Osteoporotic ankle fractures

Management of High-Risk Ankle Fractures

Successful outcomes in the surgical treatment of the fractured ankle require methods that respect the soft tissue envelope and establish a stable mortise for functional rehabilitation. Ankle fractures in patients with osteopenia and in diabetic patients with deranged bone remodeling constitute high-risk injuries that may result in catastrophic complications. These patients present unique care challenges and should not be approached in the same manner as their healthy counterparts. We present the principles of treatment in high-risk ankle fractures, operative treatment philosophy illustrating techniques frequently used at our institution, and a review of current literature.

A Comparison of Ankle Fractures Relative to Other Fragility Fractures: A Review and Analysis of the American Orthopaedic Association's Own the Bone Database

BACKGROUND

Ankle fragility fractures (AFX) continue to increase in the elderly population. There is limited knowledge of AFX characteristics compared to nonankle fragility fractures (NAFX). The American Orthopaedic Association's Own the Bone (OTB) is a fragility fracture initiative. This robust data set was used to examine and compare characteristics of patients presenting with AFX to those with NAFX.

METHODS

The OTB database contained 72,617 fragility fractures between January 2009 and March of 2022 and were reviewed in our secondary cohort comparative analysis. After exclusions, AFX accounted for 3229 patients and 54,772 patients were in the NAFX cohort. Bivariate analysis and logistic regression compared the AFX and NAFX groups concerning demographics, bone health factors, medication use, and prior fragility fracture.

RESULTS

AFX patients were found to have a higher likelihood to be younger (67.6 years old), female (81.4%), non-Caucasian (11.7%) and have a higher BMI (30.6) compared to NAFX. Prior AFX predicted the risk of a future AFX. The probability of an AFX increased with increased age and BMI.

CONCLUSION

A prior AFX is independently predictive of subsequent AFX. Therefore, these fractures should be considered a sentinel event. These patients are more likely to have higher BMI, to be of female gender, non-Caucasian race, and are younger compared to patients with NAFX.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Fracture distribution in postmenopausal women: a FRISBEE sub-study

We registered 1336 incident-validated fractures in a prospective cohort of 3560 postmenopausal (60-85 years) Belgian women (mean follow-up of 9.1 years). The increase of fracture incidence with age varied widely depending on the fracture site and was significantly steeper for central than for peripheral fractures (e.g., not significant for the ankle).

INTRODUCTION

The epidemiology of fracture sites other than MOFs has been less studied. We examined the incidence of fractures according to their sites in a prospective cohort of postmenopausal Belgian women.

METHODS

Three thousand five hundred sixty postmenopausal women, aged 60-85 years old, were recruited from 2007 to 2013 and surveyed yearly (FRISBEE). The number of validated incident fractures was recorded and analyzed in relation to age and the fracture site.

RESULTS

One thousand three hundred thirty-six fractures were recorded after a mean follow-up of 9.1 years. Seven hundred fifty-six fractures (57%) were MOFs and 580 (43%) non-MOFs, while 813 (61%) were central and 523 (39%) peripheral. The increase of fracture incidence with age differed between fracture sites and was steeper for central than for peripheral fractures. The ratio of MOFs to non-MOFs increased significantly with age, from 1.10 (95% CI: 0.83-1.45) for the 60-69 to 1.69 [1.42-2.01] for the 80-89-year subgroup (P = 0.017). This was also true for central versus peripheral fracture. We differentiated three groups of fracture incidence evolution with age: fractures with a mean increase/decade (compared to the 60-69 age group) of less than 1.5, 1.5-2.0, and 2.0-3.0. The lowest increase was seen for most peripheral fractures, whereas the greatest increase included hip, scapula, pelvis, ribs, and spine fractures.

CONCLUSION

The increase of fracture incidence with age varied widely depending on the fracture site, and the ratio of MOFs to non-MOFs rose significantly with age. Some peripheral fractures, such as the ankle, did not increase significantly with age, suggesting that bone fragility does not play a major role in their occurrence.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

Ankle fractures in the elderly are an increasing problem, with poor outcomes reported. Operative options for patients with suspected osteoporosis and needing to bear weight to ambulate can include hindfoot intramedullary nail (IMN) or fibula pro-tibia fixation (FPT). FPT involves passing 2 or more screws through a lateral fibula plate, crossing the fibular into the tibia, with 1 or more screws proximal to the incisura. We compared the outcomes of these 2 techniques.

METHOD

A retrospective review identified 68 patients aged over 60 years with unstable ankle fractures, treated with IMN or FPT. Primary outcome was surgical reoperation/revision rate, secondary outcomes included complications, length of stay, and functional status. Results: There were no significant differences in demographics between IMN and FPT. Revision rates were higher in IMN compared with FPT (P < .0001). IMN patients postoperatively had longer hospital stays (P = .02), longer follow-up times (P = .008), and higher rates of delayed wound healing (P = .03) and nonunion (P = .001). Multivariate analysis identified fixation and age to affect revision rates.

CONCLUSION

Outcomes were worse in the IMN group compared with FPT. We believe both techniques have a role in the management of elderly ankle fractures, but patient selection is key. We suggest that FPT should be the first-choice technique when soft tissues permit.

LEVELS OF EVIDENCE

Level III.

Spinal Anesthesia Associated With Increased Length of Stay Compared to General Anesthesia for Ankle Open Reduction Internal Fixation: A Propensity-Matched Analysis

General and spinal anesthesia are both utilized for patients undergoing open reduction internal fixation of the ankle, but there are little data comparing early complication rates. The purpose of this study was to compare duration of surgery, length of stay, and rates of postoperative adverse events within 30 days in patients undergoing open reduction internal fixation of ankle fracture using spinal versus general anesthesia. Adult patients who underwent open reduction internal fixation of a closed ankle fracture from 2012 to 2016 were retrospectively identified from American College of Surgeons National Surgical Quality Improvement Program. Duration of surgery, length of stay, 30-day adverse events, and unplanned readmissions were compared between patients who received general anesthesia and spinal anesthesia. Propensity adjustment with respect to known risk factors for complications and adjunctive regional block was used to match patients. Of the 10,795 patients included after applying the inclusion and exclusion criteria, 9862 (91.36%) received general anesthesia and 933 (8.64%) received spinal anesthesia. Using propensity-scored matching, 841 patients in the spinal cohort were matched to 3364 patients in the general cohort. Spinal anesthesia was associated with increased length of stay (+0.5 days, 95% confidence interval 0.23-0.77, p < .001). There were no differences in the rates of major/minor complications, mortality, transfusions, unplanned readmissions, or duration of surgery. General anesthesia is predominantly used for fixation of ankle fractures. While spinal anesthesia is associated with lower complication rates in hip and knee surgery, we found that it is associated with increased length of stay in patients undergoing open reduction internal fixation of the ankle within 30 days of surgery.

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

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

Posterior pilon fracture: Epidemiology and surgical technique

OBJECTIVES

To review a case series of patients with posterior pilon variant fracture using a novel approach, focusing on demographic data, injury pattern, surgical results based on computed tomography (CT) scan, and short-term complications.

DESIGN

Consecutive case series.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Twenty-five patients with posterior pilon fracture.

INTERVENTION

Posterior pilon fracture open reduction and internal fixation.

MAIN OUTCOME MEASUREMENTS

Parameters measured included age, sex, type of fracture, surgical technique, anatomical reduction, and complications.

RESULTS

Twenty-five patients sustained a posterior pilon fracture, accounting for 13.4% of all operatively treated ankle fractures with median follow-up of 21.7 months. The average age of patients was 42 years (22-62); 19/25 (76%) were female, and 6/25 (24%) were male. A modified posteromedial approach was used in 18/25 (72%) patients. Persistent syndesmotic instability was present in 11/25 (44%) patients after posterior malleolar stabilization. Quality of reduction was assessed under CT scan in 19 patients, with 15/19 (78.9%) having anatomic reduction. We report 2/25 (8%) patients with early wound problems and 7/25 (20%) with short-term complications during follow-up.

CONCLUSION

Posterior pilon variant fracture appears to be less common than previously reported. Most fractures can be satisfactorily treated through a modified posteromedial approach. Albeit obtaining posterior malleolar fracture rigid fixation, syndesmotic instability was more prevalent than expected. The short-term complication rate was low.

LEVEL OF EVIDENCE

Therapeutic level IV.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

DISCUSSION

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

TRIAL REGISTRATION NUMBER

ACTRN12617001588381;Pre-results andU1111-1203-1704.

Influence of age and level of activity on the applicability of a walker orthosis - a prospective study in different cohorts of healthy volunteers

Background

Walker orthosis are frequently prescribed as they are removable to allow wound control, body care and physiotherapy and are adaptable to the soft tissue conditions. The prerequisite for successful treatment with any walker orthosis is a correct use by the patient. Therefore, the aim of this study was to investigate patients’ handling of a commonly used walker.

Methods

Prospective observational study analyzing the applicability of a walker orthosis in different cohorts with varying age and level of activity. Volunteers were recruited from a mountain-biking-team (Sport), a cardiovascular-health-sports-group (Cardio) and a retirement home (Senior). The correct application was assessed following initial training (t0) and one week later (t1). Outcome parameters were an Application Score, strap tightness, vertical heel lift-off and subjective judgement of correct application.

Results

Thirty-three volunteers, 11 Sports group (31 ± 7a), 12 Cardio group (59 ± 11a), 10 Senior group, (82 ± 5a) were enrolled. No differences for any parameter could be observed between t0 and t1. Age showed a moderate correlation for all outcome parameters and the cohort influenced all variables. The Senior group presented significant inferior results to the Sport- and Cardio group for the Application Score (p = 0.002-p < 0.001) and strap tightness (p < 0.001). Heel lift-off was significantly inferior in the Cardio- and Senior- compared to the Sport group (p = 0.003-p < 0.001). 14% in the Sport-, 4% in the Cardio- and 83% in the Senior group achieved less than 9 points in the Application Score – which was considered insufficient. However, out of these 90% believed the application to be correct.

Conclusions

The elderly cohort living in a retirement home demonstrated an impaired handling of the walker orthosis. Further, participants were incapable to self-assess the correct handling. These aspects should be respected when initiating treatment with a walker orthosis.

Trial registration

Retrospectively registered on the 16th of February 2018: #DRKS00013728 on DRKS.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2366-2) contains supplementary material, which is available to authorized users.

Clinical Management of Osteoporotic Fractures

PURPOSE OF REVIEW

This review examines recent literature regarding the clinical management of fragility fractures, provides insight into new practice patterns, and discusses controversies in current management.

RECENT FINDINGS

There are declining rates of osteoporosis management following initial fragility fracture. Management of osteoporotic fractures via a multidisciplinary team reduces secondary fracture incidence and improves overall osteoporotic care. Anabolic agents (abaloparatide and teriparatide) are effective adjuvants to fracture repair, and have shown positive results in cases of re-fracture in spite of medical management (i.e., bisphosphonates). For AO 31-A1 and A2 intertrochanteric hip fractures (non-reverse obliquity), no clinical advantage of intramedullary fixation over the sliding hip screw (SHS) has been proven; SHS is more cost-effective. As fragility fracture incidence continues to rise, orthopedic surgeons must play a more central role in the care of osteoporotic patients. Initiation of pharmacologic intervention is key to preventing subsequent fragility fractures, and may play a supportive role in initial fracture healing. While the media bombards patients with complications of medical therapy (atypical femur fractures, osteonecrosis of jaw, myocardial infarction), providers need to understand and communicate the low incidence of these complications compared with consequences of not initiating medical therapy.

Comparison of the Outcomes Between Headless Cannulated Screw Fixation and Fixation Using a Locking Compression Distal Ulna Hook Plate in Fracture of Fifth Metatarsal Base

The aim of the present study was to evaluate and compare the clinical and radiologic results of internal fixation with a headless cannulated screw versus a locking compression distal ulna hook plate for fractures at the base of the fifth metatarsal bone, zone 1. From April 2012 to April 2015, 30 cases (29 patients) were retrospectively evaluated. The mean follow-up period was 13 months. The patients were divided into 2 groups stratified by the fixation method: screw (group A, n = 15) or plate (group B, n = 15). We measured the displacement to diastasis of the fracture on the foot oblique radiographs taken pre- and postoperatively in each group, recorded the time to bony union, and measured the difference in the reduction distance in each group. The clinical results were evaluated using the American Orthopaedic Foot and Ankle Society midfoot score at 12 months postoperatively. In group A, the mean interval to union was 54.2 ± 9.3 days, the mean displacement to diastasis had improved to 0.3 ± 0.4 mm postoperatively (p < .001), and the mean reduction distance was 2.9 ± 1.0 mm postoperatively. In group B, the mean interval to union was 41.5 ± 7.0 days, the mean displacement to diastasis had improved to 0.06 ± 0.2 mm postoperatively (p < .001), and the mean reduction distance was 4.1 ± 1.6 mm. The American Orthopaedic Foot and Ankle Society midfoot scale score was 97.7 ± 3.4 in group A and 98.2 ± 3.2 in group B. The interval to union was significantly different between the 2 groups (p = .01). No complications were recorded. Our findings have shown that the plate is a reasonable and alternative method for the surgical treatment of fifth metatarsal base fractures.

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

INTRODUCTION

Ankle fractures represent the third most common fracture in elderly patients, after hip and wrist fractures. Distal fibula fractures in this population are closely related to osteoporosis, which renders commonly used methods of internal fixation technically demanding and prone to failure. Currently there is a tendency to fix osteoporotic metaphyseal and epiphyseal fractures with locking plates. However, published accounts about the use of this technology in osteoporotic distal fibula fractures are scarce. In this study we compare the results of two groups of patients who underwent surgery for these types of fracture, one group received locking and the other non-locking screws, both using one-third tubular plates.

METHODS

Sixty-two patients, aged over 64 years, underwent surgery for osteoporotic distal fibula fractures between 2011 and 2014. Forty-five of them were stabilized with a non-locking plate and the remaining 17 with a locking plate fixation. Follow-up was performed at 4, 8, 12, 26, and 52 weeks. Results were assessed according to the AOFAS Ankle-Hindfoot Score and radiological criteria for consolidation.

RESULTS

Average time to union and AOFAS scores at 6 and 12 months were similar in both groups, including for the individual categories: function, pain, mobility, and alignment. Only time until partial weight bearing was significantly lower in the locking plate group (4.69 ± 2.63 vs 7.77 ± 4.30, p = 0.03). The most common complications were wound dehiscence and superficial infection (two cases of both).

CONCLUSIONS

Both locking and conventional non-locking plates achieved similar treatment outcomes in this group of osteoporotic patients aged over 64. However, locking plates may offer more benefits in cases that have to take into account immobilization time and concomitant soft-tissue damage.

Repair of Bimalleolar Ankle Fracture

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Management of nonunion after an old - neglected ankle fracture in diabetic patient; case report

Ankle fractures represent 9% of fractures. Even if it is a relatively usual fracture, the presence of diabetes makes treatment more difficult and rate of complications is higher than in the rest of population. The incidence of ankle fractures increased in the last half century. Many studies from SUA, England, Sweden and Finland suggest that the epidemiology of ankle fractures continues to change as populations age, up to the age 60 of years in men and above age of 50 years in women. Two-thirds of fractures are isolated malleolar fractures, bimalleolar fractures occur in one-fourth of patients and trimaleolar fractures occur in the rest of them. We present a case of 60 years old women with non-insulin dependent diabetes for 22 years who sustained a fracture of ankle. Her first presentation at doctor was after 4 months after injury and surgical treatment occurred after 8 months after the injury. She was operated using an external fixator. Despite the fact the treatment was delayed, the evolution of lesion was good and patient could regained normal gate.

Preoperative radiography versus computed tomography for surgical planning for ankle fractures

PURPOSE

To review preoperative radiography and computed tomography (CT) of the ankle in 69 patients who underwent surgery for ankle fractures to determine the value of CT in diagnosis and surgical planning.

METHODS

Preoperative radiography and CT of the ankle of 46 women and 23 men aged 17 to 90 (mean, 48.8) years were reviewed. CT was deemed necessary when radiographs showed the following features: (1) comminuted fracture of the medial malleolus involving the tibial plafond, (2) comminuted fracture of the posterior malleolus, (3) presence of loose bodies, and/or (4) suspected Chaput or Volkman fracture fragment. Two orthopaedic surgeons independently reviewed the radiographs to look for any of the above features for which CT was indicated. In patients whose radiographs did not show any of the above features, each surgeon formulated a surgical plan based on radiographs alone and decided if any modification was needed after reviewing the CT scan.

RESULTS

Based on radiographs of the 69 patients, 19 (28%) patients had features of posterior malleolar comminution (n=7), medial malleolar comminution (n=7), suspected Chaput fracture fragment (n=1), suspected Volkman fracture fragment (n=1), and combination of 2 lesions (n=3), and were deemed to require CT. In 10 (20%) of the remaining 50 patients, the surgical plan was modified after review of the CT scan. The intra- and inter-observer agreement was good to excellent.

CONCLUSION

Radiography alone is not adequate for surgical planning for ankle fractures. More accurate imaging tools such as CT are needed to enable a more accurate diagnosis and surgical planning.

Analysis of risk factors of the postoperative complications of surgical treatment of ankle fractures in the elderly: A series of 477 patients

INTRODUCTION

The surgical strategy of ankle fractures in elderly subjects is controversial because of the high rate of local and general complications. The goal of this study was to identify the risk factors of complications of ankle fractures in elderly subjects.

MATERIALS AND METHODS

Four hundred and seventy-seven patients operated between 2008 and 2014 were included in this retrospective study. The minimum age was 60 years old for women and 70 for men. Patients presenting with a pilon fracture or with less than 3 months of follow up were excluded. A clinical evaluation of autonomy based on the Parker score and a radiographic assessment were performed preoperatively and during follow up The characteristics of the fracture, comorbidities and the type of internal fixation used were reported.

RESULTS

This series included 384 women (81%), mean age 74 years old (60-99). Most fractures were Weber type B (n=336). Four hundred and thirty-one patients (90.4%) received so-called standard internal fixation and 46 patients (9.6%) received so-called atypical fixation. The rate of general complications was 4.6%, and local complications was 23.9%. Univariate analysis of the risk factors of general complications identified 2 significant criteria: age older than 80 (OR=3.46, P=0.012) and more than 2 comorbidities 2 (OR=10.6, P<0.0001). Univariate analysis of risk factors of local complications identified 2 criteria: an open fracture (OR=4.90, P=0.0016) and age over 80 (OR=1.85, P=0.024). Multivariate analysis of risk factors of local complications confirmed the relationship with open fractures (OR=4.67, P<0.001).

DISCUSSION

The results of the management of ankle fractures in elderly subjects is satisfactory. The use of standard internal fixation techniques is recommended. The risk of complications increases with age, the severity of the fracture and the number of associated diseases.

LEVEL OF EVIDENCE

Level 4.

Morbidity and Mortality Associated with Geriatric Ankle Fractures: A Medicare Part A Claims Database Analysis

BACKGROUND

The purpose of this study was to examine the incidence of adverse events in elderly patients who required inpatient admission after sustaining an ankle fracture and to consider these data in relation to geriatric hip fracture and other geriatric patient admissions.

METHODS

A retrospective cohort study of patients admitted with an ankle fracture, a hip fracture, or any other diagnosis was performed with the Medicare Part A database for 2008. The primary outcome measure was the one-year mortality rate, examined with multivariate analysis factoring for both patient age and preexisting comorbidity. Secondary outcome measures analyzed additional morbidity as reflected by length of stay, discharge disposition, readmissions, and medical complications.

RESULTS

There were 19,648 patients with ankle fractures, 193,980 patients with hip fractures, and 5,801,831 patients with other admitting diagnoses. Significant differences (p < 0.001) were noted in both age and comorbidity status between the group with ankle fractures and the group with hip fractures. The one-year mortality after admission was 11.9% for patients with ankle fracture, 28.2% for patients with hip fracture, and 21.5% for patients with any other admission. Upon using multivariate analysis to account for both age and comorbidity, the hazard ratio for one-year mortality associated with fracture was 1.088 for patients with hip fracture and 0.557 for patients with ankle fracture.

CONCLUSIONS

Even after selecting for admitted patients and accounting for both age and comorbidity, geriatric patients with ankle fractures were found to have a lower one-year morbidity compared with geriatric patients who had sustained a hip fracture or alternative admitting diagnoses. Geriatric patients with ankle fractures are likely healthier and more active in ways that are not captured by simply accounting for age and comorbidity. These findings may support more aggressive definitive management of such injuries in this population.

LEVEL OF EVIDENCE

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

External fixation in the elderly

Orthopaedic trauma is an increasingly common problem in geriatric patients. As demands of daily life and recreational activities are increasing in these patients, surgeons need to be able to manage geriatric fractures to achieve good functional results. Reduced bone quality in the elderly presents a considerable challenge and may preclude the use of established surgical stabilisation techniques that are performed in younger trauma patients. Furthermore, pre-existing medical conditions and considerable comorbidities in the elderly could complicate standard surgical procedures that younger patients would be offered. In this respect, application of external fixators represents a validated, minimally-invasive treatment opportunity. This review article summarises the use of external fixation in geriatric trauma patients for wrist fractures, proximal femoral fractures, pelvic fractures, and ankle fractures. Modern modifications, like pin coating with hydroxyapatite, and aspects of pin care will be discussed.

Geriatric Patients With Fractures Below the Hip are Medically Similar to Geriatric Patients With Hip Fracture

The objective of this study was to compare a cohort of geriatric patients with operatively managed isolated fractures below the hip to a cohort of geriatric patients with operatively managed isolated hip fractures. All patients greater than 59 years of age admitted to our institution for surgical care of an isolated lower extremity fracture during a 3-year period were included. Patients were divided into 2 cohorts: BTH (fracture below the subtrochanteric region of the femur) and HIP (proximal femoral fracture at subtrochanteric region or proximal). We identified 141 patients included in cohort BTH and 205 patients included in cohort HIP. HIP patients were older (P < .01) and less obese (P < .01) but were otherwise very similar. An extensive comorbidity review revealed that the 2 cohorts were similar, with the exception of an increased incidence of dementia (P = .012) or glaucoma (P = .04) in HIP patients and of peripheral neuropathy (P = .014) in BTH patients. HIP patients were more likely to be under active antiosteoporotic medication management and were more likely to be receiving pharmacological anticoagulation at the time of admission. HIP patients and BTH patients were similar with regard to necessity of assistance with ambulation preinjury, but HIP patients were less likely to reside independently at home than were BTH patients (P < .001). HIP patients were also less likely to be discharged directly home from the hospital (P < .001). Geriatric patients with fractures below the hip are medically similar to geriatric patients with hip fracture. Medical comanagement protocols have been extensively published that improve care of geriatric patients with hip fracture; consideration should be given to similar protocol-driven medical comanagement programs for geriatric patients with fractures below the hip.

Internal fixation of osteoporotic fractures

Osteoporosis leads to bone fragility and increased risk of fracture. Despite advances in diagnosis and treatment, the prevalence continues to rise. Osteoporotic fracture treatment has a unique set of difficulties related to poor bone quality and traditional approaches, and implants may not perform well. Fixation failure and repeat surgery are poorly tolerated and highly undesirable in this patient population. This review illustrates the most recent updates in internal fixation, implant design, and surgical theory regarding treatment of patients with osteoporotic fractures.

Evaluation of posterior malleolar fractures and the posterior pilon variant in operatively treated ankle fractures

BACKGROUND

Substantial attention has recently been placed on fractures of the posterior malleolus. Fracture extension to the posteromedial rim ("posterior pilon variant") may result in articular incongruity and talar subluxation. Current classification systems fail to account for these fractures. The relative frequency of this fracture, its associated patient characteristics, and the reliability of its diagnosis have never been reported in such a large series.

METHODS

We retrospectively identified 270 patients who met our inclusion criteria. Basic demographic data were collected. The fractures were classified according to Lauge-Hansen and AO/OTA. Additional radiographic data included whether the fracture involved the posterior malleolus and whether the fracture represented a posterior pilon variant. Univariate statistical methods, chi-square analysis, and interobserver reliability were assessed.

RESULTS

The relative frequency of posterior malleolus fracture was 50%. The relative frequency of the posterior pilon variant was 20%. No significant difference was noted with respect to the frequency of posterior malleolar or posterior pilon variant between the subgroups of the AO/OTA and Lauge-Hansen classification systems when compared to the overall fracture distribution. Patients with posterior malleolar fractures and posterior pilon variants were significantly older. Females were significantly more likely than men to sustain posterior malleolar fractures and posterior pilon variants. Patients with diabetes trended toward a greater risk of both types of fractures. Interobserver reliability data revealed substantial agreement for posterior malleolar fractures and posterior pilon variants.

CONCLUSION

These data represent the highest reported rate of posterior malleolar involvement in operatively treated ankle fractures and is the first to describe the percentage of the posterior pilon variant in such a large series. The interobserver reliability data demonstrate substantial agreement in identification of posterior malleolar fractures and the posterior pilon variant based on plain radiographs. Certain patient characteristics such as age, sex, and diabetes may be associated with these fractures.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Ankle fractures in elderly patients

The incidence of ankle fractures (AFs) in the elderly is rising due to the increase in life expectancy. Rather than directly related to osteoporosis, AFs are a predictor of osteoporotic fractures in other sites. In women AFs are associated with weight and BMI. AFs are difficult to categorize; therapeutic options are non-operative treatment with plaster casts or surgical treatment with Kirschner's wires, plates and screws. The choice of treatment should be based not only on the fracture type but also on the local and general comorbidity of the patient. Considering the new evidence that postmenopausal women with AFs have disrupted microarchitecture and decreased stiffness of the bone compared with women with no fracture history, in our opinion low-trauma AFs should be considered in a similar way to the other classical osteoporotic fractures.