Outcome and quality of life after surgically treated ankle fractures in patients 65 years or older

Analysis of functionality, pain and quality of life after surgically treated ankle fractures in active and inactive individuals

Although the ankle is often involved in low energy trauma, high-energy trauma may occur, being this considered more serious and more common of affecting young and active men. The purpose of the present study was to evaluate and compare the functionality, pain and quality of life of active and inactive adult individuals whose ankle fracture was surgically treated. Seventy-six patients split into two groups (active, n = 58 X inactive, n = 18), of the men (active, n = 38; inactive, n = 9) and women (active, n = 20; inactive, n = 9) gender participated in this prospective study. The IPAQ, MMSE, SF-36, VAS, sociodemographic and clinical questionnaires were applied in person right after surgery. The SF-36 and VAS questionnaires were reapplied 3 months in average after the surgery. Active and inactive patients of both genders show significant differences (p ≤ 0.05) in the functional capacity and physical aspect domains; and the bodily pain domain revealed significant difference in active and inactive men (p ≤ 0.05) between the periods post-surgical and 3 months after surgery (on average). Moderate and significant correlations were found (p ≤ 0.05) between functional capacity, physical aspect and bodily pain domains of the SF-36 and the VAS pain scores for active and inactive patients of both genders in the final follow-up period. Other significant correlations (p < 0.05) for inactive men (physical aspect and bodily pain) and inactive women (functional capacity and bodily pain) are observed (after 3 months of surgery). Three months after surgery (on average), active and inactive men had functional limitations and pain symptoms. These factors seem to have negatively influenced the patient's social involvement, worsening their quality of life. Most active and inactive patients had a positive self-perception of their general health status, emotional aspects and mental health domains. Regarding active women, we observed lower energy and vitality after the same postoperative period.

Open Ankle Fractures in Older Individuals: A Multi-center Study

The purpose of this study is to identify demographics, etiology, comorbidities, treatment, complications, and outcomes for older patients with open ankle fractures. Patients ≥60 years old who sustained an open ankle fracture between January 1, 2004 and March 31, 2014 at 6 Level 1 trauma centers were retrospectively reviewed. Univariate analysis using chi-squared or Student's t test was performed to identify associations between preoperative variables and 2 postoperative outcomes of interest: amputation and 1-year mortality. Multivariate analysis was performed using stepwise logistical regression to identify independent predictors of postoperative amputation and 1-year mortality. Of the 162 total patients, the most common mechanism of injury was a ground-level fall (51.9%). The most common fracture types were bimalleolar fractures (52.5%) followed by trimalleolar fractures (26.5%), with 41.5% of the fractures classified as Gustilo Anderson Classification Type 2 and 38.6% classified as Type 3A. The average number of surgeries required per patient was 2.1. Complications included: 15.4% superficial infection rate, 9.9% deep infection rate, and 9.3% amputation rate. The 1-year mortality rate was 13.6% and the overall mortality rate was 25.9%. Male gender and fracture type were found to be independent predictors for amputation after surgery (p = .009, .005, respectively). Older age and having diabetes were independent predictors for 1-year mortality after surgery (p = .021, .005 respectively). Overall, open ankle fractures in older individuals were associated with high rates of amputation and mortality.

Patients with more complex ankle fractures are associated with poorer patient-reported outcome: an observational study of 11,733 patients from the Swedish Fracture Register

BACKGROUND AND PURPOSE

Patient-reported outcome measures (PROMs) following ankle fractures, including all fracture types, have not been reported. It is therefore unclear whether fracture morphology correlates with outcome. We aimed to analyze PROMs in patients with an ankle fracture in relation to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) fracture classification using population-based register data from the Swedish Fracture Register (SFR).

METHODS

All patients aged ≥ 18 years with an ankle fracture (AO/OTA 44A1-C3) registered in the SFR between 2012 and 2019 were retrieved from the register. Patients with completed PROM questionnaires (Short Musculoskeletal Function Assessment and EuroQol-Visual Analogue Scale) on both day 0 (pre-trauma) and 1-year post-trauma were included. The difference in PROMs between day 0 and 1 year was calculated for each patient (delta value) and mean delta values were calculated at group level, based on the AO/OTA fracture classification.

RESULTS

11,733 patients with 11,751 fractures with complete PROMs were included. According to the AO/OTA classification, 21% were A fractures, 67% were B fractures and 12% were C fractures. All groups of patients, regardless of fracture class (A1-C3), displayed an impairment in PROMs after 1 year compared with day 0. Type C fractures displayed a larger impairment in PROMs at group level than type B, which in turn had a greater impairment than type A. The same pattern was seen in groups 3, 2, and 1 for A and B fractures.

CONCLUSION

We found that the AO/OTA classification is prognostic, where more complex fractures were associated with poorer PROMs.

Patient Characteristics and Outcomes of Geriatric Ankle Fractures: Open Fracture Is the Key Risk Factor for Complications and Functional Decline

OBJECTIVES

To determine whether open (O) or closed (C) geriatric ankle fractures had different patient characteristics or outcomes.

METHODS

.

DESIGN

Retrospective cohort study.

SETTING

Urban Level 1 trauma center.

PATIENT SELECTION CRITERIA

Patients, age 60 years and older, who underwent operative fixation of a rotational ankle fracture (OTA/AO 44A-C) between January 2012 and September 2021.

OUTCOME MEASURES AND COMPARISONS

Morbidity, defined as 90-day reoperation, 90-day readmission, or loss of mobility, as well as 1-year mortality compared between patients with closed and open fractures.

RESULTS

The open cohort was older (75 years vs. 68 years; P = 0.003) but had similar Charlson comorbidity indices (4.6 O vs. 4.0 C; P = 0.323) and preinjury rates of independent ambulation (70.4% O vs. 80.9% C; P = 0.363). There were higher rates of 1-year mortality (11% vs. 0%; P < 0.001), deep infection (14.8% vs. 3.9%; P = 0.019), and loss of mobility (64.7% vs. 23.0%; P < 0.001) in the open cohort. Multivariate regression identified open fracture as an independent predictor of 90-day reoperation (OR: 20.6; P = 0.022) and loss of mobility (OR: 5.1; P = 0.011).

CONCLUSIONS

Despite having comorbidities and preinjury function similar to the closed geriatric ankle fracture cohort, open ankle fracture was independently predictive of greater loss of mobility. Nearly two-thirds of geriatric patients with open ankle fractures experienced a decline in functional independence, compared with 1 in 4 of those with closed fractures. Open fracture was associated with higher rates of deep infection, reoperation, and 1-year mortality.

LEVEL OF EVIDENCE

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

Republication of "Ankle Fracture-Dislocations: A Review"

Ankle fractures are common musculoskeletal injuries that may result in tibiotalar joint dislocations. Ankle fracture-dislocations occur via similar mechanisms as ankle fractures, although the persistence or magnitude of the deforming force is sufficient to disrupt any remaining bony or soft-tissue stability. Ankle fracture-dislocations likely represent distinct clinical entities, as the pathology, management, and patient outcomes following these injuries differ from those seen in more common ankle fractures without dislocation. Ankle fracture-dislocations have higher rates of concomitant injury including open fractures, chondral lesions, and intra-articular loose bodies. Long-term outcomes in ankle fracture-dislocations are worse than ankle fractures without dislocation. Higher rates of posttraumatic osteoarthritis and chronic pain have also been reported. In this review, we discuss the current literature regarding the history, management, and outcomes of ankle-fracture dislocations and highlight the need for future study.

Comparing Patient-Reported Outcomes Measurement Information System Computer Adaptive Testing With Existing Measures After Operative Interventions for Extremity Fractures

INTRODUCTION

Patient-Reported Outcomes Measurement Information System (PROMIS) enables the use of computer adaptive testing (CAT). The aim of this prospective cohort study was to compare the most commonly used disease-specific instruments with PROMIS CAT questionnaires in patients with trauma.

METHODS

All patients with trauma (ages 18-75) who underwent an operative intervention for an extremity fracture between June 1, 2018, and June 30, 2019, were included. The disease-specific instruments were the Quick Disabilities of the Arm, Shoulder, and Hand for upper extremity fractures and the Lower Extremity Functional Scale (LEFS) for lower extremity fractures. Pearson's correlation (r) between the disease-specific instruments and the PROMIS CAT questionnaires (PROMIS Physical Function, PROMIS Pain Interference, and PROMIS Ability to Participate in Social Roles and Activities) was calculated at week 2, week 6, month 3, and month 6. Construct validity and responsiveness were calculated.

RESULTS

A total of 151 patients with an upper extremity fracture and 109 patients with a lower extremity fracture were included. At month 3 and month 6, the correlation was strong between the LEFS and PROMIS Physical Function (r = 0.88 and r = 0.90, respectively), and at month 3, the correlation was strong between the LEFS and PROMIS Social Roles and Activities (r = 0.72). At week 6, month 3, and month 6, there was a strong correlation between the Quick Disabilities of the Arm, Shoulder, and Hand and PROMIS Physical Function (r = 0.74, r = 0.70, and r = 0.76, respectively).

CONCLUSIONS

The PROMIS CAT measures are acceptably related to existing non-CAT instruments and may be a useful tool during follow-up after operative interventions for extremity fractures.

Clinical assessments and gait analysis for patients with Trimalleolar fractures in the early postoperative period

Background

Trimalleolar fracture is a common ankle fracture with serious complications and costly healthcare problem. Most studies used clinical assessments to evaluate the functional status of the patients. Although clinical assessments are valid, they are static and subjective. Dynamic, objective and precise evaluations such as gait analysis are needed. Ankle biomechanics studies on gait in patients with trimalleolar fractures are still rare. This study aimed to investigate the clinical outcomes and gait biomechanics in patients with trimalleolar fractures in the early postoperative period and compared to healthy controls.

Methods

This was a cross-sectional study. 12 patients with trimalleolar fractures were recruited, and 12 healthy people served as controls. All patients underwent clinical assessments: Olerud and Molander ankle score (OMAS), ankle swelling and passive range of motion (ROM) of ankle, and completed gait biomechanical analysis when weight-bearing was allowed: temporal-spatial parameters, plantar pressure distributions, and surface electromyography (sEMG). The control group only performed gait test.

Results

Patients had poor outcomes of clinical assessments in the short-term. During gait analysis, patients presented compromised gait patterns: shorter step length, larger step width, slower walking speed and shorter single support compared to healthy controls (P < 0.001), and patients showed asymmetrical gait. Symmetry index of step width and walking speed were mainly correlated with the difference of ankle inversion ROM between two sides (R = -0.750, P = 0.005; R = -0.700, P = 0.011). During walking, patients showed abnormal dynamic plantar pressure features (mainly in the hindfoot and forefoot regions), and the IEMG (integrated electromyography) of tibial anterior muscle (TA) and peroneal longus muscle (PL) were larger than healthy controls (P = 0.002, 0.050).

Conclusions

Patients with trimalleolar fractures showed physical impairments of the ankle, and presented altered gait parameters compared to healthy subjects in the short-term. The ankle stability of patients declined, and deficits in TA and PL muscle ability might contribute to it. Restoring complete muscle functions and improving passive ankle ROM are significant to promote the recovery of a normal gait pattern.

Quantifying balance deficit in people with ankle fracture six months after surgical intervention through the Y-Balance test

BACKGROUND

Ankle fractures are among the most common traumatic fractures and have a great socio-economic impact. Consequences of an ankle fracture requiring surgical treatment (e.g. pain, reduced ankle range of motion (ROM), muscle weakness, etc.) lead to balance deterioration, which has a profound impact on activities of daily living. However, to the best of the authors' knowledge, no reliable clinical tests are available to monitor balance in patients after ankle surgery.

OBJECTIVES

To quantify single-leg dynamic balance in patients with bimalleolar ankle fracture through the Y-Balance test (YBT). The second objective was to analyze the impact of ankle dorsiflexion ROM and hip strength on balance to optimize balance rehabilitation programs.

DESIGN

Cross-sectional study.

METHODS

22 participants, who had undergone surgery after bimalleolar ankle fractures, were assessed for ankle ROM, hip strength, and dynamic balance six-months after the surgical intervention. The within-session reliability of YBT was calculated through the intraclass correlation coefficient (ICC) and the standard error of measurement (SEM). Student's t-tests were used to assess leg differences. A multiple regression analysis was performed to evaluate the role of ankle dorsiflexion ROM and hip abductor and adductor strength in predicting balance performance.

RESULTS

YBT showed high-to-excellent within-session relative reliability (Healthy leg: 0.85 ≤ ICC≤0.96; Operated leg: 0.84 ≤ ICC≤0.96). SEM values were below 3.3 %. The operated leg showed significant lower YBT scores for anterior reach direction (-9.0 %; g=-0.70) and composite score (-4.5 %; g=-0.34). Multiple regression analysis showed that both, ankle dorsiflexion and hip abductor and adductor strength explained 66 % of the variance in the YBT anterior direction of the operated leg.

CONCLUSIONS

The YBT is a reliable tool that allows the quantification of single-leg dynamic balance impairments from 6-months after surgery in patients with bimalleolar ankle fracture. Between-leg YBT differences in the anterior direction can be used as reference scores (3.3 %) for balance restoration. Balance rehabilitation programs should focus on improving ankle functionality and reducing hip muscle weakness with specific hip strength exercises and balance exercises with similar demands to the reaching tasks of the YBT to promote a faster recovery.

Measuring Recovery and Understanding Long-Term Deficits in Balance, Ankle Mobility and Hip Strength in People after an Open Reduction and Internal Fixation of Bimalleolar Fracture and Their Impact on Functionality: A 12-Month Longitudinal Study

To analyze how balance and other physical capacities evolved after surgery in patients with a bimalleolar fracture and how these capacities and clinical variables (immobilization or unloading time) contribute to restoring patients’ functionality, 22 patients and 10 healthy people (HC) were assessed for static and dynamic balance (Y-Balance test, YBT), dorsiflexion ankle mobility (ADFROM) and hip strength at 6 and 12 months after surgery. Patients’ functional status was assessed through the Olerud Molander Ankle Score (OMAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Twenty-one patients with ankle fractures who completed the study showed a worse static and dynamic balance at 6 months. The YBT in the anterior direction (YBTA) revealed balance deficits in the operated limb at 12 months compared to the non-operated limb (−5.6%) and the HC (−6.7%). They also showed a decreased ADFROM compared to the non-operated limb (−7.4°) and the HC (−11°). In addition, medium-term (6 months) deficits in abductor strength hip but no hip strength deficits were found at 12 months after surgery. Relative weight analyses showed that ADFROM and hip strength explained 35–63% of the YBTA variance and AOFAS/OMAS scores. Balance, hip strength and ADFROM seem to be reliable indexes for assessing the functional status of these patients. These results could help to understand the relationship between these physical capacities and the patients’ perceived functional status.

Does musculoskeletal pain interfere with motor learning in a gait adaptation task? A proof-of-concept study

BACKGROUND

Experimental pain during gait has been shown to interfere with learning a new locomotor task. However, very few studies have investigated the impact of clinical pain on motor learning due to the challenges associated with clinical populations.

OBJECTIVE

The first objective of this proof-of-concept study was to determine the feasibility to obtain two groups of participants with chronic ankle pathology with or without residual pain while walking. The second objective was to evaluate the impact of clinical musculoskeletal pain on motor learning during gait.

METHODS

Participants with chronic isolated ankle pathology were recruited and their personal and clinical characteristics were collected (functional performance, dorsiflexion maximal strength, range of motion). To assess motor acquisition (Day 1) and retention (Day 2), participants performed an adaptation task on two consecutive days that consisted of walking while experiencing a perturbing force applied to the ankle. The level of pain during the task was measured, and participants who reported pain were attributed to the Pain group and participants without pain to the No Pain group. Learning performance was assessed by measuring ankle kinematics (Mean plantarflexion absolute error) and learning strategy was assessed by measuring the Relative timing of error and the tibialis anterior (TA) electromyographic activity.

RESULTS

Twenty-five participants took part in the experiment. Eight (32%) were excluded because they could not be included in either the Pain or No Pain group due to the intermittent pain, leaving eight participants in the Pain group and nine in the No Pain group. Both groups were similar in terms of baseline characteristics. Musculoskeletal pain had no influence on learning performance, but the learning strategy were different between the two groups. The No Pain group showed a TA activity reduction before perturbation between the days, while the Pain group did not.

CONCLUSION

Some barriers were identified in studying musculoskeletal pain including the high rates of participants' exclusion, leading to a small sample size. However, we showed that it is feasible to investigate clinical pain and motor learning. From the results of this study, musculoskeletal pain has no influence on motor learning performance but influences the learning strategy.

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

PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Anatomic Structures at Risk During Posterior to Anterior Percutaneous Screw Fixation of Posterior Malleolar Fractures: A Cadaveric Study

Background. There are no established guidelines for fixation of posterior malleolus fractures (PMFs). However, fixation of PMFs appears to be increasing with growing evidence demonstrating benefits for stability, alignment, and early functional outcomes. The purpose of this study was to determine the risk to anatomic structures utilizing a percutaneous technique for posterior to anterior (PA) screw fixation of PMFs. Methods. Percutaneous PA screw placement was carried out on 10 fresh frozen cadaveric ankles followed by dissection to identify soft tissue and neurovascular structures at risk. The distance from the guidewire to each anatomic structure of interest was measured. The correlation between the mean distances from the guidewire to each structure was calculated. Results. The sural nerve was directly transected in 1/10 specimens (10%) and in contact with the wire in a second specimen (10%). There was a significant correlation between the proximity of the guidewire to the apex of Volkmann's tubercle and its proximity to the sural nerve. The flexor hallucis longus (FHL) muscle belly was perforated by the guidewire 40% of the time but was not tethered or entrapped by the screw. Conclusions. Percutaneous PA screw placement is a safe technique which can be improved with several modifications. A mini-open technique is recommended to protect the sural nerve. There may be potential for tethering of the FHL with use of a washer or large screw head. Risk to the anterior and posterior neurovascular bundles is minimal.Levels of Evidence: Level V.

Beyond Hip Fractures: Other Fragility Fractures' Associated Mortality, Functional and Economic Importance: A 2-year-Follow-up

Background

Hip fractures are well researched in orthogeriatric literature. Equivalent investigations for fragility-associated periprosthetic and periosteosynthetic femoral, ankle joint, pelvic ring, and rib fractures are still rare.

The purpose of this study was to evaluate mortality, functional outcome, and socioeconomic parameters associated to the upper-mentioned fragility fractures prospectively in a 2-year follow-up.

Methods

Over the course of a year, all periprosthetic and periosteosynthetic femoral fractures (PPFF), ankle joint fractures (AJ), pelvic ring fractures (PR), and rib fractures (RF), that were treated on a co-managed orthogeriatric ward, were assessed. Parker Mobility Score (PMS), Barthel Index (BI), place of residence, and care level were recorded. After 2 years, patients and/or relatives were contacted by mailed questionnaires or phone calls in order to calculate mortality and reevaluate the mentioned parameters.

Results

Follow-up rate was 77.7%, assessing 87 patients overall. The relative mortality risk was significantly increased for PR (2.9 (95% CI: 1.5–5.4)) and PPFF (3.5 (95% CI: 1.2–5.8)) but not for RF (1.5 (95% CI: 0.4–2.6)) and AJ (2.0 (95% CI: 0.0–4.0)). Every fracture group except AJ showed significantly higher BI on average at follow-up. PMS was, respectively, reduced on average for PR and RF insignificantly, but significantly for PPFF and AJ in comparison to pre-hospital values. 10.0–27.3% (each group) of patients had to leave their homes permanently; care levels were raised in 30.0–61.5% of cases.

Discussion

This investigation provides a perspective for further larger examinations. PR and PPFF correlate with significant increased mortality risk. Patients suffering from PPFF, PR, and RF were able to significantly recover in their activities of daily living. AJ and PPFF conclude in significant reduction of PMS after 2 years.

Conclusion

Any fragility fracture has its impact on mortality, function, and socioeconomic aspects and shall not be underestimated. Despite some fractures not being the most common, they are still present in daily practice.

Outcomes Following Open Reduction Internal Fixation of Ankle Fractures (ORIF) By Podiatric Surgeons

Open reduction internal fixation of closed ankle fractures is a common procedure performed by podiatric surgeons. This is the first study to specifically evaluate complication rates of this procedure among podiatric surgeons using a large patient cohort. The rates of podiatric surgical complications were also compared to the complication rates reported in the orthopedic literature. There was no significant difference between podiatric surgeons and orthopedic surgeons with regards to surgical site infection. However, complication rates, including 1-year postsurgery deep vein thrombosis (DVT), malunion, and unplanned revision surgery within 90-day, were lower in our study, compared to the average rates reported in the orthopedic literature. The authors believe that the most important determinant for post ankle surgical complications is related to surgical volume and experience, rather than professional degree type.

Danish translation and validation of the Self-reported foot and ankle score (SEFAS) in patients with ankle related fractures

BACKGROUND

The Self-reported Foot and Ankle Score (SEFAS) is a patient-reported outcome measure used to evaluate foot and ankle disorders. The purpose of this study was to translate, cross-culturally adapt and validate the Danish language version of the SEFAS in patients with ankle-related fractures.

METHODS

Forward-backward translation, cross-cultural adaption and validation were performed. In total, 125 patients completed the SEFAS-DK and the Danish version of American Orthopaedic Foot and Ankle Score (AOFAS-DK) at three time points after the date of fracture. The evaluation was performed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines.

RESULTS

The intra-class correlation coefficient (ICC) level of the SEFAS-DK total score was 0.93 (95% confidence interval [CI]: 0.88-0.96). Cronbach's alpha (CA) for the SEFAS-DK was 0.93, while the floor and ceiling effect at week 6 post-injury was 22.4%. Construct validity was correlated with the AOFAS, and >75% of the pre-defined hypotheses could be confirmed. Responsiveness was analysed using longitudinal data. The minimal clinical important change (MCIC) showed that the SEFAS-DK detects changes in physical function over time.

CONCLUSION

The Danish version of the SEFAS showed overall good reliability, validity and responsiveness. SEFAS-DK can be used to evaluate physical function in patients with ankle-related fractures.

LEVEL OF EVIDENCE

level II, prospective cohort study.

Investigation of the Effect of Bone Mineral Density on the Postoperative Outcome of Ankle Fractures in Elderly Patients

BACKGROUND

The association between ankle fractures in elderly patients and low bone mineral density (BMD) has recently been recognized, but the effect of BMD on the postoperative outcome of these fractures is unknown. The aim of this study was to investigate the effect of BMD on the postoperative outcome of ankle fractures in elderly patients to evaluate the need for BMD screening.

METHODS

We retrospectively reviewed 48 patients aged 65 years or older who had ankle fractures and underwent dual-energy x-ray absorptiometry to assess BMD after surgical treatment of the fracture. Postoperative outcomes were assessed using the Olerud-Molander Ankle Score (OMAS), visual analog scale (VAS) score for pain, Kellgren and Lawrence (K&L) grading scale score, and quality of fracture reduction. The correlation between the BMD and the outcome measures at 12 months after surgery was analyzed using the Pearson correlation coefficient.

RESULTS

The mean absolute value of BMD was 0.6 ± 0.1 g/cm² (T-score, -1.5 ± 1.2) at the femoral neck and 0.8 ± 0.2 g/cm² (T-score, -1.2 ± 1.5) at the lumbar spine. Osteoporosis was present in 33% of female patients and in 11% of male patients. At 12 months after surgery, the OMAS was 70 ± 17 and the VAS score for pain was 18 ± 17. Of the patients, 20, 21, 5, 1, and 1 had K&L grades of 0, 1, 2, 3, and 4, respectively. None of the clinical and radiographic outcome measures were correlated with the BMD values of the patients.

CONCLUSION

The postoperative outcome of the ankle fractures in elderly patients at 12 months after surgery showed no correlation with femoral neck or lumbar spine BMD at the time of fracture.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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

BACKGROUND

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

METHOD

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

CONCLUSION

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

LEVELS OF EVIDENCE

Level III.

Danish Language Version of the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS) in Patients with Ankle-Related Fractures

The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS) is, to date, the most widely used scale for evaluating foot and ankle disorders. We translated it into Danish and evaluated the reliability, validity and responsiveness of the Danish version of the AOFAS-AHS (AOFAS-DK) in patients aged >18 years with isolated ankle-related fractures. Forward-backward translation, cross-cultural adaption, and validation study were performed. In total, 125 patients completed the AOFAS-DK and the Self-reported Foot and Ankle Score (SEFAS) at 3 time points after the date of fracture. The evaluation was performed according to the Consensus-based Standards for the selection of health Measurement Instruments guidelines. The intra-class correlation coefficient level of the AOFAS-DK total score was 0.87 (95% confidence interval: 0.80-0.91). Cronbach's alpha (CA) for the AOFAS-DK function subscale was 0.62, whereas the floor and ceiling effect of the function subscale was 32% (T1) and 19% (T2), respectively. Construct validity was correlated with the SEFAS, and >75% of the predefined hypotheses could be confirmed. Responsiveness was analyzed using longitudinal data, and showed that the AOFAS-DK can detect changes in scores. The Danish version of the self-administered section of the AOFAS-AHS showed overall good reliability, validity, and responsiveness. The low CA values and the presence of the floor effect might be due to the low number of items and response options available in the scale. The AOFAS-DK can be used to evaluate physical function in patients with ankle-related fractures.

Increased Risk of Nonunion and Charcot Arthropathy After Ankle Fracture in People With Diabetes

The aim of this study was to evaluate the frequency of complications after an ankle fracture in patients with and without diabetes and to evaluate risk factors for nonunion. We conducted a retrospective study of 439 patients with ankle fractures (31.7% had diabetes) and followed them for 1 year or until the fracture healed. The fracture severity and determination of nonunion and Charcot arthropathy were determined from independent evaluation of radiographs by 2 members of the research team. Nonunion was defined as a fracture that did not heal within 6 months of the fracture. The majority of patients were women (67% in each group). The risk of complications was significantly higher in patients with diabetes compared with those without diabetes. The odds ratio (OR) and 95% confidence interval (CI) for nonunion was 6.5 (3.4 to 12.8); for Charcot arthropathy, 7.6 (2.3 to 21.0); for wounds, 1.8 (1.1 to 2.9); for infection, 2.8 (1.4 to 5.7); and for amputation, 6.6 (0.98 to 80.0). In the logistical regression analysis, 6 factors were associated with fracture nonunion: dialysis (7.7; 1.7 to 35.2), diabetes (3.3; 1.5 to 7.4), fracture severity (bi- and trimalleolar fractures) (4.9; 1.4 to 18.0), beta blockers (2.5; 1.1 to 5.4), steroids (3.1; 1.2 to 7.7), and infection (3.7; 1.2 to 11.3). The results of the study demonstrate the increased risk of complications after an ankle fracture among patients with diabetes, dialysis, or open fractures and those using steroids and beta blockers. Further work is needed to identify areas for risk reduction.

Predictors of Functional Outcome in Unstable Ankle Fractures Treated Surgically - A Prospective Cohort Study

Introduction:

Unstable ankle injuries require anatomical reduction and stabilisation for optimal outcome. In spite of adequate care, a few patients have poor outcome. In this study, we assessed the risk factors that predict the clinical outcomes in surgically treated unstable ankle fractures.

Material and methods:

This prospective cohort study was conducted on 68 patients who underwent surgical management for an unstable ankle injury. Demographic details, fracture type and associated medical comorbidities were recorded. Pre-operative radiographic assessment was done for all patients. At the end of one year follow-up, clinical (American Orthopaedic foot and ankle society-AOFAS and Olerud-Molander ankle - OMAS) scores and radiological parameters were assessed and analysed.

Results:

Fracture dislocation (0.008), diabetes mellitus (0.017), level of alchohol consumption (0.008) and pre-operative talocrural angle (TCA) > 100° (0.03) were significant predictors of poor outcomes as per AOFAS. Fracture dislocation (0.029), diabetes mellitus (0.004), pre-operative TCA > 100° (0.009), female gender (0.001), age more than 60 years (0.002) and open injuries (0.034) had significantly poor outcome as per OMAS. Other parameters (smoking, hypertension, classification, syndesmotic injury, medial clear space and tibiofibular overlap) did not affect the outcome significantly.

Conclusion:

Our study showed that poor outcome predictors in unstable ankle fractures are age >60 years, female gender, diabetes mellitus, alcohol consumption, fracture dislocation, open fractures and pre-op TCA >100°.

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

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

Operative Treatment of Ankle Fractures: Predictive Factors Affecting Outcome

Purpose

Surgical management of ankle fractures has been extensively studied in literature but studies investigating validated clinical results are lacking and controversial. The purpose of this study was to evaluate functional and health-related quality of life (HRQL) outcomes after surgically treated ankle fractures and to detect some of their predictors.

Methods

Two hundred sixty-six skeletally mature patients who underwent surgery for an isolated ankle fracture from 2006 to 2017 were retrospectively identified from our hospital records and included in the study. All patients were evaluated at one, three, six and 12 months post-injury with clinical and radiographic examination. Outcome measures recorded at final two years minimum follow-up included patient-reported pain, patient satisfaction, functional (American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score) and quality of life (Short Form (SF) 36 score) status.

Results

Patient satisfaction score was 8.4 out of 10, Visual Analogue Scale mean score was 2.3, complication rate was 36.5% and mean AOFAS ankle-hindfoot score was 87.3. Mean SF36-physical summary score was 77.9 and SF36-mental summary score was 81.1. The injury demonstrated a significant effect on physical function, role-physical, bodily pain and social functioning SF-36 subdomains. Functional outcome was significantly related to occupation, syndesmotic lesion, number of fractured malleoli and delay to surgery. Main predictors of quality of life were age, occupation, cause of injury, syndesmotic lesion, number of fractured malleoli and waiting time to surgery.

Conclusions

Ankle fractures have a considerable impact on functional and quality of life status of patients. Occupation, presence of syndesmotic injury, Pott's classification and surgery delay must be considered as predictors of final outcome.

Arthroscopic Ankle Arthrodesis Provides Similarly Satisfactory Surgical Outcomes in Ankles With Severe Deformity Compared With Mild Deformity in Elderly Patients

PURPOSE

To evaluate the surgical outcome in terms of radiographic measurements, functional outcomes, and complications following arthroscopic ankle arthrodesis (AAA) in patients 60 years of age or older, and to compare the results of patients with mildly deformed ankle with those of patients with severely deformed ankle.

METHODS

We retrospectively reviewed patients who underwent AAA with 3 cannulated screws between January 2008 and December 2017 and followed postoperatively for at least 24 months. All included patients were 60 years of age or older. Demographic data and radiographic and functional outcomes were compared between patients with coronal deformity of less than 15° (group I) and those with a deformity equal to or greater than 15 degrees (group II).

RESULTS

A total of 41 patients with a mean age of 70.6 years were included (group I, n = 26; group II, n = 15) and mean follow-up was 51.4 months. Group II had significantly more severe preoperative coronal deformity of tibiotalar angle than group I (20.1 ± 2.9 vs 6.6 ± 4.1°, P < .01). Near-normal tibiotalar alignment was achieved postoperatively in both groups (group I, 3.4 ± 3.3 vs group II, 4.7 ± 3.1°, P = .227). Union was achieved in 39 (95.1%) patients with 2 cases in group I experiencing non-union. Union rate, mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and visual analog scale pain scores were not significantly different between the 2 groups at final follow-up.

CONCLUSIONS

AAA is a reliable procedure for end-stage ankle arthritis in patients 60 years of age or older resulting in a high union rate, encouraging radiographic and functional outcomes, and a low complication rate, even in cases with severe preoperative deformity. In addition, arthroscopic intra-articular malleolar osteotomy was a useful technique for correcting severe coronal deformity in our series.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

What is the validity of self-reported fractures?

We assessed the validity of self-reported fractures, over a median follow-up period of 6.2 years, in a well characterized population-based cohort of 3560 postmenopausal women, aged 60-85 years, from the Fracture Risk Brussels Epidemiological Enquiry (FRISBEE) study. Incident low-traumatic (falls from a standing height or less) or non-traumatic fractures, including peripheral fractures, were registered during each annual follow-up telephone interview. A self-reported fracture was considered as a true positive if it was validated by written reliable medical reports (radiographs, CT scans or surgical report). False positives fractures were considered to be those for which the radiology report indicated that there was no fracture at the reported site. Among self-reported fractures, false positive rates were 14.4% for all fractures. The rate of false positives of 11.2% (n = 48/429) was not negligible for the four classical major osteoporotic fractures (MOFs: hip, clinical spine, forearm or shoulder fractures). In terms of fracture site, we found the lowest false positive rate (4.4%) at the hip, and the highest (16.8%) at the spine, with the proximal humerus and the wrist in between, at about 10% each. The global rates of false positives were 12.5% (n = 22/176) for other major fractures and 22.3% (n = 49/220) for minor fractures. Younger subjects, individuals with fractures at sites other than the hip, with a lower education level, or with a higher BMI were more likely to report false positive fractures. Our data indicate that the inaccuracy of self-reported fractures is clinically relevant for several major fractures, which could influence any fracture risk prediction model.

Underevaluation of fractures by self-report: an analysis from the FRISBEE cohort

We assessed the rate of non-reported fractures in the FRISBEE cohort. Over a median follow-up period of 9.2 years, we registered 992 fractures. The global percentage of non-reported fractures was 21.3%. Underreporting of fracture event might influence any model of fracture risk prediction.

INTRODUCTION

Most fracture cohort studies rely on participant self-report of fracture event. This approach may lead to fracture underreporting. The purpose of the study was to assess the rate of non-reported fractures in a well-characterized population-based cohort of 3560 postmenopausal women, aged 60-85 years, included in the Fracture Risk Brussels Epidemiological Enquiry (FRISBEE) study.

METHODS

Incident low-traumatic or non-traumatic fractures were registered annually during phone calls. In 2018, we reviewed the medical files of 67.9% of our study participants and identified non-reported fractures ("false negatives fractures (FN)"). We also evaluated whether the rate of FN was influenced by baseline patients' characteristics and fracture risk factors. Generalized estimating equation (GEE) was used to calculate odds ratio (OR) and 95% CI.

RESULTS

Over a median follow-up period of 9.2 years, we registered 992 fractures (781 by self-report, confirmed by a radiological report and 211 unreported). The global false negative rate for all fractures was 21.3%, including 22% for MOFs (major osteoporotic fractures), 13.1% for other major fractures, and 25.8% for minor fractures. The rate of non-reported fractures varied by fracture site: for MOFs, it was 2.7% (n = 2/73) at the hip, 5.3% at the proximal humerus (n = 5/94), 7.1% at the wrist (n = 11/154), and 46.5% at the spine (n = 100/215). For "other major" fractures, the highest rate of false negatives fractures was found at the pelvic bone (21%, n = 13/62), followed by the elbow (17.9%, n = 5/28), long bones (10.5%, n = 2/19), ankle (6.2%, n = 4/65), and knee (5.9%, n = 1/17). Older subjects (OR 1.7; 95% CI, 1.2-2.4; P = 0.003), subjects with early non-substituted menopause (OR 1.8; 95% CI, 1.0-3.3; P = 0.04), with a lower education level (OR 1.5; 95%CI, 1.1-2.2; P = 0.01), and those under drug therapy for osteoporosis (OR 1.5; 95% CI, 1.0-2.2; P = 0.05) were associated with a higher rate of FN.

CONCLUSIONS

In conclusion, underreporting of a substantial proportion of fracture events will influence any model of fracture risk prediction and induce bias when estimating the associations between candidate risk factors and incident fractures.

Gait analysis related to functional outcome in patients operated for ankle fractures

Ankle fractures are among the most common lower limb fractures. Associations between postoperative radiographic results and clinical outcome have been found, but less is known about the relevant ankle biomechanics. This study analyzed ankle kinematics, radiographic findings, and patient-reported outcome measures (PROM) in patients treated for ankle fractures. The hypothesis was that patients after ankle fracture surgery had less flexion/extension in the ankle compared to healthy subjects and that fracture severity had significant influence on kinematics and patient satisfaction. Thirty-three patients (n = 33 feet) operated for ankle fractures were recruited. Ankle kinematics were analyzed using the Oxford Foot model, and results were compared with an age-matched healthy control group (11 patients, 20 feet). In addition, patients were divided by fracture (severity) classification and kinematic results were correlated with PROM and radiographic findings. Patients treated for ankle fracture showed lower walking speed (p < 0.001) when asked to walk in preferred normal speed. When compared at equal speed, significantly less range of motion (ROM) between the hindfoot and tibia in the sagittal plane (flexion/extension) during loading and push-off phases (p = 0.003 and p < 0.001) was found in patients after ankle fractures compared to healthy subjects. Lowest ROM and poorest PROM results were found for patients with trimalleolar ankle fractures. There was a significant correlation between ROM (flexion/extension) during the push-off phase and SF-36 physical functioning (r²  = 0.403, p = 0.027) and SF-36 general health (r²  = 0.473, p = 0.008). Fracture severity was significantly correlated with flexion/extension ROM in the ankle during both loading and push-off phases (r²  = -0.382, p = 0.005, and r²  = -0.568, p < 0.001) and was also significantly correlated with PROM. This study found that patients with ankle fractures had significantly altered ankle kinematics compared to healthy subjects. The poorest results were found among patients with trimalleolar fractures. Weak to strong significant correlations were found between fracture severity, ankle kinematics, and PROM. © 2019 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 37:1658-1666, 2019.

Ankle motion in common yoga poses

BACKGROUND

Motion of the ankle is essential for many yoga poses. An understanding of range of ankle motion during typical yoga poses may help the clinician to understand expected outcomes of patients when returning from ankle surgery or injury to yoga.

METHODS

The biomechanics of twenty healthy active yogis were collected during seven yoga poses that are common within their practices. Motion capture and force plates were used to assess the range of motion and joint moments of the ankle for each pose.

RESULTS

All poses resulted in plantarflexion and external rotation moments at the ankle joints. Joint loading was highest in single leg poses. The arc of motion used by the study participants in the poses was 29° of sagittal motion, 20° of frontal motion and 35° of transverse motion.

DISCUSSION

Ankle motion was evaluated when healthy yogis perform standard poses. These results may help in discussion with patients regarding expected outcomes after ankle injury or surgery.

To fix or not to fix: a novel approach to the safe management of unstable open medial malleolar fractures

Displaced medial malleolar fractures, either in isolation or as part of an unstable ankle fracture dislocation, are conventionally treated with internal fixation. We outline the case of a 76-year-old man with diabetes presenting with a grossly deformed open ankle fracture and extruded tibia through a large medial wound. Following irrigation, wound debridement and minimally invasive fibular fixation, the medial fracture reduced anatomically. Contrary to traditional teaching, the medial malleolus was left without fixation. The patient mobilised partially weight-bearing, progressing to both clinical and radiographic union by 3 months. Nine months following an injury, he walks unaided, can squat and drive and has no medial pain or instability with an Olerud-Molander Ankle Score of 80/100, indicating a good outcome. This is the first reported case of such unique management in the literature and highlights the potential to treat open medial malleolar fractures safely without fixation, particularly when concerned about the soft tissue envelope.

Alzheimer Dementia in the Orthopaedic Patient

Alzheimer disease is a neurologic disorder characterized by the progressive cognitive decline. As the population continues to age, orthopaedic surgeons need to become familiar with surgical and nonsurgical treatment considerations in this complex population. Despite the advances in geriatric and dementia care, surgical and postoperative management of both elective and emergent surgery remain complex and controversial in this patient population. Appropriate perioperative and postoperative management can optimize outcomes, and the management can significantly affect the quality of life of patient and caregiver and limit disease burden. Any treatment decision should be guided first and foremost by the goals of care as agreed between the surgeon, other providers, and family. Surgical management must be demand matched to the patient accounting for the severity of disease, life expectancy, and the social support system. The authors conducted a literature review of Alzheimer dementia care in orthopaedic patients via a Pubmed search of relevant articles published since 1980.

Short-Term Outcomes and Influencing Factors After Ankle Fracture Surgery

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

Computerized Adaptive Testing for Patient Reported Outcomes in Ankle Fracture Surgery

BACKGROUND

Advantages of using computerized adaptive testing (CAT) include decreased survey-burden, diminished floor and ceiling effect, and improved ability to detect the minimal clinical significant difference (MCID) among patients. The goal of this study was to compare the legacy patient-reported outcome measures (PROMs) to the Patient-Reported Outcomes Measurement Information System (PROMIS) scores in terms of ability to detect clinically significant changes in patients who have undergone surgery for ankle fractures.

METHODS

Patients who underwent osteosynthesis for an unstable ankle fracture between 2013-2016 and completed legacy outcome scores (Foot and Ankle Outcome Score [FAOS], Olerud and Molander Ankle Score [OMAS], and Weber Score) along with the PROMIS Physical Function (PF) and PROMIS Lower Extremity (LE) CATs postoperatively were included. Correlation between the scores at 3-month, 6-month, and 1-year intervals, as well as floor and ceiling effects, in addition to MCIDs were calculated for each instrument. A total of 132 patients were included in the study.

RESULTS

There was no observed floor or ceiling effect in either the PROMIS PF or the PROMIS LE scores. Clinically significant changes in the PROMIS LE score were detected in patients between 6-month and 12-month postoperative visits ( P = .0006), whereas the reported OMAS score and Weber scores did not identify a clinically significant difference between patients at their 6-month and 12-month visit.

CONCLUSION

The results of this study indicate that the PROMIS LE was superior for evaluating patients following ankle fracture surgery in terms of lower floor and ceiling effects and greater ability to distinguish clinically significant changes in patients between time points following surgery.

LEVEL OF EVIDENCE

Level III, comparative study.

Use of 18F-sodium fluoride bone PET for disability evaluation in ankle trauma: a pilot study

Background

There are no objective and accurate rating tools for permanent impairment of traumatized ankles. The purpose of this study is to assess the role of 18F-Sodium fluoride (18F-NaF) positron emission tomography-computed tomography (PET/CT) bone scans in evaluating patients with limited ankle range of motion (ROM) after trauma.

Methods

18F-NaF PET/CT was performed in 121 patients (75 men, 46 women; mean age: 45.8) who had ROM < 70% of normal after trauma affecting ankles. Metabolic target volume (MTV), the sum of voxels with standardized uptake value (SUV) > 2.5 was automatically obtained from the 3D volume that included the ankle joint. The maximum & mean SUV (SUVmax & SUVmean), and the total lesion activity (TLA) were measured.

Results

The median period from injury to performing 18F-NaF PET/CT was 290 days. The causes of injury were as follows: fracture (N = 95), Achilles tendon rupture (N = 12), and ligament injury (N = 12). Hot uptake in the ankle was seen in 113 of 121 patients. The fracture group had higher SUVmax, SUVmean, and TLA values than the non-fracture group. More limited ROM correlated with higher hot-uptake parameters (SUVmax, SUVmean, TLA). In subgroup analysis, the same correlations were present in the fracture, but not in the non-fracture group.

Conclusions

18F-NaF PET/CT can provide considerable information in impairment evaluations of limited ankle ROM, particularly in fracture around the ankle. Thus, 18F-NaF bone PET/CT may provide an additional option as an objective imaging tool in disability assessment after ankle injury.

Ankle Fracture-Dislocations

Ankle fractures are common musculoskeletal injuries that may result in tibiotalar joint dislocations. Ankle fracture-dislocations occur via similar mechanisms as ankle fractures, although the persistence or magnitude of the deforming force is sufficient to disrupt any remaining bony or soft-tissue stability. Ankle fracture-dislocations likely represent distinct clinical entities, as the pathology, management, and patient outcomes following these injuries differ from those seen in more common ankle fractures without dislocation. Ankle fracture-dislocations have higher rates of concomitant injury including open fractures, chondral lesions, and intra-articular loose bodies. Long-term outcomes in ankle fracture-dislocations are worse than ankle fractures without dislocation. Higher rates of posttraumatic osteoarthritis and chronic pain have also been reported. In this review, we discuss the current literature regarding the history, management, and outcomes of ankle-fracture dislocations and highlight the need for future study.

Better is the foe of good: Outcome of operatively treated ankle fractures in the elderly

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.

Outcome after surgical treatment of fragility ankle fractures in a certified orthogeriatric trauma center

INTRODUCTION

Orthogeriatric ankle fractures seem to play an essential role in terms of quality of life in the elderly. Knowledge of the outcome after orthogeriatric ankle fractures is sparse. The present study investigates the outcome after surgically treated ankle fractures at a certified orthogeriatric trauma center.

MATERIAL & METHODS

A retrospective observational study was performed investigating the outcome of surgically treated ankle fractures in orthogeriatric patients between 2015-2017. Outcome parameters included but were not limited to the EQ-5D 3 L, Barthel Index, Karlsson Score and the Charlson Comorbidity Index. Housing situation and mobility were evaluated and potential associations to the fracture pattern and the related treatment strategy were investigated.

RESULTS

In total, 58 patients were included (age 77.7 ± 6,2 years). The majority were AO-44 B2 fractures (72%). General outcome was related to the Parker score; a Parker Score of 9 prior surgery was independently associated with an improved outcome according to the EQ-5D 3 L and Barthel Index. Patients under 80 years of age also had better results. Place of residence did not significantly change after surgery. Neither different types of implants nor initial use of an external fixator (e.g. open fractures) did influence outcome. A wound healing impairment was found in 10% of our patients whereas the overall unplanned reoperation rate was 7%. Overall complication rate was 20%, one-year mortality was 10%.

CONCLUSIONS

Surgically treated ankle fractures in the elderly which are treated in a certified geriatric fracture center seem to have limited negative effect on their quality of life. We did not observe the otherwise often demonstrated high mortality rates, but still nearly half of the patients demonstrated perioperative complications, which emphasizes the need for optimal perioperative care at an orthogeriatric trauma center. Since there was a reasonable number of patients with wound healing issues this study supports the idea of a staged protocol using external fixation with secondary ORIF.

Functional Outcomes and Quality of Life After Ankle Fracture Surgically Treated: A Systematic Review

Context:Ankle fractures (AFs) are the most common fractures of the lower limbs found in emergency services. Approximately 53% of these fractures are unstable and treated surgically.Objective:To conduct a systematic review evaluating functional outcomes and quality of life of patients with AFs surgically treated.Evidence Acquisition:A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. Five electronic databases were searched, without any limit on publication dates. Only patients with an unstable AF that was surgically treated were included; functional outcomes and the quality of life were controlled by the 36-Item Short-Form Health Survey instrument.Evidence Synthesis:Five studies were included in the analysis, including 267 patients. The values of the Physiotherapy Evidence Database scale ranged between a minimum of 5 and a maximum of 7 points. Patients with surgically treated AF reported less functionality and physical capacity compared with the nonfractured population. Some patients experienced vitality, emotional, and mental health limitations for a long period. Most surgically treated patients reported no pain and a good health and social status.Conclusion:Limitations in functionality and physical capacity represent the main threats to health-related quality of life in patients with surgically treated AFs.

Determinants of Health Status Three to Six Years After Surgical Treatment of Closed Ankle Fracture and Comparison with the General Population: A Historical Cohort Study

Background:

The purposes of the present study were to identify the determinants of health status 3 to 6 years after open reduction and internal fixation (ORIF) for the treatment of closed ankle fracture and to compare the health status of patients who had undergone this procedure with that in the general population after adjusting for sociodemographic variables, body mass index (BMI), and smoking status.

Methods:

The present study was a historical cohort study combined with a postal survey. In total, 1,149 patients who underwent ORIF for the treatment of closed ankle fractures at 2 hospitals were eligible for chart review; 959 with low-energy fractures were eligible for a postal survey, and 471 (49%) responded to the Short Form Health Survey-36 (SF-36) health status questionnaire and provided data on BMI. Determinants of the physical functioning (PF), physical component summary (PCS), and mental component summary (MCS) scores of the SF-36 were analyzed by means of multivariable linear regression analysis. The health status of patients with an ankle fracture (n = 471) was compared with that in a sample of the general population (n = 5,396) by means of multivariable regression.

Results:

Age, American Society of Anesthesiologists (ASA) class III, and complications following surgery were associated with PF and PCS scores, and a BMI of ≥30 kg/m² and current smoking status was associated with PF and MCS scores. However, the PF, PCS, and MCS scores of patients with ankle fractures did not differ from those of the general population, with unstandardized regression coefficients of 0.25 (95% confidence interval [CI], –1.67 to 2.16; p = 0.80), 0.67 (95% CI, –0.35 to 1.70; p = 0.199), and –0.57 (95% CI, –1.63 to 0.49; p = 0.29), respectively.

Conclusions:

Age, ASA class III, and complications following surgery were associated with PF and PCS scores at 3 to 6 years after surgery for the treatment of closed ankle fractures. However, the health status of patients with ankle fractures did not differ from that in the general population after adjusting for differences in demographic variables, BMI, and smoking status.

Level of Evidence:

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

Trajectories in quality of life of patients with a fracture of the distal radius or ankle using latent class analysis

Purpose

This prospective study aimed to identify the different trajectories of quality of life (QOL) in patients with distal radius fractures (DRF) and ankle fractures (AF). Secondly, it was examined if subgroups could be characterized by sociodemographic, clinical, and psychological variables.

Methods

Patients (n = 543) completed the World Health Organization Quality of Life assessment instrument-Bref (WHOQOL-Bref), the pain, coping, and cognitions questionnaire, NEO-five factor inventory (neuroticism and extraversion), and the state-trait anxiety inventory (short version) a few days after fracture (i.e., pre-injury QOL reported). The WHOQOL-Bref was also completed at three, six, and 12 months post-fracture. Latent class trajectory analysis (i.e., regression model) including the Step 3 method was performed in Latent Gold 5.0.

Results

The number of classes ranged from three to five for the WHOQOL-Bref facet and the four domains with a total variance explained ranging from 71.6 to 79.4%. Sex was only significant for physical and psychological QOL (p < 0.05), whereas age showed significance for overall, physical, psychological, and environmental QOL (p < 0.05). Type of treatment or fracture type was not significant (p > 0.05). Percentages of chronic comorbidities were 1.8 (i.e., social QOL) to 4.5 (i.e., physical QOL) higher in the lowest compared to the highest QOL classes. Trait anxiety, neuroticism, extraversion, pain catastrophizing, and internal pain locus of control were significantly different between QOL trajectories (p < 0.05).

Conclusions

The importance of a biopsychosocial model in trauma care was confirmed. The different courses of QOL after fracture were defined by several sociodemographic and clinical variables as well as psychological characteristics. Based on the identified characteristics, patients at risk for lower QOL may be recognized earlier by health care providers offering opportunities for monitoring and intervention.

Translation, cross-cultural adaptation, reliability and validity of the Turkish version of the Olerud-Molander Ankle Score (OMAS)

Objective

The aim of this study was to translate and culturally adapt the Olerud-Molander Ankle Score (OMAS) into Turkish and to assess its reliability and validity.

Methods

The Turkish version of the OMAS (OMAS-Tr) was developed after the translation and back-translation, which included the stages recommended by Beaton. The OMAS-Tr was administered to one hundred patients (49 females, 51 males; average age: 42.3 ± 17.7; range 16–81 years) with malleolar fractures. The OMAS-Tr was completed twice by each participant at 7- to 10-days intervals to assess test-retest reliability based on the interrater correlation coefficient, whereas Cronbach's alpha evaluated internal consistency. The external validity was evaluated with correlations between the Turkish version of the Foot and Ankle Ability Measure (FAAM) and the Turkish version of the SF-12 questionnaire. The distribution of floor and ceiling effects was also analyzed.

Results

The internal consistency (Cronbach's α = 0.84) and the test-retest reliability (ICC = 0.98) were excellent. The mean interval between the two tests was 8.6 ± 1.4 days. The mean and standard deviation of the first and second assessments of the OMAS-Tr were 74.1 ± 23.7 and 75.7 ± 23.9, respectively. There was a strong correlation between the OMAS-Tr and the FAAM subscales on activities of daily living and sports (r = 0.86, r = 0.83; p < 0.001, respectively). The OMAS-Tr displayed very good to good correlation with the SF-12 physical component score and the SF-12 mental component score (r = 0.72, r = 0.60, p < 0.001, respectively).

Conclusion

OMAS-Tr was a valid and reliable tool to assess ankle fracture-related problems. Nonetheless, further studies are needed to assess its responsiveness.

Level of evidence

Level III, diagnostic study.

Gait analysis and functional outcomes after twelve-week rehabilitation in patients with surgically treated ankle fractures

Ankle fractures are the most common type of lower extremity fractures. The objective of our study was to analyse the changes of temporal and spatial gait parameters and functional outcomes in patients with bimalleolar fractures who followed surgery and rehabilitation compared to healthy controls. 49 patients with ankle fractures and 21 age-matched healthy volunteers were recruited. There were two assessments for the study group: T1 - once weight-bearing was allowed and T2 - twelve weeks after exercise-based rehabilitation programme. Each evaluation consisted in a functional questionnaire (Olerud-Molander Ankle Score-OMAS) and temporal and spatial gait parameters analysis. The gait parameters were analysed using a Zebris FDM platform. 30 patients completed the final assessment and their data were analysed. In T1 assessment there were significant differences in all temporal and spatial gait parameters between the patients group and controls. In T2 evaluation step time in affected ankle and non-affected ankle, swing time and stance time on affected ankle, stride time and cadence showed no significant differences in patients compared with controls. The within-group analysis showed significant differences in all temporal and spatial gait parameters except for single support time on non-affected ankle after rehabilitation. The OMAS improved significantly from T1 to T2 in all subscales except for squatting. Median value of OMAS improved from 60 (35-90) to 95 (55-100). Our study revealed significant improvements of all temporal and spatial gait parameters, as well as of the functional outcome in patients with surgically treated ankle fractures after twelve-week rehabilitation.

Lower Extremity Kinematic Profile of Gait of Patients After Ankle Fracture: A Case-Control Study

The present study examined the differences in the lower extremity gait kinematic profile of patients recovering from ankle fracture compared with healthy controls. In addition, we inquired whether the profile would differ among fracture severity groups. A total of 48 patients participated in the present prospective, case-control study. The gait of 24 patients recovering from an ankle fracture injury and 24 healthy matched controls was examined using an inertial measurement unit sensor system. The following gait parameters were evaluated: knee range of motion (ROM) during the swing phase, maximum knee flexion angle during stance, thigh and calf ROM, and stride duration. Statistically significant differences were found between the ankle fracture group and the control group for all parameters. The patients with ankle fracture had a lower knee ROM during swing phase compared with the control group (mean ± standard deviation 43.0° ± 15.5° compared with 66.7° ± 5.1°, respectively; p < .001). The maximum knee flexion angle during stance was lower in the patients with ankle fracture than in the control group (mean ± standard deviation 10.5° ± 6.1° compared with 21.2° ± 4.5°, respectively; p < .001). Patients with ankle fracture also had lower gait cycle thigh and calf ROM angles (p < .001) and a longer stride duration (p < .001) compared with the control group. No statistically significant differences were found among the severity groups. These results suggest that the gait kinematic characteristics vary between healthy people and patients recovering from an ankle fracture injury during the short-term period after injury.

Ankle fractures in the elderly: Treatment and results in 477 patients

INTRODUCTION

In the elderly, ankle fractures are likely to cause specific complications and have a major impact on their autonomy. The goal of this multicentre study was to assess these outcomes in a geriatric population treated operatively.

MATERIAL AND METHODS

This retrospective study included 477 patients with ankle fractures treated surgically between 2008 and 2014. The minimum age was 60years for women and 70 for men. Patients with a tibial pilon fracture or less than 3months' follow-up were excluded. Functional (autonomy and comorbidities) and radiological assessments were performed before surgery and at the review.

RESULTS

The cohort was 81% female (384 women, 93 men) and had median age of 74years. The preoperative autonomy was 7.8 points on average using the Parker score. Most of the fractures were either Weber type B (n=336) or type C (n=114). At the follow-up, the mean autonomy score was 7.3 points. The fibula was fixed with a plate and screws in 69% of cases (n=325), with additional internal malleolar fixation was carried out in some cases. A satisfactory result, defined as 2 points or less reduction in the Parker score, was found in 89.9% of patients; 71.8% had not lost any autonomy. The main risk factors for loss of autonomy were being more than 80years of age (OR=2.93, P<0.001), poor surgical reduction (OR=2.8, P<0.01), the presence of two or more comorbidities (OR=2.71, P<0.001), being female (OR=2.19, P<0.043) or having a Weber type C fracture (OR=2.05, P=0.023).

DISCUSSION

The functional results are satisfactory overall following standard surgical treatment consisting of internal malleolar and fibular fixation for ankle fractures in the elderly. We identified five factors that greatly impact functional recovery.

LEVEL OF EVIDENCE

IV.

Primary Retrograde Tibiotalocalcaneal Nailing For Fragility Ankle Fractures

BACKGROUND

Ankle fragility fractures are difficult to treat due to poor bone quality and soft tissues as well as the near ubiquitous presence of comorbidities including diabetes mellitus and peripheral neuropathy. Conventional open reduction and internal fixation in this population has been shown to lead to a significant rate of complications. Given the high rate of complications with contemporary fixation methods, the present study aims to critically evaluate the use of acute hindfoot nailing as a percutaneous fixation technique for high-risk ankle fragility fractures.

METHODS

In this study, we retrospectively evaluated 31 patients treated with primary retrograde tibiotalocalcaneal nail without joint preparation for a mean of 13.6 months postoperatively from an urban Level I trauma center during the years 2006-2012.

RESULTS

Overall, there were two superficial infections (6.5%) and three deep infections (9.7%) in the series. There were 28 (90.3%) patients that went on to radiographic union at a mean of 22.2 weeks with maintenance of foot and ankle alignment. There were three cases of asymptomatic screw breakage observed at a mean of 18.3 months postoperatively, which were all treated conservatively..

CONCLUSIONS

This study shows that retrograde hindfoot nailing is an acceptable treatment option for treatment of ankle fragility fractures. Hindfoot nailing allows early weightbearing, limited soft tissue injury, and a relatively low rate of complications, all of which are advantages to conventional open reduction internal fixation techniques. Given these findings, larger prospective randomized trials comparing this treatment with conventional open reduction internal fixation techniques are warranted.

Dislocation is a risk factor for poor outcome after supination external rotation type ankle fractures

INTRODUCTION

Ankle fractures are one of the most common fractures requiring surgical treatment. Ankle fracture-dislocations are significant injuries to the osseous and soft tissue envelope, but studies focused on the effect of dislocation on radiographic and functional outcomes are lacking. The objective of this study was to evaluate the effect of dislocations on postoperative outcomes in SER IV ankle fracture patients.

MATERIALS AND METHODS

From 2004 through 2010, all operative SER IV ankle fractures treated by a single surgeon were enrolled in a prospective database. SER IV ankle fractures were separated into two groups based on clinical or radiographic evidence of dislocation. The primary and secondary functional outcomes measures were the Foot and Ankle Outcome Score (FAOS) and ankle and subtalar range of motion (ROM) with a minimum of 1-year follow-up, respectively.

RESULTS

108 patients with SER IV ankle fractures were identified, with 73 in the non-dislocation group (68%) and 35 patients in the dislocation group (32%). Patient demographics and co-morbidities were similar between the two groups. The incidence of open fractures and the application of an external fixator were significantly higher in the dislocation group (p = 0.037 and p = 0.003, respectively). The dislocation group showed a significant decrease in the accuracy of articular reduction (p = 0.003). At a mean follow-up of 21 months, ankle fracture-dislocation patients had increased pain (p = 0.005) and decreased activities of daily living (p = 0.014) on FAOS outcome measures and significantly worse ankle and subtalar ROM.

CONCLUSIONS

The results of this study suggest that concurrent dislocation at time of ankle fracture is associated with worse radiographic and functional outcomes, but not an increase in superficial or deep infection. The results from this study may be helpful in counseling patients regarding expected clinical outcomes after ankle fracture-dislocation and in the surgical management of this complex injury.

Prognostic factors of health-related quality of life in patients after tibial plafond fracture. A pilot study

BACKGROUND

Tibial plafond fractures are a uncommon injury, and the outcomes described in literature are generally poor. The purposes were to determine the effect of the tibial plafond fractures on general health-related quality of life, and to examine the factors that influence these outcomes.

METHODS

Retrospective study of 43 patients with average age of 45.6 (range 18-69) years who were also invited for a clinical and radiological reassessment. The primary outcome measure was quality of life assessed by the Short Form-36 questionnaire. Visual analogue scale for pain, and motion of both ankle and subtalar joints were also assessed. Radiological evaluation was performed to assess bone healing, fracture reduction quality, and tibial alignment.

RESULTS

The mean follow-up at last visit was 8.1 (range, 4-12) years. Patients who had suffered plafond fracture had significantly poorer quality of life compared with age- and gender-matched general population of our country regardless of the treatment method used. Multivariate analyses showed that the age had influence on the emotional outcomes, educational level and fracture pattern on physical outcomes, and marital status, fracture reduction quality, and ankle motion on both physical and mental component summaries.

CONCLUSION

Tibial plafond fractures have a significant negative impact on general health-related quality of life regardless of the operative treatment used which reflects injury severity. In addition, psychosocial characteristics of patients may influence the outcomes.

Correlation of visual analogue scale foot and ankle (VAS-FA) to AOFAS score in malleolar fractures using Indian language questionnare

BACKGROUND

Visual analogue scale foot and ankle (VAS-FA score) is a new score, validated in previous studies, but never compared to AOFAS score.

OBJECTIVE

Analysis of the two scores using Indian language questionnaire.

METHODS

Fifty patients with Malleolar fractures were assessed for functional outcome, time for calculation of scores, difficulty in correlation and comprehension of the questionnaire, in Malayalam language. The score parameters were compared by SSPSS.

RESULTS

There was similarity in pattern of score values in both systems but also a difference between values in each category, with VAS-FA having lower values, reflecting its efficacy. There was significant correlation, similar sensitivity and agreement between the scoring systems. VAS-FA correlated better with patient's outcome and required less time for assessment.

CONCLUSION

This study shows that Indian language VAS-FA has a similar pattern of extracting scores as AOFAS and can be an efficient tool in ankle outcome assessment in Indian patients.

Prognosis of physical function following ankle fracture: a systematic review with meta-analysis

STUDY DESIGN

Systematic review and meta-analysis of longitudinal studies.

OBJECTIVES

To quantify the prognosis of physical function following ankle fracture.

BACKGROUND

Information about the course of recovery of physical function after ankle fracture is essential for patient care and health care policy. The existing data have not previously been included in a meta-analysis.

METHODS

Studies were identified using searches of electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PEDro, AMED, SPORTDiscus) and gray literature to September 2012. Studies of people with traumatic ankle fracture were included. Two reviewers independently screened references for inclusion, then extracted data and evaluated risk of bias. The outcome of interest was physical function (physical activity and activity limitation). Outcomes were converted to a common 100-point scale, on which higher scores indicated better outcomes. Meta-regression was conducted using generalized estimating equations.

RESULTS

Thirty-one studies (37 articles) were included. Adults with ankle fracture, present with significant activity limitation in the short term (mean at 1 month, 31.9; 95% confidence interval [CI]: 18.8, 45.1), recovered markedly but incompletely in the short to medium term (mean at 6 months, 78.3; 95% CI: 70.1, 85.1), and showed little further improvement in the long term (mean at 24 months, 86.6; 95% CI: 78.2, 95.0). Studies with older participants and predominantly male participants tended to report worse functional outcomes.

CONCLUSION

Adults typically experience a rapid initial recovery of physical function after ankle fracture (approximately 80% function at 6 months), but, on average, recovery remains incomplete 24 months after injury. PROSPERO registration number: 42012002979.

LEVEL OF EVIDENCE

Prognosis, level 2a.

A case–control study of surgical site infection following operative fixation of fractures of the ankle in a large UK trauma unit

Most of the literature on surgical site infections following the surgical treatment of fractures of the ankle is based on small series of patients, focusing on diabetics or the elderly. None have described post-operative functional scores in those patients who develop an infection. We performed an age- and gender-matched case–control study to identify patient- and surgery-related risk factors for surgical site infection following open reduction and internal fixation of a fracture of the ankle. Logistic regression analysis was used to identify significant risk factors for infection and to calculate odds ratios (OR). Function was assessed using the Olerud and Molander Ankle Score. The incidence of infection was 4% (29/717) and 1.1% (8/717) were deep infections. The median ankle score was significantly lower in the infection group compared with the control group (60 vs 90, Mann–Whitney test p < 0.0001). Multivariate regression analysis showed that diabetes (OR = 15, p = 0.031), nursing home residence (OR = 12, p = 0.018) and Weber C fractures (OR = 4, p = 0.048) were significant risk factors for infection.

A low incidence of infection following open reduction and internal fixation of fractures of the ankle was observed. Both superficial and deep infections result in lower functional scores.

Cite this article: Bone Joint J 2014;96-B:636–40.

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

BACKGROUND

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

METHODS/DESIGN

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

DISCUSSION

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

TRIAL REGISTRATION

Current Controlled Trials ISRCTN04180738.