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Lin Y, Gao J, Zheng H, Guo Y, Liu Z, Sun T. Evaluating Fibular Intramedullary Nails vs Traditional Plating in Geriatric Ankle Fractures: A 12-Year Single-Center Retrospective Study. Foot Ankle Int 2024; 45:824-832. [PMID: 38721810 DOI: 10.1177/10711007241247849] [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 evaluates the outcomes of fibular intramedullary nails (IMNs) compared to traditional plates and screws (PS) in the surgical treatment of unstable ankle injuries in patients aged ≥65 years. METHOD We conducted a retrospective study involving 32 elderly patients with unstable ankle fractures treated with IMNs from 2010 to 2022. A comparison was made with 125 case-control patients treated with PS during the same period. Outcomes compared included postoperative wound and nonwound complications, surgical reduction, union rates, implant removal rates, and the Olerud Molander Ankle Score (OMAS) at a minimum follow-up of 2 years. RESULTS The IMN group had a higher incidence of high-energy injuries, open fractures, concomitant surgery, and perioperative transfusion requirements than the PS group. Additionally, the IMN group developed fewer wound-related (3.1% vs 20% in the PS group, P = .043) and non-wound-related complications (18.8% vs 39.2% in the PS group, P = .030). Both groups had similar initial weightbearing restrictions, fracture union times, mean OMAS scores, rates of malunion or nonunion, and delayed implant removal times. Notably, there were significant differences in the quality and adequacy of mortise alignment between the groups (good: 53.1% in IMN group vs 79.2% in PS group, fair: 46.9% in IMN group vs 20.8% in PS group, P = .006). CONCLUSION Although the IMN group had an inferior outcome in the quality and adequacy of mortise reduction compared with the PS group, elderly patients with ankle fractures treated with IMN showed comparable functional outcomes to those treated with PS but with lower complication rates. Future research in this area will provide vital information for developing optimal treatment strategies, thereby improving the overall care of elderly patients with ankle fractures.
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Affiliation(s)
- Yiyun Lin
- Department of Orthopedic Surgery, Senior Department of Orthopedics, the Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Jie Gao
- Department of Orthopedic Surgery, Senior Department of Orthopedics, the Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Huayong Zheng
- Department of Orthopedic Surgery, Senior Department of Orthopedics, the Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Yongzhi Guo
- Department of Orthopedic Surgery, Senior Department of Orthopedics, the Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Zhi Liu
- Department of Orthopedic Surgery, Senior Department of Orthopedics, the Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Tiansheng Sun
- Department of Orthopedic Surgery, Senior Department of Orthopedics, the Seventh Medical Center of PLA General Hospital, Beijing, China
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Zhang D, Litvak A, Lin N, Pirkle S, Strelzow J, Hynes K. Current Trends in the Surgical Treatment of Fibular Fractures: A National Database Study of Intramedullary vs. Plate Fixation Practice Patterns, Complications, and Cost. Adv Orthop 2024; 2024:7506557. [PMID: 39036541 PMCID: PMC11260212 DOI: 10.1155/2024/7506557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/14/2024] [Accepted: 06/24/2024] [Indexed: 07/23/2024] Open
Abstract
Existing primary evidence comparing fibular intramedullary fixation (IMF) with traditional plate fixation (PF) for the treatment of distal fibular fractures remains limited by modest sample sizes. Using a large national database, this study aims to compare use rates, fracture patterns, patient characteristics, time to surgery, complication rates, and cost between fibular IMF and PF within the United States. Adults treated with fibular IMF or PF between October 2015 and October 2021 were identified within the PearlDiver Database. The ratio of IMF-treated to PF-treated patients was tracked temporally to compare use rates. Fracture patterns were determined using fracture diagnoses within one-month preceding surgery. Further comparisons of IMF- and PF-treated groups only included patients with at least 12 months of follow-up, and patients with upper tibia or tibia shaft fractures were excluded. An analysis of cohorts matched at a 1 : 4 (IMF: PF) ratio to control for risk factors was performed to compare time to surgery, complication rates (infection, nonunion, malunion, revision, hardware removal, pulmonary embolism, and deep vein thrombosis), and cost. 39329 patients (2294 IMF and 37035 PF) were identified. IMF use trended upwards relative to PF use over time. Tibia and fibula shaft fractures were the most common injuries in IMF patients versus bimalleolar and trimalleolar fractures in PF patients. A higher proportion of IMF patients had open fractures. IMF patients were younger, with higher mean ECI, fewer female patients, and higher rates of CKD. Percutaneous approaches were more common among IMF patients. There were no significant differences in time to surgery or complication rates. IMF was less costly. The popularity of IMF trended upwards across the study period. IMF was used more commonly in injuries involving higher energy trauma and soft tissue disruption. Overall, IMF patients were younger with more comorbidities. When used in similar populations, IMF appears to be a cost-effective alternative to PF.
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Affiliation(s)
- Douglas Zhang
- The University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Audrey Litvak
- The University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Nicholas Lin
- The University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Sean Pirkle
- Department of Orthopaedics and Sports MedicineUniversity of Washington, Seattle, WA 98195, USA
| | - Jason Strelzow
- Department of Orthopaedic Surgery and Rehabilitation MedicineUniversity of Chicago Medicine, Chicago, IL 60637, USA
| | - Kelly Hynes
- Department of Orthopaedic Surgery and Rehabilitation MedicineUniversity of Chicago Medicine, Chicago, IL 60637, USA
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Patel S, Dionisopoulos SB. Current Concepts in Ankle Fracture Management. Clin Podiatr Med Surg 2024; 41:519-534. [PMID: 38789168 DOI: 10.1016/j.cpm.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Ankle fractures are one of the more common musculoskeletal injuries that are treated by foot and ankle specialists. A thorough understanding of managing these injuries requires the ability to differentiate between stable and unstable fractures. The current literature supports the nonoperative management of stable Weber B ankle fractures, whereas unstable fractures have much better outcomes with surgical intervention. Specifically, we review the fixation strategies for the lateral, medial, and posterior malleolar fractures respectively. Finally, we discuss the current trends in postoperative management of some of the more common fracture patterns, and the safety in early weight-bearing protocols.
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Affiliation(s)
- Sandeep Patel
- The Permanente Medical Group Diablo Service Area, Department of Orthopedics and Podiatry, San Francisco Bay Area Foot and Ankle Residency, 1425 S. Main Street, Walnut Creek, CA 94596, USA.
| | - Shontal Behan Dionisopoulos
- The Permanente Medical Group Diablo Service Area, Department of Orthopedics and Podiatry, San Francisco Bay Area Foot and Ankle Residency, 1425 S. Main Street, Walnut Creek, CA 94596, USA
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Rodriguez-Materon S, Trynz S, Fanfan D, Fleites J, Gil J, Hodgkins C. Use of Fibula Nails With Proximal and Distal Fixation. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241230563. [PMID: 38380387 PMCID: PMC10878224 DOI: 10.1177/24730114241230563] [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: 02/22/2024] Open
Abstract
Background Ankle fractures are a frequent injury in the adult population and a quarter of all ankle fractures are classified as unstable, requiring surgical intervention. Plate-and-screw construct is the traditionally used fixation method for fibula fractures. The use of an intramedullary nail is an alternative fixation method, with current literature supporting very low complication rates and hardware removal surgeries. The purpose of this study was to evaluate the outcomes, including complication rates and implant removal rates, using a fibula nail with both proximal and distal fixation capabilities by an experienced surgeon. Methods We retrospectively reviewed 203 consecutive fibula nail cases from a single surgeon using a mini-open technique for anatomic reduction. Demographic, operative, clinical, and radiographic outcome data were analyzed, specifically examining complication rates and need for implant removal. Results The average follow-up was 18.8 months (6-54 months). All fractures healed. We identified 2 cases of superficial wound infection, 1 superficial peroneal nerve irritation, and 1 case of implant removal. In the first 110 cases, 2 fractures were converted to a plate intraoperatively prior to a technique modification which has prevented this occurrence. No deep infection, delayed union, or nonunion occurred. Conclusion Our data support that fibula nails with proximal and distal locking capabilities offer an alternative to plating with the potential for lower complication rates and lower need for implant removal. Level of evidence Level IV, case series.
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Affiliation(s)
| | - Samantha Trynz
- Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Dino Fanfan
- Miami Orthopedics and Sports Medicine Institute at Baptist Health South Florida, Coral Gables, FL, USA
| | - Jorge Fleites
- Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Jorge Gil
- Miami Orthopedics and Sports Medicine Institute at Baptist Health South Florida, Coral Gables, FL, USA
| | - Christopher Hodgkins
- Miami Orthopedics and Sports Medicine Institute at Baptist Health South Florida, Coral Gables, FL, USA
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Xiong Y, Zhang J, Liu H, Cai T, Xu W, Wu J. Intramedullary nail fixation of fibular fractures in combination with extra-articular distal tibial fractures (AO/OTA 43A): a single-center retrospective study. Acta Orthop Belg 2023; 89:719-726. [PMID: 38205766 DOI: 10.52628/89.4.12153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Treatment of fibular fractures associated with extra-articular distal tibia fractures is technically challenging and the purpose of this study was to evaluate the use of intramedullary nail fixation of fibular fractures when associated with this fracture. Between January 2018 and December 2021, 33 patients presenting extra-articular distal tibia fractures and fibular fractures (AO/OTA 43A) were treated. Clinical and radiological data were collected during routine postoperative follow-ups. Thirty-one patients were monitored for a period of time ranging from 12 to 23 months, with an average follow-up of 17.5 ± 3.3 months. Fibular bone union took an average of 3.6 ± 0.9 months. At the last follow-up, the average fibular alignment and postoperative ankle talocrural angles were 1.8° and 9.1°, respectively. No detectable radiographic rotational malalignment and serious complications related to the fibular incision was observed. The average AOFAS and OMAS scores at the most recent follow-up were 88.3 ± 6.2 and 87.4 ± 6.0, respectively. Intramedullary nail fixation worked well to keep the fibula in place in fibular fractures connected to extra-articular distal tibia fractures.
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Kavanagh AM, Schumann J, Burgess BJ. Intramedullary Nail Fixation for the Treatment of Symptomatic Fibular Nonunion: A Case Series. Foot Ankle Spec 2023:19386400231193620. [PMID: 37608750 DOI: 10.1177/19386400231193620] [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: 08/24/2023]
Abstract
Ankle fractures are a relatively common injury in the lower extremity. They can be treated with conservative management if they are nondisplaced and only involve the fibula. Nonunions at the fracture site, however, are a potential complicating factor during treatment. There is growing literature supporting the use of intramedullary fixation for fracture care. Not only does it have the advantages of using smaller incisions to preserve periosteum while providing improved biomechanical outcomes, but intramedullary reaming can help stimulate cells to promote bone healing. Few articles discuss the use and success of intramedullary reaming in revision surgery of the distal fibula. We present 3 cases of computed tomography-confirmed fibular nonunion following conservative fracture care, which underwent revision surgery with fibular nail fixation technique. These cases illustrate clinical and image findings as well as highlight the surgical technique used for each patient. At follow-up, all patients were asymptomatic and radiographs confirmed healing of the previous nonunion site. These cases are examples of successful revision for fibular fracture nonunion using intramedullary nail fixation.Level of Evidence: Level IV: Case series.
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Affiliation(s)
- Amber M Kavanagh
- Division of Hinsdale Orthopaedics, Illinois Bone & Joint Institute, Joliet, Illinois
| | - Jaclyn Schumann
- Division of Hinsdale Orthopaedics, Illinois Bone & Joint Institute, Joliet, Illinois
| | - Brian J Burgess
- Division of Hinsdale Orthopaedics, Illinois Bone & Joint Institute, Joliet, Illinois
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Cheung YC, Yee DK, Fang C. Defining the fit and ideal entry site of the fibula rod system--a computed tomography based study in elderly patients with lower limb infections, vascular diseases or tumors. J Orthop Surg (Hong Kong) 2023; 31:10225536231157129. [PMID: 36924112 DOI: 10.1177/10225536231157129] [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: 03/18/2023] Open
Abstract
OBJECTIVES To determine the configuration of the distal fibula anatomy and the fitness of the Fibula Rod System (Acumed®, Hillsboro, Oregon) in a series of fibula models and to determine the optimal entry site of the rod. METHODS Consecutive series of computed tomography (CT) of tibias and fibulae with no fracture or deformity were converted to stereo-lithograph format, and imported into Meshmixer software (Autodesk, San Rafael, California). A 3.6 × 180 mm fibula rod model was virtually inserted to best fit the intramedullary canal of the fibula model and to a depth of 0 mm proud at the distal fibula. The location of the entry point in relationship to the fibular tip, and the distance between the rod and the lateral fibula cortex were measured. RESULTS CT of 41 fibulae (23 male and 18 female patients) contributed to the three-dimensional fibula modeling. The entry point was 3.5 mm (SD 2.0) medial to (in mortise view) and 1.0 mm (SD 2.1) anterior to (in lateral view) the fibular tip. The fibula rod was inserted to a depth of 6.2 mm (SD 2.1) proximal to the fibula tip. The mean shortest distance of the rod to the outer cortex was 1.88 mm (SD 0.87). There was a breach of the posterolateral cortex in one patient. CONCLUSION The guide pin entry site of fibula rod should be medial and anterior offset with reference to the fibula tip, in contrary to the distal tip as recommended in the manual. There is a chance of breaching the posterolateral cortex with rod entry.
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Affiliation(s)
- Yan Chun Cheung
- Department of Orthopaedics and Trauamatology, 37062Alice Ho Miu Ling Nethersole Hospital, Pokfulam, Hong Kong
| | - Dennis Kh Yee
- Department of Orthopaedics and Trauamatology, 37062Alice Ho Miu Ling Nethersole Hospital, Pokfulam, Hong Kong
| | - Christian Fang
- Department of Orthopaedics and Trauamatology, 25809The University of Hong Kong, Pokfulam, Hong Kong
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Guo W, Wu F, Chen W, Tian K, Zhuang R, Pan Y. Can Locked Fibula Nail Replace Plate Fixation for Treatment of Acute Ankle Fracture? A Systematic Review and Meta-Analysis. J Foot Ankle Surg 2022; 62:178-185. [PMID: 36333182 DOI: 10.1053/j.jfas.2022.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/13/2022] [Accepted: 10/01/2022] [Indexed: 11/07/2022]
Abstract
The standard surgical treatment for unstable ankle fractures involves open reduction and internal fixation (ORIF) with plates. However, ORIF has been associated with several complications, such as soft tissue irritation, wound infection, and nerve injury. Previous studies have shown that closed reduction and internal fixation with locked intramedullary nails (LIMNs) yields satisfactory efficacy in the treatment of ankle fractures and is associated with low complication rates. Therefore, a systematic review and meta-analysis of randomized controlled trials is imperative to provide evidence on whether or not LIMN fixation is comparable to or superior than traditional ORIF. We conducted a comprehensive literature search in the PubMed, Cochrane Library and EMBASE databases. A total of 4 randomized controlled trials involving 359 participants who suffered ankle fractures were included in this systematic review and meta-analysis. The results showed that the LIMN fixation group was statistically significant in terms of functional outcomes at the 3-month follow-up and wound-related complications. There was no statistical advantage for patients in the LIMN fixation group in terms of nonwound-related complications, total complications, or mid-term follow-up functional outcomes. There was no statistical difference between the LIMN and ORIF groups regarding operation time and quality of reduction. We believe LIMN fixation is a viable option for the treatment of unstable ankle fractures in both young and elderly individuals.
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Affiliation(s)
- Wenxuan Guo
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Fan Wu
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Wenhuan Chen
- Third Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Kun Tian
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Rujie Zhuang
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yu Pan
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
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Bastías GF, Bravo F, Astudillo C, Giannini E, Contreras M, Melo R, Muñoz G, Pellegrini MJ, Cuchacovich N. Restoration of Anatomic Parameters and Syndesmotic Reduction After Intramedullary Nailing of Distal Fibular Fractures. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221141388. [PMCID: PMC9742579 DOI: 10.1177/24730114221141388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Intramedullary nailing of the fibula (FN) is a method of fixation that has proven to be useful for treating distal fibular fractures (DFs). FN minimizes soft tissue complications and provides similar stability to plating, with fewer hardware-related symptoms. Nevertheless, FN has been associated with syndesmotic malreduction and the incapacity of restoring length and rotation of the fibula. We aimed to evaluate the fibular position and syndesmotic reduction after fixation with FN compared with the uninjured ankle in the immediate postoperative period. Methods: Prospective cohort study. Patients with DF fractures treated with IN between January 2017 and January 2020 were included. Immediate postoperative bilateral ankle CT was obtained in all cases. Fibular rotation, length, and translation as well as syndesmotic diastasis were measured on both ankles and compared by 3 independent observers. Results: Twenty-eight patients were included (16 women). The mean age was 46 years (range 16-91). Fracture type distribution according to AO/ASIF classification included 19 patients with 44.B (67.9%), 8 patients with 44.C (28.6%), and 1 patient with a 44.A fracture (3.6%). No significant differences were identified considering fibular rotation (P = .661), syndesmotic diastasis (P = .147), and fibular length (P = .115) between the injured and uninjured ankle. Fibular translation had statistical differences (P = .01) compared with the uninjured ankle. The intraclass correlation coefficient showed an excellent concordance between observers except for fibular translation on the injured ankle. Conclusion: In this cohort, fixation of DF fractures with FN allows restoration of anatomical parameters of the ankle in terms of fibular rotation, length, and syndesmotic diastasis. However, fibular translation had significant differences compared with the uninjured ankle based on bilateral CT scan evaluation. Level of Evidence: Level II, prospective cohort study.
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Affiliation(s)
- Gonzalo F. Bastías
- Department of Orthopedic Surgery, Foot and Ankle Unit, Clínica Las Condes—Hospital del Trabajador, Universidad de Chile, Las Condes, Santiago, Chile
| | - Francisco Bravo
- Department of Orthopedic Surgery, Foot and Ankle Unit, Complejo Hospitalario San José—Mutual de Seguridad, Santiago, Chile
| | - Claudia Astudillo
- Department of Radiology, Clinica Las Condes, Las Condes, Santiago, Chile
| | - Esteban Giannini
- Department of Radiology, Hospital del Trabajador-Clinica MEDS, Santiago, Chile
| | - Martin Contreras
- Department of Orthopedic Surgery, Hospital del Trabajador, Santiago, Chile
| | - Rodrigo Melo
- Department of Orthopedic Surgery, Foot and Ankle Unit, Clinica Las Condes—Hospital Militar de Santiago, Santiago, Chile
| | - Gerardo Muñoz
- Department of Orthopedic Surgery, Foot and Ankle Unit, Clinica Las Condes, Las Condes, Santiago, Chile
| | - Manuel J. Pellegrini
- Department of Orthopedic Surgery, Foot and Ankle Service, Clinica Universidad de los Andes—Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Natalio Cuchacovich
- Department of Orthopedic Surgery, Foot and Ankle Unit, Clínica Las Condes—Hospital del Trabajador, Universidad de Chile, Las Condes, Santiago, Chile,Natalio Cuchacovich, MD, Department of Orthopedic Surgery, Foot and Ankle Unit, Clinica Las Condes—Hospital del Trabajador, Estoril 450, Las Condes, Santiago, 7591047, Chile.
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Walsh JP, Hsiao MS, LeCavalier D, McDermott R, Gupta S, Watson TS. Clinical outcomes in the surgical management of ankle fractures: A systematic review and meta-analysis of fibular intramedullary nail fixation vs. open reduction and internal fixation in randomized controlled trials. Foot Ankle Surg 2022; 28:836-844. [PMID: 35339374 DOI: 10.1016/j.fas.2022.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/30/2022] [Accepted: 03/15/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND What level I evidence exists to support the use of FNF for surgical management of ankle fractures in high risk patients? The purpose of this study was to compare clinical outcomes following fibular intramedullary nail fixation (FNF) and open reduction and internal fixation (ORIF) of ankle fractures. METHODS A systematic review of the current literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Certainty of evidence reported according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Our primary hypothesis was that patients undergoing FNF procedures to manage an ankle fracture would have significantly higher patient reported outcome scores (PROs) than patients undergoing ORIF. Primary study outcome measures were validated PROs. Secondary outcome measures included complication rate, secondary surgery rate, and bony union. RESULTS The primary outcome analysis revealed no evidence of a significant effect difference on Olerud and Molander Ankle Score (OMAS) PRO and no evidence of statistical heterogeneity. Secondary outcome analysis revealed a significant 0.30 (0.12-0.74 95CI) relative risk reduction for complications in FNF (P = 0.008). No evidence of an effect difference for bony union. The GRADE certainty of the evidence was rated as low for bone union. No evidence of reporting bias was appreciated. Sensitivity analyses did not significantly alter effect estimates. CONCLUSION This systematic review and meta-analysis restricted to evidence derived from RCTs revealed that the quality of evidence is reasonably strong and likely sufficient to conclude: (1) there is likely no clinically important difference between FNF and ORIF up to 12 months post-operatively, as defined by OMS (moderate certainty); (2) surgeons may reasonably expect reduced complications in 14 out of every 100 patients treated with FNF (moderate certainty); (3) there is likely no difference in bony union (low certainty). Future studies should investigate more patient-centered outcomes and if short-term findings are durable over time if these findings apply to lower risk populations. LEVEL OF EVIDENCE Systematic review and meta-analysis of level I evidence.
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Affiliation(s)
- John P Walsh
- Department of Orthopaedic Surgery, Valley Hospital Medical Center, Las Vegas, NV, USA; The Foot and Ankle Institute at Desert Orthopaedic Center, Las Vegas, NV, USA.
| | - Mark S Hsiao
- The Foot and Ankle Institute at Desert Orthopaedic Center, Las Vegas, NV, USA.
| | - Daniel LeCavalier
- Department of Orthopaedic Surgery, Valley Hospital Medical Center, Las Vegas, NV, USA.
| | - Ryland McDermott
- The Foot and Ankle Institute at Desert Orthopaedic Center, Las Vegas, NV, USA; Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, USA.
| | - Shivali Gupta
- Department of Orthopaedic Surgery, Valley Hospital Medical Center, Las Vegas, NV, USA.
| | - Troy S Watson
- Department of Orthopaedic Surgery, Valley Hospital Medical Center, Las Vegas, NV, USA; The Foot and Ankle Institute at Desert Orthopaedic Center, Las Vegas, NV, USA.
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11
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Ahmed M, Barrie A, Kozhikunnath A, Thimmegowda A, Ho S, Kunasingam K, Guryel E. Fibula Nail Outcomes in Soft Tissue Compromised Ankle Fractures. Foot Ankle Int 2022; 43:595-601. [PMID: 34964376 DOI: 10.1177/10711007211061401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND To determine the clinical outcomes following fibula nail fixation and to identify the indication for the use of fibula nails in lower limb fractures. METHODS Retrospective study of adult patients from 2 major trauma centers (MTCs) and 9 trauma units (TUs) who underwent fibula nail fixation for AO/OTA 44 fractures between January 1, 2018, and October 31, 2020. Outcome measures included infection, metalwork complications, nonunion or malunion, time to union, and length of inpatient hospital stay. RESULTS Ninety-five patients were included, with a mean age of 66 years; 57.9% of patients were female. The average body mass index was 30. Sixty-nine patients (72.6%) sustained a Weber B and 24 (27.4%) sustained a Weber C fracture. In addition, 26.3% were open fractures and all patients had soft tissue compromise affecting the lateral malleolus. The calculated infection rate for fibula nail was 4.2% and metalwork complication rate was 5.2%. The nonunion and malunion rate was 8.4% and rate of removal of hardware was 2.1%. The average time to union was 12.5 weeks, and length of inpatient stay was 9.4 days (SD 10). CONCLUSION This multicenter study demonstrates that use of a fibula nail appears to be a safe approach to treating patients who have a physiologically higher risk of surgery, poor skin condition, and a complex fracture pattern. LEVEL OF EVIDENCE Level III, case-control study.
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Affiliation(s)
- Maryam Ahmed
- University Hospitals Sussex, Brighton, United Kingdom
| | - Andrew Barrie
- University Hospitals Sussex, Brighton, United Kingdom
| | | | | | - Sebastian Ho
- Croydon University Hospital, Thornton Heath, United Kingdom
| | | | - Enis Guryel
- University Hospitals Sussex, Brighton, United Kingdom
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12
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唐 一, 梁 晓, 赵 宏, 张 言. [Progress in diagnosis and treatment of fibular fracture in ankle fracture]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:117-121. [PMID: 35038809 PMCID: PMC8844619 DOI: 10.7507/1002-1892.202108091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/11/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To summarize the diagnosis and treatment of fibular fracture in ankle fracture. METHODS Relevant literature at home and abroad in recent years was widely consulted, and various types of fractures were discussed and summarized according to Danis-Weber classification. RESULTS Conservative treatment is not an ideal treatment for type A avulsion fracture. The operation method should be determined according to the position and size of bone mass. For simple type B fracture, both conservative treatment and surgical treatment can achieve good results. When the position of type C fracture is high and does not affect the stability of ankle joint, it can be treated conservatively, while when the position is low and affects the stability of ankle joint, it needs surgical treatment. CONCLUSION First of all, whether the fibular fracture in the ankle fracture is stable or not should be determined. Whether it is treated surgically or not, the purpose is to restore the tibiofibular syndesmosis and restore the motor function of the ankle.
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Affiliation(s)
- 一丁 唐
- 西安医学院附属红会医院足踝外科(西安 710054)Department of Foot and Ankle Surgery, Honghui Hospital Affiliated to Xi’an Medical College, Xi’an Shaanxi, 710054, P. R. China
| | - 晓军 梁
- 西安医学院附属红会医院足踝外科(西安 710054)Department of Foot and Ankle Surgery, Honghui Hospital Affiliated to Xi’an Medical College, Xi’an Shaanxi, 710054, P. R. China
| | - 宏谋 赵
- 西安医学院附属红会医院足踝外科(西安 710054)Department of Foot and Ankle Surgery, Honghui Hospital Affiliated to Xi’an Medical College, Xi’an Shaanxi, 710054, P. R. China
| | - 言 张
- 西安医学院附属红会医院足踝外科(西安 710054)Department of Foot and Ankle Surgery, Honghui Hospital Affiliated to Xi’an Medical College, Xi’an Shaanxi, 710054, P. R. China
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Kho DH, Cho BK, Choi SM. Midterm Outcomes of Unstable Ankle Fractures in Young Patients Treated by Closed Reduction and Fixation With an Intramedullary Fibular Nail vs Open Reduction Internal Fixation Using a Lateral Locking Plate. Foot Ankle Int 2021; 42:1469-1481. [PMID: 34184908 DOI: 10.1177/10711007211017470] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We aimed to compare midterm radiological and clinical outcomes between closed reduction and internal fixation (CRIF) using the fibular intramedullary nail (IMN) and open reduction and internal fixation (ORIF) using the locking plate for the treatment of unstable ankle fractures in active young patients. METHODS In this retrospective cohort study, 204 patients treated with CRIF using the fibular IMN (94 patients) or ORIF using the locking plate (110 patients) were included after at least 3 years of follow-up. The mean patient age was 41.4 years. Radiographic evaluation included the quality of reduction assessed by plain radiography and 3-dimensional (3D)-reconstructed computed tomography as well as the development of posttraumatic osteoarthritis (PTOA) of the ankle assessed by weightbearing plain radiography. Clinical evaluation included the American Orthopaedic Foot & Ankle Society hindfoot score, Olerud and Molander Score, the Foot and Ankle Outcome Score, and visual analog scale pain score as well as complications. RESULTS At median follow-up greater than 4 years, we found no significant differences in measured clinical outcomes between the 2 groups. There were significantly fewer postoperative complications in the IMN group than in the ORIF group (9.5% vs 39%, P < .001). However, we did find a greater proportion of radiographically fair or poor reductions in the IMN group than in the ORIF group (P < .001). The poor reductions in the IMN group were primarily related to Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures (P < .001). PTOA was also more frequently observed in the IMN group than in the ORIF group (21.3% vs 9.1%, P = .024). CONCLUSION Given the current prevailing technologies for fracture fixation, this study suggests that surgeons should consider ORIF for unstable ankle fractures in active young patients with Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Duk-Hwan Kho
- Department of Orthopaedic Surgery, Konkuk University Chungju Hospital, Konkuk University School of Medicine, Chungju, Korea
| | - Byung-Ki Cho
- Department of Orthopaedic Surgery, School of Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Seung-Myung Choi
- Department of Orthopedic Surgery, Eulji University School of Medicine, Gyeonggi-do, Korea
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14
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Pflüger P, Braun KF, Mair O, Kirchhoff C, Biberthaler P, Crönlein M. Current management of trimalleolar ankle fractures. EFORT Open Rev 2021; 6:692-703. [PMID: 34532077 PMCID: PMC8419795 DOI: 10.1302/2058-5241.6.200138] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus. Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons. In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint. In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care. This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives.
Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138
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Affiliation(s)
- Patrick Pflüger
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Karl-Friedrich Braun
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Traumatology and Reconstructive Surgery including Department of Orthopedic Surgery, Charite Universitätsmedizin Berlin, Berlin, Germany
| | - Olivia Mair
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Chlodwig Kirchhoff
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Moritz Crönlein
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
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15
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Kamin K, Kleber C, Marx C, Schaser KD, Rammelt S. [Minimally invasive fixation of distal fibular fractures with intramedullary nailing]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 33:104-111. [PMID: 33728477 DOI: 10.1007/s00064-021-00702-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Minimally invasive osteosynthesis of distal fibula fractures serves as a biomechanically stable and soft-tissue-friendly fixation method in the case of an unstable fracture, poor bone quality, and/or critical soft tissue conditions with restoration of the length, axis and rotation of the distal fibula as well as stabilization of the ankle mortise. The goal is to reduce and stabilize the distal fibular fracture in a quick and stable manner that protects the soft tissues in ankle fractures. INDICATIONS Unstable malleolar fractures and fracture dislocations; fibular fractures in combination with distal tibia fractures; critical soft tissue conditions around the ankle. CONTRAINDICATIONS No consent to surgery by the patient. Overall critical (life-threatening) general condition preventing surgery to the extremities. Very narrow medullary canal of the fibula (less than 3 mm, depending on the implant). SURGICAL TECHNIQUE Percutaneous placement of a guidewire into the distal fibular tip, opening the medullary canal and drilling the medullary canal in the distal fragment. Reduction of the axis by introduction of the fibular nail, with additional percutaneous use of reduction clamps for restoration of fibular length and rotation, if necessary. Placement of distal locking screws over the targeting device while maintaining rotation and length, in addition proximal static locking is mandatory to maintain the length of the fibula. In case of residual syndesmotic instability after fracture fixation, syndesmotic screws are inserted through the fibular nail via the aiming device. POSTOPERATIVE MANAGEMENT Following surgery, rest and elevation of the injured leg, and local cooling are indicated. Subsequently, mobilization with partial weight bearing (15-20 kg) in an ankle foot orthosis or plaster/cast for 6 weeks. RESULTS Minimally invasive fibular fixation with an intramedullary nail results in a significantly lower rate of wound healing complications compared with lateral plating. Reported union rates range from 97.4 to 100% with current nail designs. The quality of reduction and functional outcome is comparable to that after plate fixation. A certain learning curve has to be respected.
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Affiliation(s)
- Konrad Kamin
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - Christian Kleber
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Christine Marx
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Klaus-Dieter Schaser
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Stefan Rammelt
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
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16
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Faber RM, Parry JA, Haidukewych GH, Koval KJ, Langford JL. Complications after fibula intramedullary nail fixation of pilon versus ankle fractures. J Clin Orthop Trauma 2021; 16:75-79. [PMID: 33717942 PMCID: PMC7920162 DOI: 10.1016/j.jcot.2020.12.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/05/2020] [Accepted: 12/27/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Intramedullary nail (IMN) fixation of the fibula in malleolar ankle fractures has been shown to result in less wound complications then plate fixation. Therefore, IMN fibula fixation may also be associated with lower rates of wound complications when used for higher-risk pilon fractures. The purpose of this study was to compare complications of fibula IMN fixation in pilon versus malleolar ankle fractures. METHODS A retrospective cohort comparison was performed at an urban level one trauma center involving fibula fractures in 47 patients with AO/Orthopaedic Trauma Association (OTA) type 43 fractures and 48 patients with AO/OTA type 44 fractures being treated with fibula IMN fixation. Complications, fibula-specific complications, revision surgeries, and implant removals were reviewed. RESULTS There was no detectable difference in complications (27% vs. 23%, 95% confidence interval of the odds ratio (CIOR) 0.5 to 3.2), fibular-specific complications (6% vs. 10%, CIOR 0.1 to 3.5), revision surgeries (4% vs. 4%, CIOR 0.1 to 7.5), or symptomatic fibula implant removals (13% vs. 21%, CIOR 0.1 to 1.6) between pilon and ankle fracture groups, respectively. There was one (2%) fibular nonunion and one wound complication (2%) in each of the fracture groups. CONCLUSION Fibula IMN fixation of pilon versus ankle fractures resulted in a similar number of complications. Comparative studies of fibula IMN and plate fixation are necessary to determine if the benefits of fibula IMN in ankle fractures extends to pilon fractures. LEVEL OF EVIDENCE Level III, retrospective cohort.
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Affiliation(s)
- Rachel M. Faber
- Department of Orthopaedics, Orlando Health, Orlando, FL, USA
| | - Joshua A. Parry
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA,Corresponding author. Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA.
| | | | - Kenneth J. Koval
- Department of Orthopaedics, Memorial Hospital, Gulfport, MS, USA
| | - Joshua L. Langford
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA
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Abstract
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.
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18
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Gagné OJ, Penner M, Wing K, Veljkovic A, Younger AS. Reoperation Profile of Lateral vs Anterior Approach Ankle Arthroplasty. Foot Ankle Int 2020; 41:834-838. [PMID: 32441532 DOI: 10.1177/1071100720920276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The operative procedure for a total ankle replacement (TAR) is intimately associated with the prosthetic design. The anterior and lateral approaches both have pros and cons regarding their respective soft tissue complications, osteotomy requirements, orientation of the bone cut, and gutter visualization. Although both have been studied independently, few reports have compared both in the same setting. The purpose of this retrospective study was to investigate the difference in reoperation rate after lateral or anterior approach ankle arthroplasty. We hypothesized that the anterior approach had a higher rate of wound complications. METHODS We evaluated data from a single center collected between 2014 and 2017, comprising a total of 115 total ankle replacements performed by 1 of 4 fellowship-trained foot and ankle surgeons. Reoperations were recorded as an operative report with classification by Canadian Orthopaedic Foot and Ankle Society (COFAS) Reoperations Coding System (CROCS). The index approach used was determined by the surgeon's practice preference. Patients were included when they had a primary TAR in the time frame noted and had a complete data set up to at least 2 years after surgery. The cohort comprised 67 anterior and 48 lateral operations with balanced demographics for age (95% CI: 63-67 years) and gender (47% F). The lateral group had more complex cases with higher COFAS type arthritis (more periarticular arthritis and surrounding deformity). RESULTS Comparing the 2 groups, a total of 40 reoperations (7 anterior [A], 33 lateral [L]) occurred in 27 patients (5 A, 22 L). One patient had 4 related reoperations. The only revision was in the anterior group. The only soft tissue reconstruction was a split-thickness skin graft in the lateral group. Nine reoperations were irrigation debridement related to an infection or wound complication (3 A, 6 L). The majority (19/33) of reoperations in the lateral group were gutter debridement (8) or lateral hardware removal (11). Operative time was statistically different at 145 minutes (95% CI: 127-164 minutes) in anterior TAR and 178 minutes (95% CI: 154-202 minutes) for lateral TAR (P = .0058). The odds ratio of having any reoperation with a lateral approach TAR was 6.19 compared to the anterior group. CONCLUSION The results at the 2-year time point demonstrated that there were more reoperations after a lateral approach TAR than an anterior TAR, recognizing the significant case complexity imbalance between the groups and a corresponding relative increase in resource utilization of lateral TAR patients. The 2 implant designs were associated with different reoperation rates, favoring the anterior group. Change in the lateral fixation may have reduced the risk of repeat surgery. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Oliver J Gagné
- Department of Orthopaedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Murray Penner
- Department of Orthopaedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Partner at Footbridge Centre for Integrated Orthopaedic Care, Vancouver, British Columbia, Canada
| | - Kevin Wing
- Department of Orthopaedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Partner at Footbridge Centre for Integrated Orthopaedic Care, Vancouver, British Columbia, Canada
| | - Andrea Veljkovic
- Department of Orthopaedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Partner at Footbridge Centre for Integrated Orthopaedic Care, Vancouver, British Columbia, Canada
| | - Alastair S Younger
- Department of Orthopaedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Partner at Footbridge Centre for Integrated Orthopaedic Care, Vancouver, British Columbia, Canada
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