Stabilizing incidence of low-trauma ankle fractures in elderly people Finnish statistics in 1970-2006 and prediction for the future

Effectiveness of supervised versus self-directed rehabilitation for adults aged 50 years and over with ankle fractures: protocol for the AFTER trial

Aims

Ankle fractures are common, mainly affecting adults aged 50 years and over. To aid recovery, some patients are referred to physiotherapy, but referral patterns vary, likely due to uncertainty about the effectiveness of this supervised rehabilitation approach. To inform clinical practice, this study will evaluate the effectiveness of supervised versus self-directed rehabilitation in improving ankle function for older adults with ankle fractures.

Methods

This will be a multicentre, parallel-group, individually randomized controlled superiority trial. We aim to recruit 344 participants aged 50 years and older with an ankle fracture treated surgically or non-surgically from at least 20 NHS hospitals. Participants will be randomized 1:1 using a web-based service to supervised rehabilitation (four to six one-to-one physiotherapy sessions of tailored advice and prescribed home exercise over three months), or self-directed rehabilitation (provision of advice and exercise materials that participants will use to manage their recovery independently). The primary outcome is participant-reported ankle-related symptoms and function six months after randomization, measured by the Olerud and Molander Ankle Score. Secondary outcomes at two, four, and six months measure health-related quality of life, pain, physical function, self-efficacy, exercise adherence, complications, and resource use. Due to the nature of the interventions, participants and intervention providers will be unblinded to treatment allocation.

Conclusion

This study will assess whether supervised rehabilitation is more effective than self-directed rehabilitation for adults aged 50 years and older after ankle fracture. The results will provide evidence to guide clinical practice. At the time of submission, the trial is currently completing recruitment, and follow-up will be completed in 2024.

Assessing the functional outcomes of ankle fracture and its predictive factors following surgical treatment at Addis Ababa burn, emergency, and trauma (AaBET) hospital, Addis Ababa, Ethiopia, 2021: A 5-year retrospective cross-sectional study

BACKGROUND

Ankle fracture is a common injury that is treated at Addis Ababa Burn, Emergency, and Trauma Hospital. Previous studies show that there are mixed functional outcomes after surgically treated ankle fractures.

METHODS

After Ethical clearance was obtained from the ethical review committee of St. Paul Millennium Medical College, a retrospective cross-sectional study was conducted on 122 patients from September to October 2021. Patients fulfilling the inclusion criteria were called through phone and verbal consent was obtained, and the patients' responses were recorded with Olerud and Molander ankle outcome score (OMAS). For those study subjects who were unanswered to phone calls or non-functioning cell phones were repeated at least two times per week during the data collection period. The collected data were coded, entered, checked for its completeness, cleaned, and analyzed using SPSS Version 22. Descriptive statistics were presented with frequency, percentage, text, and graphs. Finally, the strength of association between  functional outcome of ankle fracture and independent variables were evaluated using the Chi-square test, and a P-value < 0.05 was declared to be statistically significant.

RESULTS

Out of the total 122 patients, 72.1% of study subjects were males, and the mean OMAS for males and females was 76.79, and 75.65, respectively. Among all ankle fractures, nearly two-thirds (63.1%) of them were closed fractures, which are initially stabilized with splinting, open reduction, and internal fixation (ORIF), and external fixation were 77%, 13.9%, and 9%, respectively, whereas 83.3% definitive management of operatively treated ankle fracture was open reduction and internal fixation. In this study, the score of Olerud and Molander was 82.9% patients 'good' or 'excellent,' whereas 10.5% and 4.5% were fair and poor, respectively. In the present study patients with 40 years and younger (p-value, 0.022) and early surgical treatment (p-value 0.02) were strongly associated with the positive functional outcome of ankle surgery.

CONCLUSION

Even though the surgical treatment of ankle fracture results in good postoperative functional outcomes, restores ankle function, and allows good mobility of the ankle joint, still some patients experience few restrictions in functional activities of 2-5-year post-surgical treatment.

'It Makes Me Feel Old': Understanding the Experience of Recovery From Ankle Fracture at 6 Months in People Aged 50 Years and Over

Ankle fracture is a common injury, and depending on injury severity, treatment may be a support boot, cast or surgery. Older people, particularly those with severe injuries who are asked to restrict weight bearing, struggle with early recovery. To elicit older peoples' experience of recovery 6 months after injury, we drew on a phenomenological approach using interviews. Findings revealed that getting on with life was a way of accepting what it feels like to 'be vulnerable', needing to 'be safe' while determinedly working hard to 'be myself'. Being vulnerable identified endurance of inactivity, loneliness and dependency in the non-weight bearing period of recovery, followed by a struggle to weight bear while lacking confidence and being fearful of falling and causing further damage. Being safe conveyed fragility where sensations, pain and stiffness acted as bodily reminders of injury. Lack of function and awareness of danger led to carefulness where planning or curtailing of activities ensured their safety. Being myself showed a determination to push away from a disrupted self-identify of being older or disabled while being challenged by the continuous process of learning to be more mobile. A lack of readiness for old age created a drive to age well. Despite loss of ability, participants hoped to regain their pre-injury way of living. This study challenges practice that disregards the hard work required to recover from ankle fracture. As comorbidity increases with age, failure to consider this aspect may contribute to frailty in this group of older people.

Trends of incidence and treatment strategies for operatively treated distal fibula fractures from 2005 to 2019: a nationwide register analysis

INTRODUCTION

Valid epidemiological data about distal fibular fractures and their treatment strategies are missing. Innovative osteosynthesis techniques were introduced and improved during the past 15 years. The aim of this study was to investigate the epidemiologic development and the implementation of new treatment strategies in a nationwide register in Germany over a period of 15 years.

MATERIALS AND METHODS

Data of the German Federal Statistical Office from 2005 until 2019 were screened. Adults with a fracture of the distal fibula were included. Data were separated for gender, age and treatment strategy.

RESULTS

During the past 15 years, there was a steady annual incidence of distal fibula fractures of 74 ± 32 per 100,000 people without any significant changes (p = 0.436). 60.1% ± 0.6% of all fractures occurred in females. The annual incidence for male was nearly constant over the different age groups, whereas for female, there was a clear increase in incidence above the age of 40. Whereas 66% of fractures in between 20 and 30 years of age occurred in male, approximately 70% of fractures above the age of 60 occurred in females. The relative quantity of locking plates increased from 2% in 2005 to 34% in 2019. In 2019, only 1.02% of the patients were operated with an intramedullary nail.

CONCLUSIONS

Operatively treated distal fibular fractures revealed an age dependent increase in incidence in postmenopausal women compared to younger females. Regarding the treatment strategy, there was an increase in application of locking plates. The data implicate a typical fragility fracture related age and gender distribution for distal fibula fractures.

Progressive exercise versus best practice advice for adults aged 50 years or over after ankle fracture: the AFTER pilot randomised controlled trial

OBJECTIVE

The aim of the Ankle Fracture Treatment: Enhancing Rehabilitation (AFTER) study, a multicentre external pilot parallel-group randomised controlled trial (RCT), was to assess feasibility of a definitive trial comparing rehabilitation approaches after ankle fracture.

SETTING

Five UK National Health Service hospitals.

PARTICIPANTS

Participants were aged 50 years and over with an ankle fracture requiring immobilisation for at least 4 weeks.

INTERVENTIONS

Participants were allocated 1:1 via a central web-based randomisation system to: (1) best practice advice (one session of physiotherapy, up to two optional additional advice sessions) or (2) progressive exercise (up to six sessions of physiotherapy).

PRIMARY OUTCOME MEASURES

Feasibility: (1) participation rate, (2) intervention adherence and (3) retention.

RESULTS

Sixty-one of 112 (54%) eligible participants participated, exceeding progression criteria for participation of 25%. Recruitment progression criteria was 1.5 participants per site per month and 1.4 was observed. At least one intervention session was delivered for 28/30 (93%) of best practice advice and 28/31 (90%) of progressive exercise participants, exceeding the 85% progression criteria. For those providing follow-up data, the proportion of participants reporting performance of home exercises in the best practice advice and the progressive exercise groups at 3 months was 20/23 (87%) and 21/25 (84%), respectively. Mean time from injury to starting physiotherapy was 74.1 days (95% CI 53.9 to 94.1 days) for the best practice advice and 72.7 days (95% CI 54.7 to 88.9) for the progressive exercise group. Follow-up rate (6-month Olerud and Molander Ankle Score) was 28/30 (93%) for the best practice advice group and 26/31 (84%) in the progressive exercise group with an overall follow-up rate of 89%.

CONCLUSIONS

This pilot RCT demonstrated that a definitive trial would be feasible. The main issues to address for a definitive trial are intervention modifications to enable earlier provision of rehabilitation and ensuring similar rates of follow-up in each group.

TRIAL REGISTRATION NUMBER

ISRCTN16612336.

The incidence of musculoskeletal injuries: a systematic review and meta-analysis

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

Methods

PubMed (National Library of Medicine) and Scopus (Elsevier) databases were searched. Articles were eligible for inclusion if they reported incidence rate (or count with population at risk), contained data on adult population, and were written in English language. The number of cases and population at risk were collected, and the pooled incidence rates (per 100,000 person-years) with 95% confidence intervals (CIs) were calculated by using either a fixed or random effects model.

Results

The screening of titles yielded 206 articles eligible for inclusion in the study. Of these, 173 (84%) articles provided sufficient information to be included in the pooled incidence rates. Incidences of fractures were investigated in 154 studies, and the most common fractures in the whole adult population based on the pooled incidence rates were distal radius fractures (212.0, 95% CI 178.1 to 252.4 per 100,000 person-years), finger fractures (117.1, 95% CI 105.3 to 130.2 per 100,000 person-years), and hip fractures (112.9, 95% CI 82.2 to 154.9 per 100,000 person-years). The most common sprains and dislocations were ankle sprains (429.4, 95% CI 243.0 to 759.0 per 100,000 person-years) and first-time patellar dislocations (32.8, 95% CI 21.6 to 49.7 per 100,000 person-years). The most common injuries were anterior cruciate ligament (17.5, 95% CI 6.0 to 50.2 per 100,000 person-years) and Achilles (13.7, 95% CI 9.6 to 19.5 per 100,000 person-years) ruptures.

Conclusion

The presented pooled incidence estimates serve as important references in assessing the global economic and social burden of musculoskeletal injuries. Cite this article: Bone Joint Res 2022;11(11):814–825.

Three internal fixation methods for Danis-Weber-B distal fibular fractures: A biomechanical comparison in an osteoporotic fibula model

A common agreement for the surgical treatment of osteoporotic ankle fractures has not been defined yet although locking plates are preferred for fractures with poor bone quality. This study aims to evaluate the mechanical stability of locked and conventional plates on osteoporotic Danis-Weber-B-fibula fracture models. Fractured custom-made osteoporotic fibulae were treated with neutralization plate plus lag screw, locking plate plus lag screw, or a standalone locking plate. Load until failure was applied mimicking single-leg stance. Stiffness, failureload, and interfragmentary movements were investigated. Stiffness, failureload and axial fragment movement showed no significant differences among groups. Shear movements and fragment rotation around the shaft of the neutralization plate were on average twice as high as those of the locking plates. Although no superiority was shown for overall mechanical performance, the locking plate groups exhibited higher shear and rotational stability than the neutralization plate.

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

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

Changing epidemiology of lower extremity fractures in adults over a 15-year period - a National Hospital Discharge Registry study

Background

Demographic changes led to an increasingly ageing population in Germany and thus to possible changes in the frequency of fractures. The primary aim of this study was to report changes in fracture rates of the lower extremities in Germany in 2002 compared to 2017 and to evaluate those changes.

Methods

Inpatient data from the German National Hospital Discharge Registry (ICD10) for 2002 and 2017 were evaluated. Changes in total counts and incidence rates were analysed for fractures in the following locations: femoral neck, pertrochanteric, subtrochanteric, distal femur, femoral shaft, proximal and distal tibia, tibial shaft, medial and lateral malleolus, and other parts of the lower leg (including bi- and trimalleolar fractures), calcaneus, talus, other tarsal bones, metatarsal bones, greater toe, lesser toe, other fractures of foot or unspecific fractures of foot and toe. Patients were classed into age groups by sex: 15–24, 25–34,35–44, 45–54, 55–64, 65–74, 75–84, 85–90 and >  90 years.

Results

The total count for lower extremity fractures in men and women increased slightly by 4.5% from 305,764 in 2002 to 319,422 in 2017. Hip and femur fractures increased by 23.5% from 150,565 in 2002 to 185,979 in 2017. The number of these fractures among men increased by 46% and among women by 15.3%. The total count of lower leg fractures decreased by 15.4% from 131,162 in 2002 to 110,924 in 2017. Especially, younger age groups showed a decline for all tibial segments and ankle fractures. For both sexes, the number of lower leg fractures in those 75 years or older increased in all lower leg fracture locations. Most femur and lower leg fractures occurred in women. The incidence of fractures rose sharply from 2002 to 2017, especially for older cohorts.

Conclusion

The total numbers of lower extremity fractures increased slightly in 2017 compared to 2002 – especially hip and femur fractures among men. The incidence of almost all lower extremity fracture types among older people increased during this time. Women were particularly affected. Therefore, focused prevention programmes should be considered including an extended fracture spectrum in the elderly.

Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England

BACKGROUND

Evidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contact-casting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients.

METHODS

Patients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence.

RESULTS

Over the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0-19.5% < 60 years; 15.2-17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved.

CONCLUSIONS

Despite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contact-casting, in line with recent evidence.

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.

Progressive functional exercise versus best practice advice for adults aged 50 years or over after ankle fracture: protocol for a pilot randomised controlled trial in the UK - the Ankle Fracture Treatment: Enhancing Rehabilitation (AFTER) study

INTRODUCTION

Ankle fractures result in significant morbidity in adults, with prognosis worsening with increasing age. Previous trials have not found evidence supporting supervised physiotherapy sessions, but these studies have not focused on older adults or tailored the exercise interventions to the complex needs of this patient group. The Ankle Fracture Treatment: Enhancing Rehabilitation study is a pilot randomised controlled trial to assess feasibility of a later definitive trial comparing best-practice advice with progressive functional exercise for adults aged 50 years and over after ankle fracture.The main objectives are to assess: (i) patient engagement with the trial, measured by the participation rate of those eligible; (ii) establish whether the interventions are acceptable to participants and therapists, assessed by intervention adherence levels, participant interviews and a therapist focus group; (iii) participant retention in the trial, measured by the proportion of participants providing outcome data at 6 months; (iv) acceptability of measuring outcomes at 3 and 6 month follow-up.

METHODS AND ANALYSIS

A multicentre pilot randomised controlled trial with an embedded qualitative study. At least 48 patients aged 50 years and over with an ankle fracture requiring surgical management, or non-operative management by immobilisation for at least 4 weeks, will be recruited from a minimum of three National Health Service hospitals in the UK. Participants will be allocated 1:1 via a central web-based randomisation system to: (i) best-practice advice (one session of face-to-face self-management advice delivered by a physiotherapist and up to two optional additional sessions) or (ii) progressive functional exercise (up to six sessions of individual face-to-face physiotherapy). An embedded qualitative study will include one-to-one interviews with up to 20 participants and a therapist focus group.

ETHICS AND DISSEMINATION

Hampshire B Research Ethics Committee (18/SC/0281) gave approval on 2^nd July 2018.

TRIAL REGISTRATION NUMBER

ISRCTN16612336.

Lower Complication Rate Following Ankle Fracture Fixation by Orthopaedic Surgeons Versus Podiatrists

INTRODUCTION

Increased overlap in the scope of practice between orthopaedic surgeons and podiatrists has led to increased podiatric treatment of foot and ankle injuries. However, a paucity of studies exists in the literature comparing orthopaedic and podiatric outcomes following ankle fracture fixation.

METHODS

Using an insurance claims database, 11,745 patients who underwent ankle fracture fixation between 2007 and 2015 were retrospectively evaluated. Patient data were analyzed based on the provider type. Complications were identified by the International Classification of Diseases, Ninth Revision, codes, and revision surgeries were identified by the Current Procedural Terminology codes. Complications analyzed included malunion/nonunion, infection, deep vein thrombosis, and rates of irrigation and débridement. Risk factors for complications were compared using the Charlson Comorbidity Index.

RESULTS

Overall, 11,115 patients were treated by orthopaedic surgeons and 630 patients were treated by podiatrists. From 2007 to 2015, the percentage of ankle fractures surgically treated by podiatrists had increased, whereas that treated by orthopaedic surgeons had decreased. Surgical treatment by podiatrists was associated with higher malunion/nonunion rates among all types of ankle fractures. No differences in complications were observed in patients with unimalleolar fractures. In patients with bimalleolar or trimalleolar fractures, treatment by a podiatrist was associated with higher malunion/nonunion rates. Patients treated by orthopaedic surgeons versus podiatrists had similar comorbidity profiles.

DISCUSSION

Surgical treatment of ankle fractures by orthopaedic surgeons was associated with lower rates of malunion/nonunion when compared with that by podiatrists. The reasons for these differences are likely multifactorial but warrants further investigation. Our findings have important implications in patients who must choose a surgeon to surgically manage their ankle fracture, as well as policymakers who determine the scope of practice.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Cannulated Intramedullary Screw Fixation of Distal Fibular Fractures

Background: Open reduction and internal fixation (ORIF) methods, primarily plates and screws, remain the standard of treatment for distal fibular fractures. This study evaluates the use of a cannulated intramedullary screw as a minimally invasive treatment method for distal fibular fractures, which has not been reported in the current literature. Methods: This retrospective study included 45 patients with distal fibular fractures treated with cannulated intramedullary screw fixation. All patients included in the cohort had a soft-tissue condition and/or comorbidity. The mean age was 54 years. The Weber classification system was used to assess the type of fracture. Average time to union, average time to weight bearing, and complications were monitored. Results: Reduction quality criteria were collected using previously published guidelines. Accordingly, reduction was determined to be good in 25 cases, fair in 15, and poor in 5. A low complication rate of 4% was reported. Average time to union was 10 weeks (range = 8-36 weeks), whereas average time to weight bearing was 14 weeks (range = 8-40 weeks). Conclusion: Cannulated intramedullary screw fixation can serve as a minimally invasive, safe, and satisfactory treatment for distal fibular fractures with resulting high union rates and low complication rates. Levels of Evidence: Level IV: Retrospective, case series.

Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: An exploratory pilot study

BACKGROUND

Peripheral nerve blocks (PNB) are increasingly used for anaesthesia and postoperative pain control in acute orthopaedic limb surgery but rebound pain upon cessation of PNBs may challenge the benefits on the pain profile. We aimed to explore the pain profile following acute ankle fracture surgery under PNB anaesthesia and investigate if rebound pain could pose a clinical problem.

METHODS

Exploratory, observational study of adults scheduled for acute primary internal fixation of an ankle fracture under ultrasound-guided popliteal sciatic and saphenous ropivacaine block anaesthesia. Postoperatively, patients regularly registered pain scores while receiving a fixed analgesics regimen and patient controlled morphine on-demand. We analysed morphine consumption and depicted the detailed pain profiles as graphs allowing for visual analysis of pain courses, including rebound pain. Secondly, we compared the area under the curve and peak pain between relevant age-subgroups.

RESULTS

We included 21 patients aged 20-83. Depicted pain profiles reveal that PNB supplied effective and long lasting postoperative pain control, but cessation of the PNB led to intense rises in pain scores with six out of nine 20-60-year-olds reaching severe pain levels. The rebound was less pronounced in patients >60 years old, but nearly all reached moderate pain levels. Morphine consumption rates were high during the rebound.

CONCLUSIONS

This study thoroughly analyses the post-PNB pain profile and suggests rebound pain is a clinically relevant and problematic issue with the potential to outweigh the PNB benefits, especially for younger patients. The conclusions are tentative, and a randomised study is pending.

Assessing Quality of Syndesmotic Reduction in Surgically Treated Acute Syndesmotic Injuries: A Systematic Review

There is no universal method with cutoff values for the assessment of distal tibiofibular joint reduction in acute syndesmotic injuries. It is important to detect malreductions because they may lead to impaired functional outcome and may demand reoperations. The aim of this study was to systematically review the literature to evaluate the appropriateness of different image techniques in determining syndesmotic malalignment. A literature search was conducted in Medline, Embase, and the Cochrane Library to search for articles assessing syndesmotic reduction. Excluded were articles where no criteria and/or measurements for syndesmotic reduction were provided, only normative values were provided and reviews. In total, 2157 articles were found, of which 1421 studies were screened for title and abstract after exclusion of duplicates. One hundred ten studies were eligible for full-text analysis. Of these, 61 were excluded. Three studies where added after screening the included references. Fifty-two studies were included, of which 32 were original publications and 20 were publications referring to the original publications. From the original publications, 14 used plains radiographs, 19 computed tomographic (CT) scans, and 5 used 3-dimensional CT scans (some authors used >1 modality in their study). For each modality, a large number of parameters and different cutoff values were reported. CT scanning is superior to plain radiography in the assessment of the quality of joint reduction. Parameters used the most were fibular position in the incisura and fibular rotation. The criteria for adequate reduction should at least include the position of the fibula in the incisura and rotation of the fibula, while ensuring adequate fibular length, all equaling or at least approaching the values of the uninjured contralateral side.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Routine versus on demand removal of the syndesmotic screw; a protocol for an international randomised controlled trial (RODEO-trial)

BACKGROUND

Syndesmotic injuries are common and their incidence is rising. In case of surgical fixation of the syndesmosis a metal syndesmotic screw is used most often. It is however unclear whether this screw needs to be removed routinely after the syndesmosis has healed. Traditionally the screw is removed after six to 12 weeks as it is thought to hamper ankle functional and to be a source of pain. Some studies however suggest this is only the case in a minority of patients. We therefore aim to investigate the effect of retaining the syndesmotic screw on functional outcome.

DESIGN

This is a pragmatic international multicentre randomised controlled trial in patients with an acute syndesmotic injury for which a metallic syndesmotic screw was placed. Patients will be randomised to either routine removal of the syndesmotic screw or removal on demand. Primary outcome is functional recovery at 12 months measured with the Olerud-Molander Score. Secondary outcomes are quality of life, pain and costs. In total 194 patients will be needed to demonstrate non-inferiority between the two interventions at 80% power and a significance level of 0.025 including 15% loss to follow-up.

DISCUSSION

If removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. This means that patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs.

TRIAL REGISTRATION

This study was registered at the Netherlands Trial Register (NTR5965), Clinicaltrials.gov ( NCT02896998 ) on July 15th 2016.

Continuous decline in incidence of distal humeral fracture of older women in Finland

BACKGROUND

Low-trauma fractures (also called osteoporotic fragility fractures or fall-induced fractures) of older adults are a serious public health problem. However, very little population-based information is available on the nationwide numbers, incidences, and especially secular trends of elderly people's low-trauma fractures of the distal humerus.

METHODS

We assessed the current trends in the number and incidence of these fractures in 60-year-old or older women in Finland by taking into account all women who were admitted to Finnish hospitals for primary treatment of such fracture in 1970-2014.

RESULTS

The annual number of low-trauma distal humeral fractures among Finnish women 60 years of age or older rose over fivefold between 1970 and 1998 (from 42 to 224 fractures), but thereafter, the number decreased down to 198 fractures in 2014. The age-adjusted incidence (per 100,000 persons) of these fractures also increased in 1970-1998 (from 12 to 35) but decreased thereafter to 23 in 2014. The finding was similar in the age-specific patient groups (60-69, 70-79, and 80+): The incidence rose from 1970 till 1998 and decreased thereafter.

CONCLUSIONS

The steep rise in the rate of low-trauma distal humeral fractures in 60-year-old or older Finnish women from 1970 till late 1990s has been followed by a clearly declining fracture rate. The exact reasons for this secular change are unknown, but a cohort effect toward improved functional ability among elderly women, as well as measures to prevent falls and alleviate fall severity, could partly explain the phenomenon.

Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly

Purpose of Review

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

Recent Findings

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

Summary

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

Should syndesmotic screws be removed after surgical fixation of unstable ankle fractures? a systematic review

AIMS

In approximately 20% of patients with ankle fractures, there is an concomitant injury to the syndesmosis which requires stabilisation, usually with one or more syndesmotic screws. The aim of this review is to evaluate whether removal of the syndesmotic screw is required in order for the patient to obtain optimal functional recovery.

MATERIALS AND METHODS

A literature search was conducted in Medline, Embase and the Cochrane Library for articles in which the syndesmotic screw was retained. Articles describing both removal and retaining of syndesmotic screws were included. Excluded were biomechanical studies, studies not providing patient related outcome measures, case reports, studies on skeletally immature patients and reviews. No restrictions regarding year of publication and language were applied.

RESULTS

A total of 329 studies were identified, of which nine were of interest, and another two articles were added after screening the references. In all, two randomised controlled trials (RCT) and nine case-control series were found. The two RCTs found no difference in functional outcome between routine removal and retaining the syndesmotic screw. All but one of the case-control series found equal or better outcomes when the syndesmotic screw was retained. However, all included studies had substantial methodological flaws.

CONCLUSIONS

The currently available literature does not support routine elective removal of syndesmotic screws. However, the literature is of insufficient quality to be able to draw definitive conclusions. Secondary procedures incur a provider and institutional cost and expose the patient to the risk of complications. Therefore, in the absence of high quality evidence there appears to be little justification for routine removal of syndesmotic screws. Cite this article: Bone Joint J 2016;98-B:1497-1504.

Declining incidence of fall-induced ankle fractures in elderly adults: Finnish statistics between 1970 and 2014

BACKGROUND

Fall-induced fractures of older adults are a major public health concern. However, nationwide information on recent fracture trends is sparse.

METHODS

We determined the trend in the number and incidence (per 100,000 persons) of fall-induced ankle fractures among older adults in Finland by taking into account all persons 60 years of age or older who were admitted to Finnish hospitals for primary treatment of such fracture in 1970-2014.

RESULTS

The number of fall-induced ankle fractures among 60-year-old or older Finnish persons increased steadily and sharply between 1970 (369 fractures) and 1997 (1668 fractures), but since then, the increase has slowed down (1835 fractures in 2014). The raw incidence of ankle fracture, showing a clear rise from 57 fractures per 100,000 persons in 1970 to 169 fractures in 1997, declined steadily between 1997 and 2014 (to 126 fractures in 2014). Observations on the age-adjusted fracture incidence were similar. During 1970-1997, the age-adjusted incidence of fall-induced ankle fracture clearly rose in both women and men, but thereafter, the incidence declined; in women, from 199 in 1997 to 158 in 2014, and in men, from 123 in 1997 to 80 in 2014.

CONCLUSIONS

The sharp rise in the incidence of fall-induced ankle fracture in Finnish older adults from early 1970s until late 1990s has been followed by a declining fracture rate. Despite this welcome development, the rapid aging of our population is likely to increase the absolute number of these fractures in the near future, and therefore, large-scale fracture-preventing intervention studies are urgently needed.

Reinforced fixation of distal fibula fractures in elderly patients; A meta-analysis of biomechanical studies

BACKGROUND

There is an increasing incidence of fragility fractures of the ankle in the elderly population. The open reduction and internal fixation of these fractures is challenging, due to reduced bone stock quality as a result of osteoporosis. Biomechanical studies have shown contradicting results using reinforced constructions in the fixation of fibular fractures. We therefore performed a meta-analysis of biomechanical studies on reinforced fixation of distal fibular fractures.

METHODS

A literature search was conducted utilizing three online databases considering biomechanical testing of different fixation techniques of distal fibular fractures. A meta-analysis was performed on two biomechanical outcome measures; torsional stiffness and torque to failure.

FINDINGS

In a total number of 13 studies 8 different reinforcement techniques were identified. Of these studies, six compared locked lateral plating with conventional lateral plating. There were no statistically significant differences between the locking and non-locking lateral plate for torque to failure or torsional stiffness. Locked plating strength was independent from bone mineral density in four studies. An antiglide plate proved to be biomechanically superior compared to a lateral plate in one study and to a locked plate in another.

INTERPRETATION

Locked lateral plates are not biomechanically superior to conventional lateral plates. However the strength of locked plating may be independent of bone mineral density and could make this technique more suitable in the fixation of severe osteoporotic fractures.

Improvements in hip fracture incidence counterbalanced by the rise of other fracture types: data from Spain 2000-2010

BACKGROUND

In recent years, the incidence of injury in older people has increased. The aim of this study is to address the hypothesis that this increase is due to an increase in the incidence of some injuries that, while less common than hip fractures, are sufficient jointly to counteract the decrease or stabilisation in hip fracture rates observed in most countries.

METHODS

We performed a descriptive study of trends using data from the National Hospital Discharge Register. We included individuals 65 years and older who were discharged from a Spanish hospital during the period 2000-2010 with at least one injury diagnosis in the primary diagnosis field on the discharge form. The dependent variables were the following injury groups, classified using the Barell Matrix: hip fracture, shoulder and upper arm fractures, forearm and elbow fractures, thoracic fractures, lower leg and ankle fractures, and TBI type 1 internal injury. Incidence rates were calculated per 100,000 inhabitants (data from National Statistics Institute) and stratified by sex and age group. Trends, in terms of Annual Percent Change (APC), were assessed using Poisson Regression with discharge year as the independent variable.

RESULTS

Hip fracture continues to be the most important injury type in older people. Thoracic fractures and TBI internal injuries are more common in men, while fractures in the upper extremities are more common in women. All injuries increased in frequency with age, except lower leg and ankle fractures, which decreased. While a secular decreasing trend in hip fracture was noted, the incidences of fractures of the shoulder and upper arm, forearm and elbow, and lower leg and ankle, as well as of TBI type 1 internal injuries have increased steadily.

CONCLUSIONS

Although hip fracture continue to be the most common type of injury in older people, this study has allowed identifying other types of injury that are becoming increasingly common. These trends are driving paradigm changes in the burden of injuries requiring treatment within the hospital system, and must be taken into account in the design of preventative programs and actions.

Early ankle movement versus immobilization in the postoperative management of ankle fracture in adults: a systematic review and meta-analysis

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-.

Incidence of fractures requiring inpatient care

BACKGROUND

The overall incidence of fractures has been addressed in several studies, but there are few data on different types of fractures that require inpatient care, even though they account for considerable healthcare costs. We determined the incidence of limb and spine fractures that required hospitalization in people aged ≥ 16 years.

PATIENTS AND METHODS

We collected data on the diagnosis (ICD10 code), procedure code (NOMESCO), and 9 additional characteristics of patients admitted to the trauma ward of Central Finland Hospital between 2002 and 2008. Incidence rates were calculated for all fractures using data on the population at risk.

RESULTS AND INTERPRETATION

During the study period, 3,277 women and 2,708 men sustained 3,750 and 3,030 fractures, respectively. The incidence of all fractures was 4.9 per 10(3) person years (95% CI: 4.8-5.0). The corresponding numbers for women and men were 5.3 (5.1-5.4) and 4.5 (4.3-4.6). Fractures of the hip, ankle, wrist, spine, and proximal humerus comprised two-thirds of all fractures requiring hospitalization. The proportion of ankle fractures (17%) and wrist fractures (9%) was equal to that of hip fractures (27%). Four-fifths of the hospitalized fracture patients were operated. In individuals aged < 60 years, fractures requiring hospitalization were twice as common in men as in women. In individuals ≥ 60 years of age, the opposite was true.

Incidence of osteoporotic fractures in elderly women and men in Finland during 2005-2006: a population-based study

BACKGROUND AND AIMS

Osteoporosis is a major health concern in elderly population. Low-trauma fractures offer one way of identifying these patients for treatment. Population-specific incidences of osteoporotic fractures are essential to validate tools for clinical decision making.

MATERIAL AND METHODS

To evaluate population-based osteoporotic fracture incidences in Central Finland, we performed a manual search of low-trauma fractures 2005-2006 from the records of all the local health-care organizations treating trauma patients. We identified low-trauma fracture patients from radiology reports from five health centers serving the inhabitants of nine municipalities and from the patient records of two hospitals in Central Finland. The manually collected data were then compared against data from the Finnish Health Care Register.

RESULTS

The crude incidence of all osteoporotic fractures in 2005-2006 in the population aged 50 years was 1254/100,000 person years: 694/100,000 person years in men and 1718/100,000 person years in women. Fracture numbers derived from register data were similar to those manually collected for hip and humerus fractures, but clearly smaller than those for wrist and ankle fractures.

CONCLUSIONS

Population-based low-trauma fracture incidences, reported here for Finland, constitute a basis for calibration of fracture risk evaluation tools (e.g. the World Health Organization fracture risk evaluation tool, FRAX). This study showed that register data underestimate the incidences of, in particular, distal radius and ankle fractures.

Trends in fracture incidence: a population-based study over 20 years

To assess recent trends in fracture incidence from all causes at all skeletal sites, we used the comprehensive (inpatient and outpatient) data resources of the Rochester Epidemiology Project to estimate rates for Olmsted County, MN, USA, residents in 2009 to 2011 compared with similar data from 1989 to 1991. During the 3-year study period, 2009 to 2011, 3549 residents ≥50 years of age experienced 5244 separate fractures. The age- and sex-adjusted (to the 2010 US white population) incidence of any fracture was 2704 per 100,000 person-years (95% confidence interval [CI] 2614 to 2793) and that for all fractures was 4017 per 100,000 (95% CI 3908 to 4127). Fracture incidence increased with age in both sexes, but age-adjusted rates were 49% greater among the women. Overall, comparably adjusted fracture incidence rates increased by 11% (from 3627 to 4017 per 100,000 person-years; p = 0.008) between 1989 to 1991 and 2009 to 2011. This was mainly attributable to a substantial increase in vertebral fractures (+47% for both sexes combined), which was partially offset by a decline in hip fractures (-25%) among the women. There was also a 26% reduction in distal forearm fractures among the women; an increase in distal forearm fractures among men aged 50 years and over was not statistically significant. The dramatic increase in vertebral fractures, seen in both sexes and especially after age 75 years, was attributable in part to incidentally diagnosed vertebral fractures. However, the fall in hip fracture incidence, observed in most age groups, continues the steady decline observed among women in this community since 1950. More generally, these data indicate that the dramatic increases in the incidence of fractures at many skeletal sites that were observed decades ago have now stabilized.

Incidence of syndesmotic injury

Injury to the tibiofibular syndesmosis can occur with ankle sprain or fracture. The incidence of syndesmotic injury has not been specifically studied at a population level. Data on syndesmotic injury were obtained from the Healthcare Cost and Utilization Project (HCUP), a federal-state-private partnership. It is administered by the Agency for Healthcare Research and Quality, a division of the US Department of Health and Human Services. Two HCUP databases were queried for 8 states: the State Inpatient Database and the State Emergency Department Database. The first 6 International Classification of Diseases, Ninth Edition (ICD-9) code diagnoses were searched for codes that are used for syndesmotic injury (ie, 845.03). These data, along with data from the 2010 US census, were used to yield incidence rates for syndesmosis injury, as well as for various demographic groups. National estimates of injury totals were also calculated. In the 8 states, there were a total of 1821 syndesmotic injuries. Given the population of these states, the incidence rate of syndesmotic injury was 2.09 syndesmotic injuries per 100,000 person-years. This incidence correlates to an estimated 6445 syndesmotic injuries per year in the United States. These data provide some baseline numbers as to the incidence of syndesmotic injury in the United States. Although the incidence was low relative to some other injuries, the fact that syndesmotic injuries tend to occur in younger patients may have a greater effect in terms of productive years of life lost.

Temporal trends in the incidence of osteoporotic fractures

Osteoporotic fractures are associated with excess mortality and decreased functional capacity and quality of life. Age-standardized incidence rates of fragility fractures, particularly of the hip and forearm, have been noted to be decreasing in the last decade across many countries with the notable exception of Asia. The causes for the observed changes in fracture risk have not been fully identified but are likely the result of multiple factors, including birth cohort and period effects, increasing obesity, and greater use of anti-osteoporosis medications. Changing rates of fragility fractures would be expected to have an important impact on the burden of osteoporosis.

Factors associated with mobility outcomes in older people post-ankle fracture: an observational cohort study focussing on peripheral vessel function

INTRODUCTION

There are increasing numbers of older persons sustaining ankle fractures. This injury often results in a degree of functional limitation, particularly in older patients. There is currently limited research into factors associated with mobility outcomes.

DESIGN

Observational cohort study.

SETTING

Hospital Trauma Department, UK.

PARTICIPANTS

Persons aged 60 years or over who sustained an unstable ankle fracture with no established peripheral arterial disease pre-injury.

METHODS

This study investigated the association between ankle-brachial pressure index (ABPI) and extended timed 'up and go' (TUG) measures. Associations between TUG outcomes and age, pre-morbid functional mobility (Olerud-Molander Ankle Score) and fracture severity (number of malleoli injured) were also explored.

ANALYSIS

Complete cases (n=76; 84% of cohort) were entered into univariate and multivariate linear regression.

RESULTS

No association was found between ABPI and TUG at 6 months in unadjusted and adjusted analyses. Pre-morbid functional mobility (B=-0.34, 95% confidence interval (CI) -0.45 to -0.23, p<0.001) and age (B=0.46, 95% CI 0.25-0.66, p<0.001) were associated with extended TUG values (r2=0.53, p<0.001). Fracture severity was not a significant independent predictor variable.

CONCLUSIONS

Peripheral vessel function and fracture severity may have a limited independent influence on mobility outcome after ankle fracture in those patients who do not have established pre-injury peripheral arterial disease. Age and pre-morbid mobility gave an indication of mobility outcome, but a substantial amount of variance remains unexplained. Limitations of this study, including missing data and potential residual confounding, indicate the need for caution in generalising these results. The study provides a basis on which to plan larger studies of the factors associated with mobility outcome after ankle fracture in older populations.

Fall-related fracture trends among elderly in Sweden--exoring transitions among hospitalized cases

PROBLEM

Fall-related injuries have been a cause of worry during the end of the 20th century with increasing trends among the elderly.

METHOD

Using data from the Swedish National Patient Register (NPR) based on hospital admissions, this study explores the trends in fall-related fractures between 1998 and 2010.

RESULTS

The data shows a decreasing trend in fall-related fractures in all age- and sex-specific groups apart from men 80 years and above. While hip fracture incidence rates decreased in all age- and sex-specific groups, both central fractures and upper extremity fractures have increased in all age- and sex-specific groups apart from women 65-79 years. Lower extremity fractures have increased in the older age groups and decreased in the younger.

DISCUSSION

The differences found between the groups of fractures and by age- and sex-specific groups indicate a possible transition where more serious fractures are decreasing while less serious fractures increase among hospitalized cases.

SUMMARY

Perhaps due to a focus on hip fracture prevention, this study shows that while the incidence rate of hospitalized hip fractures has decreased, other fall-related hospitalized fractures have increased.

IMPACT ON INDUSTRY

Potentially, this could be indicative of a healthier younger elderly, coupled with a frailer older elderly requiring more comprehensive healthcare also for less serious injuries. Further research is needed to confirm our results.

Management of high-energy foot and ankle injuries in the geriatric population

By the year 2035 almost 20% of the US population of 389 million people will be 65 years and older. What this group has, compared with aged populations in the past, is better health, more mobility, and more active lifestyles. From January 1989 through December 2010, a total of 494 elderly patients with 536 foot and ankle injuries were identified. Within this group, 237 (48%) patients with 294 injuries were sustained as a result of a high-energy mechanism. These mechanisms consisted of 170 motor vehicle accidents, 30 as a result of high (not ground level) energy falls, 2 from industrial accidents, and 35 classified as other, which included sports, blunt trauma, bicycle, airplane or boating accidents, crush injuries, and injuries resulting from a lawn mower. The injuries produced were 17 metatarsal fractures, 9 Lisfranc injuries, 10 midfoot (navicular, cuneiform, or cuboid) fractures, 23 talus fractures, 63 calcaneal fractures, 73 unimalleolar, bimalleolar, or trimalleolar ankle fractures, 45 pilon fractures, and 3 pure dislocations of the foot or ankle. Overall, 243 (83%) of these injuries underwent surgical fixation and data have shown that when surgery is used to manage high-energy injuries of the foot and ankle in the elderly individuals, the complications and outcomes are similar to those seen in younger patients. Therefore, the decision for surgical intervention for high-energy injuries of the foot and ankle should be based primarily on the injury pattern and not solely on the age of the patient.

Osteoporotic ankle fractures

Ankle fractures are one of the most common injuries in the elderly and their incidence is anticipated to increase over the next 20 years. Appropriate management of ankle fractures in this population requires an understanding of the issues unique to the elderly. Osteoporosis must be considered when counseling patients about their ankle fracture. Good outcomes can be achieved with surgical fixation of ankle fractures in the elderly. Postoperative complications are higher in patients with diabetes and peripheral vascular disease, and in patients who smoke. This article reviews how to evaluate and treat ankle fractures in elderly patients with osteoporosis, evaluates the outcomes, and discusses surgical techniques.

Clinical review: Ethnic differences in bone mass--clinical implications

CONTEXT

Differences in bone mineral density (BMD) as assessed with dual-energy x-ray absorptiometry are observed between geographic and ethnic groups, with important implications in clinical practice.

EVIDENCE ACQUISITION

PubMed was employed to identify relevant studies. A review of the literature was conducted, and data were summarized and integrated.

EVIDENCE SYNTHESIS

The available data highlight the complex ethnic variations in BMD, which only partially account for observed variations in fracture rates. Factors contributing to ethnic differences include genetics, skeletal size, body size and composition, lifestyle, and social determinants. Despite BMD differences, the gradient of risk for fracture from BMD and other clinical risk factors appears to be similar across ethnic groups. Furthermore, BMD variation is greater within an ethnic population than between ethnic populations. New imaging technologies have identified ethnic differences in bone geometry, volumetric density, microarchitecture, and estimated bone strength that may contribute to a better understanding of ethnic differences in fracture risk.

CONCLUSIONS

Factors associated with ethnicity affect BMD and fracture risk through direct and indirect mechanisms.

Epidemiology of adult ankle fractures in Sweden between 1987 and 2004: a population-based study of 91,410 Swedish inpatients

BACKGROUND AND PURPOSE

Previous national epidemiological data on the characteristics and trends of patients with ankle fractures have been limited. We therefore analyzed data on Swedish inpatients with ankle fractures in this nationwide population study, based on data from 1987 through 2004.

PATIENTS AND METHODS

Data on all inpatients aged 15 years and older with ankle fracture were extracted from the Swedish National Patient Register for the period 1987-2004.

RESULTS

We identified 91,410 hospital admissions with ankle fracture, corresponding to an annual incidence rate of 71 per 10(5) person-years. During the study period, the number of hospital admissions increased by 0.2% annually, mainly from increase in fracture incidence in the elderly women. Mean age at admission was 45 (SD 19) years for men and 58 (18) for women. The major mechanism of injury was falling at the same level (64%).

INTERPRETATION

This nationwide study of inpatients with ankle fractures showed an increase in fracture incidence, particularly in elderly women.

Comparative trends in hospitalizations for osteoporotic fractures and other frequent diseases between 2000 and 2008

In Switzerland, the number, incidence, and cost of acute hospitalizations for major osteoporotic fractures (MOF) and major cardiovascular events (MCE) increased in both women and men between 2000 and 2008, although the mean length of stay (LOS) was significantly reduced. Similar trend patterns were observed for hip fractures and strokes (decrease) and nonhip fractures and acute myocardial infarctions (increase).

INTRODUCTION

The purpose of this study was to compare the trends and epidemiological characteristics of hospitalizations for MOF and other frequent diseases between years 2000 and 2008 in Switzerland.

METHODS

Trends in the number, age-standardized incidence, mean LOS, and cost of hospitalized MOF and MCE (acute myocardial infarction, stroke, and heart failure) were compared in women and men aged ≥ 45 years, based on data from the Swiss Federal Statistical Office.

RESULTS

Between 2000 and 2008, the incidence of acute hospitalizations for MOF increased by 3.4% in women and 0.3% in men. In both sexes, a significant decrease in hip fractures (-15.0% and -11.0%) was compensated by a concomitant, significant increase in nonhip fractures (+24.8% and +13.8%). Similarly, the incidence of acute hospitalizations for MCE increased by 4.4% in women and 8.2% in men, as an aggregated result from significantly increasing acute myocardial infarctions and significantly decreasing strokes. While the mean LOS in the acute inpatient setting decreased almost linearly between years 2000 and 2008 in all indications, the inpatient costs increased significantly (p < 0.001) for MOF (+30.1% and +42.7%) and MCE (+22.6% and +47.1%) in women and men, respectively.

CONCLUSIONS

Between years 2000 and 2008, the burden of hospitalized osteoporotic fractures to the Swiss healthcare system has continued to increase in both sexes. In women, this burden was significantly higher than that of MCE and the gap widened over time.

Conflicting trends in fall-related injury hospitalisations among older people: variations by injury type

Despite advances in prevention, fall-related hospitalisation rates among older people are still increasing. Rates between 1998/1999 and 2008/2009 for non-facture-related injuries increased by 6.1% while fracture injuries declined by -0.4%. Varying trends in rates of different injury types makes it difficult to provide a definitive explanation for these changes.

INTRODUCTION

Despite advances in fall prevention research and practice, the rate of fall-related hospitalisations continues to increase. However, hip fracture rates appear to be declining. An examination of trends in types of injuries that contribute to the overall fall injury rate is required to establish which injuries are driving the falls admission rate. The aim of this paper is to examine trends in fall-related injury hospital admissions by injury type in New South Wales (NSW), Australia.

METHODS

A retrospective review of fall-related injury hospitalisations in NSW among individuals aged 65+ years, by injury type, was conducted from 1 July 1998 to 30 June 2009. Direct age-standardised admission rates were calculated. Negative binomial regression was used to examine the statistical significance of changes in trend over time of different hospitalised fall-related injuries.

RESULTS

The fall-related hospitalisation rate increased by 1.7% each year (p < 0.0001; 95% confidence interval (CI), 1.3-2.1%). However, the rate of fracture declined by -0.4% (p < 0.03; 95% CI, -0.8-0.0%); whereas, the non-fracture rate increased by 6.1% (p < 0.0001; 95% CI, 5.5-6.7%) annually. Rates for severe head injuries, rib and pelvic fracture increased while those for hip and forearm fracture declined.

CONCLUSIONS

It appears that while fall prevention efforts in NSW are not yet affecting the overall rate of injury hospitalisation, there has been a significant decline in the rates of some fractures. Opposing trends in the rates of other fracture admissions and a significant increase in the rate of non-fracture injuries associated with falls makes a definitive explanation for these changes difficult.

Fracture hospitalizations between years 2000 and 2007 in Switzerland: a trend analysis

In Switzerland, the total number and incidence of hospitalizations for major osteoporotic fractures increased between years 2000 and 2007, while hospitalizations due to hip fracture decreased. The cost impact of shorter hospital stays was offset by the increasing cost per day of hospitalization.

INTRODUCTION

The aim of the study was to establish the trends and epidemiological characteristics of hospitalizations for major osteoporotic fractures (MOF) between years 2000 and 2007 in Switzerland.

METHODS

Sex- and age-specific trends in the number and crude and age-standardized incidences of hospitalized MOF (hip, clinical spine, distal radius, and proximal humerus) in women and men aged ≥45 years were analyzed, together with the number of hospital days and cost of hospitalization, based on data from the Swiss Federal Statistical Office hospital database and population statistics.

RESULTS

Between 2000 and 2007, the absolute number of hospitalizations for MOF increased by 15.9% in women and 20.0% in men, mainly due to an increased number of non-hip fractures (+37.7% in women and +39.7% in men). Hospitalizations for hip fractures were comparatively stable (-1.8% in women and +3.3% in men). In a rapidly aging population, in which the number of individuals aged ≥45 years grew by 11.1% (women) and 14.6% (men) over the study period, the crude and age-standardized incidences of hospitalizations decreased for hip fractures and increased for non-hip MOF, both in women and men. The length of hospital stay decreased for all MOF in women and men, the cost impact of which was offset by an increase in the daily costs of hospitalization.

CONCLUSIONS

Between years 2000 and 2007, hospitalizations for MOF continued to increase in Switzerland, driven by an increasing number and incidence of hospitalizations for non-hip fractures, although the incidence of hip fractures has declined.

Secular decreases in fracture rates 1986-2006 for Manitoba, Canada: a population-based analysis

SUMMARY

We examined trends in fracture rates over 20 years in the Province of Manitoba, Canada. Hip fractures, major low-trauma fractures, and high-trauma fractures declined significantly from 1986 to 2006.

INTRODUCTION

Secular decreases in hip fracture rates have been reported in some countries. Whether this phenomenon applies to other fracture sites is not well described.

METHODS

We used 20 years of data from the Population Health Research Data Repository for the Province of Manitoba, Canada. Age-adjusted fracture rates were calculated for men and women age 50 years and older 1986-2006 according to fracture site and mechanism (presence/absence of external injury codes). Generalized linear models with generalized estimating equations were used to derive adjusted annual rates and test for linear change in men and women.

RESULTS

Major low-trauma fractures (hip, forearm, spine, and humerus) showed a significant annual linear decline in women (-1.2% [95% CI, -0.7% to -1.8%]) and in men (-0.4% [95% CI, -0.7% to -0.2%]). Hip fracture showed a significant annual decline for both sexes, while forearm and humerus fractures showed a significant decline only in women. The only fracture category that did not show a significant annual decline in either sex was the spine. The observed annual reduction in high-trauma fractures was even larger and did not show a sex difference (-1.8% [95% CI, -2.8% to -0.7%]).

CONCLUSION

We observed a decrease in both low-trauma and high-trauma fracture rates over the study period. This decline was apparent in years prior to widespread osteoporosis testing or availability of modern pharmacotherapy.

Secular trends in distal humeral fractures of elderly women: nationwide statistics in Finland between 1970 and 2007

In some types of low-trauma fractures of older adults the number and incidence of fractures are stabilizing or even decreasing. However, very little population-based information is available concerning the nationwide numbers, incidences and especially secular trends of low-trauma fractures of the distal humerus. Therefore, we assessed the current trends in the number and incidence of low-trauma distal humeral fractures in Finnish women 60 years of age or older by taking into account all women who were admitted to Finnish hospitals for primary treatment of such fracture in 1970-2007. The annual total number of low-trauma distal humeral fractures among women 60 years of age or older more than quintupled between 1970 (42 fractures) and 1998 (224 fractures) but after that the number decreased down to 192 fractures in 2007. The age-adjusted incidence (per 100,000 persons) of these fractures also increased during 1970-1998 (from 12 to 34), but thereafter, this incidence decreased to 25 in 2007. Also, in all age groups (60-69, 70-79, and 80-) the trend of age-specific incidence was increasing from 1970 till the end of 1990s, and decreasing thereafter. In conclusion, the clear rise in the rate of low-trauma distal humeral fractures in Finnish women 60 years of age and older from 1970 till late 1990s has been followed by stabilized or even decreased fracture rates. The precise reasons for this secular change are unknown, but a cohort effect towards improved functionality among older women and actions and interventions in preventing falls and minimizing fall severity cannot be ruled out.

Rate of proximal humeral fractures in older Finnish women between 1970 and 2007

Low-trauma fractures of older women are a major public health problem. Nevertheless, nationwide information on recent trends of proximal humeral fractures is sparse. We assessed the current trend in the number and rate (per 100,000 persons) of low-trauma fractures of the proximal humerus among 80-year-old or older women in Finland, a European Union country with a well-defined white population of 5.3 million, by taking into account all women who were admitted to our hospitals for primary treatment of such fracture in 1970-2007. The number of low-trauma fractures of the proximal humerus among 80-year-old or older Finnish women rose continuously between 1970 (32 fractures) and 2007 (478 fractures), but because of a simultaneous, sharper rise in population at risk, the age-adjusted fracture rate (showing a clear rise from 88 fractures per 100,000 persons in 1970 to 304 fractures in 1995) became stabilized between 1995 and 2007 (298 fractures per 100,000 persons in 2007). In conclusion, the clear rise in the rate of low-trauma fractures of the proximal humerus in Finnish elderly women from early 1970s until mid 1990s has been followed by stabilized fracture rates. Reasons for this are largely unknown, but a cohort effect toward a healthier aging population with improved functional ability and reduced risk of injurious falls cannot be ruled out.

Outcome analysis following removal of locking plate fixation of the proximal humerus

Background

Concerning surgical management experience with locking plates for proximal humeral fractures has been described with promising results. Though, distinct hardware related complaints after fracture union are reported. Information concerning the outcome after removal of hardware from the proximal humerus is lacking and most studies on hardware removal are focused on the lower extremity. Therefore the aim of this study was to analyze the functional short-term outcome following removal of locking plate fixation of the proximal humerus.

Methods

Patients undergoing removal of a locking plate of the proximal humerus were prospectively followed. Patients were subdivided into the following groups: Group HI: symptoms of hardware related subacromial impingement, Group RD: persisting rotation deficit, Group RQ: patients with request for a hardware removal. The clinical (Constant-Murley score) and radiologic (AP and axial view) follow-up took place three and six months after the operation. To evaluate subjective results, the Medical Outcomes Study Short Form-36 (SF-36), was completed.

Results

59 patients were included. The mean length of time with the hardware in place was 15.2 ± 3.81 months. The mean of the adjusted overall Constant score before hardware removal was 66.2 ± 25.2% and increased significantly to 73.1 ± 22.5% after 3 months; and to 84.3 ± 20.6% after 6 months (p < 0.001). The mean of preoperative pain on the VAS-scale before hardware removal was 5.2 ± 2.9, after 6 months pain in all groups decreased significantly (p < 0.001). The SF-36 physical component score revealed a significant overall improvement in both genders (p < 0.001) at six months.

Conclusion

A significant improvement of clinical outcome following removal was found. However, a general recommendation for hardware removal is not justified, as the risk of an anew surgical and anesthetic procedure with all possible complications has to be carefully taken into account. However, for patients with distinct symptoms it might be justified.