Rest easy? Is bed rest really necessary after surgical repair of an ankle fracture?

Analysis of the cost-efficiency of the vascular impulse technology (VIT) in the perioperative management of complex ankle fractures: results of a prospective randomised controlled trial

INTRODUCTION

Posttraumatic swelling causes a delay in surgery, a prolonged hospital stay and a higher risk of complications. Thus, soft tissue conditioning following complex ankle fractures is of central importance in their perioperative management. Since the clinical benefit of VIT usage on the clinical course has been shown, it should now be investigated whether it is also cost-efficient in doing so.

MATERIALS AND METHODS

Included are published clinical results of the prospective, randomised, controlled, monocentric VIT study that have proven the therapeutic benefit in complex ankle fractures. Participants were allocated in a 1:1 ratio into the intervention group (VIT) and the control group (elevation). In this study, the required economic parameters of these clinical cases were collected on the data of the financial accounting and an estimation of annual cases had been performed to extrapolate the cost-efficiency of this therapy. The primary endpoint was the mean savings (in €).

RESULTS

Thirty-nine cases were studied in the period from 2016 to 2018. There was no difference in the generated revenue. However, due to lower incurred costs in the intervention group, there were potential savings of about €2000 (p_ITT = 0.073) to 3000 (p_AT = 0.008) per patient compared to the control group with therapy costs decreasing as the number of patients treated increases from €1400 in one case to below €200 per patient in 10 cases. There were 20% more revision surgeries in the control group or 50 min more OR time, respectively, and an increased attendance by staff and medical personnel of more than 7 h.

CONCLUSIONS

VIT therapy has been shown to be a beneficial therapeutic modality, but it is so not only in regard to soft-tissue conditioning but also cost efficiency.

Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review

BACKGROUND

Pain management after foot and ankle surgery must surmount unique challenges that are not present in orthopaedic surgery performed on other parts of the body. However, disparate and inconsistent evidence makes it difficult to draw meaningful conclusions from individual studies.

QUESTIONS/PURPOSES

In this systematic review, we asked: what are (1) the patterns of opioid use or prescription (quantity, duration, incidence of persistent use), (2) factors associated with increased or decreased risk of persistent opioid use, and (3) the clinical outcomes (principally pain relief and adverse events) associated with opioid use in patients undergoing foot or ankle fracture surgery?

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for our review. We searched PubMed, Embase, Scopus, Cochrane, and Web of Science on October 15, 2021. We included studies published from 2010 to 2021 that assessed patterns of opioid use, factors associated with increased or decreased opioid use, and other outcomes associated with opioid use after foot or ankle fracture surgery (principally pain relief and adverse events). We excluded studies on pediatric populations and studies focused on acute postoperative pain where short-term opioid use (< 1 week) was a secondary outcome only. A total of 1713 articles were assessed and 18 were included. The quality of the 16 included retrospective observational studies and two randomized trials was evaluated using the Methodological Index for Non-Randomized Studies criteria and the Jadad scale, respectively; study quality was determined to be low to moderate for observational studies and good for randomized trials. Mean patient age ranged from 42 to 53 years. Fractures studied included unimalleolar, bimalleolar, trimalleolar, and pilon fractures.

RESULTS

Proportions of postoperative persistent opioid use (defined as use beyond 3 or 6 months postoperatively) ranged from 2.6% (546 of 20,992) to 18.5% (32 of 173) and reached 39% (28 of 72) when including patients with prior opioid use. Among the numerous associations reported by observational studies, two or more preoperative opioid prescriptions had the strongest overall association with increased opioid use, but this was assessed by only one study (OR 11.92 [95% confidence interval (CI) 9.16 to 13.30]; p < 0.001). Meanwhile, spinal and regional anesthesia (-13.5 to -41.1 oral morphine equivalents (OME) difference; all p < 0.01) and postoperative ketorolac use (40 OME difference; p = 0.037) were associated with decreased opioid consumption in two observational studies and a randomized trial, respectively. Three observational studies found that opioid use preoperatively was associated with a higher proportion of emergency department visits and readmission (OR 1.41 to 17.4; all p < 0.001), and opioid use at 2 weeks postoperatively was associated with slightly higher pain scores compared with nonopioid regimens (β = 0.042; p < 0.001 and Likert scale 2.5 versus 1.6; p < 0.05) in one study.

CONCLUSION

Even after noting possible inflation of the harms of opioids in this review, our findings nonetheless highlight the need for opioid prescription guidelines specific for foot and ankle surgery. In this context, surgeons should utilize short (< 1 week) opioid prescriptions, regional anesthesia, and multimodal pain management techniques, especially in patients at increased risk of prolonged opioid use.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Factors Associated With Wound- and Implant-Related Complications After Surgical Treatment of Ankle Fractures

We have described the epidemiology of complications after surgical treatment of ankle fractures and assessed which factors are associated with the most frequent complications. We conducted a retrospective cohort study at 2 level 2 and 1 level 1 trauma center in a single trauma region in the Netherlands. The study variables were collected from the electronic medical patient records; all ankle fractures were classified using the Lauge-Hansen classification, and the complications were recorded. A total of 989 patients were included from 3 hospitals, with 173 complications in 156 patients (15.8%). The most frequent complication was wound related, occurring in 101 patients (10.2%). Implant-related complications occurred in 44 patients (4.4%). Other complications, such as cast pressure spots, posttraumatic dystrophy, nonunion, impingement, and pneumonia occurred in 28 patients (2.8%). The 2 most important complications were further analyzed for risk factors. Multivariate analysis showed the risk factors for wound-related complications were advanced age, increased American Society of Anesthesiologists classification, smoking, right side symptomatic, open fracture, and initial external fixation. Most implant-related complications were caused by malreduction (n = 22) or untreated syndesmotic injury (n = 19). Malreduction was associated with supination eversion fractures (p = .059), and untreated syndesmotic injury occurred more often with pronation external rotation fractures (p < .001). The most frequent complications after ankle fracture surgery were wound- and implant-related complications. Postoperative wound-related complications were multifactorial and dependent on a combination of trauma-, patient-, and treatment-related factors. In contrast, implant-related complications resulted from the interaction between the fracture type and subsequent surgical treatment.

When is indicated fibular fixation in extra-articular fractures of the distal tibia?

Background and aim of the work: There is no consensus about indications for fibular osteosynthesis in extra-articular fractures of the distal tibia (DTF). This study analyses patients affected by DTF associated to fibular fracture and has the aim to define whether the level of fibular fracture has an influence on bone healing and consequently when its fixation is indicated. Methods: Eighty-seven patients were operated from January 2005 to December 2016. Inclusion criteria were: the presence of skeletal maturity, the absence of physical limitations before trauma and a type 43-A AO closed fracture. Clinical outcomes were evaluated using Olerud–Molander Ankle Score (OMAS) and the Disability Rating Index (DRI). Malrotation was also assessed as well as incidence of nonunion and malalignment through x-rays. Results: No differences in clinical scores were reported at follow-up between patients in which fibular fixation was performed (Group 1) in comparison with those in which this procedure was not executed (Group 2). Nonunions were registered in 8 cases: four in Group 1 and four in Group 2. A statistically significant difference in incidence of external malrotation and valgus malalignment between the groups was documented, with a higher risk in patients of the second group. Conclusions: The level of fibular fracture is important to determine when the fixation of this bone is indicated. In supra-syndesmotic fractures osteosynthesis leads to a higher incidence of nonunions. Fibular osteosynthesis could prevent malrotation and malalignment and is advisable in distal metaphyseal fracture of this bone (trans- or infrasyndesmotic lesion) with syndesmotic injury. (www.actabiomedica.it)

Functional assessment of transplantar nailing for ankle fracture in the elderly: 48 weeks' prospective follow-up of 14 patients

INTRODUCTION

Retrograde transplantar intramedullary nailing (TIMN) is a recently described option for ankle fracture in elderly patients with multiple comorbidity contraindicating classical internal fixation. The main objective of the present study was to assess mobility after TIMN for ankle fracture in the elderly. The secondary objective was to assess complications.

HYPOTHESIS

Retrograde TIMN provides reliable fixation of ankle fracture in the elderly, enabling early resumption of walking.

MATERIAL AND METHODS

Fourteen patients, with a mean age of 79.6years (range: 65-99years), with fracture of the ankle or tibial pilon treated by retrograde TIMN, were prospectively included over a 1-year period (2014-2016). Full weight-bearing with walking cast boot was authorized as of day 1. Mobility was assessed on Parker score in consultation at 6, 12, 24 and 48 weeks.

RESULTS

Ten patients were followed up. Mean Parker score was 3.6 (range: 1-5) preoperatively, and 2.4 (range: 1-5) and 2.7 (range: 1-5) at 24 and 48 weeks, respectively: i.e., not significantly different from preoperative values (p=0.057 and p=0.054, respectively). There were no decubitus-related complications. Two patients (20%) showed other complications, including 1 deep infection requiring material ablation. Consolidation was systematic, without hindfoot malunion.

DISCUSSION

Retrograde TIMN appeared to be a useful option for ankle fracture in elderly patients for whom classical internal fixation was contraindicated. It allowed immediate resumption of weight-bearing and early rehabilitation, with no increased morbidity or mortality.

LEVEL OF EVIDENCE

IV.

Interventions for treating ankle fractures in children

BACKGROUND

Ankle fractures, which usually occur after a twisting incident, are a diverse collection of injuries with different levels of complexity and severity. They have an incidence of 1 in 1000 a year in children. Treatment generally involves splints and casts for minor fractures and surgical fixation with screws, plates and pins followed by immobilisation for more serious fractures.

OBJECTIVES

To assess the effects (benefits and harms) of different interventions for treating ankle fractures in children.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (22 September 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 8), MEDLINE (1946 to September Week 2 2015), MEDLINE In-Process & Other Non-Indexed Citations (21 September 2015), EMBASE (1980 to 2015 Week 38), CINAHL (1937 to 22 September 2015), trial registers (17 February 2015), conference proceedings and reference lists of articles.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials evaluating interventions for treating ankle fractures in children.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full articles for inclusion, assessed risk of bias and collected data. We undertook no meta-analysis.

MAIN RESULTS

We included three randomised controlled trials reporting results for 189 children, all of whom had a clinical diagnosis of a "low risk" ankle fracture. These were predominantly classified as undisplaced Salter-Harris type I fractures of the distal fibula. All three trials compared non-surgical management options. The three trials were at high risk of bias, primarily relating to the impracticality of blinding participants and treating clinicians to the allocated interventions.Two trials compared the Aircast Air-Stirrup ankle brace versus a rigid cast, which was a removable fibreglass posterior splint in one trial (trial A) and a below-knee fibreglass walking cast in the other trial (trial B). In trial A, both devices were removed at around two weeks. In trial B, removal of the brace was optional after five days, while the walking cast was removed after three weeks. There was low-quality evidence of clinically important differences in function scores at four weeks in favour of the brace groups of both trials. Function was measured using the Activities Scale for Kids-performance (ASKp; score range 0 to 100, higher scores mean better function) in trial A and using a modified version of the ASKp score (range 0 to 100%, higher percentages mean better function) in trial B. The results for trial A (40 participants) were median 91.9 in the brace group versus 84.2 in the splint group. The results for trial B (104 participants) were 91.3% versus 85.3%; mean difference (MD) 6.00% favouring brace (95% confidence interval (CI) 1.38% to 10.62%). Trial B indicated that 5% amounted to a clinically relevant difference in the modified ASKp score. Neither trial reported on unacceptable anatomy or related outcomes or long-term follow-up. There was very low-quality evidence relating to adverse events, none of which were serious. Trial A found twice as many children with pressure-related complications in the brace group (10 of 20 versus 5 of 20). In contrast, trial B found four times as many children in the cast group had adverse outcomes assessed in terms of an unscheduled visit to a healthcare provider (4 of 54 versus 16 of 50). Both trials linked some of the adverse events in the brace group with the failure to wear a protective sock. There was very low-quality evidence indicating an earlier return to pre-injury activity in the brace groups in both trials. Trial B provided low-quality evidence that children much prefer five days or more wearing an ankle brace than three weeks immobilised in a walking ankle cast. There was moderate-quality evidence of a lack of difference between the two groups in pain at four weeks.The third trial compared the Tubigrip bandage plus crutches and advice versus a plaster of Paris walking cast for two weeks and reported results at four weeks' follow-up for 45 children with an inversion injury of the ankle. The trial found very low-quality evidence of little difference in pain and function between the two groups, measured using a non-validated pain and function score at four weeks. The trial did not report on adverse effects. There was very low-quality evidence of an earlier return to normal activities, averaging six days, in children treated with Tubigrip (mean 14.17 days for Tubigrip versus 20.19 days for cast; MD -6.02 days, 95% CI -8.92 to -3.12 days).Recent evidence from magnetic resonance imaging studies of the main category of injury evaluated in these three trials suggests that most of the injuries in these trials were sprains or bone bruises rather than fractures of the distal fibular growth plate.

AUTHORS' CONCLUSIONS

There is low-quality evidence of a quicker recovery of self reported function at four weeks in children with clinically diagnosed low-risk ankle fractures who are treated with an ankle brace compared with those treated with a rigid cast, especially a non-removable walking cast. There is otherwise a lack of evidence from randomised controlled trials to inform clinical practice for children with ankle fractures. Research to identify and address priority questions on the treatment of these common fractures is needed.

Weight-bearing and mobilization in the postoperative care of ankle fractures: a systematic review and meta-analysis of randomized controlled trials and cohort studies

Purpose

To determine the effectiveness and safety of interventions used for rehabilitation after open reduction and internal fixation of ankle fractures.

Methods

A systematic review and meta-analysis was performed using both randomized trials and cohort studies. The effect of mobilization, weight-bearing, and unprotected weight-bearing as tolerated on postoperative recovery was compared using the Olerud Molander score, return to work/daily activities, and the rate of complications.

Results

A total of 25 articles were included. Ankle exercises resulted in earlier return to work and/or daily activities compared to immobilization (mean difference (MD) -20.76 days; 95% confidence interval (CI) -40.02 to -1.50). There was no difference in the rate of complications between exercises and immobilization (risk ratio (RR) 1.22; 95% CI 0.60 to 2.45) or between early and late weight-bearing (RR 1.26; 95%CI 0.56 to 2.85).

Interpretation

Results of this meta-analysis show that following ankle surgery, 1) active exercises accelerate return to work and daily activities compared to immobilization, 2) early weight-bearing tends to accelerate return to work and daily activities compared to late weight-bearing. Active exercises in combination with immediate weight-bearing may be a safe option.

To fix or not to fix? The role of fibular fixation in distal shaft fractures of the leg

BACKGROUND

The role of stabilisation of the fibula in distal two-bone fractures of the leg is controversial. Some studies indicate the need for fibular stabilisation in 43 AO fractures, but few studies consider the role of the fibula in 42 AO fractures. The aim of the current paper is to explain the role of stabilisation of the fibula in 42 AO fractures, correlating the rates of healing and non-union between patients with and without fibula fixation.

MATERIALS AND METHODS

A total of 60 patients with 42 AO (distal) shaft fracture of the tibia with associated fracture of the fibula were selected. Patients were divided into two groups according to whether or not the fibula was fixed: Group I (n=26) comprised patients who had their fibula fixed while Group II (n=34) comprised patients who did not. The fibular fracture was classified according to the AO and related to the level of the tibial fracture. Other parameters examined were the union rate of the two groups correlated to the fracture pattern and position of the fibular fracture; the demographic data, such as age and gender; the presence of an open fracture, and the type of tibial fixation device used (nail or plate).

RESULTS

None of the parameters considered (open injury, AO classification, device used and level of the fibular fracture relative to the tibial) were shown to have an influence on the development of a non-union.

CONCLUSION

This study showed a higher non-union rate when the fracture of the tibia and fibula were at the same level, the tibia was fixed with a bridging plate and the fibula left untouched. For this reason, we recommend fibular fixation in all 42 distal fractures when both fractures lie on the same plane and the tibial fracture is relatively stabilised.

Operative management of unstable ankle fractures in the elderly: our institutional experience

Ankle fractures represent an exceptionally common injury within the elderly population. The total incidence of ankle fractures has been reported to be up to 184 fractures per 100,000 persons per year, of which 20 to 30 percent occur in the elderly. This study reports the results of operative management of ankle fractures in the elderly, with regard to functional outcome and complication rates. This was a retrospective, non-randomized observational study. Subjects were identified from a trauma registry kept in our Department and were tested for eligibility. Patients were then categorized into two groups according to their age: Group A included all patients less than 65 years of age and Group B included all patients over the age of 65. The outcome was measured using the AOFAS Ankle-Hindfoot score and a Linear analog scale. A total of 120 consecutive patients fulfilled the eligibility criteria and were included in our study (60 patients in each group). We detected statistically significant difference between the LAS score of the two groups (p=0.02), the alignment between the two groups (p=0.04) and the AOFAS score versus LAS score in Group B (p=0.03). Two patients from Group B had wound dehiscence, but finally their wounds healed uneventfully. We didn't observe any serious complications such as skin necrosis, deep infection, osteomyelitis and failure of metalwork. Our study suggests that the operative management of Weber B2 and B3 injuries can result in a favorable outcome. It is however of great importance that there are no delays in treatment, that the reduction is anatomical, that the fracture fixation is satisfactory and that the rehabilitation is commenced early.