The management of ankle fractures in the elderly

Open Ankle Fractures in Older Individuals: A Multi-center Study

The purpose of this study is to identify demographics, etiology, comorbidities, treatment, complications, and outcomes for older patients with open ankle fractures. Patients ≥60 years old who sustained an open ankle fracture between January 1, 2004 and March 31, 2014 at 6 Level 1 trauma centers were retrospectively reviewed. Univariate analysis using chi-squared or Student's t test was performed to identify associations between preoperative variables and 2 postoperative outcomes of interest: amputation and 1-year mortality. Multivariate analysis was performed using stepwise logistical regression to identify independent predictors of postoperative amputation and 1-year mortality. Of the 162 total patients, the most common mechanism of injury was a ground-level fall (51.9%). The most common fracture types were bimalleolar fractures (52.5%) followed by trimalleolar fractures (26.5%), with 41.5% of the fractures classified as Gustilo Anderson Classification Type 2 and 38.6% classified as Type 3A. The average number of surgeries required per patient was 2.1. Complications included: 15.4% superficial infection rate, 9.9% deep infection rate, and 9.3% amputation rate. The 1-year mortality rate was 13.6% and the overall mortality rate was 25.9%. Male gender and fracture type were found to be independent predictors for amputation after surgery (p = .009, .005, respectively). Older age and having diabetes were independent predictors for 1-year mortality after surgery (p = .021, .005 respectively). Overall, open ankle fractures in older individuals were associated with high rates of amputation and mortality.

Tibiotalar nailing using an antegrade intramedullary tibial nail: a salvage procedure for unstable distal tibia and ankle fractures in the frail elderly patient

AIM

This article describes the technique of tibiotalar nailing performed using an antegrade tibial nail for salvage of distal tibia and ankle fractures in elderly patients.

MATERIALS AND METHODS

We report indications, surgical technique, and the clinical outcomes and complication rate in our series to date. A retrospective review was performed at our level 1 major trauma centre. Patient demographics, comorbidities, and 12-month post-operative course were collected. Fractures were classified using the OTA/AO and modified Gustilo-Anderson classification. Fifteen patients underwent the procedure. We present data with a minimum 12-month follow-up. The median age of the patients in this cohort was 83 years (range, 51-102). Five patients were diabetic. Six patients (6/15; 40%) presented with an open fracture.

RESULTS

At final follow-up, fourteen patients reported painless walking and had returned to baseline activity.

CONCLUSION

This technique may serve as a salvage procedure, with indications similar to those for tibio-talar-calcaneal arthrodesis. Indications would include non-constructible pilon fractures, comminuted intra-articular fractures in low-demand patients, or patients at high risk of wound complications.

LEVEL OF CLINICAL EVIDENCE

3.

Physiotherapy Management Focusing on Early Mobilisation in Complex Pelvic and Pott's Fracture

Pelvic fractures (PFs), involving the disruption of the bony structures in the pelvic region, are complex injuries often associated with high-energy trauma. Such fractures can significantly impact a patient's mobility and overall quality of life. Concurrently, fractures of the malleoli, specifically the lateral and medial aspects of the ankle, are common lower extremity injuries that can result from various mechanisms, including twisting or direct trauma. This case report presents the multidisciplinary approach employed in the successful treatment of a 26-year-old male patient with a rare combination of PFs involving both anterior and posterior columns, along with lateral and medial malleolus fractures. The patient underwent a series of surgical interventions to stabilise the fractures, followed by a tailored physiotherapy management plan. The report discusses the postoperative care strategies and the crucial role of physiotherapy in the rehabilitation process.

Survival analysis in nonagenarian patients with non-hip lower limb fractures

BACKGROUND

The United Kingdom has an aging population with nearly 1 in 5 being over the age of 65, and over 0.5 million over the age of 90. The treatment of acute fractures of the lower limb in the nonagenarian cohort of patients poses a technical challenge to orthopaedic surgeons.

AIM

To report the fracture incidence, survival outcomes of treating acute non-hip lower limb fractures in nonagenarians in Major Trauma Centre.

METHODS

Thirty Lower limb long bone fractures in patients of age from 90 to 99 years were identified during 12-mo at a Level 1 trauma centre from a computerized database. A retrospective evaluation performed for fracture incidence, treatment, length of hospital duration and mortality at 30-d, 1-year and 2-year.

RESULTS

Thirty fractures (28 patients) were identified, twenty-four fractures were treated with surgery (mean age 93 years SD ± 2.59) and 6 managed conservatively (mean age 94 years SD ± 2.07). The mean length of the hospital stay was 18.2 d for both groups. The 30-d, 1-year and 2-year mortality risks were 1/23, 6/23 and 9/23 (4%, 26% and 39%) in the surgery group and 0/5, 1/5 and 2/5 (0%, 20% and 40%) in the conservative group, with no evidence for a difference between the two groups at any time point.

CONCLUSION

Nonagenarians in the surgical group had similar length of hospital stay and mortality risks as those treated conservatively. Patients with fewer comorbidities and admitted from their own home were offered surgery.

Use of a Hindfoot Nail Without Separate Subtalar and Tibiotalar Joint Preparation to Treat Geriatric Ankle and Distal Tibia Fractures: A Case Series

Introduction

Ankle fractures in geriatric patients can be devastating injuries, as they limit an individual's mobility, autonomy, and quality of life. This study examines the functional outcomes and complications related to hindfoot nails (HFN) in geriatric patients who have suffered an ankle malleolar or distal tibia fracture.

Materials and Methods

This is a single-surgeon case-series of patients who underwent HFN for acute fixation or delayed reconstruction after an ankle or distal tibia fracture. Demographic information, comorbidities, baseline functional status, AO/OTA classification, surgical indications, need for external fixation, total operative time, length of stay (LOS), ambulation at discharge, and discharge disposition were recorded. Primary outcomes included 30-day complications, ambulation at follow-up, and time to fracture union and fusion.

Results

There were 22 patients, with average age 80.8 years. Mean LOS was 7.0 days, and 68.2% were discharged to subacute rehabilitation. Within 30 days, 1 patient developed a deep vein thrombosis and bilateral pulmonary emboli, and 2 experienced wound dehiscence requiring antibiotics. At 6-weeks, 1 patient sustained a fall with periprosthetic fracture requiring HFN revision, and another developed cellulitis necessitating hardware removal. Fracture healing was seen in 72.7% at 19.4 weeks, while radiographic fusion occurred in 18.2% at 43.0 weeks. 72.7% were ambulating with an assistive device at discharge, and 100.0% at 12-weeks post-operatively or last follow-up. Upon final examination, all patients were ambulating without pain.

Discussion

HFNs provide a reliable alternative to traditional open reduction internal fixation and have the ability to improve quality of life for geriatric patients through a faster return to weight-bearing. Additionally, radiographic fusion rates show that patients have favorable functional outcomes even without formal arthrodesis.

Conclusion

HFN is beneficial for elderly patients with low functional demand and complex medical comorbidities, as it allows for early mobility after sustaining an ankle or distal tibia fracture.

Hindfoot nailing for displaced ankle fractures in the elderly: A case-control analysis

INTRODUCTION

Management of fragility ankle fractures in the elderly poses a surgical dilemma. An alternative to open reduction and internal fixation (ORIF) with screw and plate construct in selected elderly patients who may be significantly frail and comorbid is a tibio-talo-calcaneal (TTC) or hindfoot nail. Hindfoot nailing potentially reduces the risk of wound infection and increases likelihood of earlier return to function by allowing earlier weightbearing. The aim of this study was to examine the outcomes and complications of patients who received a hindfoot nail compared to patients who underwent an ORIF.

METHODS

A retrospective review identified patients who underwent hindfoot nailing from Jan 2010 to Dec 2021. Patients aged >65-years who underwent ORIF in the same time period were concurrently identified. The patients in the ORIF group were matched with patients in the hindfoot nail group by age, gender, comorbidity according to their Charlson Comorbidity Index (CCI) and their pre-injury function by Karnofsky Performance Scale (KPS). Clinical Frailty Scale (CFS) was also collected as part of patient demographics. Outcomes examined include mortality, length of stay, operation time, return to previous mobility, wound complications, metalware failure and infections.

RESULTS

Twenty-six patients were identified in the hindfoot nail group and matched to 26 patients who underwent ORIF. Mean age was 84 and 83 years in the nail and ORIF group respectively. Overall, there were 12 and 11 complications from the hindfoot nail and ORIF group respectively with seven and two requiring return to theatre in the nail group and ORIF group (P = 0.07). The hindfoot nail group waited an average of 22 days after the operation for weightbearing compared to 59 days in the ORIF group (P < 0.001). There were no significant differences in length of stay (P = 0.58) and operation time (P = 0.19).

CONCLUSION

Hindfoot nailing was associated with an increased risk of complications and higher risk of return to the operating theatre. Despite the potential attraction of earlier weightbearing, surgeons and patients need to be aware of these potential pitfalls.

Screw-only fibular construct for Weber B ankle fractures: A retrospective clinical and cost comparison to assess feasibility for resource-limited settings

INTRODUCTION

Ankle fractures are one of the most common injuries sustained worldwide, with the majority being isolated lateral malleolus fractures. The majority of the world's population live in Low and Middle Income Countries (LMIC), where implant cost may limit surgical treatment of ankle fractures. We investigate if Weber B ankle fractures could be effectively treated with a lower-cost technique using two screws between the fibula and the tibia to neutralize an interfragmentary lag screw.

METHODS

After IRB approval, consecutive patients from January 1, 2020 to December 31, 2020 with Weber-B ankle fractures were treated using AO technique (AOT) with plate osteosynthesis neutralizing an interfragmentary screw. Syndesmotic injuries, as well as injuries to the medial malleolus or foot were treated according to the surgeon's preferences. From January 1, 2021 to December 31, 2021 these injuries were treated with a screw-only technique (SOT) with two fibula pro tibia screws to neutralize an interfragmentary screw. Patient demographics including age, sex, BMI, smoking status, associated rheumatoid arthritis, and associated diabetes mellitus were recorded. The primary outcome variable was a stable radiographic mortise at six weeks post-surgery, secondary outcome variables included clinical union, infection, hardware removal, and implant cost for lateral malleolar fixation charged to the hospital.

RESULTS

Seventeen AOT and 10 SOT constructs were included. Demographic characteristics were similar between groups. All fractures maintained a stable mortise with clinical union at 6 weeks without infection. There was a statistically significant difference in hardware removal (17.6% AOT, 50% SOT, p = 0.012). The average implant cost to the hospital of the lateral malleolar fixation was significantly less in the SOT group ($592 (SD $229)), compared to the AOT group ($1,949.97 (SD $562)), (p < 0.0001).

CONCLUSION

We introduce proof of concept of a novel lower-cost fixation strategy for Weber B ankle fractures that maintained a stable mortise with clinical union at six weeks post-surgery. However, there was a significantly higher rate of hardware removal following fixation with a screw-only construct.

Postoperative Complications of Minimally Invasive Intramedullary Nail Fixation Versus Plate Fixation for Distal Fibular Fractures in Elderly Patients: A Retrospective Double Cohort Study in a Geriatric Trauma Unit in the Netherlands

Intramedullary fixation using a fibular nail is a minimally invasive alternative to conventional plate fixation that provides superior biomechanical strength and allows immediate full weightbearing postoperatively. The study aim was to compare the postoperative complications of minimally invasive intramedullary fibular nail fixation to plate fixation for Lauge-Hansen supination external rotation type 4 (Weber B) fractures in patients aged 65 years or older treated in a single geriatric trauma unit in the Netherlands. A retrospective cohort study was performed including patients aged 65 years or older with a Lauge-Hansen supination external rotation type 4 (Weber B) fracture treated with either intramedullary fibular fixation or plate fixation between January 2017 and January 2019. A total number of 58 patients were included with a mean age of 73.9 years (range 65-95). The intramedullary fixation-cohort (n = 13) had a significantly higher mean age (82.5 vs 71.4 years, p = .002) and Charlson Co-morbidity Index (4.7 vs 3.6, p = .005) compared to the plate fixation-cohort (n = 45). The total number of postoperative complications was lower after intramedullary fixation (n = 2, 15%) compared to plate fixation (n = 15, 33%), although this relative difference was not significant (p = .307). All 2 complications observed after intramedullary fixation were wound infections demanding no debridement or implant removal. No implant related complications, hospital-acquired complications or mortality were observed after intramedullary fixation. Despite the higher mean age and co-morbidity status of patients treated with minimally invasive intramedullary fibular nailing, the total number of postoperative complications was lower after intramedullary fixation compared to plate fixation. This technique might be a promising alternative in selected patients.

Factors Affecting Hospital Length of Stay in Geriatric Patients With a Surgically Treated Fragility Ankle Fracture

Fragility ankle fractures in elderly have a rising incidence and hospitalization may be prolonged due to pre-existing comorbidities, compromised soft tissue and postoperative difficulties in the rehabilitation process. The aim of this retrospective cohort study was to investigate risk factors for longer total hospitalization duration in elderly patients with surgically treated fragility (Lauge Hansen supination external rotation type 4) fractures. We included all patients ≥ 70 years with a fragility fracture, who were treated surgically between 2011 and 2019 (n = 97) in a level 1 and 2 trauma center. Data on patient demographics, fracture characteristics, surgical treatment strategies and postoperative complications were retrieved from medical records. Multivariate regression analysis was performed to identify independent risk factors for longer hospitalization duration. The mean age of the included patients was 78.27 (± 6.56) years; 71 patients (73.20%) were female. Ten fractures (10.30%) were classified as open and 49 (50.50%) as a luxation type fracture. Fifty-nine patients (60.80%) were hospitalized after admission to the emergency department. External fixation was performed in 34 patients (35.10%) and served as bridge to definitive fixation in 29 patients (85.30%). The mean total hospital length of stay of all patients was 7.04 (± 6.58) days. Multivariate regression analysis demonstrated that the use of external fixation (p < .001) and the postoperative discharge destination (p < .001) were independently associated with a prolonged hospital stay. External fixation and discharge destination were independent risk factors for a prolonged hospital stay in elderly patients with a fragility fracture.

Early weight bearing and mobilization decrease perioperative complications in patients after ankle fracture; the retrospective multicenter (TRON group) study

BACKGROUND

Open reduction and internal fixation (ORIF) for unstable ankle fractures (AF) are relatively predictable with excellent outcomes. Rehabilitation strategies are still being debated after surgical intervention for AF: non-weight bearing and cast immobilization for six weeks after the surgical repair of unstable AF or early functional treatment with partial weight bearing. This study aimed to compare early weight bearing and functional outcomes and complications.

METHODS

Between April 2014 and March 2019, 1421 patients with AF underwent ORIF at 11 institutions (TRON group). The patients were divided into two groups: Group E started weight bearing within six weeks after surgery, and group L started weightbearing for more than six weeks after. To adjust for baseline difference between groups, a propensity score-matched algorithm was used to match Group E with Group L in a 1:1 ratio of 294 cases each. We compared the American Orthopedic Foot and Ankle Society (AOFAS) score as the functional outcome, the rate of wound dehiscence, superficial and deep infections, blistering, nonunion, neurapraxia, and reoperation at 3, 6, and 12 months after surgery.

RESULTS

The mean period of non-weight bearing was significantly shorter in group E (3.68 ± 1.02 vs. 6.67 ± 1.43; P < 0.001). The mean period of cast immobilization term were shorter in group E (1.84 ± 1.35 vs. 2.65 ± 1.51; P < 0.001). There were no differences in the AOFAS score at any period. The rates of deep infection and reoperation in Group E were significantly lower than those in Group L (1.7% vs. 6.1%; P = 0.009, 2.0% vs. 7.8%; P = 0.002, respectively). There were no significant differences in superficial infection (9 vs. 15; P = 0.297), nonunion (9 vs. 15 P = 0.30), blistering (4 vs. 3; P = 1.00), neurapraxia (2 vs. 1; P = 1.00), and wound dehiscence (15 vs. 18; P = 0.72).

CONCLUSIONS

Although functional outcome was similar depending on whether early weight bearing was allowed, the rates of deep infection and reoperation decreased in patients with early weight bearing. We recommend early postoperative weight bearing in patients with a surgically treated AF.

Outcomes after primary ankle arthrodesis in recent fractures of the distal end of the tibia in the elderly: a systematic review

PURPOSES

Management of distal tibia fractures in the elderly is complex. The results of conservative treatments may be disappointing and primary ankle arthrodesis is now regularly offered as an alternative. In this study, we aimed to review the outcomes of primary ankle arthrodesis for distal tibia fracture in the elderly.

METHODS

We conducted a systematic review of the literature, from the Cochrane, MEDLINE, and Embase databases, on studies published in English and in French between 1950 and 2020. Only studies reporting the clinical results, the function, or the complications of primary ankle arthrodesis after ankle fracture in the elderly were included.

RESULTS

We included nine studies. The total number of patients was 229: 21% of them (50/229) sustained open fractures and 41% (95/229) had three or more comorbidities. All the patients underwent a tibio-talo-calcaneal arthrodesis with a retrograde transplantar intramedullary nailing (TIMN): short nail in 52% (151/229) and long nail in 48% (78/229) of the cases. At a mean follow-up comprised between six and 21 months, 94.5% of patients (190/201) achieved bone union, 87% (123/140) recovered an ankle range of motion close to their pre-operative status, 19% (40/211) had a complication, and 11.3% (24/211) required a revision. The use of a short nail resulted in a higher rate of peri-implant complication (2%) as well as a higher rate of revision (12.4%).

CONCLUSION

Primary ankle arthrodesis in recent fractures of the distal end of the tibia in the elderly frequently results in satisfactory results. The use of a long nail may be associated with a lower rate of implant specific complications.

Impact of the COVID-19 pandemic on the trauma and orthopaedic department at level one Major Trauma Centre in the republic of Ireland

The Coronavirus Disease (COVID-19) has been identified as the cause of a rapidly spreading respira- tory illness in Wuhan, Hubei Province, China in early December 2019. Since then, the free movement of people has decreased. The trauma-related injuries and the demand on the trauma and orthopaedic service would be expected to fall. The aim of this study to examine the impact of the COVID-19 pandemic on a level 1 Trauma Centre in the Republic of Ireland (ROI). Patients admitted to the Trauma & Orthopaedic (T&O) Department at Cork University Hospital (CUH) and the South Infirmary Victoria University Hospital (SIVUH), and their associated fracture patterns and management, between 01/03/20 and the 15/04/20 were documented and compared to the patient admissions from the same time period one year earlier in 2019. The total number of T&O operations performed decreased by 10.15% (P= 0.03)between the two time periods. The number of paediatric procedures fell by 40.32% (P= 0.15). Adult Distal radius and paediatric elbow fractures (excluding supracondylar fracture) increased by 88% and 13% (P= 0.19), (P= 0.04) respectively. Hip fractures remained the most common fracture-type admitted for surgery. The COVID-19 crisis has to lead to a decrease in the total numbers of trauma surgeries in a major trauma centre in the ROI. This decline is most evident in the number of paediatric and male adult patients presenting with fractures requiring operative management. Interestingly, fractures directly related to solo outdoor activities, such as running or cycling, as well as simple mechanical falls like ankle, distal radius, elbow, and hand fractures all increased. Irish males were more compliant with outdoors restrictions than females.

Acute Hindfoot Nailing for Ankle Fractures: A Systematic Review of Indications and Outcomes

OBJECTIVES

To assess the complication rate of hindfoot nailing of acute fractures involving the tibiotalar joint, and mortality, patient-reported outcome measures, and return to preinjury activities.

DATA SOURCES

MEDLINE; EMBASE.

STUDY SELECTION

A systematic literature search for articles in English was completed using MEDLINE and EMBASE databases on April 23, 2020. Original research articles that assessed patients with acute intra-articular fractures of the ankle joint (malleolar ankle fractures and/or pilon fractures) that were treated with a locked hindfoot intramedullary nail, inserted retrograde through the plantar surface of the foot, were selected for inclusion. Case reports (≤4 patients), studies with nonlocked implants, and non-English studies were excluded.

DATA EXTRACTION AND SYNTHESIS

A validated data extraction form was used, which included study demographics (authors, journal, date of publication, and study design), patient characteristics, implant type, and reported outcomes. Risk of bias for each included study was evaluated using the Institute of Health Economics Quality Appraisal Checklist for case series and the Risk of Bias in randomized trials tool, where appropriate. The best evidence was summarized and weighted mean values were provided when appropriate.

RESULTS

Ten case series and one randomized controlled trial were included. The overall quality of studies was poor with considerable bias. The majority of studies included elderly patients (weighted mean age 75.5 years) with diabetes (42% of patients). Overall complication rate was 16% with an 8% major complication rate (deep infection, malunion, nonunion, implant failure) and an overall infection rate of 6.2%. Pooled mortality rate was 27% with fracture union rates from 88% to 100%. Mean proportion of patients able to return to preinjury level of activity was 85%.

CONCLUSIONS

Hindfoot nailing of acute ankle and pilon fractures in elderly patients and patients with diabetes is associated with complication rates comparable with other methods of fixation. Issues with elimination of subtalar joint motion and implant complications secondary to poor implant fixation persist. The literature to date has composed of primarily Level IV studies with considerable bias. Further research is necessary to clarify the role of hindfoot nailing of acute ankle and pilon fractures.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Minimally invasive treatment of AO B ankle fractures: Surgical technique and long-term outcomes

BACKGROUND

Ankle fractures are the most common traumatic bone injuries of the lower limb. Over 50% of ankle fractures occur at the syndesmosis level (type AO B). The goal of treatment is to achieve an anatomical reduction and appropriate stabilization. The present study aimed to evaluate the clinical-functional and radiological results, and complications of minimally invasive reduction and fixation technique for ankle fractures type AO B. The surgical technique also is detailed.

MATERIAL AND METHODS

A prospective analysis of 451 patients undergoing surgery for type AO B displaced ankle fracture was performed. All patients were treated with minimally invasive surgery. The following times were recorded: time between trauma and osteosynthesis, hospitalization length, surgical time, and exposure time to fluoroscopy. Age and gender, mechanism of injury, and characteristics of fractures were recorded. For functional outcome, AOFAS score, VAS, and Weber score were used. Radiographic analysis was performed. The average follow-up was 112 months.

RESULTS

Mean age was 48.2 years old. Average length of stay in hospital was 5.72 h. Mean duration of the surgery was 32.8 min. Average fluoroscopic exposure time during surgery was 9.25 s. Mean bone union time was 38.2 days. Weber's score was on average 1.5/24 points and the long-term follow-up AOFAS score was on average 97.5/100. Postoperative complications incidence was 2.7%.

CONCLUSIONS

Distal fibula fixation with the MIPO technique presented good functional outcomes and could be helpful in the avoidance of the complications associated with conventional open reduction and internal fixation. However, it needs more exposition to intraoperative fluoroscopy.

LEVEL OF EVIDENCE

II.

A novel fixation method for unstable ankle fractures in the elderly using dual percutaneous tibiotalar cannulated screws

Ankle fractures in the elderly are often complicated by osteoporosis and poor skin quality, resulting in poorer outcomes. This retrospective case-series describes a novel minimally invasive fixation method for managing unstable ankle fractures in the high-risk elderly patient. Six elderly patients who underwent dual tibiotalar cannulated screw fixation for unstable ankle fractures between January 2019 and 2020 were identified. Data on post-operative pain scores, mobility and complications were collected. Pre- and post-operative radiographs were analysed for fracture type and complications. Functional outcomes were excellent with 83.3% of patients pain free, and 100% ambulatory with walking-aids at 10.25 months follow-up. Four of the six patients (66.7%) had satisfactory post-operative radiographs, and there were no soft tissue injury or infections due to the surgery. Dual percutaneous tibiotalar cannulated screws can be used to manage unstable ankle fractures in the low demand elderly patient, resulting in excellent functional outcomes.

Optimal management of older people with frailty non-weight bearing after lower limb fracture: a scoping review

BACKGROUND

Patients with lower limb fractures who are non-weight bearing are at risk of the complications of the associated immobility and disability, particularly people with frailty, but there is lack of clarity about what constitutes optimal care for such patients. A scoping literature review was conducted to explore what evidence is available for the management of this patient group.

METHODS

MEDLINE (PubMed) CINAHL, EMBASE and the Cochrane databases of published literature and the HMIC and SIGLE sites for grey literature were searched for primary research studies and expert reports, using an iterative approach initially including the key term 'non-weight bearing'. All study types were included. Analysis was by narrative synthesis.

RESULTS

No papers were identified from a search using the key phrase 'non-weight bearing'. With this term removed, 11 indirectly relevant articles on lower limb fractures were retrieved from the searches of the electronic databases comprising three observational studies, five non-systematic review articles, a systematic review, an opinion piece and a survey of expert opinion that had relevance to restricted weight bearing patients. The observational studies indicated depression, cognition and nutrition affect outcome and hence have indirect relevance to management. The non-systematic reviews articles emphasised the importance of maintaining strength and range of movement during immobilisation and advised an orthogeriatric model of care. Fourteen UK and 97 non-UK guidelines relevant to fragility fractures, falls and osteoporosis management were found in the grey literature, but none made specific recommendations regarding the management of any period of non-weight bearing.

DISCUSSION

These findings provide a summary of the evidence base that can be used in the development of a clinical guideline for these patients but is not sufficient. We propose that, a guideline should be developed for these patients using an expert consensus process.

A Comparison of Fibula Pro-Tibia Fixation Versus Hindfoot Nailing for Unstable Fractures of the Ankle in Those Older Than 60 Years

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.

Early full weight-bearing in patients with isolated displaced lateral malleolar fracture after rigid internal fixation with locking plates

BACKGROUND

The timing of post-operative full weight-bearing in patients of isolated displaced lateral malleolar fractures remains controversial. The aim of this study was to evaluate the outcomes of early full weight-bearing after rigid internal fixation of such fractures with locking plates.

METHODS

From 2012 to 2018, 46 patients who had closed isolated displaced lateral malleolar fractures were included in the study. All fractures were managed with open reduction and internal fixation with locking plates. The patients were allowed to walk bearing their full weight 2 weeks after the operation. The follow-up period was 41.5 months on average (range: 12-70 months). The patients were available to evaluate union conditions, functional results, and complications.

RESULTS

The fractures united smoothly with an average union time of 10.5 weeks (range: 8-16). At the final follow-up, the average American Orthopaedic Foot and Ankle Score Ankle-Hindfoot Score was 91 (range: 85-98). No complications were observed.

CONCLUSION

For patients with isolated displaced lateral malleolar fractures, full weight-bearing is safe and effective, without an increase in the rate of complications, 2 weeks after open reduction and rigid fixation with locking plates.

Increasing age and modifiable comorbidities are associated with short-term complications after open reduction and internal fixation of ankle fractures

BACKGROUND

Ankle fractures are common orthopedic injuries with complication rates fixation of up to 40%. Limited evidence exists in the literature regarding complications in the elderly population, and moreover, these studies frequently define elderly arbitrarily at 60-65 years old. The purpose of the present study was to utilize a large, validated database to evaluate whether there is an inflection point of age when postoperative complications after an ankle fracture significantly increase.

METHODS

A retrospective review of all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent fixation of an ankle fracture between 2012 and 2018 was performed. Patients were identified within the database using the Current Procedural Terminology codes. Appropriate statistical analysis was performed with p value less than 0.05 considered statistically significant.

RESULTS

A total of 27,633 fractures were including and comprised of 221 posterior malleolar, 1567 medial malleolar, 8495 lateral malleolar, 10,175 bimalleolar, and 7175 trimalleolar. A total of 1545 complications were encountered (5.6%). There was a statistically significant association between increasing age and complications (OR = 1.03; p < 0.001). Further analysis shows the largest spike in complications within the age 78 + bracket. There were no overall interaction effects between age and fracture subtype (p = 0.223).

CONCLUSION

ORIF of ankle fractures is a common orthopedic procedure performed on patients of all ages, with complications ranging in severity. In order to best counsel patients on their individual postoperative risks, large datasets are often necessary to prognosticate. This study found that postoperative complications increase with advanced age. The incidence of complications did not spike for patients around the age of 65, but rather followed an incremental linear pattern with the largest increase in odds ratio occurring at age 78 and above. Complication rate was not associated with specific fracture type based off of ICD codes.

Utility of Ottawa Ankle Rules in an Aging Population: Evidence for Addition of an Age Criterion

The Ottawa ankle rules (OAR) indicate that any patient with the inability to ambulate up to four steps or with tenderness at either malleoli should receive diagnostic imaging for an acute ankle injury. Current trends indicate that health care providers tend to order more images in practice than necessary according to OAR. The purpose of this study is to analyze OAR in geriatric versus nongeriatric patients. Secondarily, we hope to refine these guidelines for ankle imaging in the hopes that health care providers will be comfortable in adhering to these guidelines more strictly. A retrospective chart review was conducted of 491 adult patients with an average (± standard deviation) age of 54.4 ± 21.6 years (range 18 to 96). Applying the current OAR resulted in a sensitivity of 98.2% and a specificity of 58.6% in this entire cohort. The calculated sensitivities were comparable between the nongeriatric and geriatric cohorts, at 98.60% and 97.99%, respectively. The specificities varied between the nongeriatric and geriatric cohorts, at 60.13% and 33.33%. We propose new guidelines that would mandate imaging studies for any patient ≥65 years of age presenting to the emergency department with ankle pain. When applying these proposed guidelines, the sensitivity of the entire study population was found to be improved to 99.0%, whereas the specificity dropped to 56.7%. The slight decrease in specificity was deemed acceptable because these guidelines are meant to be used as a screening tool and because the risk of OAR not correctly identifying ankle fracture (2% of geriatric fractures) was completely mitigated in the geriatric population.

Comparison of Partially Threaded and Fully Threaded 4mm Cancellous Screws in Fixation of Medial Malleolar Fractures

Background

Several devices have been described for fixation of displaced medial malleolar fractures. Fully threaded cancellous screws engaging the bone may provide advantages compared to partially threaded screws. This study was designed to compare the clinical results of fully and partially threaded 4 millimeter cancellous screws in fixation of medial malleolar fractures.

Methods

In a randomized clinical trial study 44 patients with displaced closed medial malleolar fractures were randomly divided into two groups. Two fully threaded four millimeter cancellous screws were used for fracture stabilization (FT group) in the first group, while, the second group was operated by use of two partially threaded four millimeter cancellous screws (PT group). The clinical outcomes and complications were compared in two groups at one year follow up.

Results

Nineteen patients in FT group and 21 in PT group were present at final follow up. Nonunion was not developed in either group but two cases (9%) of delayed union occurred in PT group. The rate of postoperative infection and symptomatic hardware were not statistically different. Functional assessment using AOFAS, MOXFQ and VAS scores showed no significant difference between the two groups.

Conclusion

Both fully and partially threaded 4 mm cancellous screws can be considered as acceptable devices for the fixation of medial malleolar fractures with good and comparable clinical results.

Ankle fractures in the elderly: Current concepts

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.

Novel Technique for Reduction of Ankle Valgus Malunion and Chronic Talus Subluxation during Hindfoot Nailing

In recent years, there has been a significant increase in the incidence and severity of ankle fractures in the elderly. We present a case of an elderly patient with significant medical comorbidities and social issues who sustained an unstable ankle fracture that led to a severe malunion secondary to refusal for surgery and noncompliance with weight-bearing precautions. By choosing an intramedullary fixation method that can be inserted through a biologically advantageous surgical exposure, we can permit early mobilization, create a stable plantigrade foot for ambulation, and alleviate the expected noncompliance with weight-bearing precautions in this patient. Despite debridement of callus, fibular osteotomy, and plate-assisted reduction, a displaced valgus angulation of the ankle joint remained. The nail was removed then reinserted backwards with the bend directed medially instead of its normal lateral position in order to use the bend in the nail as a reduction aid to finalize the reduction. We feel this technique may be of assistance to future surgeons encountering a similar situation.

The AO triangular external fixator: a backup option in the treatment of ankle fractures in geriatric patients?

Purpose

To analyze the indications, radiological short-term outcomes, and complications of ankle fractures in geriatric patients treated with a triangular external fixator (AEF) until fracture healing. Furthermore, the effect of an additional osteosynthesis to AEF on the radiological outcome was investigated.

Methods

Retrospective analysis of ankle fractures treated in a Level I Trauma Center between 2005 and 2015 with an AEF in patients aged ≥ 65 years until fracture has healed. The combination of AEF and at least one additional osteosynthesis of a malleolus was defined as hybrid external fixator (HEF). At the time of AEF removal, a preserved ankle joint congruity was defined as good radiological outcome. Incongruity more than 2 mm was defined as poor radiologic results.

Results

16 patients (13 women, 3 men) with a mean age of 74 years (SD 6.2) were treated with AEF until fracture healing, 9 with a single AEF and 7 with a HEF. Stabilization with HEF (n = 7 [100%]) showed higher rates of good radiological outcome than AEF alone (n = 4 [44%] of 9; p = 0.034). The duration of therapy did not differ between HEF and AEF (70 day vs 77 days). 4 patients (22%) required surgical revision.

Conclusion

It could be shown that osteosynthesis in addition to AEF leads to a better radiological short-term results than using AEF alone. Therefore, in the situation where an AEF is considered as the definitive treatment option for an ankle fracture in geriatric patients with expected or existing soft tissue problems, it should be done or completed as a HEF.

Level of evidence

Therapeutic level IV.

Mortality and Morbidity of Surgical Management of Geriatric Ankle Fractures

INTRODUCTION

The incidence of geriatric ankle fractures is rising. With the substantial variation in the physiologic and functional status within this age group, our null hypothesis was that mortality and complications of open reduction and internal fixation (ORIF) between patients who are aged 65 to 79 are equivalent to ORIF in patients who are aged 80 to 89.

METHODS

Patients with ankle fracture were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Patients treated with ORIF were identified using the Current Procedural Terminology codes. Patients were divided into two age cohorts: 65 to 79 years of age and 80 to 89 years of age. The primary outcome studied was 30-day mortality. Secondary outcomes included 30-day readmission, revision surgery, surgical site infection, sepsis, wound dehiscence, pulmonary embolism, deep vein thrombosis, blood transfusion, urinary tract infection, pneumonia, stroke, myocardial infarction, renal insufficiency or failure, and length of hospital stay.

RESULTS

Our cohort included 2,353 ankle fractures: 1,877 were among 65 to 79 years of age and 476 were among 80 or older. Thirty-day mortality was 3.2-fold higher in the 80 to 89 years of age group compared with the 65 to 79 years of age group (1.47% versus 0.48%, P = 0.019). However, after controlling for the ASA class, 80 to 89 years of age patients no longer had a significantly higher mortality (P = 0.0647). Similarly, revision surgery rate (3.36% versus 1.81%, P = 0.036), transfusion requirement (2.94% versus 1.49%, P = 0.033), urinary tract infection (1.89% versus 0.75%, P = 0.023), and hospital length of stay (4.9 versus 2.9 days, P < 0.0001) were all significantly higher in the 80 to 90 years of age group compared with the 65 to 79 years old group. However, after controlling for the ASA class, 80 to 89 years old patients no longer had a rate of complications in comparison to the 65 to 79 years old age group.

DISCUSSION

After controlling for comorbidities (ie, the ASA class), no increased risk is observed for the 30-day mortality or complication rate between geriatric ankle fracture in the 65 to 79 years old and the 80 to 99 years old age groups.

LEVEL OF EVIDENCE

Prognostic level III, retrospective study.

Treatment options for unstable ankle fractures in older adults: A systematic review and meta-analysis

Background

Ankle fractures are the third most common fracture in the elderly. Patients over 60 years are more severely affected by these injuries than their younger counterparts and have a higher rate of complications regardless of the management strategy. Traditional management strategies for unstable ankle fractures include plaster immobilisation and open reduction and internal fixation, with newer modalities such as intramedullary fixation becoming increasingly popular. The aim of this review is to establish the best current evidence for or against different treatment strategies.

Methods

A systematic review and meta-analysis of randomised controlled trials comparing treatment options for unstable ankle fractures in adults over 55 was conducted, with the primary outcome being functional assessment score at 6–12 months (Olerud and Molander Ankle Score). Secondary outcomes were adverse events including infection and re-operation.

Results

The search strategies identified 426 articles. After screening and full text review, four papers met the inclusion and exclusion criteria, providing data on 754 ankle fractures. Alternative treatment groups were tibio-talo-calcaneal nail, fibular nail and casting and were compared to open reduction and internal fixation. Meta-analysis of the data showed no difference in Olerud and Molander Ankle Score between treatment modalities at 6–12 months. There was, however, a significant reduction in the incidence of adverse events (OR 0.59 (0.44, 0.81)) and wound infection (0.13 (0.05, 0.31)) in the alternative treatment groups compared to open reduction and internal fixation.

Conclusion

The current evidence shows no significant difference between treatment modalities for ankle fractures in older adults in terms of functional outcome. Open reduction and internal fixation has a higher rate of adverse events and wound infection when compared to alternative treatments. Therefore, surgery should be carefully considered and if undertaken, in a select patient cohort other treatment modalities, such as intramedullary fixation should be considered.

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.

Management of Lower Extremity Fractures in the Elderly: A Focus on Post-Operative Rehabilitation

Fractures in the elderly population are increasing in incidence and represent a rising burden of disease. It is difficult for the elderly population to adhere to restricted weight bearing, and immobility poses significant risks and increased morbidity. Therefore, a primary goal of fracture management in the elderly population is early post-operative weight bearing. This review examines published literature regarding lower extremity fracture management in the elderly, with a focus on post-operative rehabilitation. While extensive literature supports early weight bearing after hip fractures in the elderly, further research is warranted to provide guidelines for management of other lower extremity fractures in this population.

Comparison of risk factors for postoperative complications across age groups in patients undergoing ORIF of the ankle

INTRODUCTION

Risk factors associated with various adverse outcomes for patients undergoing open reduction and internal fixation (ORIF) of the ankle, and how these risks differ between younger and older patient populations, has not been clearly established. Objective quantitative data may aid physicians in surgical decision making, individualizing postoperative management, and targeting interventions for reducing postoperative comorbidity. The purpose of this study is to compare the incidence of and risk factors for adverse postoperative outcomes following ORIF of ankle fractures across patient age groups.

MATERIALS AND METHODS

Charts of patients age 18 years and older who underwent open reduction and internal fixation (ORIF) for any closed, non-polytraumatic, non-pilon ankle fracture at a single institution between the years 2008 and 2018 were reviewed. Demographic information, comorbidities, and postoperative outcomes were collected. Relative risks for adverse outcomes were calculated and compared between patients younger than 50 and patients 50 years and older.

RESULTS

A total of 886 patients were included, 375 (42.3%) of which were over age 50. In both age groups, risk of infection was significantly increased among patients with hypertension, although risk among older patients (RR = 3.52, p = 0.004) was greater than that among younger patients (RR = 2.46, p = 0.017). In patients younger than 50, significant risk of wound dehiscence was associated with tobacco use (RR = 3.39, p = 0.022), substance use (RR = 3.07, p = 0.020), and CHF (RR = 12.77, p < 0.001). Risk of implant failure was significantly increased among younger patients with HIV (RR = 4.33, p = 0.026), CHF (RR = 10.54, p < 0.001), and CKD (RR = 10.54, p < 0.001), and among older patients with HTN (RR = 4.51, p = 0.006), CHF (RR = 5.83, p < 0.001), and tobacco use (RR = 3.82, P = 0.001).

CONCLUSION

Patients undergoing ORIF of the ankle should be well-informed of the potential risks of surgery as they pertain to specific comorbidities. Multidisciplinary approaches are warranted for appropriate management of patients with multiple comorbidities.

[Fractures of the ankle joint in elderly patients]

The number of ankle fractures in elderly patients is increasing. The aim of treatment of ankle fractures in the elderly is to guarantee a possible unlimited autonomy and quality of life for patients. This is achieved by minimization of the complications and impairments after ankle joint fractures. Decisive for the further course is the initial treatment. The results are essentially determined by the soft tissue management, reduction and stable osteosynthesis; however, an orthogeriatric co-management with the implementation of treatment paths and standard operating procedures is recommended. The advantages of an interdisciplinary cooperation of trauma surgeons and geriatricians are obvious in this situation.

How well do we reduce ankle fractures intra-operatively: A retrospective 1 year review using Pettrone's criteria

INTRODUCTION

Ankle ORIF is a common orthopaedic procedure. Assessment of the reduction is often performed by 'eyeballing' the intra-operative images.

AIMS

This study aimed to assess the radiographic reduction of all ankle fracture ORIFs at COCH over a 1-year period using Pettrone's criteria METHOD: Using the trauma database at the COCH all patients admitted for ankle ORIF over a 1 year period (n = 284) were identified. Each patient was retrospectively reviewed, duplicates or non-ankle fractures excluded and data collected on: patient demographics, Lauge-Hansen classification, time from injury to theatre, level of primary surgeon, type of fixation, reduction of medial, lateral or posterior malleolar reduction, syndesmosis reduction, date and satisfaction at last clinic appointment and complications.

RESULTS

After exclusions 187 patients were included in the study. The average age of patients was 49 years old (14-93). The most common Lauge-Hansen fracture classifications were SER (51.6% (98)) and PER (29.9% (57)). Registrars were first surgeon in 49.7% (93) of cases. 80% (111 of 139) of medial malleoli were reduced, 90% of lateral malleoli were reduced 11% (21) had residual talar shift. The syndesmosis was reduced in 76.4% (143) of cases. 19% (36) had further operations. There were 35 major complications in 25 (13.4%) patients. Not all malposition of fracture fixation were in the same ankles, 34.2% (64) ankle ORIFs had residual deformity after being fixed.

CONCLUSION

The implications of this study are very important. The authors aim to raise awareness of Pettrone's radiographic criteria of a successful ORIF of the ankle and subsequently improve the mal-reduction rate of post-fixation ankle ORIF.

Single- vs 2-Screw Lag Fixation of the Medial Malleolus in Unstable Ankle Fractures

BACKGROUND

The purpose of this study was to determine the efficacy of medial malleolar fixation with 1 vs 2 screws.

METHODS

Between April 2013 and February 2017, 196 patients who presented at 2 hospitals within one academic institution with an unstable rotational ankle fracture with a medial fracture and were treated operatively by a trained orthopedic surgeon were identified. These patients' charts were reviewed and their injury, radiographic, surgical, and follow-up data recorded. Medial malleolus fragment size was assessed on the anteroposterior (AP) and lateral views of the initial injury radiograph. Functional outcome was assessed using Maryland Foot Score (MFS). Patients were grouped based upon the number of screws utilized to fox the medial malleolar fragment. Data were assessed using Fisher exact tests and independent t tests with SPSS, version 23.

RESULTS

Out of the 196 patients who met inclusion criteria, 47 patients (24%) were fixed with 1 medial malleolar screw and 149 patients (76%) were fixed with 2 screws. There were no differences among patients who received 1 vs 2 screws with regard to age, gender, body mass index, American Society of Anesthesiologists grade, or smoking status. The average malleolar fragment size was smaller in those treated with 1 screw on both the AP and lateral radiographic views than those with 2 screws (P = .009, P = .001, respectively). There was no difference between groups in ankle dorsiflexion or plantarflexion at 1 year postoperation (P = .451, P = .581). Patients who received 1 screw did not differ from those who received 2 screws with respect to Maryland Foot Scores (P = .924). There was no difference in rate of revision surgery or need for hardware removal between groups (P = .093). Furthermore, time to healing and postoperative complication rate did not differ between groups.

CONCLUSION

The use of a single screw for medial malleolar fixation provided stable fixation to allow ankle fracture healing, without an increase in complications. This information is especially important in situations when the fragment is too small to accommodate multiple fixation points.

LEVEL OF EVIDENCE

Level III, retrospective case-control 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.

Comparison of different locking plate fixation methods in lateral malleolus fractures

BACKGROUND

Several fixation methods may be used for displaced lateral malleolar fractures. We aimed to compare clinical and radiologic outcomes associated with use of locking one third tubular plate vs. anatomical distal fibula locking plate in lateral malleolar fractures.

METHODS

A total of 62 orthopedic patients operated for lateral malleolus fracture were included in this retrospective study. Patients were divided into two groups regarding the plate used for fixation as locking one third tubular plate (group I; n=37) and locking anatomical distal fibula plate (group II; n=25). Data on Danis-Weber ankle fracture classification (Type A, Type B), duration of follow up, clinical outcome [ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) score], radiological outcomes (adequacy of reduction, loss of alignment), time to fracture healing and complications were recorded in study groups.

RESULTS

No significant difference was noted between groups in terms of AOFAS score [87.0 (73-100) vs. 85.0 (71-100), respectively (p=0.339)] and no patients had severe restriction in sagittal and hindfoot motion in both groups. The two groups showed similar healing time [9.0 (7-13) weeks vs. 10.0 (8-13) weeks, respectively (p=0.355)] and complication rate [0.0% vs. 4.0%, respectively (p=0.403)].

CONCLUSIONS

This study revealed no significant difference between use of locking one third tubular plate and locking anatomical distal fibula plate in lateral malleolar fixation, in terms of clinical and radiological outcomes, complication rates and fracture healing time.

Transarticular tibiotalocalcaneal nailing versus open reduction and internal fixation for treatment of the elderly ankle fracture: protocol for a multicentre, prospective, randomised controlled trial

INTRODUCTION

Ankle fractures are common in the elderly population. Surgical fixation is technically challenging and often results in complications due to high rates of osteoporosis and vascular disease. Open reduction and internal fixation (ORIF) often requires prolonged periods of non-weight bearing increasing the risks of complications. Tibiotalocalcaneal (TTC) nailing has been suggested as an alternative to ORIF which allows immediate weight bearing, and is suggested to result in fewer complications. This study aims to compare the two surgical techniques in the elderly population with ankle fractures.

METHODS AND ANALYSIS

The study will be a multicentre, prospective, randomised controlled trial comparing ORIF to TTC nailing in 110 patients with ankle fractures aged 50 or above with a Charlson Comorbidity Index of greater than or equal to four. Participants and assessors will not be blinded to intervention. The primary outcome measure will be overall complication rate. Secondary outcomes include length of hospital stay, mobility at discharge, discharge destination, the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score, the Olerud-Molander Ankle Score, mortality rate, rate of secondary surgical interventions and number of blood transfusions required postoperatively. Our null hypothesis is that there is no clinically significant difference in the primary outcome measure between the two treatment groups.

ETHICS AND DISSEMINATION

The study has been approved by Metro South Hospital and Health Services Human Research Ethics Committee (EC00167) (reference number HREC/17/QPAH/351).

DISCUSSION

Completion of this trial will provide evidence on the effectiveness of TTC nailing versus ORIF in treatment of the elderly ankle fracture. If TTC nailing is found to result in superior outcomes, this trial has the capacity to change current clinical practice.

TRIAL REGISTRATION NUMBER

ACTRN12617001588381;Pre-results andU1111-1203-1704.

Comparison of Locking Versus Nonlocking Plates for Distal Fibula Fractures

Locking plates might offer a biomechanical fixation advantage for distal fibula fractures with comminution or osteoporotic bone. In January 2011, our unit introduced a bone-specific locking plate for the distal fibula. The aim of the present study was to compare it against more conventional plating system implants for lateral malleolar fixation in terms of outcomes, crude costs, and complications. We retrospectively reviewed a consecutive cohort of patients with closed ankle fractures who presented within a 24-month period. The clinical and radiographic outcomes were compared among conventional plating using a one-third semitubular plate, a 3.5-mm limited-contact dynamic compression plate, and a 2.7-mm/3.5-mm locking compression distal fibula plate. A total of 145 patients with ankle fractures underwent surgical fixation: 87 (60.0%) with the semitubular plate, 22 (15.2%) with the limited-contact dynamic compression plate, and 36 (24.8%) with the locking compression distal fibula plate. A greater proportion of patients with established osteoporosis or osteoporosis risk factors were in the locking compression distal fibula plate group (27.8% versus 2.3% and 0%). Four patients (2.8%) required washout for infection. No significant differences were found between the sex distribution within the 3 groups (p = .432). No significant difference was found in the complication rate (p = .914) or the reoperation rate (p = .291) among the 3 groups. Although costing >6 times more than a standard fibula fixation construct (implant cost), bone-specific locking compression distal fibula plates add to the portfolio of implants available, especially for unstable fractures with poor bone quality.

Fractures in older adults. A view of the future?

INTRODUCTION

It is accepted that the incidence of fractures in patients aged ≥ 65 years is increasing but little is known about which fractures are becoming more common in this group of patients. Virtually all research has concentrated on the classic fragility fractures of the proximal femur, proximal humerus, pelvis, spine and distal radius but it is likely that other fractures are becoming more common.

METHODS

We have examined two prospectively collected databases 10 years apart to see which fractures are becoming more common in ≥ 65 year old patients. We compared the fractures to look for epidemiological differences over the 10-year period and we compared the epidemiology of the fractures that had increased in incidence with equivalent fractures in the < 65 year old population.

RESULTS

Analysis shows that in older female patients fractures of the clavicle, finger phalanges, ankle and metatarsus are increasing in incidence. In males there is an increasing incidence of fractures of the proximal humerus, distal humerus, metacarpus, pelvis, femoral diaphysis, distal tibia and ankle. In females the basic epidemiology of fractures in the ≥ 65 year old population was very similar to the fractures seen in younger females and we believe that the increasing incidence of fractures in the future will mainly be low velocity fractures following falls. In older males however, it is apparent that there is a much wider variation in the causes of fracture.

DISCUSSION

We believe that the changes in fracture epidemiology in older patients relate to improved health and longevity and analysis of our population during the study period shows significant social changes which are associated with increased longevity and improved health. It is probable that fractures in older patients will continue to increase in incidence and that other fractures that are now commonly seen in middle-aged patients will be seen in older patients. Surgeons will have to treat more complex fractures in older males than in older females and it is likely that there will be a higher incidence of open and multiple fractures. Appropriate management techniques will need to be established.

Locking versus non-locking one-third tubular plates for treating osteoporotic distal fibula fractures: a comparative study

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.

Anatomic Structures at Risk When Utilizing an Intramedullary Nail for Distal Fibular Fractures: A Cadaveric Study

BACKGROUND

Retrograde intramedullary fibular nail fixation is being utilized with increasing frequency, particularly in patients at higher risk of wound complications. The purpose of this anatomic study was to assess the relative risk to nearby anatomic structures when implanting a contemporary retrograde locked intramedullary fibular nail.

METHODS

Ten human cadaveric lower extremities were instrumented with a fibular nail. The cadavers were dissected. The shortest distance, in millimeters (mm), between the site of procedural steps and nearby named structures of interest (ie, sural nerve, superficial peroneal nerve, and the peroneal tendons) was measured and recorded. Levels of risk were assigned based on observed distances as high (0 to 5 mm), moderate (5.1-10 mm), and low (greater than 10 mm).

RESULTS

The peroneus brevis (PB) tendon was found to be less than 5.0 mm from the distal skin incision in all specimens. When reaming and inserting the nail through the distal fibula aperture, the PB was less than 5.0 mm in 6 specimens. The peroneus longus tendon was at moderate to high risk when inserting both the proximal and distal syndesmotic screws in 9 specimens. The superficial peroneal nerve was at high risk when inserting an anterior to posterior distal locking screw in 7 specimens. The sural nerve was at low risk for all procedural steps. No structures were violated or damaged during any portion of the fibular nail instrumentation.

CONCLUSION

The peroneal tendons and superficial peroneal nerve were at the highest risk; however, no structures were injured during instrumentation.

CLINICAL RELEVANCE

The current findings indicate that strict adherence to sound percutaneous technique is needed in order to minimize iatrogenic damage to neighboring structures when performing retrograde locked intramedullary fibular nail insertion. This includes making skin-only incisions, blunt dissection down to bone, and maintaining close approximation between tissue protection sleeves and bone at all times.

Repair of Bimalleolar Ankle Fracture

PURPOSE

The incidence of ankle fractures is rapidly increasing in geriatric populations. Of the 4 fracture patterns described by the Lauge-Hansen classification system, supination-external rotation (SER) accounts for most ankle fractures. This video demonstrates surgical repair of a SER type 4 ankle fracture in a geriatric patient.

METHODS

SER type 4 ankle fractures are considered unstable and are generally treated with surgical fixation. After placement of plate and screws, intraoperative stress tests can be used to assess for syndesmotic widening. If necessary, the syndesmosis can be reduced open, with screw fixation placed parallel to the joint. Patients are kept non-weight-bearing for 6 weeks after surgery.

RESULTS

This video, shot on an iPhone 6S, shows the case of a 66-year-old female status after a fall with twisting mechanism resulting in an unstable SER type 4 fracture requiring operative repair. Intraoperative stress test revealed medial clear space widening requiring syndesmotic reduction.

CONCLUSIONS

SER type 4 ankle fractures are a common injury that must be properly managed to return patients to baseline functional status. The surgical technique described in this video provides for good stabilization and allows for early range of motion with advancement to weight-bearing as tolerated at 6 weeks postoperatively.

Do clinical outcomes correlate with bone density after open reduction and internal fixation of tibial plateau fractures

INTRODUCTION

The operative management of tibial plateau fractures in elderly patients has historically led to inconsistent results, and these clinical outcomes were thought to be associated with poor bone quality often in elderly patients. The goal of this study was to investigate the relationship between bone density and subjective clinical outcome scores after open reduction and internal fixation of tibial plateau fractures.

MATERIALS AND METHODS

This is a retrospective cohort study from a single-surgeon conducted at an Academic, Level 1 Trauma Center. A preoperative computed tomography (CT) scan was obtained for all patients. Bone density of the distal femur was quantified with Hounsfield units (HU) as measured on axial CT scans. Inter-rater reliability of HU measurements was assessed using interclass correlation coefficients. Regression models controlling for age were used to identify relationships between bone density (HU) and the following variables: articular subsidence and 1-year subjective clinical outcomes scores [Knee Outcome Survey Activities of Daily Living Scale (KOS-ADLS), and Short-Form-36 (SF-36) physical and mental component scores (PCS, MCS)].

RESULTS

Sixty-one patients with a mean age of 59.3 years (range 27-85 years) and a minimum of 12 months of clinical follow-up were included in the study. The majority of the fractures (32 of 61) were classified as Schatzker II tibial plateau fractures, and there were 13 Schatzker V fractures, 11 Schatzker VI fractures, 2 Schatzker IV fractures and 1 Schatzker 1 fracture. HU measurements demonstrated an almost perfect inter-observer reliability (ICC = 0.97). Age was negatively correlated with HU measurements (r = -0.51, p < 0.001), and using a geriatric cut-off of 65 years of age, the geriatric group had a lower mean HU compared to the non-geriatric group (78.2 versus 114.8, p = 0.018). There was no significant relationship between bone quality, as assessed by distal femoral HU, and any subjective clinical outcome score.

CONCLUSIONS

Inferior bone mineral density alone does not appear to affect clinical outcomes 1 year postoperatively when bone grafting is used to restore osseous voids. Poor bone quality should not be used as an indication for non-operative management of tibial plateau fractures.

Ankle fractures in the elderly: risks and management challenges

Ankle fractures are the third most common osseous injury in the elderly, behind hip and distal radius fractures. While there is a rich history of clinical advancement in the timing, technique, perioperative management, and associated risks of hip fractures, similar evaluations are only more recently being undertaken for ankle fractures. Traditionally, elderly patients were treated more conservatively; however, nonoperative management has been found to be associated with increased mortality. As such, older and less healthy patients have become operative candidates. The benefits of geriatric/orthopedic inpatient comanagement that have been well elucidated in the hip fracture literature also seem to improve outcomes in elderly patients with ankle fractures. One of the orthopedist’s roles is to recognize the complexities of osteoporotic bone fixation and optimize wound healing potential. Though the immediate cost of this surgical approach is inevitably higher, the ultimate cost of long-term care has been found to be substantially reduced. It is important to consider the mortality and morbidity benefits and cost reductions of operative intervention and proper inpatient care of geriatric ankle fractures when they present to the emergency department or the office.

Fragility fractures of the ankle in the elderly: Open reduction and internal fixation versus tibio-talo-calcaneal nailing: Short-term results of a prospective randomized-controlled study

INTRODUCTION

The management of ankle fractures in the elderly remains unpredictable, secondary to their various co-morbidities. Although tibiotalocalcaneal (TTC) nailing has been an effective option for ankle arthrodesis due to ankle arthritis or Charcot arthropathy there are few reports regarding the use of TTC nail for the treatment of ankle fractures.

PURPOSE

Aim of this study was to compare the results of ORIF versus TTC nailing for the treatment of unstable ankle fractures in the elderly. We hypothesized that the elderly may benefit from TTC nailing, as it allows the patient to be mobilized immediately after surgery and minimizes the risk of wound or bone problems.

PATIENTS AND METHODS

This was a prospective, randomized-controlled, comparative study. Between 2009 and 2015, 43 patients were treated with a TTC nail (Group A) and 44 with ORIF (Group B). The Olerud-Molander ankle score was obtained and intraoperative-postoperative complications, length of hospital stay, mobility status and reoperation rate were recorded. The nail fixation was performed with the TrigenR hindfoot nail after closed reduction. ORIF was performed, using a 1/3 tubular plate and 3.5mm screws for the lateral malleolus and two 4.0 mm cannulated screws for the medial.

RESULTS

Mortality rate at one year was 13.9% for Group A and 18.1% for Group B. Mean follow-up was 14 months (12-18m). There were no intraoperative complications. Three complications in Group A (8.1%) and twelve (33.3%) in Group B were encountered postoperatively (p<0.05). There was significant shorter hospital stay in Group A (5.2±3.1d) than in Group B (8.4±5.2d). In Group A, 28 patients returned to their pre-injury mobility status (75.6%) while 9 declined one level of the mobility scale (24.3%). In Group B, 26 patients remained at the same mobility level (72.2%) and 10 declined one level (27.7%). There was no significant difference between the postoperative OMAS scores in the two Groups (56.9±9.85 and 56.6±9.3 respectively).

CONCLUSIONS

We believe that TTC nailing is a safe and effective method of treatment of unstable ankle fractures in the elderly because it has a low risk of complications and restores function and mobility allowing an immediate return to full weight-bearing.

Comparison of Medial Malleolar Fracture Healing at 8 Weeks After Open Reduction Internal Fixation Versus Percutaneous Fixation: A Retrospective Cohort Study

Unstable medial malleolar fractures are treated with either standard open reduction internal fixation (ORIF) or a percutaneous approach. The percutaneous approach avoids the potentially excessive soft tissue dissection associated with an open approach but can also result in inadequate anatomic reduction. No studies have compared the incidence of radiographic healing of medial malleolar fractures between an open approach and percutaneous fixation. A retrospective comparative study was performed at a single institution across multiple sites. Electronic medical records and digital radiographs were reviewed for 845 patients who had undergone either ORIF or percutaneous screw fixation (PSF) of a medial malleolar fracture. The interval to fracture healing was measured. Logistic regression analysis was used. Of the 490 included patients, 458 (93.44%) underwent standard ORIF and 32 (6.53%) underwent PSF. Patients who underwent ORIF were 5 times more likely to have a healed fracture at 8 weeks than were patients who had undergone PSF (p < .001). Compared with standard ORIF, PSF of medial malleolar fractures leads to an increased risk of an unhealed fracture at 8 weeks. This was likely due to a combination of soft tissue interposition within the fracture site and inadequate fluoroscopic reliability, leading to poor anatomic reduction and inaccurate fixation.

Relationship of Prolonged Operative Time and Comorbidities With Complications After Geriatric Ankle Fractures

BACKGROUND

The incidence of geriatric ankle fractures has increased during the last few decades. In contrast to younger patients, increased complication rates have been observed. Thus, the goal of the present study was to identify risk factors for perioperative complications following open reduction and internal fixation of geriatric ankle fractures.

METHODS

Two hundred thirty-seven patients over the age of 65 years (mean, 72.5 ± 6.1 years) treated for ankle fractures in our institution between 2004 and 2014 were included. Complications associated with operative treatment as well as complications requiring revision surgery were analyzed. In a multivariate analysis, risk factors were determined.

RESULTS

In 68 patients (28.7%), 74 complications were documented. The most common complications were impaired wound healing and operative site infections. The multivariate analysis revealed that the operative time was the only independent risk factor for the development of a complication. The operative time as well as the presence of an open fracture represented risk factors for needing revision surgery. Comorbidities did not influence the development of complications.

CONCLUSION

The operative management of geriatric ankle fractures was associated with a high complication rate. In the present study, the operative time was the only modifiable factor for the development of a complication that required revision surgery. During preoperative preparation, we believe that perfusion of the affected limb should be optimized to reduce the incidence of wound complications.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Biomechanical Analysis of Stability of Posterior Antiglide Plating in Osteoporotic Pronation Abduction Ankle Fracture Model With Posterior Tibial Fragment

BACKGROUND

We performed a biomechanical comparison of 2 methods for operative stabilization of pronation-abduction stage III ankle fractures; group 1: Anterior-posterior lag screws fixing the posterior tibial fragment and lateral fibula plating (LSLFP) versus group 2: locked plate fixation of the posterior tibial fragment and posterior antiglide plate fixation of the fibula (LPFP).

METHODS

Seven pairs of fresh-frozen osteoligamentous lower leg specimens (2 male, and 5 female donors) were used for the biomechanical testing. Bone mineral density (BMD) of each specimen was assessed by means of dual-energy x-ray absorptiometry. After open transection of the deltoid ligament, an osteotomy model of pronation abduction stage III ankle fracture was created. Specimens were systematically assigned to LSLFP (group 1, left ankles) or LPPFP (group 2, right ankles). After surgery, all specimens were evaluated via CT to verify reduction and fixation. Axial load was then applied onto each specimen using a servohydraulic testing machine starting from 0 N (Zwick/Roell, Ulm, Germany) at a speed of 10 N/s with the foot fixed in a 10 degrees pronation and 15 degrees dorsiflexion position. Construct stiffness, yield, and ultimate strength were measured and dislocation patterns were documented with a high-speed camera. The normal distribution of all data was analyzed using Shapiro-Wilk test. The group comparison was performed using paired Student t test. Statistical significance was assumed at a P value of .05.

RESULTS

All specimens had BMD values consistent with osteoporosis. BMD values did not differ between the left and right ankles of the same pair ( P = .762). The mean BMD values between feet of men (0.603 g/cm²) and women (0.329 g/cm²) were statistically different ( P = .005). The ultimate strength for LSLFP (group 1) with 1139 ± 669 N and LPPFP (group 2) with 2008 ± 943 N was statistically different ( P = .036) as well as the yield in LSLFP (group 1) 812 ± 452 N and LPPFD (group 2) 1292 ± 625 N ( P = .016). Construct stiffness trended to be higher in group 2 (179 ± 100 kNn) compared to group 1 (127 ± 73 kN/m) but this difference was not statistically significant ( P = .120). BMD correlated with bone-construct failure.

CONCLUSION

Fixation of the posterior tibial edge with a posterolateral locking plate resulted in higher biomechanical stability than anterior-posterior lag screw fixation in an osteoporotic pronation-abduction fracture model.

CLINICAL RELEVANCE

The clinical implication of this biomechanical study is that the posterior antiglide plating might be advantageous in patients with osteoporotic pronation abduction stage III ankle fracture.

Ankle fractures in the elderly: Treatment and results in 477 patients

INTRODUCTION

In the elderly, ankle fractures are likely to cause specific complications and have a major impact on their autonomy. The goal of this multicentre study was to assess these outcomes in a geriatric population treated operatively.

MATERIAL AND METHODS

This retrospective study included 477 patients with ankle fractures treated surgically between 2008 and 2014. The minimum age was 60years for women and 70 for men. Patients with a tibial pilon fracture or less than 3months' follow-up were excluded. Functional (autonomy and comorbidities) and radiological assessments were performed before surgery and at the review.

RESULTS

The cohort was 81% female (384 women, 93 men) and had median age of 74years. The preoperative autonomy was 7.8 points on average using the Parker score. Most of the fractures were either Weber type B (n=336) or type C (n=114). At the follow-up, the mean autonomy score was 7.3 points. The fibula was fixed with a plate and screws in 69% of cases (n=325), with additional internal malleolar fixation was carried out in some cases. A satisfactory result, defined as 2 points or less reduction in the Parker score, was found in 89.9% of patients; 71.8% had not lost any autonomy. The main risk factors for loss of autonomy were being more than 80years of age (OR=2.93, P<0.001), poor surgical reduction (OR=2.8, P<0.01), the presence of two or more comorbidities (OR=2.71, P<0.001), being female (OR=2.19, P<0.043) or having a Weber type C fracture (OR=2.05, P=0.023).

DISCUSSION

The functional results are satisfactory overall following standard surgical treatment consisting of internal malleolar and fibular fixation for ankle fractures in the elderly. We identified five factors that greatly impact functional recovery.

LEVEL OF EVIDENCE

IV.

Cortical Bone Thickness of the Distal Part of the Tibia Predicts Bone Mineral Density

BACKGROUND

Poor bone density may affect surgical planning, treatment outcome, and postoperative protocols. Many patients with foot and ankle problems have not undergone a dual x-ray absorptiometry (DXA) scan, which is currently the gold standard for determining bone density. The purpose of this study was to determine if the cortical bone thickness (CBT) of the distal part of the tibia measured on radiographs correlated with bone mineral density.

METHODS

After exclusion criteria were applied, 167 consecutive adult patients (mean age and standard deviation [SD], 62 ± 11.62 years) who had had standardized ankle radiographs and a DXA scan within 6 months of each other were included in this retrospective study. The CBT was measured with both the gauge and the average method on standardized anteroposterior, lateral, and hindfoot alignment radiographs. The relationship between CBT in the distal part of the tibia and DXA findings in the hip, proximal part of the femur, and lumbar spine was assessed with Pearson correlations. The interrater and intrarater reliability of CBT measurements was assessed with intraclass correlation coefficients. Subgroup analysis was performed to determine the ability of CBT thresholds to predict osteoporosis.

RESULTS

Average CBT measurements on the anteroposterior, lateral, and hindfoot alignment views strongly correlated with DXA findings in the proximal part of the femur (r = 0.70, 0.64, and 0.55, respectively; p < 0.0001), the hip (r = 0.74, 0.67, and 0.53; p < 0.0001), and the lumbar spine (r = 0.61, 0.60, and 0.47; p < 0.0001). The interrater and intrarater reliability of the CBT measurements was excellent. Use of a 3.5-mm average CBT of the distal part of the tibia on the anteroposterior view as the threshold value for predicting osteoporosis (T score less than -2.5) had a sensitivity of 100%, a specificity of 25%, an accuracy of 33%, a positive predictive value of 19%, and a negative predictive value of 100%.

CONCLUSIONS

Measurement of the average CBT of the distal part of the tibia is a quick and reliable method for obtaining information on bone quality. CBT measured on standard ankle radiographs correlated strongly with DXA results and may prove to be a useful screening tool for osteoporosis.

LEVEL OF EVIDENCE

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.