Early complications of surgery in operative treatment of ankle fractures in those over 60: a review of 186 cases

Operative Treatment of Ankle Fractures: Predictive Factors Affecting Outcome

Purpose

Surgical management of ankle fractures has been extensively studied in literature but studies investigating validated clinical results are lacking and controversial. The purpose of this study was to evaluate functional and health-related quality of life (HRQL) outcomes after surgically treated ankle fractures and to detect some of their predictors.

Methods

Two hundred sixty-six skeletally mature patients who underwent surgery for an isolated ankle fracture from 2006 to 2017 were retrospectively identified from our hospital records and included in the study. All patients were evaluated at one, three, six and 12 months post-injury with clinical and radiographic examination. Outcome measures recorded at final two years minimum follow-up included patient-reported pain, patient satisfaction, functional (American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score) and quality of life (Short Form (SF) 36 score) status.

Results

Patient satisfaction score was 8.4 out of 10, Visual Analogue Scale mean score was 2.3, complication rate was 36.5% and mean AOFAS ankle-hindfoot score was 87.3. Mean SF36-physical summary score was 77.9 and SF36-mental summary score was 81.1. The injury demonstrated a significant effect on physical function, role-physical, bodily pain and social functioning SF-36 subdomains. Functional outcome was significantly related to occupation, syndesmotic lesion, number of fractured malleoli and delay to surgery. Main predictors of quality of life were age, occupation, cause of injury, syndesmotic lesion, number of fractured malleoli and waiting time to surgery.

Conclusions

Ankle fractures have a considerable impact on functional and quality of life status of patients. Occupation, presence of syndesmotic injury, Pott's classification and surgery delay must be considered as predictors of final outcome.

Mortality and Morbidity of Surgical Management of Geriatric Ankle Fractures

INTRODUCTION

The incidence of geriatric ankle fractures is rising. With the substantial variation in the physiologic and functional status within this age group, our null hypothesis was that mortality and complications of open reduction and internal fixation (ORIF) between patients who are aged 65 to 79 are equivalent to ORIF in patients who are aged 80 to 89.

METHODS

Patients with ankle fracture were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Patients treated with ORIF were identified using the Current Procedural Terminology codes. Patients were divided into two age cohorts: 65 to 79 years of age and 80 to 89 years of age. The primary outcome studied was 30-day mortality. Secondary outcomes included 30-day readmission, revision surgery, surgical site infection, sepsis, wound dehiscence, pulmonary embolism, deep vein thrombosis, blood transfusion, urinary tract infection, pneumonia, stroke, myocardial infarction, renal insufficiency or failure, and length of hospital stay.

RESULTS

Our cohort included 2,353 ankle fractures: 1,877 were among 65 to 79 years of age and 476 were among 80 or older. Thirty-day mortality was 3.2-fold higher in the 80 to 89 years of age group compared with the 65 to 79 years of age group (1.47% versus 0.48%, P = 0.019). However, after controlling for the ASA class, 80 to 89 years of age patients no longer had a significantly higher mortality (P = 0.0647). Similarly, revision surgery rate (3.36% versus 1.81%, P = 0.036), transfusion requirement (2.94% versus 1.49%, P = 0.033), urinary tract infection (1.89% versus 0.75%, P = 0.023), and hospital length of stay (4.9 versus 2.9 days, P < 0.0001) were all significantly higher in the 80 to 90 years of age group compared with the 65 to 79 years old group. However, after controlling for the ASA class, 80 to 89 years old patients no longer had a rate of complications in comparison to the 65 to 79 years old age group.

DISCUSSION

After controlling for comorbidities (ie, the ASA class), no increased risk is observed for the 30-day mortality or complication rate between geriatric ankle fracture in the 65 to 79 years old and the 80 to 99 years old age groups.

LEVEL OF EVIDENCE

Prognostic level III, retrospective study.

Functional Outcomes Following Operative and Nonoperative Management of Weber C Ankle Fractures: A Systematic Review

Weber C ankle fractures are unstable ankle fractures occurring above the syndesmosis. These fractures are often managed operatively, although a small population of patients are still selected for nonoperative management. This study primarily aimed to summarize the current evidence on functional outcomes for Weber C patients managed operatively and nonoperatively. Evidence on secondary outcomes such as complications and radiographic outcomes were also reviewed. This systematic search was conducted according to PRISMA guidelines. A literature search was conducted using the EMBASE, Medline, and Central databases. A total of 26 studies were included in the final analysis. All papers studied the management of Weber C fractures using open reduction and internal fixation (ORIF). Three main functional outcome scores were identified: American Orthopedic Foot and Ankle Society score, Olerud-Molander Ankle Score, and Foot and Ankle Outcome Score. Only 1 study compared operative and conservative management, which showed similar outcomes for either option (median Olerud-Molander Ankle Score 95 [range 20 to 95] vs 100 [70 to 100], respectively). Complications associated with operative management included infection, wound dehiscence, implant failure, and malunion or nonunion. The mean rate of syndesmosis malreduction was 18.2%. This study showed that operative management, regardless of the method of ORIF used, as well as nonoperative management resulted in good functional outcomes, indicating that patient selection for either method is important. However, there is limited evidence on the complications and radiographic outcomes associated with nonoperative management. We recommend further studies to compare all ORIF methods with conservative management and examine the complications associated with nonoperative management.

Epidemiology, Clinical Assessments, and Current Treatments of Nonunions

PURPOSE OF REVIEW

The failure of bony union following a fracture, termed a fracture nonunion, has severe patient morbidity and economic consequences. This review describes current consensuses and future directions of investigation for determining why, detecting when, and effective treatment if this complication occurs.

RECENT FINDINGS

Current nonunion investigation is emphasizing an expanded understanding of the biology of healing. This has led to assessments of the immune environment, multiple cytokines and morphogenetic factors, and the role of skeletogenic stem cells in the development of nonunion. Detecting biological markers and other objective diagnostic criteria is also a current objective of nonunion research. Treatment approaches in the near future will likely be dominated by the development of specific adjunct therapies to the nonunion surgical management, which will be informed by an expanded mechanistic understanding of nonunion biology. Current consensus among orthopedists is that improved diagnosis and treatment of nonunion hinges first on discoveries at the bench side with later translation to the clinic.

Osteoporotic ankle fractures: A narrative review of management options

The management of Osteoporotic ankle fractures is still considered to be a challenge by many surgeons. One of the issues seems to be a lack of data focused on this special subgroup, with very little evidence of good quality. We did a narrative review of the literature in an attempt to identify the magnitude of the problem and to evaluate the evidence in support of management options.The current review of the literature has brought to light some interesting facts. Despite limited data there seems to be an in increase in the incidence of these fractures. Although we could not demonstrate any clear distinction between geriatric and osteoporotic ankle fractures from the available literature; it is clear that all geriatric fractures are not necessarily osteoporotic and neither is the reverse true. The evidence to associate osteoporotic ankle fractures with poor outcomes is weak, and factors other than osteoporosis may have a stronger influence. From this analysis, we could not establish a higher incidence of implant failure for this specific fracture group, although many modifications in technique have been proposed due to the fear of fixation failure. Hook plating and Tibia-pro fibula fixation have weak evidence in support, but posterior fibular plating is preferred due to soft tissue protection. There is weak evidence in support of Locking plates for these fractures, as publications focused on this are limited; nevertheless some advantages have been documented. Augmentation by calcium based bone graft substitutes has been reported to improve pull out strengths of screws, but again the evidence of its role in Osteoportic fractures is limited. Fibular nailing has been proposed with specific advantages in osteoporotic fibular fractures, but the concept is new and it is indicated only in a select a subgroup of cases. Some evidence exists for the use of trans-articular nails in geriatric subgroups with limited pre-injury mobility, but the technique has to be used with caution to prevent other complications.

INFERENCE

More data needs to be accumulated before clear guidelines for management of osteoporotic ankle factures are defined; however the current literature supports the need for modifications in standard ankle facture fixation methods to improve outcomes.

Variability in the Reporting Terminology of Adverse Events and Complications in Ankle Fracture Fixation: A Systematic Review

BACKGROUND

Classification systems for the reporting of surgical complications have been developed and adapted for many surgical subspecialties. The purpose of this systematic review was to examine the variability and frequency of reporting terms used to describe adverse events and complications in ankle fracture fixation. We hypothesized that the terminology used would be highly variable and inconsistent, corroborating previous results that have suggested a need for standardized reporting terminology in orthopedics.

METHODS

Ankle fracture outcome studies meeting predetermined inclusion and exclusion criteria were selected for analysis by 2 independent observers. Terms used to define adverse events and complications were identified and recorded. Discrepancies were resolved by consensus with the aid of a third observer. All terms were then compiled and assessed for variability and frequency of use throughout the studies involved. Reporting terminology was subsequently grouped into 10 categories.

RESULTS

In the 48 studies analyzed, 301 distinct terms were utilized to describe complications or adverse events. Of these terms, 74.4% (224/301) were found in a single study each. Only 1 term, "infection," was present in 50% of studies, and only 19 of 301 terms (6.3%) were used in at least 10% of papers. The category that was most frequently reported was "infection," with 89.6% of studies reporting on this type of adverse event using 25 distinct terms. Other categories were "wound healing complications" (72.9% of papers, 38 terms), "bone/joint complications" (66.7% of papers, 35 terms), "hardware/implant complications" (56.3% of papers, 47 terms), "revision" (56.3% of papers, 35 terms), "cartilage/soft tissue injuries" (45.8% of papers, 31 terms), "reduction/alignment issues" (45.8% of papers, 29 terms), "medical complications" (43.8% of papers, 32 terms), "pain" (29.2% of papers, 16 terms), and "other complications" (20.8% of papers, 13 terms). There was a 78.6% interobserver agreement in the identification of terms across the 48 studies included.

CONCLUSION

The reporting terminology utilized to describe complications and adverse events in ankle fracture fixation was found to be highly variable and inconsistent. This variability prevents accurate reporting of complications and adverse events and makes the analysis of potential outcomes difficult. The development of standardized reporting terminology in orthopedics would be instrumental in addressing these challenges and allow for more accurate and consistent outcome reporting.

LEVEL OF EVIDENCE

Level III; systematic review of Level III studies and above.

Subsequent Pain or Injury After Foot and Ankle Surgery in Patients Receiving Workers' Compensation

BACKGROUND

Workers' compensation (WC) has been associated with poor outcomes following a variety of injuries and surgeries, but rates of subsequent pain or injury (SPI) following surgery have not been studied. The purpose of this study was to investigate the rates, locations, and risk factors of SPI in WC patients and non-WC patients who underwent the same surgeries.

METHODS

With institutional review board approval, records from foot or ankle surgery performed by author P.P. from 2009 to 2015 were obtained. A retrospective chart review was performed on all WC and non-WC patients with at least 1 Current Procedural Terminology code of interest. SPI was defined as a new injury at a different anatomical location occurring 2 months to 2 years after the index surgery. Chi-square and 2-tailed t tests were used to compare risk factors and rates of SPI in both groups.

RESULTS

The WC population had higher rates of SPI than the non-WC population. Specifically, 13 of 56 WC patients (23.2%) vs 12 of 165 non-WC patients (7.3%) reported SPI (P = .001). The hip, knee, and contralateral foot and ankle were common areas of SPI in both groups. Legal representation and increased age were risk factors for SPI in the WC population. Specifically, 10 of 13 WC patients with SPI had legal representation vs 16 of 43 WC patients without SPI (P = .02). Female sex was a risk factor for SPI in the non-WC population.

CONCLUSIONS

WC patients had higher rates of subsequent pain or injury than non-WC patients. Legal representation was a risk factor for SPI in the WC population.

LEVEL OF EVIDENCE

Level III, comparative series.

Operative treatment of geriatric ankle fractures with conventional or locking plates. A retrospective case-control study

BACKGROUND

The incidence of geriatric ankle fractures continues to rise due to demographic changes. While locking plates have become standard implants for injuries of other body regions, clinical studies on their use for geriatric ankle fractures are rare.

METHODS

Therefore, a retrospective case-control study, including 333 patients with a mean age of 73.5 years was performed. 263 patients underwent operative fixation with one- third tubular plates and 70 were treated with locking plates. Early outcomes and complication rates of locking plates as compared with conventional one- third tubular plates are described.

RESULTS

In the present study, patients treated with locking plates were older and suffered from more severe fracture patterns. In addition, these patients had more severe comorbidities. Treatment with conventional or locking plate fixation resulted in a comparable complication and revision rate. A matched pair analysis showed significantly more complications and required revision surgeries and a trend towards more implant failures in the group that underwent conventional plating.

CONCLUSIONS

Therefore, we conclude that precontoured locking plates represent an appropriate treatment option for severe ankle fractures in patients suffering from relevant co-morbidities. Prospective randomized trials are warranted to prove superiority of locking plates for treatment of geriatric ankle fractures. Level 3: Retrospective case- control study.

Comparison of risk factors for postoperative complications across age groups in patients undergoing ORIF of the ankle

INTRODUCTION

Risk factors associated with various adverse outcomes for patients undergoing open reduction and internal fixation (ORIF) of the ankle, and how these risks differ between younger and older patient populations, has not been clearly established. Objective quantitative data may aid physicians in surgical decision making, individualizing postoperative management, and targeting interventions for reducing postoperative comorbidity. The purpose of this study is to compare the incidence of and risk factors for adverse postoperative outcomes following ORIF of ankle fractures across patient age groups.

MATERIALS AND METHODS

Charts of patients age 18 years and older who underwent open reduction and internal fixation (ORIF) for any closed, non-polytraumatic, non-pilon ankle fracture at a single institution between the years 2008 and 2018 were reviewed. Demographic information, comorbidities, and postoperative outcomes were collected. Relative risks for adverse outcomes were calculated and compared between patients younger than 50 and patients 50 years and older.

RESULTS

A total of 886 patients were included, 375 (42.3%) of which were over age 50. In both age groups, risk of infection was significantly increased among patients with hypertension, although risk among older patients (RR = 3.52, p = 0.004) was greater than that among younger patients (RR = 2.46, p = 0.017). In patients younger than 50, significant risk of wound dehiscence was associated with tobacco use (RR = 3.39, p = 0.022), substance use (RR = 3.07, p = 0.020), and CHF (RR = 12.77, p < 0.001). Risk of implant failure was significantly increased among younger patients with HIV (RR = 4.33, p = 0.026), CHF (RR = 10.54, p < 0.001), and CKD (RR = 10.54, p < 0.001), and among older patients with HTN (RR = 4.51, p = 0.006), CHF (RR = 5.83, p < 0.001), and tobacco use (RR = 3.82, P = 0.001).

CONCLUSION

Patients undergoing ORIF of the ankle should be well-informed of the potential risks of surgery as they pertain to specific comorbidities. Multidisciplinary approaches are warranted for appropriate management of patients with multiple comorbidities.

Wound-Healing Issues Following Rotational Ankle Fracture Surgery: Predictors and Local Management Options

Background. The incidence and risk factors of wound-healing complications following rotational ankle fracture surgery are well documented in the literature. However, there is a paucity regarding management options following these complications. The goal of this study was to provide a descriptive analysis of one surgeon's experience managing wound complications in patients who have undergone ankle fracture surgery. Methods. A total of 215 patients who were operatively treated for an unstable ankle were retrospectively identified. Patient demographics, medical histories, initial injury characteristics, surgical interventions, and clinical follow-up were collected. Twenty-five of these patients developed postoperative wound problems. Results. Of the original cohort of 215 patients, 25 (11.6%) developed wound-healing complications. Their average age was 53.6 ± 18.0 years; there were 12 males (48.0%). Connective tissue/inflammatory disease (odds ratio [OR] 3.9), cardiovascular disease (OR 3.6), and active smoking (OR 3.3) were associated with an increased likelihood of developing postoperative wound complications. With regard to injuries, open fractures (OR 17.9) had the highest likelihood of developing postoperative complications, followed by type 44-C (OR 2.8) and trimalleolar fractures (OR 2.0). Conclusion. Wound complications following open treatment of ankle fractures occurred with an incidence of 11.6% in this series, of which only about half required operative intervention. A third of wounds were managed by orthopaedics in conjunction with plastic surgery. Levels of Evidence: Level III: Retrospective comparative study.

Medial malleolus: Operative Or Non-operative (MOON) trial protocol - a prospective randomised controlled trial of operative versus non-operative management of associated medial malleolus fractures in unstable fractures of the ankle

BACKGROUND

There are limited data reporting the outcome of patients with non-operatively managed medial malleolus fractures compared to those treated surgically in the presence of fibular stabilisation for unstable fractures of the ankle. Conservative management could result in fewer complications, reduced surgical time and lower cost. The purpose of this study is to determine if any difference exists in patient reported and surgical outcomes 1 year after surgery between operative and non-operative treatment of medial malleolar fractures in combination with stabilisation of the lateral malleolus.

METHODS/DESIGN

This is a single-centre, prospective, randomised controlled trial that aims to randomise 154 participants with an unstable ankle fracture to 'non-fixation' (n = 77) or 'fixation' (n = 77) of an associated well-reduced medial malleolus fracture following fibular stabilisation. The study will include patients ≥ 16 years of age with a closed bimalleolar or trimalleolar ankle fracture who are able to consent, complete questionnaires in the English language, and complete follow-up over a 1-year period. Randomisation will occur intra-operatively when the medial malleolus fracture is deemed 'well-reduced', with 2 mm or less of fluoroscopic displacement. The technique for fixation of both the medial and lateral malleoli is at the discretion of the operating surgeon. Patient-reported, observer-rated, and radiographic assessments will be collected at baseline and then at the following post-operative assessment points: 2 weeks, 6 weeks and 1 year. Postal questionnaire outcome data will be collected at 3 and 6 months. The primary outcome measure will be the Olerud Molander Ankle Score (OMAS) at 1 year following surgery. Secondary outcome measures will include the Manchester-Oxford Foot Questionnaire (MOXFQ), EuroQol-5D (EQ-5D), pain, treatment satisfaction, time to return to activity, operative tourniquet time, and complications.

DISCUSSION

There is only one previous randomised trial comparing non-fixation with fixation of associated medial malleolus fractures but that was limited by the lack of baseline patient-reported outcome data and an inferior sample size. This current prospective trial aims to provide high-quality evidence regarding the requirement for medial malleolar fixation in unstable ankle fractures.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03362229 . Registered retrospectively on 5 December 2017.

Evaluation of Syndesmosis Reduction after Removal Syndesmosis Screw in Ankle Fracture with Syndesmosis Injury

Background:

Ankle fracture–dislocation with a syndesmotic injury has been treated with syndesmotic screw fixation. There are little evidences about the safety and efficacy of syndesmotic screw removal on the syndesmotic malreduction. This study aimed to evaluate the effects of syndesmotic screw removal of distal attachment of the fibula and tibia bones on the syndesmotic reduction and also impact of syndesmotic screw removal on the final functional score of ankle joint.

Materials and Methods:

Patients who underwent syndesmotic screw fixation for diagnosed syndesmosis injury during internal fixation surgery for ankle fractures from April 2017 to March 2018 were assessed for enrollment in our study. During open reduction and internal fixation for ankle fracture, existence of syndesmosis injury was evaluated using the Cotton test and external rotation stress test. Appropriate rehabilitation including short leg cast and nonweight bearing have been accomplished for a duration 12 weeks before removing of syndesmotic screws. At 12 weeks, screws were removed. After 1-month weight bearing, bilateral axial computed tomography (CT) scan and single-leg weight-bearing X-ray for injured ankle were obtained.

Results:

Of all 60 participants, 42 cases (70%) were male and 18 cases (30%) were female. Postoperative ankle radiographies were normal except one case with increased medial clear space. It was interesting findings that from total 60 cases, 18 patients (30%) had evidence of syndesmosis malreduction on postoperative initial CT scan, and after removing of syndesmotic screws (12 weeks) and a period of weight bearing and rehabilitation (4 weeks), there is evidence of appropriate reduction in 13 cases (of 18 patients [72.2%]) on final CT scans.

Conclusion:

Syndesmotic screw removal and weight bearing may be advantageous to achieve final anatomic reduction of the syndesmosis. Syndesmotic screw removal at appropriate time could not improve foot functional outcomes; however, more studies with the larger sample size are required to confirm the results of the study.

Surgical Considerations for Osteoporosis in Ankle Fracture Fixation

As the geriatric population and associated ankle fractures continues to increase, fracture surgeons should be prepared to surgically manage osteoporotic ankle fractures. There are abundant challenges in management, soft tissue care, and fixation of ankle fractures with poor bone quality especially in elderly patients who have difficulty limiting weight bearing. This article summarizes several different surgical techniques that can be used to optimize outcomes of these fractures.

Optimizing Long-Term Outcomes and Avoiding Failure With the Fibula Intramedullary Nail

OBJECTIVES

To identify risk factors for fixation failure, report patient outcomes, and advise on modifications to the surgical technique for fibula nail stabilization of unstable ankle fractures.

DESIGN

Retrospective review.

SETTING

Academic orthopaedic trauma unit.

PATIENTS

All 342 patients were identified retrospectively from a prospectively collected single-center trauma database over a 9-year period.

INTERVENTION

Unstable ankle fractures managed surgically with a fibula nail.

MAIN OUTCOME MEASUREMENTS

The primary short-term outcome was failure, defined as any case that required revision surgery because of an inadequate mechanical construct. The mid-term outcomes included the Olerud-Molander Ankle Score and the Manchester-Oxford Foot Questionnaire.

RESULTS

Twenty failures occurred (6%), of which 7 (2%) were due to device failure and 13 (4%) due to surgeon error. Of the surgeon errors, 8 consisted of inappropriate weight-bearing after syndesmotic diastasis, and 5 were due to inadequate fracture reduction or poor nail placement. Proximal locking screw (PLS) pull-out was the cause of all device failures. Positioning the PLS >20 mm above the plafond significantly increased failure risk (P = 0.003). At a mean follow-up of 5.1 years (range, 8 months-8 years) the median Olerud-Molander Ankle Score and Manchester-Oxford Foot Questionnaire were 80 (interquartile range, 45) and 10.94 (interquartile range, 44.00), respectively. Patient outcome was not negatively affected by the requirement for revision surgery.

CONCLUSIONS

The fibula nail offers secure fixation and good patient-reported outcomes for unstable ankle fractures. Appropriate postoperative management and surgical technique, including careful placement of the PLS, is essential to minimize construct failure risk.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Short-Term Outcomes and Influencing Factors After Ankle Fracture Surgery

The present study investigated the factors influencing the early clinical outcomes after ankle fracture surgery. We included 88 patients, who had undergone implant removal surgery at 1 year after ankle fracture surgery, with ankle computed tomographic (CT) scans obtained before ankle fracture surgery and at implant removal available. We collected demographic information, including age, sex, the presence of diabetes mellitus, level of trauma energy, and fracture classification from the medical records. We also recorded the fracture height using the radiographs and CT images. The medial joint space and articular incongruity were assessed on the follow-up radiographs and CT scans. Bone attenuation was measured by placing a circular region of interest around the ankle joint on the preoperative CT image. The postimplant removal outcomes were assessed using 2 functional questionnaires, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and Foot and Ankle Outcome Score (FAOS). Significant factors related to the AOFAS ankle-hindfoot scale scores and FAOS were identified through univariate analysis using age, sex, radiographic measurements, and CT findings as explanatory variables, followed by multiple regression analysis. On multiple regression analysis, the total FAOS was independently related to the AO classification (p = .003) and Lauge-Hansen classification (p = .003). The total AOFAS ankle-hindfoot scale score was related to articular incongruity (p = .044). The early clinical outcomes after ankle fracture surgery were affected by involvement of the ankle joint fracture rather than the lateral malleolus fracture height. Female sex and the presence of postoperative articular incongruity correlated with inferior early clinical outcomes.

Factors Associated With Wound- and Implant-Related Complications After Surgical Treatment of Ankle Fractures

We have described the epidemiology of complications after surgical treatment of ankle fractures and assessed which factors are associated with the most frequent complications. We conducted a retrospective cohort study at 2 level 2 and 1 level 1 trauma center in a single trauma region in the Netherlands. The study variables were collected from the electronic medical patient records; all ankle fractures were classified using the Lauge-Hansen classification, and the complications were recorded. A total of 989 patients were included from 3 hospitals, with 173 complications in 156 patients (15.8%). The most frequent complication was wound related, occurring in 101 patients (10.2%). Implant-related complications occurred in 44 patients (4.4%). Other complications, such as cast pressure spots, posttraumatic dystrophy, nonunion, impingement, and pneumonia occurred in 28 patients (2.8%). The 2 most important complications were further analyzed for risk factors. Multivariate analysis showed the risk factors for wound-related complications were advanced age, increased American Society of Anesthesiologists classification, smoking, right side symptomatic, open fracture, and initial external fixation. Most implant-related complications were caused by malreduction (n = 22) or untreated syndesmotic injury (n = 19). Malreduction was associated with supination eversion fractures (p = .059), and untreated syndesmotic injury occurred more often with pronation external rotation fractures (p < .001). The most frequent complications after ankle fracture surgery were wound- and implant-related complications. Postoperative wound-related complications were multifactorial and dependent on a combination of trauma-, patient-, and treatment-related factors. In contrast, implant-related complications resulted from the interaction between the fracture type and subsequent surgical treatment.

Comparison of Locking Versus Nonlocking Plates for Distal Fibula Fractures

Locking plates might offer a biomechanical fixation advantage for distal fibula fractures with comminution or osteoporotic bone. In January 2011, our unit introduced a bone-specific locking plate for the distal fibula. The aim of the present study was to compare it against more conventional plating system implants for lateral malleolar fixation in terms of outcomes, crude costs, and complications. We retrospectively reviewed a consecutive cohort of patients with closed ankle fractures who presented within a 24-month period. The clinical and radiographic outcomes were compared among conventional plating using a one-third semitubular plate, a 3.5-mm limited-contact dynamic compression plate, and a 2.7-mm/3.5-mm locking compression distal fibula plate. A total of 145 patients with ankle fractures underwent surgical fixation: 87 (60.0%) with the semitubular plate, 22 (15.2%) with the limited-contact dynamic compression plate, and 36 (24.8%) with the locking compression distal fibula plate. A greater proportion of patients with established osteoporosis or osteoporosis risk factors were in the locking compression distal fibula plate group (27.8% versus 2.3% and 0%). Four patients (2.8%) required washout for infection. No significant differences were found between the sex distribution within the 3 groups (p = .432). No significant difference was found in the complication rate (p = .914) or the reoperation rate (p = .291) among the 3 groups. Although costing >6 times more than a standard fibula fixation construct (implant cost), bone-specific locking compression distal fibula plates add to the portfolio of implants available, especially for unstable fractures with poor bone quality.

Better is the foe of good: Outcome of operatively treated ankle fractures in the elderly

BACKGROUND

Ankle fractures are the second most common fractures of the lower extremities. Nonetheless, no standardized treatment protocol for unstable ankle fractures of the elderly exists today. Choices to treat ankle fractures are debated controversially, including (1) conservative treatment, (2) open reduction and internal fixation (ORIF), and (3) primary hind-foot arthrodesis. This retrospective study aimed to examine the healing result in patients treated by ORIF after unstable ankle fractures.

METHODS

The study was designed as a retrospective comparative series. The American Orthopaedic Foot and Ankle Society (AOFAS) score was followed to assess the postsurgical outcome. Data was obtained from 66 patients younger than 65 (median age, 42 years; range, 18-63) and 28 patients aged 65 or older (median age, 71 years; range, 65-81). The mean follow-up period for the younger-than-65 group was 48 months; for patients older than 65, it was 49 months.

RESULTS

An AOFAS score of 86.4 in the older and 92.4 in the younger group was determined, p-value<0.05. Elderly patients suffered from significantly more open-ankle fractures and comorbidities than the younger group did, p-value<0.05 each. The duration of hospital stay and the time needed to reach sufficient self-mobilization were both significantly different between the two groups, p-value<0.05.

CONCLUSION

ORIF treatment of ankle fractures resulted in good functional assessment after a mean follow-up of 49 months in the elderly. Pre-fracture health condition positively affected the healing results in younger patients. This study confirms the basic AO Foundation principles for good postsurgical results.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

A comparison of complication rates between locking and non-locking plates in distal fibular fractures

BACKGROUND

Locking compression plates have become increasingly popular in orthopaedic surgery. However, the gold standard of treatment for distal fibular fractures remains fixation with a non-locking one-third tubular plate. It has been reported that locking plates in distal fibular fractures are associated with an increased complication rate.

HYPOTHESIS

The objective of this study is to assess the complication rates of locking versus non-locking plates in patients who underwent surgical fixation of distal fibular fractures.

MATERIALS & METHODS

A retrospective analysis of closed distal fibular fractures that underwent surgical repair over a 2-year period with either a locking or non-locking plate was undertaken, analysing the groups for both wound and overall postoperative complications.

RESULTS

A total of 160 patients were treated over 2 years, of which 129 and 31 patients were treated with non-locking and locking plates respectively. There was no significant difference between the non-locking and locking plates overall complication rates (13.5% versus 15.4%, p=0.76) or wound complication rates (3.97% versus 3.85%, p=1.00).

DISCUSSION

Distal fibular fractures managed with locking plates do not have a higher complication rate in comparison to those managed with non-locking plates.

LEVEL OF EVIDENCE

III (case control study).

Functional assessment of transplantar nailing for ankle fracture in the elderly: 48 weeks' prospective follow-up of 14 patients

INTRODUCTION

Retrograde transplantar intramedullary nailing (TIMN) is a recently described option for ankle fracture in elderly patients with multiple comorbidity contraindicating classical internal fixation. The main objective of the present study was to assess mobility after TIMN for ankle fracture in the elderly. The secondary objective was to assess complications.

HYPOTHESIS

Retrograde TIMN provides reliable fixation of ankle fracture in the elderly, enabling early resumption of walking.

MATERIAL AND METHODS

Fourteen patients, with a mean age of 79.6years (range: 65-99years), with fracture of the ankle or tibial pilon treated by retrograde TIMN, were prospectively included over a 1-year period (2014-2016). Full weight-bearing with walking cast boot was authorized as of day 1. Mobility was assessed on Parker score in consultation at 6, 12, 24 and 48 weeks.

RESULTS

Ten patients were followed up. Mean Parker score was 3.6 (range: 1-5) preoperatively, and 2.4 (range: 1-5) and 2.7 (range: 1-5) at 24 and 48 weeks, respectively: i.e., not significantly different from preoperative values (p=0.057 and p=0.054, respectively). There were no decubitus-related complications. Two patients (20%) showed other complications, including 1 deep infection requiring material ablation. Consolidation was systematic, without hindfoot malunion.

DISCUSSION

Retrograde TIMN appeared to be a useful option for ankle fracture in elderly patients for whom classical internal fixation was contraindicated. It allowed immediate resumption of weight-bearing and early rehabilitation, with no increased morbidity or mortality.

LEVEL OF EVIDENCE

IV.

Functional Outcomes and Quality of Life After Ankle Fracture Surgically Treated: A Systematic Review

Context:Ankle fractures (AFs) are the most common fractures of the lower limbs found in emergency services. Approximately 53% of these fractures are unstable and treated surgically.Objective:To conduct a systematic review evaluating functional outcomes and quality of life of patients with AFs surgically treated.Evidence Acquisition:A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. Five electronic databases were searched, without any limit on publication dates. Only patients with an unstable AF that was surgically treated were included; functional outcomes and the quality of life were controlled by the 36-Item Short-Form Health Survey instrument.Evidence Synthesis:Five studies were included in the analysis, including 267 patients. The values of the Physiotherapy Evidence Database scale ranged between a minimum of 5 and a maximum of 7 points. Patients with surgically treated AF reported less functionality and physical capacity compared with the nonfractured population. Some patients experienced vitality, emotional, and mental health limitations for a long period. Most surgically treated patients reported no pain and a good health and social status.Conclusion:Limitations in functionality and physical capacity represent the main threats to health-related quality of life in patients with surgically treated AFs.

The application of intraoperative ankle dislocation approach in the treatment of the unstable trimalleolar fractures involving posterior ankle comminuted fracture: a retrospective cohort study

Background

The aim of this study was to introduce a novel intraoperative lateral ankle dislocation approach during surgical treatment for patients with unstable trimalleolar fractures involving posterior ankle comminuted fractures and compare its effects and safety with those with conventional approach.

Methods

From June 2006 to June 2014, 69 patients diagnosed as unstable trimalleolar fractures involving posterior ankle comminuted fracture were included in this study. The patients were divided into intraoperative dislocating ankle group (experimental group) and conventional treatment group (control group) according to surgical modalities. The following parameters including rate of primary healing, healing time, incidence of talus necrosis, incidence of post-traumatic arthritis, functional outcomes according to Baird-Jackson classification system, and any possible complications in two groups were recorded and compared.

Results

There were no significant differences regarding the rate of primary healing, healing time and the rate of talus necrosis in two groups (P > 0.05). The incidence of post-traumatic arthritis in experimental and control group were 0 and 24.24% (P = 0.0006), respectively. The rate of excellent and good outcomes were achieved in 91.67% in experimental group and 72.73% in control group (P = 0.038), respectively.

Conclusions

The findings suggest that the intraoperative ankle dislocation approach appears to be a promising surgical option for unstable trimalleolar fractures involving posterior ankle comminuted fracture because it can provide better functional outcomes and lower incidence of post-traumatic arthritis while not compromising primary healing and healing time.

Involvement of Residents Does Not Increase Postoperative Complications After Open Reduction Internal Fixation of Ankle Fractures: An Analysis of 3251 Cases

Ankle fractures are common injuries frequently treated by foot and ankle surgeons. Therefore, it has become a core competency for orthopedic residency training. Surgical educators must balance the task of training residents with optimizing patient outcomes and minimizing morbidity and mortality. The present study aimed to determine the effect of resident involvement on the 30-day postoperative complication rates after open reduction and internal fixation of ankle fractures. A second objective of the present study was to determine the independent risk factors for complications after this procedure. We identified patients in the American College of Surgeons National Surgical Quality Improvement Program database who had undergone open reduction internal fixation for ankle fractures from 2005 to 2012. Propensity score matching was used to help account for a potential selection bias. We performed univariate and multivariate analyses to identify the independent risk factors associated with short-term postoperative complications. A total of 3251 open reduction internal fixation procedures for ankle fractures were identified, of which 959 (29.4%) had resident involvement. Univariate (2.82% versus 4.54%; p = .024) and multivariate (odds ratio 0.71; p = .75) analyses demonstrated that resident involvement did not increase short-term complication rates. The independent risk factors for complications after open reduction internal fixation of ankle fractures included insulin-dependent diabetes, increasing age, higher American Society of Anesthesiologists score, and longer operative times.

The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years

BACKGROUND

Close contact casting (CCC) may offer an alternative to open reduction and internal fixation (ORIF) surgery for unstable ankle fractures in older adults.

OBJECTIVES

We aimed to (1) determine if CCC for unstable ankle fractures in adults aged over 60 years resulted in equivalent clinical outcome compared with ORIF, (2) estimate cost-effectiveness to the NHS and society and (3) explore participant experiences.

DESIGN

A pragmatic, multicentre, equivalence randomised controlled trial incorporating health economic evaluation and qualitative study.

SETTING

Trauma and orthopaedic departments of 24 NHS hospitals.

PARTICIPANTS

Adults aged over 60 years with unstable ankle fracture. Those with serious limb or concomitant disease or substantial cognitive impairment were excluded.

INTERVENTIONS

CCC was conducted under anaesthetic in theatre by surgeons who attended training. ORIF was as per local practice. Participants were randomised in 1 : 1 allocation via remote telephone randomisation. Sequence generation was by random block size, with stratification by centre and fracture pattern.

MAIN OUTCOME MEASURES

Follow-up was conducted at 6 weeks and, by blinded outcome assessors, at 6 months after randomisation. The primary outcome was the Olerud-Molander Ankle Score (OMAS), a patient-reported assessment of ankle function, at 6 months. Secondary outcomes were quality of life (as measured by the European Quality of Life 5-Dimensions, Short Form questionnaire-12 items), pain, ankle range of motion and mobility (as measured by the timed up and go test), patient satisfaction and radiological measures. In accordance with equivalence trial US Food and Drug Administration guidance, primary analysis was per protocol.

RESULTS

We recruited 620 participants, 95 from the pilot and 525 from the multicentre phase, between June 2010 and November 2013. The majority of participants, 579 out of 620 (93%), received the allocated treatment; 52 out of 275 (19%) who received CCC later converted to ORIF because of loss of fracture reduction. CCC resulted in equivalent ankle function compared with ORIF at 6 months {OMAS 64.5 points [standard deviation (SD) 22.4 points] vs. OMAS 66.0 points (SD 21.1 points); mean difference -0.65 points, 95% confidence interval (CI) -3.98 to 2.68 points; standardised effect size -0.04, 95% CI -0.23 to 0.15}. There were no differences in quality of life, ankle motion, pain, mobility and patient satisfaction. Infection and/or wound problems were more common with ORIF [29/298 (10%) vs. 4/275 (1%)], as were additional operating theatre procedures [17/298 (6%) vs. 3/275 (1%)]. Malunion was more common with CCC [38/249 (15%) vs. 8/274 (3%); p < 0.001]. Malleolar non-union was lower in the ORIF group [lateral: 0/274 (0%) vs. 8/248 (3%); p = 0.002; medial: 3/274 (1%) vs. 18/248 (7%); p < 0.001]. During the trial, CCC showed modest mean cost savings [NHS mean difference -£644 (95% CI -£1390 to £76); society mean difference -£683 (95% CI -£1851 to £536)]. Estimates showed some imprecision. Incremental quality-adjusted life-years following CCC were no different from ORIF. Over common willingness-to-pay thresholds, the probability that CCC was cost-effective was very high (> 95% from NHS perspective and 85% from societal perspective). Experiences of treatments were similar; both groups endured the impact of fracture, uncertainty regarding future function and the need for further interventions.

LIMITATIONS

Assessors at 6 weeks were necessarily not blinded. The learning-effect analysis was inconclusive because of limited CCC applications per surgeon.

CONCLUSIONS

CCC provides a clinically equivalent outcome to ORIF at reduced cost to the NHS and to society at 6 months.

FUTURE WORK

Longer-term follow-up of trial participants is under way to address concerns over potential later complications or additional procedures and their potential to impact on ankle function. Further study of the patient factors, radiological fracture patterns and outcomes, treatment responses and prognosis would also contribute to understanding the treatment pathway.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN04180738.

FUNDING

The National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 75. See the NIHR Journals Library website for further project information. This report was developed in association with the National Institute for Health Research Oxford Biomedical Research Unit funding scheme. The pilot phase was funded by the AO Research Foundation.

The role of diabetes mellitus and BMI in the surgical treatment of ankle fractures

BACKGROUND

Open reduction and internal fixation is the standard treatment for displaced ankle fractures. However, the presence of comorbidities such as diabetes mellitus and body mass index (BMI) are associated with poor bone quality, and these factors may predict the development of postoperative complications. The study aim was to assess the role of diabetes mellitus and BMI in wound healing in patients younger than 65 years who were surgically treated for malleoli fractures.

METHODS

Ninety patients, aged from 18 to 65 years old, with surgically treated ankle fracture, were retrospectively enrolled. Patients were classified in two groups: patient with diabetes and patients without diabetes (insulin-dependent and noninsulin dependent). All patients were assessed for wound complications, Visual Analogue Scale and Foot and Ankle Disability Index (FADI) were assessed for all patients. Logistic regression was used to identify the risk of wound complications after surgery using the following factors as explanatory variables: age, gender, duration of surgery, BMI, hypercholesterolemia, smoking history, diabetes mellitus, and high blood pressure.

RESULTS

In total, 38.9% of patients showed wound complications. Of them, 17.1% were nondiabetics and 82.9% were diabetics. We observed a significant association between DM and wound complications after surgery (P = .005). Logistic regression analysis revealed that DM (P < .001) and BMI (P = .03) were associated with wound complications. The odds of having a postoperative wound complication were increased 0.16 times in the presence of diabetes and 1.14 times for increasing BMI.

CONCLUSION

This study showed that diabetes mellitus and higher BMI delay the wound healing and increase the complication rate in young adult patients with surgically treated bimalleolar fractures.

Outpatient Management of Ankle Fractures

Interest in outpatient orthopedic surgery has been fueled by provider desire to control costs and development of rapid recovery protocols. Open reduction and internal fixation (ORIF) is a commonly elected treatment strategy for ankle fracture that may be performed in an outpatient setting. Lessons on cost-savings of the outpatient model in orthopedics can be learned in total joint replacement and spine surgery. Moreover, in properly selected patients, outpatient ORIF has been shown to be comparably safe. Reasons for admission of the surgically managed patient with ankle fractures, including concern for surgical delay and additional social factors, warrant further investigation.

Standardised pre-operative diagnostics and treatment of peripheral arterial disease reduce wound complications in geriatric ankle fractures

PURPOSE

The aim of this study was to evaluate a standardised algorithm to assess and treat impaired limb perfusion prior to surgical fixation of geriatric ankle fractures and determine the prevalence of peripheral arterial disease (PAD) in geriatric patients presenting with ankle fractures.

METHODS

Eighty-four patients >65 years pre-operatively diagnosed and treated according to an algorithm (study group) were compared with 84 patients diagnosed and treated before the algorithm was introduced (control group).

RESULTS

In 14 patients of the study group, clinical noninvasive examination revealed signs of relevant PAD, which was confirmed with computed tomographic angiography (CTA) in nine patients, all of whom had successful angioplasty prior to surgical fixation of the ankle fracture. In three of these patients, PAD had previously been diagnosed. After standardised diagnostics and treatment of malperfusion, a significantly reduced overall and, particularly, wound complication rate was found.

CONCLUSION

PAD is an underdiagnosed condition in geriatric patients presenting with ankle fractures. This study underlines the relevance of limb perfusion for adequate wound healing in geriatric ankle fractures. Therefore, special attention should be paid to diagnose and-if indicated-optimise limb perfusion prior to surgical fixation of geriatric ankle fractures.

Locking versus non-locking one-third tubular plates for treating osteoporotic distal fibula fractures: a comparative study

INTRODUCTION

Ankle fractures represent the third most common fracture in elderly patients, after hip and wrist fractures. Distal fibula fractures in this population are closely related to osteoporosis, which renders commonly used methods of internal fixation technically demanding and prone to failure. Currently there is a tendency to fix osteoporotic metaphyseal and epiphyseal fractures with locking plates. However, published accounts about the use of this technology in osteoporotic distal fibula fractures are scarce. In this study we compare the results of two groups of patients who underwent surgery for these types of fracture, one group received locking and the other non-locking screws, both using one-third tubular plates.

METHODS

Sixty-two patients, aged over 64 years, underwent surgery for osteoporotic distal fibula fractures between 2011 and 2014. Forty-five of them were stabilized with a non-locking plate and the remaining 17 with a locking plate fixation. Follow-up was performed at 4, 8, 12, 26, and 52 weeks. Results were assessed according to the AOFAS Ankle-Hindfoot Score and radiological criteria for consolidation.

RESULTS

Average time to union and AOFAS scores at 6 and 12 months were similar in both groups, including for the individual categories: function, pain, mobility, and alignment. Only time until partial weight bearing was significantly lower in the locking plate group (4.69 ± 2.63 vs 7.77 ± 4.30, p = 0.03). The most common complications were wound dehiscence and superficial infection (two cases of both).

CONCLUSIONS

Both locking and conventional non-locking plates achieved similar treatment outcomes in this group of osteoporotic patients aged over 64. However, locking plates may offer more benefits in cases that have to take into account immobilization time and concomitant soft-tissue damage.

The association of body mass index with complications and functional outcomes after surgery for closed ankle fractures

AIMS

This study assessed the association of classes of body mass index in kg/m² (classified as normal weight 18.5 kg/m² to 24.9 kg/m², overweight 25.0 kg/m² to 29.9 kg/m², and obese ≥ 30.0 kg/m²) with short-term complications and functional outcomes three to six years post-operatively for closed ankle fractures.

PATIENTS AND METHODS

We performed a historical cohort study with chart review of 1011 patients who were treated for ankle fractures by open reduction and internal fixation in two hospitals, with a follow-up postal survey of 959 of the patients using three functional outcome scores.

RESULTS

Obese patients had more severe overall complications and higher odds of any complication than the normal weight group, with adjusted odds ratio 1.67 (95% confidence interval (CI) 1.08 to 2.59; p = 0.021) and 1.71 (95% CI 1.10 to 2.65; p = 0.016), respectively. In total 479 patients (54.6%) responded to the questionnaire. Obese patients had worse scores on the Olerud and Molander Ankle Score (p < 0.001), Self-Reported Foot and Ankle Questionnaire (p = 0.003) and Lower Extremity Functional Scale (p = 0.01) than those with normal weight. In contrast, overweight patients did not have worse functional scores than those with normal weight.

CONCLUSION

Obese patients had more complications, more severe complications, and worse functional outcomes three to six years after ankle surgery compared with those with normal weight. Cite this article: Bone Joint J 2017;99-B:1389-98.

Associations of timing of surgery with postoperative length of stay, complications, and functional outcomes 3-6 years after operative fixation of closed ankle fractures

AIMS

To evaluate the associations of timing of surgery with postoperative length of stay (LOS), complications, and functional outcomes 3-6 years after open reduction and internal fixation (ORIF) in closed ankle fractures.

PATIENTS AND METHODS

Historical cohort study by chart review of 1011 patients for postoperative LOS and complications; 959 individuals were invited to participate in a postal survey with functional outcomes questionnaires. Complications were classified as perioperative, early, or late. The associations with time from trauma to surgery (<8h, 8h to 6days, >6days) were assessed with (1) postoperative LOS using multivariable random-effects negative binomial regression, (2) complications using multivariable binary and multinomial logistic regression, and (3) three different functional outcomes using multivariable linear regression.

RESULTS

The mean patient age was 51.4 (range 18-94) years, 556 (55%) were female, and 567 individuals (59%) responded to the questionnaire. There were no statistically significant associations between time to surgery and either postoperative LOS or complications after adjusting for several patient and fracture characteristics. Patients operated on >6days after the trauma had significantly worse scores on the Olerud and Molander Ankle Score (OMAS) (p=0.039) and somewhat worse, but non-significant, scores on the Lower Extremity Functional Scale (LEFS; p=0.573) and the Self-Reported Foot and Ankle Score (SEFAS) scale (p=0.161) than those operated on <8h after trauma.

CONCLUSION

In ankle-fracture surgery, there was no apparent association between timing of surgery and postoperative LOS or complications. A delay of surgery for 8h to 6days resulted in similar functional outcomes after 3-6 years suggesting there may be a safe window of time for surgery of up to 6days after trauma that can be used to plan and perform the final ORIF.

Is It Worth Discriminating Against Patients Who Smoke? A Systematic Literature Review on the Effects of Tobacco Use in Foot and Ankle Surgery

Although numerous studies have linked smoking with lower extremity wound and bone healing complications, a comprehensive study on the effects of smoking in foot and ankle surgery has not yet been reported. The purpose of the present study was to report the results of our systemic literature review, identifying the effects of tobacco use on common foot and ankle procedures. The systematic literature review was performed according to guidelines set by the PRIMSA statement (Preferred Reporting Items for Systematic Review and Meta-Analyses). Smoking, as a single risk factor, was analyzed and used to compare adverse outcomes in the postoperative setting of foot and ankle surgery. We reviewed 528 abstracts that met our initial identification criteria. After an extensive review process, 46 of the articles (8.71%) met the eligibility requirements to be included in the present study. Distal bunionectomy with osteotomy, first metatarsophalangeal joint arthrodesis, Lapidus bunionectomy, toe amputation, transmetatarsal amputation, Syme's amputation, open reduction internal fixation (ORIF) of calcaneal fractures, ankle fracture ORIF, pilon fracture ORIF, subtalar arthrodesis, rearfoot arthrodesis, tibiocalcaneal arthrodesis, ankle arthrodesis, total ankle arthroplasty, and plastic surgery procedures and their respective negative association with smoking was identified and described in our review. Our systematic literature review revealed that procedures involving arthrodesis, fracture ORIF, and plastic surgery were associated with negative outcomes in smokers. Procedures that did not involve osseous unions such as total ankle arthroplasty and amputations did not appear to have negative outcomes associated with smoking.

Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly

Purpose of Review

Treatment of osteoporotic and neuropathic ankle fractures in the elderly is challenging. The purpose of this paper is to review recent publications on this topic and to identify the optimal treatment for these fractures.

Recent Findings

Treatment consists of a variety of conservative or operative options all with advantages and disadvantages as described in this review. Little research has been published that specifically focuses on elderly patients with ankle fractures. Operative treatment has a high complication rate. Multiple comorbidities are predictors for complications.

Summary

An optimal treatment could not be distilled but based on the available literature, a general treatment algorithm is proposed. Since the elderly typically are accompanied by multiple comorbidities as well as impaired mobility, the physician should focus not only on treating the fractured ankle but also on the patient as a whole. Further research on this specific topic is needed.

Operative treatment of early infection after internal fixation of limb fractures (exclusive of severe open fractures)

Early infection after open reduction and internal fixation (ORIF) of a limb bone is defined as bacteriologically documented, deep and/or superficial surgical-site infection (SSI) diagnosed within 6months after the surgical procedure. This interval is arbitrarily considered sufficient to obtain fracture healing. The treatment of early infection after ORIF should be decided by a multidisciplinary team. The principles are the same as for revision arthroplasty. Superficial SSIs should be differentiated from deep SSIs, based on the results of bacteriological specimens collected using flawless technique. A turning point in the local microbial ecology occurs around the third or fourth week, when a biofilm develops around metallic implants. This biofilm protects the bacteria. The treatment relies on both non-operative and operative measures, which are selected based on the time to occurrence of the infection, condition of the soft tissues, and stage of bone healing. Both the surgical strategy and the antibiotic regimen should be determined during a multidisciplinary discussion. When treating superficial SSIs after ORIF, soft-tissue management is the main challenge. The treatment differs according to whether the hardware is covered or exposed. Defects in the skin and/or fascia can be managed using reliable reconstructive surgery techniques, either immediately or after a brief period of vacuum-assisted closure. In deep SSIs, deciding whether to leave or to remove the hardware is difficult. If the hardware is removed, the fracture site can be stabilised provisionally using either external fixation or a cement rod. Once infection control is achieved, several measures can be taken to stimulate bone healing before the end of the classical 6-month interval. If the hardware was removed, then internal fixation must be performed once the infection is eradicated.

The impact of lifestyle risk factors on the rate of infection after surgery for a fracture of the ankle

Aims

Lifestyle risk factors are thought to increase the risk of infection after acute orthopaedic surgery but the evidence is scarce. We aimed to investigate whether smoking, obesity and alcohol overuse are risk factors for the development of infections after surgery for a fracture of the ankle.

Patients and Methods

We retrospectively reviewed all patients who underwent internal fixation of a fracture of the ankle between 2008 and 2013. The primary outcome was the rate of deep infection and the secondary outcome was any surgical site infection (SSI). Associations with the risk factors and possible confounding variables were analysed univariably and multivariably with backwards elimination.

Results

A total of 1043 patients were included; 64 (6.1%) had a deep infection and 146 (14.0%) had SSI. Obesity was strongly associated with both outcomes (odds ratio (OR) 2.21, p = 0.017 and OR 1.68, p = 0.032) in all analyses. Alcohol overuse was similarly associated, though significant only in unadjusted analyses. Surprisingly, smoking did not yield statistically significant associations with infections.

Conclusion

These findings suggest that obesity and possibly alcohol overuse are independent risk factors for the development of infection following surgery for a fracture of the ankle. This large study brings new evidence concerning these common risk factors; although prospective studies are needed to confirm causality. Cite this article: Bone Joint J 2017;99-B:225–30.

Fragility fractures of the ankle in the elderly: Open reduction and internal fixation versus tibio-talo-calcaneal nailing: Short-term results of a prospective randomized-controlled study

INTRODUCTION

The management of ankle fractures in the elderly remains unpredictable, secondary to their various co-morbidities. Although tibiotalocalcaneal (TTC) nailing has been an effective option for ankle arthrodesis due to ankle arthritis or Charcot arthropathy there are few reports regarding the use of TTC nail for the treatment of ankle fractures.

PURPOSE

Aim of this study was to compare the results of ORIF versus TTC nailing for the treatment of unstable ankle fractures in the elderly. We hypothesized that the elderly may benefit from TTC nailing, as it allows the patient to be mobilized immediately after surgery and minimizes the risk of wound or bone problems.

PATIENTS AND METHODS

This was a prospective, randomized-controlled, comparative study. Between 2009 and 2015, 43 patients were treated with a TTC nail (Group A) and 44 with ORIF (Group B). The Olerud-Molander ankle score was obtained and intraoperative-postoperative complications, length of hospital stay, mobility status and reoperation rate were recorded. The nail fixation was performed with the TrigenR hindfoot nail after closed reduction. ORIF was performed, using a 1/3 tubular plate and 3.5mm screws for the lateral malleolus and two 4.0 mm cannulated screws for the medial.

RESULTS

Mortality rate at one year was 13.9% for Group A and 18.1% for Group B. Mean follow-up was 14 months (12-18m). There were no intraoperative complications. Three complications in Group A (8.1%) and twelve (33.3%) in Group B were encountered postoperatively (p<0.05). There was significant shorter hospital stay in Group A (5.2±3.1d) than in Group B (8.4±5.2d). In Group A, 28 patients returned to their pre-injury mobility status (75.6%) while 9 declined one level of the mobility scale (24.3%). In Group B, 26 patients remained at the same mobility level (72.2%) and 10 declined one level (27.7%). There was no significant difference between the postoperative OMAS scores in the two Groups (56.9±9.85 and 56.6±9.3 respectively).

CONCLUSIONS

We believe that TTC nailing is a safe and effective method of treatment of unstable ankle fractures in the elderly because it has a low risk of complications and restores function and mobility allowing an immediate return to full weight-bearing.

Relationship of Prolonged Operative Time and Comorbidities With Complications After Geriatric Ankle Fractures

BACKGROUND

The incidence of geriatric ankle fractures has increased during the last few decades. In contrast to younger patients, increased complication rates have been observed. Thus, the goal of the present study was to identify risk factors for perioperative complications following open reduction and internal fixation of geriatric ankle fractures.

METHODS

Two hundred thirty-seven patients over the age of 65 years (mean, 72.5 ± 6.1 years) treated for ankle fractures in our institution between 2004 and 2014 were included. Complications associated with operative treatment as well as complications requiring revision surgery were analyzed. In a multivariate analysis, risk factors were determined.

RESULTS

In 68 patients (28.7%), 74 complications were documented. The most common complications were impaired wound healing and operative site infections. The multivariate analysis revealed that the operative time was the only independent risk factor for the development of a complication. The operative time as well as the presence of an open fracture represented risk factors for needing revision surgery. Comorbidities did not influence the development of complications.

CONCLUSION

The operative management of geriatric ankle fractures was associated with a high complication rate. In the present study, the operative time was the only modifiable factor for the development of a complication that required revision surgery. During preoperative preparation, we believe that perfusion of the affected limb should be optimized to reduce the incidence of wound complications.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Ankle fractures in the elderly: Treatment and results in 477 patients

INTRODUCTION

In the elderly, ankle fractures are likely to cause specific complications and have a major impact on their autonomy. The goal of this multicentre study was to assess these outcomes in a geriatric population treated operatively.

MATERIAL AND METHODS

This retrospective study included 477 patients with ankle fractures treated surgically between 2008 and 2014. The minimum age was 60years for women and 70 for men. Patients with a tibial pilon fracture or less than 3months' follow-up were excluded. Functional (autonomy and comorbidities) and radiological assessments were performed before surgery and at the review.

RESULTS

The cohort was 81% female (384 women, 93 men) and had median age of 74years. The preoperative autonomy was 7.8 points on average using the Parker score. Most of the fractures were either Weber type B (n=336) or type C (n=114). At the follow-up, the mean autonomy score was 7.3 points. The fibula was fixed with a plate and screws in 69% of cases (n=325), with additional internal malleolar fixation was carried out in some cases. A satisfactory result, defined as 2 points or less reduction in the Parker score, was found in 89.9% of patients; 71.8% had not lost any autonomy. The main risk factors for loss of autonomy were being more than 80years of age (OR=2.93, P<0.001), poor surgical reduction (OR=2.8, P<0.01), the presence of two or more comorbidities (OR=2.71, P<0.001), being female (OR=2.19, P<0.043) or having a Weber type C fracture (OR=2.05, P=0.023).

DISCUSSION

The functional results are satisfactory overall following standard surgical treatment consisting of internal malleolar and fibular fixation for ankle fractures in the elderly. We identified five factors that greatly impact functional recovery.

LEVEL OF EVIDENCE

IV.

Risk factors for long bone fracture non-union: a stratification approach based on the level of the existing scientific evidence

Non-union continues to be the most devastating complication after fracture fixation. Its treatment can be prolonged and often unpredictable. The burden to the patient, surgeon and health care system can be immense. Strategies to prevent it and or identify early its development are desirable in order to improve the clinical course of the affected patients and their outcomes. We undertook a systematic review of the literature in order to identify the most common and important risk factors based on the hierarchy of level of evidence. Accordingly, a stratification scale was formed which highlighted 10 risk factors including; an open method of fracture reduction, open fracture, presence of post-surgical fracture gap, smoking, infection, wedge or comminuted types of fracture, high degree of initial fracture displacement, lack of adequate mechanical stability provided by the implant used, fracture location in the poor zone of vascularity of the affected bone, and the presence of the fracture in the tibia. Clinicians should take in to account these findings when managing patients with long bone fractures, particularly the femur and tibia in order to minimise the risk of non-union.

Patient-Based and Surgical Risk Factors for 30-Day Postoperative Complications and Mortality After Ankle Fracture Fixation

OBJECTIVE

The purpose was to calculate the incidence rates and determine risk factors for 30-day postoperative mortality and morbidity after ankle fracture open reduction and internal fixation (ORIF).

METHODS

The NSQIP database was queried to identify patients undergoing ankle fracture ORIF from 2006 to 2011, with extraction patient-based or surgical variables and a 30-day clinical course. Multivariable logistic regression analysis identified significant predictors on outcome measures.

RESULTS

Mean age was 50.3 (±18.2) years while diabetes mellitus (12.8%) and body mass index ≥40 kg/m(2) (9.2%) were documented from a total of 3328 patients identified. The 30-day mortality rate was 0.30%, and complications occurred in 5.1%. Chronic obstructive pulmonary disease [odds ratio (OR): 4.23, 95% confidence interval (CI): 1.19-15.06] and a nonindependent functional status before surgery (OR: 2.25, 95% CI: 1.13-4.51) were the sole independent predictors of mortality and major local complications, respectively. Major local complications occurred in 2.2% of patients, and significant predictors were peripheral vascular disease (OR: 6.14; 95% CI: 1.95-19.35), open wound (OR: 5.04; 95% CI: 2.25-11.27), nonclean wound classification (OR: 3.02; 95% CI: 1.31-6.93), and smoking (OR: 2.85; 95% CI: 1.42-5.70). Independent predictors of hospital stay >3 days were cardiac disease, age 70 years or older, open wound, partially/totally dependent functional status, American Society of Anesthesiologists (ASA) classification ≥3, body mass index ≥40 kg/m(2), bimalleolar or trimalleolar ankle fracture pattern, female sex, and diabetes.

CONCLUSIONS

Chronic obstructive pulmonary disease increased the risk of mortality after ankle fracture ORIF. Risk factors for postoperative complications included peripheral vascular disease, open wound, nonclean wound classification, age 70 years or older, and ASA classification ≥3.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Ankle fractures in the elderly: an overlooked burden

Ankle fractures in the elderly are a complex under-recognized burden which require a multidisciplinary approach to management. This article discusses the holistic approach required, including the up-to-date surgical management options and the areas for future development.

Occupational Outcomes and Return to Running Following Internal Fixation of Ankle Fractures in a High-Demand Population

BACKGROUND

Literature evaluating surgical outcomes after ankle fixation in an active patient population is limited. This study determined occupational outcomes and return to running following ankle fracture fixation in a military cohort.

METHODS

All service members undergoing ankle fracture fixation at a single military hospital from August 2007 to August 2012 were reviewed. Univariate analysis determined the association between patient demographic information, type of fracture fixation, and the development of posttraumatic ankle arthritis and functional outcomes, including medical separation, return to running, and reoperation. Seventy-two primary ankle fracture fixation procedures were performed on patients with mean age of 29.1 years. The majority of patients were male (88%), were 25 years of age or older (61%), were of junior rank (57%), underwent unimalleolar fracture fixation (78%), and did not require syndesmotic fixation (54%). The average follow-up was 35.9 months.

RESULTS

The mean time to radiographic union was 8.6 weeks. Twelve service members (17%) were medically separated from the military due to refractory pain following ankle fracture fixation with a minimum of 2-year occupational follow-up. Among military service members undergoing ankle fracture fixation, 64% returned to running. Service members with higher occupational demands had a statistical trend to return to running (odds ratio [OR] 2.49; 95% CI, 0.93-6.68). Junior enlisted rank was a risk factor for medical separation (OR 11.00; 95% CI, 1.34-90.57). Radiographic evidence of posttraumatic ankle osteoarthritis occurred in 8 (11%) service members.

CONCLUSIONS

At mean 3-year follow-up, 83% of service members undergoing ankle fracture fixation remained on active duty or successfully completed their military service, while nearly two-thirds returned to occupationally required daily running.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Fractures of the ankle joint: investigation and treatment options

BACKGROUND

Ankle fractures are common, with an incidence of up to 174 cases per 100 000 adults per year. Their correct classification and treatment are of decisive importance for clinical outcome.

METHOD

Selective review of the literature.

RESULTS

Ankle fractures are initially evaluated by physical examination and then by x-ray. They can be classified according to either the AO Foundation (Association for the Study of Internal Fixation) or the Weber classification. Dislocated fractures need emergency treatment with immediate reduction; this is crucial for the prevention of hypoperfusion and nerve damage. Weber A fractures can usually be treated conservatively, while Weber B and C fractures are usually treated with surgery. An evaluation of the stability of the syndesmosis is important for anatomical reconstruction of the joint. Wound hematoma and wound-edge necrosis are the most common complications, and the postoperative infection rate is 2%. Up to 10% of patients develop ankle arthrosis over the intermediate or long term.

CONCLUSION

With properly chosen treatment, a good clinical outcome can be achieved. The long-term objective is to prevent post-traumatic ankle arthrosis. The evidence level for optimal treatment strategies is low.

Preliminary experience with Piccolo Composite™, a radiolucent distal fibula plate, in ankle fractures

The radiolucent plate has many advantageous properties in the treatment of complex ankle fractures, particularly trimalleolar fractures. Surgeons may sometimes have difficulty observing the posterior malleolus after synthesis of lateral malleolus with a traditional plate because common materials of conventional plates are not radiolucent. In this study, the authors highlight the importance of the radiolucent property in the treatment of ankle fractures and describe their preliminary experience with a carbon fibre-reinforced polyetheretherketone distal fibula plate, with good results at 4 months' follow-up and no signs of tissue inflammatory reaction.

The costs of operative complications for ankle fractures: a case control study

As our healthcare system moves towards bundling payments, it is vital to understand the potential financial implications associated with treatment of surgical complications. Considering that surgical treatment of ankle fractures is common, there remains minimal data relating costs to postsurgical intervention. We aimed to identify costs associated with ankle fracture complications through case-control analysis. Using retrospective analysis at a level I trauma center, 28 patients with isolated ankle fractures who developed complications (cases) were matched with 28 isolated ankle fracture patients without complications (controls) based on ASA score, age, surgery type, and fracture type. Patient charts were reviewed for demographics and complications leading to readmission/reoperation and costs were obtained from the financial department. Wilcoxon tests measured differences in the costs between the cases and controls. 28 out of 439 patients (6.4%) developed complications. Length of stay and median costs were significantly higher for cases than controls. Specifically, differences in total costs existed for infection and hardware-related pain. This is the first study to highlight the considerable costs associated with the treatment of complications due to isolated ankle fractures. Physicians must therefore emphasize methods to control surgical and nonsurgical factors that may impact postoperative complications, especially under a global payment system.