Complications of Open Reduction and Internal Fixation of Ankle Fractures in Patients With Positive Urine Drug Screen
We conducted a study to identify complications associated with open treatment of ankle fractures in patients who tested positive for illicit drugs on urine drug screen (UDS). We hypothesized that patients who had a history of positive UDS and underwent open reduction and internal fixation of an ankle fracture would have a higher incidence of major and minor complications.
We retrospectively reviewed the cases of 142 patients who had surgical stabilization of an ankle fracture during a 3-year period. Patients with a history of positive UDS were compared with matched controls with negative UDS. Outcomes measures included nonunion, malunion, and superficial or deep infection. Fisher exact test, Wilcoxon rank sum test, and univariate logistic regression were used to determine statistical significance.
There were no significant differences in age, sex, fracture type, incidence of diabetes, or incidence of open fracture between the groups. Incidence of nonunion was higher in patients with positive UDS (P = .01), as was incidence of deep infection (P = .05). Incidence of pooled major complications was also higher in positive UDS patients (P = .03).
Patients with a history of illicit drug use, as evidenced by positive UDS, are at increased risk for perioperative complications during treatment for ankle fracture.
The 2 groups were not significantly different with respect to mean follow-up time or loss to follow-up. Although mean follow-up was longer in negative UDS patients, the standard deviation was large in both groups. Given the positive UDS patients’ higher incidence of deep infection and nonunion, both of which typically prolong the course of treatment, the results were likely deceptive. Patients with a history of illicit drug use have confounding variables (eg, psychiatric disorders, financial strife) that make treatment compliance and follow-up difficult.17
Some of the weaknesses of this study are inherent to its retrospective design and limited sample size. Furthermore, patient satisfaction scores and ankle-specific outcome measures, such as AOFAS (American Orthopaedic Foot and Ankle Society) scores, were not considered. Prospective collection of data that include patient satisfaction scores and ankle-specific outcome measures would be optimal. Our current recommendation is to obtain preoperative UDS and illicit drug use history for all trauma patients. In addition, operating surgeons should exercise caution when caring for patients who test positive for illicit drugs.
Conclusion
We evaluated the incidence of complications experienced by positive UDS patients undergoing surgical treatment of ankle fractures. It is well documented that illicit drug users who receive general anesthesia have complications. However, little is known about the untoward effects of illicit drugs on postoperative complications. Furthermore, the efficacy of drug cessation programs in minimizing these complications has not been fully explored.
In conclusion, similar to patients with diabetes, patients with a history of recent illicit drug use, as evidenced by preoperative positive UDS, are at increased risk for complications during treatment for ankle fracture. These data suggest that practicing orthopedists should be more vigilant when caring for ankle fracture patients with preoperative positive UDS.
