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Kang H, Kim HH, Lim C. Bone Mineral Density and Clinical Outcome after Ankle Fracture. J Bone Metab 2024; 31:228-235. [PMID: 39307523 PMCID: PMC11416874 DOI: 10.11005/jbm.2024.31.3.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 09/26/2024] Open
Abstract
BACKGROUND No gold standard exists for bone mineral density (BMD) measurement of the ankle. This study aimed to determine the correlation between bone density using Hounsfield units (HU) based on computed tomography (CT) and BMD using dual energy X-ray absorptiometry (DXA) as well as to evaluate the correlation between HU and clinical outcome of ankle fracture. METHODS Fifty-one patients aged ≥65 years who underwent surgical treatment for trimalleolus or bimalleolus ankle fractures were included. The HU were measured at the distal tibia metaphyseal region approximately 1 cm proximal to the plafond on the axial images of preoperative CT. BMD was measured using DXA within one year before the injury. The clinical outcome was evaluated according to the Foot and Ankle Outcome Score (FAOS). RESULTS Although the HU of an osteoporosis group was lower than that of a non-osteoporosis group, we observed no significant difference between the two groups. The mean HU significantly correlated with the lumbar and total lumbar spine BMD using DXA. Increased HU significantly correlated with improved clinical outcomes in three of five FAOS subscales: symptoms, pain, activity of daily living (ADL), and quality of life (QOL). In a linear regression analysis adjusted for age and body mass index, increased HU significantly correlated with improved clinical outcomes in three of five FAOS subscales: symptoms, pain, ADL, and QOL. CONCLUSIONS The correlations between bone density using HU and BMD and those between HU and the clinical outcome were confirmed in ankle fractures. The HU of preoperative CT might provide valuable information for predicting postoperative clinical outcomes.
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Affiliation(s)
- Hyunseong Kang
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, Korea
| | - Ho-Hyup Kim
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, Korea
| | - Chaemoon Lim
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, Korea
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2
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Welzel L, Omar M, Müller CW. Complications following surgical treatment of ankle fractures in the elderly: can they be avoided? Orthop Rev (Pavia) 2024; 16:116370. [PMID: 38666190 PMCID: PMC11043027 DOI: 10.52965/001c.116370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/24/2024] [Indexed: 04/28/2024] Open
Abstract
Background Following surgical treatment of ankle fractures, geriatric patients face high complication rates (CR) in literature. Commonly used diagnostic and treatment algorithms fail to consider requirements of ageing patients which increases the risk of postoperative complications. Objective Present study critically evaluated surgical management of ankle fractures in patients over 65 years old, with focus on identifying modifiable risk factors and effective comorbidity management strategies. Methods We conducted a retrospective single-center study on patients who underwent surgical treatment of an ankle fracture. Based on their age, participants were divided into non-geriatric patients (NGP<65y) and geriatric patients (GP≥65y). We analyzed overall CR and number of minor and major complications in relation to timing of surgery, biological sex, injury pattern, osteosynthesis, pre-existing medical conditions, and postoperative care. Results 402 patients were included. GP encountered significantly higher overall (p<0.001), minor (p<0.001) and major (p=0.003) complications. They presented more complex, displaced and open fractures. Predominant factor contributing to higher CR in NGP and markedly in GP was concomitant diseases, presenting a strong OR of 19,290 (p<0.001) and 17,022 (p<0.001). Delaying surgery and managing comorbidities preoperatively had a favorable impact. Conclusion We revealed a high significant correlation between pre-existing medical conditions and postoperative results. To ascertain viability of delayed surgery in facilitating additional diagnostics and treatment of comorbidities, further comparative trials with a larger cohort are imperative.
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Affiliation(s)
- Lukas Welzel
- Department of Orthopedics and Traumatology Asklepios Klinik Wandsbek
- Department of Traumatology Hannover Medical School
- Department of Orthopedics and Traumatology Schön Klinik Neustadt
| | - Mohamed Omar
- Department of Traumatology Hannover Medical School
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3
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So E, Juels C, Scott RT, Sietsema DL. A Comparison of Ankle Fractures Relative to Other Fragility Fractures: A Review and Analysis of the American Orthopaedic Association's Own the Bone Database. Foot Ankle Int 2023; 44:879-887. [PMID: 37300238 DOI: 10.1177/10711007231178536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Ankle fragility fractures (AFX) continue to increase in the elderly population. There is limited knowledge of AFX characteristics compared to nonankle fragility fractures (NAFX). The American Orthopaedic Association's Own the Bone (OTB) is a fragility fracture initiative. This robust data set was used to examine and compare characteristics of patients presenting with AFX to those with NAFX. METHODS The OTB database contained 72,617 fragility fractures between January 2009 and March of 2022 and were reviewed in our secondary cohort comparative analysis. After exclusions, AFX accounted for 3229 patients and 54,772 patients were in the NAFX cohort. Bivariate analysis and logistic regression compared the AFX and NAFX groups concerning demographics, bone health factors, medication use, and prior fragility fracture. RESULTS AFX patients were found to have a higher likelihood to be younger (67.6 years old), female (81.4%), non-Caucasian (11.7%) and have a higher BMI (30.6) compared to NAFX. Prior AFX predicted the risk of a future AFX. The probability of an AFX increased with increased age and BMI. CONCLUSION A prior AFX is independently predictive of subsequent AFX. Therefore, these fractures should be considered a sentinel event. These patients are more likely to have higher BMI, to be of female gender, non-Caucasian race, and are younger compared to patients with NAFX. LEVEL OF EVIDENCE Level III, retrospective cohort.
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Affiliation(s)
- Eric So
- Capital Foot and Ankle - Bryan Physician Network, Lincoln, NE, USA
| | | | | | - Debra L Sietsema
- The CORE Institute (retired), Phoenix, AZ, USA
- MORE Foundation (retired), Phoenix, AZ, USA
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4
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Pflüger P, Harder FN, Müller K, Willinger L, Biberthaler P, Crönlein M. Use of Distal Tibial Cortical Bone Thickness and FRAX Score for Further Treatment Planning in Patients with Trimalleolar Ankle Fractures. J Clin Med 2023; 12:jcm12113666. [PMID: 37297861 DOI: 10.3390/jcm12113666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Trimalleolar ankle fractures show a bimodal age distribution, affecting younger men and older women. Postmenopausal women often exhibit low bone mineral density, which contributes to a higher prevalence of osteoporotic-related fractures. The primary goal of this study was to analyse the association of patient characteristics with the cortical bone thickness of the distal tibia (CBTT) in trimalleolar ankle fractures. METHODS A total of 193 patients with a trimalleolar ankle fracture treated between 2011 and 2020 were included. Patient registries were reviewed regarding demographics, mechanism, and type of injury. The CBTT was assessed in radiographs and CT images. The FRAX score was calculated to estimate the probability for an osteoporotic fracture. A multivariable regression model was calculated to identify independent variables affecting the cortical bone thickness of the distal tibia. RESULTS Patients older than 55 years were 4.22 (95% CI: 2.12; 8.38) times more likely to be female. In the multivariable regression analysis, female sex (β -0.508, 95% CI: -0.739; -0.278, p < 0.001) and a higher age (β -0.009, 95% CI: -0.149; -0.003, p = 0.002) were independent variables associated with a lower CBTT. Patients with a CBTT < 3.5 mm had a higher 10-year probability for a major osteoporotic fracture (12% vs. 7.75%; p = 0.001). CONCLUSIONS The assessment of the peripheral bone quality in routine computed tomography demonstrated that higher age and female sex are significantly associated with reduced cortical bone thickness of the distal tibia. Patients with a lower CBTT showed a higher probability for a subsequent osteoporotic fracture. In female patients with reduced distal tibial bone quality and associated risk factors, an osteoporosis assessment should be evaluated.
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Affiliation(s)
- Patrick Pflüger
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Felix N Harder
- Institute of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, 81675 Munich, Germany
| | - Karoline Müller
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Lukas Willinger
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University Munich, 81675 Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Moritz Crönlein
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
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5
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Zuo Y, Li Q, Cheng X. Bone mineral density at the ankle measured with quantitative CT (QCT). J Clin Densitom 2023; 26:101364. [PMID: 36967322 DOI: 10.1016/j.jocd.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/05/2023] [Indexed: 03/11/2023]
Affiliation(s)
- Yuhong Zuo
- Department of Radiology, Guizhou Orthopaedic Hospital, Guiyang, China
| | - Qing Li
- Department of Radiology, Beijing Jishuitan Hospital and Fourth Medical College of Peking University, Beijing, China
| | - Xiaoguang Cheng
- Department of Radiology, Beijing Jishuitan Hospital and Fourth Medical College of Peking University, Beijing, China.
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6
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Zhao K, Dong S, Wang W. When is the optimum time for the initiation of early rehabilitative exercise on the postoperative functional recovery of peri-ankle fractures? A network meta-analysis. Front Surg 2022; 9:911471. [PMID: 36051702 PMCID: PMC9424660 DOI: 10.3389/fsurg.2022.911471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/29/2022] [Indexed: 11/17/2022] Open
Abstract
Objective The purpose of this study was to explore the safe and most effective initiation time for the functional recovery of patients with peri-ankle fractures after surgery. Method We searched electronic databases, including the Cochrane Library, Embase, PubMed and the reference lists of relevant articles published from inception to October 30, 2021. Two researchers independently performed literature screening and data extraction and evaluated the quality of the included literature using the Newcastle–Ottawa Scale. Network meta-analysis, including consistency testing, publication bias, and graphical plotting, was performed using Stata (v16.0). Results A total of 25 articles involving 1756 patients were included in this study. The results of the meta-analysis showed that functional exercise within 2 days after surgery may result in lower VAS scores compared to other techniques (P < 0.05). Functional exercise within 12 months may lead to higher AOFAS scores than that of other techniques (P < 0.05). The total postoperative complication rate, including deep vein thrombosis, showed no statistically significant differences between any two interventions (P > 0.05). The results of the surface under the cumulative ranking (SUCRA) showed that functional exercise within two days postoperatively may have the lowest VAS scores (SUCRA = 82.8%), functional exercise within 1 week postoperatively may have the lowest deep vein thrombosis rate (SUCRA = 66.8%), functional exercise within 10 days postoperatively may have the fewest total postoperative complication rate (SUCRA = 73.3%) and functional exercise within 12 months postoperatively may contribute to the highest AOFAS scores (SUCRA = 85.5%). Conclusion The results of this study suggest that initiation of rehabilitation within two days after surgery may be the best time to reduce postoperative pain; rehabilitation interventions within 10 days after surgery may be the optimal time for reducing the total postoperative complication rate, including deep vein thrombosis; and continued functional exercise within 12 months after surgery may steadily and ideally improve the function of the ankle joint. Systematic Review Registration: doi: 10.37766/inplasy2021.12.0030, identifier: INPLASY2021120030
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Affiliation(s)
- Ke Zhao
- College of Acupuncture-Moxibustion and Orthopedics, Hubei University of Traditional Chinese Medicine, Wuhan, China
| | - Shilei Dong
- Department of Orthopedics, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Department of Orthopedics, Affiliated Hospital of Hubei University of Traditional Chinese Medicine, Wuhan, China
- Institute of Orthopedics, Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Wei Wang
- Department of Orthopedics, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Department of Orthopedics, Affiliated Hospital of Hubei University of Traditional Chinese Medicine, Wuhan, China
- Institute of Orthopedics, Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
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7
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So E, Rushing C, Prissel MA, Berlet GC. The Role of Secondary Imaging Techniques for Assessing Bone Mineral Density in Elderly Ankle Fractures. J Foot Ankle Surg 2022; 61:149-156. [PMID: 34312077 DOI: 10.1053/j.jfas.2021.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 06/20/2021] [Accepted: 06/30/2021] [Indexed: 02/03/2023]
Abstract
Elderly ankle fractures in the elderly represent a substantial healthcare burden. Dual-energy x-ray absorptiometry (DXA) is the gold standard for diagnosis of osteoporosis. However, there is emerging research regarding secondary imaging techniques to evaluate bone mineral density (BMD). The purpose of this systematic review was to summarize the role of secondary imaging techniques for measuring BMD in elderly ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Eight studies were included in the systematic review. Computed tomography (CT) may have a role in preoperative surgical planning, provide an explanation for injury patterns in elderly patients, and may be correlated with clinical outcomes. High-resolution peripheral quantitative CT may be better suited than DXA for the assessment of ankle fractures due to the resolution of the image and its ability to distinguish between bone compartments, as well as provide a more accurate estimation of bone quality. Quantitative ultrasound has shown promise as a tool for measuring BMD in patients with osteoporosis, but is not able to detect osteoporosis in patients with ankle fractures. This paper helps define the role of each modality in the spectrum of care in the evaluation of osteoporosis as it pertains to elderly ankle fractures.
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Affiliation(s)
- Eric So
- Bryan Health, Lincoln, NE; Ohio Innovation Group, Columbus, OH.
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8
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Zhang H, Hu Y, Chen X, Wang S, Cao L, Dong S, Shi Z, Chen Y, Xiong L, Zhang Y, Zhang D, Yu B, Chen W, Wang Q, Tong P, Liu X, Zhang J, Zhou Q, Niu F, Yang W, Zhang W, Wang Y, Chen S, Jia J, Yang Q, Zhang P, Zhang Y, Miao J, Sun K, Shen T, Yu B, Yang L, Zhang L, Wang D, Liu G, Zhang Y, Su J. Expert consensus on the bone repair strategy for osteoporotic fractures in China. Front Endocrinol (Lausanne) 2022; 13:989648. [PMID: 36387842 PMCID: PMC9643410 DOI: 10.3389/fendo.2022.989648] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
Osteoporotic fractures, also known as fragility fractures, are prevalent in the elderly and bring tremendous social burdens. Poor bone quality, weak repair capacity, instability, and high failure rate of internal fixation are main characteristics of osteoporotic fractures. Osteoporotic bone defects are common and need to be repaired by appropriate materials. Proximal humerus, distal radius, tibia plateau, calcaneus, and spine are common osteoporotic fractures with bone defect. Here, the consensus from the Osteoporosis Group of Chinese Orthopaedic Association concentrates on the epidemiology, characters, and management strategies of common osteoporotic fractures with bone defect to standardize clinical practice in bone repair of osteoporotic fractures.
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Affiliation(s)
- Hao Zhang
- Institute of Translational Medicine, Shanghai University, Shanghai, China
- Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yan Hu
- Institute of Translational Medicine, Shanghai University, Shanghai, China
| | - Xiao Chen
- Changhai Hospital, Naval Medical University, Shanghai, China
| | - Sicheng Wang
- Department of Orthopedics, Shanghai Zhongye Hospital, Shanghai, China
| | - Liehu Cao
- Department of Orthopedics, Shanghai Baoshan Luodian Hospital, Shanghai, China
| | - Shiwu Dong
- Department of Biomedical Materials Science, Army Medical University, Chongqing, China
| | - Zhongmin Shi
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yanxi Chen
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liming Xiong
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yunfei Zhang
- Tangdu Hospital, Air Force Medical University, Xi'an, China
| | | | - Baoqing Yu
- Department of Orthopedics, Shanghai Pudong Hospital, Shanghai, China
| | - Wenming Chen
- Institute of Biomedical Engineering, Academy for Engineering and Technology, Fudan University, Shanghai, China
| | - Qining Wang
- Department of Advanced Manufacturing and Robotics, College of Engineering, Peking University, Beijing, China
| | - Peijian Tong
- Department of Orthopedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Ximing Liu
- Department of Orthopedics, General Hospital of Central Theater Command, Wuhan, China
| | - Jianzheng Zhang
- Department of Orthopedic Surgery, People's Liberation Army (PLA), Army General Hospital, Beijing, China
| | - Qiang Zhou
- Department of Orthopedics, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Niu
- Department of Orthopedics, The First Hospital of Jilin University, Changchun, China
| | - Weiguo Yang
- Li Ka Shing Faculty of Medicine, Hongkong University, Hong Kong, Hong Kong SAR, China
| | - Wencai Zhang
- Department of Orthopedics, The Third Affiliated Hospital of Guangzhou University of Traditional Chinese medicine (TCM), Guangzhou, China
| | - Yong Wang
- Department of Orthopedics, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, China
| | - Shijie Chen
- Department of Orthopedics, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Jinpeng Jia
- Department of Orthopedics, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Qiang Yang
- Department of Orthopedics, Tianjin Hospital, Tianjin, China
| | - Peng Zhang
- Department of Orthopedics, Shandong Province Hospital, Jinan, China
| | - Yong Zhang
- Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jun Miao
- Department of Orthopedics, Tianjin Hospital, Tianjin, China
| | - Kuo Sun
- Department of Orthopedics, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tao Shen
- Department of Orthopedics, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bin Yu
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Lei Yang
- Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lei Zhang
- Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Dongliang Wang
- Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Dongliang Wang, ; Guohui Liu, ; Yingze Zhang, ; Jiacan Su,
| | - Guohui Liu
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Dongliang Wang, ; Guohui Liu, ; Yingze Zhang, ; Jiacan Su,
| | - Yingze Zhang
- Department of Orthopedics, Third Hospital of Hebei Medical University, Shijiazhuang, China
- *Correspondence: Dongliang Wang, ; Guohui Liu, ; Yingze Zhang, ; Jiacan Su,
| | - Jiacan Su
- Institute of Translational Medicine, Shanghai University, Shanghai, China
- Changhai Hospital, Naval Medical University, Shanghai, China
- *Correspondence: Dongliang Wang, ; Guohui Liu, ; Yingze Zhang, ; Jiacan Su,
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9
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Relationship between calf muscle cross-sectional area and ankle fracture. Foot Ankle Surg 2021; 27:860-864. [PMID: 33303352 DOI: 10.1016/j.fas.2020.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 10/20/2020] [Accepted: 11/23/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Whether calf muscles and peroneal muscles have a role in the occurrence of an ankle fractures remains unclear. This study aimed to quantify the calf muscle mass and peroneal muscle mass in patients with an ankle fracture and in controls, then to analyze them together with demographic factors to identify the effects of the regional muscles on the risk of developing ankle fracture. METHODS A total of 101 ankles with computed tomography (CT) images were retrospectively reviewed. Of them, 51 ankles showed fractures (all unilateral) and 50 ankles, in controls who underwent CT for screening the other diseases, were clinically diagnosed with simple contusion. The cross-sectional areas (CSA) of the calf muscles and the peroneal muscles were measured at approximately 6 cm above the Achilles myotendinous junction in the axial plane of ankle CT. These parameters were compared between the two groups and analyzed with respect to age, sex, body mass index (BMI), laterality, and bone attenuations of the ankle. RESULTS The demographic factors, including bone attenuation of the ankle showed no significant association with ankle fracture. The ratio of the CSA of the peroneal muscle group to the CSA of the entire calf muscle group was smaller in patients with an fracture (0.12 ± 0.03) than in controls (0.14 ± 0.02) (p = 0.027). The odds ratio for the effect of the calf muscle CSA on the risk of developing ankle fractures was 1.38 (95% confidence interval 1.12-1.69, p = 0.003), whereas that for the effect of peroneal muscle CSA on the risk of developing ankle fractures was 0.18 (95% confidence interval 0.05 to 0.66, p = 0.010). CONCLUSION The ratio of the peroneal muscle CSA to the entire calf muscle CSA was negatively related to the occurrence of ankle fractures in this study. Further prospective studies on whether peroneal muscle-strengthening exercise are effective in preventing ankle fractures may be needed. LEVEL OF EVIDENCE III, case-control study.
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10
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Hjelle AM, Apalset EM, Gjertsen JE, Nilsen RM, Lober A, Tell GS, Mielnik PF. Associations of overweight, obesity and osteoporosis with ankle fractures. BMC Musculoskelet Disord 2021; 22:723. [PMID: 34425796 PMCID: PMC8381556 DOI: 10.1186/s12891-021-04607-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Studies exploring risk factors for ankle fractures in adults are scarce, and with diverging conclusions. This study aims to investigate whether overweight, obesity and osteoporosis may be identified as risk factors for ankle fractures and ankle fracture subgroups according to the Danis-Weber (D-W) classification. METHODS 108 patients ≥40 years with fracture of the lateral malleolus were included. Controls were 199 persons without a previous fracture history. Bone mineral density of the hips and spine was measured by dual-energy x-ray absorptiometry, and history of previous fracture, comorbidities, medication, physical activity, smoking habits, body mass index and nutritional factors were registered. RESULTS Higher body mass index with increments of 5 gave an adjusted odds ratio (OR) of 1.30 (95% confidence interval (CI) 1.03-1.64) for ankle fracture, and an adjusted OR of 1.96 (CI 0.99-4.41) for sustaining a D-W type B or C fracture compared to type A. Compared to patients with normal bone mineral density, the odds of ankle fracture in patients with osteoporosis was 1.53, but the 95% CI was wide (0.79-2.98). Patients with osteoporosis had reduced odds of sustaining a D-W fracture type B or C compared to type A (OR 0.18, CI 0.03-0.83). CONCLUSIONS Overweight increased the odds of ankle fractures and the odds of sustaining an ankle fracture with possible syndesmosis disruption and instability (D-W fracture type B or C) compared to the stable and more distal fibula fracture (D-W type A). Osteoporosis did not significantly increase the odds of ankle fractures, thus suffering an ankle fracture does not automatically warrant further osteoporosis assessment.
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Affiliation(s)
- Anja M Hjelle
- Department of Rheumatology, Division of Medicine, District General Hospital of Førde, Førde, Norway. .,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | - Ellen M Apalset
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Bergen group of Epidemiology and Biomarkers in Rheumatic Disease (BeABird), Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | - Jan-Erik Gjertsen
- Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Roy M Nilsen
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Anja Lober
- Department of Radiology, District General Hospital of Førde, Førde, Norway
| | - Grethe S Tell
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Pawel F Mielnik
- Department of Rheumatology, Division of Medicine, District General Hospital of Førde, Førde, Norway
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11
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So E, Rushing CJ, Simon JE, Goss DA, Prissel MA, Berlet GC. Association Between Bone Mineral Density and Elderly Ankle Fractures: A Systematic Review and Meta-Analysis. J Foot Ankle Surg 2021; 59:1049-1057. [PMID: 32386919 DOI: 10.1053/j.jfas.2020.03.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 02/03/2023]
Abstract
Ankle fractures are becoming increasingly more common in the elderly population and present a significant burden to the United States health care system. Many factors have been associated with fragility ankle fractures including age, gender, body mass index, diabetes, tobacco use, and osteoporosis. However, the literature is inconsistent regarding the relationship between ankle fractures and osteoporosis. The primary aim of this meta-analysis was to quantify the relationship between bone mineral density (BMD) in elderly patients with ankle fractures compared with BMD in elderly patients without ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Data were combined using standard meta-analysis methods. Seven studies were used in the final analysis. A small-pooled effect size was found indicating the control group had increased BMD regardless of measurement used (95% confidence interval 0.09-0.58; I2 = 98.39%). Lower femoral neck BMD showed a small-pooled effect size (femoral neck 0.36; 95% confidence interval 0.00-0.73; I2 = 94.91%) with the ankle fracture cohort. This is the first meta-analysis to quantify the relationship between BMD and ankle fractures in the elderly population. Elderly ankle fractures showed a significant association with femoral neck BMD. The current data can be used in orthopedic clinics and Fracture Liaison Service programs to assign the appropriate subgroup of ankle fracture patients to investigative and treatment groups, assess fracture risk, and serve as an indication for secondary fracture prevention by stimulating an osteoporosis prevention workup. There may be a role for a team approach to fracture care including metabolic optimization.
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Affiliation(s)
- Eric So
- Foot and Ankle Surgeon, Bryan Health, Lincoln, NE.
| | | | - Janet E Simon
- Assistant Professor, Ohio University, College of Health Sciences and Professions, Athens, OH
| | - David A Goss
- Foot and Ankle Surgeon, Associates in Orthopedics and Sports Medicine, Dalton, GA
| | - Mark A Prissel
- Foot and Ankle Surgeon, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Gregory C Berlet
- Foot and Ankle Surgeon, Orthopedic Foot and Ankle Center, Worthington, OH
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Ochman S, Raschke MJ. [Ankle fractures in older patients : What should we do differently?]. Unfallchirurg 2021; 124:200-211. [PMID: 33566120 DOI: 10.1007/s00113-021-00953-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 02/07/2023]
Abstract
As a result of the demographic developments ankle fractures in older patients are part of routine trauma surgery. Due to comorbidities, such as diabetes mellitus, reduced bone quality and limited compliance in follow-up treatment, these fractures are prone to complications. The primary goal in the treatment of older patients with ankle fractures is to maintain mobility. In contrast to young patients most fractures are unstable pronation-abduction injuries. In the diagnostics the recognition and optimization of factors influencing the outcome, such as the blood perfusion and the generous use of computed tomography (CT) are recommended. As in the case of younger patients, conservative treatment is reserved for stable fracture forms and, if there are contraindications, should also be initiated in the case of unstable injuries. The choice of approaches is different for surgical treatment, which is adapted to the soft tissues, if necessary minimally invasive and increasingly carried out by a posterolateral approach. The initial transfixation can reduce soft tissue problems. Special surgical techniques and implants that provide a high level of stability, such as dorsal plate positioning, hook plates, angular stable plate systems and intramedullary systems as well as additional options, such as tibia pro fibula constructs are used. Primary retrograde nail arthrodesis is reserved as a salvage procedure only for exceptional cases. As part of the follow-up treatment, an interdisciplinary approach with respect for and optimization of concomitant diseases seems to make sense.
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Affiliation(s)
- Sabine Ochman
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert Schweitzer Campus 1, Gebäude W1, Waldeyerstr. 1, 48149, Münster, Deutschland.
| | - Michael J Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert Schweitzer Campus 1, Gebäude W1, Waldeyerstr. 1, 48149, Münster, Deutschland
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13
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Hennings R, Spiegl UJ, Fakler JKM, Ahrberg AB. The AO triangular external fixator: a backup option in the treatment of ankle fractures in geriatric patients? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:719-727. [PMID: 33156469 PMCID: PMC8053181 DOI: 10.1007/s00590-020-02740-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 07/14/2020] [Indexed: 01/06/2023]
Abstract
Purpose To analyze the indications, radiological short-term outcomes, and complications of ankle fractures in geriatric patients treated with a triangular external fixator (AEF) until fracture healing. Furthermore, the effect of an additional osteosynthesis to AEF on the radiological outcome was investigated.
Methods Retrospective analysis of ankle fractures treated in a Level I Trauma Center between 2005 and 2015 with an AEF in patients aged ≥ 65 years until fracture has healed. The combination of AEF and at least one additional osteosynthesis of a malleolus was defined as hybrid external fixator (HEF). At the time of AEF removal, a preserved ankle joint congruity was defined as good radiological outcome. Incongruity more than 2 mm was defined as poor radiologic results. Results 16 patients (13 women, 3 men) with a mean age of 74 years (SD 6.2) were treated with AEF until fracture healing, 9 with a single AEF and 7 with a HEF. Stabilization with HEF (n = 7 [100%]) showed higher rates of good radiological outcome than AEF alone (n = 4 [44%] of 9; p = 0.034). The duration of therapy did not differ between HEF and AEF (70 day vs 77 days). 4 patients (22%) required surgical revision. Conclusion It could be shown that osteosynthesis in addition to AEF leads to a better radiological short-term results than using AEF alone. Therefore, in the situation where an AEF is considered as the definitive treatment option for an ankle fracture in geriatric patients with expected or existing soft tissue problems, it should be done or completed as a HEF. Level of evidence Therapeutic level IV.
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Affiliation(s)
- Robert Hennings
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Ulrich J Spiegl
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Johannes K M Fakler
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Annette B Ahrberg
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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Is ankle fracture related to low bone mineral density and subsequent fracture? A systematic review. Osteoporos Sarcopenia 2020; 6:151-159. [PMID: 33102810 PMCID: PMC7573497 DOI: 10.1016/j.afos.2020.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 08/09/2020] [Accepted: 08/29/2020] [Indexed: 01/22/2023] Open
Abstract
Objectives Ankle fractures are common in the elderly. However, their association with osteoporosis remains controversial. This systematic review aims to determine the relationship between ankle fracture and bone mineral density (BMD), and to investigate the risk of subsequent fractures after ankle fracture. Methods MEDLINE and Scopus publications were searched from inception to March and April 2019, respectively. Articles were selected by 2 independent reviewers for cross-sectional, cohort, or case-control studies comparing BMD or subsequent fracture risk in low-energy ankle fractures patients with that of the normal population. Data extraction was performed by 2 investigators. Discrepancies were resolved with the third reviewer. Quality assessment was conducted using the modified Newcastle-Ottawa Scale. Results Overall, 19 articles were included. The quality assessment showed a generally low-to-moderate risk of bias among studies, mainly due to potential confounders and inadequate follow-up. Of 13 studies exploring BMD in ankle fractured-patients, lower central and peripheral BMD was found in 3 and 2 studies, respectively. The risk of subsequent fracture was examined in 11 studies with relative risks ranging from 0.7 to 4.59. An increased risk of any subsequent fractures in women, both genders, and men was found in 5, 2, and 1 articles, respectively. Conclusions Despite the lack of clear association with BMD, the contribution of ankle fracture to increased subsequent fracture risk and its associated microarchitectural changes cannot be overlooked. Moreover, its potential role as an early predictor of future fracture may promote secondary prevention. Further studies with longer follow-up and stricter confounder control are recommended.
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Dhillon MS, Rajnish RK, Patel S, Chouhan DK, Bansal T. Osteoporotic ankle fractures: A narrative review of management options. J Clin Orthop Trauma 2020; 11:380-387. [PMID: 32405196 PMCID: PMC7211825 DOI: 10.1016/j.jcot.2019.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Sandeep Patel
- Department of Orthopaedics, PGIMER, Chandigarh, 160012, India
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Burden of fractures in France: incidence and severity by age, gender, and site in 2016. INTERNATIONAL ORTHOPAEDICS 2020; 44:947-955. [PMID: 32036489 PMCID: PMC7190681 DOI: 10.1007/s00264-020-04492-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/20/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE Fractures are common events, but the exact incidence and severity of fractures have not been clearly determined for most anatomical sites. We estimated the incidence and severity of fractures in France regardless of the anatomical site. METHODS Observational cross-sectional study in France in 2016 based on the national health data system. All incident fractures in patients 20 years and older were included. We determined the anatomical fracture site (12 sites) and the severity using a 4-point scale (outpatient care, hospitalization, surgery, and in-hospital death). RESULTS We identified 562,094 incident fractures, predominantly occurring in women (319,858: 56.9%); with a mean age of 63.6 years, and an exponential increase after the age of 70 years. Distal upper limb (172,591: 30.7%), distal lower limb (84,602: 15.1%), and femoral neck (78,766: 14.0%) accounted for more than one-half of all fractures. Sex and age of onset distributions varied widely according to fracture sites, with earlier onset for distal lower limb fractures (mean age: 54.2 years) and distal upper limb fractures (mean age: 55.2 years) with a men predominance for skull fractures. Only 105,165 (18.7%) fractures were treated on an outpatient basis; 11,913 (2.1%) in-hospital deaths occurred in patients with a mean age of 79.5 years. High mortality was observed for skull (12.9%), rib (4.9%), and femoral fractures (femoral neck 4.3% and proximal lower limb 4.2%). CONCLUSION We estimated the incidence of fractures in France by sex and anatomical site. We also showed that fractures remain common and serious life events, especially in older people.
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McKeown R, Kearney RS, Liew ZH, Ellard DR. Patient experiences of an ankle fracture and the most important factors in their recovery: a qualitative interview study. BMJ Open 2020; 10:e033539. [PMID: 32024789 PMCID: PMC7044932 DOI: 10.1136/bmjopen-2019-033539] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The objective of this qualitative research study is to explore patient experiences of ankle fracture and the factors most important to them in recovery. DESIGN Semistructured interviews exploring patient experiences of ankle fracture recovery at 16-23 weeks following injury. Interviews followed a topic guide and were recorded with an encrypted audio recorder and then transcribed verbatim. Thematic content analysis was used to identify themes in the data. SETTING Individuals were recruited from a sample of participants of a UK-based clinical trial of immobilisation methods for ankle fracture (ISRCTN15537280 at the pre-results stage at time of writing). Interviews were conducted at the participants' own homes or on a university campus setting. PARTICIPANTS A purposive sample was used to account for key variables of age, gender and fracture management. Participants recruited from the clinical trial sample were adults aged 18 years or over with a closed ankle fracture. RESULTS Ten participants were interviewed, five of whom were female and six of whom needed an operation to fix their ankle fracture. The age range of participants was 21-75 years with a mean of 51.6 years. Eight themes emerged from the data during analysis; mobility, loss of independence, healthcare, psychological effects, social and family life, ankle symptoms, sleep disturbance and fatigue, and activities of daily living. Factors of importance to participants included regaining their independence, sleep quality and quantity, ability to drive, ability to walk without walking aids or weight-bearing restrictions, and radiological union. CONCLUSIONS The results of this research demonstrates the extensive impact of ankle fracture on individuals' lives, including social and family life, sleep, their sense of independence and psychological well-being. The results of this study will enable an increased understanding of the factors of relevance to individuals with ankle fracture, allowing collection of appropriate outcomes in clinical studies for this condition. Ultimately these results will help formulate appropriate patient-centred rehabilitation plans for these patients. TRIAL REGISTRATION NUMBER ISRCTN15537280; Pre-results.
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Affiliation(s)
- Rebecca McKeown
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Rebecca Samantha Kearney
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
- University Hospitals Coventry and Warwickshire, Coventry, West Midlands, UK
| | - Zi Heng Liew
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
- University Hospitals Coventry and Warwickshire, Coventry, West Midlands, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
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Lesnyak O, Svedbom A, Belova K, Dobrovolskaya O, Ershova O, Golubev G, Grebenshikov V, Ivanov S, Kochish A, Menshikova L, Nikitinskaya O, Nurligayanov R, Solodovnikov A, Toroptsova N, Varavko J, Zotkin E, Borgstrom F, Kanis JA. Quality of life after fragility fracture in the Russian Federation: results from the Russian arm of the International Cost and Utility Related to Osteoporotic Fractures Study (ICUROS). Arch Osteoporos 2020; 15:37. [PMID: 32124066 PMCID: PMC7051923 DOI: 10.1007/s11657-020-0699-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 02/27/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Changes in health-related quality of life (QoL) due to hip, humeral, ankle, spine, and distal forearm fracture were measured in Russian adults age 50 years or more over the first 18 months after fracture. The accumulated mean QoL loss after hip fracture was 0.5 and significantly greater than after fracture of the distal forearm (0.13), spine (0.21), proximal humerus (0.26), and ankle (0.27). INTRODUCTION Data on QoL following osteoporotic fractures in Russia are scarce. The present study evaluated the impact of hip, vertebral, proximal humerus, distal forearm, and ankle fracture up to 18 months after fracture from the Russian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study. METHODS Individuals age ≥ 50 years with low-energy-induced humeral, hip, clinical vertebral, ankle, or distal forearm fracture were enrolled. After a recall of pre-fracture status, HRQoL was prospectively collected over 18 months of follow-up using EQ-5D-3L. Multivariate regression analysis was used to identify determinants of QALYs loss. RESULTS At 2 weeks, patients with hip fracture (n = 223) reported the lowest mean health state utility value (HSUV) compared with other fracture sites. Thereafter, utility values increased but remained significantly lower than before fracture. For spine (n = 183), humerus (n = 166), and ankle fractures (n = 214), there was a similar pattern of disutility with a nadir within 2 weeks and a progressive recovery thereafter. The accumulated mean QoL loss after hip fracture was 0.5 and significantly greater than after fracture of the distal forearm (0.13), spine (0.21), proximal humerus (0.26), and ankle (0.27). Substantial impairment in self-care and usual activities immediately after fracture were important predictors of recovery across at all fracture sites. CONCLUSIONS Fractures of the hip, vertebral, distal forearm, ankle, and proximal humerus incur substantial loss of QoL in Russia. The utility values derived from this study can be used in future economic evaluations.
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Affiliation(s)
- Olga Lesnyak
- North West Mechnikov State Medical University, St. Petersburg, Russia
| | | | - Ksenia Belova
- Yaroslavl State Medical University, Yaroslavl, Russia
| | - Olga Dobrovolskaya
- grid.488825.bV.A. Nasonova Research Institute of Rheumatology named after V.A. Nasonova, Moscow, Russia
| | - Olga Ershova
- Yaroslavl State Medical University, Yaroslavl, Russia
| | - Georgij Golubev
- Rostov-on-Don State Medical University, Rostov-on-Don, Russia
| | | | - Sergej Ivanov
- The L.G. Sokolov Memorial Hospital №122, St. Petersburg, Russia
| | - Alexander Kochish
- Vreden Russian Research Institute of Traumatology and Orthopedics, St. Petersburg, Russia
| | | | - Oxana Nikitinskaya
- Research Institute of Rheumatology named after V.A. Nasonova, Moscow, Russia
| | | | | | - Natalia Toroptsova
- Research Institute of Rheumatology named after V.A. Nasonova, Moscow, Russia
| | - Julia Varavko
- grid.446313.70000 0001 0451 2298Irkutsk State Medical University, Irkutsk, Russia
| | - Eugenij Zotkin
- Research Institute of Rheumatology named after V.A. Nasonova, Moscow, Russia
| | - Fredrik Borgstrom
- grid.4714.60000 0004 1937 0626LIME/MMC, Karolinska Institutet, Stockholm, Sweden
| | - John A Kanis
- grid.411958.00000 0001 2194 1270Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK and Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
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McKeown R, Ellard DR, Rabiu AR, Karasouli E, Kearney RS. A systematic review of the measurement properties of patient reported outcome measures used for adults with an ankle fracture. J Patient Rep Outcomes 2019; 3:70. [PMID: 31848877 PMCID: PMC6917678 DOI: 10.1186/s41687-019-0159-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 11/05/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ankle fractures are painful and debilitating injuries that pose a significant burden to society and healthcare systems. Patient reported outcome measures (PROMs) are commonly used outcome measures in clinical trials of interventions for ankle fracture but there is little evidence on their validity and reliability. This systematic review aims to identify and appraise evidence for the measurement properties of ankle specific PROMs used in adults with an ankle fracture using Consensus Based Standards for the Selection of Health Measurement Instrument (COSMIN) methodology. METHODS We searched MEDLINE, Embase and CINAHL online databases for evidence of measurement properties of ankle specific PROMs. Articles were included if they assessed or described the development of the PROM in adults with ankle fracture. Articles were ineligible if they used the PROM to assess the measurement properties of another instrument. Abstracts without full articles and conference proceedings were ineligible, as were articles that adapted the PROM under evaluation without any formal justification of the changes as part of a cross-cultural validation or translation process. Two reviewers completed the screening. To assess methodological quality we used COSMIN risk of bias checklist and summarised evidence using COSMIN quality criteria and a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Two reviewers assessed the methodological quality and extracted the data for a sample of articles. RESULTS The searches returned a total of 377 articles. From these, six articles were included after application of eligibility criteria. These articles evaluated three PROMs: A-FORM, OMAS and AAOS. The A-FORM had evidence of a robust development process within the patient population, however lacks post-formulation testing. The OMAS showed sufficient levels of reliability, internal consistency and construct validity. The AAOS showed low quality evidence of sufficient construct validity. CONCLUSIONS There is insufficient evidence to support the recommendation of a particular PROM for use in adult ankle fracture research based on COSMIN methodology. Further validation of these outcome measures is required in order to ensure PROMs used in this area are sufficiently valid and reliable to assess treatment effects. This would enable high quality, evidenced-based management of adults with ankle fracture.
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Affiliation(s)
- Rebecca McKeown
- Warwick Clinical Trials Unit, Warwick Medical School, Clinical Sciences Research Laboratories, University of Warwick, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK.
| | - David R Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, Clinical Sciences Research Laboratories, University of Warwick, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Abdul-Rasheed Rabiu
- Trauma and Orthopaedics Department, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Eleni Karasouli
- Warwick Clinical Trials Unit, Warwick Medical School, Clinical Sciences Research Laboratories, University of Warwick, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Rebecca S Kearney
- Warwick Clinical Trials Unit, Warwick Medical School, Clinical Sciences Research Laboratories, University of Warwick, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
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Anderson PA, Morgan SL, Krueger D, Zapalowski C, Tanner B, Jeray KJ, Krohn KD, Lane JP, Yeap SS, Shuhart CR, Shepherd J. Use of Bone Health Evaluation in Orthopedic Surgery: 2019 ISCD Official Position. J Clin Densitom 2019; 22:517-543. [PMID: 31519473 DOI: 10.1016/j.jocd.2019.07.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 02/07/2023]
Abstract
This position development conference (PDC) Task Force examined the assessment of bone status in orthopedic surgery patients. Key questions included which orthopedic surgery patients should be evaluated for poor bone health prior to surgery and which subsets of patients are at high risk for poor bone health and adverse outcomes. Second, the reliability and validity of using bone densitometry techniques and measurement of specific geometries around the hip and knee before and after arthroplasty was determined. Finally, the use of computed tomography (CT) attenuation coefficients (Hounsfield units) to estimate bone quality at anatomic locations where orthopedic surgery is performed including femur, tibia, shoulder, wrist, and ankle were reviewed. The literature review identified 665 articles of which 198 met inclusion exclusion criteria and were selected based on reporting of methodology, reliability, or validity results. We recommend that the orthopedic surgeon be aware of established ISCD guidelines for determining who should have additional screening for osteoporosis. Patients with inflammatory arthritis, chronic corticosteroid use, chronic renal disease, and those with history of fracture after age 50 are at high risk of osteoporosis and adverse events from surgery and should have dual energy X-ray absorptiometry (DXA) screening before surgery. In addition to standard DXA, bone mineral density (BMD) measurement along the femur and proximal tibia is reliable and valid around implants and can provide valuable information regarding bone remodeling and identification of loosening. Attention to positioning, selection of regions of interest, and use of special techniques and software is required. Plain radiographs and CT provide simple, reliable methods to classify the shape of the proximal femur and to predict osteoporosis; these include the Dorr Classification, Cortical Index, and critical thickness. Correlation of these indices to central BMD is moderate to good. Many patients undergoing orthopedic surgery have had preoperative CT which can be utilized to assess regional quality of bone. The simplest method available on most picture archiving and communications systems is to simply measure a regions of interest and determine the mean Hounsfield units. This method has excellent reliability throughout the skeleton and has moderate correlation to DXA based on BMD. The prediction of outcome and correlation to mechanical strength of fixation of a screw or implant is unknown.
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Affiliation(s)
- Paul A Anderson
- Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin UWMF Centennial Building, Madison, WI, USA.
| | - Sarah L Morgan
- UAB Osteoporosis Prevention and Treatment Clinic, University of Alabama Birmingham, Birmingham, AL, USA
| | - Diane Krueger
- University of Wisconsin, Osteoporosis Clinical Research Program, Madison, WI, USA
| | | | - Bobo Tanner
- Division Rheumatology, Vanderbilt University, Nashville, TN, USA
| | - Kyle J Jeray
- Greenville Health System, Deparment of Orthopaedic Surgery, Greenville, SC, USA
| | | | - Joseph P Lane
- Department of Orthopedic Surgery, Hospital for Special surgery, New York, USA
| | | | | | - John Shepherd
- University of Hawaii Cancer Center, University of Hawaii, Honolulu, HI, USA
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Meriläinen M, Oikarinen P, Mikkonen K, Kaakinen P. Predictors of fragility fractures and osteoporosis among people over 50 years old - a retrospective cohort study. Int J Orthop Trauma Nurs 2019; 36:100709. [PMID: 31422067 DOI: 10.1016/j.ijotn.2019.100709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 07/07/2019] [Accepted: 07/31/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Merja Meriläinen
- Oulu University Hospital, The Operational Division, Box 21, 90029, OYS, Oulu, Finland.
| | - Pirjo Oikarinen
- Oulu University Hospital, The Operational Division, Department of Orthopedic Surgery, Oulu, Finland
| | - Kristina Mikkonen
- Research Unit of Nursing Science and Health Management, Medical Research Group, Box 5000, 90014, University of Oulu, Oulu, Finland.
| | - Pirjo Kaakinen
- Research Unit of Nursing Science and Health Management, Medical Research Group, Box 5000, 90014, University of Oulu, Oulu, Finland.
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Tanoğlu O, Gökgöz MB, Özmeriç A, Alemdaroğlu KB. Two-Stage Surgery for the Malleolar Fracture-Dislocation With Severe Soft Tissue Injuries Does Not Affect the Functional Results. J Foot Ankle Surg 2019; 58:702-705. [PMID: 31079983 DOI: 10.1053/j.jfas.2018.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Indexed: 02/03/2023]
Abstract
Soft tissue injuries associated with malleolar fracture-dislocations may increase postoperative rates of wound complication. Ankle-spanning frame plays a fundamental role in the local damage control orthopedics while gaining time for definitive surgery. The objective of this study was to evaluate the effect of a 2-stage surgery for the unstable malleolar fracture-dislocations with severe soft tissue injuries compared to a 1-stage surgery in terms of the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle and Olerud-Molander ankle scores (OMAS). We analyzed 45 patients who met our study criteria. The patients were divided into 2 groups according to staged surgeries. Demographic data of patients, comorbidities, alcohol and tobacco use, Tscherne soft tissue injury scores, the AOFAS hindfoot-ankle and OMAS, postoperative complications, total hospitalization times, waiting time between stages, and waiting time from admission to surgery times were investigated. There was a statistically significant difference between the groups in terms of the mean total hospitalization times (p = .007), waiting time from admission to surgery (p < .001), gender (p = .005), and Tscherne soft tissue injury scores (p < .001). The mean AOFAS hindfoot-ankle and OMAS of the groups did not differ statistically at a minimum of 12 months of the follow-up period (p = .094 and p = .126, respectively). A 2-stage surgery can be performed safely in the carefully selected patients with the unstable malleolar fracture-dislocations with Tscherne grades 2 and 3 soft tissue injuries, and this surgery does not affect the postoperative AOFAS hindfoot-ankle and OMAS statistically compared to a 1-stage surgery at a minimum of 12 months of the follow-up period.
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Affiliation(s)
- Oğuzhan Tanoğlu
- Specialist in Orthopedics, Department of Orthopedics and Traumatology, Erzincan University Mengucek Gazi Research and Training Hospital, Erzincan, Turkey.
| | - Mehmet Burak Gökgöz
- Resident Doctor in Orthopedics, Department of Orthopedics and Traumatology, University of Health Sciences, Ankara Research and Training Hospital, Ankara, Turkey
| | - Ahmet Özmeriç
- Associate Professor in Orthopedics, Department of Orthopedics and Traumatology, University of Health Sciences, Ankara Research and Training Hospital, Ankara, Turkey
| | - Kadir Bahadır Alemdaroğlu
- Professor in Orthopedics, Department of Orthopedics and Traumatology, University of Health Sciences, Ankara Research and Training Hospital, Ankara, Turkey
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Hoffmeyer P, Miozzari H, Holzer N. Non-hip/non-vertebral fractures - How to treat best? Best Pract Res Clin Rheumatol 2019; 33:236-263. [PMID: 31547981 DOI: 10.1016/j.berh.2019.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.
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Affiliation(s)
- Pierre Hoffmeyer
- Swiss Foundation for Innovation and Training in Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1205, Switzerland.
| | - Hermes Miozzari
- Department of Orthopaedics, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1205, Switzerland.
| | - Nicolas Holzer
- Department of Orthopaedics, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1205, Switzerland.
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Sung KH, Kwon SS, Yun YH, Park MS, Lee KM, Nam M, Jung JH, Lee SY. Short-Term Outcomes and Influencing Factors After Ankle Fracture Surgery. J Foot Ankle Surg 2019; 57:1096-1100. [PMID: 30146336 DOI: 10.1053/j.jfas.2018.03.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Ki Hyuk Sung
- Assistant Professor, Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea
| | - Soon-Sun Kwon
- Assistant Professor, Department of Mathematics, College of Natural Science, Ajou University, Gyeonggi, Republic of Korea
| | - Yeo-Hon Yun
- Professor, Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Moon Seok Park
- Professor, Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea
| | - Kyoung Min Lee
- Associate Professor, Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea
| | - Muhyun Nam
- Orthopedist, Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Jae Hong Jung
- Orthopedist, Joeun Orthopaedic Clinic, Gyeonggi, Republic of Korea
| | - Seung Yeol Lee
- Clinical Associate Professor, Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea.
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Juto H, Nilsson H, Morberg P. Epidemiology of Adult Ankle Fractures: 1756 cases identified in Norrbotten County during 2009-2013 and classified according to AO/OTA. BMC Musculoskelet Disord 2018; 19:441. [PMID: 30545314 PMCID: PMC6293653 DOI: 10.1186/s12891-018-2326-x] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 10/29/2018] [Indexed: 01/15/2023] Open
Abstract
Background The ankle fracture is one of the most common fractures, increasing in an ageing population, but not generally seen as an osteoporotic fracture. The aim of this study was to examine the relationship between different AO/OTA classes of ankle fractures, age, sex and type of trauma. Methods Ankle fractures, treated at any of the hospitals in Norrbotten County in Sweden between 2009 and 2013, were retrospectively identified and classified according to the AO/OTA-classification system. Information about the trauma mechanism was also obtained. Results In Norrbotten County, 1756 ankle fractures in 1735 patients aged 20 years or older were identified. This gave an incidence in the county of 179 per 100,000 person-years. Of these patients, 34.6% were 65 years or older, 58.4% were women and 68.2% of the trauma leading to a fracture was defined as low-energy. In 1.5% of the cases the fractures were open. Incidences of type B fractures increased substantially with age, from 62 (95% CI 50–77) at 30–39 years of age to 158 (95% CI 131–190) in patients older than 80 years of age per 100,000 person-years. Type B fractures showed a slightly higher proportion of low-energy trauma while type C showed a lower mean age and proportion of women. Conclusions This study shows an incidence of 179 adult ankle fractures annually per 100,000 persons. More than two thirds of the fractures were caused by a low-energy trauma and ankle fractures are more frequent among females. Females generally have an increased incidence during their life, mainly between the ages of 30 and 60. This is in contrast to men who have more of an even distribution throughout their life. Classification according to AO/OTA reveals some heterogeneity among the classes of ankle fractures in age and gender as well as the energy involved in the trauma.
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Affiliation(s)
- Hans Juto
- Sunderby Research Unit, Department of Surgical and Perioperative Sciences (orthopaedics), Umeå University, Umeå, Sweden.
| | - Helena Nilsson
- Sunderby Research Unit, Department of Surgical and Perioperative Sciences (orthopaedics), Umeå University, Umeå, Sweden
| | - Per Morberg
- Sunderby Research Unit, Department of Surgical and Perioperative Sciences (orthopaedics), Umeå University, Umeå, Sweden
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Sung KH, Choi Y, Cho GH, Chung CY, Park MS, Lee KM. Peripheral DXA measurement around ankle joint to diagnose osteoporosis as assessed by central DXA measurement. Skeletal Radiol 2018; 47:1111-1117. [PMID: 29404660 DOI: 10.1007/s00256-018-2876-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 12/22/2017] [Accepted: 01/02/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study evaluated the correlation between central and peripheral bone mineral density (BMD) of the ankle joint, using dual-energy X-ray absorptiometry (DXA). We also investigated whether peripheral ankle BMD could be used to identify individuals who were diagnosed with osteoporosis, using central DXA. METHODS We recruited 134 volunteers aged 20-90 years who agreed to participate in this study. Central BMD of the lumbar spine and left femur, and peripheral BMD of the medial malleolus, distal tibia, lateral malleolus, and talus were measured with DXA. RESULTS Among the peripheral sites of the ankle, the highest and lowest BMD were observed in the talus and lateral malleolus, respectively. All peripheral DXA measurements of the ankle joint were significantly correlated with central DXA measurements. There was a good correlation (r: 0.656-0.725) between peripheral and central BMD for the older age group (> 50 years), but fair-to-good correlation (r: 0.263-0.654) for the younger age group (< 50 years). The cut-off values for peripheral BMD of the ankle joint between osteoporosis and non-osteoporosis were 0.548 g/cm2 (sensitivity, 89.0%; specificity, 69.0%) for the medial malleolus, 0.626 g/cm2 (sensitivity, 83.3%; specificity, 82.8%) for the distal tibia, 0.47 g/cm2 (sensitivity, 100.0%; specificity, 65.5%) for the lateral malleolus, and 0.973 g/cm2 (sensitivity, 72.2%; specificity, 83.6%) for the talus (p < 0.001). CONCLUSIONS This study showed good correlation between peripheral BMD around ankle joint and central BMD for older age group. Further study is required to use the ankle DXA as a valid clinical tool for the diagnosis of osteoporosis and fracture risk assessment.
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Affiliation(s)
- Ki Hyuk Sung
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, Gyeonggi, 13620, South Korea
| | - Young Choi
- Department of Orthopaedic Surgery, Kosin University Gaspel Hospital, Busan, South Korea
| | - Gyeong Hee Cho
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, Gyeonggi, 13620, South Korea
| | - Chin Youb Chung
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, Gyeonggi, 13620, South Korea
| | - Moon Seok Park
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, Gyeonggi, 13620, South Korea.
| | - Kyoung Min Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, Gyeonggi, 13620, South Korea
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Functional assessment of transplantar nailing for ankle fracture in the elderly: 48 weeks' prospective follow-up of 14 patients. Orthop Traumatol Surg Res 2018; 104:507-510. [PMID: 29654935 DOI: 10.1016/j.otsr.2018.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 02/26/2018] [Accepted: 03/20/2018] [Indexed: 02/02/2023]
Abstract
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.
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Harding BN, Weiss NS, Walker RL, Larson EB, Dublin S. Proton pump inhibitor use and the risk of fractures among an older adult cohort. Pharmacoepidemiol Drug Saf 2018; 27:596-603. [PMID: 29493043 PMCID: PMC5984154 DOI: 10.1002/pds.4406] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 01/13/2018] [Accepted: 01/17/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of the study is to determine if the use of a proton pump inhibitor (PPI) is associated with an increased fracture risk, as some prior studies have suggested. METHODS This retrospective cohort study included data on 4438 participants aged 65 and older who had no fracture in the year prior to baseline and had ≥5 years of enrollment history in Kaiser Permanente Washington, an integrated healthcare delivery system in Seattle, WA, during 1994 to 2014. Time-varying cumulative exposure to PPIs was determined from automated pharmacy data by summing standard daily doses (SDDs) across fills, and patients were categorized as no use (reference group, ≤30 SDD), light use (31-540 SDD), moderate use (541-1080 SDD), and heavy use (≥1081 SDD). Incident fractures were assessed using International Classification of Diseases, Ninth Revision codes from electronic medical records. Potential confounders, chosen a priori, were assessed at baseline and at each 2-year follow-up visit. Fracture risk was analyzed using a Cox proportional hazards model. RESULTS Over a mean follow-up of 6.1 years, 802 (18.1%) participants experienced a fracture. No overall association was found between PPI use and fracture risk. Adjusted hazard ratios comparing users to the referent category were 1.08 (95% CI 0.83-1.40) for light users, 1.31 (95% CI 0.86-1.95) for moderate users, and 0.95 (95% CI 0.68-1.34) for heavy users. Among patients with SSD > 30, no appreciable increase in fracture risk was present in persons with recent versus distant use (adjusted hazard ratio of 1.14 [95% CI 0.91-1.42]). CONCLUSIONS No association was observed between PPI use and fracture risk among older adults.
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Affiliation(s)
- Barbara N Harding
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Noel S Weiss
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Rod L Walker
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Sascha Dublin
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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González Quevedo D, Sánchez Siles JM, Rojas Tomba F, Tamimi Mariño I, Bravo Bardaji MF, Villanueva Pareja F. Blisters in Ankle Fractures: A Retrospective Cohort Study. J Foot Ankle Surg 2018. [PMID: 28633769 DOI: 10.1053/j.jfas.2017.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The most frequent postoperative complications after an ankle fracture are usually skin related. We present the results of a retrospective study of 112 patients with ankle fracture who had undergone open reduction and internal fixation from January 2014 to December 2014. The following features were analyzed: patient comorbidities, fracture type, the presence of an open fracture or fracture-dislocation, timing and duration of surgery, preoperative glucose level, and short-term complications (i.e., blisters, wound dehiscence, deep and superficial infections, and reintervention). The mean age of the patients was 50.38 years. Fracture blisters were present in 20.5% of the cases. The operative time was 75.74 ± 25.09 minutes for patients with blisters and 64.48 ± 19.73 minutes for patients without blisters (p = .023). The preoperative blood glucose levels were 122.96 ± 28.46 g/dL in the patients with blisters and 106.70 ± 21.32 g/dL in the patients without blisters (p = .003). No statistically significant differences were observed between the patients who had undergone surgery <24 hours after injury and those who had done so >24 hours after injury. In conclusion, the presence of postoperative blisters in patients with ankle fractures was associated with prolonged surgical procedures and high serum glucose levels.
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Affiliation(s)
- David González Quevedo
- Surgeon, Department of Orthopedic Surgery and Traumatology, Regional University Hospital of Málaga, Málaga, Spain.
| | - Juan Manuel Sánchez Siles
- Surgeon, Department of Orthopedic Surgery and Traumatology, Regional University Hospital of Málaga, Málaga, Spain
| | - Facundo Rojas Tomba
- Surgeon, Department of Orthopedic Surgery and Traumatology, Regional University Hospital of Málaga, Málaga, Spain
| | - Iskandar Tamimi Mariño
- Surgeon, Department of Orthopedic Surgery and Traumatology, Regional University Hospital of Málaga, Málaga, Spain
| | | | - Francisco Villanueva Pareja
- Chief, Department of Orthopedic Surgery and Traumatology, Regional University Hospital of Málaga, Málaga, Spain
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Lee DO, Kim JH, Yoo BC, Yoo JH. Is osteoporosis a risk factor for ankle fracture?: Comparison of bone mineral density between ankle fracture and control groups. Osteoporos Sarcopenia 2017; 3:192-194. [PMID: 30775529 PMCID: PMC6372814 DOI: 10.1016/j.afos.2017.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 11/16/2022] Open
Abstract
Objectives There remains controversy over osteoporotic feature of the ankle. Therefore, we investigated the possibility of the existence of a relationship between axial bone mineral density (BMD) in patients with ankle fracture group with that of the normal population in Korea under control of other confounding factors such as body mass index (BMI). Methods This study retrospectively reviewed medical records of patients who were treated in our institution from 2005 to 2015. A comparative analysis was carried out between 116 patients with ankle fracture (ankle fracture group) and 113 patients admitted with other orthopedic reasons (control group). Sex, age, energy level of trauma, and BMI were analyzed as variables affecting axial BMD. Results Age and sex of ankle fracture group were not different from them of control group (P = 0.968 and P = 0.870, respectively). BMI of ankle fracture group was higher than that of control (P = 0.029). The other variables showed no differences between the 2 groups. The energy level of trauma in ankle fracture group was related to only BMI (P = 0.013). Conclusions Axial BMD of ankle fracture patients showed no difference from that of a control group in Korean population. The occurrence of ankle fracture is affected by only BMI rather than axial BMD. Evaluation of osteoporosis for patients with ankle fracture should be considered separately.
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Affiliation(s)
| | | | | | - Jeong-Hyun Yoo
- Corresponding author. Department of Orthopedic Surgery, Myongji Hospital, 55 Hwasu-ro 14beon-gil, Deokyang-gu, Goyang 10475, Korea.
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Park SC, Gong HS, Kim K, Lee SH, Kim S, Baek GH. Olecranon Fractures Have Features of Osteoporotic Fracture. J Bone Metab 2017; 24:175-181. [PMID: 28955693 PMCID: PMC5613022 DOI: 10.11005/jbm.2017.24.3.175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/09/2017] [Accepted: 08/11/2017] [Indexed: 11/11/2022] Open
Abstract
Background To determine whether olecranon fractures have osteoporotic features such as age-dependent, low bone attenuation and low-energy trauma as a cause of injury. Methods Elbow computed tomography (CT) and medical record review were performed in 114 patients (53 males and 61 females) with acute olecranon fractures. The mean age was 57 years. Bone attenuation was measured on the central part of the olecranon on sagittal CT images avoiding the fracture, and on the distal humerus (distal metaphysis and medial and lateral condyles) on coronal CT images. We compared bone attenuation and causes of injury (high or low energy trauma) between younger (<50 years) and older (≥50 years) patients in each gender. Multiple regression analysis was performed to determine the effect of age and gender on bone attenuation. Results Mean bone attenuation in older male and female patients was significantly lower than in younger patients, except at the medial condyle in men. The proportion of low-energy trauma in older male patients was significantly higher than in younger male patients. In female patients, low-energy trauma was predominant in both younger and older patients. Age and female gender had significantly negative effects on bone attenuation. Conclusions This study demonstrated that olecranon fractures have osteoporotic features, including age-dependent low bone attenuation and low-energy trauma as the predominant cause of injury. Our results suggest that osteoporosis evaluation should be considered for patients aged 50 years or more with olecranon fractures.
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Affiliation(s)
- Seong Cheol Park
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Sik Gong
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kahyun Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Hoo Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sehun Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Goo Hyun Baek
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
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Abstract
The incidence and severity of ankle fractures in elderly patients is increasing steadily. These injuries are challenging to treat and prone to complications. Individual fracture treatment is tailored depending on bone quality, skin conditions, comorbidities, and functional demand of the patient. This article provides a review of current techniques to obtain stable fixation despite poor bone quality. To avoid complications, it is imperative to consider and treat comorbidities such as diabetes and osteoporosis. In the absence of severe systemic comorbidities, the results after open reduction and internal fixation of malleolar fractures in patients above and below 60 years of age are nearly identical, while nonoperative treatment of unstable fractures leads to significantly inferior outcomes. Therefore, the general indications for surgery in elderly patients should not differ from those in younger patients. However, it is essential to detect severe conditions such as Charcot neuro-osteoarthropathy because these require a completely different treatment regime, and standard internal fixation will invariably fail in these patients.
Cite this article: Rammelt S. Management of ankle fractures in the elderly. EFORT Open Rev 2016;1:239-246. DOI: 10.1302/2058-5241.1.000023.
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Affiliation(s)
- Stefan Rammelt
- University Center of Orthopaedics & Traumatology, University Hospital Carl Gustav Carus, Dresden, Germany
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Sung KH, Chung CY, Lee KM, Lee J, Chung MK, Cho BC, Moon SJ, Park MS. Correlation Between Central and Peripheral Bone Mineral Density Around the Elbow Measured by Dual-Energy X-Ray Absorptiometry in Healthy Children and Adolescents. J Clin Densitom 2017; 20:114-119. [PMID: 27210802 DOI: 10.1016/j.jocd.2016.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 11/21/2022]
Abstract
This pilot study was performed to evaluate the correlation between central bone mineral density (BMD) and peripheral BMD around the elbow in children and adolescents and to compare BMD values across skeletal sites. Twenty-seven healthy volunteers between 5 and 18 yr of age were recruited for the study. Anthropometric measurements including height and weight were performed. Central BMD at the lumbar spine and left femur and peripheral BMD at the supracondylar area, medial condyle, lateral condyle, and olecranon were measured using dual-energy X-ray absorptiometry (DXA). Higher BMD levels were found in the central skeleton (lumbar spine and femur) than in peripheral sites around the elbow (p < 0.001). BMD values around the elbow ranged from 44.4% to 63.2% compared to the BMD values of the central skeleton. Among the peripheral sites around the elbow, the highest BMD was observed at the supracondylar area and olecranon, and the lowest BMD was found at the lateral condyle. Peripheral DXA measurements around the elbow were significantly correlated with central DXA measurements at the lumbar spine and femur. In conclusion, this study demonstrated that the measurements of BMD around the elbow were correlated with BMD at central sites. Given the small sample size in this pilot study, further study with a large cohort is required to use the BMD measurements around the elbow as a valid clinical tool for fracture risk assessment and population-based epidemiological studies.
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Affiliation(s)
- Ki Hyuk Sung
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, Republic of Korea
| | - Chin Youb Chung
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, Republic of Korea
| | - Kyoung Min Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, Republic of Korea
| | - Jaebong Lee
- Medical Research Collaboration Center, Seoul National University Bundang Hospital, Kyungki, Republic of Korea
| | - Myung Ki Chung
- Department of Orthopaedic Surgery, Kangwon National University Hospital, Kangwon, Republic of Korea
| | - Byung Chae Cho
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, Republic of Korea
| | - Seung Jun Moon
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, Republic of Korea
| | - Moon Seok Park
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, Republic of Korea.
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Lee SY, Kwon SS, Kim TH, Shin SJ. Is central skeleton bone quality a predictor of the severity of proximal humeral fractures? Injury 2016; 47:2777-2782. [PMID: 27802889 DOI: 10.1016/j.injury.2016.10.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 10/14/2016] [Accepted: 10/16/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The objectives of this study were to evaluate the correlation between bone attenuation around the shoulder joint assessed on conventional computed tomography (CT) and bone mineral density (BMD) based on dual-energy X-ray absorptiometry (DEXA) of the central skeleton and the correlation between the bone quality around the shoulder joint and the severity of the fracture pattern of the proximal humerus. MATERIALS AND METHODS A total of 200 patients with proximal humeral fracture who underwent preoperative 3-dimensional shoulder CT as well as DEXA within 3 months of the CT examination were included. Fracture types were divided into simple and comminuted fracture based on the Neer classification. After reliability testing, bone attenuation of the glenoid, three portions of the humeral head, and metaphysis was measured by placing a circular region of interest on the center of each bony region on CT images. Partial correlation analysis was used to assess the correlation between the bone quality around the shoulder joint on CT and the BMD on the central skeleton after adjusting for age and body mass index. Partial correlations between fracture classification and CT/DEXA results were also evaluated. RESULTS Bone attenuation measurements of the glenoid and humeral head showed good to excellent reliability (intraclass correlation coefficient, 0.623-0.998). Bone attenuation of the central portion of the humeral head on CT showed a significant correlation with the BMD of L1, L4, the femoral neck, and femoral trochanter (correlation coefficient, 0.269-0.431). Bone attenuation of other areas showed a lower correlation with BMD by DEXA. As the level of the Neer classification increased from a 2 to 4-part fracture, bone attenuation of the central humeral head decreased significantly (r=-0.150, p=0.034). However, the BMD on DEXA was not a predictive factor for comminuted fracture of the proximal humerus. CONCLUSIONS DEXA examination of the central skeleton may not reflect the bone quality of the proximal humerus and severity of proximal humeral fracture. Direct assessment of the bone quality of the proximal humerus is recommended to determine the osteoporotic nature of the fracture.
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Affiliation(s)
- Seung Yeol Lee
- Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul, South Korea
| | - Soon-Sun Kwon
- Department of Mathematics, College of Natural Science, Ajou University, Gyeonggi, South Korea
| | - Tae Hoon Kim
- Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul, South Korea
| | - Sang-Jin Shin
- Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul, South Korea.
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Gavrilă TM, Cristea Ș. Management of nonunion after an old - neglected ankle fracture in diabetic patient; case report. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2016. [DOI: 10.25083/2559.5555.12.7478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Ankle fractures represent 9% of fractures. Even if it is a relatively usual fracture, the presence of diabetes makes treatment more difficult and rate of complications is higher than in the rest of population. The incidence of ankle fractures increased in the last half century. Many studies from SUA, England, Sweden and Finland suggest that the epidemiology of ankle fractures continues to change as populations age, up to the age 60 of years in men and above age of 50 years in women. Two-thirds of fractures are isolated malleolar fractures, bimalleolar fractures occur in one-fourth of patients and trimaleolar fractures occur in the rest of them. We present a case of 60 years old women with non-insulin dependent diabetes for 22 years who sustained a fracture of ankle. Her first presentation at doctor was after 4 months after injury and surgical treatment occurred after 8 months after the injury. She was operated using an external fixator. Despite the fact the treatment was delayed, the evolution of lesion was good and patient could regained normal gate.
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Lee SY, Park MS, Kwon SS, Sung KH, Jung HS, Lee KM. Influence of ankle fracture surgery on glycemic control in patients with diabetes. BMC Musculoskelet Disord 2016; 17:137. [PMID: 27005680 PMCID: PMC4804547 DOI: 10.1186/s12891-016-0987-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 03/16/2016] [Indexed: 12/17/2022] Open
Abstract
Background Although ankle fracture surgery can affect glycemic control by either trauma-induced stress or a postoperative decrease in physical activity, there is little evidence on this issue. This study aimed to evaluate the influence of ankle fracture surgery on glycemic control and to assess the risk factors for poor glycemic control after surgery in patients with diabetes. Methods We reviewed the medical records of consecutive patients with diabetes who underwent open reduction and internal fixation for the treatment of ankle fracture at our hospital. Patients who underwent blood testing, including fasting blood glucose (FBG), glycated hemoglobin (HbA1c), and cholesterol levels, as part of a routine check-up before surgery and again more than 2 times after surgery were included. Changes in blood test results were adjusted by multiple factors using a linear mixed model with sex, age at time of surgery, body mass index (BMI), and type of ankle fracture as the fixed effects and each subject and timing of blood test as the random effects. Results Sixty patients were ultimately included in this study. At 1 month postoperatively, mean FBG and cholesterol levels had increased significantly compared with preoperative levels (p = 0.011 and 0.024, respectively). After surgery, FBG levels showed an estimated monthly decrease of 2.2 mg/dL (p = 0.017). Sex, age at time of surgery, and type of ankle fracture did not significantly affect the monthly change in FBG level. FBG returned to the preoperative level at an estimated period of 8.1 months. BMI significantly affected preoperative FBG level (p = 0.015) but not the postoperative change in FBG level (p = 0.500). Conclusion Ankle fracture surgery increased the FBG level at 1 month postoperatively. FBG levels decreased gradually after surgery at an estimated monthly rate of 2.2 mg/dL. Physicians should be aware of the difficulty in postoperative blood glucose control in patients with diabetes, even several months after surgery.
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Affiliation(s)
- Seung Yeol Lee
- Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Moon Seok Park
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soon-Sun Kwon
- Department of Mathematics, College of Natural Science, Ajou University, Suwon, Republic of Korea
| | - Ki Hyuk Sung
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyun Soo Jung
- Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Kyoung Min Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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Yoo JH, Moon SH, Ha YC, Lee DY, Gong HS, Park SY, Yang KH. Osteoporotic Fracture: 2015 Position Statement of the Korean Society for Bone and Mineral Research. J Bone Metab 2015; 22:175-81. [PMID: 26713308 PMCID: PMC4691591 DOI: 10.11005/jbm.2015.22.4.175] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 11/11/2022] Open
Abstract
Osteoporotic fractures are one of the most common causes of disability and a major contributor to medical care costs worldwide. Prior osteoporotic fracture at any site is one of the strongest risk factors for a new fracture, which occurs very soon after the first fracture. Bone mineral density (BMD) scan, a conventional diagnostic tool for osteoporosis, has clear limitations in diagnosing osteoporotic fractures and identifying the risk of subsequent fractures. Therefore, early and accurate diagnosis of osteoporotic fractures using the clinical definition which is applicable practically and independent of BMD, is essential for preventing subsequent fractures and reducing the socioeconomic burden of these fractures. Fractures caused by low-level trauma equivalent to a fall from a standing height or less at major (hip, spine, distal radius, and proximal humerus) or minor (pelvis, sacrum, ribs, distal femur and humerus, and ankle) sites in adults over age 50, should be first regarded as osteoporotic. In addition, if osteoporotic fractures are strongly suspected on history and physical examination even though there are no positive findings on conventional X-rays, more advanced imaging techniques such as computed tomography, bone scan, and magnetic resonance imaging are necessary as soon as possible.
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Affiliation(s)
- Je-Hyun Yoo
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Seong-Hwan Moon
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Dong Yeon Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Sik Gong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Si Young Park
- Department of Orthopaedic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kyu Hyun Yang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
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Biver E, Durosier C, Chevalley T, Herrmann FR, Ferrari S, Rizzoli R. Prior ankle fractures in postmenopausal women are associated with low areal bone mineral density and bone microstructure alterations. Osteoporos Int 2015; 26:2147-55. [PMID: 25851699 DOI: 10.1007/s00198-015-3119-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 03/23/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED In a cross-sectional analysis in postmenopausal women, prior ankle fractures were associated with lower areal bone mineral density (BMD) and trabecular bone alterations compared to no fracture history. Compared to women with forearm fractures, microstructure alterations were of lower magnitude. These data suggest that ankle fractures are another manifestation of bone fragility. INTRODUCTION Whether ankle fractures represent fragility fractures associated with low areal bone mineral density (aBMD) and volumetric bone mineral density (vBMD) and/or bone microstructure alterations remains unclear, in contrast to the well-recognised association between forearm fractures and osteoporosis. The objective of this study was to investigate aBMD, vBMD and bone microstructure in postmenopausal women with prior ankle fracture in adulthood, compared with women without prior fracture or with women with prior forearm fractures, considered as typically of osteoporotic origin. METHODS In a cross-sectional analysis in the Geneva Retirees Cohort study, 63 women with ankle fracture and 59 with forearm fracture were compared to 433 women without fracture (mean age, 65 ± 1 years). aBMD was measured by dual-energy X-ray absorptiometry; distal radius and tibia vBMD and bone microstructure were measured by high-resolution peripheral quantitative computed tomography. RESULTS Compared with women without fracture, those with ankle fractures had lower aBMD, radius vBMD (-7.9%), trabecular density (-10.7%), number (-7.3%) and thickness (-4.6%) and higher trabecular spacing (+14.5%) (P < 0.05 for all). Tibia trabecular variables were also altered. For 1 standard deviation decrease in total hip aBMD or radius trabecular density, odds ratios for ankle fractures were 2.2 and 1.6, respectively, vs 2.2 and 2.7 for forearm fracture, respectively (P ≤ 0.001 for all). Compared to women with forearm fractures, those with ankle fractures had similar spine and hip aBMD, but microstructure alterations of lower magnitude. CONCLUSION Women with ankle fractures have lower aBMD and vBMD and trabecular bone alterations, suggesting that ankle fractures are another manifestation of bone fragility.
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Affiliation(s)
- E Biver
- Division of Bone Diseases, Department of Internal Medicine Specialties, Faculty of Medicine, Geneva University Hospitals, 4 Rue Gabrielle Perret-Gentil, 1211, Geneva 14, Switzerland,
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Lee SY, Kwon SS, Kim HS, Yoo JH, Kim J, Kim JY, Min BC, Moon SJ, Sung KH. Reliability and validity of lower extremity computed tomography as a screening tool for osteoporosis. Osteoporos Int 2015; 26:1387-94. [PMID: 25592134 DOI: 10.1007/s00198-014-3013-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/17/2014] [Indexed: 01/22/2023]
Abstract
UNLABELLED We evaluated the correlation between central bone mineral density (BMD) and peripheral bone attenuation using lower extremity computed tomography (CT). A good correlation was found between lower extremity CT and central BMD suggesting that CT is useful for screening osteoporosis, and that peripheral bone attenuation adequately reflects central BMD. INTRODUCTION This study aimed to evaluate the reliability and validity of CT as a screening tool for osteoporosis and to estimate the correlation between central BMD and peripheral bone attenuation using lower extremity CT. METHODS In total, 292 patients who underwent a lower extremity, lumbar spine, or abdomen and pelvic CT scan within a 3-month interval of a dual-energy X-ray absorptiometry (DEXA) examination were included. Following reliability testing, bone attenuation of the L1, L2, L3, L4, femoral head, femoral neck, greater trochanter, distal femur, proximal tibia, distal tibia, and talus was measured by placing a circular region of interest on the central part of each bony region on a coronal CT image. Partial correlation was used to assess the correlation between CT and DEXA after adjusting for age and body mass index. RESULTS In terms of reliability, all bone attenuation measurements, except the femoral neck, showed good to excellent interobserver reliability (intraclass correlation coefficients, 0.691-0.941). In terms of validity, bone attenuation of the L1 to L4, femoral neck, and greater trochanter on CT showed significant correlations with BMD of each area on DEXA (correlation coefficients, 0.399-0.613). Bone attenuation of the distal tibia and talus on CT showed significant correlations with BMD of all parts on DEXA (correlation coefficients, 0.493-0.581 for distal tibia, 0.396-0.579 for talus). CONCLUSION Lower extremity CT is a useful screening tool for osteoporosis, and peripheral bone attenuation on lower extremity CT adequately reflects central BMD on DEXA.
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Affiliation(s)
- S Y Lee
- Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul, South Korea
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Cawsey S, Padwal R, Sharma AM, Wang X, Li S, Siminoski K. Women with severe obesity and relatively low bone mineral density have increased fracture risk. Osteoporos Int 2015; 26:103-11. [PMID: 25182230 DOI: 10.1007/s00198-014-2833-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 07/29/2014] [Indexed: 12/29/2022]
Abstract
UNLABELLED Among women with obesity, those with the lowest bone density have the highest fracture risk. The types of fractures include any fracture, fragility-type fractures (vertebra, hip, upper arm, forearm, and lower leg), hand and foot fractures, osteoporotic, and other fracture types. INTRODUCTION Recent reports have contradicted the traditional view that obesity is protective against fracture. In this study, we have evaluated the relationship between fracture history and bone mineral density (BMD) in subjects with obesity. METHODS Fracture risk was assessed in 400 obese women in relation to body mass index (BMI), BMD, and clinical and laboratory variables. RESULTS Subjects (mean age, 43.8 years; SD, 11.1 years) had a mean BMI of 46.0 kg/m(2) (SD, 7.4 kg/m(2)). There were a total of 178 self-reported fractures in 87 individuals (21.8% of subjects); fragility-type fractures (hip, vertebra, proximal humerus, distal forearm, and ankle/lower leg) were present in 58 (14.5%). There were higher proportions of women in the lowest femoral neck BMD quintile who had any fracture history (41.3 vs. 17.2%, p < 0.0001), any fragility-type fractures (26.7 vs. 11.7%, p = 0.0009), hand and foot fractures (16.0 vs. 5.5%, p = 0.002), other fracture types (5.3 vs. 1.2%, p = 0.02), and osteoporotic fractures (8.0 vs. 1.2%, p < 0.0001) compared to the remaining population. The odds ratio for any fracture was 0.63 (95% CI, 0.49-0.89; p = 0.0003) per SD increase in BMD and was 4.3 (95% CI, 1.9-9.4; p = 0.003) in the lowest BMD quintile compared to the highest quintile. No clinical or biochemical predictors of fracture risk were identified apart from BMD. CONCLUSIONS Women with obesity who have the lowest BMD values, despite these being almost normal, have an elevated risk of fracture compared to those with higher BMD.
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Affiliation(s)
- S Cawsey
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, 362 Heritage Medical Building, Edmonton, AB, Canada, T6G 2S2,
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Early ankle movement versus immobilization in the postoperative management of ankle fracture in adults: a systematic review and meta-analysis. J Orthop Sports Phys Ther 2014; 44:690-701, C1-7. [PMID: 25098197 DOI: 10.2519/jospt.2014.5294] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVES To compare early ankle movement versus ankle immobilization after surgery for ankle fracture on clinical and patient-reported outcomes. BACKGROUND A significant proportion of patients undergoing surgery for ankle fracture experience postoperative complications and delayed return to function. The risks and benefits of movement of the ankle in the first 6 weeks after surgery are not known, and clinical practice varies widely. METHODS We searched bibliographic databases and reference lists to identify eligible trials. Two independent reviewers conducted data extraction and risk-of-bias assessments. RESULTS Fourteen trials (705 participants) were included in the review, 11 of which were included in the meta-analysis. The quality of the trials was universally poor. The pooled effect of early ankle movement on function at 9 to 12 weeks after surgery compared to immobilization was inconclusive (standardized mean difference, 0.46; 95% confidence interval: -0.02, 0.93; P = .06; I(2) = 72%), and no differences were observed between groups at 1 year. The odds of venous thromboembolism were significantly lower with early ankle movement compared to immobilization (Peto odds ratio = 0.12; 95% confidence interval: 0.02, 0.71; P = .02; I(2) = 0%). Deep surgical site infection (Peto odds ratio = 7.08; 95% confidence interval: 1.39, 35.99; P = .02; I(2) = 0%), superficial surgical site infection, fixation failure, and reoperation to remove metalwork were more common after early ankle movement compared to immobilization. CONCLUSION The quality of evidence is poor. The effects of early movement after ankle surgery on short-term functional outcomes are unclear, but there is no observable difference in the longer term. There is a small reduction in risk of postoperative thromboembolism with early ankle movement. Current evidence suggests that deep and superficial surgical site infections, fixation failure, and the need to remove metalwork are more common after early ankle movement. Level of Evidence Therapy, level 1a-.
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Ankle fractures in elderly patients. Aging Clin Exp Res 2013; 25 Suppl 1:S77-9. [PMID: 24046044 DOI: 10.1007/s40520-013-0076-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 06/17/2013] [Indexed: 10/26/2022]
Abstract
The incidence of ankle fractures (AFs) in the elderly is rising due to the increase in life expectancy. Rather than directly related to osteoporosis, AFs are a predictor of osteoporotic fractures in other sites. In women AFs are associated with weight and BMI. AFs are difficult to categorize; therapeutic options are non-operative treatment with plaster casts or surgical treatment with Kirschner's wires, plates and screws. The choice of treatment should be based not only on the fracture type but also on the local and general comorbidity of the patient. Considering the new evidence that postmenopausal women with AFs have disrupted microarchitecture and decreased stiffness of the bone compared with women with no fracture history, in our opinion low-trauma AFs should be considered in a similar way to the other classical osteoporotic fractures.
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