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Penning D, Tausendfreund J, Naryapragi MA, Reisinger KW, Joosse P, Tanis E, Schepers T. Timing of Fracture Fixation in Ankle Fracture-Dislocations. Foot Ankle Spec 2024:19386400241273105. [PMID: 39367857 DOI: 10.1177/19386400241273105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2024]
Abstract
Ankle fracture-dislocations may require delayed internal fixation. Our aim was to compare acute open reduction and internal fixation (ORIF) with delayed ORIF, using external fixation or cast splint in ankle fracture-dislocations. Factors that affect the rates of re-operation and Surgical site infection (SSI) were identified. In this retrospective cohort study, patients were included with open and closed ankle fracture-dislocations treated with ORIF from two large peripheral hospitals and one academic center in the Netherlands. This study included 447 patients with an ankle fracture-dislocation. In the multivariate analysis, the difference between surgery <48 hours compared to bridging with cast or external fixation had no significant influence on unscheduled re-operation or SSI. Higher body mass index (BMI) and open fractures had a significant positive correlation with re-operation while diabetes mellitus (DM) and open fractures correlated with SSI. In patients with open fractures, there was also no significant difference in outcome between acute or delayed internal fixation. We suggest that it is safe to perform primary ORIF on all dislocated ankle fractures if the soft tissue injury allows surgery within 48 hours. When significant swelling is present, patients with well-reduced fractures and with no soft tissue injury could be treated safely with a cast until delayed ORIF is possible.Level of Evidence: Therapeutic level 2B (retrospective cohort study).
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Affiliation(s)
- Diederick Penning
- Trauma Unit, Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jasper Tausendfreund
- Department of Trauma Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - M Azad Naryapragi
- Trauma Unit, Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kostan W Reisinger
- Trauma Unit, Department of Surgery, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Pieter Joosse
- Department of Trauma Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Erik Tanis
- Department of Trauma Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Tim Schepers
- Trauma Unit, Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Chen D, Liu S, Liu P, Song W. Effect of Elevated Blood Glucose on Postoperative Complications Among Diabetic Patients After Surgical Treatment of Torsional Ankle Fracture. Foot Ankle Int 2024; 45:839-844. [PMID: 38722181 DOI: 10.1177/10711007241250005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
BACKGROUND This study aims to evaluate the association of elevated blood glucose and postoperative complications among diabetic patients after surgical treatment of torsional ankle fracture. METHODS This was a retrospective study of consecutive diabetic patients treated surgically for a torsional ankle injury between January 2017 and December 2021 at a large tertiary hospital. All patients who met inclusion and exclusion criteria were divided into a high-HbA1c group or a low-HbA1c group according to the HbA1c cutoff of 7.0% within 3 months of operation, then a propensity score match was performed to control potential confounding factors. The primary outcomes were postoperative complications, and secondary outcomes were unplanned secondary procedures. RESULTS A matched cohort of 238 patients was finally included, with 119 patients with high HbA1c levels and 119 with low HbA1c levels. Patients with high HbA1c levels experienced more complications (31.1% vs 18.5%, P < .01) and more secondary procedures (22.7% and 8.4%, P < .01) than those with low HbA1c levels. Multivariate logistic regression indicated that patients with high HbA1c levels were significantly associated with higher proportions of any complications (OR 2.25, 95% CI 1.08-4.69; P = .03), superficial infection (OR 4.03, 95% CI 2.13-5.41; P < .01), deep infection (OR 1.42, 95% CI 1.23-2.02; P < .01), and any unplanned secondary operations (OR 3.72, 95% CI 1.62-8.52; P < .01) compared with those with low HbA1c levels after controlling for potential confounders. Multivariate linear regression showed that high HbA1c levels were significantly associated with a higher number of complications (β = 4.61, 95% CI 2.63-18.18; P < .01) and a higher number of secondary procedures (β = 4.44, 95% CI 2.79-10.87; P < .01). CONCLUSION Patients with an HbA1c >7.0% within 3 months of operation are more likely to have a wound issue/infection and more likely to undergo a secondary procedure after surgical treatment of torsional ankle fractures in diabetic patients than patients with an HbA1c ≤7.0% within 3 months of operation.
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Affiliation(s)
- Dong Chen
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai, China
| | - Shenghe Liu
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai, China
| | - Pei Liu
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai, China
| | - Wenqi Song
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai, China
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Fadle AA, El-Adly W, Fekry MA, Osman AE, Khalifa AA. Primary arthrodesis for diabetic ankle fractures using a modified retrograde femoral intramedullary locking nail combined with lateral plating, surgical technique, and early results of a pilot study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2549-2556. [PMID: 38693347 PMCID: PMC11291572 DOI: 10.1007/s00590-024-03947-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/02/2024] [Indexed: 05/03/2024]
Abstract
PURPOSE We aimed to report the early results of performing acute ankle arthrodesis using a modified retrograde femoral intramedullary locking IMN concomitant with plating at the same setting for managing diabetic patients' acute ankle fractures. METHODS We prospectively included patients who presented acutely with ankle fractures, where hemoglobin A1C (HbA1C) on admission was > 7%, and the Adelaide Fracture in the Diabetic Ankle (AFDA) algorithm score was 5 or above. All patients were treated by acute ankle arthrodesis using a modified retrograde femoral IMN combined with lateral plating. Functional assessment was reported according to a modified American Orthopaedic Foot and Ankle Society ankle hindfoot scale (AOFAS), and complications were documented. RESULTS Six patients had an average age of 55.7 years (37-65). The average HbA1C on admission was 7.9 (7.3-9), and the average AFDA score was 7.3 (6-8). The average operative time was 79.2 min (70-90). All patients, except for one, achieved union at the arthrodesis site after an average of 10.3 weeks (8-14). After an average last follow-up of 9 months (6-12), the average modified AOFAS was 73.2 (82 to 62); four patients had an excellent score and one good. Complications developed in two, one deep infection after 2 weeks treated by metal removal and Ilizarov, and the other patient developed a stress fracture at the tibial end of the nail, which was treated by open reduction and internal fixation using a plate and screws. CONCLUSION Using a modified femoral IMN combined with lateral plating is a promising technique to achieve ankle arthrodesis in diabetic patients with acute ankle fractures with acceptable outcomes; however, further studies with larger numbers are needed. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Amr A Fadle
- Department of Orthopedic, Assiut University Hospital, Assiut, Egypt
| | - Wael El-Adly
- Department of Orthopedic, Assiut University Hospital, Assiut, Egypt
| | | | - Ahmed E Osman
- Department of Orthopedic, Assiut University Hospital, Assiut, Egypt
| | - Ahmed A Khalifa
- Department of Orthopedic, Qena Faculty of Medicine and University Hospital, South Valley University, Kilo 6 Qena-Safaga Highway, Qena, 83523, Egypt.
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Baig MS, Mehta S, Morales DS, Maniar HH, Dahodwala T, Horwitz DS. Successful Primary Treatment of Ankle Fractures in Diabetic Patients with Peripheral Neuropathy Using a Tibiotalocalcaneal Nail: A Case Series. Indian J Orthop 2023; 57:1068-1075. [PMID: 37384012 PMCID: PMC10293542 DOI: 10.1007/s43465-023-00882-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 03/24/2023] [Indexed: 06/30/2023]
Abstract
Background Among diabetics, patients with peripheral neuropathy are at increased risk of developing complications following an ankle fracture. While the outcomes in these patients treated nonoperatively have been poor, the outcomes in those undergoing open reduction and internal fixation are at the best modest. We hypothesize that closed reduction and internal fixation with tibiotalocalcaneal nail is an effective primary procedure in this complication prone patient group. Methods A retrospective review of diabetic patients with peripheral neuropathy who underwent acute treatment of an ankle fracture with closed reduction and internal fixation with a tibiotalocalcaneal nail at two Level 1 trauma centers was performed. 30 patients were identified and divided into 2 groups with respect to their postoperative weight bearing protocol: 20 patients in the early weight bearing (EWB) group and 10 patients in the touch-down weight bearing (TDWB). The primary outcome was the rate of return to baseline function and the secondary outcomes included the incidence of wound dehiscence, wound infection, implant failure, loss of fixation, loss of reduction and amputation. Results In the EWB group, 15/20 patients returned to their baseline function, 5/20 had wound dehiscence and infection, 2/20 had implant failure, 5/20 had loss of fixation, 4/20 had loss of reduction, and 4/20 underwent amputation. In the TDWB group, 9/10 patients returned to their baseline function, 1/10 had implant failure, 1/10 had loss of fixation. No patients from this group had loss of reduction or underwent amputation. Conclusion Treatment with tibiotalocalcaneal nail is an effective primary procedure in this complication prone group of patients, assuming that weight bearing is delayed for six weeks to protect soft tissues and surgical incisions. Level of Evidence Level IV, retrospective case series.
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Affiliation(s)
- Mirza Shahid Baig
- Geisinger Medical Center, Musculoskeletal Institute, 100N. Academy Avenue, Danville, PA 17822-2130 USA
| | - Samir Mehta
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA USA
| | - Daniela S. Morales
- Geisinger Medical Center, Musculoskeletal Institute, 100N. Academy Avenue, Danville, PA 17822-2130 USA
| | - Hemil H. Maniar
- Geisinger Medical Center, Musculoskeletal Institute, 100N. Academy Avenue, Danville, PA 17822-2130 USA
| | - Taikhoom Dahodwala
- Geisinger Medical Center, Musculoskeletal Institute, 100N. Academy Avenue, Danville, PA 17822-2130 USA
| | - Daniel Scott Horwitz
- Geisinger Medical Center, Musculoskeletal Institute, 100N. Academy Avenue, Danville, PA 17822-2130 USA
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Johnson MJ, Kandasamy S, Raspovic KM, Manchanda K, Liu GT, VanPelt MD, Lavery LA, Wukich DK. Fractures and dislocations of the foot and ankle in people with diabetes: a literature review. Ther Adv Endocrinol Metab 2023; 14:20420188231163794. [PMID: 37323164 PMCID: PMC10265356 DOI: 10.1177/20420188231163794] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/27/2023] [Indexed: 06/17/2023] Open
Abstract
Diabetes (DM) increases fracture risk, and bone quality depends on type diabetes type, duration, and other comorbidities. Diabetes is associated with a 32% increased relative risk (RR) of total fractures and 24% increased RR of ankle fractures compared with patients without DM. Type 2 DM is associated with a 37% increased RR of foot fractures compared with patients without DM. The incidence of ankle fractures in the general population is 169/100,000 per year, while foot fractures occur less frequently, with an incidence of 142/100,000 per year. Biomechanical properties of bone are negatively impacted by stiff collagen, contributing to the increased risk of fragility fractures in patients with DM. Systemic elevation of proinflammatory cytokines, such as tumor necrosis factor-alpha (TNFα), interleukin-1β (IL-1β), and interleukin 6 (IL-6), impact bone healing in patients with DM. Fractures in patients with DM, can be associated with poorly regulated levels of RANKL (receptor activator of nuclear transcription factor kappa-b ligand) leading to prolonged osteoclastogenesis, and net bone resorption. One of the most salient factors in treating fractures and dislocations of the foot and ankle is to recognize the difference between patients with uncomplicated and complicated DM. Complicated diabetes is defined as 'end organ damage', and for the purposes of this review, includes patients with neuropathy, peripheral artery disease (PAD) and/or chronic renal disease. Uncomplicated diabetes is not associated with 'end organ damage'. Foot and ankle fractures in patients with complicated DM pose challenges, and surgery is associated with increased risks of impaired wound healing, delayed fracture healing, malunion, infection, surgical site infection, and revision surgery. While patients with uncomplicated DM can be treated like patients without DM, patients with complicated DM require close follow-up and robust fixation methods should be considered to withstand the anticipated prolonged healing period. The aims of this review are as follows: (1) to review pertinent aspects of DM bone physiology and fracture healing, (2) to review the recent literature on treatment of foot and ankle fractures in patients with complicated DM, and (3) to provide treatment protocols based on the recent published evidence.
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Affiliation(s)
- Matthew J. Johnson
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Suganthi Kandasamy
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Katherine M. Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kshitij Manchanda
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - George Tye Liu
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael D. VanPelt
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lawrence A. Lavery
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Goldberg EM, Polachek WS, Hynes K. Ankle Fractures in Diabetic Patients: A Critical Analysis. JBJS Rev 2023; 11:01874474-202303000-00003. [PMID: 36927706 DOI: 10.2106/jbjs.rvw.22.00147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
» Patients with diabetes are at higher risk for complications after surgical fixation of unstable fractures due to impaired neurovascular functioning and wound-healing capabilities. » Patients with uncontrolled diabetes have higher rates of complications when compared with patients with controlled diabetes. » Despite higher rates of complications, operative fixation of unstable ankle fractures in diabetic patients reliably leads to a functional lower extremity with an overall lower rate of complications than nonoperative management. » Operatively and nonoperatively managed ankle fractures in patients with diabetes should remain non-weight-bearing for an extended period of time. » Discussion of risk of poor outcomes including deep infection, loss of reduction, return to the operating room, and risk of arthrodesis or amputation should be explicitly discussed with patients and families when managing unstable ankle fractures in diabetic patients.
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Affiliation(s)
- Ellen M Goldberg
- University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - William S Polachek
- Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois
| | - Kelly Hynes
- Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois
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7
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Czerwonka N, Yi A, Miller CP. Diagnosis and Treatment of Neuropathic Ankle Fractures. JBJS Rev 2022; 10:01874474-202212000-00002. [PMID: 36732284 DOI: 10.2106/jbjs.rvw.22.00122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
» Standard 3-view ankle radiographs are the first-line imaging modality for suspected neuropathic ankle fractures. Computed tomography is helpful to evaluate for concomitant osseous changes and soft-tissue infection. » Nonoperative management may be considered for low-demand, elderly, or comorbid patients for whom surgery and anesthesia are contraindicated. However, the presence of comorbidities alone should not necessarily preclude operative intervention. Given the overall poor results of nonoperative treatment in the neuropathic ankle fracture population, operative intervention may in fact be less risky to the patient. » The authors have 2 preferred treatment techniques. For cases in which the vascular supply and bone stock are adequate, open reduction and internal fixation (ORIF) with locking fixation for the fibula, a medial buttress/hook plate with lag screws for the medial malleolus, multiple syndesmotic screws for additional fixation even in the absence of a syndesmotic injury, and temporary transfixation Steinmann pins from the calcaneus into the tibia are used. For cases in which there is a concern for wound healing or previously failed ORIF, minimally invasive surgical tibiotalocalcaneal arthrodesis with a retrograde locked intramedullary nail is used.
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Affiliation(s)
- Natalia Czerwonka
- Columbia University Irving Medical Center, New York-Presbyterian, New York, New York
| | - Anthony Yi
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher P Miller
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Sinkler MA, Pennacchio CA, Kotchman HM, Vallier HA. Association of Chronic Kidney Disease and Complications Following Acute Torsional Ankle Fracture. Foot Ankle Int 2022; 43:1569-1576. [PMID: 36254721 DOI: 10.1177/10711007221127026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although chronic kidney disease (CKD) has been associated with poor outcomes following traumatic fractures, there is a scarcity of literature describing the effect on outcomes of ankle fractures. We will examine the impact of CKD on clinical outcomes following torsional ankle fracture, including complications and unplanned surgical procedures. METHODS A retrospective review of 1981 adult patients with torsional ankle fractures treated at a level 1 trauma center was performed to identify patients with CKD based on glomerular filtration rate. Demographic, injury, and treatment-related characteristics were collected. Outcomes included any unplanned procedure: implant removal, debridement, revision, arthrodesis, and amputation; in addition to complications of superficial infection, deep infection, and implant irritation. Patients with CKD were matched with patients without CKD by propensity score matching. Univariate comparisons between groups were conducted using chi-square and Mann-Whitney U tests. RESULTS 136 patients (68 with CKD and 68 without CKD) were analyzed. Of the 68 patients with CKD, the mean stage of disease was 3.7 with 24% on dialysis for a mean length of 4.1 years. Patients without CKD were more likely to undergo primary ORIF (100% vs 54%, P < .001). Thirty-five percent of patients with CKD had surgical complications vs 19% in the cohort without (P = .07). Patients with open fractures, dislocation, and chronic kidney disease were, respectively, 5.19, 3.77, and 3.91 times more likely to have any complication (P = .02, P = .05, P = .05). Patients with CKD were more likely to undergo unplanned arthrodesis (P = .01). Only dislocation was an independent predictor for unplanned procedure (odds ratio = 5.08, P = .026). CONCLUSION Following torsional ankle fracture, CKD is associated with increased likelihood of having a complication or an unplanned arthrodesis. Open fractures and dislocation at time of injury are also associated with complications. Our findings encourage caution about surgical treatment of ankle fractures in patients with CKD. LEVEL OF EVIDENCE Level III, retrospective, comparative, prognostic.
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Affiliation(s)
- Margaret A Sinkler
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | - Halle M Kotchman
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Heather A Vallier
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Surgical timing for torsional ankle fractures is not associated with post-operative complications in patients with type II diabetes mellitus. Arch Orthop Trauma Surg 2022; 142:3889-3894. [PMID: 35083521 DOI: 10.1007/s00402-021-04321-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/14/2021] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Surgical stabilization of ankle fractures is one of the most commonly performed procedures in orthopedics, but these injuries can prove difficult to manage in patients with type II diabetes mellitus (DMII). The goal of this study is to determine if a correlation exists between surgical timing and complication rates among diabetic patients with ankle fractures. METHODS This is a retrospective case-control study spanning from 2012 to 2019 including patients with DMII undergoing operative fixation for ankle fractures. The primary independent variable was surgical timing and the primary dependent variable was the rate of post-operative complications. RESULTS The overall complication rate was 25.5% with 60% of these patients requiring repeat surgical intervention. The most common complication was superficial surgical-site infection. There was no significant difference in surgical timing between patients experiencing post-operative complication compared to those who did not. CONCLUSION Among patients with DMII, we failed to show a correlation between surgical timing and post-operative complication.
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Hong CC, Rammelt S. Managing Acute Fore- and Midfoot Fractures in Patients with Diabetes. Foot Ankle Clin 2022; 27:617-637. [PMID: 36096555 DOI: 10.1016/j.fcl.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Few is investigated about the management of acute fore- and midfoot injuries in diabetics. With well controlled diabetes, indications and techniques are similar to non-diabetics. With poorly controlled diabetes, medical optimization should be exercised. Stable internal fixation in case of surgical treatment and prolonged offloading independent of the choice of treatment are advised. With manifest Charcot neuroarthropathy, the goal is to achieve a plantigrade, stable foot that is infection- and ulcer-free and ambulant with orthopaedic shoes. If operative treatment is chosen, the concept of superconstructs in combination with prolonged protection in a well-padded total contact cast is applied.
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Affiliation(s)
- Choon Chiet Hong
- Department of Orthopaedic Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074
| | - Stefan Rammelt
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany.
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Abstract
The management of ankle fractures in the diabetic population requires special attention as the risks of injury or treatment-related complications are high. Thorough review of clinical history and detailed assessment provide the treating surgeons with key information to guide treatment pathway. Vigilance is required when opting for nonoperative treatment in undisplaced stable ankle fractures in patients with peripheral neuropathy. The presence of critical ischemia in injured limb demands vascular consultation and ultimately, an intervention before surgical fixation of ankle fracture. An extended period of immobilization is one of the key principles in the management of ankle fracture patients with diabetes.
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Affiliation(s)
- Ngwe Phyo
- Department of Trauma and Orthopaedics, Frimley Park Hospital, Frimley Health NHS Foundation Trust, Portsmouth Road, Camberley GU16 7UJ, UK.
| | - Alexander Wee
- Department of Trauma and Orthopaedics, Frimley Park Hospital, Frimley Health NHS Foundation Trust, Portsmouth Road, Camberley GU16 7UJ, UK
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Polachek WS, Baker HP, Dahm JS, Strelzow JA, Hynes KK. Diabetic Kidney Disease Is Associated With Increased Complications Following Operative Management of Ankle Fractures. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221112106. [PMID: 35898793 PMCID: PMC9309779 DOI: 10.1177/24730114221112106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Diabetes mellitus and peripheral neuropathy are established risk factors for complications in operatively treated ankle fractures. Generally, the presence of peripheral neuropathy and diabetic nephropathy have been used as independent variables in studies of diabetic ankle fracture cohorts but are typically treated as binary risk factors. Our purpose was to quantify the effects of risk factors on complication rate specific to diabetic patients undergoing ankle fracture fixation. Methods: We identified 617 rotational ankle fractures treated operatively at a single academic medical center from 2010 to 2019, of which 160 were identified as diabetic. Of these, 91 ankle fractures in 90 diabetic patients met criteria for retrospective review of clinical and radiographic data. Criteria included perioperative laboratory studies, including glycated hemoglobin (HbA1c) and estimated glomerular filtration rate (eGFR), as well as follow-up radiographs in the electronic record. We defined complications in this surgical cohort as deep surgical site infection, unplanned return to the operating room, and failure of fixation. Logistic regression was performed and odds ratios (ORs) calculated. Results: The overall complication rate was 28.6% (26/91) in this cohort. Median follow-up was 29 weeks (range: 5-520 weeks). Mean perioperative HbA1c in patients who experienced postoperative complications was 7.6% (range: 5.1%-14.2%) compared with 7.8% (range: 5.6%-13.5%) who did not ( P = .69). Diabetic patients with chronic kidney disease (eGFR <60 mL/min per body surface area) (OR 5.29, P = .006) and peripheral neuropathy (OR 4.61, P = .003) were at significantly higher risk of all complications compared with diabetic patients without these comorbidities. Of note, we did not find an association between perioperative HbA1c or body mass index and complication rate. Conclusion: Patients with diabetes complicated by chronic kidney disease are at significantly higher risk of complications following operative management of ankle fractures. Our study also corroborated previous reports that within this high-risk cohort, the presence of peripheral neuropathy is a significant risk factor for complications. These sequalae of diabetic disease are manifestations of microvascular disease, glycosylation of soft tissues, and impaired metabolic pathways. Identifying these risk factors in diabetic patients allows for patient-specific risk stratification, education, and management decisions of ankle fractures. Level of Evidence: Level III, retrospective cohort study.
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Affiliation(s)
- William S. Polachek
- University of Chicago Department of Orthopaedic Surgery and Rehabilitation Medicine, Chicago, IL, USA
| | - Hayden P. Baker
- University of Chicago Department of Orthopaedic Surgery and Rehabilitation Medicine, Chicago, IL, USA
| | - James S. Dahm
- University of Chicago Department of Orthopaedic Surgery and Rehabilitation Medicine, Chicago, IL, USA
| | - Jason A. Strelzow
- University of Chicago Department of Orthopaedic Surgery and Rehabilitation Medicine, Chicago, IL, USA
| | - Kelly K. Hynes
- University of Chicago Department of Orthopaedic Surgery and Rehabilitation Medicine, Chicago, IL, USA
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Fonkoue L, Sarr L, Muluem KO, Gueye AB, Dembele B, Fon C, Ngongang O, Dieme CB, Sané AD. Early posttraumatic ankle osteoarthritis following ankle fracture-dislocations in a sub-Saharan African setting. Orthop Traumatol Surg Res 2021; 107:102996. [PMID: 34198007 DOI: 10.1016/j.otsr.2021.102996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Ankle fracture-dislocation (AFD) represents a major threat to the joint and a potential source of complication and functional disability. This study was performed to assess the outcome of AFD in a resource-limited setting and factors associated with the posttraumatic ankle osteoarthritis (PTAOA). We hypothesized that conservative treatment after AFD was associated with higher risk of PTAOA compared to surgical treatment. PATIENTS AND METHODS Data from 52 consecutive patients (mean age 37.2±11.1years, with 57.7% n=30, males) who were treated and followed in a teaching hospital for AFD during a period of six years were collected. Forty-four of these patients were obtained at the time of the study for a retrospective evaluation. Functional outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS), ankle-hindfoot scale, and the patient's global satisfaction index. Radiographs were performed and analyzed for PTAOA. Logistic regression was used to determine factors associated with the presence of PTAOA. RESULTS PTAOA was found in 19 (43.2%) patients after an average follow-up period of 27.2±18.3months. Anatomic fracture reduction was achieved in 22 (50%) patients, while the talus was centered in the mortise in 30 (68.2%) patients. Despite these poor anatomical results, the clinical outcome was good to excellent in 33 (75%) patients, and 88.6% was satisfied or very satisfied. Factors associated with the presence of PTAOA were the non-anatomical reduction (OR=11.07; p=0.007, 95% CI: 2.096-58.77) and the time elapsed since trauma (OR=1.073; p=0.007, 95% CI: 1.109-1.129). CONCLUSION This study indicates that AFDs are associated with high rate of early and severe PTAOA. Non-anatomical realignment and a delay since trauma were positive predictors of PTAOA. There was no difference regarding the occurrence of PTAOA after AFD whatever the type of treatment, surgical or conservative. LEVEL OF EVIDENCE IV; retrospective cohort study.
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Affiliation(s)
- Loïc Fonkoue
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal; Department of orthopaedics and trauma, national emergency centre, Yaoundé, Cameroon; University of Yaoundé 1, department of surgery and specialities, Yaoundé, Cameroon.
| | - Lamine Sarr
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal
| | - Kennedy Olivier Muluem
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal; University of Yaoundé 1, department of surgery and specialities, Yaoundé, Cameroon
| | - Alioune Badara Gueye
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal
| | - Badara Dembele
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal
| | - Clovis Fon
- University of Yaoundé 1, department of surgery and specialities, Yaoundé, Cameroon
| | - Olivier Ngongang
- Department of orthopaedics and trauma, national emergency centre, Yaoundé, Cameroon; University of Yaoundé 1, department of surgery and specialities, Yaoundé, Cameroon
| | - Charles Bertin Dieme
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal
| | - André-Daniel Sané
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal
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14
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Tuncer K, Topal M, Tekin E, Sade R, Pirimoglu RB, Polat G. The new ultralow dose CT protocol for the diagnosis of fractures of the ankle: A prospective comparative study with conventional CT. J Orthop Surg (Hong Kong) 2021; 28:2309499020960238. [PMID: 32985384 DOI: 10.1177/2309499020960238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Computerized tomography (CT) imaging is increasingly being used to evaluate patients with ankle trauma. However, conventional CT (C CT) has a significantly higher radiation dose (RD) than plain radiography. This study aimed to evaluate the diagnostic accuracy and reliability of ultra-low-dose CT (ULDCT) protocol for ankle fractures. METHODS Ninety-eight consecutive patients who had ankle CT for suspected ankle fracture were included in our prospective study. C CT and ULDCT protocols were simultaneously performed on these 98 patients. Two observers independently evaluated ULDCT and C CT images. The effective RD of the ULDCT and C CT groups was calculated. RESULTS The interobserver agreement was 1 (perfect). ULDCT and C CT group images showed no significant difference in image quality. The effective RD of the ULDCT was significantly lower than the C CT (p < 0.001). CONCLUSIONS By evaluating the results of this study, ULDCT proved to be a reliable diagnostic imaging method for fractures of the ankle. The satisfactory diagnostic image quality of the ULDCT protocol provides promising results. LEVEL OF EVIDENCE Level II/lesser quality RCT or prospective comparative study.
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Affiliation(s)
- Kutsi Tuncer
- Department of Orthopedics and Traumatology, 64060Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Murat Topal
- Department of Orthopedics and Traumatology, 485657Kastamonu University Faculty of Medicine, Kastamonu, Turkey
| | - Erdal Tekin
- Department of Emergency Medicine, 64060Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Recep Sade
- Department of Radiology, 64060Ataturk University Faculty of Medicine, Erzurum, Turkey.,Clinical Research, Development and Design Application and Research Center, 64060Ataturk University, Erzurum, Turkey
| | | | - Gokhan Polat
- Department of Radiology, 64060Ataturk University Faculty of Medicine, Erzurum, Turkey
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15
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Galanopoulos IP, Stavlas P, Voyaki SM, Psarakis SA. Ankle Fractures in Diabetic Patients: Report of Two Cases. Cureus 2021; 13:e13519. [PMID: 33786226 PMCID: PMC7994030 DOI: 10.7759/cureus.13519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Although ankle fractures are very common cases for orthopedic surgeons with an easy diagnosis and very good outcomes either with conservative or with operative treatment, in diabetic patients, these fractures can be complex with difficult solutions. We report two cases with ankle fractures in diabetic patients from our department with demanding diagnostic or therapeutic approaches and poor outcomes. The first case, a 65-year-old man with undiagnosed diabetes mellitus and neglected ankle fracture dislocation because of diabetic neuropathy, underwent open reduction internal fixation with additional external fixation. Early after the operation, he presented with pin-tract infection, and later after the operation, he developed osteomyelitis which led to salvage below-knee amputation. In the second case, a 70-year-old woman with diabetes mellitus and severe coexisting medical comorbidities underwent open reduction internal fixation plus external fixation for an acute fracture-dislocation of the left ankle. Early after the operation, she developed ischemic lesions of the toes with worsened status despite the vascular surgeon's instructions. Although a below-knee amputation could be an acceptable choice, she denied it. As a result, systematic complications led to her death. It is very important for surgeons to follow an algorithm when they have to manage ankle injuries in diabetic patients because, in these patients, ankle fractures are very demanding and misdiagnosed cases with difficult treatment algorithms and often poor outcomes.
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Affiliation(s)
| | | | - Sofia M Voyaki
- Department of Internal Medicine, G. Gennimatas Athens General Hospital, Athens, GRC
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16
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Current concepts and challenges in managing ankle fractures in the presence of diabetes: A systematic review of the literature. J Clin Orthop Trauma 2021; 17:44-53. [PMID: 33717970 PMCID: PMC7919966 DOI: 10.1016/j.jcot.2021.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Ankle fractures in diabetic patients are known to have an increased morbidity. This systematic review aims to evaluate the current evidence in terms of risk profile and inform treatment options. METHODS Following the methodology of the Cochrane collaboration, an extensive literature search was conducted. Outcomes included, complications, operative and non-operative management and early weight-bearing. RESULTS A total of 40 studies were included. Complication rates were higher in diabetic patients and more so in poorly controlled diabetes, IDDM, or "complicated" diabetes. Supplementary fixation was associated with lower complication rates. Regarding early weight-bearing, similar results to non-diabetics in the stable fracture pattern were found providing there was no evidence of neuropathy. CONCLUSION Diabetes, especially complicated diabetes, presents an increased risk of complications. However non operative management of diabetic ankle fractures do poorly, and with the use of 'ORIF plus' techniques there is no increase in complications from early fixation. The use of external fixation for definitive fixation should be minimised as it is associated with high complication rates.
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17
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Loh J, Cyr K, Martin R. Ankle Fracture in Hereditary Sensory Neuropathy Type 1. J Foot Ankle Surg 2021; 60:621-625. [PMID: 33509718 PMCID: PMC7538394 DOI: 10.1053/j.jfas.2020.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/30/2020] [Indexed: 02/03/2023]
Abstract
Ankle fractures account for approximately 9% of all adult fractures annually. The ankle anatomically is particularly vulnerable to significant skin compromise in the setting of trauma. Significant fracture blistering and soft tissue compromise is predominantly seen in high-energy ankle injuries. Hereditary sensory autonomic neuropathy type I is a rare progressive neurological disorder resulting in distal sensory loss and autonomic disturbances with variable motor involvement. We present a case involving a hereditary sensory autonomic neuropathy type I patient with unexpected significant soft tissue injury on the background of a low energy ankle fracture. The aim was to outline the diagnosis and complex management considerations related to hereditary sensory neuropathic-associated ankle injuries.
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Affiliation(s)
- Jeremy Loh
- Resident, Orthopaedic Surgery Department, Eastern Heath, St. John's, NL, Canada,Address correspondence to: Jeremy Loh, MBBS, 1168 W.42nd Ave, Vancouver, BC V6M 2A8, Canada
| | - Kayla Cyr
- Resident, Orthopaedic Surgery Department, Eastern Heath, St. John's, NL, Canada
| | - Roderick Martin
- Clinical Associate Professor, Memorial University, St. Clare's Mercy Hospital, St. John's, NL, Canada
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18
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Manchanda K, Nakonezny P, Sathy AK, Sanders DT, Starr AJ, Wukich DK. A systematic review of ankle fracture treatment modalities in diabetic patients. J Clin Orthop Trauma 2020; 16:7-15. [PMID: 33717936 PMCID: PMC7920114 DOI: 10.1016/j.jcot.2020.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 12/27/2022] Open
Abstract
AIM This systematic review evaluated the surgical outcomes of various ankle fracture treatment modalities in patients with Diabetes Mellitus as well as the methodological quality of the studies. METHODS For our review, four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). The overall methodological quality of the studies was assessed with the Coleman Methodology Score. Data regarding diabetic ankle fractures were pooled into three outcomes groups for comparison: (1) the standard fixation cohort with management of diabetic ankle fractures using ORIF with small or mini fragment internal fixation techniques following AO principles, (2) the minimally invasive cohort with diabetic ankle fracture management utilizing percutaneous cannulated screws or intramedullary fixation, and (3) the combined construct cohort treated with a combination of ORIF and another construct (transarticular or external fixation). RESULTS The search strategy identified 2228 potential studies from the four databases and 11 were included in the final review. Compared to the standard fixation cohort, the minimally invasive cohort had increased risk of hardware breakage or migration and the combined constructs cohort had increased risk of hardware breakage or migration, surgical site infection and nonunion. Limb salvage rates were similar for the standard fixation and minimally invasive cohorts; however, the combined constructs cohort had a significantly lower limb salvage rate compared to that of the standard fixation cohort. The mean Coleman Methodology Score indicated the quality of the studies in the review was poor and consistent with its limitations. DISCUSSION The overall quality of published studies on operative treatment of diabetic ankle fractures is low. Treating diabetic ankle fractures operatively results in a high number of complications regardless of fixation method. However, limb salvage rates remain high overall at 97.9% at a mean follow-up of 21.7 months. To achieve improved limb salvage rates and decrease complications, it is critical is to follow basic AO principles, respect the soft tissue envelope or utilize minimally invasive techniques, and be wary that certain combined constructs may be associated with higher complication rates. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Kshitij Manchanda
- Orthopaedic Foot and Ankle Surgery Fellow, Miami Orthopedics and Sports Medicine Institute, USA
| | - Paul Nakonezny
- Department of Population Health and Data Science, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ashoke K. Sathy
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Drew T. Sanders
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Adam J. Starr
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Dane K. Wukich
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA,Corresponding author. Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, 75390, USA.
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19
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Abstract
Surgical complications are more common in patients with complicated diabetes (presence of inner organ failure, neuropathy). Of all patients undergoing ankle fracture fixation, approximately 13% are diabetic and 2% have complicated diabetes mellitus. Non-operative management of ankle fractures in patients with complicated diabetes results in an even higher rate of complications. Insufficient stability of ankle fractures (treated operatively, or non-operatively) can trigger Charcot neuroarthropathy, and result in bone loss, deformity, ulceration, and the need for amputation. Rigid fixation is recommended. Hindfoot arthrodesis (as primary procedure or after failed ankle fracture management) can salvage the limb in approximately 80% of patients. Early protected weight bearing can be allowed, provided rigid fixation without deformity has been achieved.
Cite this article: EFORT Open Rev 2020;5:457-463. DOI: 10.1302/2058-5241.5.200025
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Affiliation(s)
| | - Hesham Oshba
- Frimley Health NHS Foundation Trust, Frimley Park Hospital, Frimley, UK
| | | | | | - Alexander Wee
- Frimley Health NHS Foundation Trust, Frimley Park Hospital, Frimley, UK
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20
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Hellwinkel JE, Miclau T, Provencher MT, Bahney CS, Working ZM. The Life of a Fracture: Biologic Progression, Healing Gone Awry, and Evaluation of Union. JBJS Rev 2020; 8:e1900221. [PMID: 32796195 PMCID: PMC11147169 DOI: 10.2106/jbjs.rvw.19.00221] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
New knowledge about the molecular biology of fracture-healing provides opportunities for intervention and reduction of risk for specific phases that are affected by disease and medications. Modifiable and nonmodifiable risk factors can prolong healing, and the informed clinician should optimize each patient to provide the best chance for union. Techniques to monitor progression of fracture-healing have not changed substantially over time; new objective modalities are needed.
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Affiliation(s)
- Justin E Hellwinkel
- Department of Orthopedic Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
- Center for Regenerative Sports Medicine, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado
| | - Theodore Miclau
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFG), San Francisco, California
| | - Matthew T Provencher
- Center for Regenerative Sports Medicine, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado
| | - Chelsea S Bahney
- Center for Regenerative Sports Medicine, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFG), San Francisco, California
| | - Zachary M Working
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFG), San Francisco, California
- Oregon Health & Science University, Portland, Oregon
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21
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Ramasamy A, Humphrey J, Robinson AHN. The Ankle Injury Management (AIM) trial: the way forward or off target? Bone Joint J 2019; 101-B:1466-1468. [PMID: 31786995 DOI: 10.1302/0301-620x.101b12.bjj-2019-0901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Arul Ramasamy
- Royal British Legion Centre for Blast Injuries, Imperial College London, London, UK.,Department of Trauma and Orthopaedics, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Joel Humphrey
- Department of Trauma and Orthopaedics, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK.,Department of Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | - A H N Robinson
- Department of Orthopaedics, Addenbrooke's Hospital, Cambridge, UK.,Spire Cambridge Lea Hospital, Cambridge, UK
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22
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Ebaugh MP, Umbel B, Goss D, Taylor BC. Outcomes of Primary Tibiotalocalcaneal Nailing for Complicated Diabetic Ankle Fractures. Foot Ankle Int 2019; 40:1382-1387. [PMID: 31423816 DOI: 10.1177/1071100719869639] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ankle fractures in patients with complicated diabetes have significantly increased the rates of complications and poorer functional outcomes when treated nonoperatively, and there have been only modest reductions when treated operatively. We hypothesized that the minimally invasive, robust construct that tibiotalocalcaneal fixation with an intramedullary nail offers would result in high rates of limb salvage, acceptable rates of complications, and less loss of function, in this difficult patient population. METHODS This was an institutional review board-approved retrospective study of 27 patients with complicated diabetes who underwent tibiotalocalcaneal nailing of their ankle fracture as a primary treatment without formal joint preparation. Patients with complicated diabetes were defined as having neuropathy, nephropathy, and/or peripheral vascular disease. The mean clinical follow-up was 888 days. Patients were screened for associated risk factors. Data were collected on surgical complications. The outcomes measured included length of hospital stay, loss of ambulatory level, amputation, and time to death. The mean age was 66 years with an average body mass index of 38 and hemoglobin A1c of 7.4. Six fractures were open. RESULTS The limb salvage rate was 96%. The average hospital stay was 6 days, and the mean time to weightbearing was 6.7 weeks. The fracture union rate was 88%. The surgical complication rate was 18.5%, with no instances of malunions, symptomatic nonunions, or Charcot arthropathy. Eight patients died by final follow-up (mean, 1048 days). An ambulatory level was maintained in 81% of the patients. CONCLUSION With high limb salvage rates, relatively early weightbearing, maintained ambulatory level, and acceptable complication rates, we believe our technique can be considered an appropriate approach to increase the overall survivability of threatened limbs and lives in this patient population. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | | | - David Goss
- Orthopedic Foot and Ankle Center, Westerville, OH, USA
| | - Benjamin C Taylor
- OhioHealth Orthopedic Trauma and Reconstructive Surgeons, Grant Medical Center, Columbus, OH, USA
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23
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Rupp M, Kockmann S, El Khassawna T, Raschke MJ, Heiss C, Ochman S. Better is the foe of good: Outcome of operatively treated ankle fractures in the elderly. Foot (Edinb) 2018; 36:15-20. [PMID: 30321763 DOI: 10.1016/j.foot.2018.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 04/08/2018] [Accepted: 04/18/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ankle fractures are the second most common fractures of the lower extremities. Nonetheless, no standardized treatment protocol for unstable ankle fractures of the elderly exists today. Choices to treat ankle fractures are debated controversially, including (1) conservative treatment, (2) open reduction and internal fixation (ORIF), and (3) primary hind-foot arthrodesis. This retrospective study aimed to examine the healing result in patients treated by ORIF after unstable ankle fractures. METHODS The study was designed as a retrospective comparative series. The American Orthopaedic Foot and Ankle Society (AOFAS) score was followed to assess the postsurgical outcome. Data was obtained from 66 patients younger than 65 (median age, 42 years; range, 18-63) and 28 patients aged 65 or older (median age, 71 years; range, 65-81). The mean follow-up period for the younger-than-65 group was 48 months; for patients older than 65, it was 49 months. RESULTS An AOFAS score of 86.4 in the older and 92.4 in the younger group was determined, p-value<0.05. Elderly patients suffered from significantly more open-ankle fractures and comorbidities than the younger group did, p-value<0.05 each. The duration of hospital stay and the time needed to reach sufficient self-mobilization were both significantly different between the two groups, p-value<0.05. CONCLUSION ORIF treatment of ankle fractures resulted in good functional assessment after a mean follow-up of 49 months in the elderly. Pre-fracture health condition positively affected the healing results in younger patients. This study confirms the basic AO Foundation principles for good postsurgical results. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Markus Rupp
- University Hospital Giessen and Marburg, Campus Giessen, Department of Trauma, Hand, and Reconstructive Surgery, Rudolf-Buchheim-Strasse 7, 35385 Giessen, Germany; Justus-Liebig-University of Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany.
| | - Stefan Kockmann
- Westfaelische-Wilhelms-University of Muenster, University Hospital Muenster, Department of Trauma, Hand, and Reconstructive Surgery, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
| | - Thaqif El Khassawna
- Justus-Liebig-University of Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany
| | - Michael J Raschke
- Westfaelische-Wilhelms-University of Muenster, University Hospital Muenster, Department of Trauma, Hand, and Reconstructive Surgery, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
| | - Christian Heiss
- University Hospital Giessen and Marburg, Campus Giessen, Department of Trauma, Hand, and Reconstructive Surgery, Rudolf-Buchheim-Strasse 7, 35385 Giessen, Germany; Justus-Liebig-University of Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany
| | - Sabine Ochman
- Westfaelische-Wilhelms-University of Muenster, University Hospital Muenster, Department of Trauma, Hand, and Reconstructive Surgery, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
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Abstract
PURPOSE OF REVIEW Ankle fractures and diabetes mellitus are both increasing in prevalence. Patients with both diabetes and an ankle fracture have been shown to have an increased rate of complications which can be catastrophic. The purposes of this review are to identify factors placing patients at an increased risk and offer guidance on the management of these injuries, in order to reduce potential complications. RECENT FINDINGS Non-operative management of unstable ankle fractures in patients with diabetes results in an unacceptably high rate of complications. Operatively managed patients with uncomplicated diabetes seem to fair as well as patients without diabetes. Thus, it is important to recognize patients as either complicated or uncomplicated at the onset of their treatment based on comorbidities. There is limited evidence to guide the management of ankle fractures in patients with diabetes, in particular those deemed complicated. Non-operative management of unstable fractures in diabetic patients should be avoided.
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25
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Abstract
The surgical treatment of diabetic patients can be challenging. The physiologic and metabolic abnormalities seen in diabetic patients can adversely affect healing and outcomes in even the simplest of procedures. This article examines some of the special considerations in the treatment of diabetic patients undergoing foot and ankle surgeries.
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Affiliation(s)
- Aaron J Guyer
- Tallahassee Orthopedic Clinic, 3334 Capital Medical Boulevard, Tallahassee, FL 32308, USA; Florida State University College of Medicine, 1115 W Call Street, Tallahassee, FL 32304, USA; Alabama College of Osteopathic Medicine, 445 Health Sciences Boulevard, Dothan, AL 36303, USA; Tallahassee Memorial Hospital, 1300 Miccosukee Road, Tallahassee, FL 32308, USA.
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26
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Ntalos D, Rupprecht M, Grossterlinden LG, Hamurcu A, Regier M, Klatte TO, Rueger JM, Spiro AS. Incidence and severity of malreduction of the tibiofibular syndesmosis following surgical treatement of displaced ankle fractures and impact on the function -Clinical study and MRI evaluation. Injury 2018; 49:1220-1227. [PMID: 29706250 DOI: 10.1016/j.injury.2018.04.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/18/2018] [Accepted: 04/23/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare tibiofibular reduction quality in different types of operatively treated ankle fractures and the impact on clinical and functional outcome at mid-term follow-up. PATIENTS AND METHODS One hundred patients with an acute ankle fracture who had undergone open reduction and internal fixation were included. Eighty-eight patients who suffered from ligamentous ankle injury with neither fracture nor syndesmotic lesions served as a control group. Tibiofibular alignment was measured on MR images in all 188 patients. In case of tibiofibular malreduction tibiotalar positioning was determined as well. Clinical and functional outcome was assessed using the AOFAS hindfoot score as well as the SF-36. RESULTS No tibiofibular malreduction was found in type Weber B fractures, irrespective of syndesmotic instability followed by syndesmotic screw placement, as compared to the control group. A significant tibiofibular malreduction was detected in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic screw, in comparison to the control group. Tibiotalar displacement could not be detected. Clinical and functional outcome analysis revealed no significant differences between the treatment groups. CONCLUSION Three-dimensional imaging may improve tibiofibular malreduction visualization in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic transfixation. The clinical impact of improving tibiofibular positioning remains highly questionable since there was no correlation between tibiofibular alignment and the clinical outcome at mid-term follow-up.
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Affiliation(s)
- D Ntalos
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - M Rupprecht
- Department of Pediatric Orthopaedic Surgery, Children's Hospital, Altona, Hamburg, Germany; Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - L G Grossterlinden
- Department of Orthopaedic, Trauma and Spine Surgery, Asklepios Hospital Altona, Hamburg, Germany
| | - A Hamurcu
- Department of Orthopaedic and Trauma Surgery, Albertinen Hospital, Hamburg, Germany
| | - M Regier
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T O Klatte
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J M Rueger
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A S Spiro
- Department of Pediatric Orthopaedic Surgery, Children's Hospital, Altona, Hamburg, Germany; Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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