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Schermann H, Ogawa T, Lubberts B, Waryasz GR, Kaiser P, DiGiovanni CW, Guss D. Open ankle fractures in the elderly: predisposing factors and the associated mortality. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:3015-3021. [PMID: 38869627 DOI: 10.1007/s00590-024-04016-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/31/2024] [Indexed: 06/14/2024]
Abstract
The purpose of this study was to investigate the independent effect of open ankle fractures on postoperative mortality and to identify factors leading to open ankle fractures in the elderly population. This is a retrospective case-control study of 1,045 patients aged 65 years and older, with ankle fractures undergoing surgical fixation between 2010 and 2020 at three medical centers (Levels 1-2). A logistic regression analysis was used to identify risk factors for open fractures. Propensity score matching and survival analysis were used to measure the hazard of mortality attributable to open versus closed ankle fractures. There were 128 (12.2%) patients with open ankle fractures. Patients with open ankle fractures were more likely to be older, to be active smokers (OR = 1.7, p = 0.049), and tended to have a higher number of medical comorbidities including hypertension (OR = 2, p = 0.006) and chronic kidney disease (OR = 2.9, p = 0.005). Open ankle fractures were, independently of comorbid conditions and age, associated with higher risk of mortality (HR = 1.7, p = 0.03).
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Affiliation(s)
- Haggai Schermann
- Adelson School of Medicine, Ariel University, 4070000, Ariel, Israel.
- Division of Orthopedic Surgery, Laniado Hospital, Sanz Medical Center, Netanya, Israel.
| | - Takahisa Ogawa
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Bart Lubberts
- Foot & Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, 158 Boston Post Road, Weston, MA, 02493, USA
| | - Gregory R Waryasz
- Foot & Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, 158 Boston Post Road, Weston, MA, 02493, USA
- Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
- Newton-Wellesley Hospital, Harvard Medical School, 2014 Washington St, Newton, MA, 02462, USA
| | - Philip Kaiser
- Foot & Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, 158 Boston Post Road, Weston, MA, 02493, USA
- Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
- Newton-Wellesley Hospital, Harvard Medical School, 2014 Washington St, Newton, MA, 02462, USA
| | - Christopher W DiGiovanni
- Foot & Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, 158 Boston Post Road, Weston, MA, 02493, USA
- Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
- Newton-Wellesley Hospital, Harvard Medical School, 2014 Washington St, Newton, MA, 02462, USA
| | - Daniel Guss
- Foot & Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, 158 Boston Post Road, Weston, MA, 02493, USA
- Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
- Newton-Wellesley Hospital, Harvard Medical School, 2014 Washington St, Newton, MA, 02462, USA
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Guryel E, McEwan J, Qureshi AA, Robertson A, Ahluwalia R. Consensus on managing open ankle fractures in the frail patient. Bone Jt Open 2024; 5:236-242. [PMID: 38516934 PMCID: PMC10958533 DOI: 10.1302/2633-1462.53.bjo-2023-0155.r1] [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: 03/23/2024] Open
Abstract
Aims Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest. Methods A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS). Results In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures. Conclusion A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing.
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Affiliation(s)
| | - Jo McEwan
- University Hospital Southampton, Southampton, UK
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Hasan YO, Bourget-Murray J, Page P, Penn-Barwell JG, Handley R. Tibiotalar nailing using an antegrade intramedullary tibial nail: a salvage procedure for unstable distal tibia and ankle fractures in the frail elderly patient. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:847-852. [PMID: 37742301 DOI: 10.1007/s00590-023-03735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/10/2023] [Indexed: 09/26/2023]
Abstract
AIM This article describes the technique of tibiotalar nailing performed using an antegrade tibial nail for salvage of distal tibia and ankle fractures in elderly patients. MATERIALS AND METHODS We report indications, surgical technique, and the clinical outcomes and complication rate in our series to date. A retrospective review was performed at our level 1 major trauma centre. Patient demographics, comorbidities, and 12-month post-operative course were collected. Fractures were classified using the OTA/AO and modified Gustilo-Anderson classification. Fifteen patients underwent the procedure. We present data with a minimum 12-month follow-up. The median age of the patients in this cohort was 83 years (range, 51-102). Five patients were diabetic. Six patients (6/15; 40%) presented with an open fracture. RESULTS At final follow-up, fourteen patients reported painless walking and had returned to baseline activity. CONCLUSION This technique may serve as a salvage procedure, with indications similar to those for tibio-talar-calcaneal arthrodesis. Indications would include non-constructible pilon fractures, comminuted intra-articular fractures in low-demand patients, or patients at high risk of wound complications. LEVEL OF CLINICAL EVIDENCE 3.
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Affiliation(s)
- Yusuf Omran Hasan
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom.
- Orthopaedic Department, Salmaniya Medical Complex, Manama, Kingdom of Bahrain.
| | - Jonathan Bourget-Murray
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
- Division of Orthopaedic Surgery, Royal Inland Hospital, Kamloops, Canada
| | - Piers Page
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Jowan G Penn-Barwell
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Robert Handley
- Oxford Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
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Bowers M, Ta C, Vasudevan RS, Trimm CD, Kent WT. Patient Characteristics and Outcomes of Geriatric Ankle Fractures: Open Fracture Is the Key Risk Factor for Complications and Functional Decline. J Orthop Trauma 2024; 38:42-47. [PMID: 38277236 DOI: 10.1097/bot.0000000000002732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/28/2024]
Abstract
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.
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Duvvuri P, Trout SM, Bub CD, Goldman AT. Use of a Hindfoot Nail Without Separate Subtalar and Tibiotalar Joint Preparation to Treat Geriatric Ankle and Distal Tibia Fractures: A Case Series. Geriatr Orthop Surg Rehabil 2023; 14:21514593231195239. [PMID: 37581176 PMCID: PMC10423445 DOI: 10.1177/21514593231195239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 07/15/2023] [Accepted: 07/28/2023] [Indexed: 08/16/2023] Open
Abstract
Introduction Ankle fractures in geriatric patients can be devastating injuries, as they limit an individual's mobility, autonomy, and quality of life. This study examines the functional outcomes and complications related to hindfoot nails (HFN) in geriatric patients who have suffered an ankle malleolar or distal tibia fracture. Materials and Methods This is a single-surgeon case-series of patients who underwent HFN for acute fixation or delayed reconstruction after an ankle or distal tibia fracture. Demographic information, comorbidities, baseline functional status, AO/OTA classification, surgical indications, need for external fixation, total operative time, length of stay (LOS), ambulation at discharge, and discharge disposition were recorded. Primary outcomes included 30-day complications, ambulation at follow-up, and time to fracture union and fusion. Results There were 22 patients, with average age 80.8 years. Mean LOS was 7.0 days, and 68.2% were discharged to subacute rehabilitation. Within 30 days, 1 patient developed a deep vein thrombosis and bilateral pulmonary emboli, and 2 experienced wound dehiscence requiring antibiotics. At 6-weeks, 1 patient sustained a fall with periprosthetic fracture requiring HFN revision, and another developed cellulitis necessitating hardware removal. Fracture healing was seen in 72.7% at 19.4 weeks, while radiographic fusion occurred in 18.2% at 43.0 weeks. 72.7% were ambulating with an assistive device at discharge, and 100.0% at 12-weeks post-operatively or last follow-up. Upon final examination, all patients were ambulating without pain. Discussion HFNs provide a reliable alternative to traditional open reduction internal fixation and have the ability to improve quality of life for geriatric patients through a faster return to weight-bearing. Additionally, radiographic fusion rates show that patients have favorable functional outcomes even without formal arthrodesis. Conclusion HFN is beneficial for elderly patients with low functional demand and complex medical comorbidities, as it allows for early mobility after sustaining an ankle or distal tibia fracture.
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Affiliation(s)
- Priya Duvvuri
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Sally May Trout
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Christine Decker Bub
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Ariel Tenny Goldman
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, New Hyde Park, NY, USA
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Manz WJ, Nash AE, Novak J, Fink J, Kadakia R, Coleman MM, Bariteau JT. Non-emergent Conditions of the Ankle, Hindfoot, and Midfoot in Elderly Patients Are as Mobility Limiting as Congestive Heart Failure. Foot Ankle Spec 2022:19386400221127836. [PMID: 36210764 DOI: 10.1177/19386400221127836] [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: 11/16/2022]
Abstract
BACKGROUND Mobility limitations are well linked to increased morbidity and mortality. Older patients with chronic pathologies of the foot and ankle can suffer from significant mobility limitations; however, the magnitude of limitation experienced by this cohort is not well characterized. Conversely, the effects of congestive heart failure (CHF) on patient mobility are routinely assessed via the New York Heart Association (NYHA) classification. New York Heart Association classification is determined by a patient's physical activity limitation and is strongly correlated to functional status. We hypothesized that non-emergent conditions of the foot and ankle would be as mobility limiting as CHF. METHODS Life-Space Mobility Assessments (LSAs) were prospectively collected from orthopaedic patients at their preoperative visits and from CHF patients at a cardiology clinic. Patients over the age of 50 years were included in this study. Congestive heart failure patients NYHA class II or greater were included. The non-emergent foot and ankle cohort included Achilles tendonitis, ankle joint cartilage defects, ankle arthritis, subtalar arthritis, and midfoot arthritis. Patient demographics and LSA scores were analyzed using Mann-Whitney U and chi-squared tests. RESULTS A total of 96 elderly, non-emergent foot and ankle operative patients and 45 CHF patients met inclusion criteria. All medical comorbidities, except smoking status, were significantly more prevalent in the CHF cohort. No statistical difference was observed between CHF and preoperative foot and ankle LSA scores (56.1 vs 62.4, P = .320). Life-Space Mobility Assessment scores in the foot and ankle cohort were significantly improved relative to CHF patients, at 6-month and 1-year postoperative visits (P = .028, P < .0001, respectively). CONCLUSION Non-emergent ankle, hindfoot, and midfoot pathology is associated with similar mobility limitation to that of NYHA class II and III CHF. Older patients undergoing elective foot and ankle procedures exceeded the mobility of CHF patients at 6 months post-operation, and the mobility gains persisted at 1-year post-operation. LEVELS OF EVIDENCE Level II: Prospective cohort study.
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Affiliation(s)
- Wesley J Manz
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Amalie E Nash
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Jack Novak
- Emory University School of Medicine, Atlanta, Georgia
| | - Juliet Fink
- Emory University School of Medicine, Atlanta, Georgia
| | - Rishin Kadakia
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Michelle M Coleman
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Jason T Bariteau
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
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Cho BK, Kim JB, Choi SM. Efficacy of hook-type locking plate and partially threaded cancellous lag screw in the treatment of displaced medial malleolar fractures in elderly patients. Arch Orthop Trauma Surg 2022; 142:2585-2596. [PMID: 34089372 DOI: 10.1007/s00402-021-03945-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/03/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Traditionally, partially threaded cancellous lag screws (PTCS) are used for most medial malleolar fractures but are often challenging to execute in elderly patients because of the high risk of postoperative complications. Limited literature explores whether hook-type locking compression plates (LCPs) reliably offer better outcomes than PTCS in elderly patients. We aimed to compare the midterm radiologic and clinical outcomes between hook-type LCP and PTCS for medial malleolar fractures in an elderly population. METHODS We included 258 patients, aged 65 years and above, treated with either a hook-type locking plate (hook LCP group: 121 patients) or PTCS (screw group: 137 patients), and with follow-ups of at least 36 months in this retrospective study. Radiographic assessments included the union rate and interval to fracture union. Clinical assessment included the postoperative complications and revision procedures. RESULTS Although a significantly higher rate of comminuted fractures was observed in the hook LCP group than in the screw group (p < .001), no significant difference in the union rate was observed between the two groups (hook LCP group: 93.4% vs. screw group: 89.8%, p = .151), and a significantly shorter interval to union was observed in the hook LCP group (10.2 ± 7.0 vs. 12.3 ± 6.7 weeks, p = .015). There was a trend toward a lower rate of complications, including revision procedures, in the hook LCP group than in the screw group (19.9% vs. 28.5%, p = .107 and 6.6% vs. 13.8%, p = .074). CONCLUSION Hook-type LCP may be an alternative option for treating medial malleolar fractures with comminution in elderly patients.
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Affiliation(s)
- Byung-Ki Cho
- Department of Orthopaedic Surgery, School of Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Jun-Beom Kim
- Wellbone Orthopedic Clinic, Daejeon, Republic of Korea
| | - Seung-Myung Choi
- Department of Orthopedic Surgery, Eulji University School of Medicine, Uijeongbu Hospital, 712, Dongil-ro, Uijeongbu-si, Gyeonggi-do, 11759, Republic of Korea.
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Odeh A, Archer J, Budair B, Marsh A, Fenton P. Management of Open Ankle Fractures in Elderly Patients With a Fibula Nail is a Safe and Reliable Technique. Foot Ankle Spec 2022:19386400221099660. [PMID: 35770327 DOI: 10.1177/19386400221099660] [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: 11/17/2022]
Abstract
BACKGROUND Ankle fractures are becoming more common in the elderly and their management is frequently challenging. There is increasing evidence of good outcomes following fibula nail fixation in the management of ankle fractures. The use of a fibula nail in open fractures comes with potential advantages such as minimal soft tissue dissection, early rehabilitation, and decreased wound complications. We aimed to assess their use in the management of open ankle fractures in the elderly. METHODS A review of patients aged 60 years or older with an open ankle fracture treated with a fibular nail at a major trauma center was conducted. All patients were managed with joint Orthopaedic and Plastic Surgical input to determine their optimal management. Functional outcome scores, postoperative complications, and re-operation rates were determined. RESULTS Fifteen patients were identified with a mean age of 76 years. Patient-reported outcomes (Olerud and Molander Score) were calculated in 73% of patients. Our results demonstrated excellent outcome scores (>91) in 1 patient, good outcome scores (61-90) in 7 patients, and fair outcome scores (31-60) in 3 patients. There were no postoperative complications or re-operations within our study group. CONCLUSION This article is the largest series presenting the outcomes of fibula nails in the management of open ankle fractures in elderly patients. We conclude that it can be used as a treatment option to safely manage open ankle fractures in the elderly. It provides a stable fixation, early weight-bearing, low risk of postoperative complications while maintaining good patient-reported functional outcomes. LEVEL OF EVIDENCE Level 4.
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Malyavko A, Quan T, Stoll WT, Manzi JE, Gu A, Tabaie S, Stein BE. Association of Bleeding Disorders and Risk of Complications Following Open Reduction and Internal Fixation of the Ankle. Foot Ankle Int 2022; 43:551-559. [PMID: 34852658 DOI: 10.1177/10711007211058163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open reduction and internal fixation (ORIF) of the ankle is a common procedure performed to correct ankle fractures in many different patient populations. Diabetes, peripheral vascular disease, and osteoporosis have been identified as risk factors for postoperative complications following surgery for ankle fractures. To date, there have not been any studies evaluating postoperative outcomes in patients with bleeding disorders undergoing operative treatment for ankle fractures. The aim of this study was to determine the postoperative complication rate following ORIF of the ankle in patients with a bleeding disorder vs those without a bleeding disorder. METHODS From 2006 to 2018, patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database. Two patient cohorts were defined: patients with a bleeding disorder and patients without a bleeding disorder. Patients who underwent either inpatient or outpatient ORIF of the ankle were included in this study. In this analysis, demographics, medical comorbidities, and postoperative complications variables were assessed between the 2 cohorts. Bivariate and multivariate analyses were performed. RESULTS Of 10 306 patients undergoing operative treatment for ankle fracture, 9909 patients (96.1%) had no bleeding disorder whereas 397 patients (3.9%) had a bleeding disorder. Following adjustment on multivariate analysis, compared to patients who did not have a bleeding disorder, those with a bleeding disorder had an increased risk of any postoperative complications (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.05-2.08, P = .024), requirement for postoperative blood transfusion (OR 2.86, 95% CI 1.53-5.36, P = .001), and extended length of hospital stay greater than 5 days (OR 1.46, 95% CI 1.10-1.93, P = .010). CONCLUSION Patients with bleeding disorders are associated with increased risk of postoperative complications following ORIF for ankle fractures. Determining patient risk factors and creating optimal preoperative and perioperative management plans in patients with bleeding disorders undergoing ORIF can be beneficial in reducing postoperative complications, improving patient outcomes, and reducing overall morbidity. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Alisa Malyavko
- Department of Orthopedic Surgery, George Washington Hospital, Washington, DC, USA
| | - Theodore Quan
- Department of Orthopedic Surgery, George Washington Hospital, Washington, DC, USA
| | - William T Stoll
- Department of Orthopedic Surgery, George Washington Hospital, Washington, DC, USA
| | | | - Alex Gu
- Department of Orthopedic Surgery, George Washington Hospital, Washington, DC, USA
| | - Sean Tabaie
- Department of Orthopaedic Surgery, Children's National Health System, Washington, DC, USA
| | - Benjamin E Stein
- Department of Orthopaedic Surgery, Johns Hopkins Sibley Memorial Hospital, Washington, DC, USA
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Schuijt HJ, Lehmann LS, Javedan H, von Keudell AG, Weaver MJ. A Culture Change in Geriatric Traumatology: Holistic and Patient-Tailored Care for Frail Patients with Fractures. J Bone Joint Surg Am 2021; 103:e72. [PMID: 33974580 DOI: 10.2106/jbjs.20.02149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Medical decision-making for frail geriatric trauma patients is complex, especially toward the end of life. The goal of this paper is to review aspects of end-of-life decision-making, such as frailty, cognitive impairment, quality of life, goals of care, and palliative care. Additionally, we make recommendations for composing a patient-tailored treatment plan. In doing so, we seek to initiate the much-needed discussion regarding end-of-life care for frail geriatric patients.
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Affiliation(s)
- Henk Jan Schuijt
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Soleymani Lehmann
- Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Houman Javedan
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Arvind G von Keudell
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael John Weaver
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Boston, Massachusetts
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Evaluation of Geriatric Fractures Admitted to the Emergency Department According to Years and Seasons. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.939625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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12
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Kyriacou H, Mostafa AMHAM, Davies BM, Khan WS. Principles and guidelines in the management of ankle fractures in adults. J Perioper Pract 2021; 31:427-434. [PMID: 33826430 PMCID: PMC8575982 DOI: 10.1177/1750458920969029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Ankle fractures are common injuries that have many physical and psychosocial complications. As a result, it is important to be aware of how these patients present and are managed perioperatively. Detailed guidelines from NICE and the British Orthopaedic Association have been produced on this topic, including recent developments such as the decision to weight-bear early after surgery and the use of virtual fracture clinics. This article provides an overview of the key perioperative factors that need to be considered in cases of ankle fracture and the relevant clinical guidelines.
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Affiliation(s)
- Harry Kyriacou
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Benjamin M Davies
- Department of Trauma & Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | - Wasim S Khan
- Department of Trauma & Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
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Scheer RC, Newman JM, Zhou JJ, Oommen AJ, Naziri Q, Shah NV, Pascal SC, Penny GS, McKean JM, Tsai J, Uribe JA. Ankle Fracture Epidemiology in the United States: Patient-Related Trends and Mechanisms of Injury. J Foot Ankle Surg 2021; 59:479-483. [PMID: 32354504 DOI: 10.1053/j.jfas.2019.09.016] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 09/11/2019] [Indexed: 02/03/2023]
Abstract
Current nationwide epidemiological data regarding ankle fractures are scarce. Such information is important towards better quantifying the mortality associated with such injuries, financial impact, as well as the implementation of preventative measures. This study evaluated the epidemiology of ankle fractures that occurred during a 5-year period. Specifically, we evaluated demographics, mechanism of injury, and disposition. The National Electronic Injury Surveillance System was queried to identify all patients with ankle fractures that presented to US hospital emergency departments between 2012 and 2016. Census data were used to determine the incidence rates of ankle fractures in terms of age, sex, and race. There was an estimated total of 673,214 ankle fractures that occurred during this period, with an incidence rate of 4.22/10,000 person-years. The mean age of patients with an ankle fracture was 37 ± 22.86 (SD) years; 23.5% of ankle fractures occurred in patients aged 10 to 19 years (7.56/10,000 person-years). In addition, 44% of ankle fractures occurred in men (3.81/10,000 person-years), whereas 56% occurred in women (4.63/10,000 person-years). Data on race/ethnicity were available for 71% of the subjects, with incidence rates of 2.85/10,000 person-years for whites, 3.01/10,000 person-years for blacks, and 4.08/10,000 person-years for others. The most common mechanism of injury was falls (54.83%), followed by sports (20.76%), exercise (16.84%), jumping (4.42%), trauma (2.84%), and other (0.30%). For disposition, 81.84% of patients were treated and released, 1.43% were transferred, 16.01% were admitted, 0.59% were held for observation, and 0.13% left against medical advice. The highest incidence of ankle fractures in men occurred in the 10-to-19-years age group, but women were more commonly affected in all other age groups.
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Affiliation(s)
- Ryan C Scheer
- Medical Student, Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY
| | - Jared M Newman
- Orthopaedic Surgery Resident, Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY.
| | - Jack J Zhou
- Medical Student, Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY
| | - Alvin J Oommen
- Medical Student, Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY
| | - Qais Naziri
- Orthopaedic Surgeon, Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY; Orthopaedic Surgeon, Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Neil V Shah
- Orthopaedic Surgery Resident, Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY
| | - Scott C Pascal
- Orthopaedic Surgery Resident, Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY
| | - Gregory S Penny
- Orthopaedic Surgery Resident, Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY
| | - Jason M McKean
- Orthopaedic Surgeon, Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY; Orthopaedic Surgeon, Department of Orthopaedic Surgery, Brookdale University Hospital Medical Center, Brooklyn, NY
| | - Justin Tsai
- Orthopaedic Surgeon, Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, New York, NY
| | - Jaime A Uribe
- Assistant Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY
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Using the STTGMA Risk Stratification Tool to Predict Complications, Additional Operations, and Functional Outcomes After Ankle Fracture. J Orthop Trauma 2021; 35:e134-e141. [PMID: 32890072 DOI: 10.1097/bot.0000000000001955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the usefulness of a validated trauma triage score to stratify postdischarge complications, secondary procedures, and functional outcomes after ankle fracture. DESIGN Retrospective cohort. SETTING Level 1 trauma center. PATIENTS Four hundred fifteen patients 55 years of age and older with 431 ankle fractures. INTERVENTION Closed or open reduction. MAIN OUTCOME MEASUREMENTS Score for Trauma Triage in Geriatric and Middle-Aged Patients (STTGMA), postdischarge complications, secondary operations, Foot Function Index (FFI, n = 167), and Short Musculoskeletal Function Assessment (SMFA, n = 165). RESULTS Mean age was 66 years, 38% were men, and 68% of fractures were secondary to ground-level falls. Forty patients (9.6%) required an additional procedure, with implant removal most common (n = 21, 5.1%), and 102 (25%) experienced a postdischarge complication. On multiple linear regression, STTGMA was not a significant independent predictor of complications or secondary procedures. Patients completed FFI and SMFA surveys a median of 62 months (5.2 years) after injury. On the FFI, low-risk STTGMA stratification was an independent predictor of worse functional outcomes. Similarly, low-risk stratification was a predictor of worse scores on the SMFA dysfunction and daily activity subcategories (both B > 10, P < 0.05). CONCLUSIONS Low-risk STTGMA stratification predicted worse long-term function. The STTGMA tool was not able to meaningfully stratify risk of postdischarge complications and secondary procedures after ankle fracture. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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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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Predicting Length of Stay and Readmissions After an Ankle Fracture Using a Risk Stratification Tool (STTGMA). J Orthop Trauma 2020; 34:e407-e413. [PMID: 33065665 DOI: 10.1097/bot.0000000000001788] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the usefulness of a validated trauma triage score to stratify short-term outcomes including hospital length of stay (LOS), in-hospital complications, discharge location, and rate of readmission after an ankle fracture. DESIGN Retrospective cohort. SETTING Level 1 trauma center. PATIENTS Four hundred fifteen patients, age ≥55 with 431 ankle fractures. INTERVENTION Closed or open reduction. MAIN OUTCOME MEASUREMENTS Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA). RESULTS Of the 415 patients, 38% were male, 72% were white, and the mean age was 66 years. The mean LOS was 4.4 days, and this increased from 2.6 days in the minimal-risk group to 11.8 days in the high-risk group (P < 0.001). Similarly, 74% of minimal-risk patients were discharged home versus 13% of high-risk patients (P < 0.001). There were 19 readmissions (4.6%) within 30 days, ranging from 1.5% to 10% depending on the risk cohort (P = 0.006). Seventy-three patients (18%) experienced an in-hospital complication. On multiple linear regression, moderate- and high-risk STTGMA stratification was predictive of a longer hospital LOS, and moderate-risk STTGMA stratification was predictive of subsequent readmission after injury. CONCLUSIONS Calculation of the STTGMA score is helpful for stratifying patients according to hospital LOS and readmission rates, which have substantial bearing on resource utilization and cost of care. The STTGMA tool may allow for effective identification of patients to potentially ameliorate these common issues and to inform payers and policymakers regarding patients at risk for greater costs of care. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Simske NM, Benedick A, Audet MA, Vallier HA. Ankle fractures in patients over age 55 years: Predictors of functional outcome. OTA Int 2020; 3:e080. [PMID: 33937704 PMCID: PMC8023118 DOI: 10.1097/oi9.0000000000000080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 03/12/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To identify predictors of functional outcomes following treatment of ankle fracture in patients 55 years or older. SETTING Level 1 Trauma Center. PATIENTS/PARTICIPANTS Four hundred twenty-nine patients with torsional ankle fractures (44A-C): 233 patients (54%) were ages 55 to 64, 25% were between the ages 65 and 74; 21% were 75 years or older. INTERVENTION Operative or nonoperative management of ankle fracture. MAIN OUTCOME MEASURE Early complications were assessed for all patients after minimum of 6 months, and functional outcome scores as assessed by the Foot Function Index (FFI; n = 166, 39%) and Short Musculoskeletal Function Assessment (SMFA; n = 168, 39%) after median 57 months follow-up. RESULTS Surgical management was elected in 67% of patients. Nonoperative management became more common with advancing age and was associated with fewer unplanned operations (12% vs 3%, P < .01) and complications (21% vs 13%, P = .07). African American race was associated with worse pain on the FFI (P = .002) and BMI was associated with worse (higher) scores on all categories of the FFI and SMFA (all P < .05). Diabetes, neuropathy, and mental illness were also predictive of worse scores on various categories of both surveys. Assistive device use or nonambulatory status at the time of injury was associated with worse disability/dysfunction, activity, and mobility scores on both the FFI and SMFA (all P > 15, P < .05). Sex, Hispanic ethnicity, tobacco use, open fracture, dislocation, fracture pattern, and operative management were not independent predictors in this regression model. CONCLUSIONS Baseline health and ambulatory capacity at injury were more predictive of outcomes following ankle fracture than were fracture characteristics or type of treatment.
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Affiliation(s)
- Natasha M Simske
- MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, Ohio
| | - Alex Benedick
- MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, Ohio
| | - Megan A Audet
- MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, Ohio
| | - Heather A Vallier
- MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, Ohio
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Abstract
INTRODUCTION The incidence of geriatric ankle fractures is rising. With the substantial variation in the physiologic and functional status within this age group, our null hypothesis was that mortality and complications of open reduction and internal fixation (ORIF) between patients who are aged 65 to 79 are equivalent to ORIF in patients who are aged 80 to 89. METHODS Patients with ankle fracture were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Patients treated with ORIF were identified using the Current Procedural Terminology codes. Patients were divided into two age cohorts: 65 to 79 years of age and 80 to 89 years of age. The primary outcome studied was 30-day mortality. Secondary outcomes included 30-day readmission, revision surgery, surgical site infection, sepsis, wound dehiscence, pulmonary embolism, deep vein thrombosis, blood transfusion, urinary tract infection, pneumonia, stroke, myocardial infarction, renal insufficiency or failure, and length of hospital stay. RESULTS Our cohort included 2,353 ankle fractures: 1,877 were among 65 to 79 years of age and 476 were among 80 or older. Thirty-day mortality was 3.2-fold higher in the 80 to 89 years of age group compared with the 65 to 79 years of age group (1.47% versus 0.48%, P = 0.019). However, after controlling for the ASA class, 80 to 89 years of age patients no longer had a significantly higher mortality (P = 0.0647). Similarly, revision surgery rate (3.36% versus 1.81%, P = 0.036), transfusion requirement (2.94% versus 1.49%, P = 0.033), urinary tract infection (1.89% versus 0.75%, P = 0.023), and hospital length of stay (4.9 versus 2.9 days, P < 0.0001) were all significantly higher in the 80 to 90 years of age group compared with the 65 to 79 years old group. However, after controlling for the ASA class, 80 to 89 years old patients no longer had a rate of complications in comparison to the 65 to 79 years old age group. DISCUSSION After controlling for comorbidities (ie, the ASA class), no increased risk is observed for the 30-day mortality or complication rate between geriatric ankle fracture in the 65 to 79 years old and the 80 to 99 years old age groups. LEVEL OF EVIDENCE Prognostic level III, retrospective study.
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Passias BJ, Korpi FP, Chu AK, Myers DM, Grenier G, Galos DK, Taylor B. Safety of Early Weight Bearing Following Fixation of Bimalleolar Ankle Fractures. Cureus 2020; 12:e7557. [PMID: 32382461 PMCID: PMC7202576 DOI: 10.7759/cureus.7557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Ankle fractures are common orthopedic injuries. Although operative indications and subsequent stabilization of these fractures have not significantly changed, postoperative protocols remain highly variable. Effects of early weight bearing (EWB) on fracture characteristics in operatively stabilized bimalleolar and bimalleolar equivalent ankle fractures remain poorly publicized. This study seeks to clarify postoperative fracture union rates, rates of hardware loosening or failure, and radiographic medial clear space changes when comparing EWB to late weight bearing (LWB) following open reduction and internal fixation (ORIF). A total of 95 patients with either bimalleolar (66%) or bimalleolar equivalent (34%) fractures who underwent ORIF were retrospectively reviewed. Weight bearing was allowed at three weeks in the EWB group and when signs of radiographic union were noted in the LWB group. Postoperatively, patients were evaluated at regular intervals for fracture union, signs of implant failure, and evidence of medial clear space widening radiographically. There were 38 patients (40%) in the EWB group and 57 patients (60%) comprising the LWB cohort. There were no significant demographic differences between groups. The EWB group on average began to weight bear at 3.1 + 1.4 weeks postoperatively, whereas the LWB group began at 7.2 + 2.1 weeks postoperatively (p<0.01). Union rate (p=0.51), time to union (p=0.23), and implant failure (p>0.1 at all time intervals) were not notably different between groups. No differences in medial clear space were detected at any postoperative interval between groups (p>0.1 at all time intervals). This study suggests that EWB at three weeks postoperatively does not increase markers of radiographic failure compared to six weeks of non-weight bearing (NWB), which has been regarded as the gold standard of treatment to allow for healing; this may represent an improvement to rehabilitation protocols after bimalleolar ankle ORIF of unstable ankle fractures.
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Affiliation(s)
| | | | - Anson K Chu
- Foot and Ankle Surgery, OhioHealth, Columbus, USA
| | | | | | - David K Galos
- Orthopedic Trauma, Nassau University Medical Center, Great Neck, USA
| | - Benjamin Taylor
- Orthopedic Trauma, OhioHealth Grant Medical Center, Columbus, USA
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Abstract
The number of ankle fractures in elderly patients is increasing. The aim of treatment of ankle fractures in the elderly is to guarantee a possible unlimited autonomy and quality of life for patients. This is achieved by minimization of the complications and impairments after ankle joint fractures. Decisive for the further course is the initial treatment. The results are essentially determined by the soft tissue management, reduction and stable osteosynthesis; however, an orthogeriatric co-management with the implementation of treatment paths and standard operating procedures is recommended. The advantages of an interdisciplinary cooperation of trauma surgeons and geriatricians are obvious in this situation.
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Hsu RY, Ramirez JM, Blankenhorn BD. Surgical Considerations for Osteoporosis in Ankle Fracture Fixation. Orthop Clin North Am 2019; 50:245-258. [PMID: 30850082 DOI: 10.1016/j.ocl.2018.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
As the geriatric population and associated ankle fractures continues to increase, fracture surgeons should be prepared to surgically manage osteoporotic ankle fractures. There are abundant challenges in management, soft tissue care, and fixation of ankle fractures with poor bone quality especially in elderly patients who have difficulty limiting weight bearing. This article summarizes several different surgical techniques that can be used to optimize outcomes of these fractures.
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Affiliation(s)
- Raymond Y Hsu
- Department of Orthopedic Surgery, The Warren Alpert Medical School at Brown University, 1 Kettle Point Avenue, East Providence, RI 02915, USA.
| | - Jose M Ramirez
- Department of Orthopedic Surgery, The Warren Alpert Medical School at Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Brad D Blankenhorn
- Department of Orthopedic Surgery, The Warren Alpert Medical School at Brown University, 1 Kettle Point Avenue, East Providence, RI 02915, USA
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Tuckett P, Hope M, Tetsworth K, Van De Pol J, McDougall C. Transarticular tibiotalocalcaneal nailing versus open reduction and internal fixation for treatment of the elderly ankle fracture: protocol for a multicentre, prospective, randomised controlled trial. BMJ Open 2019; 9:e026360. [PMID: 30670529 PMCID: PMC6347874 DOI: 10.1136/bmjopen-2018-026360] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Ankle fractures are common in the elderly population. Surgical fixation is technically challenging and often results in complications due to high rates of osteoporosis and vascular disease. Open reduction and internal fixation (ORIF) often requires prolonged periods of non-weight bearing increasing the risks of complications. Tibiotalocalcaneal (TTC) nailing has been suggested as an alternative to ORIF which allows immediate weight bearing, and is suggested to result in fewer complications. This study aims to compare the two surgical techniques in the elderly population with ankle fractures. METHODS AND ANALYSIS The study will be a multicentre, prospective, randomised controlled trial comparing ORIF to TTC nailing in 110 patients with ankle fractures aged 50 or above with a Charlson Comorbidity Index of greater than or equal to four. Participants and assessors will not be blinded to intervention. The primary outcome measure will be overall complication rate. Secondary outcomes include length of hospital stay, mobility at discharge, discharge destination, the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score, the Olerud-Molander Ankle Score, mortality rate, rate of secondary surgical interventions and number of blood transfusions required postoperatively. Our null hypothesis is that there is no clinically significant difference in the primary outcome measure between the two treatment groups. ETHICS AND DISSEMINATION The study has been approved by Metro South Hospital and Health Services Human Research Ethics Committee (EC00167) (reference number HREC/17/QPAH/351). DISCUSSION Completion of this trial will provide evidence on the effectiveness of TTC nailing versus ORIF in treatment of the elderly ankle fracture. If TTC nailing is found to result in superior outcomes, this trial has the capacity to change current clinical practice. TRIAL REGISTRATION NUMBER ACTRN12617001588381;Pre-results andU1111-1203-1704.
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Affiliation(s)
- Paul Tuckett
- Department of Orthopaedics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Matthew Hope
- Department of Orthopaedics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Kevin Tetsworth
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jerry Van De Pol
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Catherine McDougall
- Department of Orthopaedics, The Prince Charles Hospital, Chermside, Queensland, Australia
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Kadakia RJ, Ahearn BM, Schwartz AM, Tenenbaum S, Bariteau JT. Ankle fractures in the elderly: risks and management challenges. Orthop Res Rev 2017; 9:45-50. [PMID: 30774476 PMCID: PMC6209347 DOI: 10.2147/orr.s112684] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Ankle fractures are the third most common osseous injury in the elderly, behind hip and distal radius fractures. While there is a rich history of clinical advancement in the timing, technique, perioperative management, and associated risks of hip fractures, similar evaluations are only more recently being undertaken for ankle fractures. Traditionally, elderly patients were treated more conservatively; however, nonoperative management has been found to be associated with increased mortality. As such, older and less healthy patients have become operative candidates. The benefits of geriatric/orthopedic inpatient comanagement that have been well elucidated in the hip fracture literature also seem to improve outcomes in elderly patients with ankle fractures. One of the orthopedist’s roles is to recognize the complexities of osteoporotic bone fixation and optimize wound healing potential. Though the immediate cost of this surgical approach is inevitably higher, the ultimate cost of long-term care has been found to be substantially reduced. It is important to consider the mortality and morbidity benefits and cost reductions of operative intervention and proper inpatient care of geriatric ankle fractures when they present to the emergency department or the office.
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Affiliation(s)
- Rishin J Kadakia
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA,
| | - Briggs M Ahearn
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA,
| | - Andrew M Schwartz
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA,
| | - Shay Tenenbaum
- Department of Orthopedic Surgery, Chaim Sheba Medical Center at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jason T Bariteau
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA,
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Hoogervorst P, Bergen CV, Van den Bekerom M. Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly. CURRENT GERIATRICS REPORTS 2017; 6:9-14. [PMID: 28316904 PMCID: PMC5334400 DOI: 10.1007/s13670-017-0196-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Purpose of Review Treatment of osteoporotic and neuropathic ankle fractures in the elderly is challenging. The purpose of this paper is to review recent publications on this topic and to identify the optimal treatment for these fractures. Recent Findings Treatment consists of a variety of conservative or operative options all with advantages and disadvantages as described in this review. Little research has been published that specifically focuses on elderly patients with ankle fractures. Operative treatment has a high complication rate. Multiple comorbidities are predictors for complications. Summary An optimal treatment could not be distilled but based on the available literature, a general treatment algorithm is proposed. Since the elderly typically are accompanied by multiple comorbidities as well as impaired mobility, the physician should focus not only on treating the fractured ankle but also on the patient as a whole. Further research on this specific topic is needed.
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Affiliation(s)
- P Hoogervorst
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC Amsterdam, the Netherlands
| | - Cja Van Bergen
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM Hoofddorp, the Netherlands
| | - Mpj Van den Bekerom
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC Amsterdam, the Netherlands
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Masrouha KZ, Tamim H, Taha A, Sheikh Taha AM, Abi-Melhem R, Al-Taki M. Comparison of Early Adverse Events After Operative Treatment of Bimalleolar and Trimalleolar Fractures Versus Pilon Fractures. J Foot Ankle Surg 2016; 56:332-335. [PMID: 28041949 DOI: 10.1053/j.jfas.2016.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Indexed: 02/03/2023]
Abstract
Ankle fractures requiring open reduction and internal fixation vary in severity from unimalleolar fractures to bimalleolar/trimalleolar (BT) fractures to pilon fractures. Consequently, the postoperative outcomes with these surgeries can vary. Most previous studies of these injuries had small sample sizes, studied a single risk factor or adverse event, or did not compare different injuries by severity. The purpose of the present study was to describe and compare the patient characteristics and postoperative outcomes of 2 high-energy ankle fractures: BT and pilon fractures. The relevant patients were identified from the American College of Surgeons National Surgical Quality Improvement Program database using the Current Procedural Terminology codes for BT and pilon fractures. Patient demographics, characteristics, comorbidities, and 30-day mortality and adverse events were recorded and compared between the 2 types of ankle fractures. More than 45% of patients with these fracture types were aged 40 to 65 years. Pilon fractures occurred more frequently in younger patients, were more likely to occur in men, required a longer hospital stay and operative time, were less likely to occur in patients with a body mass index of >30 kg/m2, and conferred a greater risk of wound complications (odds ratio 1.76; p = .048) compared with BT fractures. The findings from the present study help us understand the differences in patient characteristics and potential early adverse events after open reduction and internal fixation of BT fractures versus pilon fractures.
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Affiliation(s)
- Karim Z Masrouha
- Chief Orthopaedic Resident, Division of Orthopaedic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Tamim
- Associate Professor of Medicine, Director of the Biostatistics Unit, Clinical Research Unit, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Assad Taha
- Associate Professor of Clinical Surgery, Division of Orthopaedic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdel Majid Sheikh Taha
- Instructor of Clinical Surgery, Division of Orthopaedic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Racha Abi-Melhem
- Medical Student, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Muhyeddine Al-Taki
- Assistant Professor of Clinical Surgery, Assistant Director of Operating Room Administration, Division of Orthopaedic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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