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

[Translated article] Fractures of the peroneal malleolus: Current concepts

Ankle fractures represent up to 9% of all fractures, with an increased incidence in the elderly population. Among these fractures, isolated fractures of the lateral malleolus are the most common, representing 65-70% of all cases. The therapeutic decision-making primarily relies on the stability of the ankle ring, considering it stable if affected at one point and unstable if two or more points are affected. Surgical treatment focuses on restoring the length of the fibula, joint reconstruction, stabilising the syndesmosis, and providing a stable fixation. It is crucial to rule out associated injuries that may influence therapeutic management. This article reviews the evaluation and management of lateral malleolus fractures, proposes a decision-making algorithm, and examines several fibular fixation options.

Fractures of the peroneal malleolus: Current concepts

Ankle fractures represent up to 9% of all fractures, with an increased incidence in the elderly population. Among these fractures, isolated fractures of the lateral malleolus are the most common, representing 65-70% of all cases. The therapeutic decision-making primarily relies on the stability of the ankle ring, considering it stable if affected at one point and unstable if two or more points are affected. Surgical treatment focuses on restoring the length of the fibula, joint reconstruction, stabilizing the syndesmosis, and providing a stable fixation. It is crucial to rule out associated injuries that may influence therapeutic management. This article reviews the evaluation and management of lateral malleolus fractures, proposes a decision-making algorithm, and examines several fibular fixation options.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Effect of buttress plate in Herscovici type D vertical medial malleolar fractures and peripheral fractures: a retrospective comparative cohort study

BACKGROUND

The purpose of current retrospective study was to review the surgical methods and to evaluate the clinical efficacy of supporting plate for the treatment of vertical medial malleolus fractures on the basis of stable fixation of ipsilateral fibula.

METHODS

This retrospective study included a total of 191 patients with vertical medial malleolus fractures. Patients enrolled were divided into simple vertical medial malleolus fractures and complex types of fractures. General demographic information and surgical information, including age, sex, surgical procedure and postoperative complications, were collected. The functional prognosis of patients was evaluated by American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS) and Visual Analog Scale (VAS).

RESULT

Among patients with simple vertical fractures, the respective incidence of internal fixation failure in screw group, buttress plate group, and screw combined buttress plate fixation group (combined fixation group) was 10/61 (16.4%),1/54 (7.4%) and 1 (1.9%), and the difference was statistically significant (P = 0.024). The incidence of abnormal fracture growth and healing in screw group, buttress plate group and combined fixation group was, respectively, 13/61 (21.3%), 6/54 (12.5%) and 2 (3.85%), with statistically significant difference (P = 0.019). In the patients with complex types of fractures, after 2 years of postoperative follow-up, the AOFAS score and VAS score of the following subgroups had good results: 91.18 ± 6.05 and 2.18 ± 1.08 in patients with joint surface collapse, and 92.50 ± 4.80 and 2.50 ± 1.29 in patients with tibial fractures, with 100% excellent and good rate.

CONCLUSION

For simple and complex vertical medial malleolus fractures, buttress plate showed excellent fixation. Despite poor wound healing and extensive soft tissue dissection with this approach, buttress plate may provide a novel insight into medial malleolar fractures, especially for extremely unstable medial malleolar fractures.

Fibula Nail versus Locking Plate Fixation-A Biomechanical Study

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

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

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

Resumption of complete weight bearing after osteosynthesis of bimalleolar fractures using locking plates

INTRODUCTION

Bimalleolar fractures represent 9% of fractures and affect 187/100,000 people per year. The gold standard for osteosynthesis is a one-third tubular or lateral locking plate and compression screwing or use of tension band wiring, with complete weight bearing planned around the 6th week. The development of locking plates seems to allow earlier resumption of weight bearing. The objective of our study was to evaluate the clinical and radiological results after internal fixation of bimalleolar fractures using locking plates with complete weight bearing authorized from the outset. The hypothesis was that this does not predispose to cutaneous or mechanical complications.

HARDWARE AND METHOD

A continuous multi-operator retrospective study was performed. The clinical and radiological data of 55 patients operated on for bimalleolar fractures were collected. All underwent osteosynthesis with medial and lateral locking plates with authorization for weight bearing from the outset.

RESULTS

Complete weight bearing was resumed at 27.4 days 14.7 [7-60] postoperatively. No non-union or malunion was found. Two patients presented with delayed medial healing without the need for hardware removal. Two patients required removal of the lateral Plate 1 month postoperatively due to infection. Seven patients presented with discomfort related to hardware, justifying its removal at 1 year. The Kitaoka score at 1 year was 94.6 7.7 [71-100].

CONCLUSION

The use of medial and lateral locking plates in bimalleolar fractures associated with complete weight bearing authorized from the outset allows complete consolidation. There was no increase in cutaneous or mechanical complications.

LEVEL OF EVIDENCE

IV, retrospective study.

Tibio-Talar-Calcaneal Nail Fixation for Ankle Fractures: A Systematic Review and Meta-Analysis

Unstable ankle fractures are traditionally treated with open reduction and internal fixation. An alternative surgical option is primary tibio-talar-calcaneal fusion. Our aims were to determine the indication, complication rates, and functional outcomes, of tibio-talar-calcaneal nailing when used as the primary treatment of ankle fractures. A multidatabase literature search was performed on December 14, 2019 according to PRISMA guidelines. All studies in the English language reporting complications and outcomes involving tibio-talar-calcaneal nailing for primary treatment of ankle fractures were included. Ten studies with 252 ankle fractures were included. Mean age of patients was 75.5 (32-101) years. Mean follow-up duration was 79 weeks (36-104 weeks). Surgical site infection occurred in 11.2% (95% confidence interval [CI] 6.3%-19%) of patients, implant failure occurred in 8.1% (95% CI 5%-12.8%) of patients, and unplanned return to operating room occurred in 10.1% (95% CI 6.1%-16.2%) of patients. There were no cases of wound dehiscence. All-cause mortality rate at the end of follow-up was 26.6% (95% CI 19.7%-34.9%). Average reduction in Olerud-Molander Ankle Score after surgery was 7.9 points (5.0-11.8). Eighty-one point five percent (95% CI: 67.4%-90.4%) of patients were able to return to similar preoperative mobility aid after surgery. Tibio-talar-calcaneal nailing is an alternative procedure for patients who have sustained fractures unsuitable for nonoperative management, but have low functional demands and at increased risks of complications after open reduction and internal fixation. About 81.5% (95% CI 67.4%-90.4%) of patients were able to return to a similar preinjury mobility status after tibio-talar-calcaneal nailing.

Risk Factors for Aseptic Revision of Operatively Treated Ankle Fractures

BACKGROUND

Early revision rates within 12 months after ankle fracture open reduction internal fixation (AF-ORIF) are fairly low; however, they remain relevant given the volume of ankle fractures occurring annually. Understanding these rates is complex because reoperation due to technical or mechanical complications is typically reported alongside soft tissue-related problems such as symptomatic hardware, wound dehiscence, or infection. There are limited data identifying risk factors specifically for revision of ankle fracture fixation in the absence of soft tissue complications. Understanding variables that predispose to aseptic technical and mechanical failure without this confounder may provide insight and improve patient care.

METHODS

A retrospective cohort study was performed at 2 large academic medical centers. Research Patient Data Registry (RPDR) data available from 2002 to 2019 were used to identify patients who underwent aseptic revision of AF-ORIF within 12 months (n = 33). A control group (n = 100) was selected by identifying sequential patients who underwent AF-ORIF not requiring revision within 12 months. Multiple factors were recorded for all patients in both cohorts. Each fracture was also evaluated according to the Ankle Reduction Classification System (ARCS) of Chien et al,⁸ which categorizes biplanar talar displacement in relation to a central tibial plumb line into 1 of 3 grades: A (0-2 mm), B (3-10 mm), and C (>10 mm). Adapted from its original purpose of grading reduction quality, we applied ARCS to pre-reduction radiographs to assess initial fracture displacement. All variables collected were compared in univariate analysis. Variables that achieved significance in univariate comparisons were included as candidates for multivariable analysis.

RESULTS

Final multivariable logistic regression modeling demonstrated the following factors to independently predict the need for aseptic revision surgery: documented falls in the early postoperative period (aOR, 298; 95% CI, 15.4, 5759; P < .001), movement-altering disorders (aOR, 81.7; 95% CI, 4.12, 1620; P = .004), a nonanatomic mortise (medial clear space [MCS] > superior clear space [SCS]) on immediate postoperative imaging (aOR, 38.4; 95% CI, 5.53, 267; P < .001), initial coronal plane tibiotalar displacement >10 mm and sagittal plane tibiotalar dislocation (ARCS-C) (aOR vs ARCS-A, 25.8; 95% CI, 2.81, 237; P = .004), substance abuse (aOR, 15.7; 95% CI, 2.66, 92.8; P = .002), and polytrauma (aOR, 12.3; 95% CI, 2.02, 74.8; P = .006).

CONCLUSION

In this investigation we found a notable increase in risk for revision surgery after AF-ORIF for patients who had one of the following: (1) falls in the early postoperative period, (2) movement-altering disorders, (3) a nonanatomic mortise (MCS > SCS) on immediate postoperative imaging, (4) more severe initial fracture displacement, (5) substance abuse, or (6) polytrauma. Identifying these factors may allow surgeons to better understand risk and counsel patients, and may serve as future targets for intervention aimed at improving patient safety and outcomes after ankle fracture ORIF.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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

PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Complications After Surgical Treatment of Geriatric Ankle Fractures

The incidence of geriatric ankle fractures is rising and the potential for complications is high in this population. Little is known about factors associated with increased postoperative complications after surgical fixation of ankle fractures in older-age patients. The purpose of this retrospective cohort study was to assess the epidemiology and risk factors for complications after surgically treated ankle fractures in geriatric patients. All patients who were 65 years or older and had a surgically treated ankle fracture were included. Pilon fractures, patients who were initially treated conservatively or who had less than 1 month of follow-up were excluded. Postoperative complications, demographic-, fracture- and surgical data of 282 patients were recorded from two level 2 trauma centers between 2012 and 2017. A total of 87 (30.9%) patients developed a complication, of which wound related complications were most frequently reported. Superficial and deep wound infections were observed in 27 (9.6%) and 18 (6.4%) patients, respectively. Multivariate regression analysis demonstrated increased age to be an independent predictive variable for the occurrence of postoperative complications (odds ratio 1.04; 95% confidence interval 1.00-1.09), while cast immobilization for more than 2 weeks was a protective factor for the development of wound related complications (odds ratio 0.34; 95% confidence interval 0.17-0.66). In conclusion, the incidence of postoperative complications among geriatric patients after surgical treatment of ankle fractures is high and patients should be informed accordingly.

Currents concepts of the perioperative management of closed ankle fractures

Ankle fractures are common injuries that can result in substantial morbidity in the population. This review discusses the management of closed ankle fractures and outlines the recent evidence and guidelines on perioperative management. In general, a detailed history should be undertaken, followed by examination and imaging of the affected limb. Fixation is based on the AO principles of fracture management that aims towards restoring stability of the joint and reducing the risk of long-term complications. A multidisciplinary approach towards perioperative management is recommended in view of the increasing proportion of aging patients with significant comorbidities.

Fibula fractures management

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

Prevention of postoperative surgical wound complications in ankle and distal tibia fractures: results of Incisional Negative Pressure Wound Therapy

BACKGROUND AND AIM OF THE WORK

complications in surgical wound healing represent the main postoperative complication in ankle and distal tibia fractures. Whereas the use of Incisional Negative Pressure Wound Therapy (INPWT) is recognized to have a role in wound complications prevention in prosthetic surgery, literature about its use in trauma surgery is scarce. The aim of this study was to compare the effectiveness of INWPT with a conventional dressing in order to prevent surgical wound complications in ankle and distal tibia fractures.

METHODS

The study population included patients over 65 years as well as patients under 65 years considered at risk for wound complications (smokers, obese, affected by diabetes), who underwent ORIF for bi/tri-malleolar ankle fractures or distal tibia (pilon) fractures. After surgery, patients were randomized to receive a conventional dressing or INPWT. Complications in surgical wound healing were classified in major (requiring surgical intervention) and minor complications.

RESULTS

65 patients were included in the study. The rate of minor and major complications between the two groups was not significantly different, although a positive trend towards a lower minor complications rate was noted in the INPWT group (12.6% vs 34.7%). No complications or complaints were reported for the INPWT device.

CONCLUSIONS

INPWT proved to be safe, well-tolerated and showed promising results in preventing surgical wound complications in ankle and distal tibia fractures.

Ankle fractures in patients over age 55 years: Predictors of functional outcome

OBJECTIVES

To identify predictors of functional outcomes following treatment of ankle fracture in patients 55 years or older.

SETTING

Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

Four hundred twenty-nine patients with torsional ankle fractures (44A-C): 233 patients (54%) were ages 55 to 64, 25% were between the ages 65 and 74; 21% were 75 years or older.

INTERVENTION

Operative or nonoperative management of ankle fracture.

MAIN OUTCOME MEASURE

Early complications were assessed for all patients after minimum of 6 months, and functional outcome scores as assessed by the Foot Function Index (FFI; n = 166, 39%) and Short Musculoskeletal Function Assessment (SMFA; n = 168, 39%) after median 57 months follow-up.

RESULTS

Surgical management was elected in 67% of patients. Nonoperative management became more common with advancing age and was associated with fewer unplanned operations (12% vs 3%, P < .01) and complications (21% vs 13%, P = .07). African American race was associated with worse pain on the FFI (P = .002) and BMI was associated with worse (higher) scores on all categories of the FFI and SMFA (all P < .05). Diabetes, neuropathy, and mental illness were also predictive of worse scores on various categories of both surveys. Assistive device use or nonambulatory status at the time of injury was associated with worse disability/dysfunction, activity, and mobility scores on both the FFI and SMFA (all P > 15, P < .05). Sex, Hispanic ethnicity, tobacco use, open fracture, dislocation, fracture pattern, and operative management were not independent predictors in this regression model.

CONCLUSIONS

Baseline health and ambulatory capacity at injury were more predictive of outcomes following ankle fracture than were fracture characteristics or type of treatment.

Fibular nails for open and closed ankle fractures: Results from a non-designer level I major trauma centre

AIM

To evaluate the outcome of a fibular nail in the treatment of open and closed unstable ankle fractures in a non-designer centre.

METHODS

In a retrospective cohort study, a total of 39 ankle fractures (14 open and 25 closed) treated with a locking fibular nail were evaluated between 2012 and 2015 in a non-designer level I major trauma centre. Post-operative radiographs were analysed to assess the quality of reduction (McLennan and Ungersma marking system), fracture union and complications. Three patient reported outcome scores (Olerud and Molander score (OMAS), American Association of Orthopaedic Surgeons (AAOS) foot and ankle score and 12-Item Short Form Survey (SF-12)) were collected to obtain an overall measure of the patient's physical and mental outcome.

RESULTS

The adequacy of reduction data was available for 38 of 39 cases; 33 (87%) achieved good, 3 (8%) fair and 2 (5%) poor ratings, based on the McLennan and Ungersma marking system. Thirty-five (12 open and 23 closed) patients were available for initial follow-up. Five (14.3%) of 35 had documented complications (2 of 12 in the open cohort and 3 of 23 in the closed cohort). All fibular fractures treated with the fibular nail went on to unite. Twenty-three (66%) of 35 patients were available at 1-year follow-up for measurement of objective outcome. The combined mean OMAS for both groups was 53.7 (0-85) with statistically better results (59.5 (25-85) vs. 37.3 (0-75)) in favour of the closed versus open injuries, respectively. The mean AAOS score was also statistically better for the closed group than the open, 70.3 (30-95) versus 46.6 (20-77), respectively. The mean SF-12 score (physical component) was 40 (21.6-52.4) in the closed group versus 36.1 (19.4-51.5) in the open group; the mean mental component was 42.5 (26.6-54.3) in the closed group versus 38.8 (28.4-60.5) in the open group, these however were not statistically different.

CONCLUSION

Fibular nails are an effective alternative for the treatment for both closed and open unstable ankle fractures with soft tissue compromise.

Biomechanics of Osteoporotic Fracture Fixation

PURPOSE OF REVIEW

Fractures of osteoporotic bone in elderly individuals need special attention. This manuscript reviews the current strategies to provide sufficient fracture fixation stability with a particular focus on fractures that frequently occur in elderly individuals with osteoporosis and require full load-bearing capacity, i.e., pelvis, hip, ankle, and peri-implant fractures.

RECENT FINDINGS

Elderly individuals benefit immensely from immediate mobilization after fracture and thus require stable fracture fixation that allows immediate post-operative weight-bearing. However, osteoporotic bone has decreased holding capacity for metallic implants and is thus associated with a considerable fracture fixation failure rate both short term and long term. Modern implant technologies with dedicated modifications provide sufficient mechanical stability to allow immediate weight-bearing for elderly individuals. Depending on fracture location and fracture severity, various options are available to reinforce or augment standard fracture fixation systems. Correct application of the basic principles of fracture fixation and the use of modern implant technologies enables mechanically stable fracture fixation that allows early weight-bearing and results in timely fracture healing even in patients with osteoporosis.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Surgical Considerations for Osteoporosis in Ankle Fracture Fixation

As the geriatric population and associated ankle fractures continues to increase, fracture surgeons should be prepared to surgically manage osteoporotic ankle fractures. There are abundant challenges in management, soft tissue care, and fixation of ankle fractures with poor bone quality especially in elderly patients who have difficulty limiting weight bearing. This article summarizes several different surgical techniques that can be used to optimize outcomes of these fractures.

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.

Medial malleolus fractures: A biomechanical comparison of tension band wiring fixation methods

BACKGROUND

This study compared the biomechanical properties of three different fixation methods of tension band wirings, used in the treatment of medial malleolus fractures. The first method used an innovative "handmade bent pin" for cerclage fixation. The second method used a U-shaped K-wire to attach the cerclage to the medial tibial cortex. These two novel fixation techniques were compared with the traditional tension band wiring technique which is fixated to the bone by a screw.

HYPOTHESIS

Novel fixation techniques of tension band wiring provide stable fixation.

MATERIAL AND METHODS

In this study 27 artificial bone models, which medial malleolus fractures were simulated on, were used. Using an electromechanical test device, the force required to pull out each implant was assessed and compared.

RESULTS

This study found that; while handmade bent pinning resulted averagely 840.25N (range: 647-1066±118.72) and U-shaped K-wire fixation was 381.71N (range: 176-651±150.2) pull out strength, traditional tension band wiring indicated 871.33N (range: 549-1008±137.74) pull out strength.

DISCUSSION

Handmade bent pinning method provide similar results with traditional tension band wiring. Therefore, in suitable cases, it may be an acceptable alternative to traditional tension band wiring techniques when treating malleolar fractures. Although the outcomes of U-shaped K-wire fixation indicated lower than other two groups, the outcomes were comparable with the literature. So while performing tension band wiring, both handmade fixation systems may be used in certain cases. For Orthopaedic surgeons, it is better to know and think about these alternative handmade pinning systems created from simple K-wires during the surgery if needed.

LEVEL OF EVIDENCE

IV, Biomechanical trial.

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

INTRODUCTION

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

HYPOTHESIS

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

MATERIAL AND METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

IV.

Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly

Purpose of Review

Treatment of osteoporotic and neuropathic ankle fractures in the elderly is challenging. The purpose of this paper is to review recent publications on this topic and to identify the optimal treatment for these fractures.

Recent Findings

Treatment consists of a variety of conservative or operative options all with advantages and disadvantages as described in this review. Little research has been published that specifically focuses on elderly patients with ankle fractures. Operative treatment has a high complication rate. Multiple comorbidities are predictors for complications.

Summary

An optimal treatment could not be distilled but based on the available literature, a general treatment algorithm is proposed. Since the elderly typically are accompanied by multiple comorbidities as well as impaired mobility, the physician should focus not only on treating the fractured ankle but also on the patient as a whole. Further research on this specific topic is needed.