Results of operative fixation of unstable ankle fractures in geriatric patients

Elective Foot and Ankle Procedures in the Patients Greater than 65 Years of Age: Worth the Mobility Gains

Chronic, non-traumatic pathologies of the foot and ankle can be mobility-limiting for patients of all ages. The objective of this study was to compare postoperative changes in LifeSpace Mobility Assessment (LSA) scores of adult and elderly patients following elective foot and ankle surgery. A prospective study of 184 patients undergoing elective ankle, hindfoot, and midfoot procedures conducted by one surgeon between 2015 and 2019 was undertaken. Patient-reported LSA scores were collected at preoperative, 6-month, and 12-month follow-up. Patient data was compared using an independent sample t-test for continuous, normally distributed data and a chi-squared or Fischer's exact test for categorical data. Alpha and beta were .05 and .8. Patients were divided based on age. 140 patients were observed in the younger (<65) group, 44 patients were observed in the elderly (≥65) group. The average LSA score of elderly patients at the preoperative visit was 58.3 (SD 38.0) vs 79.3 (SD 38.8) in the younger cohort (P = .041). Both patient cohorts saw decreased mobility at 3-month postoperative visits but surpassed preoperative mobility scores by 6 months and 1 year postop. No difference in average mobility score was observed between young (85.6, SD 36.1) and elderly (90.1, SD 34.3) cohorts at 1-year follow up. Given the increased rates of perioperative comorbidities and the heightened risks of intraoperative complications, physicians may be more inclined to manage elderly patients with longer periods of conservative treatment for similar pathologies. However, these results imply that elderly patients experience similar improvements after surgery to younger cohorts and should not be excluded from surgical consideration. Our results, in tandem with literature showing the deleterious effects of decreased mobility in the elderly, suggest that the discussion to pursue or hold surgical correction of chronic foot and ankle disease in patients over age 65 must consider the mobility benefits of surgery.

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

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

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.

Fibular Rod Osteosynthesis in Ankle Fractures With Compromised Soft Tissue

BACKGROUND

Complications after plate and screw fixation of ankle fractures are frequently reported in the literature, with a higher rate in patients with advanced age, comorbidities, and poor skin conditions. A reduced complication rate has been reported with intramedullary nailing (IMN) of the fibula; however, the indication has been based on the surgeon's preferences. We report the results after IMN in patients with compromised soft tissue exclusively.

METHODS

A total of 71 patients with 72 distal fibula fractures were included in this retrospective study. Information about medical history, the ankle injury, treatment, and complications were collected from the medical records. Additionally, the preinjury and 6-week follow-up radiographs were evaluated.

RESULTS

Postoperative information was available for a minimum of 4.3 years postoperatively or until death. In all, 10 patients had complications related to the nail and required secondary surgery. These included 6 symptomatic hardware issues, 2 construct failures, 1 deep infection, and 1 combined deep infection and construct failure.

CONCLUSIONS

After IMN of the fibula, 14% of the patients required reoperation. Our results support the previous literature suggesting IMN as an acceptable surgical alternative where the risk of complications with plate and screw fixation is considered too high. Compromised soft tissue is one important indication.

LEVEL OF EVIDENCE

Level IV: Case series without control.

The Surgical Outcomes of Unstable Ankle Fractures in Patients Aged >65 Years

AIM

To evaluate the surgical outcomes and complications of patients over 65 years of age, with unstable ankle fractures.

MATERIAL AND METHOD

The study included 111 patients (73F/38 M) operated on between January 2015 and February 2019 and followed up for a mean of 21.2 months (range, 6-62 months).Demographic characteristics, comorbidities, fracture type, and mechanisms of injury were evaluated. Relationships between postoperative complications and comorbidities were examined. In the postoperative functional evaluations, the AOFAS score was used and pre and postoperative mobilization (eg, use of assistive devices) was assessed.

RESULTS

The mean age of the patients was 70.5 ± 6.1 years (range, 65-90 years). The mechanism of trauma was low-energy trauma in 90.1% of the fractures and high-energy trauma in 9.9%. The fractures were formed with a SER injury (supination external rotation) in 83.7% of cases and bimalleolar fractures were seen most frequently (85/111, 76%).Complications developed in 16 (14.4%) patients and a second operation was performed in 11 (9.9%) patients with complications. Plate was removed and debridement was performed in 5 of 6 patients due to wound problems. Nonunion was developed in the medial malleolus in 4 patients. Revision surgery was performed because of implant irritation in 2 patients and early fixation loss in the medial malleolus fracture in one patient. Calcaneotibial arthrodesis was performed in 3 patients because of implant failure and ankle luxation associated with non-union. A correlation was determined between ASA score and DM and complications, but not with osteoporosis. The mean follow-up AOFAS score was 86.7 ± 12.5 (range, 36-100).A total of 94 (84.7%) patients could walk without assistance postoperatively and 92 (82.9%) were able to regain the preoperative level of mobilization.

CONCLUSION

Although surgery can be considered an appropriate treatment option for ankle fractures in patients aged >65 years, care must be taken to prevent potential complications and the necessary precautions must be taken against correctable comorbidities.

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

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

Ankle fractures in the elderly: Current concepts

Ankle fractures remain the third most common musculoskeletal injury in the elderly population. The presence of osteoporosis, significant multiple comorbidities and limited functional independence makes treatment of such injuries challenging. Early studies highlighted high rates of post-operative complications and poor outcomes after surgical intervention. With advances in surgical techniques and a greater understanding of multi-disciplinary team (MDT)-driven peri-operative care and rehabilitation, evidence now appears to suggest improved outcomes for operative management. Approaches must be adapted according to co-morbidities, baseline function and patient wishes. This review article aims to discuss contemporary treatment strategies and the complex challenges associated with the management of the elderly ankle fracture.

Medial malleolus: Operative Or Non-operative (MOON) trial protocol - a prospective randomised controlled trial of operative versus non-operative management of associated medial malleolus fractures in unstable fractures of the ankle

BACKGROUND

There are limited data reporting the outcome of patients with non-operatively managed medial malleolus fractures compared to those treated surgically in the presence of fibular stabilisation for unstable fractures of the ankle. Conservative management could result in fewer complications, reduced surgical time and lower cost. The purpose of this study is to determine if any difference exists in patient reported and surgical outcomes 1 year after surgery between operative and non-operative treatment of medial malleolar fractures in combination with stabilisation of the lateral malleolus.

METHODS/DESIGN

This is a single-centre, prospective, randomised controlled trial that aims to randomise 154 participants with an unstable ankle fracture to 'non-fixation' (n = 77) or 'fixation' (n = 77) of an associated well-reduced medial malleolus fracture following fibular stabilisation. The study will include patients ≥ 16 years of age with a closed bimalleolar or trimalleolar ankle fracture who are able to consent, complete questionnaires in the English language, and complete follow-up over a 1-year period. Randomisation will occur intra-operatively when the medial malleolus fracture is deemed 'well-reduced', with 2 mm or less of fluoroscopic displacement. The technique for fixation of both the medial and lateral malleoli is at the discretion of the operating surgeon. Patient-reported, observer-rated, and radiographic assessments will be collected at baseline and then at the following post-operative assessment points: 2 weeks, 6 weeks and 1 year. Postal questionnaire outcome data will be collected at 3 and 6 months. The primary outcome measure will be the Olerud Molander Ankle Score (OMAS) at 1 year following surgery. Secondary outcome measures will include the Manchester-Oxford Foot Questionnaire (MOXFQ), EuroQol-5D (EQ-5D), pain, treatment satisfaction, time to return to activity, operative tourniquet time, and complications.

DISCUSSION

There is only one previous randomised trial comparing non-fixation with fixation of associated medial malleolus fractures but that was limited by the lack of baseline patient-reported outcome data and an inferior sample size. This current prospective trial aims to provide high-quality evidence regarding the requirement for medial malleolar fixation in unstable ankle fractures.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03362229 . Registered retrospectively on 5 December 2017.

Single- vs 2-Screw Lag Fixation of the Medial Malleolus in Unstable Ankle Fractures

BACKGROUND

The purpose of this study was to determine the efficacy of medial malleolar fixation with 1 vs 2 screws.

METHODS

Between April 2013 and February 2017, 196 patients who presented at 2 hospitals within one academic institution with an unstable rotational ankle fracture with a medial fracture and were treated operatively by a trained orthopedic surgeon were identified. These patients' charts were reviewed and their injury, radiographic, surgical, and follow-up data recorded. Medial malleolus fragment size was assessed on the anteroposterior (AP) and lateral views of the initial injury radiograph. Functional outcome was assessed using Maryland Foot Score (MFS). Patients were grouped based upon the number of screws utilized to fox the medial malleolar fragment. Data were assessed using Fisher exact tests and independent t tests with SPSS, version 23.

RESULTS

Out of the 196 patients who met inclusion criteria, 47 patients (24%) were fixed with 1 medial malleolar screw and 149 patients (76%) were fixed with 2 screws. There were no differences among patients who received 1 vs 2 screws with regard to age, gender, body mass index, American Society of Anesthesiologists grade, or smoking status. The average malleolar fragment size was smaller in those treated with 1 screw on both the AP and lateral radiographic views than those with 2 screws (P = .009, P = .001, respectively). There was no difference between groups in ankle dorsiflexion or plantarflexion at 1 year postoperation (P = .451, P = .581). Patients who received 1 screw did not differ from those who received 2 screws with respect to Maryland Foot Scores (P = .924). There was no difference in rate of revision surgery or need for hardware removal between groups (P = .093). Furthermore, time to healing and postoperative complication rate did not differ between groups.

CONCLUSION

The use of a single screw for medial malleolar fixation provided stable fixation to allow ankle fracture healing, without an increase in complications. This information is especially important in situations when the fragment is too small to accommodate multiple fixation points.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Short-Term Outcomes and Influencing Factors After Ankle Fracture Surgery

The present study investigated the factors influencing the early clinical outcomes after ankle fracture surgery. We included 88 patients, who had undergone implant removal surgery at 1 year after ankle fracture surgery, with ankle computed tomographic (CT) scans obtained before ankle fracture surgery and at implant removal available. We collected demographic information, including age, sex, the presence of diabetes mellitus, level of trauma energy, and fracture classification from the medical records. We also recorded the fracture height using the radiographs and CT images. The medial joint space and articular incongruity were assessed on the follow-up radiographs and CT scans. Bone attenuation was measured by placing a circular region of interest around the ankle joint on the preoperative CT image. The postimplant removal outcomes were assessed using 2 functional questionnaires, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and Foot and Ankle Outcome Score (FAOS). Significant factors related to the AOFAS ankle-hindfoot scale scores and FAOS were identified through univariate analysis using age, sex, radiographic measurements, and CT findings as explanatory variables, followed by multiple regression analysis. On multiple regression analysis, the total FAOS was independently related to the AO classification (p = .003) and Lauge-Hansen classification (p = .003). The total AOFAS ankle-hindfoot scale score was related to articular incongruity (p = .044). The early clinical outcomes after ankle fracture surgery were affected by involvement of the ankle joint fracture rather than the lateral malleolus fracture height. Female sex and the presence of postoperative articular incongruity correlated with inferior early clinical outcomes.

Comparison of Surgical Site Infections in Ankle Fracture Surgery With or Without the Use of Postoperative Antibiotics

BACKGROUND

Surgeon preference has been replaced by an approach using evidence-based medicine in clinical decision making. The use of postoperative antibiosis in ankle fracture surgery is more common for inpatients but variable for outpatient surgery. Some surgeons prefer to prescribe 24 hours of oral antibiotics, whereas others give no antibiotics at all postoperatively. In this study, inpatients receiving 24 hours of intravenous antibiotics were compared to those patients receiving 24 hours of oral antibiotics and those receiving no postoperative antibiotics.

METHODS

A total of 1442 patients with ankle fractures requiring operative fixation were retrospectively reviewed in this multicenter study. Demographic data including age, sex, and body mass index were collected. Clinical data including diabetes status, smoking status, hepatitis C virus (HCV) or human immunodeficiency virus (HIV) status, infection requiring additional antibiotics, and infection requiring return to operating room (RTOR) were compared across the groups.

RESULTS

No differences in incidence of cellulitis or return to OR for infection were demonstrated between the 3 groups. No differences were noted among the groups for any risk factors for infection including body mass index, previous infection, smoking status, HCV/HIV status, or diabetes. The rates of cellulitis ( P = .402), infection requiring additional antibiotics ( P = .563), and infection requiring return to the operating room ( P = .878) showed no difference between the groups.

CONCLUSION

The use of antibiotics postoperatively did not decrease the incidence of surgical site infection. The findings in this study suggest that the routine use of postoperative antibiotics after ankle fracture surgery is not beneficial.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Minimally Invasive Plate Osteosynthesis for Treatment of Ankle Fractures in High-Risk Patients

Wound healing problems are the most common complication after open reduction with internal fixation (ORIF) of unstable ankle fractures. The incidence is especially high among elderly patients with medical comorbidities and patients with compromised soft tissues. Minimally invasive plate osteosynthesis (MIPO) might provide a safer alternative to ORIF by preventing extensive soft tissue dissection and preserving the blood supply. We conducted a retrospective review of 44 consecutive patients who had undergone MIPO of unstable ankle fractures. All patients had a minimum 1-year follow-up (mean 82 weeks); 80% were aged ≥60 years, 52% had diabetes, and 45% had a compromised soft tissue envelope. Immediate postoperative radiographs were evaluated for the quality of reduction, and clinical records were analyzed for the complication rate. Good to excellent anatomic reduction was achieved in 89% of the patients. The overall complication rate was 27%, including 25% surgical wound dehiscence, 9% infection, and 11% loss of reduction. No patient experienced nerve injury. Those with a history of ankle fracture dislocation and a compromised soft tissue envelope preoperatively had a significantly greater incidence of surgical wound dehiscence and complications overall compared with those without (p = .016 and p = .035; p = .045 and p = .009, respectively). Peripheral vascular disease was a statistically significant predictor of surgical wound dehiscence (p = .010). The overall complication rate in our study was comparable to that seen in similar populations treated with conventional ORIF. In conclusion, our results suggest that MIPO in high-risk patients is a safe alternative, with predictable outcomes, comparable to those of traditional open techniques.

Effect of Postoperative Ketorolac Administration on Bone Healing in Ankle Fracture Surgery

BACKGROUND

In an effort to minimize narcotic analgesia and its potential side effects, anti-inflammatory agents offer great potential provided they do not interfere with bone healing. The safety of ketorolac administration after foot and ankle surgery has not been well defined in the current literature. The purpose of this study was to report clinical healing and radiographic outcomes for patients treated with a perioperative ketorolac regimen after open reduction and internal fixation (ORIF) of ankle fractures.

METHODS

A retrospective review was performed on all patients that received perioperative ketorolac at the time of lateral malleolar, bimalleolar, and trimalleolar ankle ORIF by a single surgeon between 2010 and 2016 with minimum 4 months follow-up. Patients received 20 tablets of 10 mg ketorolac Q6 hours. Radiographs were evaluated independently by 2 blinded fellowship-trained orthopedic foot and ankle surgeons to assess for radiographic healing. A total of 281 patients were included, with a median age of 51 years and 138 males (47%). Statistical analysis consisted of a linear mixed-effects regression.

RESULTS

In all, 265/281 (94%) were clinically healed within 12 weeks and 261/281 (92%) were radiographically healed within 12 weeks. Within the group of patients that did not heal within 12 weeks, mean time to clinical healing was 16.9 weeks (range = 14-25 weeks), and mean time to radiographic healing was 17.1 weeks (range = 14-25 weeks). In patients taking ketorolac, there were no cases of nonunion in our series (n = 281) and no significant difference found between fracture patterns and healing or complications ( P = .500).

CONCLUSIONS

Perioperative ketorolac use was associated with a high rate of fracture union by 12 weeks. This is the first study to examine the effect of ketorolac on radiographic time to union of ankle fractures. Additional studies are necessary to determine whether ketorolac helps reduce opioid consumption and improve pain following ORIF of ankle fractures.

LEVEL OF EVIDENCE

Level IV, case series.

Tibiotalocalcaneal nail fixation and soft tissue coverage of Gustilo-Anderson grade 3B open unstable ankle fractures in a frail population; a case series in a major trauma centre

BACKGROUND

Gustilo-Anderson grade 3B open ankle fracture-dislocations requiring stable fixation and soft tissue coverage are increasingly common in frail populations.

METHODS

We identified all patients with open ankle fracture-dislocations treated with a tibiotalocalcaneal nail and soft tissue coverage over a five-year period. We retrospectively recorded pre-morbid status, fracture and soft tissue injury pattern, surgical details, post-operative mobility, length of hospital stay, complication and re-operation rate and survival.

RESULTS

21 ankles (20 patients) are included, all grade 3B open fractures. All patients were permitted to mobilise by one to six weeks post-surgery. One patient required further soft tissue surgery. Six patients had superficial wound colonization/infection, none developed deep infections. None of the nails have required removal. We observed a 15% three-month mortality rate.

CONCLUSION

Tibiotalocalcaneal nail fixation and soft tissue coverage of unstable open ankle fractures in frail patients facilitates early return to ambulation with a low complication and re-operation rate.

Open treatment of ankle fracture as inpatient increases risk of complication

Background

Ankle fracture is one of the most common injuries treated by orthopaedic surgeons, and its incidence is only expected to rise with an aging population. It is also associated with often costly complications, yet there is little literature on risk factors, especially modifiable ones, driving these complications. The aim of this study is to reveal whether inpatient treatment after ankle fracture is associated with higher incidence of postoperative complications. As the USA moves towards a bundled payment healthcare system, it is imperative that orthopaedists maximize patient outcome and quality of care while also reducing overall costs.

Materials and methods

We used the American College of Surgeons National Surgical Quality Improvement Program database to compare complication rates between inpatient and outpatient treatment of ankle fracture. We collected patient demographics, comorbidities, and postoperative complications from both groups, then compared treatments using a multinomial logistic regression model.

Results

We identified 7383 patients, with 2630 (36%) in the outpatient and 2630 (36%) in the inpatient group. Of these, 104 (4.0%) inpatients compared with 52 (2.0%) outpatients developed a complication (p < 0.001).

Conclusions

Inpatients developed major complications including deep wound infection and pulmonary embolism, as well as minor complications such as pneumonia and urinary tract infection, at significantly greater rates. As reimbursement models begin to incorporate value-based care, orthopaedic surgeons need to be aware of factors associated with increased incidence of postoperative complications.

Level of evidence

Level III retrospective comparative study.

Predictors of Time to Union After Operative Fixation of Closed Ankle Fractures

BACKGROUND

Ankle fractures are common and represent a significant burden to society. We aim to report the rate of union as determined by clinical and radiographic data, and to identify factors that predict time to union.

METHODS

A cohort of 112 consecutive patients with isolated, closed, operative malleolar ankle fractures treated with open reduction and internal fixation was retrospectively reviewed for time to clinical union. Clinical union was defined based on radiographic and clinical parameters, and delayed union was defined by time to union >12 weeks. Injury characteristics, patient factors and treatment variables were recorded, and statistical techniques employed included the Chi-square test, the Student's T-test, and multivariate linear regression modeling.

RESULTS

Forty-two (37.5%) of patients who achieved union did so in less than 12 weeks, and 69 (61.6%) of these patients demonstrated delayed union at a mean of 16.7 weeks (range, 12.1-26.7 weeks), and the remaining patient required revision surgery. Factors associated with higher rates of delayed union or increased time to union included tobacco use, bimalleolar fixation, and high energy mechanism (all p<0.05). In regression analysis, statistically significant negative predictors of time to union were BMI, dislocation of the tibiotalar joint, external fixation for initial stabilization and delay of definitive management (all p<0.05).

CONCLUSION

Patient characteristics, injury factors and treatment variables are predictive of time to union following open reduction and internal fixation of closed ankle fractures. These findings should assist with patient counseling, and help guide the provider when considering adjunctive therapies that promote bone healing.

LEVELS OF EVIDENCE

Prognostic, Level IV: Case series.

Fragility fractures of the ankle in the elderly: Open reduction and internal fixation versus tibio-talo-calcaneal nailing: Short-term results of a prospective randomized-controlled study

INTRODUCTION

The management of ankle fractures in the elderly remains unpredictable, secondary to their various co-morbidities. Although tibiotalocalcaneal (TTC) nailing has been an effective option for ankle arthrodesis due to ankle arthritis or Charcot arthropathy there are few reports regarding the use of TTC nail for the treatment of ankle fractures.

PURPOSE

Aim of this study was to compare the results of ORIF versus TTC nailing for the treatment of unstable ankle fractures in the elderly. We hypothesized that the elderly may benefit from TTC nailing, as it allows the patient to be mobilized immediately after surgery and minimizes the risk of wound or bone problems.

PATIENTS AND METHODS

This was a prospective, randomized-controlled, comparative study. Between 2009 and 2015, 43 patients were treated with a TTC nail (Group A) and 44 with ORIF (Group B). The Olerud-Molander ankle score was obtained and intraoperative-postoperative complications, length of hospital stay, mobility status and reoperation rate were recorded. The nail fixation was performed with the TrigenR hindfoot nail after closed reduction. ORIF was performed, using a 1/3 tubular plate and 3.5mm screws for the lateral malleolus and two 4.0 mm cannulated screws for the medial.

RESULTS

Mortality rate at one year was 13.9% for Group A and 18.1% for Group B. Mean follow-up was 14 months (12-18m). There were no intraoperative complications. Three complications in Group A (8.1%) and twelve (33.3%) in Group B were encountered postoperatively (p<0.05). There was significant shorter hospital stay in Group A (5.2±3.1d) than in Group B (8.4±5.2d). In Group A, 28 patients returned to their pre-injury mobility status (75.6%) while 9 declined one level of the mobility scale (24.3%). In Group B, 26 patients remained at the same mobility level (72.2%) and 10 declined one level (27.7%). There was no significant difference between the postoperative OMAS scores in the two Groups (56.9±9.85 and 56.6±9.3 respectively).

CONCLUSIONS

We believe that TTC nailing is a safe and effective method of treatment of unstable ankle fractures in the elderly because it has a low risk of complications and restores function and mobility allowing an immediate return to full weight-bearing.

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.

[Open reduction and internal fixation of displaced ankle fractures in patients older than 65 years of age. Analysis of results at five-year follow-up]

OBJECTIVE

The aim of this study was to evaluate the long term outcome of surgical treatment for displaced ankle fractures in patients over 65 years of age, and determine the influence of age and comorbidity in the occurrence of complications.

MATERIAL AND METHOD

Retrospective descriptive study on 40 patients, with a mean age of 72.7 years (range: 65-88), who underwent open reduction and internal fixation for the treatment of a displaced ankle fracture. The patients were clinically evaluated according to the AOFAS criteria (functional outcome). Data collection also included the presence of comorbidities, radiographic evaluation, the occurrence of postoperative complications, and a questionnaire on satisfaction with treatment received. The mean follow-up was 5.73 years.

RESULTS

At the end of the follow-up, according to the AOFAS criteria, excellent/good results were obtained in 75% of the patients (n=30), with 38 patients referring to be quite/very happy with the result. Wound skin problems and metal work migration were the most common post-operative complications. No statistically significant relationship was found between increased age or a high number of comorbidities and an increased occurrence of postoperative complications (p>.05). Only 3 patients needed postoperative rehabilitation, and 95% of the patients (n=38) returned to their activities of normal daily living.

CONCLUSIONS

Surgical treatment of displaced ankle fractures in the elderly patient facilitates the early resumption of the activities of daily living.

Medial Malleolar Fractures: An Anatomic Survey Determining the Ideal Screw Length

Background:

Medial malleolar fractures are frequent, and their treatment is familiar to the orthopedic surgeon. Lag screw fixation using partially threaded screws remains the standard treatment method for medial malleolar fractures. However, the literature lacks a defined method for selecting lag screw length, relying more so on the empiric choice of the surgeon.

Aim:

The aim of this study is to help define the ideal lag screw length for medial melleolar fracture fixation.

Materials and Methods:

One hundred and sixteen anatomic specimens were included in the study. A transverse cut was performed in the distal third of the tibia, roughly 1 and a half times the distal tibial plafond width from the ankle joint. A coronal cut was then performed using the center of the medial malleolus. Three observers measured the distance between the medial malleolus tip and beginning of the medullary canal in all anatomic specimens. Differences in measurements were statistically compared, level of (P ≤ 0.05). Interclass correlation coefficient (ICC) significance level was set at P < 0.05.

Results:

Measurement average was 55 mm between the medial malleolus tip and the medullary canal, with a standard deviation of 10 mm. High concordance (ICC: 0.819) was achieved among all pairs of observers (P < 0.01). The systematic difference among measurements was absent, and random distribution around general measurements was observed.

Conclusion:

The authors recommend a screw length of no more than 45 mm to optimize the location of the screw threads in the best cancellous bone in an effort to obtain the most compression.

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.

[Treatment of fractures of the ankle in the elderly]

BACKGROUND

Osteoporotic fractures of the ankle were observed three times more often in the year 2000 than in the year 1970 and it is predicted that this will increase another three times by the year 2030. The most important predictive values for ankle fractures in the elderly are smoking, multipharmacy and poor mobility.

INJURY PATTERNS

Conservative treatment only seems to be successful in stable ankle fractures with good surrounding soft tissue. Pronation-abduction (PA) fractures most commonly affect elderly females and 90% of the cases present as the very unstable type III. Unstable fractures, such as PA type III, supination-eversion (SE) and pronation-eversion (PE) fractures type IV can be treated better by 2-stage open reduction internal fixation (ORIF). Because the PA type III fracture is often associated with dorsal dislocation of the foot it is proposed that this type should be classified as type IV, which needs urgent surgery to prevent further soft tissue damage.

THERAPY

Recommended techniques are the K-wire cage or fibula-pro-tibia technique. Locking plates are also preferred for stable fracture fixation. According to the recommended preoperative computed tomography (CT) scan a Volkmann's fracture should be fixed through a posterolateral approach. The additional tibiotarsal internal transfixation should remain for 6-8 weeks after ORIF until it is changed to a protective lower leg cast after wound healing. An underlying osteoporosis should be diagnosed and inpatient treatment of this entity should be initiated by trauma surgeons whereby coordination training is also important.

CONCLUSION

Due to the increasing number of ankle fractures in the elderly particularly in postmenopausal women with osteoporosis, the insufficient diagnostics and therapy of osteoporosis and because the number of these difficult to treat fractures will increase by a factor of 3 by 2030, special surgical techniques and particularly implants are necessary for unstable ankle fractures types PA III, SE IV and PE.

Management in high-risk patients

Injuries to the foot and ankle are often missed or underestimated in patients with polytrauma and are a source of long-term limitations. Injures below the knee are among the highest causes for unemployment, longer sick leave, more pain, more follow-up appointments, and decreased overall outcome. As mortalities decrease for patients with polytrauma a greater emphasis on timely diagnosis and treatment of foot and ankle injuries is indicated. Geriatric patients represent nearly one-quarter of trauma admissions in the United States. This article discusses perioperative management and complications associated with foot and ankle injuries in polytrauma, and in diabetic and geriatric patients.

What are the patterns of prophylactic postoperative oral antibiotic use after foot and ankle surgery?

BACKGROUND

The CDC estimates 23% of healthcare-associated infections to be surgical site infections, with alarming prevalence of antibiotic-resistant organisms. While there is consensus regarding preoperative prophylaxis, orthopaedic surgeons' use of prophylactic postoperative oral antibiotics is less defined.

QUESTIONS/PURPOSES

We investigated surgeons' use of prophylactic postoperative oral antibiotics after elective outpatient foot or ankle procedures, identifying (1) frequency of use, (2) regimen preferences, (3) personal indications, and (4) associated experience and demographics.

METHODS

Using a cross-sectional survey design, a questionnaire was emailed to all active and candidate members of the American Orthopaedic Foot and Ankle Society. Supplementary questions captured demographic information. We invited 1136 members to participate; 22 addresses produced delivery failure messages, leaving 1114 members as potential participants. After nonresponses and exclusions, 312 (28%) responses were analyzed. Statistical analysis used Pearson's chi-square test, Fisher's exact test, and multivariate regression.

RESULTS

The majority (75%) of respondents reported use of prophylactic postoperative oral antibiotics. Most users (69%) prescribed to fewer than 25% of patients, although 16% prescribed for all elective cases. The most frequent regimen was cephalexin 500 mg four times a day (63%) and the most common duration was 5 to 7 days (50%). Surgeons' most common indications were previous infection (71%), medical comorbidities (65%), and previous wound-healing difficulties (56%). Those who do and do not prescribe prophylactic postoperative oral antibiotics showed no difference in surgical site infection rate or any demographic category.

CONCLUSIONS

Surgeons' reported use of prophylactic postoperative oral antibiotics after elective foot or ankle surgery was common, without demographic association. Commonalities were identified in antibiotic regimen and personal indications for this practice. Comparative clinical studies are warranted to elucidate the efficacy of prophylactic postoperative oral antibiotics and establish evidence-based guidelines for their use.

Biomechanical comparison of a lateral polyaxial locking plate with a posterolateral polyaxial locking plate applied to the distal fibula

BACKGROUND

Polyaxial locking plates are becoming popular for the fixation of distal fibula fractures. This study establishes how construct stiffness and plate loosening, measured as range of motion, differs between lateral and posterolateral plate location.

METHODS

Seven matched pairs of cadaver fibulae were osteotomized in standardized fashion to produce a Weber type B distal fibula fracture. The fragments were fixated with an interfragmentary lag screw and polyaxial locking plates, with one fibula in each pair receiving a posterolateral anti-glide-plate, and the other a lateral neutralization-plate. In a biomechanical test, the bending and torsional stiffnesses of the constructs and the ranges of motion (ROM) were measured and subjected to a paired comparison.

RESULTS

The laterally plated group had a higher median (interquartile range) bending stiffness (29.2 (19.7) N/mm) and a smaller range of motion (2.06 (1.99) mm) than the posterolaterally plated group (14.6 (20.6) N/mm, and 4.11 (3.28) mm, respectively); however, the results were not statistically significant (pbending=0.314; pROM=0.325). Similarly, the torsional stiffness did not differ significantly between the two groups (laterally plated: 426 (259) Nmm/°; posterolaterally plated: 248 (399) Nmm/°; ptorsion=0.900). The range of motion measurements between the two groups under torsional loading were also statistically insignificant (laterally plated: 8.88 (6.30) mm; posterolaterally plated: 15.34 (12.64) mm; pROM=0.900).

CONCLUSION

In biomechanical cadaver-model tests of Weber type B fracture fixation with polyaxial locking plates, laterally plated constructs and posterolaterally plated constructs performed without significantly difference. Therefore, other considerations, such as access morbidity, associated injuries, patient anatomy, or surgeon's preference, may guide the choice of plating pattern. Further clinical studies will be needed for the establishment of definitive recommendations.

CLINICAL RELEVANCE

Information on the behavior of polyaxial locking plates is relevant to surgeons performing internal fixation of distal fibula fractures.

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

INTRODUCTION

Ankle fractures are among the most common injuries of the lower extremity encountered by orthopaedic surgeons. With increasing population age and osteoporosis, the prevalence of these fractures is expected to increase. The aim of this study was to evaluate complications and the need for revision surgery after the surgical treatment of ankle fractures in patients over 60 years of age. We report the outcomes of 186 consecutive patients who underwent operative treatment for rotational ankle fractures in our institution from 2007 to 2010.

MATERIALS AND METHODS

Data were collected retrospectively for the purpose of this study. The outcome measures included minor complications which did not need further surgical intervention, that is, superficial wound infections, delayed wound healing, prominent implants and skin irritation, and major complications that prompted surgical intervention (due to deep wound infection, loosening of implants or loss of fixation). Medical complications were also recorded. Long-term complications (postoperative osteoarthritis) were not assessed in this study. Logistic regression analysis and Fisher's exact test were used to identify factors predicting higher risk of complications.

RESULTS

The average age was 70.67 years (standard deviation (SD) 7.40). There were 132 (71%) females and 54 (29%) males. The overall rate of complications was 21.5% with 10.8% of them being major complications prompting surgical intervention for wound washout, removal of implants and revision of fixation. Statistical analysis showed that smoking, age, diabetes, local factors (osteopaenia, peripheral neuropathy, peripheral vascular disease, lymphoedema and venous insufficiency) and modified Charlson score were significantly associated with occurrence of complications. Gender had a marginally significant effect. Coronary artery disease and fracture type (Weber classification) did not have a significant effect on the outcome.

DISCUSSION AND CONCLUSION

Our data show that surgical treatment of ankle fractures in the elderly is associated with a high rate of complications. The factors predicting a high rate of complications include smoking, age, diabetes, local factors and a higher modified Charlson score. It is important to bear the factors in mind whilst deciding whether surgical treatment should be used in the treatment of such fractures in the elderly and explains these to patients at the time of obtaining consent. Further large-scale studies are needed to validate the predictive value of the suggested modified Charlson score.

Ankle Injury Management (AIM): design of a pragmatic multi-centre equivalence randomised controlled trial comparing Close Contact Casting (CCC) to Open surgical Reduction and Internal Fixation (ORIF) in the treatment of unstable ankle fractures in patients over 60 years

BACKGROUND

Ankle fractures account for 9% of all fractures with a quarter of these occurring in adults over 60 years. The short term disability and long-term consequences of this injury can be considerable. Current opinion favours open reduction and internal fixation (ORIF) over non-operative treatment (fracture manipulation and the application of a standard moulded cast) for older people. Both techniques are associated with complications but the limited published research indicates higher complication rates of fracture malunion (poor position at healing) with casting. The aim of this study is to compare ORIF with a modification of existing casting techniques, Close Contact Casting (CCC). We propose that CCC may offer an equivalent functional outcome to ORIF and avoid the risks associated with surgery.

METHODS/DESIGN

This study is a pragmatic multi-centre equivalence randomised controlled trial. 620 participants will be randomised to receive ORIF or CCC after sustaining an isolated displaced unstable ankle fracture. Participants will be recruited from a minimum of 20 National Health Service (NHS) acute hospitals throughout England and Wales. Participants will be aged over 60 years and be ambulatory prior to injury. Follow-up will be at six weeks and six months after randomisation. The primary outcome is the Olerud & Molander Ankle Score, a functional patient reported outcome measure, at 6 months. Follow-up will also include assessments of mobility, ankle range of movement, health related quality of life and complications. The six-month follow-up will be conducted face-to-face by an assessor blinded to the allocated intervention. A parallel economic evaluation will consider both a health service and a broader societal perspective including the individual and their family. In order to explore patient experience of their treatment and recovery, a purposive sample of 40 patients will also be interviewed using a semi-structured interview schedule between 6-10 weeks post treatment.

DISCUSSION

This multicentre study was open to recruitment July 2010 and recruitment is due to be completed in December 2013.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN04180738.

A biomechanical evaluation of locked plating for distal fibula fractures in an osteoporotic sawbone model

BACKGROUND

Supination external rotation (SER) injuries are commonly fixed with a one third tubular neutralization plate. This study investigated if a combination locked plate with additional fixation options was biomechanically superior in osteoporotic bone and comminuted fracture models.

METHODS

Using an osteoporotic and a comminuted Sawbones model, SER injuries were fixed with a lag screw for simple oblique fibula fractures, and either a one third tubular neutralization plate or a locking plate. Samples were tested in stiffness, peak torque, displacement at failure, and torsion fatigue.

RESULTS

There was no statistically significant difference in biomechanical testing for fractures treated with a lag screw and plate. For comminuted fractures, locked plating demonstrated statistically significant stiffer fixation.

CONCLUSION

A combination locked plate is biomechanically superior to a standard one third tubular plate in comminuted SER ankle fractures. There was no biomechanical superiority between locked and one third tubular plates when the fracture was amenable to a lag screw.

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

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

Management of high-energy foot and ankle injuries in the geriatric population

By the year 2035 almost 20% of the US population of 389 million people will be 65 years and older. What this group has, compared with aged populations in the past, is better health, more mobility, and more active lifestyles. From January 1989 through December 2010, a total of 494 elderly patients with 536 foot and ankle injuries were identified. Within this group, 237 (48%) patients with 294 injuries were sustained as a result of a high-energy mechanism. These mechanisms consisted of 170 motor vehicle accidents, 30 as a result of high (not ground level) energy falls, 2 from industrial accidents, and 35 classified as other, which included sports, blunt trauma, bicycle, airplane or boating accidents, crush injuries, and injuries resulting from a lawn mower. The injuries produced were 17 metatarsal fractures, 9 Lisfranc injuries, 10 midfoot (navicular, cuneiform, or cuboid) fractures, 23 talus fractures, 63 calcaneal fractures, 73 unimalleolar, bimalleolar, or trimalleolar ankle fractures, 45 pilon fractures, and 3 pure dislocations of the foot or ankle. Overall, 243 (83%) of these injuries underwent surgical fixation and data have shown that when surgery is used to manage high-energy injuries of the foot and ankle in the elderly individuals, the complications and outcomes are similar to those seen in younger patients. Therefore, the decision for surgical intervention for high-energy injuries of the foot and ankle should be based primarily on the injury pattern and not solely on the age of the patient.

Osteoporotic ankle fractures

Ankle fractures are one of the most common injuries in the elderly and their incidence is anticipated to increase over the next 20 years. Appropriate management of ankle fractures in this population requires an understanding of the issues unique to the elderly. Osteoporosis must be considered when counseling patients about their ankle fracture. Good outcomes can be achieved with surgical fixation of ankle fractures in the elderly. Postoperative complications are higher in patients with diabetes and peripheral vascular disease, and in patients who smoke. This article reviews how to evaluate and treat ankle fractures in elderly patients with osteoporosis, evaluates the outcomes, and discusses surgical techniques.

Early protected weightbearing after open reduction internal fixation of ankle fractures

The present retrospective study assessed the complications and loss of reduction in 126 patients aged 16 years or older who bore weight in a short leg cast within 15 days after surgical repair of acute unilateral closed ankle fractures from January 1997 to December 2003. Fracture reduction was assessed on immediate postoperative and weightbearing digital radiographs at least 6 weeks after surgery. The medical records were reviewed for postoperative complications. Complete radiographs were available for 81 patients. The mean follow-up period was 171 (range 42 to 1275) days. The mean patient age was 50 years. Patients began walking an average of 8 days after surgery. From the medical record review, no cases of malunion or nonunion occurred. A total of 14 complications developed in 12 (9.5%) of 126 patients, including a delay in wound healing in 6, nerve paresthesia in 5, and hardware migration in 1. The patients aged 60 years or older had a slightly greater overall complication rate (6 of 38, p = .18). Patients who walked on postoperative day 1 had slightly more wound problems (2 of 19, p = .36). Of the 81 ankle fracture radiographs, 80 (98.8%) showed no displacement in fracture reduction on the final follow-up examination. One patient had a 2-mm loss of fracture reduction and was allowed to walk on postoperative day 1 (p = .09). These results support early protected weightbearing after operative treatment of closed isolated lateral malleolar and bimalleolar ankle fractures without syndesmotic involvement in patients of all ages.

Bicortical fixation of medial malleolar fractures: a review of 23 cases at risk for complicated bone healing

Several methods have been described for fixation of unstable medial malleolar fractures. Certain patient populations, including the elderly, those with osteoporosis and osteopenia, and patients with diabetes mellitus, are generally known to be susceptible to complications associated with ankle fracture healing. The goal of the present retrospective investigation was to review the outcomes of a series of patients who had undergone medial malleolar fracture repair using fully threaded bicortical interfragmental compression screw fixation. Patients were included in the present series if they had undergone bicortical fixation of an unstable ankle fracture with a medial malleolar fracture component, in addition to having at least 1 of the following comorbidities: age 55 years or older, osteoporosis or osteopenia, diabetes mellitus, peripheral arterial disease, end-stage renal disease, chronic kidney disease, previous kidney transplantation, peripheral neuropathy, or current tobacco use. A total of 23 ankle fractures in 22 consecutive patients met the inclusion criteria. The mean age of the patients was 69.52 (range 45 to 89) years; 17 were female (77.27%) and 5 were male (22.73%). Of the 23 medial malleolar fractures, 21 (91.3%) achieved complete, uncomplicated healing. The mean interval to union was 62.6 (range 42 to 156) days. A total of 4 complications (17.39%) were noted, including 1 nonunion (4.35%), 1 malunion (4.35%), and 2 cases of painful retained hardware (8.7%). From our experience with this series of patients, bicortical screw fixation for medial malleolus fractures appears to be an acceptable alternative for fixation that provides a stable construct for patients at greater risk of bone healing complications.

Augmented osteosynthesis of OTA 44-B fractures in older patients: a technique allowing early weightbearing

OBJECTIVES

To determine the effectiveness of an augmented technique of osteosynthesis in allowing early weightbearing in older patients with OTA 44-B (Danis-Weber B) fractures.

DESIGN

Case series.

SETTING

University Level I trauma center.

PATIENTS

Thirty-six patients, nonconsecutive, with OTA 44-B fractures.

INTERVENTION

Augmented internal fixation using an intramedullary wire, lateral plate, and screw augmentation with polymethylmethacrylate.

MAIN OUTCOME

Healed fracture with no loss of reduction.

SECONDARY OUTCOMES

American Orthopaedic Foot and Ankle Society score; percentage of patients who returned to prefracture function.

RESULTS

All patients began weightbearing as tolerated in a removable brace at a mean of 13.5 days postoperatively. Thirty patients were available for follow-up at a minimum of 12 months (range, 12-14 months). All fractures healed with no loss of reduction. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 84.9 (range, 74-100), and 90% of patients returned to prefracture function. There were two infections, one in a 74-year-old diabetic woman and the other in a 92-year-old woman with pre-existing arterial insufficiency and a small ulcer over the tip of the second toe.

CONCLUSIONS

Augmented internal fixation consisting of intramedullary wire, lateral plate, and screw augmentation with polymethylmethacrylate may allow for very early weightbearing without risk of secondary loss of reduction or disruption of the ankle mortise in older patients with OTA 44-B (Danis-Weber B) malleolar fractures.

Functional outcomes after fibula locking nail for fragility fractures of the ankle

The aim of the present study was to assess the functional outcome of fragility fractures of the ankle treated with a fibular locking nail. A retrospective review of 24 patients with fragility fractures treated with a fibular locking nail from January 2005 to December 2007 was performed. The fibular nail used in our study was Biomet SST (stainless steel taper) small bone locking nail for the fibula. The Olerud and Molander scale was used to assess the functional outcome at the end of 1 year. The domains of the Olerud and Molander scale are pain, stiffness, swelling, stair climbing, running, jumping, squatting, support, and the activities of daily living. The patients were interviewed by telephone or the questionnaire was send by mail. Of the 24 patients, 2 were men and 22 were women. The left side was affected in 15 patients. The age group ranged from 71 to 91 years (average, 79). Of the fractures, 10 were lateral alveolus, 8 were bimalleolar, and 6 were trimalleolar fractures. All the patients were followed up at 6 weeks, 12 weeks, and after 6 months. The average period to fracture union was 8.7 weeks. No wound breakdown or any deep infections developed. The average Olerud and Molander scale score was 57 (range 30 to 65). The use of fibular locking nails to treat these difficult fracture are quite crucial to achieve early mobilization and also to maintain a good fracture position. In our study, the use of fibular nails was a very useful and successful method of treating fragility fractures with a very low risk of complications. It also helps to restore function and results in patient satisfaction.

Operative fixation of unstable ankle fractures in patients aged over 80 years

INTRODUCTION

Controversy exists regarding the surgical treatment of unstable ankle fractures in the very elderly age group of over 80 years. However, the literature regarding the prognosis of surgery in this elderly group is limited. The purpose of our study was to evaluate the results of patients above 80 years old who underwent operative fixation for unstable ankle fractures.

MATERIALS AND METHODS

Ninety-two consecutive patients, 80 females and 12 males, above 80 years of age had open reduction and internal fixation for unstable ankle fractures during the period of January 1998 to August 2007. The data was collected retrospectively from the case records and radiographs. The complications were noted and the risk factors for poor outcome were analyzed. The average age was 85.2 (range, 80.1 to 95.1) years. The minimum duration of followup was 9 months, with an average of 15 (range, 9 to 28) months.

RESULTS

The most common fracture pattern was Danis-Weber B type. The superficial wound infection rate was 7% (6 cases) and the deep infection rate was 4.6% (4 cases). The 30 day postoperative mortality was 5.4% (five cases). Eighty-six percent (75 out of 87 cases) were able to return back to their pre injury mobility at the last followup. Diabetes, dementia, peripheral vascular disease and smoking were found to be statistically significant risk factors associated with wound complications.

CONCLUSION

The results of operative fixation of unstable ankle fractures were encouraging with good functional recovery and return to pre injury mobility status in most cases.

Surgical versus nonsurgical treatment of the SE4-equivalent ankle fracture: a retrospective functional outcome study

Treatment of Lauge-Hansen supination-eversion (SE)4-equivalent ankle fractures is controversial. This retrospective study conducted at a level-I trauma center compared the clinical outcome of nonsurgical vs open management of these fractures. One thousand eight ankle fractures treated between 1998 and 2003 were reviewed. Forty-three patients who met the criteria for a SE4-equivalent ankle fracture were identified. Average patient age of 23 men and 20 women was 42 years (range, 18-84 years). Olerud Molander ankle scores were recorded. Medical records and radiographs of all patients were reviewed. Average follow-up was 20 months.Twenty-six patients were treated nonsurgically, with an average ankle score of 84 ± 4. Seventeen patients treated surgically had an average ankle score of 63 ± 5. The difference is statistically significant (unpaired t test, P=.0035). There was no difference between open vs closed treatment in maintaining a reduction. To investigate the reason for poor results in the surgical group, we sought an association between functional ankle score and common covariables and found that age and preoperative radiographic grading were important variables for ankle score. Patients younger than 30 years had an average ankle score of 85, whereas those older than 50 years had an average score of 61 (P<.001). Type 1 fractures (medial clear space >5 mm in stress view only) had an average ankle score of 89, type 2 (medial clear space >5 mm but <10 mm) an average score of 76, and type 3 (medial clear space >10 mm or presented with fracture dislocation and/or syndesmosis injury) an average score of 61. Our data support that type 1 and 2 fractures can effectively be treated nonsurgically.

Functional outcome after operatively treated ankle fractures in the elderly

BACKGROUND

The goal of this review was to compare the functional outcomes of patients less than 60 and greater than or equal to 60 years old following operative stabilization of unstable ankle fractures. The review was conducted as a retrospective analysis of prospectively collected data at two level one trauma centers and a tertiary referral academic center.

MATERIALS AND METHODS

All patients operatively treated for an unstable ankle fracture were entered into a database and prospectively followed. The postoperative protocol was standardized for all patients. Baseline characteristics, complications, additional surgery, functional status and the American Orthopaedic Foot and Ankle Society score (AOFAS) were assessed. The intervention chosen was open reduction and internal fixation of unstable ankle fractures. AOFAS hindfoot score and Short Musculoskeletal Functional Assessment (SMFA) questionnaire were used as the main outcome measures in the study. A p < 0.05 was considered significant.

RESULTS

Three hundred sixty-nine (369) patients were entered into the database, 313 (84.8%) were less than 60 years old. At 3 months, 57% (32/56) of patients greater than or equal to 60 years old reported limitation of activities versus 33% (103/313) of patients less than 60 years old (p = 0.005). At 6 and 12 months, these percentages improved to 41% versus 10% (p = 0.001), and 29% versus 7.4% (p = 0.001) for older and younger individuals respectively. However, when compared to their baseline scores, both groups achieved a return to pre-injury status. Total AOFAS scores were not significantly different at 3, 6, or 12 months (p = 0.431).

CONCLUSION

Operative fixation of unstable ankle fractures in patients greater than or equal to 60 years old can provide a reasonable functional result at the 1-year followup with a return to preoperative baseline even though they report more limitation of activities than younger patients.

Ankle fractures in the elderly: initial and long-term outcomes

BACKGROUND

Surgical management of ankle fractures will be an increasing part of the orthopaedic practice for aging adults. To date, there are few studies comparing outcomes after ankle fracture surgery between patients over and under 65 years. The purpose of this study was to evaluate short- and long-term outcomes after surgical treatment of isolated malleolar fractures in both the elderly and non-elderly population.

MATERIALS AND METHODS

Charts and radiographs were reviewed for 25 patients over age 65 and 46 patients under age 65 who underwent operative treatment of an ankle fracture during a 2-year period. Postoperative complications and need for placement in a skilled nursing facility following discharge were noted. The SF-36 and the Olerud and Molander Ankle Score were completed. Mean duration of followup in patients greater than 65 was 27 months and 24 months for patients less than or equal to 65 years.

RESULTS

Patients over 65 had a higher number of postoperative complications (40% vs. 11%, p < 0.007), and required nursing home placement more frequently than patients under 65 (p < 0.0001). At long-term followup, the data showed no significant difference in patient reported physical outcomes.

CONCLUSION

Early postoperative outcomes after operative fixation of ankle fractures suggest significantly worse outcomes for patients over age 65. However, long-term function in the elderly was comparable to patients under age 65 in this sample. The elderly population had a significantly better mental composite score than the non-elderly.

The treatment of unstable ankle fractures in patients over eighty years of age

BACKGROUND

The current study examined the outcomes of operative treatment of unstable ankle fractures in patients at least 80 years old at the time of injury.

METHODS

Of 2,682 patients who presented for treatment of ankle fractures, 17 patients met the study criteria. These patients had open reduction and internal fixation after sustaining 15 closed and two open unstable ankle fractures. There were 11 type B fractures and six type C fractures by the Danis-Weber classification, and 12 supination-external rotation and five pronation-external rotation fractures by the Laugen-Hansen classification systems.

RESULTS

When noncompliant patients who developed complications were removed from analysis, the fixation failure and deep infection rates were 0% each.

CONCLUSIONS

These results highlight the importance of patient compliance and non-weightbearing status in the treatment of ankle fractures in patients over 80 years.

Complications after ankle fracture in elderly patients

BACKGROUND

Controversy exists regarding the risks and benefits of ankle fracture treatment in elderly patients. The purpose of this study was to use the United States Medicare database to determine the complication rate for ankle fractures in elderly patients treated operatively and to compare it to fractures treated nonoperatively.

METHODS

We used the National Medicare Claims History System to study all enrollees who sustained ankle fractures between 1998 and 2001. A total of 33,704 patients were identified and their outcomes at numerous time points were evaluated. These outcomes included mortality, rate of repeat hospitalization, rate of medical and operative complications, and the rate of additional surgery. The predictor variables were either nonoperative or operative intervention. Covariates included patient age, gender, race, medical comorbidity status, and fracture type.

RESULTS

Patients treated nonoperatively had significantly higher mortality (p < 0.05) than those treated operatively at all time periods except for 30 days. However, patients treated operatively had significantly higher rehospitalization rates (p < 0.05) at all time periods studied. The medical and operative complication rates at all time periods were less than or equal to 2% for patients who had either operative or nonoperative treatment. In the group that had operative management, a relatively small number of patients had additional procedures. Eleven percent had removal of hardware. Less than 1% of all patients had revision of the internal fixation, arthroplasty, arthrodesis, or amputation.

CONCLUSION

In properly selected cases, the complication rates of both operatively and nonoperatively treated elderly patients are low.

The management of ankle fractures in the elderly

In recent years, the incidence and severity of ankle fractures in the elderly population have increased. Although surgical fixation has gained wide acceptance for younger ankle fracture patients, controversy exists within the orthopaedic community with respect to the optimal way to manage these fractures in the geriatric patient population. Although some authors categorise ankle fractures in the elderly as fragility fractures associated with osteoporosis, it appears that risk factors such as increased weight, poly-pharmacy and propensity for falls play larger roles than poor bone quality. The presence of osteoporosis may increase the level of difficulty involved with the surgical management of these patients, leading some authors to alter their standard operative technique. Early studies cited high complication rates and poor outcome following operative intervention, however, more recent investigations have demonstrated successful functional outcomes following surgical management and appropriate postoperative rehabilitation. Based on the current evidence, the literature appears to support surgical fixation of displaced ankle fractures in the elderly patient population.

Fragility fractures of the ankle: stabilisation with an expandable calcaneotalotibial nail

Fragility fractures of the ankle occur mainly in elderly osteoporotic women. They are inherently unstable and difficult to manage. There is a high incidence of complications with both non-operative and operative treatment. We treated 12 such fractures by closed reduction and stabilisation using a retrograde calcaneotalotibial expandable nail. The mean age of patients was 84 years (75 to 95). All were women and were able to walk fully weight-bearing after surgery. There were no wound complications. One patient died from a myocardial infarction 24 days after surgery. The 11 other patients were followed up for a mean of 67 weeks (39 to 104). All the fractures maintained satisfactory alignment and healed without delay. Six patients refused removal of the nail after union of the fracture. The functional rating using the scale of Olerud and Molander gave a mean score at follow-up of 61, compared with a pre-injury value of 70.

Ankle fractures resulting from rotational injuries

Ankle fractures are among the most common skeletal injuries; selection of an optimal management method depends on ankle stability. Stable fractures (eg, isolated lateral malleolar) generally are managed nonsurgically; unstable fractures (eg, bimalleolar, bimalleolar equivalent) usually are managed with open reduction and internal fixation. Stress radiographs may aid in the management of incomplete deltoid injury in which there is medial swelling and tenderness without radiographic talar shift. A posterior malleolar fracture should be reduced and stabilized if it comprises >30% of the articular surface and remains displaced after fibular stabilization. Ankle fractures with syndesmotic injury have additional tibiofibular instability that can be controlled by screw fixation. However, the choice between metal and bioabsorbable screws, screw size, number of cortices fixed, and indications for screw removal remain controversial. Conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations.

Complications of open reduction and internal fixation of ankle fractures

This article discusses the complications after open reduction and internal fixation of ankle fractures. Complications are classified as perioperative (malreduction, inadequate fixation, and intra-articular penetration of hardware), early postoperative (wound edge dehiscence, necrosis, infection and compartment syndrome), and late (stiffness, distal tibiofibular synostosis, degenerative osteoarthritis, and hardware related complications). Emphasis is placed on preventive measures to avoid such complications.