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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Obesity is associated with increased postoperative complications after

operative management of tibial shaft fractures§
M. Tyrrell Burrus a, Brian C. Werner a, Seth R. Yarboro b,*
a
Department of Orthopaedic Surgery, University of Virginia Health System, United States
b
Division of Orthopaedic Trauma, University of Virginia Health System, PO Box 800159 HSC, Charlottesville, VA, 22908, United States

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To assess the association of obesity and postoperative complications after operative
Accepted 13 October 2015 management of tibial shaft fractures.
Methods: Patients who underwent operative management of a tibial shaft fracture were identified in a
Keywords: national database by Current Procedural Terminology (CPT) codes for: (1) open reduction and internal
Tibia fracture fixation (ORIF) and (2) intramedullary nailing (IMN) procedures in the setting of International
Obesity Classification of Diseases, Ninth Revision (ICD-9) codes for tibial shaft fracture. These groups were then
Complication
divided into non-obese, obese, and morbidly obese cohorts using ICD-9 codes. Each cohort was then
Infection
Medical
assessed for grouped complications within 90 days, removal of implants within 6 months, and nonunion
Nonunion within 9 months postoperatively. Odds ratios and 95% confidence intervals were calculated.
Results: From 2005 to 2012, 14,638 patients who underwent operative management of tibial shaft
fractures were identified, including 4425 (30.2%) ORIF and 10,213 (69.8%) IMN. Overall, 1091 patients
(7.4%) were coded as obese and 820 (5.6%) morbidly obese. In each operative group, obesity and morbid
obesity was associated with a substantial increase in the rate of major and minor medical complications,
venous thromboembolism, infection, procedures for implant removal, and nonunion.
Conclusions: In patients who undergo either ORIF or IMN for tibial shaft fractures, obesity and its related
medical comorbidities are associated with significantly increased rates of postoperative medical
complications, infection, nonunion, and implant removal compared to non-obese patients.
ß 2015 Elsevier Ltd. All rights reserved.

Introduction As the incidence of tibial shaft fractures continues to increase,

Lower extremity fractures are a common cause of morbidity in
the United States population, with tibial shaft fractures constitut-
ing a significant fraction of this category [1]. Most are a result of
high-energy trauma, although lower-energy ground level falls and
twisting injuries are also responsible for a number of these injuries.
Due to the prevalence of these injuries and the morbidity of
nonoperative treatment for certain fracture types, operative
treatment has become the accepted treatment for most tibial
shaft fractures [1]. Operative management with open reduction
and internal fixation (ORIF) or intramedullary nailing (IMN) are
two widely used surgical options for tibial shaft fractures. However,
even with significant improvements in operative techniques and
instrumentation, complications and poor outcomes continue to
occur.
§
The investigation was performed at the University of Virginia Health System.
* Corresponding author. Tel.: +1 434 243 0274; fax: +1 434 243 0290.
E-mail address: SRY2J@virginia.edu (S.R. Yarboro).
obesity in the United States continues to rise at an even higher
rate. In this country, the prevalence of obesity has increased over
120% in the past decade, and more than one third of adults have a
body mass index (BMI) over 30 kg/m2 [2]. An estimated 83.6% of
adults will be overweight or obese by 2013 [3]. When examining
the cost of obesity, there has been a 100% increase in obesity and
overweight related spending since the 1990’s, which is comparable
to the cost of tobacco related complications [3–5].
Obesity is of particular importance to orthopaedic surgeons
since numerous studies have demonstrated an increased incidence
of postoperative complications. Total joint arthroplasty has
received considerable attention in this area as increased complica-
tions are seen in obese patients undergoing total knee arthroplasty
(TKA), total hip arthroplasty (THA), total shoulder arthroplasty
(TSA), and total elbow arthroplasty (TEA) [2,4,6–8]. However, the
effect of obesity on perioperative complications and long-term
outcomes is not limited to arthroplasty procedures.
To our knowledge, there has been no study specifically
comparing the complication rates of operatively treated tibial

http://dx.doi.org/10.1016/j.injury.2015.10.026
0020–1383/ß 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Burrus MT, et al. Obesity is associated with increased postoperative complications after operative
management of tibial shaft fractures. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.10.026
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2 M.T. Burrus et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
shaft fractures in obese patients compared to non-obese patients.
The purpose of the current study is to use a large nationwide
database to investigate the association of obesity with postopera-
tive complications after ORIF or IMN for tibial shaft fractures. Our
hypothesis is that obese patients will have a higher postoperative
complication rate compared to non-obese patients who have
undergone the same procedures.
Materials and methods
All data for the present study was obtained from a publicly
available, for-fee database of patients, the PearlDiver Patient
Records Database (www.pearldiverinc.com; PearlDiver Inc, Fort
Wayne, Indiana). This administrative insurance database contains
actual data, including procedural volumes, demographics, and
average charge information for patients with International
Classification of Diseases, 9th Revision (ICD-9) diagnoses and
procedures recorded by Current Procedural Terminology (CPT)
codes. Data for the present study was derived from three databases
within PearlDiver: two private-payer insurance databases (with
largest contributions from United HealthCare and Humana), with
more than 50 million patient records from 2007 to 2014 and a
Medicare-based database within, which has over 100 million
individual patient records from 2005 to 2012. Access to the
database was granted to the authors by PearlDiver Technologies for
the purpose of academic research. The database was stored on a
password-protected server maintained by PearlDiver. This study
did not require informed consent or Institutional Review Board
(IRB) or ethical approval.
The database was queried for two common procedures utilised
in the management of tibial shaft fractures: open reduction and
internal fixation (ORIF, CPT 27758) and intramedullary nailing
(IMN, CPT 27759). Patients in each operative group were then
divided into non-obese, obese and morbidly obese cohorts using
ICD-9 codes for each: obesity (ICD-9s 278.00, V85.30-39) and
morbid obesity (ICD-9s 278.01, V85.41-45).
The non-obese, obese, and morbidly obese cohorts for each
operative management group were queried for basic demographics
including sex and age group (<40, 40–65, and >65 years old).
Comorbidities for each cohort were assessed, including diabetes
mellitus, obstructive sleep apnea, hyperlipidemia, hypertension,
peripheral vascular disease, congestive heart failure, coronary artery
disease, chronic kidney disease, chronic lung disease and chronic
liver disease using ICD-9 codes for each disease.
The non-obese, obese, and morbidly cohorts for each operative
management group were then queried for postoperative compli-
cations within 90 days after the surgical procedure utilizing ICD-9
and CPT codes. Complications were pooled into the following
categories to yield usable data: major medical complications,
minor medical complications, infection, removal of implants,
nonunion, venous thromboembolism (including pulmonary em-
bolism (PE) and/or deep vein thrombosis (DVT)), and all medical
complications. Rates of removal of implants and nonunions were
calculated using data from 6 and 9 months postoperatively,
respectively.
Major medical complications included PE, myocardial infarc-
tion, cerebrovascular accident (CVA), pneumonia, acute renal
failure, and respiratory failure. Minor medical complications
included urinary tract infection, DVT, acute cholecystitis, and
postoperative blood transfusion. All medical complications includ-
ed patients with major medical complications, minor medical
complications, or both.
Odds ratios (OR) and 95% confidence intervals (CI) were
calculated for each comparison between obese and non-obese
cohorts. Pearson chi-square tests were calculated to determine
statistical significance, with P < 0.05 considered significant.
Please cite this article in press as: Burrus MT, et al. Obesity is associated with increased postoperative complications after operative
management of tibial shaft fractures. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.10.026
Results
14,638 individual patients who underwent either ORIF or IMN
for a tibial shaft fracture were identified in the database from
2005 to 2012, including 4425 patients who underwent ORIF and
10,213 who underwent IMN. Overall, 1091 patients (7.4%) were
coded as obese and 820 (5.6%) morbidly obese. The non-obese,
obese, and morbidly obese cohorts for each operative management
group wfdical comorbidities [Tables 1A and 1B].
Within the ORIF group, 384 (8.7%) patients were coded as obese,
and 340 (7.7%) were morbidly obese. Compared to the non-obese
patients, the obese ORIF patients had a significantly increased risk
of 90 days major medical [OR 3.0, 95% CI 2.2–3.9, P < 0.0001],
minor medical [OR 2.8, 95% CI 2.1–3.7, P < 0.0001] and all medical
[OR 2.6, 95% CI 2.0–3.4, P < 0.0001] complications. Additionally,
obese ORIF patients also had significantly higher rates of infection
[15.1% vs. 8.6%, OR 1.9, P < 0.0001], nonunion [16.9% vs. 11.6%, OR
1.5, P < 0.003], VTE [4.4% vs. 2.2%, OR 2.1, P < 0.011]. Only the rate
of implant removal was not significantly different between the two
cohorts [Table 2].
When the ORIF postoperative complications in the morbidly
obese cohort were compared to those in the non-obese cohort,
all complications had significantly higher odds ratios in the
morbidly obese cohort. However, there was no statistically
significant difference in the complication rates between the
morbidly obese and obese cohorts even though there was a trend
towards higher complications in the morbidly obese cohort
[Table 2].
Within the IMN group, 707 (6.9%) patients were coded as obese,
and 480 (4.7%) were coded as morbidly obese. When compared to
the non-obese cohort, the obese IMN patients had a significantly
increased risk of 90 days major medical [OR 2.2, 95% CI 1.8–2.7,
P < 0.0001], minor medical [OR 3.0, 95% CI 2.4–3.7, P < 0.0001] and
all medical [OR 2.4, 95% CI 2.0–3.0, P < 0.0001] complications.
Obese IMN patients also had significantly higher rates of infection
[8.5% vs. 6.1%, OR 1.4, P < 0.017], nonunion [15.4% vs. 11.1%, OR 1.5,
P = 0.001], VTE [4.5% vs. 2.0%, OR 2.3, P < 0.0001]. Simple to the
ORIF cohort, there was not a significantly increased rate of implant
remove in the obese cohort [Table 3].
When the IMN postoperative complications in the morbidly
obese cohort were compared to those in the non-obese cohort, all
complications had significantly higher odds ratios in the morbidly
obese cohort. Unlike in the ORIF cohorts, there were statistically
significant differences in the complication rates between the
morbidly obese and obese cohorts for medical complications and
infections [Table 3].
Discussion
Obesity has been shown in multiple prior studies to increase the
complication rate following elective and non-elective orthopaedic
surgery [2,4,6–11]. The current study clearly demonstrates that
obese patients with tibial shaft fractures treated with either open
reduction and internal fixation (ORIF) or intramedullary nailing
(IMN) have a significantly higher medical complication rate,
infection risk, rate of implant removal, and nonunion when
compared to a non-obese cohort.
The detrimental effect of obesity on outcomes after orthopaedic
procedures has been demonstrated in all subspecialties [4,9–16].
As these prior studies have shown, the presence of obesity results
in higher rates of local complications, systemic complications, and
long term complications such as revision procedures. Although it is
often difficult to definitely state that obesity directly causes
complications, it is likely that obesity results in various physical
and medical dilemmas, which are ultimately responsible for the
increased complications.
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Table 1A
ORIF tibial shaft fracture: patient demographics.

Non-obese Obese Morbidly obese Obese v non Morbid v non

Total number 3701 384 340 P P

Demographics
Female 1,762 (47.6%) 236 (61.5%) 213 (62.6%) <0.0001 <0.0001
Male 1,939 (52.4%) 148 (38.5%) 127 (37.4%)
Age < 40 1,126 (30.4%) 29 (7.6%) 12 (3.5%) <0.0001 <0.0001
Age 40–64 1,495 (40.4%) 169 (44.0%) 160 (47.1%) 0.170 0.017
Age > 65 1,080 (29.2%) 186 (48.4%) 168 (49.4%) <0.0001 <0.0001
Smoker 622 (16.8%) 102 (26.6%) 84 (24.7%) <0.0001 <0.0001

Comorbidities
DM 730 (19.7%) 219 (57.0%) 242 (71.2%) <0.0001 <0.0001
OSA 109 (2.9%) 71 (18.5%) 140 (41.2%) <0.0001 <0.0001
HLD 1,241 (33.5%) 284 (74.0%) 270 (79.4%) <0.0001 <0.0001
HTN 1,657 (44.8%) 313 (81.5%) 316 (92.9%) <0.0001 <0.0001
PVD 358 (9.7%) 88 (22.9%) 121 (35.6%) <0.0001 <0.0001
CHF 426 (11.5%) 118 (30.7%) 159 (46.8%) <0.0001 <0.0001
CAD 576 (15.6%) 154 (40.1%) 153 (45.0%) <0.0001 <0.0001
CKD 313 (8.5%) 100 (26.0%) 132 (38.8%) <0.0001 <0.0001
COPD 556 (15.0%) 128 (33.3%) 165 (48.5%) <0.0001 <0.0001
CLD 125 (3.4%) 40 (10.4%) 50 (14.7%) <0.0001 <0.0001

Fracture type
Open fracture 786 (21.2%) 78 (20.3%) 72 (21.2%) 0.637 0.979

Patient demographics of the non-obese, obese, and morbidly obese patients who underwent open reduction and internal fixation (ORIF) (A) and intramedullary nailing (IMN)
(B) of tibial shaft fractures. DM – diabetes mellitus, OSA – obstructive sleep apnea, HLD – hyperlipidemia, HTN – hypertension, PVD – peripheral vascular disease, CHF –
congestive heart failure, CAD – coronary artery disease, CKD – chronic kidney disease, COPD – chronic obstructive pulmonary disease, CLD – chronic liver disease.

Using data from the National Trauma Data Bank, Baldwin et al.
compared outcomes of morbidly obese patients (body mass index
(BMI) >40 kg/m2) to non-morbidly obese patient who underwent
operative fixation of either isolated femur or tibia fractures [11].
They found no difference in morbidity or inpatient complications,
although morbidly obese patients were more likely to be
discharged to acute rehabilitation facilities. However, their data
only included the patients’ perioperative course during the same
admission and thus likely missed many complications that
often present later, such as infections and deep vein thromboses
(DVT). The data collection period in the current study includes up
to 90 days postoperatively for all complication, 6 months for the
removal of implants, and 9 months for nonunion. Additionally,
their BMI cut-off of 40 kg/m2 groups patients in the 30–40 BMI
range with non-obese patients (BMI < 30 kg/m2), and thus any
potential reduced complication rate in the non-obese population
would be diluted by the increased complication rate in the
30–40 kg/m2 range.
Weinlein et al., in their series of 507 patients with femoral shaft
fractures, demonstrated a significant increase in the complications
rates (including sepsis and acute respiratory distress syndrome)
and mortality of morbid obese patients (BMI > 40 kg/m2) com-
pared to non-obese patients [9]. In 356 paediatric trauma patients
with femur or tibia fractures, obese patients were found to have

Table 1B
IMN tibial shaft fracture: patient demographics.

Non-Obese Obese Morbidly Obese Obese v Non Morbid v Non

Total number 9026 707 480 P P

Demographics
Female 3,627 (40.2%) 364 (51.5%) 304 (63.3%) <0.0001 <0.0001
Male 5,399 (59.8%) 343 (48.5%) 176 (36.7%)
Age < 40 3,486 (38.6%) 50 (7.1%) 27 (5.6%) <0.0001 <0.0001
Age 40–64 3,675 (40.7%) 344 (48.7%) 254 (52.9%) <0.0001 <0.0001
Age > 65 1,865 (20.7%) 313 (44.3%) 199 (41.5%) <0.0001 <0.0001
1,486 (16.5%) 190 (26.9%) 136 (28.3%) <0.0001 <0.0001

Comorbidities
DM 1,445 (16.0%) 332 (47.0%) 320 (66.7%) <0.0001 <0.0001
OSA 248 (2.7%) 129 (18.2%) 173 (36.0%) <0.0001 <0.0001
HLD 2,534 (28.1%) 488 (69.0%) 355 (74.0%) <0.0001 <0.0001
HTN 3,329 (36.9%) 554 (78.4%) 424 (88.3%) <0.0001 <0.0001
PVD 635 (7.0%) 166 (23.5%) 141 (29.4%) <0.0001 <0.0001
CHF 803 (8.9%) 206 (29.1%) 218 (45.4%) <0.0001 <0.0001
CAD 1,116 (12.4%) 255 (36.1%) 222 (46.3%) <0.0001 <0.0001
CKD 604 (6.7%) 179 (25.3%) 173 (36.0%) <0.0001 <0.0001
COPD 1,110 (12.3%) 227 (32.1%) 222 (46.3%) <0.0001 <0.0001
CLD 253 (2.8%) 85 (12.0%) 80 (16.7%) <0.0001 <0.0001

Fracture type
Open fracture 2,248 (24.9%) 169 (23.9%) 119 (24.8%) 0.450 0.848

Patient demographics of the non-obese, obese, and morbidly obese patients who underwent open reduction and internal fixation (ORIF) (A) and intramedullary nailing (IMN)
(B) of tibial shaft fractures. DM – diabetes mellitus, OSA – obstructive sleep apnea, HLD – hyperlipidemia, HTN – hypertension, PVD – peripheral vascular disease, CHF –
congestive heart failure, CAD – coronary artery disease, CKD – chronic kidney disease, COPD – chronic obstructive pulmonary disease, CLD – chronic liver disease.

Please cite this article in press as: Burrus MT, et al. Obesity is associated with increased postoperative complications after operative
management of tibial shaft fractures. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.10.026
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Table 2
Tibial ORIF postoperative complication rates.

Non-Obese Obese Morbidly obese Statistical comparison

Morbid v non Obese v non Morbid v obese

Total number 3,701 384 340 OR [95% CI], P OR [95% CI], P OR [95% CI], P
Major medical complications* 267 72 81 4.0 [3.0–5.3] 3.0 [2.2–3.9] 1.5 [0.9–1.9]
7.2% 18.8% 23.8% P < 0.0001 P < 0.0001 P = 0.115

Minor medical complications¥ 293 74 75 3.3 [2.5–4.4] 2.8 [2.1–3.7] 1.2 [0.8–1.7]
7.9% 19.3% 22.1% P < 0.0001 P < 0.0001 P = 0.404

Infection 320 58 65 2.5 [1.9–3.4] 1.9 [1.4–2.5] 1.3 [0.9–2.0]

8.6% 15.1% 19.1% P < 0.0001 P < 0.0001 P = 0.182

Removal of hardware 268 30 38 1.6 [1.1–2.3] 1.1 [0.7–1.6] 1.5 [0.9–2.5]

7.2% 7.8% 11.2% P = 0.012 P = 0.759 P = 0.155

Nonunion 431 65 64 1.8 [1.3–2.4] 1.5 [1.2–2.1] 1.1 [0.8–1.7]

11.6% 16.9% 18.8% P < 0.0001 P = 0.003 P = 0.570

VTE 81 17 19 2.6 [1.6–4.4] 2.1 [1.2–3.5] 1.3 [0.7–2.5]

2.2% 4.4% 5.6% P < 0.0001 P = 0.011 P = 0.585
s
All medical complications 384 90 98 3.5 [2.7–4.5] 2.6 [2.0–3.4] 1.3 [0.9–1.8]
10.4% 23.4% 28.8% P < 0.0001 P < 0.0001 P = 0.118

Postoperative complication rates of obese and non-obese patients after ORIF of tibial shaft fractures. VTE – venous thromboembolism. BMI – body mass index.
*
Major medical complications included pulmonary embolism (PE), pneumonia, myocardial infarction (MI), acute renal failure (ARF), cerebrovascular accident (CVA), and
respiratory failure.
¥
Minor medical complications included urinary tract infection (UTI), deep vein thrombosis (DVT), acute cholecystitis, and postoperative blood transfusion.
s
All medical complications included patients with major medical complications, minor medical complications, or both.

higher Injury Severity Score (ISS), higher rates of intra-abdominal
injuries, bilateral tibia fractures, intensive care admissions, and in-
hospital deaths [10]. In the adult population, obese patients with
femur or tibia fractures have a higher rate of discharge to subacute
facilities [11].
In the current study, obese patients who underwent ORIF had a
15.1% risk of infection compared to 8.6% in the non-obese cohort
(P < 0.0001). This rate rose even higher in the morbidly obese
cohort to 19.1%. Prior studies have provided some basis for this
finding. Obesity often results in longer operative duration during
acetabular and lower extremity surgery which is most likely
secondary to increased soft tissue dissection, difficulty with
implant positioning, and longer closure times, as the incisions
are often longer compared to those used in non-obese patients
[4,8,17–19]. Longer operative times have been associated
with increased infection rates in orthopaedic surgery as the
physical barrier provided by the skin is compromised thus
allowing bacteria prolonged access to the exposed deeper tissue
[15,20,21]. It is important to note that for the ORIF and IMN groups
there were no significant differences in the rates of open fractures
between the various BMI cohorts. Thus, one of the major risk
factors of postoperative infection was statistically similar between
the cohorts.
Increased weight places additional stress across the tibial
implant, and after distal femoral fracture fixation using a lateral
locked plate, obesity was found to be a risk factor for implant
failure [13]. A separate study by Rodriquez et al. showed a
significantly increased rate of nonunion of distal femur fractures in

Table 3
Tibial IMN postoperative complication rates.

Non-obese Obese Morbidly obese Statistical comparison

Morbid v non Obese v non Morbid v obese

Total number 9,026 707 480 OR [95% CI], P OR [95% CI], P OR [95% CI], P
Major medical complications* 770 120 114 3.3 [2.7–4.2] 2.2 [1.8–2.7] 1.5 [1.1–2.0]
8.5% 17.0% 23.8% P < 0.0001 P < 0.0001 P = 0.005

Minor medical complications¥ 566 118 120 5.0 [4.0–6.2] 3.0 [2.4–3.7] 1.7 [1.3–2.2]
6.3% 16.7% 25.0% P < 0.0001 P < 0.0001 P = 0.001

Infection 554 60 61 2.2 [1.7–3.0] 1.4 [1.1–1.9] 1.6 [1.1–2.3]

6.1% 8.5% 12.7% P < 0.0001 P = 0.017 P = 0.024

Removal of hardware 731 61 55 1.5 [1.1–2.0] 1.1 [0.8–1.4] 1.4 [0.9–2.0]

8.1% 8.6% 11.5% P = 0.012 P = 0.671 P = 0.131

Nonunion 998 109 91 1.9 [1.5–2.4] 1.5 [1.2–1.8] 1.3 [0.9–1.7]

11.1% 15.4% 19.0% P < 0.0001 P = 0.001 P = 0.128

VTE 180 32 30 3.3 [2.2–4.9] 2.3 [1.6–3.4] 1.4 [0.8–2.3]

2.0% 4.5% 6.3% P < 0.0001 P < 0.0001 P = 0.239
s
All medical complications 937 156 155 4.1 [3.4–5.0] 2.4 [2.0–3.0] 1.7 [1.3–2.2]
10.4% 22.1% 32.3% P < 0.0001 P < 0.0001 P < 0.0001

Postoperative complication rates of obese and non-obese patients after ORIF of tibial shaft fractures. VTE – venous thromboembolism. BMI – body mass index.
*
Major medical complications included pulmonary embolism (PE), pneumonia, myocardial infarction (MI), acute renal failure (ARF), cerebrovascular accident (CVA), and
respiratory failure.
¥
Minor medical complications included urinary tract infection (UTI), deep vein thrombosis (DVT), acute cholecystitis, and postoperative blood transfusion.
s
All medical complications included patients with major medical complications, minor medical complications, or both.

Please cite this article in press as: Burrus MT, et al. Obesity is associated with increased postoperative complications after operative
management of tibial shaft fractures. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.10.026
G Model
JINJ-6434; No. of Pages 6

M.T. Burrus et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx 5

Table 4
Effect of obesity as seen in previous studies.

Study Population studied Variable evaluated Effect of obesity

Weinlein et al. [9]
Backstrom et al. [10]
Baldwin et al. [11]
Rodriguez et al. [22]
Glance et al. [26]
Femoral shaft fractures
Paediatric lower extremity
long bone fractures
Closed, lower extremity
long bone fractures
Distal femur fractures
General surgery trauma patients
Morbidity and mortality after IMN
Inpatient morbidity and mortality
LOS, cost, rehabilitation admission
rates, complications, mortality
Rate of nonunion
Complications and mortality
(For morbidly obese patients)
Increased systemic complications and mortality
Increased rate of abdominal injuries,
pelvic fractures, bilateral tibial fractures,
operative femur fractures, ICU admissions, mortality
(For morbidly obese patients) Increased LOS and
rehabilitation admission rates
Increased rate of nonunion
(For severe obesity) Increased risk of death and
major complications

IMN – intramedullary nail, ICU – intensive care unit, LOS – length of stay.

their obese cohort [22]. Green et al. described their 28 patients
with delayed union or nonunion of midshaft humerus fractures,
35% (9/28) of whom were obese [23]. Nonunion of humeral shaft
fractures suggest that nonunion in obese patients is not simply a
lower extremity or weight-bearing issue and may have a biologic
origin [23]. In an open tibia fracture model, mice with increased
body weight and glucose intolerance (similar to the physiology of a
patient with type II diabetes mellitus) demonstrated a significantly
decreased amount of woven bone formation, overall callus
formation, and torsional rigidity when compared to control mice
[24]. Researchers also noted markedly increased adiposity in the
callus of the experimental mice, which suggests preferential
differentiation of mesenchymal cells into adipocytes in lieu of
osteoblasts due to endocrine alterations seen in mice with
diabetic-like disease. Additionally, bone turnover markers have
been found to be lower in obese, non-injured patients, but it is not
known if this baseline decreased bone turnover can be extrapolat-
ed in the fracture environment [25]. Although the increased
nonunion rate in obese patients has not yet been completely
explained, the current study once again demonstrates the
increased risk of nonunion seen in this population.
Other than the physical problems posed by the larger lower
extremities of obese patients, these patients are prone to have
more medical co-morbidities and postoperative complications as
was seen in this study [Tables 1A and 1B] and in prior studies. A
retrospective review by Glance et al. compared complications and
mortality of 147,680 obese and non-obese patients [26]. After
adjusting for injury severity, severely obese patients were 30%
more like to die and had a two-fold increased risk of major
complications including acute renal failure, wound complications,
and decubitus ulceration. Data such as this was corroborated in a
similar study by Ditillo et al. in 2014 [27].
In addition to causing preoperative obstacles, medical comor-
bidities very likely play an important role in the postoperative
course. Obese patients having undergone lower extremity
orthopaedic procedures have demonstrated increased medical
complications and length of inpatient hospitalisation in numerous
studies [8,28]. Table 4 highlights some of the effects of obesity on
patient complications as seen in prior studies. As the data in
the current study demonstrates, obese patients have once again
be found to be at a higher risk of major and minor medical
complications.
The current study shows that obese patients who undergo tibial
shaft fracture fixation are at an increased risk of developing a VTE,
and the association between DVTs or pulmonary emboli (PE) and
obesity in general has been previously demonstrated [29–31].
Mantilla et al. calculated an odds ratio for the development of a
DVT of 1.5 for each 5-kg/m2 increase when patients undergo total
hip or knee arthroplasty [31]. One possible explanation for this is
that previous data has demonstrated that increased operative
duration is associated with a higher risk of developing a DVT [21].
As deep vein thrombosis (DVT) and pulmonary embolism (PE)
avoidance, diagnosis, and treatment are currently very prominent
topics in orthopaedic literature, patients with this diagnosis are
likely to undergo long term anticoagulation which is not without
inherent risks. Often after lower extremity surgery, patients who are
unable to safely weight bear on an extremity are an increased fall
risk, and anticoagulation predisposes them to epidural and subdural
hematomas. Local wound complications from hematomas after
anticoagulation are a constant concern for orthopaedic surgeons
and may results in additional procedures including irrigation and
débridements, implant removal, and amputations [32].
This study has several limitations. Many of the limitations of
our study are inherent to all studies utilising large administrative
databases such as PearlDiver. The power of the analysis is
dependent on the quality of the available data, which includes
accuracy of billing codes and miscoding or non-coding by
physicians all as potential sources of error. While we attempted
to accurately represent a large population of interest by using this
database, we cannot assure that the database represents a true
cross-section of the United States. The PearlDiver database consists
of de-identified data, and thus only limited demographic
information is available. We can only characterise the patients,
their fractures and the complications following operative treat-
ment based on the provided demographics and those diagnoses
and complications which are coded using ICD-9 or CPT codes.
Furthermore, the majority of the findings in our study represent
90-day outcomes to increase the likelihood that the complications
were related to the postoperative management of the tibial shaft
fracture, and not another condition or medical/surgical issue that
arose. Late complications outside the 90-day postoperative
window are thus not captured in our study, with the exclusion
of non-union and implant removal. Finally, the data is reported in
cohorts, preventing multivariate or regression analysis and thus
the independent effect of BMI on postoperative complications
cannot be reported, as factors such as age, gender, and medical
comorbidities cannot be controlled.
Conclusion
Obesity and its associated medical comorbidities is associated
with increased rates of postoperative medical complications,
infection, nonunion, and implant removal in patients who undergo
operative fixation of tibial shaft fractures with either ORIF or IMN.
Obese patients should be counselled preoperatively regarding this
increased surgical risk and, in an effort to minimise complications,
medical optimisation and management during the perioperative
period is paramount.
Source of funding
None.

Please cite this article in press as: Burrus MT, et al. Obesity is associated with increased postoperative complications after operative
management of tibial shaft fractures. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.10.026
G Model
JINJ-6434; No. of Pages 6
6 M.T. Burrus et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Conflict of interest
There are no any financial and personal relationships with other
people or organisations that could inappropriately influence this
work.
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