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Bowers M, Ta C, Vasudevan RS, Trimm CD, Kent WT. Patient Characteristics and Outcomes of Geriatric Ankle Fractures: Open Fracture Is the Key Risk Factor for Complications and Functional Decline. J Orthop Trauma 2024; 38:42-47. [PMID: 38277236 DOI: 10.1097/bot.0000000000002732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/28/2024]
Abstract
OBJECTIVES To determine whether open (O) or closed (C) geriatric ankle fractures had different patient characteristics or outcomes. METHODS . DESIGN Retrospective cohort study. SETTING Urban Level 1 trauma center. PATIENT SELECTION CRITERIA Patients, age 60 years and older, who underwent operative fixation of a rotational ankle fracture (OTA/AO 44A-C) between January 2012 and September 2021. OUTCOME MEASURES AND COMPARISONS Morbidity, defined as 90-day reoperation, 90-day readmission, or loss of mobility, as well as 1-year mortality compared between patients with closed and open fractures. RESULTS The open cohort was older (75 years vs. 68 years; P = 0.003) but had similar Charlson comorbidity indices (4.6 O vs. 4.0 C; P = 0.323) and preinjury rates of independent ambulation (70.4% O vs. 80.9% C; P = 0.363). There were higher rates of 1-year mortality (11% vs. 0%; P < 0.001), deep infection (14.8% vs. 3.9%; P = 0.019), and loss of mobility (64.7% vs. 23.0%; P < 0.001) in the open cohort. Multivariate regression identified open fracture as an independent predictor of 90-day reoperation (OR: 20.6; P = 0.022) and loss of mobility (OR: 5.1; P = 0.011). CONCLUSIONS Despite having comorbidities and preinjury function similar to the closed geriatric ankle fracture cohort, open ankle fracture was independently predictive of greater loss of mobility. Nearly two-thirds of geriatric patients with open ankle fractures experienced a decline in functional independence, compared with 1 in 4 of those with closed fractures. Open fracture was associated with higher rates of deep infection, reoperation, and 1-year mortality. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Zahra W, Seifo M, Cool P, Ford D, Okoro T. Clinical outcome of open ankle fractures in patients above 70 years of age. World J Orthop 2023; 14:554-561. [PMID: 37485433 PMCID: PMC10359747 DOI: 10.5312/wjo.v14.i7.554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/06/2023] [Accepted: 06/16/2023] [Indexed: 07/17/2023] Open
Abstract
BACKGROUND Open fractures of the ankle are complex injuries requiring multidisciplinary input and are associated with significant morbidity and mortality. However, data on the clinical outcomes of open ankle fracture management in patients older than 70 is minimal.
AIM To evaluate the clinical outcomes following open ankle fracture management in patients older than 70. Our secondary aim is to look at predictors of poor outcomes.
METHODS Following local research and audit department registration, 22 years of prospectively collated data from an electronic database in a district general hospital were assessed. All patients older than 70 years of age with an open ankle fracture requiring surgical intervention were identified. Demographic information, the nature, and the number of surgical interventions were collated. Complications, including surgical site infection (SSI), venous thromboembolic events (VTEs) during hospital stay, and mortality rate, were reviewed.
RESULTS A total of 37 patients were identified (median age: 84 years, range: 70-98); n = 30 females median age: 84 years, range: 70-97); n = 7 males median age: 74 years, range: 71-98)) who underwent surgical intervention after an open ankle fracture. Sixteen patients developed SSIs (43%). Superficial SSIs (n = 8) were managed without surgical intervention and treated with antibiotics and regular dressing changes. Deep SSIs (n = 8; 20%) required a median of 3 (range: 2-9) surgical interventions, with four patients requiring multiple washouts and one patient having metalwork removed. VTE incidence was 5% during the hospital stay. Eight patients died within 30 d, and mortality at one year was 19%. The 10-year mortality rate was 57%. The presence of a history of stroke, cancer, or prolonged inpatient stay was found to be predictive of lower survivorship in this population (log-rank test: cancer P = 0.008, stroke P = 0.001, length of stay > 33 d P = 0.015). The presence of a cardiac history was predictive of wound complications (logistic regression, P = 0.045). Age, number of operations, and diabetic history were found to be predictive of an increase in the length of stay (general linear model; age P < 0.001, number of operations P < 0.001, diabetes P = 0.041).
CONCLUSION An open ankle fracture in a patient older than 70 years has at least a 20% chance of requiring repeated surgical intervention due to deep SSIs. The presence of a cardiac history appears to be the main predictor for wound complications.
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Affiliation(s)
- Wajiha Zahra
- Department of Trauma and Orthopedics, Royal Shrewsbury Hospital, Shrewsbury SY3 8XQ, United Kingdom
| | - Mina Seifo
- Department of Trauma and Orthopedics, Royal Shrewsbury Hospital, Shrewsbury SY3 8XQ, United Kingdom
| | - Paul Cool
- Department of Trauma and Orthopedics, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, United Kingdom
- Department of Trauma and Orthopedics, Keele University, Stafford ST5 5BG, United Kingdom
| | - David Ford
- Department of Trauma and Orthopedics, Royal Shrewsbury Hospital, Shrewsbury SY3 8XQ, United Kingdom
- Department of Trauma and Orthopedics, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, United Kingdom
| | - Tosan Okoro
- Department of Trauma and Orthopedics, Royal Shrewsbury Hospital, Shrewsbury SY3 8XQ, United Kingdom
- Department of Trauma and Orthopedics, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, United Kingdom
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Pflüger P, Harder FN, Müller K, Willinger L, Biberthaler P, Crönlein M. Use of Distal Tibial Cortical Bone Thickness and FRAX Score for Further Treatment Planning in Patients with Trimalleolar Ankle Fractures. J Clin Med 2023; 12:jcm12113666. [PMID: 37297861 DOI: 10.3390/jcm12113666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
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.
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Affiliation(s)
- Patrick Pflüger
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Felix N Harder
- Institute of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, 81675 Munich, Germany
| | - Karoline Müller
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Lukas Willinger
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University Munich, 81675 Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Moritz Crönlein
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
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Meinert M, Colcuc C, Herrmann E, Harbering J, Gramlich Y, Blank M, Hoffmann R, Fischer S. Septic History Limits the Outcome of Tibiotalocalcaneal Arthrodesis. J Clin Med 2023; 12:jcm12103422. [PMID: 37240528 DOI: 10.3390/jcm12103422] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Joint destruction necessitates tibiotalocalcaneal arthrodesis (TTCA) in cases of clinical deficits that cannot be controlled conservatively, possibly leading to sepsis. We aimed to compare the underlying etiology of posttraumatic joint destruction and the outcomes after TTCA in patients with a septic or aseptic history. Between 2010 and 2022, 216 patients with TTCA were retrospectively enrolled (septic TTCA (S-TTCA) = 129; aseptic TTCA (A-TTCA) = 87). Patient demographics, etiology, Olerud and Molander Ankle Scores (OMASs), Foot Function Index (FFI-D) scores, and Short Form-12 Questionnaire (SF-12) scores were recorded. The mean follow-up period was 6.5 years. Tibial plafond and ankle fractures were the most common causes of sepsis. The mean OMAS was 43.0; the mean FFI-D was 76.7; and the mean SF-12 physical component summary score was 35.5. All the scores differed significantly between the groups (p < 0.001). With an average of 11 operations until the arthrodesis was achieved, the S-TTCA patients underwent about three times as many operations as the A-TTCA patients (p < 0.001), and 41% of S-TTCA patients remained permanently unable to work (p < 0.001). The significantly worse results of S-TTCA compared to A-TTCA show the long and stressful ordeal that patients with a septic history suffer. Further attention must be paid to infection prophylaxis and, if necessary, early infection revision.
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Affiliation(s)
- Magalie Meinert
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany
| | - Christian Colcuc
- Department for Trauma and Orthopaedic Surgery, Evangelical Hospital Bethel Bielefeld, 33611 Bielefeld, Germany
| | - Eva Herrmann
- Division of Biostatistics and Mathematical Modelling, Goethe-University, Frankfurt am Main, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - Johannes Harbering
- Department for Septic Bone Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany
| | - Yves Gramlich
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany
| | - Marc Blank
- Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany
| | - Reinhard Hoffmann
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany
| | - Sebastian Fischer
- Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany
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Williams J, Davies M, Gopal V, Din A, Ahluwalia R. The multi-ligament ankle fracture: Epidemiology, key anatomical findings and fixation strategies in unstable open injuries. J Clin Orthop Trauma 2023; 36:102086. [PMID: 36714436 PMCID: PMC9875718 DOI: 10.1016/j.jcot.2022.102086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Background Ankle fracture surgery has traditionally focussed on restoration of bony anatomy, with fixation of the malleoli and syndesmotic stabilisation where applicable. However, high energy open fracture-dislocations can also result in periosteal stripping of the stabilising capsuloligamentous attachments. As such, restoration of osseous anatomy alone may not result in sufficient articular stability. Objectives In this series from a level 1 trauma centre, we report a subset of highly unstable open ankle fractures with combined capsuloligamentous injuries, in which restoration of osseous anatomy did not result in a stable joint. Supplementary soft tissue reconstruction and other stabilisation techniques were required. Methods Retrospective case series of eligible patients from a level 1 trauma centre. Inclusion criteria were open ankle fractures with tibial extrusion (AO 44) and persistent instability post-bony fixation, age over 18 years and non-diabetic. Analysis of injury pattern, mechanism, pathological anatomy, soft tissue and orthopaedic reconstruction methods was performed. Results 16 patients were identified during the study period who met the eligibility criteria, out of 95 open ankle fractures treated between January 2017-December 2020. Most patients were under 65 (n = 13; 81.3%) and sustained combined or isolated injuries of the deltoid ligament, anterior capsule, lateral ligament complex (ATFL±CFL) and tibialis posterior retinaculum. The commonest injury pattern was tibial extrusion via a medial soft tissue defect with deltoid ligament and anteromedial capsule rupture. Associated syndesmotic instability and fixation was common (n = 10; 62.5%). Supplementary stabilisation methods to standard bony fixation included capsuloligamentous reconstruction or repair, "ORIF+" external fixation, or conversion to primary fusion or hindfoot nail. Six patients required either local or free flap soft tissue coverage. Conclusions A subset of up to 20% of open ankle fractures require supplementary fixation beyond anatomical restoration of the bony anatomy due to persistent ligamentous instability. They are associated with capsuloligamentous and syndesmotic disruption, more commonly affecting the medial structures. These rare injuries can be defined as multi-ligament ankle fractures. Surgeons should be aware of this subset and be able to recognise where supplementary stabilisation strategies are required.
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Affiliation(s)
- John Williams
- Department of Orthopaedics, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
- Department of Plastic Surgery Kings College Hospital and Guy's and St Thomas's Hospital NHS Trust, United Kingdom
| | - Monica Davies
- Department of Orthopaedics, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
- Department of Plastic Surgery Kings College Hospital and Guy's and St Thomas's Hospital NHS Trust, United Kingdom
| | - Venu Gopal
- Department of Orthopaedics, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
- Department of Plastic Surgery Kings College Hospital and Guy's and St Thomas's Hospital NHS Trust, United Kingdom
| | - Asmat Din
- Department of Orthopaedics, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
- Department of Plastic Surgery Kings College Hospital and Guy's and St Thomas's Hospital NHS Trust, United Kingdom
| | - Raju Ahluwalia
- Department of Orthopaedics, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
- Department of Plastic Surgery Kings College Hospital and Guy's and St Thomas's Hospital NHS Trust, United Kingdom
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Gerlach R, Toepfer A, Jacxsens M, Zdravkovic V, Potocnik P. 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. BMC Musculoskelet Disord 2022; 23:698. [PMID: 35869482 PMCID: PMC9306170 DOI: 10.1186/s12891-022-05646-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/08/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Cao MM, Zhang YW, Hu SY, Rui YF. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg 2022; 9:965814. [PMID: 36017521 PMCID: PMC9398172 DOI: 10.3389/fsurg.2022.965814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAnkle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations.MethodsThe available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores.ResultsA total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%).ConclusionsCollectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.
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Affiliation(s)
- Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Sheng-Ye Hu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Correspondence: Yun-Feng Rui
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Deemer AR, Drake JH, Littlefield CP, Egol KA. Surgeon Volume Impacts Outcomes Following Ankle Fracture Repair. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221116790. [PMID: 36046553 PMCID: PMC9421026 DOI: 10.1177/24730114221116790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The purpose of this study was to determine the impact of surgeon volume on outcomes following ankle fracture fixation. Methods: Over 7 years, 362 patients who met inclusion criteria (>18 years with rotational ankle fractures) were identified and treated by orthopaedic surgeons at several hospitals within an academic medical center and were retrospectively reviewed. Surgeons that completed less than 24 ankle fixations per year (<90th percentile) during the study period were classified as low-volume (LV) and surgeons completing 24 or more ankle fixations per year (>90th percentile) were classified as high-volume (HV). Chart review was conducted to gather data regarding perioperative, radiographic, inpatient, and long-term outcome data (average 12-month follow-up). Results: One hundred thirty-four patients (37.0%) were treated by LV surgeons and 228 (63.0%) were treated by HV surgeons. Although both cohorts had a similar breakdown of fracture patterns (P = .638), the LV cohort had a greater incidence of open fractures (P = .024). No differences were found regarding wait time to surgery, surgery duration, and LOS. Radiographically, more patients in the HV cohort achieved anatomic mortise after surgery (96.5% vs 89.6%, P = .008). Patients in the LV cohort took longer to heal radiographically (4.27 ± 2.4 months vs 5.59 ± 2.9 months, P < .001), and also had higher rates of reoperation and hardware removal (P < .05). Lastly, all cost variables were lower for high-volume surgeons (P < .05). Conclusion: In this single-center study, we found that patients treated by LV surgeons took 30% longer to heal radiographically and had greater reoperation rates than those treated by HV surgeons. Additionally, patients treated by high-volume surgeons had more anatomic postoperative radiographic ankle mortise reductions and was less cost-effective than when performed by high-volume surgeons. Level of Evidence: Level III, retrospective comparative study.
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Affiliation(s)
- Alexa R. Deemer
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Jack H. Drake
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Connor P. Littlefield
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Kenneth A. Egol
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
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Jaibaji M, Sohatee M, Watkins C, Qasim S, Fearon P. Open ankle fractures: Factors influencing unplanned reoperation. Injury 2022; 53:2274-2280. [PMID: 35397874 DOI: 10.1016/j.injury.2022.03.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/22/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Ankle fractures are amongst the most common open fracture injuries presenting to major trauma centres (MTC) and their management remains a topic of debate. Incidence is increasing particularly in the elderly population however the optimal surgical approach and risk factors for unplanned reoperation remain scarce. We therefore conducted a retrospective case study to analyse our institution's outcomes as well as identify risk factors for early unplanned reoperation. MATERIALS AND METHODS Sixty-five consecutive open ankle fractures were identified using our institutional database between July 2016 and July 2020. Medical records and operation notes were reviewed to identify patient age at injury, Sex, co-morbidities and other co-morbidities, fracture configuration, extent of soft tissue injury, fixation type and post-operative complications. The data was categorised into four groups for analysis, 1) age, 2) AO-OTA classification 3) Sex 4) Gustilo-Anderson grade. Statistical analysis was undertaken to identify predictors of unplanned reoperation. RESULTS The mean age of patients at the time of injury was 60.8. Unplanned reoperation rate was 17.5%. Age and Gustilo-Anderson classification grade were both statistically significant predictors of unplanned reoperation. AO-OTA classification, Sex and Diabetes were not statistically significant factors associated with unplanned reoperation. CONCLUSION Age and quality of soft tissue envelope are significant risk factors for unplanned reoperation. Patients with these risk factors may benefit from an alternative surgical approach.
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Affiliation(s)
- Monketh Jaibaji
- Health Education England North East, Newcastle Upon Tyne, United Kingdom.
| | - Mark Sohatee
- Health Education England North East, Newcastle Upon Tyne, United Kingdom
| | - Christopher Watkins
- Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Sultan Qasim
- Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Paul Fearon
- Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
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10
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Open lower limb fractures in the elderly. Injury 2022; 53:2268-2273. [PMID: 35337660 DOI: 10.1016/j.injury.2022.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/21/2022] [Accepted: 03/14/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this study was to assess the outcomes of open lower limb fractures in patients aged 65 and over. The primary outcome was mortality at 30 days, and the secondary outcome was reoperation. METHODS This study retrospectively identified patients aged 65 and over, presenting with an open tibia or ankle fracture, over a two-year period. Patient demographics, injury characteristics and surgical interventions were documented. The 30-day and one-year mortality was recorded, as well as any complications encountered. RESULTS There were 88 patients included in the study, with a mean age of 78 years and 66% of patients were female. Of this cohort, 67 patients (76%) had low energy injuries and 64 patients (73%) had Gustillo-Anderson type IIIB injuries. Treatment consisted of a one-stage surgical procedure in 49 patients (56%) and a two-stage procedure in 37 patients (42%), with two patients dying before definitive treatment. Primary wound closure was performed in 23 patients (26%), four patients (5%) had a split skin graft alone, 35 patients (40%) had local flaps, 21 patients (24%) were managed with free flaps and three patients (3%) had primary below knee amputations. The 30-day mortality rate was 10%, the one-year mortality rate was 19% and the reoperation rate was 8%. CONCLUSION Open lower limb fractures in the elderly are a life and limb threatening injury, with a similar demographic and mortality profile to hip fracture. This study demonstrates that limb salvage can be achieved in 93% of cases, with treatment performed as a one-stage procedure in 56% of cases.
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Abstract
OBJECTIVE To identify the patient, injury, and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multicenter retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction. DESIGN Multicenter retrospective review. SETTING Sixteen trauma centers. PATIENTS One thousand and 3 consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures. MAIN OUTCOME MEASURES Fracture-related infection (FRI) in open ankle fractures. RESULTS The charts of 1003 consecutive patients were reviewed, and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction, and/or implant failure; FRI was associated with higher rates of these complications (P = 0.01). CONCLUSIONS Several patient, injury, and surgical factors were associated with FRI in the treatment of open ankle fractures. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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12
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Surgical Site Complications in Open Pronation-Abduction Ankle Fracture-Dislocations With Medial Tension Failure Wounds. J Orthop Trauma 2021; 35:e481-e485. [PMID: 33771964 DOI: 10.1097/bot.0000000000002128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To examine the incidence of surgical site complications associated with pronation-abduction ankle fracture-dislocations with an open medial tension wound. DESIGN Retrospective case series. SETTING Accredited Level-1 trauma center. PATIENTS/PARTICIPANTS Forty-eight open pronation-abduction ankle fracture-dislocations with medial tension failure wounds treated at our institution from 2014 to 2016. INTERVENTION Immediate irrigation and debridement along with surgical stabilization of open ankle fracture-dislocation. MAIN OUTCOME MEASURES The primary outcome measure was deep surgical site infection. Secondary outcome measures included other surgical site complications and adverse radiographic events. RESULTS A total of 5 patients (10.4%) developed a deep surgical site infection requiring additional surgical debridement. One of the patients with a deep surgical site infection required a below-knee amputation as a result of sepsis. Adverse radiographic outcomes included 3 fibular nonunions (6.3%), 3 implant failures related to syndesmotic fixations (6.3%), one periimplant fracture (2.1%), and postoperative collapse of the tibial plafond in 3 patients (6.3%). CONCLUSIONS Open pronation-abduction ankle fracture-dislocations with medial tension failure wounds remain a challenging and potentially devastating injury. Our study suggests that with appropriate surgical debridement, early stabilization, and primary wound closure, acceptable outcomes with a relatively low risk of surgical site complications can be achieved. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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13
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Lee A, Geoghegan L, Nolan G, Cooper K, Super J, Pearse M, Naique S, Hettiaratchy S, Jain A. Open tibia/fibula in the elderly: A retrospective cohort study. JPRAS Open 2021; 31:1-9. [PMID: 34805472 PMCID: PMC8585579 DOI: 10.1016/j.jpra.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/07/2021] [Indexed: 12/17/2022] Open
Abstract
The incidence of open tibia/fibula fractures in the elderly is increasing, but current national guidelines focus on the aggressive treatment of high-energy injuries in younger patients. There is conflicting evidence regarding whether older age affects treatment provision and outcomes in open fractures. The aim of this study was to determine if elderly patients are sustaining a different injury to younger patients and how their treatment and outcomes differ. This may have implications for future guidelines and verify their application in the elderly. In this retrospective single centre cohort study (December 2015-July 2018), we compared the injury characteristics, operative management and outcomes of elderly (≥65 years) and younger (18-65 years) patients with open tibia/fibula fractures. An extended cohort examined free flap reconstruction. In total, 157 patients were included. High-energy injuries were commoner in younger patients (88% vs 37%; p<0.001). Most were Gustilo-Anderson IIIb in both age groups. Elderly patients waited longer until debridement (21:19 vs 19:00 h) and had longer inpatient stays (23 vs 15 days). There was no difference in time to antibiotics, operative approach or post-operative complications. Despite the low-energy nature of elderly patients' injuries, the severity of soft tissue insult was equivalent to younger patients with high-energy injuries. Our data suggest that age and co-morbidities should not prohibit lower limb reconstruction. The current application of generic guidelines appears suitable in the elderly, particularly in the acute management. We suggest current management pathways and targets be reviewed to reflect the greater need for peri-operative optimisation and rehabilitation in elderly patients.
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Affiliation(s)
- Alice Lee
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Luke Geoghegan
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Grant Nolan
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Kerri Cooper
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Jonathan Super
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Michael Pearse
- Department of Orthopaedic Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Satyajit Naique
- Department of Orthopaedic Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Shehan Hettiaratchy
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Abhilash Jain
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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14
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Pflüger P, Braun KF, Mair O, Kirchhoff C, Biberthaler P, Crönlein M. Current management of trimalleolar ankle fractures. EFORT Open Rev 2021; 6:692-703. [PMID: 34532077 PMCID: PMC8419795 DOI: 10.1302/2058-5241.6.200138] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus. Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons. In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint. In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care. This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives.
Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138
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Affiliation(s)
- Patrick Pflüger
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Karl-Friedrich Braun
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Traumatology and Reconstructive Surgery including Department of Orthopedic Surgery, Charite Universitätsmedizin Berlin, Berlin, Germany
| | - Olivia Mair
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Chlodwig Kirchhoff
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Moritz Crönlein
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
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15
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Tang R, Wang S, Yang J, Wu T, Fei J. Application of platelet-rich plasma in traumatic bone infections. Expert Rev Anti Infect Ther 2020; 19:867-875. [PMID: 33259253 DOI: 10.1080/14787210.2021.1858801] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Traumatic bone infection represents a clinical challenge for orthopedic surgeons. Traditional treatments include surgical debridement and antibiotic, but prolonged use of antibiotic may lead to colonization of resistant bacteria and other adverse reactions.Areas covered: Platelet-rich plasma (PRP), a biological product extracted from the peripheral blood of patients, has been widely used in the field of tissue repair in recent years. Because if its structural and antibacterial properties, PRP is an innovative option for the prevention and treatment of infections. This review assesses the recent scientific literature on PRP, specifically its in the treatment of infections. To this end, a literature review was conducted using the PubMed and Web of Science databases with the following keywords 'platelet-rich plasma (PRP)'; 'PRP AND traumatic bone infections'; 'PRP AND bone defect'; 'PRP AND antibiotics'; and 'PRP AND wound healing'.Expert opinion: This review focuses on the mechanism of action, preparation methods, clinical applications and other aspects related to PRP to provide a reference for its use in the treatment of traumatic bone infections, thereby enhancing the therapeutic effectiveness and improving the prognosis of patients.
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Affiliation(s)
- Ruohui Tang
- Outpatient Department of 96824 Troops of the Chinese People's Liberation Army, Kunming, China
| | - Shaochuan Wang
- Emergency Department of Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jing Yang
- Emergency Department of Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Tong Wu
- Department of Orthopedics, Yan'an Hospital Affiliated to Kunming Medical University, Kunming, China
| | - Jun Fei
- Emergency Department of Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University (Army Medical University), Chongqing, China
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16
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Karkkola S, Kortekangas T, Pakarinen H, Flinkkilä T, Niinimäki J, Leskelä HV. Fibular nailing for fixation of ankle fractures in patients at high risk of surgical wound infection. Foot Ankle Surg 2020; 26:784-789. [PMID: 31734044 DOI: 10.1016/j.fas.2019.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 10/10/2019] [Accepted: 10/17/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Postoperative infection is a severe complication after operative treatment of ankle fractures, associated with age, comorbidities, and severe soft tissue injuries. We assessed the efficacy of intramedullary fibular nailing for treating ankle fractures in patients at high risk of wound complications. METHODS 41 high-risk patients were included in the study. We retrospectively reviewed the medical records to assess the risk profile, the treatment data, and possible infections and re-operations. After a minimum of 2 years eight patients had died, three had advanced-staged dementia and two were lost to follow-up. Remaining 28 patients reported the functional outcome and QoL through patient-reported questionnaires. Radiographs and cone-beam computed tomography were performed, as well as range-of-motion was measured. RESULTS No surgical wound infections were found. The mean Olerud-Molander score was 67 points (SD 28 [20-100]). The osteoarthritis stages and the range-of-motion were significantly different between the injured and uninjured ankles, but we detected no significant effect on the QoL. CONCLUSION Intramedullary fibular fixation appeared to be a safe treatment choice for ankle fractures in high-risk patients. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Sini Karkkola
- Oulu University Hospital, Department of Surgery, Division of Orthopedic and Trauma Surgery, Oulu, Finland; Medical Research Center, University of Oulu, Oulu, Finland.
| | - Tero Kortekangas
- Oulu University Hospital, Department of Surgery, Division of Orthopedic and Trauma Surgery, Oulu, Finland
| | - Harri Pakarinen
- Oulu University Hospital, Department of Surgery, Division of Orthopedic and Trauma Surgery, Oulu, Finland
| | - Tapio Flinkkilä
- Oulu University Hospital, Department of Surgery, Division of Orthopedic and Trauma Surgery, Oulu, Finland
| | - Jaakko Niinimäki
- Oulu University Hospital, Department of Diagnostic Radiology, Oulu, Finland
| | - Hannu-Ville Leskelä
- Oulu University Hospital, Department of Surgery, Division of Orthopedic and Trauma Surgery, Oulu, Finland
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17
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Veldman FJ, Aldous CM, Smith ID, Rollinson PD. The importance of anatomical reduction in the functional outcome of open ankle fractures. J Orthop 2020; 21:166-170. [PMID: 32255999 PMCID: PMC7125312 DOI: 10.1016/j.jor.2020.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/23/2020] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Whilst closed ankle fracture injuries are common, well characterized and have treatment guidelines derived from the literature, open ankle fractures are rare and are not well studied. The few studies that exist are from the developed First World and these well resourced circumstances are not available in most parts of the world. The purpose of this prospective study was to assess the functional outcomes of open ankle fractures and the factors associated with their outcome in an adult population in rural South Africa. METHODS This prospective study was done at a referral hospital in a rural and semi-rural part of South Africa during the study period from January 1, 2013 until April 30, 2019 and was a retrospective chart review of 59 adult patients who sustained open ankle fractures. Pre-, peri- and postoperative factors in the chart review were assessed for each patient. Twenty-one patients were available for follow-up and were reviewed at least 6 months post injury for a functional assessment using the American Orthopedic Foot and Ankle Society Score (AOFAS). RESULTS The average AOFAS was 68,2 out of 100 (fair outcome). The lowest score recorded was 38 (one patient) and the highest score 95 (two patients). Nine patients presented with a poor outcome (<60), six with a fair outcome (60-79), two with a good outcome (80-89) and four with an excellent outcome (90-100). The only significant finding, using a Fisher's exact test, indicated that anatomical reduction of the fracture lead to a fair, good or excellent outcome compared to a non-anatomical reduction leading to a poor functional outcome (p = 0,046). CONCLUSIONS Our results showed that open ankle fractures are serious injuries with a very variable outcome when managed in a rural or semi-rural setting and that anatomical reduction is required to achieve an optimal functional outcome.
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Affiliation(s)
- Frederik J. Veldman
- Department of Orthopaedics, Ngwelezana Hospital, Empangeni, South Africa
- Corresponding author. PO Box 977, Durban, 4000, South Africa.
| | - Colleen M. Aldous
- SCM Dean & Managers Office, 4th Floor Main Building, Nelson R Mandela School of Medicine Campus, 719 Umbilo Road, Durban, South Africa
| | - Iain D. Smith
- Department of Orthopaedics, Ngwelezana Hospital, Empangeni, South Africa
| | - Paul D. Rollinson
- Department of Orthopaedics, Ngwelezana Hospital, Empangeni, South Africa
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18
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Early Definitive Care Is as Effective as Staged Treatment Protocols for Open Ankle Fractures Caused by Rotational Mechanisms: A Retrospective Case-Control Study. J Orthop Trauma 2020; 34:376-381. [PMID: 31934952 DOI: 10.1097/bot.0000000000001734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare immediate internal fixation with primary wound closure to temporary fixation/stabilization with delayed fixation and wound closure protocols for management of open ankle fractures. DESIGN Retrospective case-control study. SETTING Level 1 trauma center. PATIENTS Eighty-eight consecutive patients who presented with a Gustilo-Anderson type I, II, or IIIa open ankle fracture to a single center. INTERVENTION Patients were divided into 2 cohorts: either immediate internal fixation with primary wound closure (EARLY) or temporary fixation/stabilization with delayed fixation and wound closure (STAGED) due to practice differences of the attending surgeons. MAIN OUTCOME MEASURES Infection, length of stay, number and type of operations, and clinical measures. We also assessed the 2 groups with regard to demographics and radiographic classification. RESULTS Overall, incidence of infection was 6 (6.8%) with no significant difference between patients treated with EARLY versus STAGED protocols. The EARLY cohort had a significantly shorter length of hospital stay, fewer number of reoperations but similar clinical outcomes for pain, ambulation, and radiographic evidence of osteoarthritis for patients followed for >12 months. CONCLUSION Our study showed that early definitive treatment compared with a staged protocol for Gustilo-Anderson type I, II, and IIIa open ankle fractures has similar rates of infection, shorter hospital stay, fewer surgical interventions, and similar clinical outcomes. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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19
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Simske NM, Audet MA, Kim CY, Vallier HA. Open ankle fractures are associated with complications and reoperations. OTA Int 2019; 2:e042. [PMID: 33937670 PMCID: PMC7997115 DOI: 10.1097/oi9.0000000000000042] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 06/22/2019] [Indexed: 01/14/2023]
Abstract
Objectives: To assess clinical and functional outcomes after open versus closed ankle fracture. Design: Retrospective comparative study. Location: Level 1 Trauma Center. Patients/Participants: 1303 patients treated for ankle fractures (Weber B and C) between 2003 and 2015. One hundred sixty-five patients (12.7%) presented with open fracture and 1138 (87.3%) with closed fracture. Intervention: Surgical or conservative management of ankle fracture. Main Outcome Measure: Rates of complications and reoperations. Patient-reported functional outcomes were assessed with the Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA), after a minimum of 12 months. Results: Mean age was 46 years and 49% of patients were male. Higher mean age was associated with open injuries (51 vs 45 years, P < 0.001), and fractures were increasingly open with aging. Open fractures were associated with high-energy mechanisms: 44% following motor vehicle or motorcycle collisions, although the majority of open fractures in patients >65 years occurred after ground-level fall. Complications occurred more often after open fracture (33% vs 11%) and necessitated more secondary procedures (19% vs. 7%), both P < 0.001. Multivariate regression analysis identified open fracture as a predictor of complications and of worse scores on the activity categories of both the FFI and SMFA. Conclusion: Open fractures occurred more often after high energy mechanisms, and were generally more complex than closed fractures. Advanced age was common among open fracture patients, likely contributing to higher complication and secondary procedure rates. Greater morbidity after open ankle fractures was associated with minor differences on activity functions of the FFI and SMFA. Level of Evidence: Level 3, prognostic
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Affiliation(s)
- Natasha M Simske
- MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
| | - Megan A Audet
- MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
| | - Chang-Yeon Kim
- MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
| | - Heather A Vallier
- MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
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20
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Saleh H, Konda S, Driesman A, Stranix J, Ly C, Saadeh P, Egol K. Wound-Healing Issues Following Rotational Ankle Fracture Surgery: Predictors and Local Management Options. Foot Ankle Spec 2019; 12:409-417. [PMID: 30442021 DOI: 10.1177/1938640018810422] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. The incidence and risk factors of wound-healing complications following rotational ankle fracture surgery are well documented in the literature. However, there is a paucity regarding management options following these complications. The goal of this study was to provide a descriptive analysis of one surgeon's experience managing wound complications in patients who have undergone ankle fracture surgery. Methods. A total of 215 patients who were operatively treated for an unstable ankle were retrospectively identified. Patient demographics, medical histories, initial injury characteristics, surgical interventions, and clinical follow-up were collected. Twenty-five of these patients developed postoperative wound problems. Results. Of the original cohort of 215 patients, 25 (11.6%) developed wound-healing complications. Their average age was 53.6 ± 18.0 years; there were 12 males (48.0%). Connective tissue/inflammatory disease (odds ratio [OR] 3.9), cardiovascular disease (OR 3.6), and active smoking (OR 3.3) were associated with an increased likelihood of developing postoperative wound complications. With regard to injuries, open fractures (OR 17.9) had the highest likelihood of developing postoperative complications, followed by type 44-C (OR 2.8) and trimalleolar fractures (OR 2.0). Conclusion. Wound complications following open treatment of ankle fractures occurred with an incidence of 11.6% in this series, of which only about half required operative intervention. A third of wounds were managed by orthopaedics in conjunction with plastic surgery. Levels of Evidence: Level III: Retrospective comparative study.
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Affiliation(s)
- Hesham Saleh
- New York University Langone Orthopaedic Hospital, New York, New York (HS, SK, AD, KE).,Department of Plastic Surgery, New York University, New York, New York (JS, CL, PS)
| | - Sanjit Konda
- New York University Langone Orthopaedic Hospital, New York, New York (HS, SK, AD, KE).,Department of Plastic Surgery, New York University, New York, New York (JS, CL, PS)
| | - Adam Driesman
- New York University Langone Orthopaedic Hospital, New York, New York (HS, SK, AD, KE).,Department of Plastic Surgery, New York University, New York, New York (JS, CL, PS)
| | - John Stranix
- New York University Langone Orthopaedic Hospital, New York, New York (HS, SK, AD, KE).,Department of Plastic Surgery, New York University, New York, New York (JS, CL, PS)
| | - Catherine Ly
- New York University Langone Orthopaedic Hospital, New York, New York (HS, SK, AD, KE).,Department of Plastic Surgery, New York University, New York, New York (JS, CL, PS)
| | - Pierre Saadeh
- New York University Langone Orthopaedic Hospital, New York, New York (HS, SK, AD, KE).,Department of Plastic Surgery, New York University, New York, New York (JS, CL, PS)
| | - Kenneth Egol
- New York University Langone Orthopaedic Hospital, New York, New York (HS, SK, AD, KE).,Department of Plastic Surgery, New York University, New York, New York (JS, CL, PS)
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21
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Krissian S, Samargandi R, Druon J, Rosset P, Le Nail LR. Poor prognosis for infectious complications of surgery for ankle and hindfoot fracture and dislocation. A 34-case series. Orthop Traumatol Surg Res 2019; 105:1119-1124. [PMID: 31375389 DOI: 10.1016/j.otsr.2019.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 05/21/2019] [Accepted: 06/11/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Ankle and hindfoot fractures are associated with high rates of complications, and of infection in particular, for which rates of 1% to 48% are reported. HYPOTHESIS Treatment of bone and joint infection (BJI) secondary to surgery for ankle or hindfoot fracture is at high risk of failure. We analyzed results of treatment of BJI in this context. MATERIAL AND METHODS 33 patients (34 cases) were treated for ankle or hindfoot BJI between 2010 and 2015. Cure was defined by absence of fistula and of local or general inflammatory signs and by normal C-reactive protein level, at a minimum 2 years' follow-up. Fusion without infection was counted as success; recurrent infection and amputation were counted as failure. Mean age at trauma was 52 years (range, 16-85 years). Median time to diagnosis of BJI was 44 days (range, 2-830 days). RESULTS Mean follow-up was 20 months (range, 3-59 months). Twenty-two patients were cured (65%). Seven cases required joint fusion (21%). The failure rate was 15%, including 5 transtibial amputations. Skin cover flap was required for 15 patients (44%), at a median 33 days (range, 0-167 days). DISCUSSION Despite its retrospective design and small numbers, the present study confirmed the poor prognosis of BJI following surgery for ankle and/or hindfoot fracture. Patients need to be informed of this. TYPE OF STUDY AND LEVEL OF EVIDENCE IV, retrospective observational.
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Affiliation(s)
- Stéphanie Krissian
- Services d'orthopédie et traumatologie 1 et 2, faculté de médecine, université de Tours, CHU de Trousseau, avenue de la République, 37170 Chambray-les-Tours, France.
| | - Ramy Samargandi
- Services d'orthopédie et traumatologie 1 et 2, faculté de médecine, université de Tours, CHU de Trousseau, avenue de la République, 37170 Chambray-les-Tours, France
| | - Jérôme Druon
- Services d'orthopédie et traumatologie 1 et 2, faculté de médecine, université de Tours, CHU de Trousseau, avenue de la République, 37170 Chambray-les-Tours, France
| | - Philippe Rosset
- Services d'orthopédie et traumatologie 1 et 2, faculté de médecine, université de Tours, CHU de Trousseau, avenue de la République, 37170 Chambray-les-Tours, France
| | - Louis Romé Le Nail
- Services d'orthopédie et traumatologie 1 et 2, faculté de médecine, université de Tours, CHU de Trousseau, avenue de la République, 37170 Chambray-les-Tours, France
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22
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Liu JW, Ahn J, Raspovic KM, Liu GT, Nakonezny PA, Lavery LA, Wukich DK. Increased Rates of Readmission, Reoperation, and Mortality Following Open Reduction and Internal Fixation of Ankle Fractures Are Associated With Diabetes Mellitus. J Foot Ankle Surg 2019; 58:470-474. [PMID: 30760411 DOI: 10.1053/j.jfas.2018.09.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to compare the rates of readmission, reoperation, and mortality in patients with and without diabetes mellitus during the 30-day postoperative period after ankle fracture surgery. Patients who underwent operative management for ankle fractures between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program® database by using Current Procedural Terminology codes for ankle fracture surgery. A total of 17,464 patients undergoing ankle fracture surgery were identified. Of these patients, 2044 (11.7%) had diabetes and 15,420 (88.3%) did not have diabetes. We excluded patients older than 90 years or with inadequate perioperative data. Patients with diabetes had significantly higher rates of readmission (2.84% vs 1.05%, p < .0001), significantly higher rates of unplanned reoperation (2.3% vs 0.74%, p < .0001), and significantly higher rates of mortality (0.7% vs 0.2%, p < .0001) compared with patients without diabetes. Additionally, patients with diabetes had significantly greater age-adjusted odds ratios (ORs) of unplanned readmission (OR 2.40, 95% confidence interval [CI] 1.74 to 3.31, p < .0001), unplanned reoperation (OR 2.56, 95% CI 1.44 to 3.27, p < .0001), and mortality (OR 2.01, 95% CI 1.08 to 3.62, p = .0432) than did patients without diabetes after ankle surgery. In this large-scale retrospective study, we demonstrated that the presence of diabetes significantly increases the risk of unplanned readmission, unplanned reoperation, and mortality during the 30-day postoperative period after ankle fracture surgery.
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Affiliation(s)
- Jennifer W Liu
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Junho Ahn
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - George T Liu
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Paul A Nakonezny
- Department of Clinical Sciences, Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
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23
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Pérez-Prieto D, Portillo ME, González-Lucena G, Ginés-Cespedosa A. Foot and ankle infections: Debridement, early fixation and rifampicin provide earlier recovery of function and quality of life. Foot Ankle Surg 2019; 25:13-18. [PMID: 29409262 DOI: 10.1016/j.fas.2017.07.644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 06/28/2017] [Accepted: 07/21/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Infection after foot and ankle fractures is a major concern for orthopedic surgeons. It is widely believed that final osteosynthesis should be delayed until the infection is cured. However, there is no literature that supports this practice. In addition, the delay impairs patient function and quality of life (QoL). METHODS In the present study, four cases of ankle infection treated with aggressive debridement, early fixation and antibiofilm antibiotics are described. It is thought that, like other implant related infections, ankle infections can be rapidly treated with the definitive fixation and by curing the infection to make for a fast recovery of QoL and function. RESULTS The infections were caused by MSSA and Pseudomonas aeruginosa in case 1, MSSA in case 2 and MRSA as well as K. pneumonia in case 3. Case 4 was a culture negative infection. They were susceptible to antibiofilm antibiotics (the gram-negative bacilli susceptible to ciprofloxacin and the gram-positive cocci susceptible to rifampicin). Cases 1, 3 and 4 were treated with a tibio-talo-calcaneal arthrodesis and case 2 was treated with a de-rotational fibular osteotomy and a medial closing wedge supramalleolar osteotomy. All cases improved at a median time of 4 weeks in terms of quality of life (SF-36) and function (AOFAS). At 2-years follow-up, no recurrence of infection was observed in any of the cases. All the cases achieved fusion or osteotomy healing at final follow-up. CONCLUSIONS Early fixation after debridement combined with antibiofilm antibiotics can be performed in foot and ankle inflections to provide early recovery of QoL and function in patients.
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Affiliation(s)
- Daniel Pérez-Prieto
- Orthopedic Department, Hospital del Mar - Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - María E Portillo
- Microbiology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Gemma González-Lucena
- Orthopedic Department, Hospital del Mar - Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alberto Ginés-Cespedosa
- Orthopedic Department, Hospital del Mar - Universitat Autònoma de Barcelona, Barcelona, Spain
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24
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Smeeing DPJ, Briet JP, van Kessel CS, Segers MM, Verleisdonk EJ, Leenen LPH, Houwert RM, Hietbrink F. Factors Associated With Wound- and Implant-Related Complications After Surgical Treatment of Ankle Fractures. J Foot Ankle Surg 2019; 57:942-947. [PMID: 30005967 DOI: 10.1053/j.jfas.2018.03.050] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Diederik P J Smeeing
- Surgical Resident, Traumacenter Utrecht, Utrecht, The Netherlands; Surgical Resident, Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Jan P Briet
- Surgical Resident, Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Charlotte S van Kessel
- Surgical Resident, Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Michiel M Segers
- Trauma Surgeon, Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Egbert J Verleisdonk
- Trauma Surgeon, Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Professor in Trauma Surgery, Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roderick M Houwert
- Trauma Surgeon, Traumacenter Utrecht, Utrecht, The Netherlands; Trauma Surgeon, Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Falco Hietbrink
- Trauma Surgeon, Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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25
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Challagundla SR, Shewale S, Cree C, Hawkins A. Intramedullary fixation of lateral malleolus using Fibula Rod System in ankle fractures in the elderly. Foot Ankle Surg 2018; 24:423-426. [PMID: 29409203 DOI: 10.1016/j.fas.2017.04.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/11/2017] [Accepted: 04/19/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Operative management of ever increasing ankle fractures in the elderly need a reliable system of internal fixation. We present results of one such fixation, Fibula Rod System. METHODS Patients who underwent Fibula Rod System were included. Fracture union rate, complications, time to weight bearing and patient satisfaction using FAAM score were studied. RESULTS The mean age of the fifteen patients included was 74 years. Satisfactory reduction was achieved and maintained in all. All fractures united. There were no infections. Complications included lack of purchase of distal AP screw (n=1), fracture of fibula shaft (n=1), failure to insert syndesmotic screws through zig (n=2), delayed secondary wound healing (n=1) and removal of metal ware (n=2). At a mean follow-up of 12 months (n=10 responses), median FAAM score was 91% (Interquartile range of 62%-99%). CONCLUSION Fibula Rod System providing good stability and union, is a reliable operation for ankle fractures in the elderly.
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Affiliation(s)
- Sudhakar Rao Challagundla
- Department of Trauma & Orthopaedics, Dumfries and Galloway Royal Infirmary, Bankend Road, Dumfries DG1 4AP, United Kingdom.
| | - Sandeep Shewale
- Department of Trauma & Orthopaedics, Dumfries and Galloway Royal Infirmary, Bankend Road, Dumfries DG1 4AP, United Kingdom
| | - Calum Cree
- Department of Trauma & Orthopaedics, Dumfries and Galloway Royal Infirmary, Bankend Road, Dumfries DG1 4AP, United Kingdom
| | - Amanda Hawkins
- Department of Trauma & Orthopaedics, Dumfries and Galloway Royal Infirmary, Bankend Road, Dumfries DG1 4AP, United Kingdom
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26
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Rupp M, Kockmann S, El Khassawna T, Raschke MJ, Heiss C, Ochman S. Better is the foe of good: Outcome of operatively treated ankle fractures in the elderly. Foot (Edinb) 2018; 36:15-20. [PMID: 30321763 DOI: 10.1016/j.foot.2018.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 04/08/2018] [Accepted: 04/18/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ankle fractures are the second most common fractures of the lower extremities. Nonetheless, no standardized treatment protocol for unstable ankle fractures of the elderly exists today. Choices to treat ankle fractures are debated controversially, including (1) conservative treatment, (2) open reduction and internal fixation (ORIF), and (3) primary hind-foot arthrodesis. This retrospective study aimed to examine the healing result in patients treated by ORIF after unstable ankle fractures. METHODS The study was designed as a retrospective comparative series. The American Orthopaedic Foot and Ankle Society (AOFAS) score was followed to assess the postsurgical outcome. Data was obtained from 66 patients younger than 65 (median age, 42 years; range, 18-63) and 28 patients aged 65 or older (median age, 71 years; range, 65-81). The mean follow-up period for the younger-than-65 group was 48 months; for patients older than 65, it was 49 months. RESULTS An AOFAS score of 86.4 in the older and 92.4 in the younger group was determined, p-value<0.05. Elderly patients suffered from significantly more open-ankle fractures and comorbidities than the younger group did, p-value<0.05 each. The duration of hospital stay and the time needed to reach sufficient self-mobilization were both significantly different between the two groups, p-value<0.05. CONCLUSION ORIF treatment of ankle fractures resulted in good functional assessment after a mean follow-up of 49 months in the elderly. Pre-fracture health condition positively affected the healing results in younger patients. This study confirms the basic AO Foundation principles for good postsurgical results. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Markus Rupp
- University Hospital Giessen and Marburg, Campus Giessen, Department of Trauma, Hand, and Reconstructive Surgery, Rudolf-Buchheim-Strasse 7, 35385 Giessen, Germany; Justus-Liebig-University of Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany.
| | - Stefan Kockmann
- Westfaelische-Wilhelms-University of Muenster, University Hospital Muenster, Department of Trauma, Hand, and Reconstructive Surgery, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
| | - Thaqif El Khassawna
- Justus-Liebig-University of Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany
| | - Michael J Raschke
- Westfaelische-Wilhelms-University of Muenster, University Hospital Muenster, Department of Trauma, Hand, and Reconstructive Surgery, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
| | - Christian Heiss
- University Hospital Giessen and Marburg, Campus Giessen, Department of Trauma, Hand, and Reconstructive Surgery, Rudolf-Buchheim-Strasse 7, 35385 Giessen, Germany; Justus-Liebig-University of Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany
| | - Sabine Ochman
- Westfaelische-Wilhelms-University of Muenster, University Hospital Muenster, Department of Trauma, Hand, and Reconstructive Surgery, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
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27
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Wijendra A, Alwe R, Lamyman M, Grammatopoulos GA, Kambouroglou G. Low energy open ankle fractures in the elderly: Outcome and treatment algorithm. Injury 2017; 48:763-769. [PMID: 28093252 DOI: 10.1016/j.injury.2016.11.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/04/2016] [Accepted: 11/16/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND With an aging but still active population, open ankle fractures are increasingly presenting as low energy fragility injuries, sharing many characteristics with that of hip fractures. Yet, there is little in the literature on the management and outcome of these fractures. The primary aim of this study was to describe the outcome following open, ankle fragility fracture. Our secondary aim was to identify potential factors that improved outcome. METHODS All consecutive, low energy open ankle fractures treated at a Level I Trauma Centre over a five-year period were included. The method of fracture fixation, soft tissue closure, patient demographics, complications and mortality were recorded. Functional outcome was assessed using the Enneking Scoring system. RESULTS The cohort comprised 61 patients with a mean age of 73 years (range 27-100); 50 (82%) were females and all patients requiring operative intervention. The overall rate of complication was 24.5% (n=15), with reoperation due to loss of reduction, non-union, infection or amputation required in 7 cases (11.5%). The one-year mortality was 23%. The mean Enneking score, measuring functional outcome, was 36 out of 40 (SD: 6, range: 16-40). It was significantly higher for those treated with internal fixation (37, SD: 5 range: 16-40) than those with external fixation (31, SD: 6 range: 21-38) (p=0.01). Similarly, definitive wound closure - primary closure (37, SD: 5) or flap with split thickness skin graft (SSG) (36, SD: 6) - led to better outcomes than non-definitive closure (31, SD: 8). CONCLUSIONS The high morbidity associated with low energy ankle fractures is likely to reflect the hosts' reserves and is comparable to other fractures seen in the elderly. It is evident that definitive fracture fixation providing absolute, rather than relative stability; and definitive wound cover, with either primary closure or flap and SSG, enable early mobilization and shorter hospital stays with improved overall functional outcomes.
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Affiliation(s)
- Asanka Wijendra
- Trauma Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, United Kingdom.
| | - Rupali Alwe
- Trauma Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, United Kingdom
| | - Michael Lamyman
- Trauma Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, United Kingdom
| | - George A Grammatopoulos
- Trauma Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, United Kingdom
| | - Gregoris Kambouroglou
- Trauma Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, United Kingdom
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28
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Meyr AJ, Mirmiran R, Naldo J, Sachs BD, Shibuya N. American College of Foot and Ankle Surgeons ® Clinical Consensus Statement: Perioperative Management. J Foot Ankle Surg 2017; 56:336-356. [PMID: 28231966 DOI: 10.1053/j.jfas.2016.10.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Indexed: 02/07/2023]
Abstract
A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.
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Affiliation(s)
- Andrew J Meyr
- Committee Chairperson and Clinical Associate Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
| | | | - Jason Naldo
- Assistant Professor, Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Brett D Sachs
- Private Practice, Rocky Mountain Foot & Ankle Center, Wheat Ridge, CO; Faculty, Podiatric Medicine and Surgery Program, Highlands-Presbyterian St. Luke's Medical Center, Denver, CO
| | - Naohiro Shibuya
- Professor, Department of Surgery, Texas A&M, College of Medicine, Temple, TX
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29
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Zheng X, Li DY, Wangyang Y, Zhang XC, Guo KJ, Zhao FC, Pang Y, Chen YX. Effect of Chemical Thromboprophylaxis on the Rate of Venous Thromboembolism After Treatment of Foot and Ankle Fractures. Foot Ankle Int 2016; 37:1218-1224. [PMID: 27521353 DOI: 10.1177/1071100716658953] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a well-documented complication in patients with lower limb fractures, but management guidelines for its prevention in isolated foot and ankle fracture patients are conflicting. The aim of this study was to conduct a multicenter, prospective cohort study to define the prevalence of VTE in patients with isolated foot and ankle fractures and determine whether routine prophylaxis is necessary in these patients. METHODS In a double-blind, placebo-controlled study, consecutive patients in 3 hospitals who met our criteria were enrolled. After randomization, patients received either thromboprophylaxis with low-molecular-weight heparin units (LMWH group) or placebo (placebo group) for a period of 2 weeks. All patients underwent routine ultrasonography 1 day preoperatively, 1 week postoperatively, and 1 month postoperatively. Demographic parameters were then collected and compared. RESULTS Of the 814 patients who met our criteria, 19 patients (2.3%, 95% confidence interval [CI], 0%-31.9%) were found to have objectively confirmed VTE, but none of the patients were symptomatic. Of the 411 patients in the LMWH group, 2 developed VTEs preoperatively and 4 postoperatively; of the 403 patients in the placebo group, 5 developed VTEs preoperatively and 8 postoperatively. The overall incidence of asymptomatic postoperative deep vein thrombosis (DVT) was 0.98% (95% CI 0%-20.3%) in the LMWH group and 2.01% (95% CI 0%-29.5%) in the placebo group without significant difference. Advanced age (odds ratio [OR] 1.050, 95% CI 1.014-1.088, P = .007) and high body mass index (OR 1.201, 95% CI 1.034-1.395, P = .016) were identified as risk factors in predicting occurrence of DVT. No fatal pulmonary emboli or major bleeding complication occurred in either group. CONCLUSION Routine anticoagulant prophylaxis was not found to be necessary for patients with foot and ankle fractures, although further investigation with a properly powered study design is required to definitively determine which foot and ankle patients are best served by anticoagulation and which ones are not. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Xin Zheng
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China.,Department of Orthopaedics, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Dong-Ya Li
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Yufan Wangyang
- Department of Orthopaedics, The Central Hospital of Xuzhou City, Xuzhou, China
| | - Xing-Chen Zhang
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Kai-Jin Guo
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Feng-Chao Zhao
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Yong Pang
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Yi-Xin Chen
- Department of Orthopaedics, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
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30
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Ovaska MT, Madanat R, Mäkinen TJ. Predictors of Postoperative Wound Necrosis Following Primary Wound Closure of Open Ankle Fractures. Foot Ankle Int 2016; 37:401-6. [PMID: 26830839 DOI: 10.1177/1071100715609182] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most open malleolar ankle fracture wounds can be closed primarily after meticulous debridement. However, the development of wound necrosis following operative treatment of open malleolar ankle fractures can have catastrophic consequences. The aim of this study was to identify risk factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. METHODS A total of 137 patients with open malleolar ankle fractures were identified. The open fracture wound was primarily closed in 110 of 137 (80%) patients, and postoperative wound necrosis occurred in 18 (16%) of these patients. These patients were compared to the open fracture patients without wound necrosis. Twenty possible risk factors for the development of wound necrosis were studied with logistic regression analysis. RESULTS The variables that were independently associated with an increased risk for postoperative wound necrosis included ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery. CONCLUSIONS Our study showed that ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery were the most important factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. The findings warrant a further study specifically comparing primary and delayed wound closure in patients with Gustilo grade III open malleolar ankle fractures and different ASA classes. Also, the role of pulsatile lavage should be re-evaluated. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Mikko T Ovaska
- Department of Orthopaedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Rami Madanat
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Tatu J Mäkinen
- Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
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31
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Court-Brown CM, Honeyman CS, Clement ND, Hamilton SA, McQueen MM. The role of primary plastic surgery in the management of open fractures. Injury 2015; 46:2443-7. [PMID: 26456270 DOI: 10.1016/j.injury.2015.09.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A study was undertaken to determine the requirement for primary plastic surgery in the treatment of open fractures. We reviewed 3297 consecutive open fractures in a 22-year period in a defined population. Analysis showed that 12.6% of patients required primary plastic surgery with 5.6% being treated with split skin grafting and 7.2% with a flap. Only 3.5% of open upper limb fractures required primary plastic surgery compared to 27.9% of open lower limb fractures. The fractures that required most primary plastic surgery were those of the femoral diaphysis and all fractures between the proximal tibia and the midfoot. The incidence of open fractures that require primary plastic surgery was 28/10(6)/year. The incidence in open upper and lower limb fractures was 5.3/10(6)/year and 22.7/10(6)/year respectively. Using these figures it is possible to estimate the numbers of open fractures that will require primary plastic surgery each year in the United Kingdom.
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Affiliation(s)
| | - Calum S Honeyman
- Southmead Hospital, Southmead Way, Avon, Bristol BS10 5NB, United Kingdom
| | - Nick D Clement
- Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SA, Scotland
| | - Stuart A Hamilton
- St John's Hospital, Howden Road West, Howden, West Lothian EH54 6PP, Scotland
| | - Margaret M McQueen
- Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SA, Scotland
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32
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Gee CW, Dahal L, Rogers BA, Harry LE. Ankle fractures in the elderly: an overlooked burden. Br J Hosp Med (Lond) 2015; 76:564-9. [PMID: 26457936 DOI: 10.12968/hmed.2015.76.10.564] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Ankle fractures in the elderly are a complex under-recognized burden which require a multidisciplinary approach to management. This article discusses the holistic approach required, including the up-to-date surgical management options and the areas for future development.
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Affiliation(s)
- Christopher W Gee
- ST5 in Trauma and Orthopaedics in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals NHS Trust, Brighton, East Sussex BN2 5BE
| | - Luna Dahal
- 4th Year Medical Student, Brighton and Sussex Medical School, Brighton
| | - Benedict A Rogers
- Consultant Trauma and Orthopaedic Surgeon in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals NHS Trust and Honorary Senior Lecturer at Brighton and Sussex Medical School, Brighton
| | - Lorraine E Harry
- Consultant Orthoplastic Surgeon in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals NHS Trust and Queen Victoria Hospital NHS Foundation Trust, East Grinstead
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33
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Pfeifer CG, Grechenig S, Frankewycz B, Ernstberger A, Nerlich M, Krutsch W. Analysis of 213 currently used rehabilitation protocols in foot and ankle fractures. Injury 2015; 46 Suppl 4:S51-7. [PMID: 26542866 DOI: 10.1016/s0020-1383(15)30018-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Fractures of the ankle, hind- and midfoot are amongst the five most common fractures. Besides initial operative or non-operative treatment, rehabilitation of the patients plays a crucial role for fracture union and long term functional outcome. Limited evidence is available with regard to what a rehabilitation regimen should include and what guidelines should be in place for the initial clinical course of these patients. This study therefore investigated the current rehabilitation concepts after fractures of the ankle, hind- and midfoot. METHODS Written rehabilitation protocols provided by orthopedic and trauma surgery institutions in terms of recommendations for weight bearing, range of motion (ROM), physiotherapy and choice of orthosis were screened and analysed. All protocols for lateral ankle fractures type AO 44A1, AO 44B1 and AO 44C1, for calcaneal fractures and fractures of the metatarsal as well as other not specific were included. Descriptive analysis was carried out and statistical analysis applied where appropriate. RESULTS 209 rehabilitation protocols for ankle fractures type AO 44B1 and AO 44C1, 98 for AO 44A1, 193 for metatarsal fractures, 142 for calcaneal fractures, 107 for 5(th) metatarsal base fractures and 70 for 5(th) metatarsal Jones fractures were evaluated. The mean time recommended for orthosis treatment was 6.04 (SD 0.04) weeks. While the majority of protocols showed a trend towards increased weight bearing and increased ROM over time, the best consensus was noted for weight bearing recommendations. CONCLUSION Our study shows that there exists a huge variability in rehabilitation of fractures of the ankle-, hind- and midfoot. This may be contributed to a lack of consensus (e.g. missing publication of guidelines), individualized patient care (e.g. in fragility fractures) or lack of specialization. This study might serve as basis for prospective randomized controlled trials in order to optimize rehabilitation for these common fractures.
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Affiliation(s)
- Christian G Pfeifer
- Department of Trauma and Orthopedic Surgery, University Medical Centre Regensburg, Germany.
| | - Stephan Grechenig
- Department of Trauma and Orthopedic Surgery, University Medical Centre Regensburg, Germany
| | - Borys Frankewycz
- Department of Trauma and Orthopedic Surgery, University Medical Centre Regensburg, Germany
| | - Antonio Ernstberger
- Department of Trauma and Orthopedic Surgery, University Medical Centre Regensburg, Germany
| | - Michael Nerlich
- Department of Trauma and Orthopedic Surgery, University Medical Centre Regensburg, Germany
| | - Werner Krutsch
- Department of Trauma and Orthopedic Surgery, University Medical Centre Regensburg, Germany
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Otchwemah R, Grams V, Tjardes T, Shafizadeh S, Bäthis H, Maegele M, Messler S, Bouillon B, Probst C. Bacterial contamination of open fractures - pathogens, antibiotic resistances and therapeutic regimes in four hospitals of the trauma network Cologne, Germany. Injury 2015; 46 Suppl 4:S104-8. [PMID: 26542854 DOI: 10.1016/s0020-1383(15)30027-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The bacterial contamination of soft tissues and bone in open fractures leads to an infection rate of up to 50%. Pathogens and their resistance against therapeutic agents change with time and vary in different regions. In this work, our aims were to characterize the bacterial spectrum present in open fractures, analyze the bacterial resistance to antibiotic agents and question the EAST guideline recommendations for antibiotic prophylaxis after open fractures in a German Trauma Network. MATERIALS AND METHODS We conducted a retrospective cohort study and included all patients with open fractures from 1(st) of January 2011 until the 31(st) of December 2014 in four hospitals of the trauma network cologne. Soft tissue damage was classified according to the Gustilo Anderson classification. RESULTS We included 123 patients. Forty-five injuries (37%) were classified I°, 45 (37%) as II° and 33 (27%) as III°. Lower leg (34%) was the most commonly injured location. An antibiotic prophylaxis was administered to 109 patients (89%). In 107 of them (98%) a cephalosporin or cephalosporin combination was given. In 35 of the patients (28%), microbiological samples were taken of the fracture site. Wound cultures were positive in 21 patients (60%). Fifty percent of the bacterial detections occurred in III° fractures. Coagulase negative Staphylococci (COST) were the most frequent pathogens. In II° open fractures one gram-negative strain was isolated. Fewest resistances were seen against quinolones and co-trimoxazole. DISCUSSION The recommended EAST guideline prophylaxis would have covered all but one bacterium (97% of positive cultures). One Escherichia coli was found in a II° open fracture and would have been missed. One of the isolated Staphylococci epidermidis and an Enterococcus faecium were resistant against gentamycin and first- and second-generation-cephalosporin's which were used as prophylaxis frequently. However, a regional adaption of the EAST guidelines seems not justified due to the rather low number of cases in our study. CONCLUSION The EAST guideline seems to be adequate in a high percentage of cases (97%) in the setting of the trauma network cologne. Further research should be guided at identification of initial open fracture pathogens to improve the efficiency of antibiotic prophylaxis.
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Affiliation(s)
- Robin Otchwemah
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany.
| | - Volker Grams
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
| | - Thorsten Tjardes
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
| | - Sven Shafizadeh
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
| | - Holger Bäthis
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
| | - Marc Maegele
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
| | - Sabine Messler
- Institute for Hygiene, Cologne-Merheim Medical Center, Germany
| | - Bertil Bouillon
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
| | - Christian Probst
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
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