing BMI. Our findings appear to indicate that increased BMI at surgery is an important contributor to adverse outcome in the operative management of rotational ankle fractures.

Level of evidence

III.

Elsoe R, Ostgaard SE, Larsen P. Population-based epidemiology of 9767 ankle fractures. Foot Ankle Surg. 2018;24(1):34–9. https://doi.org/10.1016/j.fas.2016.11.002.CrossRefPubMed

Beerekamp MSH, de Muinck Keizer RJO, Schep NWL, Ubbink DT, Panneman MJM, Goslings JC. Epidemiology of extremity fractures in the Netherlands. Injury. 2017;48(7):1355–62. https://doi.org/10.1016/j.injury.2017.04.047.CrossRefPubMed

King CM, Hamilton GA, Cobb M, Carpenter D, Ford LA. Association between ankle fractures and obesity. J Foot Ankle Surg. 2012;51(5):543–7. https://doi.org/10.1053/j.jfas.2012.05.016.CrossRefPubMed

Organization WH: Obesity and Overweight. https://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight (2019). Accessed 17.06.2019.

Mickle KJ, Steele JR, Munro BJ. he feet of overweight and obese young children: are they flat or fat? Obesity (Silver Spring). 2006;14(11):1949–53. https://doi.org/10.1038/oby.2006.227.CrossRef

Mihalko WM. Obesity, orthopaedics, and outcomes. J Am Acad Orthop Surg. 2015;23(4):211–2.PubMed

Shibuya N, Liu GT, Davis ML, Grossman JP, Jupiter DC. Risk Factors for Open Malleolar Fractures: An Analysis of the National Trauma Data Bank (2007 to 2011). J Foot Ankle Surg. 2016;55(1):94–8. https://doi.org/10.1053/j.jfas.2015.07.016.CrossRefPubMed

Stavem K, Naumann MG, Sigurdsen U, Utvåg SE. Association of Body Mass Index With the Pattern of Surgically Treated Ankle Fractures Using Two Different Classification Systems. J Foot Ankle Surg. 2017;56(2):314–8. https://doi.org/10.1053/j.jfas.2016.10.008.CrossRefPubMed

Vieira Cardoso D, Dubois-Ferrière V, Gamulin A, Baréa C, Rodriguez P, Hannouche D, et al. Operatively treated ankle fractures in Switzerland, 2002–2012: epidemiology and associations between baseline characteristics and fracture types. BMC Musculoskelet Disord. 2021;22(1):266. https://doi.org/10.1186/s12891-021-04144-5.CrossRefPubMedPubMedCentral

10.

Park YH, Kim W, Park JH, Kim HJ. Impact of metabolic syndrome on patient outcomes of supination-external rotation ankle fracture. Injury. 2019. https://doi.org/10.1016/j.injury.2019.05.033.CrossRefPubMed

11.

Benedick A, Audet MA, Vallier HA. The effect of obesity on post-operative complications and functional outcomes after surgical treatment of torsional ankle fracture: A matched cohort study. Injury. 2020;51(8):1893–8. https://doi.org/10.1016/j.injury.2020.05.006.CrossRefPubMed

12.

SooHoo NF, Shuler M, Fleming LL. Evaluation of the validity of the AOFAS Clinical Rating Systems by correlation to the SF-36. Foot Ankle Int. 2003;24(1):50–5. https://doi.org/10.1177/107110070302400108.CrossRefPubMed

13.

Garces JB, Winson I, Goldhahn S, Castro MD, Swords MP, Grujic L, et al. Reliability, validity and responsiveness of the Spanish Manchester-Oxford Foot Questionnaire (MOXFQ) in patients with foot or ankle surgery. Foot Ankle Surg. 2016;22(1):59–70. https://doi.org/10.1016/j.fas.2015.09.004.CrossRefPubMed

14.

Talu B, Bayramlar K, Bek N, Yakut Y. Validity and reliability of the Turkish version of the Manchester-Oxford Foot Questionnaire for hallux valgus deformity evaluation. Acta Orthop Traumatol Turc. 2016;50(2):207–13. https://doi.org/10.3944/AOTT.2015.15.0152.CrossRefPubMed

15.

Venkatesan S, Schotanus MG, Hendrickx RP. Dutch Translation of the Manchester-Oxford Foot Questionnaire: Reassessment of Reliability and Validity. J Foot Ankle Surg. 2016;55(6):1199–201. https://doi.org/10.1053/j.jfas.2016.07.015.CrossRefPubMed

16.

Arbab D, Kuhlmann K, Ringendahl H, Bouillon B, Eysel P, Konig D. Reliability, validity and responsiveness of the German Manchester-Oxford Foot Questionnaire (MOXFQ) in patients with foot or ankle surgery. Foot Ankle Surg. 2018;24(6):481–5. https://doi.org/10.1016/j.fas.2017.05.007.CrossRefPubMed

17.

Mousavian A, Ebrahimzadeh MH, Birjandinejad A, Omidi-Kashani F, Kachooei AR. Translation and cultural adaptation of the Manchester-Oxford Foot Questionnaire (MOXFQ) into Persian language. Foot (Edinb). 2015;25(4):224–7. https://doi.org/10.1016/j.foot.2015.07.004.CrossRef

18.

Park MJ, Ko YC, Huh JW, Park SH, Park TH, Park JH. Validation of the Korean Version of the Manchester-Oxford Foot Questionnaire in Patients With Hallux Valgus. J Foot Ankle Surg. 2017;56(2):252–4. https://doi.org/10.1053/j.jfas.2016.11.013.CrossRefPubMed

19.

Dawson J, Boller I, Doll H, Lavis G, Sharp R, Cooke P, et al. The MOXFQ patient-reported questionnaire: assessment of data quality, reliability and validity in relation to foot and ankle surgery. Foot (Edinb). 2011;21(2):92–102. https://doi.org/10.1016/j.foot.2011.02.002.CrossRef

20.

Vieira Cardoso D, Dubois-Ferriere V, Hannouche D, Lubbeke A, Perneger T. Development and psychometric performance of the French language version of the Manchester-Oxford Foot Questionnaire (MOXFQ). Foot Ankle Surg. 2019. https://doi.org/10.1016/j.fas.2019.12.002.CrossRefPubMed

21.

Marinozzi A, Martinelli N, Panasci M, Cancilleri F, Franceschetti E, Vincenzi B, et al. Italian translation of the Manchester-Oxford Foot Questionnaire, with re-assessment of reliability and validity. Qual Life Res. 2009;18(7):923–7. https://doi.org/10.1007/s11136-009-9508-9.CrossRefPubMed

22.

Roos EM, Brandsson S, Karlsson J. Validation of the foot and ankle outcome score for ankle ligament reconstruction. Foot Ankle Int. 2001;22(10):788–94. https://doi.org/10.1177/107110070102201004.CrossRefPubMed

23.

Dawson J, Boller I, Doll H, Lavis G, Sharp R, Cooke P, et al. Responsiveness of the Manchester-Oxford Foot Questionnaire (MOXFQ) compared with AOFAS, SF-36 and EQ-5D assessments following foot or ankle surgery. J Bone Joint Surg Br. 2012;94(2):215–21. https://doi.org/10.1302/0301-620X.94B2.27634.CrossRefPubMed

24.

Dawson J, Boller I, Doll H, Lavis G, Sharp R, Cooke P, et al. Minimally important change was estimated for the Manchester-Oxford Foot Questionnaire after foot/ankle surgery. J Clin Epidemiol. 2014;67(6):697–705. https://doi.org/10.1016/j.jclinepi.2014.01.003.CrossRefPubMed

25.

Schrier JC, Palmen LN, Verheyen CC, Jansen J, Koeter S. Patient-reported outcome measures in hallux valgus surgery. A review of literature. Foot Ankle Surg. 2015;21(1):11–5. https://doi.org/10.1016/j.fas.2014.11.004.CrossRefPubMed

26.

Stavem K, Naumann MG, Sigurdsen U, Utvag SE. The association of body mass index with complications and functional outcomes after surgery for closed ankle fractures. Bone Joint J. 2017;99-B(10):1389–98. https://doi.org/10.1302/0301-620X.99B10.BJJ-2016-1038.R1.CrossRefPubMed

27.

Organization WH: Global Database on Body Mass Index. http://apps.who.int/bmi/index.jsp. Accessed 8 Jan 2018.

28.

Broos PL, Bisschop AP. A new and easy classification system for ankle fractures. Int Surg. 1992;77(4):309–12.PubMed

29.

Lampridis V, Gougoulias N, Sakellariou A. Stability in ankle fractures: Diagnosis and treatment. EFORT Open Rev. 2018;3(5):294–303. https://doi.org/10.1302/2058-5241.3.170057.CrossRefPubMedPubMedCentral

30.

Morley D, Jenkinson C, Doll H, Lavis G, Sharp R, Cooke P, et al. The Manchester-Oxford Foot Questionnaire (MOXFQ): Development and validation of a summary index score. Bone Joint Res. 2013;2(4):66–9. https://doi.org/10.1302/2046-3758.24.2000147.CrossRefPubMedPubMedCentral

31.

Cohen J. The statistical power of abnormal-social psychological research: a review. J Abnorm Soc Psychol. 1962;65:145–53. https://doi.org/10.1037/h0045186.CrossRefPubMed

32.

Okifuji A, Hare BD. The association between chronic pain and obesity. J Pain Res. 2015;8:399–408. https://doi.org/10.2147/JPR.S55598.CrossRefPubMedPubMedCentral

33.

Okifuji A, Donaldson GW, Barck L, Fine PG. Relationship between fibromyalgia and obesity in pain, function, mood, and sleep. J Pain. 2010;11(12):1329–37. https://doi.org/10.1016/j.jpain.2010.03.006.CrossRefPubMedPubMedCentral

34.

Weisberg SP, McCann D, Desai M, Rosenbaum M, Leibel RL, Ferrante AW Jr. Obesity is associated with macrophage accumulation in adipose tissue. J Clin Invest. 2003;112(12):1796–808. https://doi.org/10.1172/JCI19246.CrossRefPubMedPubMedCentral

35.

Bluher M, Fasshauer M, Tonjes A, Kratzsch J, Schon MR, Paschke R. Association of interleukin-6, C-reactive protein, interleukin-10 and adiponectin plasma concentrations with measures of obesity, insulin sensitivity and glucose metabolism. Exp Clin Endocrinol Diabetes. 2005;113(9):534–7. https://doi.org/10.1055/s-2005-872851.CrossRefPubMed

36.

Louer CR, Furman BD, Huebner JL, Kraus VB, Olson SA, Guilak F. Diet-induced obesity significantly increases the severity of posttraumatic arthritis in mice. Arthritis Rheum. 2012;64(10):3220–30. https://doi.org/10.1002/art.34533.CrossRefPubMedPubMedCentral

37.

Adams SB, Leimer EM, Setton LA, Bell RD, Easley ME, Huebner JL, et al. Inflammatory Microenvironment Persists After Bone Healing in Intra-articular Ankle Fractures. Foot Ankle Int. 2017;38(5):479–84. https://doi.org/10.1177/1071100717690427.CrossRefPubMed

38.

Adams SB, Setton LA, Bell RD, Easley ME, Huebner JL, Stabler T, et al. Inflammatory Cytokines and Matrix Metalloproteinases in the Synovial Fluid After Intra-articular Ankle Fracture. Foot Ankle Int. 2015;36(11):1264–71. https://doi.org/10.1177/1071100715611176.CrossRefPubMed

39.

Lubbeke A, Salvo D, Stern R, Hoffmeyer P, Holzer N, Assal M. Risk factors for post-traumatic osteoarthritis of the ankle: an eighteen year follow-up study. Int Orthop. 2012;36(7):1403–10. https://doi.org/10.1007/s00264-011-1472-7.CrossRefPubMedPubMedCentral

Title: The effect of BMI on long-term outcomes after operatively treated ankle fractures: a study with up to 16 years of follow-up
Authors: Diogo Vieira Cardoso
Joris Paccaud
Victor Dubois-Ferrière
Christophe Barea
Didier Hannouche
Andrea Veljkovic
Anne Lübbeke
Publication date: 01-12-2022
Publisher: BioMed Central
Keywords: Obesity
Ankle Fracture
Obesity
Overweight
Published in: BMC Musculoskeletal Disorders / Issue 1/2022
Electronic ISSN: 1471-2474
DOI: https://doi.org/10.1186/s12891-022-05247-3

Keynote webinar | Spotlight on medication adherence

Springer Medicine

The effect of BMI on long-term outcomes after operatively treated ankle fractures: a study with up to 16 years of follow-up

Abstract

Background

Methods

Results

Conclusion

Level of evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Level of evidence

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