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Epperly S, Nedley A, Chung JH, Rodrigues E, Johnson J. Use of locking fibular plates versus non-locking dual plate fixation: A biomechanical study. J Clin Orthop Trauma 2024; 53:102439. [PMID: 39036509 PMCID: PMC11260034 DOI: 10.1016/j.jcot.2024.102439] [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: 09/27/2023] [Revised: 03/31/2024] [Accepted: 06/05/2024] [Indexed: 07/23/2024] Open
Abstract
Introduction Distal fibula osteoporotic comminuted fractures are challenging to treat and are often treated with periarticular locking plates. This study examined the biomechanical difference between locked plating and dual non-locked one-third tubular plating. Methods Using an osteoporotic Sawbones fibula model, simulated fracture were fixated with one-third tubular dual plating and locked periarticular plating. The samples were then torqued to failure and peak torque, stiffness, and displacement were recorded. Results The peak torque of the dual plating group was found to be statistically higher than the periarticular locked plating group (0.841 Nm and 0.740 Nm respectively; p = 0.024). However overall stiffness calculated at each 10° increment of displacement was noted to have no significant difference between the two constructs. Conclusion Dual non-locked plating of distal fibula osteoporotic comminuted fractures is biomechanically equivalent to locked periarticular plating.
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Affiliation(s)
| | - Allen Nedley
- Loma Linda University Department of Orthopaedics, Loma Linda, CA, United States
| | - Jun Ho Chung
- Loma Linda University Department of Orthopaedics, Loma Linda, CA, United States
| | - Evelyn Rodrigues
- Loma Linda University Department of Orthopaedics, Loma Linda, CA, United States
| | - Joseph Johnson
- University of Alabama Birmingham Department of Orthopaedics, Birmingham, AL, United States
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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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Patel R, McCarthy K, Christensen J, Jacobs B, Karsch J, Sephien A, Matson C, Sanders RW, Mir HR. Cost analysis and clinical outcomes of anatomic pre-contoured locking versus conventional plates for distal fibula ankle fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:959-965. [PMID: 37779131 DOI: 10.1007/s00590-023-03728-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE To analyze differences in union, complication rates and cost from surgical fixation of distal fibula fractures with fibular plating implants. METHODS In total, 380 adult patients from 2012 to 2015 treated with 12 fibular plates from 4 different manufacturers utilized by 9 surgeons were retrospectively reviewed. They were stratified into a conventional one-third tubular fibular plate group, pre-contoured anatomic locking plate group, or a heterogeneous group including 3.5-mm reconstruction, one-third tubular locking, composite, and limited compression plates. The outcomes included failure of fixation, deep infection requiring debridement, time to union, anatomic reduction, superficial infection, hardware removal, and post-traumatic arthritis. Plate and screw costs were calculated from hospital billing records. RESULTS Pre-contoured locking plates were used in older, female patients with a greater number of comorbidities. Open injuries and OTA 44B fractures were more likely to be an indication for pre-contoured plates. There was no difference noted in time to union between the different plating groups. Risk factors for deep infection requiring debridement included a history of tobacco use, open fractures, and pre-contoured locking plates relative to the conventional plating group. The pre-contoured plating group was on average $586 more expensive compared to the conventional group. CONCLUSION Pre-contoured locking plates achieved similar radiographic outcomes compared to conventional plates with an increased risk of complications and higher cost. Surgeons should consider their choice of implant based on the patient's fracture pattern, underlying comorbidities, and risk for infection.
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Affiliation(s)
- Raahil Patel
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA.
| | - Kevin McCarthy
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
| | - Joseph Christensen
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
| | - Bonamico Jacobs
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
| | - Jordan Karsch
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
| | - Andrew Sephien
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
| | - Christopher Matson
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
| | - Roy W Sanders
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
- Florida Orthopaedic Institute, 13020 N Telecom Parkway, Tampa, FL, 33637, USA
| | - Hassan Riaz Mir
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL, 33606, USA
- Florida Orthopaedic Institute, 13020 N Telecom Parkway, Tampa, FL, 33637, USA
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Penning D, Jonker CAL, Buijsman R, Halm JA, Schepers T. Minifragment plating of the fibula in unstable ankle fractures. Arch Orthop Trauma Surg 2023; 143:1499-1504. [PMID: 35224664 PMCID: PMC9958153 DOI: 10.1007/s00402-022-04397-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/14/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Only 6.4-17% of the load is transmitted through the fibula when weight-bearing. Plate fixation of distal fibular fractures using minifragments (≤ 2.8 mm) could lead to similar reduction with less implant removal (IR) rates, compared to small-fragment plates (3.5 mm). We hypothesized that the use of minifragment plates is at least similar in unscheduled secondary surgery. MATERIALS AND METHODS In this retrospective cohort study, all patients with surgically treated distal fibular fractures between October 2015 and March 2021 were included. Patients treated with plate fixation using minifragments and patients treated with small-fragment plates were compared regarding the following outcomes: secondary dislocation, malreduction, implant malposition, nonunion, surgical site infections (SSI) and IR. RESULTS Sixty-five patients (54.2%) received a minifragment implant (≤ 2.8 mm) and 55 patients (45.8%) received a small-fragment implant (3.5 mm). There were no patients needing secondary surgery in the minifragment group compared to 9 patients following fixation using small-fragment implants (3 with secondary dislocation, 5 with malreduction and 1 with malposition, p = 0.001). SSI rates were 3.1% for minifragment and 9.1% for small-fragment implants (p = 0.161). Implant removal was performed significantly less often following use of minifragment implants (17.8% and 53.2%, p < 0.001). CONCLUSIONS In this cohort, minifragment plate fixation for distal fibular fractures is an adequate fixation method offering stable fixation with significant lower need for implant removal and comparable complications to small-fragment plates, although an adequately powered randomized controlled study is needed for implementation in a clinical setting. LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- D. Penning
- Trauma Unit Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - C. A. L. Jonker
- Trauma Unit Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - R. Buijsman
- Department of Traumasurgery, Tergooi MC, Van Riebeeckweg 212, 1213 XZ Hilversum, The Netherlands
| | - J. A. Halm
- Trauma Unit Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - T. Schepers
- Trauma Unit Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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A Prospective Randomized Study Comparing Functional Outcome in Distal Fibula Fractures between Conventional AO Semitubular Plating and Minimal Invasive Intramedullary "Photodynamic Bone Stabilisation". J Clin Med 2022; 11:jcm11237178. [PMID: 36498750 PMCID: PMC9736249 DOI: 10.3390/jcm11237178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
(1) Background: As age in western populations is rising, so too are fractures, e.g., of the distal fibula. The aim of this study was to find out whether a novel, minimally invasive intramedullary osteosynthesis technique for the treatment of distal fibula fractures in elderly patients results in not only a reduction of postoperative complications, but also a shorter hospitalization time, an improved clinical outcome, and preserved autonomy in geriatric trauma patients. (2) Methods: In this prospective study, the results following surgical treatment for distal fibula fractures in geriatric patients after using DePuy Synthes® one-third semitubular plate (Group I) or a minimally invasive intramedullary photodynamic Bone StabilizationSystem (IlluminOss®) (Group II) were compared at 6 weeks, 12 weeks, 6 months, and 1 year after initial treatment. (3) Results: Significant improvement regarding clinical outcome was shown in Group II 6 and 12 weeks after surgery. (4) Conclusions: Our study results demonstrate that the use of this new intramedullary stabilization system in combination with an immediate postoperative weight bearing seems to be a safe and stable treatment option for ankle fractures in geriatric patients, especially in the early stages of recovery.
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Schagemann JC, Neumann H, Schäfers J, Paech A, Wendlandt R, Oheim R, Schulz AP. Similar Clinical Outcome in Locking and Conventional Plate Osteosynthesis for the Treatment of AO 44-B2 Ankle Fractures. Foot Ankle Spec 2022:19386400221136757. [PMID: 36418935 DOI: 10.1177/19386400221136757] [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] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Biomechanical studies have proved that locking plates have better primary stability besides versatility regarding fracture pattern while reducing bone contact and bridging the gap, whereas conventional nonlocking plates (plus lag screw) depend on bone-plate compression. The clinical benefit of locking plates over nonlocking plates remains unanswered, however. Therefore, this retrospective cohort study was set up to test the hypothesis that the use of locking plates for unstable ankle fractures will result in fewer re-displacements, superior bony healing, and functional and clinical outcomes better than observed in the nonlocking cohort. METHODS Bimalleolar ankle fractures (AO 44-B2) without syndesmotic injury treated with either a locking or a nonlocking plate were included. Groups were compared for complications, bone healing, secondary dislocation, progressions of osteoarthritis, and clinical outcome using patient-reported outcome measures. RESULTS Data revealed no clinical outcome differences (Olerud-Molander Ankle Score: nonlocking 88.2 ± 14.4, locking 88.8 ± 12.3, P = .69, robust two 1-sided test for equality (RTOST): P = .03; American Orthopaedic Foot and Ankle Score: nonlocking 91.2 ± 12.9, locking 91.8 ± 11.3, P = .96, RTOST: P = .04). Nevertheless, a significant postoperative progression of osteoarthritis was detected in both groups (P = .04). This was independent of implant (P = .16). Although difference was not significant, locking plates were preferred in older (P = .78) and sicker patients (P = .63) and in cases with severer osteoarthritis (P = .16), and were associated with a higher complication rate (P = .42) and secondary dislocation (nonlocking 9.4%, locking 18.2%; P = .42). Re-displacement, however, was not a compelling reason for revision. CONCLUSIONS The present study shows statistically significant equality of both types of implants. Contrary to our expectation, locking plates seemed to be associated with a higher risk for re-displacement. Overall, the use of either locking or nonlocking plates for unstable AO 44-B2 fractures is safe and successful despite significant progression of osteoarthritis. LEVEL OF EVIDENCE III, Retrospective observational cohort study.
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Affiliation(s)
- Jan C Schagemann
- Christophorus Kliniken Coesfeld, Coesfeld, Germany
- Universität zu Lübeck, Lübeck, Germany
| | | | | | | | | | - Ralf Oheim
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Arndt Peter Schulz
- Universität zu Lübeck, Lübeck, Germany
- BG Klinikum Hamburg, Hamburg, Germany
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Jacobsen GH, Gude MH, Viberg B, Gundtoft PH. Risk of Reoperation in Simple Ankle Fracture Surgery When Comparing Locking Plate With Nonlocking Plate. J Foot Ankle Surg 2022; 61:567-571. [PMID: 34838457 DOI: 10.1053/j.jfas.2021.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/12/2021] [Accepted: 10/05/2021] [Indexed: 02/03/2023]
Abstract
Locking plates were initially designed to provide improved stability to ankle fractures with poor bone quality but are currently widely used. The aim of this study was to compare the reoperation risk when using locking plates compared with nonlocking plates in patients with simple ankle fractures. This study was a population-based register study. Data regarding patients with AO type 44A1/2 and 44B1/2 injuries who were treated with either locking or nonlocking plates were obtained from the Danish Fracture Database. The follow-up period was 24 months. Major complications were defined as complications requiring surgical intervention, with the exception of simple hardware removal 6 weeks after primary surgery, which was defined as a minor complication. Multivariate regression analysis was performed to determine relative risk (RR), adjusted for age, sex, American Society of Anesthesiologists physical status classification (ASA)-score, and level of the surgeon's experience. A total of 2177 ankle fractures were included, among which 718 (33%) were treated with locking plates, and 1459 (67%) were treated with nonlocking plates. Data were linked with the Danish National Patient Registry to ensure complete information was obtained regarding reoperations, which were divided into major and minor complications. In both groups, the risks for major and minor complications were 3% and 22%, respectively, resulting in adjusted RRs of 1.00 (0.66; 1.66) for major reoperation comparing locking with nonlocking plates and 0.92 (0.76; 1.11) for minor reoperations. We conclude that no significant association with reoperation exists for locking compared with nonlocking plates among patients with surgically treated simple ankle fractures.
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Affiliation(s)
- Gudrun Holm Jacobsen
- Resident, Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Denmark.
| | - Mads Holm Gude
- Resident, Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Denmark
| | - Bjarke Viberg
- Consultant Associate Professor and Head of Research, Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Denmark
| | - Per Hviid Gundtoft
- Consultant, Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Denmark
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Eyre-Brook AI, Ring J, Chadwick C, Davies H, Davies M, Blundell C. A Comparison of Fibula Pro-Tibia Fixation Versus Hindfoot Nailing for Unstable Fractures of the Ankle in Those Older Than 60 Years. Foot Ankle Spec 2021; 16:135-144. [PMID: 34176315 DOI: 10.1177/19386400211017373] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ankle fractures in the elderly are an increasing problem, with poor outcomes reported. Operative options for patients with suspected osteoporosis and needing to bear weight to ambulate can include hindfoot intramedullary nail (IMN) or fibula pro-tibia fixation (FPT). FPT involves passing 2 or more screws through a lateral fibula plate, crossing the fibular into the tibia, with 1 or more screws proximal to the incisura. We compared the outcomes of these 2 techniques. METHOD A retrospective review identified 68 patients aged over 60 years with unstable ankle fractures, treated with IMN or FPT. Primary outcome was surgical reoperation/revision rate, secondary outcomes included complications, length of stay, and functional status. Results: There were no significant differences in demographics between IMN and FPT. Revision rates were higher in IMN compared with FPT (P < .0001). IMN patients postoperatively had longer hospital stays (P = .02), longer follow-up times (P = .008), and higher rates of delayed wound healing (P = .03) and nonunion (P = .001). Multivariate analysis identified fixation and age to affect revision rates. CONCLUSION Outcomes were worse in the IMN group compared with FPT. We believe both techniques have a role in the management of elderly ankle fractures, but patient selection is key. We suggest that FPT should be the first-choice technique when soft tissues permit. LEVELS OF EVIDENCE Level III.
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Abstract
Ankle fractures remain the third most common musculoskeletal injury in the elderly population. The presence of osteoporosis, significant multiple comorbidities and limited functional independence makes treatment of such injuries challenging. Early studies highlighted high rates of post-operative complications and poor outcomes after surgical intervention. With advances in surgical techniques and a greater understanding of multi-disciplinary team (MDT)-driven peri-operative care and rehabilitation, evidence now appears to suggest improved outcomes for operative management. Approaches must be adapted according to co-morbidities, baseline function and patient wishes. This review article aims to discuss contemporary treatment strategies and the complex challenges associated with the management of the elderly ankle fracture.
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Shih CA, Jou IM, Lee PY, Lu CL, Su WR, Yeh ML, Wu PT. Treating AO/OTA 44B lateral malleolar fracture in patients over 50 years of age: periarticular locking plate versus non-locking plate. J Orthop Surg Res 2020; 15:112. [PMID: 32197662 PMCID: PMC7082938 DOI: 10.1186/s13018-020-01622-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 03/04/2020] [Indexed: 02/06/2023] Open
Abstract
Background The role of locking plate in lateral malleolar fracture fixation for the elderly remains unclear. The aim of our study is to compare radiological and functional outcomes in older patients (> 50 years) with AO/OTA 44B lateral malleolar fractures after locking plate (PLP) or one-third non-locking tubular plate (TP) lateral fixation. Methods We retrospectively reviewed the medical records of 72 patients (PLP group, 34 patients; TP group, 38 patients; mean age, 61.9 ± 7.6 years; range, 51–80 years; follow-up, 1 year). Patients with open fractures, syndesmosis injuries, and a previous ankle trauma or surgery were excluded. Demographic data, union rate, complications, radiographic outcomes, visual analog scale (VAS) scores, and foot and ankle outcome scores (FAOSs) between the groups were recorded and compared. We also investigated the association of clinical features with pain and function. Statistically, the Fisher’s exact test was used for categorical variables and the Mann-Whitney U test for the continuous variables. The final model for the multiple regression analysis was used to predict factors related to functional outcomes. Results There were no significant between-group differences in demographic data, complication rates, immediately postoperative distal fibula lengths, ankle osteoarthritis (OA) grades, talar tilt angles (TTAs) ≥ 2°, or reduction accuracy. All fractures achieved union. The PLP group had significantly lower rates of distal screw loosening, fibula shortening > 2 mm, OA grade progression, and TTAs ≥ 2°, and better FAOSs and VAS scores than was the case for the TP group after 1 year of follow-up (all p < 0.05). The severity of OA, TTA ≥ 2°, and distal screw loosening were positively associated with VAS scores, and negatively associated with FAOSs. Conclusions When treating AO/OTA 44B fractures in patients over 50 years of age, PLPs provided better VAS scores, FAOSs, and radiological outcomes, including less fibula shortening > 2 mm, less osteoarthritic (OA) ankle progression, less implant removal rate, and fewer TTAs ≥ 2° than was the case for TPs after a 1-year follow-up. Level of evidence Therapeutic level III
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Affiliation(s)
- Chien-An Shih
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopedics, National Cheng Kung University Hospital Dou-Liou Branch, Yunlin, Taiwan
| | - I-Ming Jou
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Pei-Yuan Lee
- Department of Orthopedics, Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Chin-Li Lu
- Institute of Food Safety, National Chung Hsing University, Taichung, Taiwan
| | - Wei-Ren Su
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Medical Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Long Yeh
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Medical Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Po-Ting Wu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan. .,Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Orthopedics, National Cheng Kung University Hospital Dou-Liou Branch, Yunlin, Taiwan. .,Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Medical Innovation Center, National Cheng Kung University, Tainan, Taiwan.
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11
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Agarwala S, Menon A, Bhadiyadra R. Twisted Plating - A Method of Distal Fibula Fixation. Rev Bras Ortop 2020; 55:33-39. [PMID: 32123444 PMCID: PMC7048577 DOI: 10.1055/s-0039-1700820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 11/06/2018] [Indexed: 10/31/2022] Open
Abstract
Objective The literature entails various intramedullary and extramedullary methods for distal fibula fracture fixation; with no consensus yet over the ideal method of fixation. We have retrospectively analyzed the results of using a twisted and contoured 3.5 mm locking compression plate (LCP) as a posterior buttress plate. Methods Of the 62 cases with ankle fractures managed at our institute by the senior author from 1 st January 2012 to 31 st December 2015, 41 patients met our inclusion criteria (Danis-Weber types B and C). Results All 41 distal fibular fractures healed uneventfully, at a mean of 10.4 weeks (8-14 weeks) (Figs. 6, 7, 8 to 9) with no complications. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 92.6 (86-100) at a mean follow-up of 31.5 months (14-61 months). Conclusions We have achieved excellent clinical and radiological outcomes using a twisted 3.5 mm LCP as a posterior buttress by combining the advantages of posterior antiglide plating and lateral LCP.
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Affiliation(s)
- Sanjay Agarwala
- Departamento de Ortopedia, Hinduja Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim (West), Mumbai, Maharashtra, Índia
| | - Aditya Menon
- Departamento de Ortopedia, Hinduja Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim (West), Mumbai, Maharashtra, Índia
| | - Ravi Bhadiyadra
- Departamento de Ortopedia, Hinduja Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim (West), Mumbai, Maharashtra, Índia
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Abstract
PURPOSE OF REVIEW Fractures of osteoporotic bone in elderly individuals need special attention. This manuscript reviews the current strategies to provide sufficient fracture fixation stability with a particular focus on fractures that frequently occur in elderly individuals with osteoporosis and require full load-bearing capacity, i.e., pelvis, hip, ankle, and peri-implant fractures. RECENT FINDINGS Elderly individuals benefit immensely from immediate mobilization after fracture and thus require stable fracture fixation that allows immediate post-operative weight-bearing. However, osteoporotic bone has decreased holding capacity for metallic implants and is thus associated with a considerable fracture fixation failure rate both short term and long term. Modern implant technologies with dedicated modifications provide sufficient mechanical stability to allow immediate weight-bearing for elderly individuals. Depending on fracture location and fracture severity, various options are available to reinforce or augment standard fracture fixation systems. Correct application of the basic principles of fracture fixation and the use of modern implant technologies enables mechanically stable fracture fixation that allows early weight-bearing and results in timely fracture healing even in patients with osteoporosis.
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Affiliation(s)
- Marianne Hollensteiner
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Sabrina Sandriesser
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Emily Bliven
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Christian von Rüden
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
- Department of Trauma Surgery, BG Klinikum Murnau, Murnau, Germany
| | - Peter Augat
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany.
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria.
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Randall RM, Nagle T, Steckler A, Billow D, Berkowitz MJ. Dual Nonlocked Plating as an Alternative to Locked Plating for Comminuted Distal Fibula Fractures: A Biomechanical Comparison Study. J Foot Ankle Surg 2019; 58:916-919. [PMID: 31345755 DOI: 10.1053/j.jfas.2019.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Indexed: 02/06/2023]
Abstract
The purpose of this cadaveric study was to compare the biomechanical properties of dual nonlocked plating and single-locked plating using matched pairs of isolated fibula specimens. Fractures were simulated in 10 matched pairs of isolated cadaveric fibulae and plated with a single lateral locking plate for right-sided specimens, or with a one-third tubular plate and a 7-hole 2.4-mm minifragment adaption plate for left-sided specimens. An external rotation torque was applied at a rate of 1°/second, and torque at 10° was measured. Each fibula specimen was evaluated using a micro computed tomography scanner, and bone mineral density was calculated as milligrams of bone per cubic centimeter of volume. Dual nonlocked plating and locked plating specimens demonstrated torque measurements that were not significantly different at 10° of external rotation (1.48 N·m and 1.92 N·m, respectively; p = .093). The stiffness of the dual nonlocked plated and locked plating constructs were not significantly different (p = .228 and p = .543, respectively). The effect of bone mineral density on maximum torque at failure was not a reliable predictor of maximum torque in either the dual nonlocked plating or locked plating specimens (R2 = 0.548 and R2 = 0.096, respectively). We found no differences in torque at 10° of external rotation or stiffness between locking plate and dual nonlocking plate fixation constructs. This study provides evidence that dual nonlocked plating likely constitutes adequate fixation in situations in which a locking plate is being considered for comminuted distal fibula fractures.
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Affiliation(s)
- Rachel M Randall
- Orthopaedic Surgery Resident, Department of Orthopaedics and Rheumatology, Cleveland Clinic Foundation, Cleveland, OH.
| | - Tara Nagle
- Principle Biomechanical Research Engineer, Biomechanical Engineering Department, Cleveland Clinic Foundation, Cleveland, OH
| | - Andrew Steckler
- Director of Orthopaedic Skills Laboratory, Biomechanical Engineering Department, Cleveland Clinic Foundation, Cleveland, OH
| | - Damien Billow
- Center Director for Trauma, Department of Orthopaedics and Rheumatology, Cleveland Clinic Foundation, Cleveland, OH
| | - Mark J Berkowitz
- Center Director for Foot and Ankle Surgery, Department of Orthopaedics and Rheumatology, Cleveland Clinic Foundation, Cleveland, OH
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14
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Ebraheim NA, Vander Maten JW, Delaney JR, White E, Hanna M, Liu J. Cannulated Intramedullary Screw Fixation of Distal Fibular Fractures. Foot Ankle Spec 2019; 12:264-271. [PMID: 30091366 DOI: 10.1177/1938640018790082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- Nabil A Ebraheim
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | | | - Joshua R Delaney
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Erik White
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Maged Hanna
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Jiayong Liu
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
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15
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Gausepohl T, Gick S, Heck S, Pennig D. [Osteoporotic bone fractures: intramedullary augmentation and hybrid osteosynthesis]. Unfallchirurg 2019; 122:596-603. [PMID: 31073703 DOI: 10.1007/s00113-019-0660-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The increasing number of people who are living longer and have a far more active lifestyle is inevitably associated with greater numbers of fractures. Stabilization of these fractures in older patients with plates and screws is complicated by fragile bone substance, especially in osteoporotic bone, since osteosynthesis with a conventional plate depends exclusively on the holding power of the screws. Therefore, treatment requires new stabilization technologies designed for these specific tasks. A small diameter polyethylene terephthalate (PET, Dacron®) balloon is delivered in a minimally invasive fashion and placed within the canal, transversing the fracture. Once positioned, the balloon is expanded with a liquid monomer to fill the medullary canal. The liquid monomer is then rapidly cured using visible blue light, forming a patient-customized intramedullary implant that stabilizes the entire length of the bone in contact with the implant. The described intramedullary implant can be easily drilled in any position or location, providing a substantial increase in screw holding power. Thus, a major advantage of the technique is the possibility to augment the newly formed balloon "nail" with a conventional plate and screws at the primary stabilization or at any later time.
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Affiliation(s)
- Thomas Gausepohl
- Zentrum Unfallchirurgie und Orthopädie, Standort Wetzlar (Lehrkrankenhaus der Universität Gießen), Lahn-Dill-Klinken, Wetzlar, Deutschland. .,Zentrum Unfallchirurgie und Orthopädie, Standort Dillenburg (Lehrkrankenhaus der Universität Marburg), Lahn-Dill-Klinken, Dillenburg, Deutschland. .,, Ludwigstr. 72, 35392, Gießen, Deutschland.
| | - Sascha Gick
- Abteilung für Unfallchirurgie, Hand- und Wiederherstellungschirurgie, St. Vinzenz Hospital Köln (Lehrkrankenhaus der Universität zu Köln), Köln, Deutschland
| | - Steffen Heck
- Abteilung für Unfallchirurgie, Hand- und Wiederherstellungschirurgie, St. Vinzenz Hospital Köln (Lehrkrankenhaus der Universität zu Köln), Köln, Deutschland
| | - Dietmar Pennig
- Abteilung für Unfallchirurgie, Hand- und Wiederherstellungschirurgie, St. Vinzenz Hospital Köln (Lehrkrankenhaus der Universität zu Köln), Köln, Deutschland
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16
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Hsu RY, Ramirez JM, Blankenhorn BD. Surgical Considerations for Osteoporosis in Ankle Fracture Fixation. Orthop Clin North Am 2019; 50:245-258. [PMID: 30850082 DOI: 10.1016/j.ocl.2018.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
As the geriatric population and associated ankle fractures continues to increase, fracture surgeons should be prepared to surgically manage osteoporotic ankle fractures. There are abundant challenges in management, soft tissue care, and fixation of ankle fractures with poor bone quality especially in elderly patients who have difficulty limiting weight bearing. This article summarizes several different surgical techniques that can be used to optimize outcomes of these fractures.
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Affiliation(s)
- Raymond Y Hsu
- Department of Orthopedic Surgery, The Warren Alpert Medical School at Brown University, 1 Kettle Point Avenue, East Providence, RI 02915, USA.
| | - Jose M Ramirez
- Department of Orthopedic Surgery, The Warren Alpert Medical School at Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Brad D Blankenhorn
- Department of Orthopedic Surgery, The Warren Alpert Medical School at Brown University, 1 Kettle Point Avenue, East Providence, RI 02915, USA
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17
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Principles and current concepts in the surgical treatment of fragility fractures in the elderly. Best Pract Res Clin Rheumatol 2019; 33:264-277. [DOI: 10.1016/j.berh.2019.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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18
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Dingemans SA, Sintenie FW, de Jong VM, Luitse JSK, Schepers T. Fixation Methods for Calcaneus Fractures: A Systematic Review of Biomechanical Studies Using Cadaver Specimens. J Foot Ankle Surg 2018; 57:116-122. [PMID: 29129315 DOI: 10.1053/j.jfas.2017.05.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Indexed: 02/03/2023]
Abstract
Calcaneal fractures are notoriously difficult to treat and wound complications occur often. However, owing to the rare nature of these fractures, clinical trials on this subject are lacking. Thus, biomechanical studies form a viable source of information on this subject. With our systematic review of biomechanical studies, we aimed to provide an overview of all the techniques available and guide clinicians in their choice of method of fracture fixation. A literature search was conducted using 3 online databases to find biomechanical studies investigating methods of fixation for calcaneal fractures. A total of 14 studies investigating 237 specimens were identified. Large diversity was found in the tested fixation methods and in the test setups used. None of the studies found a significant difference in favor of any of the fixation methods. All tested methods provided a biomechanically stable fixation. All the investigated methods of fixation for calcaneal fractures seem to be biomechanically sufficient. No clear benefit was found for locking plates in the fixation of calcaneal fractures; however, a subtle mechanical superiority might exist compared with nonlocking plates in the case of fractures in osteoporotic bone. Several of the techniques tested would be suitable for a minimal invasive approach. These should be investigated further in clinical trials.
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Affiliation(s)
- Siem A Dingemans
- Resident General Surgery, Trauma Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Floris W Sintenie
- Medical Student, Trauma Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Vincent M de Jong
- Traumasurgeon, Trauma Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan S K Luitse
- Traumasurgeon, Trauma Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Tim Schepers
- Traumasurgeon, Trauma Unit, Academic Medical Center, Amsterdam, The Netherlands.
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19
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Herrera-Pérez M, Gutiérrez-Morales MJ, Guerra-Ferraz A, Pais-Brito JL, Boluda-Mengod J, Garcés GL. Locking versus non-locking one-third tubular plates for treating osteoporotic distal fibula fractures: a comparative study. Injury 2017; 48 Suppl 6:S60-S65. [PMID: 29162244 DOI: 10.1016/s0020-1383(17)30796-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Ankle fractures represent the third most common fracture in elderly patients, after hip and wrist fractures. Distal fibula fractures in this population are closely related to osteoporosis, which renders commonly used methods of internal fixation technically demanding and prone to failure. Currently there is a tendency to fix osteoporotic metaphyseal and epiphyseal fractures with locking plates. However, published accounts about the use of this technology in osteoporotic distal fibula fractures are scarce. In this study we compare the results of two groups of patients who underwent surgery for these types of fracture, one group received locking and the other non-locking screws, both using one-third tubular plates. METHODS Sixty-two patients, aged over 64 years, underwent surgery for osteoporotic distal fibula fractures between 2011 and 2014. Forty-five of them were stabilized with a non-locking plate and the remaining 17 with a locking plate fixation. Follow-up was performed at 4, 8, 12, 26, and 52 weeks. Results were assessed according to the AOFAS Ankle-Hindfoot Score and radiological criteria for consolidation. RESULTS Average time to union and AOFAS scores at 6 and 12 months were similar in both groups, including for the individual categories: function, pain, mobility, and alignment. Only time until partial weight bearing was significantly lower in the locking plate group (4.69 ± 2.63 vs 7.77 ± 4.30, p = 0.03). The most common complications were wound dehiscence and superficial infection (two cases of both). CONCLUSIONS Both locking and conventional non-locking plates achieved similar treatment outcomes in this group of osteoporotic patients aged over 64. However, locking plates may offer more benefits in cases that have to take into account immobilization time and concomitant soft-tissue damage.
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Affiliation(s)
- Mario Herrera-Pérez
- Department of Orthopaedics, University Hospital of Canary Islands, Tenerife, Spain; School of Medicine, Universidad de La Laguna, Tenerife, Spain
| | | | - Ayron Guerra-Ferraz
- Department of Orthopaedics, University Hospital of Canary Islands, Tenerife, Spain
| | - Jose L Pais-Brito
- Department of Orthopaedics, University Hospital of Canary Islands, Tenerife, Spain; School of Medicine, Universidad de La Laguna, Tenerife, Spain
| | - Juan Boluda-Mengod
- Department of Orthopaedics, University Hospital of Canary Islands, Tenerife, Spain
| | - Gerardo L Garcés
- Department of Orthopaedics, Hospital Perpetuo Socorro, Gran Canaria, Spain; School of Medicine, Universidad de Las Palmas de Gran Canaria, Gran Canaria, Spain.
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20
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Hoogervorst P, Bergen CV, Van den Bekerom M. Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly. CURRENT GERIATRICS REPORTS 2017; 6:9-14. [PMID: 28316904 PMCID: PMC5334400 DOI: 10.1007/s13670-017-0196-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- P Hoogervorst
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC Amsterdam, the Netherlands
| | - Cja Van Bergen
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM Hoofddorp, the Netherlands
| | - Mpj Van den Bekerom
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC Amsterdam, the Netherlands
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