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

Complications following surgical treatment of ankle fractures in the elderly: can they be avoided?

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.

Free-flap reconstruction of the lower limb in octogenarians - A comparative analysis of indications, management, and outcomes

INTRODUCTION

Impaired microcirculation, along with an increase in chronic medical conditions in the geriatric cohort, may favor the development of soft-tissue defects in the lower extremity and equally impair the options for plastic-reconstructive surgery. In particular, outcome analyses in the increasing patient cohort ≥ 80 years (octogenarians) are limited.

METHODS

Setting 80 years as the cutoff, we conducted an age-related outcome analysis of all patients undergoing free-flap reconstruction of the lower extremity from 2014 to 2020, comprising the American Society of Anesthesiologists (ASA) score and Charlson Comorbidity Index (CCI) as the possible outcome predicting factors.

RESULTS

During the study period, a total of 424 free flaps were performed in 385 patients (∅: 54.7 years ± 16.1; range: 9-89), including 19 octogenarians. Compared with the younger patient cohort, there was a significantly higher rate of early flap revision (p = 0.023) and flap loss (p = 0.028). Furthermore, the mean length of hospital (60.6 ± 37.6 vs. 51.1 ± 37.0) and intensive care unit/intermediate care stay (6.5 ± 15.0 vs. 3.5 ± 8.5) was extended (n.s.). The ASA score presented an independent predictor for major surgical [odds ratio (OR): 1.66; p = 0.041) and medical complications (OR: 3.97; p<0.001). Neither the CCI nor the ASA served as an independent predictor for total flap loss.

CONCLUSION

Free-flap reconstruction of the lower extremity in octogenarians is associated with a higher risk of flap revision and flap loss. Considering the prolonged immobilization associated with increased morbidity following limb amputation, it presents still a reasonable option to achieve limb salvage in carefully chosen patients. An adequate tool to predict the success of free-flap survival is still unavailable.

Fragility Fractures: Risk Factors and Management in the Elderly

Given the progressive ageing of Western populations, the fragility fractures market has a growing socioeconomic impact. Fragility fractures are common in the elderly, negatively impacting their quality of life, limiting autonomy, increasing disability, and decreasing life expectancy. Different causes contribute to the development of a fractures in frail individuals. Among all, targeting fragile patients before the development of a fracture may represent the greatest challenge, and current diagnostic tools suffer from limitations. This study summarizes the current evidence on the management of fragility fractures, discussing risk factors, prevention, diagnosis, and actual limitations of the clinical therapeutic options, putting forward new ideas for further scientific investigation.

Interventional revascularization prior to operative fixation of fractures below the knee. A retrospective case series

AIMS

The goal of the current study was to describe the results of an innovative standardized approach to prevent wound complications in patients with PAD sustaining fractures below the knee.

PATIENTS AND METHODS

In this retrospective case series, patients submitted to our institution with fractures below the knee, which were treated with endovascular recanalization of relevant stenosis or occlusions prior to definitive open reduction and fracture fixation between January 2015 and December 2019 were included.

RESULTS

Overall 23 patients (mean age 77 ± 9.8 years) were included in the current case series. In five patients (21.7 %) PAD was previously diagnosed. Endovascular interventions were performed 6.9 ± 2.5 days after fracture event and 2.5 ± 1.3 days prior to definitive surgical fixation of the lower limb fracture. After intervention 2 patients had one vessel, 10 patients two vessels and 11 patients three vessels for arterial perfusion of the lower limb. No interventional- radiology procedure related complications were observed. In this case series only two wound infections (8.7 %) occurred.

CONCLUSION

Endovascular intervention prior to surgical fixation resulted in a low complication rate after surgical fixation of fractures below the knee in patients with PAD. These results emphasize the crucial role of limb perfusion for adequate wound healing in lower limb fractures. Therefore, examination of limb perfusion should be an integral part of preoperative preparation of patients at high risk for PAD presenting with fractures below the knee. Endovascular recanalization seems to be an appropriate method to prevent wound complications.

[Ankle fractures in older patients : What should we do differently?]

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.

Osteoporotic ankle fractures: A narrative review of management options

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

INFERENCE

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

[Treatment of patients with fragility fractures]

BACKGROUND

Fragility fractures are fractures in multimorbid, geriatric patients. Currently, their number is already high and is likely to increase in the future.

OBJECTIVE

This article gives an overview of the principles in the management of patients with fragility fractures.

MATERIAL AND METHODS

A selective literature review was performed to describe the epidemiology and relevance of fragility fractures. In addition, the principles of the perioperative management and surgical treatment of patients with fragility fractures are shown.

RESULTS

Due to the significant number of comorbidities, the treatment of patients with fragility fractures represents an interdisciplinary challenge. Ideally, treatment should be carried out in an interdisciplinary team under the leadership of orthopedic surgeons and geriatricians. Treatment should be based on consensus guidelines, which have been adapted to the local circumstances. Attention should be paid to some special aspects of the surgical treatment in this vulnerable patient cohort. Important are optimal soft tissue management, cement augmentation procedures and joint replacement in cases of periarticular fractures.

CONCLUSION

There is evidence that with optimal care the treatment of patients with fragility fractures can be significantly improved.

Special Considerations in the Management of Diabetic Ankle Fractures

PURPOSE OF REVIEW

Ankle fractures and diabetes mellitus are both increasing in prevalence. Patients with both diabetes and an ankle fracture have been shown to have an increased rate of complications which can be catastrophic. The purposes of this review are to identify factors placing patients at an increased risk and offer guidance on the management of these injuries, in order to reduce potential complications.

RECENT FINDINGS

Non-operative management of unstable ankle fractures in patients with diabetes results in an unacceptably high rate of complications. Operatively managed patients with uncomplicated diabetes seem to fair as well as patients without diabetes. Thus, it is important to recognize patients as either complicated or uncomplicated at the onset of their treatment based on comorbidities. There is limited evidence to guide the management of ankle fractures in patients with diabetes, in particular those deemed complicated. Non-operative management of unstable fractures in diabetic patients should be avoided.