Complex Ankle Fractures: Practical Approach for Surgical Treatment

Risk factors contributing to postoperative surgical site infections in patients undergoing ankle fracture fixation: A systematic review and meta-analysis

Surgical site infections (SSIs) following ankle fracture fixation pose significant challenges in patient recovery and healthcare management. Identifying risk factors contributing to SSIs can aid in developing targeted prevention and treatment strategies. This systematic review and meta-analysis were conducted according to the PRISMA guidelines and the PICO framework. A comprehensive literature search across major databases, including PubMed, Embase, Web of Science and the Cochrane Library, was completed on September 26, 2023. The inclusion criteria encompassed peer-reviewed studies of various designs that investigated risk factors for SSIs post-ankle fracture fixation. Quality assessment was performed using the Newcastle-Ottawa Scale. Statistical analyses assessed heterogeneity and calculated combined effect sizes using fixed- or random-effects models, depending on the heterogeneity observed. The initial search yielded 1250 articles, with seven meeting the inclusion criteria after rigorous screening and full-text review. The included studies, conducted between 2006 and 2019, predominantly utilized case-control designs. The meta-analysis identified diabetes, open fractures, smoking, age, alcohol consumption, ASA score ≥3, high BMI, contaminated incisions, fracture dislocation and heart disease as significant risk factors for postoperative SSIs. Publication bias assessment showed no significant bias across studies. The identification of key risk factors such as diabetes, open fractures, smoking, advanced age, alcohol consumption, high ASA score, elevated BMI, contaminated incisions, fracture dislocation and heart disease is essential in managing SSIs post-ankle fracture fixation. Targeted interventions addressing these risk factors are crucial to reduce the incidence of SSIs and improve overall patient outcomes.

Epidemiology & management of complex ankle fractures in the United Kingdom: A multicentre cohort study

BACKGROUND

Patient factors are known to contribute to decision making and treatment of ankle fractures. The presence of poor baseline mobility, diabetes, neuropathy, alcoholism, cognitive impairment, inflammatory arthritis or polytrauma can result in a higher risk of failure or complications. Limited evidence is available on the optimum management for this challenging cohort of patients herein described as complex ankle fractures. This UK multicentre study assessed and evaluated the epidemiology of ankle fractures complicated by significant comorbidity and patient factors and use of specialist surgical techniques such as hindfoot nails (HFN) / tibiotalarcalcaneal (TCC) nails and enhanced open reduction and internal fixation (ORIF).

PATIENTS AND METHODS

A UK-wide collaborative study was performed of adult distal AO43/AO44 fractures, associated with 1 or more of the patient factors listed above. Primary outcomes included patient demographics, comorbidities, surgical technique and implants. Secondary outcomes included surgical complications and early post-operative weight bearing instructions. Statistical analysis was performed to assess patient and fracture characteristics on outcome, including propensity matching.

RESULTS

One-thousand three hundred and sixty patients, with at least one of the above complex factors, from 56 centres were included with a mean age of 53.1 years. 90.2% (1227) patients underwent primary fixation which included 78.9% (1073) standard open reduction internal fixations (ORIF), 3.25% (43) extended ORIF and 8.1% (111) primary HFN / TCC. Overall wound complications and thromboembolic events were similar in the hindfoot nail group and the ORIF group (11.7% vs 10.7%). Wound complications were greater in diabetic patients versus non-diabetic patients independent of fixation method (15.8% vs 9.0%). After propensity matching for comorbidities and fracture type, overall complications were lower in the hindfoot nail (11.8%) and extended ORIF groups (16.7%), than the standard ORIF group (18.6%).

CONCLUSION

Only a minority of complex ankle fractures are treated with specialised techniques (HFN/TCC or extended ORIF). Though more commonly used in older and frail patients their perceived advantages are often negated by a reluctance to bear weight early. These techniques demonstrated a better complication profile to standard ORIF but hindfoot nail with joint preparation for fusion was associated with more complications than hindfoot nail for fixation.

LEVEL OF EVIDENCE

III.

Safety of the modified posteromedial approach in complex ankle fractures: Comparative analysis versus posterolateral access

INTRODUCTION

The aim of the study was to evaluate the safety of the modified posteromedial approach (MfPM) in the surgical management of complex ankle fractures in terms of local complications.

METHODS

Retrospective multicenter review of a series of malleolar fractures surgically treated by posterior ankle approaches between 2016 and 2022. Two approaches were used. In the MfPM group patients were placed in a prone position and the incision was made 1 cm medially to the Achilles tendon. In the posterolateral access (PL) group patients were placed in a prone or lateral decubitus position and the incision was made between the lateral malleolus and the Achilles tendon. Complications evaluated were divided into wound complications, infections, neuritis, vascular alterations and others.

RESULTS

81 ankle fractures with a posterior malleolar fragment treated by open reduction and internal fixation were identified. 20 cases were approached through the MfPM approach and 61 through the PL access. The mean follow up was 18.60 months (range 4-78 months). In the MfPM group the local complication rate was 10% (2/10 patients), both corresponding to minor wound problems which required no surgical intervention. No infection or other neural or vascular complications were found. In the PL group a complication rate of 8,19% (5/61 patients) was found, all of them corresponding to minor wound problems which required no surgical intervention. No infection or other neural or vascular complications were found. There were no significant differences between the two approaches regarding postoperative local complications (z score 0.249 - P: 0.803).

CONCLUSION

The MfPM approach is safe and may become as readily used as the PL due to the low incidence of postoperative local complications, especially in fractures with a large fragment and posteromedial extension in which greater access to the posterior pilon can facilitate instrumentation for anatomic reduction and fixation.

Medial malleolar window approach for varus-type tibial pilon fractures: a retrospective study

PURPOSE

Choosing a suitable surgical approach is crucial and challenging for type C pilon fractures. This article aims to explore the clinical efficacy of the medial malleolar window approach for varus-type tibial pilon fractures.

METHODS

A retrospective analysis was conducted on 38 patients with type C varus-type pilon fractures treated between May 2018 and June 2021. In total, 16 cases underwent surgical treatment through the medial malleolar window approach and 22 cases were treated with the traditional anteromedial approach combined with a posterior approach. The operation time, hospitalization time, fracture healing time, the American Orthopedic Foot and Ankle score, Visual Analogue Scale, and complications were recorded to comprehensively evaluate the clinical efficacy of the technique. Fracture reduction quality was evaluated using the criteria proposed by Burwell and Charnley.

RESULTS

All patients were followed up. No patients presented delayed union or nonunion. Compared with the conventional approach, the medial malleolar window approach had the advantage of better clinical effect recovery and better fracture reduction (P < 0.05). Meanwhile, the medial malleolar window approach had a shorter operation time, although the statistics suggest no significant difference with the control group. No implant exposure or infection occurred. There was good wound healing at two weeks after surgery in all but two cases. Local wound edge necrosis developed in one case in the medial malleolar window approach group, and the wound could not be closed at one stage in another case in the conventional group because of excessive tension, requiring secondary closure.

CONCLUSION

The medial malleolar window approach provides excellent exposure to type C pilon fractures, allowing for satisfactory fracture reduction and functional rehabilitation. The medial window approach is recommended for varus-type pilon fractures, which can effectively avoid a posterior incision and reduce the operation time.

Instability of the distal tibiofibular syndesmosis

The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.

[Translated article] Posterior malleolar fractures: Indications and surgical approaches

Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.

Posterior malleolar fractures: Indications and surgical approaches

Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2 mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2 mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.

Analysis of the Effect of Posterior Lateral Malleolus Plate Fixation on the Curative Effect and Mechanical Stability of Complex Ankle Fractures

This paper investigates the effect of lateral and posterior 1/3 tubular plate bone plate fixation on the curative effect, wound healing, and mechanical stability of complex ankle fracture. 80 patients with complex ankle fractures treated in our hospital from January 2018 to July 2020 are selected for the study, and 80 patients are randomly divided into posterior fixation group and lateral fixation group according to the number table method, with 40 patients in each group. Patients in the posterior malleolus fixation group are treated with posterior lateral malleolus plate fixation, and patients in the lateral malleolus fixation group are treated with lateral malleolus plate fixation. The differences in efficacy, mechanical stability, wound healing, visual analog scale (VAS) pain score, and American Association of Foot and Ankle Surgery (AOFAS) ankle function are compared. The subjects are followed up for 6 months until January 2022. In patients with complex ankle fracture, 1/3 tubular plate osteoplate fixation in the posterior lateral malleolus can improve clinical efficacy and mechanical stability, which is helpful to promote incision healing and reduce the risk of complications. The 1/3 tubular plate osteoplate fixation in the posterior lateral malleolus is worthy of clinical promotion and application.