Early complications of surgery in operative treatment of ankle fractures in those over 60: a review of 186 cases

Three predictive scores compared in a retrospective multicenter study of nonunion tibial shaft fracture

BACKGROUND

Delayed union, malunion, and nonunion are serious complications in the healing of fractures. Predicting the risk of nonunion before or after surgery is challenging.

AIM

To compare the most prevalent predictive scores of nonunion used in clinical practice to determine the most accurate score for predicting nonunion.

METHODS

We collected data from patients with tibial shaft fractures undergoing surgery from January 2016 to December 2020 in three different trauma hospitals. In this retrospective multicenter study, we considered only fractures treated with intramedullary nailing. We calculated the tibia FRACTure prediction healING days (FRACTING) score, Nonunion Risk Determination score, and Leeds-Genoa Nonunion Index (LEG-NUI) score at the time of definitive fixation.

RESULTS

Of the 130 patients enrolled, 89 (68.4%) healed within 9 months and were classified as union. The remaining patients (n = 41, 31.5%) healed after more than 9 months or underwent other surgical procedures and were classified as nonunion. After calculation of the three scores, LEG-NUI and FRACTING were the most accurate at predicting healing.

CONCLUSION

LEG-NUI and FRACTING showed the best performances by accurately predicting union and nonunion.

Temporary immobilization methods for closed low-energy ankle fracture-dislocations: comparative analysis of a retrospective cohort

PURPOSE

Ankle fracture-dislocations (AFD) often necessitate staged management involving temporary external fixation (EF) due to mechanical instability or blistering. However, limited literature exists on the optimal temporary immobilization method for low-energy closed AFD. This study compared baseline patient and fracture characteristics, along with clinical and radiological outcomes between AFD initially immobilized with EF versus splinting.

METHODS

A retrospective cohort study was conducted involving patients with AFD temporarily immobilized using EF or splinting, followed by definitive open reduction and internal fixation. Quality of reduction (QOR) was assessed for each patient post-initial immobilization and after the definitive surgery.

RESULTS

The study encompassed 194 patients: 138 treated with a splint (71.1%) and 56 (28.9%) with EF. Secondary loss of reduction had occurred in three patients who were splinted (2.2%). The mean ages in the EF and splint groups were 63.2 and 56.1 years, respectively (p = 0.01). Posterior malleolus fracture (PMF) and blisters were more prevalent in EF patients (69.6% vs. 43.5% for PMF and 76.8% vs. 20.3% for blisters, respectively; p = 0.05 and p < 0.01). Postoperative complication rates were 8.9% for EF versus 10.9% for splinting (p = 0.69). Satisfactory final QOR was attained in 79.8% of patients treated with a splint versus 64.3% with EF (p = 0.02).

CONCLUSION

Patients immobilized by EF presented with poorer baseline characteristics and had more unstable injuries. Nevertheless, postoperative complication rates were comparable. Thus, EF appears to be a valuable tool for standardizing outcomes in AFD patients with a less favorable prognosis.

Percutaneous intramedullary screw or rush pin fixation of unstable ankle fractures in patients with fragile soft tissue - retrospective study of 80 cases

INTRODUCTION

The standard surgical procedure for unstable ankle fractures is fixation of the lateral malleolus with a plate and screws. This method has a high risk of complications, especially among patients with fragile skin conditions. The aim of this study was to estimate the re-operation rates and identify complications in patients with an unstable ankle fracture, surgically treated with an intramedullary screw or rush pin.

MATERIALS AND METHODS

We identified all patients who were surgically treated with either a 3.5-mm screw or rush pin at Aarhus University Hospital, Denmark, from 2012 to 2018. Major complications were re-operations within three months. We included 80 patients, of which 55 (69%) were treated with a 3.5-mm intramedullary screw and 25 (31%) with a rush pin. The majority of the study population was female (59) and the mean age was 75 (range 24 to 100) years. Of the 80 patients included, 41 patients had more than 2 comorbidities.

RESULTS

Three patients underwent re-operation within three months due to either fracture displacement or hardware cutout. Radiographs obtained after six weeks showed that nine patients had loss of reduction. Additionally, four patients had superficial wound infections and six patients had delayed wound healing.

CONCLUSIONS

Intramedullary fixation of distal fibula fractures with either a screw or rush pin has low re-operation rates. However, the high proportion of patients with radiological loss of reduction is concerning.

Complications After Ankle Fracture Surgery in Finland Between 1998 and 2020

BACKGROUND

Ankle fracture is a common injury and often requires operative treatment. This study investigated short-term (≤4 months) and long-term (>4 months) complications after ankle fracture surgery in a 23-year period with use of data from a comprehensive, nationwide, individual-level register.

METHODS

Data regarding patients who underwent operative treatment for ankle fracture were collected from the Finnish Care Register for Health Care and analyzed with use of logistic and Cox regression.

RESULTS

A total of 83,666 ankle fractures were operatively treated between 1998 and 2020. Of these, 36% were lateral malleolar fractures, 7% were medial malleolar fractures, 52% were bimalleolar or trimalleolar fractures, and 5% were other types of fractures. Fifty-one percent of the fractures were in female patients. The overall rate of short-term complications was 7.2%. Specifically, infection occurred in 4.4% of cases; thromboembolic complications,1.6% of cases; mechanical complications, 0.4% of cases; and other complications, 0.9% of cases. An age of >75 years was associated with a higher rate of short-term complications than an age of 51 to 75 years, with an odds ratio of 1.53 in the multivariable analysis (95% confidence interval, 1.39 to 1.67; p < 0.001). Short-term complications were also more prevalent in patients with diabetes (with or without associated complications); chronic pulmonary, kidney, or liver disease; or peripheral vascular disease. Mortality during the first 4 months after the ankle fracture operation was 0.6%. The most common reason for reoperation in the long term (>4 months after the index procedure) was fixation device removal, with a cumulative incidence of 17% within the first 3 years postoperatively. The risk of implant removal increased in younger patients and patients with bimalleolar or trimalleolar fractures. The cumulative incidence of ankle arthrodesis and arthroplasty was low.

CONCLUSIONS

Although postoperative complications are relatively rare, their treatment can lead to considerable morbidity. The findings of this study allow us to identify patients who are prone to complications or reoperations after undergoing operative treatment for ankle fracture.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preventing Surgical Site Infections in Geriatric Ankle Fracture Surgery with Closed-Incision Vacuum Therapy: A Pilot Study

BACKGROUND

Ankle fractures are among the most common fractures in older adult patients that need surgical treatment. The risk of surgical site infections (SSIs) after ankle fracture surgery ranges between 0.5% and 30%; SSI incidence is higher among older adults. Further, SSIs have significant consequences for subjective functional outcomes and create a need for prolonged intravenous antibiotic therapy and wound care. Accordingly, it is critical to determine risk factors for and establish optimal postoperative wound care to prevent SSIs.

OBJECTIVE

The aim of the pilot study was to examine the feasibility of closed-incision vacuum therapy (CIVT) to reduce rates of SSI in older adults.

METHODS

The authors performed a pilot study of a CIVT system in a population of 10 older adult patients after ankle fracture surgery.

RESULTS

Nine patients experienced uncomplicated wound healing of the lateral incision. One patient (10%) developed an SSI after premature removal of the vacuum system because of technical failure. Six weeks postoperation, overall satisfaction with the CIVT was high; none of the participants complained of incapacitating discomfort or disruptive limitations in postsurgical recovery.

CONCLUSIONS

The authors conclude that CIVT is a feasible, safe, and generally well-tolerated therapy to prevent SSIs in postoperative wound healing after open reduction and internal fixation in older adult patients after ankle fracture.

Wound complication risk factors following open reduction and internal fixation of ankle fractures

This study was designed to identify risk factors for wound complications including surgical site infection (SSI) and wound healing issues following open reduction and internal fixation (ORIF) of ankle fractures. A retrospective analysis of individuals with ankle fractures treated with ORIF was undertaken. Study subjects were divided into a wound complications (WC) group and a no wound complication (NWC) group. The WC group was further divided into an SSI group and wound healing issues group. Twenty-one potential risk factors associated with wound complications after ORIF were tracked. Uni- and multivariate binary logistical regression analyses were used to identify risk factors associated with wound complications, ISS and wound healing issues. In total, 613 individuals, who had undergone surgery for ankle fractures formed the study cohort. The incidence of postoperative wound complications was 10.3% (63 cases), including 5.2% of SSI (32 cases) and 5.1% of wound healing issues (31 cases). The independent risk factors for wound complications were age 65 years or older, preoperative serum albumin level below 35 g/L, peripheral neuropathy, open fracture, fewer than seven cases per year in surgical volume, and attending surgeon level. The independent risk factors for SSI were age 65 years or older, preoperative serum albumin level below 35 g/L, open fracture and fewer than seven cases per year in surgical volume. The independent risk factors for wound healing issues were preoperative serum albumin level below 35 g/L, peripheral neuropathy, open fracture and attending surgeon level. Herein we found both factors inherent to the injury and individual and those pertaining to the surgical team affected the frequency of wound complications after ORIF of ankle fractures. Specifically, advanced age and low surgical volume were associated with a greater risk of SSI. Peripheral neuropathy and the low expertise level on the part of the surgeon were associated with a greater risk of wound healing issues. Hypoproteinaemia and open fracture were both associated with a greater risk of both SSI and wound healing issues.

Predictors of first-year postoperative complications after fixation of low-energy ankle fractures: A single-center, retrospective cohort study of 663 consecutive fractures

INTRODUCTION

Rotational ankle fractures are common, have diverse personalities and affect both robust and fragile patients. Postoperative complications are frequent, creating a sizeable economic burden. The primary purpose of this study was to expand current knowledge on predictors of postoperative complications after low-energy ankle fracture fixation.

MATERIALS AND METHODS

A retrospective single-center cohort study was completed of patients undergoing internal fixation OF low-energy ankle fractures. The primary outcome was first-year postoperative complications, classified as major (surgical) or minor (non-surgical). Data on patients, their injuries, and treatments were collected. To identify potential predictors of outcomes, logistic regression methods were used, with a backward-stepwise method used for model fitting.

RESULTS

In total, 663 patients of median age 59 years were analysed. We found a high rate of complications (28.4%), with wound-healing issues and infections predominant. Overall, 14.8% had minor complications, while 13.6% required an unplanned reoperation. On multivariable analysis, the most consistent predictors of complications were older age (OR: 1.02 per year), longer operating time (3.32 per hour), and smoking (2.91).

CONCLUSIONS

Older patients and smokers who sustain fractures requiring more complex surgery are at higher risk of postoperative complications.

Results of prophylactic simple fasciocutaneous advancement in the initial management of acute ankle fractures with high risk of operative wound complication

Ankle fracture is the third most prevalent fracture in older adults. Wound dehiscence is the most frequent complication. Our objective is to determine the operative wound complication rate in patients with unstable ankle fracture in whom a prophylactic simple fasciocutaneous advancement was used.

METHODS

Prospective registry of patients with unstable ankle fracture, in whom a prophylactic fasciocutaneous advancement was performed between August 2020 and July 2021. Demographic variables, time spent in performing the flap, cost of osteosynthesis, minor and major complications of the surgical wound, readmission or reoperation were registered.

RESULTS

42 older adults with ankle fracture were included. Median age 69 (60-94). 31% diabetics and 21.5% active smokers. A 40% trimalleolar fracture pattern. There were 7% of superficial complications of the surgical wound. No major complications, no reoperations.

CONCLUSIONS

Prophylactic fasciocutaneous advancement at the beginning of traumatological surgery is technically simple, reproducible, cheap and with low complications.

LEVEL OF EVIDENCE

Level IV, cross-sectional study.

Hindfoot nailing without joint preparation for ankle fractures in extremely elderly patients: Comparison of clinical and patient-reported outcomes with standard ORIF

INTRODUCTION

Tibiotalocalcaneal (TTC) nailing without joint preparation has been indicated as an alternative to open reduction and internal fixation (ORIF) in the treatment of unstable fragility ankle fractures. We hypothesized that primary hindfoot nailing without joint preparation, and immediate weight bearing can provide a safe and effective treatment for unstable fragility fractures of the ankle compared to ORIF.

METHODS

A retrospectively single-center cohort was reviewed for all surgically treated ankle fractures in patients aged 75 years and older between 2016 and 2021. The cases were grouped by the surgical technique: ORIF or TTC nailing. Diagnosis and treatment were validated by a review of the radiographs and the patients' charts. Primary outcomes included complication rates and revision rates. The PROMs questionnaires included the Foot and Ankle-Ability Measure (FAAM-ADL) and the Olerud-Molander Ankle Score (OMAS).

RESULTS

Forty-six cases met the inclusion criteria during the study period. Eighteen in the TTC group and 28 in the ORIF group. The average follow-up was 46.4 months (Median 49.5, SD ± 25.3). The mean age of the TTC group was significantly higher (88.6 versus 81.8, p < 0.001). The mean surgery duration and length of stay were similar. The complication rates were 50.0 % in the ORIF group (28.6 % major) versus 22.2 % in the TTC group (5.6 % major), (p = 0.060). The revision rates were 28.6 % and 11.1 % in the ORIF and TTC groups respectively (p = 0.161). The FAAM-ADL was higher in the ORIF group (62.6 % versus 32.4 %, p = 0.020), as well as the OMAS (60.0 versus 32.8, p = 0.029).

CONCLUSION

TTC nailing without joint preparation for unstable fragility fractures of the ankle in the extremely elderly provided a better complication profile compared to traditional ORIF. However, PROMs were inferior.

Predictors of first-year postoperative complications after fixation of low-energy ankle fractures: A single-center, retrospective cohort study of 663 consecutive fractures

INTRODUCTION

Rotational ankle fractures are common, have diverse personalities and affect both robust and fragile patients. Postoperative complications are frequent, creating a sizeable economic burden. The primary purpose of this study was to expand current knowledge on predictors of postoperative complications after low-energy ankle fracture fixation.

MATERIALS AND METHODS

A retrospective single-center cohort study was completed of patients undergoing internal fixation OF low-energy ankle fractures. The primary outcome was first-year postoperative complications, classified as major (surgical) or minor (non-surgical). Data on patients, their injuries, and treatments were collected. To identify potential predictors of outcomes, logistic regression methods were used, with a backward-stepwise method used for model fitting.

RESULTS

In total, 663 patients of median age 59 years were analyzed. We found a high rate of complications (28.4%), with wound-healing issues and infections predominant. Overall, 14.8% had minor complications, while 13.6% required an unplanned reoperation. On multivariable analysis, the most consistent predictors of complications were older age (OR=1.02 per year), longer operating time (3.32 per hour), and smoking (2.91).

CONCLUSIONS

Older patients and smokers who sustain fractures requiring more complex surgery are at higher risk of postoperative complications.

Postoperative Outcomes in Malleolar Fractures Fixed With a 3.5-mm Locking Compression Plate Hook Plate

Ankle fractures are among the most common types of fractures seen in the United States. Few studies have analyzed the use of a locking compression plate (LCP) hook plate in the fixation of malleolar fractures. The goal of this study was to analyze postoperative outcomes in malleolar fractures fixed with a 3.5-mm LCP hook plate. A cohort of 74 patients with ankle fractures treated operatively with hook plates between 2011 and 2021 by a single orthopedic surgeon was retrospectively reviewed. Time to union, duration of non-weight bearing, final range of motion, postoperative complications, demographics, and comorbidities were recorded. A total of 66 patients fulfilled our inclusion criteria. There were 5 isolated medial malleolar, 34 bimalleolar, and 27 trimalleolar fractures. There were 46 women and 20 men with a mean age of 60.9±18.9 years. Fourteen patients had diabetes, 27 had osteoporosis, and 4 were current or former tobacco users. All patients achieved union, with a mean time to union of 10.9±5.3 weeks. The mean time to weight bearing was 50.2±18.4 days. The mean length of follow-up was 8.1±5.6 months. At final follow-up, mean dorsiflexion was 9.9°±4.3° and mean plantarflexion was 14.1°±5.1°. Six patients experienced postoperative complications such as surgical site infections and posttraumatic osteoarthritis. This study demonstrates that the use of a 3.5-mm LCP hook plate in the operative fixation of malleolar fractures has a high rate of union while maintaining low rates of postoperative complications. [Orthopedics. 2023;46(6):340-344.].

Risk factors for fracture-related infection after ankle fracture surgery

INTRODUCTION

Ankle fracture surgery comes with a risk of fracture-related infection (FRI). Identifying risk factors are important in preoperative planning, in management of patients, and for information to the individual patient about their risk of complications. In addition, modifiable factors can be addressed prior to surgery. The aim of the current paper was to identify risk factors for FRI in patients operated for ankle fractures.

METHODS

A cohort of 1004 patients surgically treated for ankle fractures at Haukeland University Hospital in the period of 2015-2019 was studied retrospectively. Patient charts and radiographs were assessed for the diagnosis of FRI. Binary logistic regression was used in analyses of risk factors. Regression coefficients were used to calculate the probability for FRI based on the patients' age and presence of one or more risk factors.

RESULTS

FRI was confirmed in 87 (9%) of 1004 patients. Higher age at operation (p < .001), congestive heart failure (CHF), p = 0.006), peripheral artery disease (PAD, p = 0.001), and current smoking (p = .006) were identified as risk factors for FRI. PAD and CHF were the risk factors displaying the strongest association with FRI with an adjusted odds ratio of 4.2 (95% CI 1.8-10.1) and 4.7 (95% CI 1.6-14.1) respectively.

CONCLUSION

The prevalence of FRI was 9% after surgical treatment of ankle fractures. The combination of risk factors found in this study demonstrate the need for a thorough, multidisciplinary, and careful approach when faced with an elderly or frail patient with an ankle fracture. The results of this study help the treating surgeons to inform their patients of the risk of FRI prior to ankle fracture surgery.

LEVEL OF EVIDENCE

Level III retrospective case-control study.

Locking plates for distal fibula fractures in young and elderly patients: A retrospective study

BACKGROUND

Ankle fractures are common injuries in the young and elderly populations. To prevent post-traumatic arthritis, an anatomic reconstruction of the ankle structure is mandatory. Open reduction and internal fixation is the treatment of choice among orthopaedics. Conventional plates allow stability of the fracture if bone quality is present. Locking plates might offer an advantage for the treatment of lateral malleolar fracture in patients with comminution, severe instability, distal fractures, or osteoporotic bone. Our hospital introduced a new locking plate for fracture of the distal fibula.

AIM

To evaluate locking plates in terms of outcomes and complications in young and elderly patients.

METHODS

We retrospectively reviewed a total of 67 patients treated for displaced distal fibula fractures. Demographic data, number of comorbidities, use of inter fragmentary screw, complication, time of fracture healing, partial or full weight bearing, and reoperation were recorded for all patients. Clinical outcome was assessed by the American Orthopedic Foot and Ankle Society clinical scoring system. Radiographs were obtained at 4, 8, 12, 16, 20, and 24 wk until radiographic union was obtained.

RESULTS

All patients displayed complete bony union on radiographic assessment, and no patients developed any serious complications. We observed two superficial infections, one delayed wound healing, and two plate intolerances. Significant differences were observed between the two age groups in terms of radiographic healing (11.9 wk in younger patients vs 13.7 wk in older patients; P = 0.011) and in the American Orthopedic Foot and Ankle Society score at 6 mo after surgery (88.2 in younger patients vs 86.0 in older patients; P = 0.001) and at 12 mo after surgery (92.6 in younger patients vs 90.0 in older patients; P = 0.000).

CONCLUSION

Locking plates provide a stable and rigid fixation in multifragmentary and comminuted fractures or in the presence of poor bone quality.

The Impact of Surgical Timing After Ankle Fracture on Clinical and Long-Term Patient Reported Outcomes

The goal of this study is to evaluate the effect of time-to-surgery following closed ankle fractures on long-term patient reported outcomes, fracture healing, and wound complications. To date, little research has been done focusing on the impact "time to definitive fixation" has on patient reported outcomes. We performed a retrospective analysis of 215 patient records who underwent open reduction and internal fixation (ORIF) for an ankle fracture from July 2011 to July 2018. A total of 86 patients completed the patient reported outcome measurement information systems (PROMIS) survey at long-term follow-up. Primary outcomes were the rate of delayed union, postoperative wound complications, patient reported outcome measurement information system (PROMIS) pain interference (PI), and physical function (PF) scores. No differences were found when comparing time to surgery on a continuous scale with rates of delayed union, nonunion, or wound complications (p = .84, .47, and .63, respectively). PROMIS scores were collected at a median of 4.5 years (2.0 interquartile range (IQR), range 2.5-12.3) postoperatively. The time from ankle fracture to surgery was independently associated with worse PROMIS PI scores (unstandardized β 0.38, 95% CI 0.07-0.68) but not PROMIS PF scores. Severe Lauge-Hansen injuries were independently associated with decreased PROMIS PF scores (unstandardized β -7.02, 95% CI -12.0 to -2.04). Increased time to surgical intervention and severe Lauge-Hansen injuries were independently associated with worse long-term patient reported outcomes. Surgical timing did not impact union rates or wound complications. Surgeons should be aware that delaying ankle fracture repair beyond 12 days after injury may negatively affect long-term patient reported pain scores.

Use of Distal Tibial Cortical Bone Thickness and FRAX Score for Further Treatment Planning in Patients with Trimalleolar Ankle Fractures

Trimalleolar ankle fractures show a bimodal age distribution, affecting younger men and older women. Postmenopausal women often exhibit low bone mineral density, which contributes to a higher prevalence of osteoporotic-related fractures. The primary goal of this study was to analyse the association of patient characteristics with the cortical bone thickness of the distal tibia (CBTT) in trimalleolar ankle fractures.

METHODS

A total of 193 patients with a trimalleolar ankle fracture treated between 2011 and 2020 were included. Patient registries were reviewed regarding demographics, mechanism, and type of injury. The CBTT was assessed in radiographs and CT images. The FRAX score was calculated to estimate the probability for an osteoporotic fracture. A multivariable regression model was calculated to identify independent variables affecting the cortical bone thickness of the distal tibia.

RESULTS

Patients older than 55 years were 4.22 (95% CI: 2.12; 8.38) times more likely to be female. In the multivariable regression analysis, female sex (β -0.508, 95% CI: -0.739; -0.278, p < 0.001) and a higher age (β -0.009, 95% CI: -0.149; -0.003, p = 0.002) were independent variables associated with a lower CBTT. Patients with a CBTT < 3.5 mm had a higher 10-year probability for a major osteoporotic fracture (12% vs. 7.75%; p = 0.001).

CONCLUSIONS

The assessment of the peripheral bone quality in routine computed tomography demonstrated that higher age and female sex are significantly associated with reduced cortical bone thickness of the distal tibia. Patients with a lower CBTT showed a higher probability for a subsequent osteoporotic fracture. In female patients with reduced distal tibial bone quality and associated risk factors, an osteoporosis assessment should be evaluated.

Effects of Venous Insufficiency in Patients Undergoing Primary Total Knee Arthroplasty: An Analysis of 1.2 Million Patients

Chronic venous insufficiency (CVI) is extraordinarily prevalent in our aging population with over 30 million people in the United States suffering from the disease. There is a paucity of data analyzing the effects of CVI on outcomes following total knee arthroplasty (TKA). The purpose of this study was to utilize a nationwide administrative claims database to determine whether patients with CVI undergoing TKA have higher rates of: (1) in-hospital lengths of stay (LOS); (2) readmission rates; (3) medical complications; (4) implant-related complications; and (5) costs of care compared to controls. Using a nationwide database, we matched patients with CVI undergoing TKA to controls without CVI undergoing TKA in a 1:5 ratio by age, sex, and medical comorbidities associated with CVI. Primary outcomes analyzed within the study included LOS, 90-day readmission rates, 90-day medical complications, 2-year implant-related complications, in addition to 90-day total global episode of care costs. The query yielded 1,265,534 patients with (n = 210,926) and without (n = 1,054,608) CVI undergoing primary TKA. Patients with CVI had significantly longer LOS (4 vs. 3 days, p < 0.0001), higher 90-day readmission rates (20.96 vs. 15.34%; odds ratio [OR]: 1.46, 95% confidence interval [CI]: 1.44-1.48, p < 0.0001), and higher odds of medical complications (2.27 vs. 1.30%; OR: 1.76, 95% CI: 1.70-1.83, p < 0.0001) compared to matched controls. Patients with CVI also had higher odds of periprosthetic joint infections (2.23 vs. 1.03%; OR: 2.18, p < 0.0001) and implant-related complications in general (4.27 vs. 2.17%; OR: 2.01, 95% CI: 1.96-2.06, p < 0.0001). Additionally, patients with CVI had higher total global 90-day episode of care costs ($15,583.07 vs. $14,286.95, p < 0.0001). Patients with CVI undergoing TKA have increased LOS, higher odds of medical and implant complications, and increased costs of care compared to those without CVI. The study can be utilized by orthopaedic surgeons to counsel patients on the potential complications following this procedure. This is a level III, retrospective cohort study.

[Reconstruction of posttraumatic soft tissue defects of the ankle using free fascial flaps from the anterolateral thigh]

BACKGROUND

Free fascial flaps from the anterolateral thigh (ALT) were used to reconstruct soft tissue defects after trauma to the ankle. This modification was compared to the conventional fasciocutaneous method.

MATERIAL AND METHODS

The defect size, the thickness of the subcutaneous fat layer on the thigh and the extent of the soft tissue covering the ankle were determined retrospectively. The evaluations were compared between fascial (Fo) and fasciocutaneous flaps (Fc). The foot and ankle outcome score (FAOS) was used. Esthetic outcome surveys were carried out.

RESULTS

A total of 18 isolated fractures of the ankle were evaluated. In 94% of the cases a closed soft tissue damage predominated. After fracture fixation using a plate, soft tissue defects with a mean area of 40.4 ± 13.1 cm2 (28-76 cm2) developed. The thickness of the soft tissue covering over the affected malleoli increased significantly in both groups as a result of the flap surgery (4.5 ± 0.7 vs. 21.1 ± 6.4 mm, p < 0.05). A significant difference was found when comparing the body mass index (BMI) between the groups (Fc 26.3 ± 3.4 kg/m2 vs. Fo 30.1 ± 4.2 kg/m2, p < 0.05). For both groups there was a positive correlation (r = 0.843) between the BMI and the thickness of the epifascial fat layer of the thigh. The FOAS survey revealed 75.9 ± 28.9 and 47.9 ± 32.4 points, respectively, for "function in daily life" and "foot and ankle-related quality of life". The esthetic reconstruction result was rated as "acceptable" by 55% and as "good" by 45%.

DISCUSSION

The modified method of a free fascial flap from the ALT can be useful in situations where a bulky flap makes it difficult to fit it into the defect.

Fibula Nail versus Locking Plate Fixation-A Biomechanical Study

In the treatment of ankle fractures, complications such as wound healing problems following open reduction and internal fixation are a major problem. An innovative alternative to this procedure offers a more minimally invasive nail stabilization. The purpose of this biomechanical study was to clarify whether this method was biomechanically comparable to the established method. First, the stability (range of motion, diastasis) and rotational stiffness of the native upper ankle were evaluated in eight pairs of native geriatric specimens. Subsequently, an unstable ankle fracture was created and fixed with a locking plate or a nail in a pairwise manner. The ankles showed significantly less stability and rotational stiffness properties after nail and plate fixations than the corresponding native ankles (p < 0.001 for all parameters). When comparing the two methods, both showed no differences in their range of motion (p = 0.694) and diastasis (p = 0.166). The nail also presented significantly greater rotational stiffness compared to the plate (p = 0.001). However, both fixations remained behind the native stability and rotational stiffness. Due to the comparable biomechanical properties of the nail and plate fixations, an early weight-bearing following nail fixation should be assessed on a case-by-case basis considering the severity of fractures.

Temporizing cast immobilization is a safe alternative to external fixation in ankle fracture-dislocation while posterior malleolar fragment size predicts loss of reduction: a case control study

Background

To determine if temporizing cast immobilization is a safe alternative to external fixator (ex-fix) in ankle fracture-dislocations with delayed surgery or moderate soft-tissue injury, we analysed the early complications and re-dislocation rates of cast immobilization in relation to ex-fix in patients sustaining these injuries.

Methods

All skeletally mature patients with a closed ankle fracture-dislocation and a minimum 6-months follow-up treated between 2007 and 2017 were included. Baseline demographics, comorbidities, injury description, treatment history and complications were assessed.

Results

In 160 patients (94 female; mean age 50 years) with 162 ankle fracture-dislocations, 35 underwent primary ex-fix and 127 temporizing cast immobilizations. Loss of reduction (LOR) was observed in 25 cases (19.7%) and 19 (15.0%) were converted to ex-fix. The rate of surgical site infections (ex-fix: 11.1% vs cast: 4.6%) and skin necrosis (ex-fix: 7.4% vs cast: 6.5%) did not differ significantly between groups (p = 0.122 and p = 0.825). Temporizing cast immobilization led to an on average 2.7 days earlier definite surgery and 5.0 days shorter hospitalization when compared to ex-fix (p < 0.001). Posterior malleolus fragment (PMF) size predicted LOR with ≥ 22.5% being the threshold for critical PMF-size (p < 0.001).

Conclusion

Temporizing cast immobilization was a safe option for those ankle fracture-dislocations in which immediate definite treatment was not possible. Those temporized in a cast underwent definite fixation earlier than those with a fix-ex and had a complication rate no worse than the ex-fix patients. PMF-size was an important predictor for LOR. Primary ex-fix seems appropriate for those with ≥ 22.5% PMF-size.

Trial registration

The study does not meet the criteria of a prospective, clinical trial. There was no registration.

Diagnosis and Treatment of Neuropathic Ankle Fractures

»

Standard 3-view ankle radiographs are the first-line imaging modality for suspected neuropathic ankle fractures. Computed tomography is helpful to evaluate for concomitant osseous changes and soft-tissue infection.

»

Nonoperative management may be considered for low-demand, elderly, or comorbid patients for whom surgery and anesthesia are contraindicated. However, the presence of comorbidities alone should not necessarily preclude operative intervention. Given the overall poor results of nonoperative treatment in the neuropathic ankle fracture population, operative intervention may in fact be less risky to the patient.

»

The authors have 2 preferred treatment techniques. For cases in which the vascular supply and bone stock are adequate, open reduction and internal fixation (ORIF) with locking fixation for the fibula, a medial buttress/hook plate with lag screws for the medial malleolus, multiple syndesmotic screws for additional fixation even in the absence of a syndesmotic injury, and temporary transfixation Steinmann pins from the calcaneus into the tibia are used. For cases in which there is a concern for wound healing or previously failed ORIF, minimally invasive surgical tibiotalocalcaneal arthrodesis with a retrograde locked intramedullary nail is used.

Is the osteosynthesis of lateral malleolar fractures by pin/cerclage effective? A retrospective study

INTRODUCTION

Lateral malleolar fractures are present in about 90% of ankle fractures. The standard treatment is plate osteosynthesis. Although the plates are thin, the risk of cicatricial complications is not insignificant and can lead to cutaneous or even infectious complications and the latter can cause functional repercussions. We therefore aimed to evaluate a technique consisting of osteosynthesis of the lateral malleolus using two cerclages and two intramedullary pins.

HYPOTHESIS

Our hypothesis is that the use of osteosynthesis by pin/cerclage of the lateral malleolus makes it possible to have objective reduction criteria, similar to the reference treatment.

METHODS

This is a retrospective study of patients who had an interligamentous spiral fracture of the lateral malleolus. One group of patients had internal fixation of the lateral malleolus fracture by pins, and the other by plate. Our primary outcome was to compare the reduction of the fracture of the lateral malleolus between the two techniques using the "Dime sign", the measurement of the talocrural angle and respect for Shenton's line.

RESULTS

A total of 118 lateral malleolar fractures were included: 56 patients (47.5%) in the "pin" group and 62 patients (52.5%) in the "plate" group. The mean age of the patients was 46.6 years (17.4) with an average body mass index of 25.2kg/m² (4.8) and 55.1% of the patients were women. We found a difference in the reduction criteria between the two groups by looking at Shenton's line: 73.2% (41/56) of postoperative X-rays in the "pin" group respected Shenton's line, compared to 90.3% (56/62) in the "plate" group (p=0.02). We did not find any difference regarding the "Dime sign" and the talocrural angle.

CONCLUSION

Our study shows the superiority of plate osteosynthesis for lateral malleolar fractures compared to pin/cerclage osteosynthesis, regarding one of the three radiological criteria for reduction. No significant difference was found in the one-year rates of complications and of hardware removal, between the two groups.

LEVEL OF EVIDENCE

IV, retrospective study.

Efficacy of hook-type locking plate and partially threaded cancellous lag screw in the treatment of displaced medial malleolar fractures in elderly patients

INTRODUCTION

Traditionally, partially threaded cancellous lag screws (PTCS) are used for most medial malleolar fractures but are often challenging to execute in elderly patients because of the high risk of postoperative complications. Limited literature explores whether hook-type locking compression plates (LCPs) reliably offer better outcomes than PTCS in elderly patients. We aimed to compare the midterm radiologic and clinical outcomes between hook-type LCP and PTCS for medial malleolar fractures in an elderly population.

METHODS

We included 258 patients, aged 65 years and above, treated with either a hook-type locking plate (hook LCP group: 121 patients) or PTCS (screw group: 137 patients), and with follow-ups of at least 36 months in this retrospective study. Radiographic assessments included the union rate and interval to fracture union. Clinical assessment included the postoperative complications and revision procedures.

RESULTS

Although a significantly higher rate of comminuted fractures was observed in the hook LCP group than in the screw group (p < .001), no significant difference in the union rate was observed between the two groups (hook LCP group: 93.4% vs. screw group: 89.8%, p = .151), and a significantly shorter interval to union was observed in the hook LCP group (10.2 ± 7.0 vs. 12.3 ± 6.7 weeks, p = .015). There was a trend toward a lower rate of complications, including revision procedures, in the hook LCP group than in the screw group (19.9% vs. 28.5%, p = .107 and 6.6% vs. 13.8%, p = .074).

CONCLUSION

Hook-type LCP may be an alternative option for treating medial malleolar fractures with comminution in elderly patients.

Ankle tibiotalocalcaneal nailing in elderly ankle fractures as an alternative to open reduction internal fixation: technique and literature review

The use of tibiotalocalcaneal nails for unstable ankle fractures in low demand elderly patients has been introduced as an alternative to open reduction internal fixation to allow early weight-bearing and to decrease soft tissue complications and mechanical failures. This paper describes the technique of hindfoot nailing and reviews the current literature. Overall, it is a minimally invasive and expeditious procedure that provides stable fixation to withstand immediate ambulation of the frail elderly patient. Future high-quality randomized controlled trials will determine if complications and outcomes compare favorably to open reduction and internal fixation.

High-risk ankle fractures in high-risk older patients: to fix or nail?

INTRODUCTION

Optimal treatment of high-risk ankle fractures in older, comorbid patients is unknown. Results of open reduction internal fixation (ORIF) versus tibiotalocalcaneal (TTC) fusion nailing for the treatment of high-risk geriatric ankle fractures were investigated.

MATERIALS AND METHODS

Results of ORIF versus TTC fusion nailing were evaluated via retrospective case-control cohort study of 60 patients over age 50 with an open ankle fracture or one with at least 50% talar subluxation and at least 1 high-risk comorbidity: diabetes mellitus (DM), peripheral vascular disease, immunosuppression, active smoking, or a BMI > 35. The primary outcome was reoperation rate within 1-year post-surgery. Secondary outcomes include infection, peri-implant fracture, malunion/nonunion, mortality, length of stay, disposition, and hospital acquired complications.

RESULTS

Mean age was 71 (ORIF) and 68 (TTC). 12/47 (25.5%) ORIF cases were open fractures versus 4/14 (28.6%) with TTC. There were no significant differences between ORIF and TTC in 1-year reoperation rates (17% vs 21.4%), infection rates (12.8% vs 14.3%), or union rates (76.% vs 85.7%), respectively. One TTC patient sustained a peri-implant fracture treated nonoperatively. There were no significant differences in medical risk factors between groups other than a higher rate of DM in the TTC group, 42.6% vs 78.6%, p = 0.02. Incomplete functional outcome data in this challenging patient cohort precluded drawing conclusions.

CONCLUSION

ORIF and TTC fusion nailing result in comparable and acceptable reoperation, infection, and union rates in treating high-risk ankle fractures in patients over 50 with at least 1 major comorbidity for increased complications; further study is warranted.

Comparing the 30-Day Complications Between Smokers and Nonsmokers Undergoing Surgical Fixation of Ankle Fractures

Background:

There have been conflicting reports regarding the effect of smoking on complications after surgical treatment of ankle fractures. This study aimed at identifying the complications for which smokers and subgroups of smokers are at a higher risk compared to nonsmokers when undergoing surgery for fixation of rotational ankle fractures.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program data set from 2008 to 2019 was used to compare the 30-day wound, cardiac, renal, and infectious complications, related readmissions, and return to the operating room between the 2 cohorts.

Results:

Of 33 741 patients included, 25 642 (76.0%) were nonsmokers and 8099 (24.0%) were smokers. Multivariate analysis showed that smokers were at a higher risk for deep wound infection (OR 2.34, 95% CI 1.48-3.69, P < .001), wound dehiscence (OR 2.43, 95% CI 1.56-3.77, P < .001), related return to the operating room (OR 1.69, 95% CI 1.36-2.11, P < .001), and related readmissions (OR 1.67, 95% CI 1.32-2.09, P < .001). Smokers at an increased risk for deep infection included patients between 50 and 59 years (OR 5.75, 95% CI 1.78-18.5, P = .003), who were Black (OR 4.24, 95% CI 1.04-17.23, P = .044), who had body mass index (BMI) 35 to 39.9 (OR 3.73, 95% CI 1.46-9.50, P = .006), or operative times between 60 and 90 minutes (OR 3.64, 95% CI 1.79-7.39, P < .001). Smoker subgroups at a higher risk for wound dehiscence included patients between 50 and 59 years (OR 9.86, 95% CI 3.29-29.53, P < .001), with operative times between 90 and 120 minutes (OR 4.88, 95% CI 1.89-12.58, P < .001), with BMI 30 to 34.9 (OR 3.06, 95% CI 1.45-6.45, P = .003) and who underwent spinal/epidural anesthesia (OR 9.31, 95% CI 2.31-37.58, P = .002).

Conclusion:

Smokers were at an increased risk for deep wound infection, wound dehiscence, related reoperations, and related readmissions after ankle fracture surgery. Certain subgroups were at an even higher risk for these complications.

Level of Evidence:

Level III, retrospective cohort study.

The local soft tissue status and the prediction of local complications following fractures of the ankle region

INTRODUCTION

Well-known risk factors (RF) for soft tissue complications following surgical treatment of fracture of the ankle region include diabetes, smoking, and the local soft tissue status. A weighted analysis might provide a risk profile that guides the surgical treatment strategy. The aim of this meta-analysis was to provide a risk profile for soft tissue complications following closed fractures of the ankle region.

METHODS

This review provides a meta-analysis of studies that investigate potential risk factors for complications in fractures of the ankle region.

INCLUSION CRITERIA

Original articles that were published between 2000 and 2020 in English or German language that calculated odds ratios (OR) of RF for soft tissue complications. Further, this study only includes articles that investigated fractures of the ankle region including pilon fracture, calcaneal fractures, and fractures of the malleoli. This study excluded articles that provide exploratory analyses, narrative reviews, and case reports. RF were stratified as patient specific systemic RF (PSS), patient specific local RF (PSL), and non-patient specific RF (NPS). PSS RF includes comorbidities, American society of anaesthesiology (ASA), requirement of medication, additional injuries, and smoking or substance abuse. PSL RF includes soft tissue status, wounds, and associated complications. NPS RF includes duration of surgery, staged procedure, or time to definitive surgery. Random effect (RE) models were utilized to summarize the effect measure (OR) for each group or specific RF.

RESULTS

Out of 1352 unique articles, 34 were included for quantitative analyses. Out of 370 complications, the most commonly assessed RF were comorbidities (34.6%). Local soft tissue status accounted for 7.5% of all complications. The overall rate for complication was 10.9% (standard deviation, SD 8.7%). PSS RF had an OR of 1.04 (95%CI 1.01 to 1.06, p = 0.006), PSL an OR of 1.79 (95% 1.28 to 2.49, p = 0.0006), and NPS RF an OR of 1.01 (95%CI 0.97 to 1.05, p = 0.595). Additional injuries did not predict complications (OR 1.23, 95%CI 0.44 to 3.45, p = 0.516). The most predictive RF were open fracture (OR 3.47, 95%CI 1.64 to 7.34, p < 0.001), followed by local tissue damage (OR 3.05, 95%CI 1.23 to 40.92, p = 0.04), and diabetes (OR 2.3, 95%CI 1.1 to 4.79, p = 0.26).

CONCLUSION

Among all RFs for regional soft tissue complications, the most predictive is the local soft tissue status, while additional injuries or NPS RF were less predictive. The soft tissue damage can be quantified and outweighs the cofactors described in previous publications. The soft tissue status appears to have a more important role in the decision making of the treatment strategy when compared with comorbidities such as diabetes.

Association of Delayed Surgery for Ankle Fractures and Patient-Reported Outcomes

BACKGROUND

Several studies probe the association between prolonged time to surgery and postoperative complications in ankle fractures, but little is known about how a longer wait time affects clinical outcomes. The present study aims to assess the association between time from injury to surgery and patient-reported outcomes after operative treatment of severe ankle fractures.

METHOD

Patients treated operatively for low-energy ankle fractures that also involve the posterior malleolus from 2014 to 2016 were included. Patient charts were reviewed for patient demographics, type of trauma, fracture characteristics, treatment given, and complications. Ankle function was evaluated on a follow-up visit by clinical examination, radiographs, and patient-reported outcome measures (Self-Reported Foot and Ankle Score [SEFAS], RAND-36, visual analog scale [VAS] of Pain, VAS of Satisfaction). We compared patients treated within 1 week to those treated later than a week from injury for analyses.

RESULTS

Follow-up visits of 130 patients were performed at mean 26 (SD 9) months after surgery. Patient demographics and fracture characteristics were similar between groups. Mean SEFAS was 34 (SD 10) in patients treated later than a week from injury vs 38 (SD 9) in those treated earlier (P = .012). Patients operated on later than 7 days from injury reported more pain (P = .008) and lower satisfaction than those treated earlier (P = .016).

CONCLUSION

In this retrospective patient series of low-energy ankle fractures with posterior malleolar fragments, we found that waiting >7 days for definitive surgery was associated with poorer clinical outcomes and more pain compared with those who had surgery earlier.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Association of Bleeding Disorders and Risk of Complications Following Open Reduction and Internal Fixation of the Ankle

BACKGROUND

Open reduction and internal fixation (ORIF) of the ankle is a common procedure performed to correct ankle fractures in many different patient populations. Diabetes, peripheral vascular disease, and osteoporosis have been identified as risk factors for postoperative complications following surgery for ankle fractures. To date, there have not been any studies evaluating postoperative outcomes in patients with bleeding disorders undergoing operative treatment for ankle fractures. The aim of this study was to determine the postoperative complication rate following ORIF of the ankle in patients with a bleeding disorder vs those without a bleeding disorder.

METHODS

From 2006 to 2018, patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database. Two patient cohorts were defined: patients with a bleeding disorder and patients without a bleeding disorder. Patients who underwent either inpatient or outpatient ORIF of the ankle were included in this study. In this analysis, demographics, medical comorbidities, and postoperative complications variables were assessed between the 2 cohorts. Bivariate and multivariate analyses were performed.

RESULTS

Of 10 306 patients undergoing operative treatment for ankle fracture, 9909 patients (96.1%) had no bleeding disorder whereas 397 patients (3.9%) had a bleeding disorder. Following adjustment on multivariate analysis, compared to patients who did not have a bleeding disorder, those with a bleeding disorder had an increased risk of any postoperative complications (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.05-2.08, P = .024), requirement for postoperative blood transfusion (OR 2.86, 95% CI 1.53-5.36, P = .001), and extended length of hospital stay greater than 5 days (OR 1.46, 95% CI 1.10-1.93, P = .010).

CONCLUSION

Patients with bleeding disorders are associated with increased risk of postoperative complications following ORIF for ankle fractures. Determining patient risk factors and creating optimal preoperative and perioperative management plans in patients with bleeding disorders undergoing ORIF can be beneficial in reducing postoperative complications, improving patient outcomes, and reducing overall morbidity.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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.

Male sex, Gustillo-Anderson type III open fracture and definitive external fixation are risk factors for a return to the or following the surgical management of geriatric low energy open ankle fractures

INTRODUCTION

Open ankle fractures in geriatric (age > 60 years) patients are a source of significant morbidity and mortality. Surgical management includes plate and screw fixation (ORIF), retrograde hindfoot nail (HFN), definitive external fixation (ex-fix) and below knee amputation. However, each modality poses unique challenges for this population. We sought to identify predictors of unplanned OR and short-term mortality after geriatric open ankle fractures managed by our service.

MATERIALS AND METHODS

In an IRB-approved protocol, we evaluated patients over 60 years of age managed for a low energy open ankle/distal tibia pilon fracture by trauma fellowship-trained surgeons from a single academic department that covers two level I trauma centers. Our primary outcome was an unplanned return to the OR. Secondary outcomes were a 90-day "event", defined as an all-cause hospital readmission or mortality, and 1-year mortality. Differences with a p-value < 0.1 measured on univariate analysis were evaluated using a multivariable logistic regression to identify independent outcome predictors.

RESULTS

A total of 113 (60 ORIF, 36 HFN, 11 ex-fix, 6 amputations) were performed. Cohort mean age was 75.2 ± 9.8 years, and 31 patients (27.4%) were male. Mean age-adjusted charlson comorbidity index was 5.5 ± 2.0. Significant independent predictors of an unplanned return to the OR were male sex (OR 4.4, 95% CI 1.3 to 15.4), Gustilo Type III open fracture (OR 4.9, 95% CI 1.5 to 17.5) and ex-fix (OR 15.6, 95% CI 2.7 to 126.3). Independent predictors of a 90-day "event" were walker/minimal ambulation (OR 3.5, 95% CI 1.3 to 10.4), surgical site infection (OR 4.8, 95% CI 1.8 to 13.8) and reduced BMI (OR 0.9, 95% CI 0.9 - 0.99), while independent predictors of 1-year mortality were age (OR 1.1, 95% CI 1.003 to 1.2), ACCI (OR 1.4, 95% CI 1.02 to 2.0) and walker/minimal ambulator (OR 7.5, 95% CI 1.7 to 53) CONCLUSIONS: Host factors, particularly pre-operative mobility, were most predictive of 90-day event and 1-year mortality. Only definitive external fixation was found to influence patient morbidity as a significant predictor of unplanned OR. However, no surgical modality had any influence on short-term readmission or survival.

Diabetic ankle fracture complications: a meta-analysis

INTRODUCTION

This meta-analysis aimed to review complication rates following the treatment of an ankle fracture in diabetic patients and to early detect the subgroup of patients at potential risk in order to minimise this complication rate.

METHODS

A search of 3 databases was performed for studies published till March 2018. Twelve studies met the eligibility criteria for further statistical analysis. An odds ratio (OR) with a 95% confidence interval (95% CI) for each complication was calculated between the diabetic and non-diabetic groups.

RESULTS

The overall complication risk after ankle fracture was twice as high in diabetes mellitus (DM) than non-diabetes mellitus (non-DM) patients (OR 1.9, 95%CI: 1.7-2.03). This risk was considerably higher with surgery versus non-surgical treatment (OD 3.7, 95%CI: 2.3-6.2). The risk of infection was 3 times higher in DM than in non-DM patients (OR 3.4, 95%CI: 2.9-9.8). The complication rate was even higher in patients with advanced DM (OR 8.4, 95%CI: 2.9-24.5).

CONCLUSION

This meta-analysis provides evidence that diabetic patients are at a greater risk of complication after an ankle fracture.

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.

Fewer reoperations after posterolateral plate positioning compared with lateral plate positioning in ankle fractures-a retrospective study on 453 AO/OTA 44-B injuries

INTRODUCTION

Ankle fractures are commonly treated by open reduction and internal fixation with plate and screws. Unplanned return to theatre is common, in many cases to extract prominent osteosynthesis material from the lateral malleolus as swelling subsides. We hypothesised that patients operated with a posterolateral plate placement on the lateral malleolus would have fewer reoperations, and fewer complications, compared to patients with a lateral plate placement.

MATERIALS AND METHODS

From a prospectively collected database of all orthopaedic surgery performed at our institution, we identified 664 ankle fractures undergoing plate fixation between 2008-01-01 and 2012-04-30. Radiographs were analysed to only include AO/OTA 44-B-fractures (n = 453), and to define study groups based on plate positioning. Hospital files were assessed to identify possible confounding factors, and any unplanned reoperation or complication. Complications were classified according to Dindo-Clavien.

RESULTS

The risk of reoperation was 13% after posterolateral plating, compared with 24% after lateral plating; absolute risk reduction 10% (95% CI: 2.5-18), p = 0.02. After adjusting for possible confounders, the odds ratio of undergoing reoperation after lateral plating was 2.2 (95% CI: 1.17-4.1), p = 0.01. The two surgical methods did not differ with regard to complication frequency: 31% vs 34%, p = 0.6, but complications following lateral plate fixation were more serious, p = 0.03. Plate positioning depended on surgeon preference.

DISCUSSION

The two studied methods are both considered standard treatment of ankle fractures, and relatively simple surgical procedures. High rates of secondary surgery after plate fixation have been reported, but no study comparing plate positioning has been previously published to our knowledge. AO Sweden has recently switched to teaching posterolateral plating in group exercises during the AO Basic Fracture Surgery course, based on the belief that it may be safer than lateral plating. Our findings support this change in practice.

CONCLUSIONS

Posterolateral plate positioning on the lateral malleolus in AO/OTA 44-B-fractures may be preferential to lateral plate positioning, due to a large difference in unplanned secondary surgery.

Interventional revascularization prior to operative fixation of fractures below the knee. A retrospective case series

AIMS

The goal of the current study was to describe the results of an innovative standardized approach to prevent wound complications in patients with PAD sustaining fractures below the knee.

PATIENTS AND METHODS

In this retrospective case series, patients submitted to our institution with fractures below the knee, which were treated with endovascular recanalization of relevant stenosis or occlusions prior to definitive open reduction and fracture fixation between January 2015 and December 2019 were included.

RESULTS

Overall 23 patients (mean age 77 ± 9.8 years) were included in the current case series. In five patients (21.7 %) PAD was previously diagnosed. Endovascular interventions were performed 6.9 ± 2.5 days after fracture event and 2.5 ± 1.3 days prior to definitive surgical fixation of the lower limb fracture. After intervention 2 patients had one vessel, 10 patients two vessels and 11 patients three vessels for arterial perfusion of the lower limb. No interventional- radiology procedure related complications were observed. In this case series only two wound infections (8.7 %) occurred.

CONCLUSION

Endovascular intervention prior to surgical fixation resulted in a low complication rate after surgical fixation of fractures below the knee in patients with PAD. These results emphasize the crucial role of limb perfusion for adequate wound healing in lower limb fractures. Therefore, examination of limb perfusion should be an integral part of preoperative preparation of patients at high risk for PAD presenting with fractures below the knee. Endovascular recanalization seems to be an appropriate method to prevent wound complications.

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.

Tibiotalocalcaneal Intramedullary Nailing for Unstable Geriatric Ankle Fractures

BACKGROUND

Tibiotalocalcaneal (TTC) intramedullary nailing has been suggested as an alternative to open reduction and internal fixation (ORIF) for the primary treatment of unstable fragility ankle fractures with a poor soft tissue envelope. This study aims to investigate the clinical efficacy of TTC intramedullary nail fixation for the primary treatment of unstable ankle fractures in frail elderly patients with poor soft tissue condition, by assessing the number of postoperative complications and the patient-reported functional outcomes.

METHODS

A retrospective cohort study was performed including patients with an unstable ankle fracture treated between 2015 and 2019 with TTC stabilization using a retrograde intramedullary hindfoot nail that was inserted without joint preparation and allowing immediate weight-bearing postoperatively. The primary outcome was the total number of postoperative complications.

RESULTS

A total of 10 patients were included out of 365 operatively treated ankle fractures. The mean age was 85.2 years (range 66-92) with a mean follow-up of 11.2 months (range 6-16). Fracture types included AO/OTA 44-B2 (n = 1), 44-B3 (n = 6), 44-C1 (n = 2) and 44-C3 (n = 1). Postoperative complications were observed in 4 patients (40%), including 3 nonunions, 2 implant related complications and 1 wound infection. No wound healing disorder or below-the-knee amputation was observed. Four patients (40%) deceased between post-operative 6 to 16 months due to medical conditions unrelated to surgery. The mean Foot and Ankle Outcome Score was 52.6 (range 44.2-73.8).

CONCLUSION

Hindfoot nailingis a viable treatment option in selected high-risk patients with an advanced age, unstable ankle fractures with significant bone loss, poor soft tissue condition and/or severely impaired pre-injury mobility. In a frail geriatric population, hindfoot nailing may be a safe alternative fixation method with a low risk of wound complication or major amputation. However, unprepared joint may lead to symptomatic nonunion after TTC intramedullary nailing.

Is postoperative non-weight-bearing necessary? INWN Study protocol for a pragmatic randomised multicentre trial of operatively treated ankle fracture

BACKGROUND

Postoperative management regimes vary following open reduction and internal fixation (ORIF) of unstable ankle fractures. There is an evolving understanding that extended periods of immobilisation and weight-bearing limitation may lead to poorer clinical outcomes. Traditional non-weight-bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates.

METHODS

A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 h versus non-weight-bearing (NWB) and immobilisation in a cast for 6 weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury) is proposed. All patients presenting to three trauma units will be included. The exclusion criteria will be skeletal immaturity and tibial plafond fractures. The three institutional review boards have granted ethical approval. The primary outcome measure will be the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection (deep and superficial), displacement of osteosynthesis, the full arc of ankle motion (plantar flexion and dorsal flection), RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. The trial will be reported in accordance with the CONSORT statement for reporting a pragmatic trial, and this protocol will follow the SPIRIT guidance.

DISCUSSION

Traditional management of operatively treated ankle fractures includes an extended period of non-weight-bearing. There is emerging evidence that earlier weight-bearing may have equivocal outcomes and favourable patient satisfaction but higher wound-related complications. These studies often preclude more complicated fracture patterns or patient-related factors. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner in recent decades. This pragmatic randomised-controlled multicentre trial will investigate immediate weight-bearing following ORIF of all ankle fracture patterns in the usual care condition. It is hoped that these results will contribute to the modern management of ankle fractures.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN76410775 . Retrospectively registered on 30 June 2019.

Fibula fractures management

Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.

Nontraditional Methods of Fibula Fixation

This article explores different nontraditional methods that could be adopted in clinical settings as alternatives to the traditional fibular fixation. Less invasive methods, such as intramedullary nail and screw fixation, might be viable alternatives for managing ankle fractures. These methods might especially benefit patients with poor soft tissue envelopes, low immunity, and poor bone quality. There is minimal soft tissue coverage for most orthopedic implants around the ankle. Various authors have highlighted the importance of minimally invasive surgery as an effective modality for ensuring superior prognosis for ankle fracture surgery or those fractures involving both the distal tibia and fibula.

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.

Intramedullary Fixation of Distal Fibula Fractures

BACKGROUND

Ankle fractures pose a unique challenge to the treating orthopedic surgeon. Intramedullary (IM) distal fibula fixation is a relatively newer entity offering a viable option to minimize wound complications while providing similar outcomes. Our study utilizes an IM nail featuring proximal fixation via IM talons ensuring maintenance of fracture reduction this is the largest case series utilizing this novel device assessing time to weight-bearing (WB) and fracture union in addition to the safety and reproducibility of percutaneous reduction.

METHODS

A retrospective case series was conducted on 51 ankle fractures treated with a single IM device for lateral malleolar fixation. Postoperative radiographs were assessed, qualifying reductions as good, fair, or poor based on a reduction classification. Patient charts were reviewed for fracture characteristics, reduction method, fracture union, time to WB, and complications.

RESULTS

Mean follow-up time was 32.2 weeks; 47 fracture reductions (92%) were classified as good, and 4 (8%) were fair. All but 1 fracture (98%) went onto union. Average time to union was 10.3 weeks. Average time to WB with and without a walking boot was 6.8 and 11.2 weeks, respectively. Two patients experienced painful hardware. One patient had a superficial wound infection.

CONCLUSION

When evaluating this novel IM device, fracture union and time to union were found to be acceptable, with minimal wound or other complications. Percutaneous reduction permitted good fracture reduction quality. Consistent time to WB for a variety of fractures was reliably demonstrated following operative fixation with this device, including those in the elderly population.

LEVELS OF EVIDENCE

Level IV: Clinical case series.

[Ankle fractures in older patients : What should we do differently?]

As a result of the demographic developments ankle fractures in older patients are part of routine trauma surgery. Due to comorbidities, such as diabetes mellitus, reduced bone quality and limited compliance in follow-up treatment, these fractures are prone to complications. The primary goal in the treatment of older patients with ankle fractures is to maintain mobility. In contrast to young patients most fractures are unstable pronation-abduction injuries. In the diagnostics the recognition and optimization of factors influencing the outcome, such as the blood perfusion and the generous use of computed tomography (CT) are recommended. As in the case of younger patients, conservative treatment is reserved for stable fracture forms and, if there are contraindications, should also be initiated in the case of unstable injuries. The choice of approaches is different for surgical treatment, which is adapted to the soft tissues, if necessary minimally invasive and increasingly carried out by a posterolateral approach. The initial transfixation can reduce soft tissue problems. Special surgical techniques and implants that provide a high level of stability, such as dorsal plate positioning, hook plates, angular stable plate systems and intramedullary systems as well as additional options, such as tibia pro fibula constructs are used. Primary retrograde nail arthrodesis is reserved as a salvage procedure only for exceptional cases. As part of the follow-up treatment, an interdisciplinary approach with respect for and optimization of concomitant diseases seems to make sense.

Is early full weight bearing safe following locking plate ORIF of distal fibula fractures?

Background

In the modern western world appraisal of economical points such as treatment and disability after trauma present a financial burden. In this context open reduction internal fixation techniques allowing for early full weight bearing might not only improve the clinical outcome but also shorten the period of disability in working life. The aim of the study was to analyze whether ORIF of ankle fractures using either a standard semitubular plate or a new polyaxial locking plate system result in a better clinical outcome.

Methods

In this prospective study, all patients with distal fibula fractures (AO 44 B1.1, B1.2, B1.3), with indication for surgery were included. Patients were randomized to either the DePuy Synthes® one-third semitubular plate (Group I) or NEWCLIP TECHNICS, Active Ankle® polyaxial locking plate (Group II). Primary outcome parameter was function of the ankle joint, assessed by the Olerud and Molander ankle score, Foot and Ankle outcome score and Karlsson and Peterson Scoring System for Ankle function. Secondary outcome parameter were postoperative complications. Superficial wound infection, delayed wound healing, mechanically prominent implant, skin irritations were considered as minor and deep wound infection, material loosening, loss of reduction were regarded as major complications requiring revision surgery. Clinical and radiological follow-up were performed 6 and 12 weeks, 6 months and 1 year postoperatively.

Results

Fifty-two patients (31 W/21 M) with a mean age of 43 yrs. (range 22–64 yrs.) were enrolled. Seven patients (13.5%) were excluded, so that 45 patients were available for follow up. Twenty-five patients were treated with DePuy Synthes® one-third semitubular plate (55.6%; group I) while 20 patients received an anatomically preformed polyaxial locking plate (44.4%, group II). Four minor complications occurred in Group I (16%) compared to two minor complications in group II (10%). Significant better clinical results regarding OMAS (p < 0.02, < 0.04), KPSS (p < 0.04) and FAOS (p < 0.02, < 0.03) were observed 6 and 12 weeks after surgery in group II.

Conclusions

The results of the presented study demonstrate a significant better clinical functional outcome in the early postoperative follow-up in patients treated with a polyaxial locking plate. Furthermore, our data show that ORIF using polyaxial locking plates in combination with an early postoperative weight bearing presents a safe, stable treatment option for ankle fractures so that patients benefit especially in the early stages of recovery.

Trial registration

Registered 20 April 2020, retrospectively on ClinicalTrails.gov (NCT04370561).

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.

Treatment of fragility ankle fractures using hindfoot nail, systemic review

With an aging population, the prevalence of fragility ankle fractures is rising. The surgical management of these injuries is challenging and associated with high rates of complications. An extensive literature review (inception of data until September 2019) was undertaken to locate previous studies that have addressed the same topic. Seven studies met the inclusion criteria. The post-operative Olerud and Molander scores were comparable/slightly lower than pre-injury scores. Bony union was achieved in 90.3%-100% of cases. Hindfoot nails, when used to treat fragility ankle fractures, can facilitate early rehabilitation and restoration of function among elderly osteoporotic patients.

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.

Factors affecting emergency department visits, readmissions, and reoperations within 30 days of ankle fracture surgery- an institutional retrospective study

INTRODUCTION

With the U.S. healthcare system focused on value of care, providers and hospitals are increasingly measured by factors that increase patient care and decrease healthcare cost. Early postoperative adverse events not only increase healthcare cost, but also illuminate areas of potential improvement in patient care. This large single institution study aims to delineate factors that may influence emergency department visits, admissions, and reoperations within 30 days of ankle fracture surgery.

METHODS

This retrospective review of patients at a Level 1 trauma center evaluated 30-day outcomes after ankle fracture surgery over a 4-year period (2015-2018). A total of 596 patients were included in final analysis. The primary outcome measures assessed were emergency department (ED) visits within 30 days, unplanned readmissions within 30 days and unplanned return to the operating room (OR) within 30 days. Patient and injury characteristics were investigated as potential factors related to these 30-day outcomes. Multiple linear regression was used for outcomes.

RESULTS

Forty-three (7.2%) patients visited the ED within thirty days, 30 (5.0%) patients were readmitted within thirty days, and 10 (1.7%) patients requiring reoperation within thirty days. Sex, insurance status, several comorbidities, smoking status, and fracture type/location were not found to be significantly related to 30-day events. Age less than 45 was a significant risk factor for returning to the ED within 30 days (RR 2.1, p = 0.016). Open fractures were more likely to require unplanned reoperation than closed fractures (RR 5.7, p<0.01). Fifty-four percent of ED visits were for postoperative pain, while 37% of ED visits and 60% of readmissions within 30 days were for issues unrelated to the ankle fracture.

CONCLUSIONS

Age less than 45 years old was a risk factor for early ED visits, highlighting a potential "at-risk" population after ankle fracture surgery. Furthermore, many of the ED visits (37%) and readmissions (60%) were unrelated to the ankle fracture suggesting unnecessary healthcare utilization may be avoided with protocols that increase emphasis on reconditioning and optimization of comorbidities.