Prediction of outcome after ankle fracture

Effectiveness of supervised versus self-directed rehabilitation for adults aged 50 years and over with ankle fractures: protocol for the AFTER trial

Aims

Ankle fractures are common, mainly affecting adults aged 50 years and over. To aid recovery, some patients are referred to physiotherapy, but referral patterns vary, likely due to uncertainty about the effectiveness of this supervised rehabilitation approach. To inform clinical practice, this study will evaluate the effectiveness of supervised versus self-directed rehabilitation in improving ankle function for older adults with ankle fractures.

Methods

This will be a multicentre, parallel-group, individually randomized controlled superiority trial. We aim to recruit 344 participants aged 50 years and older with an ankle fracture treated surgically or non-surgically from at least 20 NHS hospitals. Participants will be randomized 1:1 using a web-based service to supervised rehabilitation (four to six one-to-one physiotherapy sessions of tailored advice and prescribed home exercise over three months), or self-directed rehabilitation (provision of advice and exercise materials that participants will use to manage their recovery independently). The primary outcome is participant-reported ankle-related symptoms and function six months after randomization, measured by the Olerud and Molander Ankle Score. Secondary outcomes at two, four, and six months measure health-related quality of life, pain, physical function, self-efficacy, exercise adherence, complications, and resource use. Due to the nature of the interventions, participants and intervention providers will be unblinded to treatment allocation.

Conclusion

This study will assess whether supervised rehabilitation is more effective than self-directed rehabilitation for adults aged 50 years and older after ankle fracture. The results will provide evidence to guide clinical practice. At the time of submission, the trial is currently completing recruitment, and follow-up will be completed in 2024.

Predictive Factors of Functional Outcomes and Quality of Life in Patients with Ankle Fractures: A Systematic Review

Background: Evaluating the predictors of unfavorable outcomes in patients with ankle fractures is crucial for identifying high-risk patients and implementing personalized treatment strategies. This study aimed to analyze factors that influence quality of life in patients with ankle fractures. Methods: Four databases were consulted. The main outcomes were functionality and quality of life scales combined using the standard mean difference (SMD) (Review Manager 5.4). Results: Eight studies with 2486 patients were included. A significant correlation was found between female sex and worse functionality scores (beta 4.15, 95% CI 1.84-6.46). Additionally, older age was correlated with worse functionality scores (beta -0.24, 95% CI -0.29 to -0.19). Patients with diabetes or metabolic syndrome also had worse outcomes (SMD 0.27, 95% CI 0.18-0.36). High BMI and obesity were also associated with worse quality of life scores (beta 2.62, 95% CI 0.77-4.48). Smokers had greater disability in the analyzed scales (SMD 0.22, 95% CI 0.05-0.39). No significant differences were observed with respect to syndesmotic involvement. Conclusions: Age, sex, diabetes, high BMI, and smoking negatively impact functional outcomes and quality of life in patients with ankle fractures.

Differences and relationships between weightbearing and non-weightbearing dorsiflexion range of motion in foot and ankle injuries

BACKGROUND

This study aimed to: (1) identify assessment methods that can detect greater ankle dorsiflexion range of motion (DROM) limitation in the injured limb; (2) determine whether differences in weightbearing measurements exist even in the absence of DROM limitations in the injured limb according to non-weightbearing measurements; and (3) examine associations between DROM in the weightbearing and non-weightbearing positions and compare those between a patient group with foot and ankle injuries and a healthy group.

METHODS

Eighty-two patients with foot and ankle injuries (e.g., fractures, ligament and tendon injuries) and 49 healthy individuals participated in this study. Non-weightbearing DROM was measured under two different conditions: prone position with knee extended and prone position with knee flexed. Weightbearing DROM was measured as the tibia inclination angle (weightbearing angle) and distance between the big toe and wall (weightbearing distance) at maximum dorsiflexion. The effects of side (injured, uninjured) and measurement method on DROM in the patient groups were assessed using two-way repeated-measures ANOVA and t-tests. Pearson correlations between measurements were assessed. In addition, we analyzed whether patients without non-weightbearing DROM limitation (≤ 3 degrees) showed limitations in weightbearing DROM using t-tests with Bonferroni correction.

RESULTS

DROM in patient groups differed significantly between legs with all measurement methods (all: P < 0.001), with the largest effect size for weightbearing angle (d = 0.95). Patients without non-weightbearing DROM limitation (n = 37) displayed significantly smaller weightbearing angle and weightbearing distance on the injured side than on the uninjured side (P < 0.001 each), with large effect sizes (d = 0.97-1.06). Correlation coefficients between DROM in non-weightbearing and weightbearing positions were very weak (R = 0.17, P = 0.123) to moderate (R = 0.26-0.49, P < 0.05) for the patient group, and moderate to strong for the healthy group (R = 0.51-0.69, P < 0.05).

CONCLUSIONS

DROM limitations due to foot and ankle injuries may be overlooked if measurements are only taken in the non-weightbearing position and should also be measured in the weightbearing position. Furthermore, DROM measurements in non-weightbearing and weightbearing positions may assess different characteristics, particularly in patient group.

LEVEL OF EVIDENCE

Level IV, cross-sectional study.

[Factors associated with functionality in patients with closed ankle fracture]

Background

Ankle fractures are among the most frequent fractures in the lower limb, predominantly affecting young people and representing approximately 9% of all fractures.

Objective

To identify the factors associated with functionality in patients with closed ankle fracture.

Material and methods

Observational and retrospective study. Records of people with a diagnosis of ankle fractures admitted to rehabilitation between January to December 2020 in a Physical Medicine and Rehabilitation Unit of a third level hospital were included. Age, sex, body mass index (BMI), days of disability, mechanism of injury, type of treatment, length of stay in rehabilitation, type of fracture and functionality were captured. Chi-squared and Student's t test were used to determine the association. Subsequently a multivariate analysis with binary logistic regression was performed.

Results

The average age of the subjects was 44.8 years, the female sex was presented in 54.7%, the average BMI was 28.8%, 66% carried out a paid work activity, 65% received surgical treatment, the average time of disability was 140 days, the factors associated with functionality independently were age, pain, dorsiflexion and plantar flexion upon admission to rehabilitation.

Conclusions

Ankle fractures occur in a young population and the factors associated with functionality were age, dorsiflexion, plantar flexion, and pain upon admission to rehabilitation.

Progressive exercise versus best practice advice for adults aged 50 years or over after ankle fracture: the AFTER pilot randomised controlled trial

OBJECTIVE

The aim of the Ankle Fracture Treatment: Enhancing Rehabilitation (AFTER) study, a multicentre external pilot parallel-group randomised controlled trial (RCT), was to assess feasibility of a definitive trial comparing rehabilitation approaches after ankle fracture.

SETTING

Five UK National Health Service hospitals.

PARTICIPANTS

Participants were aged 50 years and over with an ankle fracture requiring immobilisation for at least 4 weeks.

INTERVENTIONS

Participants were allocated 1:1 via a central web-based randomisation system to: (1) best practice advice (one session of physiotherapy, up to two optional additional advice sessions) or (2) progressive exercise (up to six sessions of physiotherapy).

PRIMARY OUTCOME MEASURES

Feasibility: (1) participation rate, (2) intervention adherence and (3) retention.

RESULTS

Sixty-one of 112 (54%) eligible participants participated, exceeding progression criteria for participation of 25%. Recruitment progression criteria was 1.5 participants per site per month and 1.4 was observed. At least one intervention session was delivered for 28/30 (93%) of best practice advice and 28/31 (90%) of progressive exercise participants, exceeding the 85% progression criteria. For those providing follow-up data, the proportion of participants reporting performance of home exercises in the best practice advice and the progressive exercise groups at 3 months was 20/23 (87%) and 21/25 (84%), respectively. Mean time from injury to starting physiotherapy was 74.1 days (95% CI 53.9 to 94.1 days) for the best practice advice and 72.7 days (95% CI 54.7 to 88.9) for the progressive exercise group. Follow-up rate (6-month Olerud and Molander Ankle Score) was 28/30 (93%) for the best practice advice group and 26/31 (84%) in the progressive exercise group with an overall follow-up rate of 89%.

CONCLUSIONS

This pilot RCT demonstrated that a definitive trial would be feasible. The main issues to address for a definitive trial are intervention modifications to enable earlier provision of rehabilitation and ensuring similar rates of follow-up in each group.

TRIAL REGISTRATION NUMBER

ISRCTN16612336.

Blood-flow restricted exercise following ankle fractures - A feasibility study

BACKGROUND

The objective was to investigate the feasibility of blood flow restricted exercise (BFRE) as a rehabilitation modality in patients with a unilateral ankle fracture.

METHODS

Feasibility study with a prospective cohort design. Inclusion criteria were above 18 years of age and unilateral ankle fractures.

EXCLUSION CRITERIA

history of cardiac or embolic diseases, cancer, diabetes, hypertension and family history of cardio or vascular diseases. The predefined feasibility outcome was based on three criteria regarding patients experience with participating in the BFRE protocol and the absence of any serious adverse events.

RESULTS

Eight patients were included. Median age was 33 years (range: 23-60). All eight patients reported maximum satisfaction on the two questions regarding patient's perception of the overall experience with BFRE training and the feasibility to introduce BFRE as an intervention.

CONCLUSION

Early use of BFRE in patients with unilateral ankle fractures seems feasible in patients without comorbidity.

Association of Delayed Surgery for Ankle Fractures and Patient-Reported Outcomes

BACKGROUND

Several studies probe the association between prolonged time to surgery and postoperative complications in ankle fractures, but little is known about how a longer wait time affects clinical outcomes. The present study aims to assess the association between time from injury to surgery and patient-reported outcomes after operative treatment of severe ankle fractures.

METHOD

Patients treated operatively for low-energy ankle fractures that also involve the posterior malleolus from 2014 to 2016 were included. Patient charts were reviewed for patient demographics, type of trauma, fracture characteristics, treatment given, and complications. Ankle function was evaluated on a follow-up visit by clinical examination, radiographs, and patient-reported outcome measures (Self-Reported Foot and Ankle Score [SEFAS], RAND-36, visual analog scale [VAS] of Pain, VAS of Satisfaction). We compared patients treated within 1 week to those treated later than a week from injury for analyses.

RESULTS

Follow-up visits of 130 patients were performed at mean 26 (SD 9) months after surgery. Patient demographics and fracture characteristics were similar between groups. Mean SEFAS was 34 (SD 10) in patients treated later than a week from injury vs 38 (SD 9) in those treated earlier (P = .012). Patients operated on later than 7 days from injury reported more pain (P = .008) and lower satisfaction than those treated earlier (P = .016).

CONCLUSION

In this retrospective patient series of low-energy ankle fractures with posterior malleolar fragments, we found that waiting >7 days for definitive surgery was associated with poorer clinical outcomes and more pain compared with those who had surgery earlier.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The association between person and fracture characteristics with patient reported outcome after ankle fractures in adults: A systematic review

BACKGROUND

The incidence of ankle fractures is increasing and the clinical outcome is highly variable.

QUESTION

What person and fracture characteristics are associated with patient reported outcomes after surgically or conservatively managed ankle fractures in adults?

DATA SOURCES

Medline, EMBASE, and Allied and Complimentary Health Medical Database (AMED) databases were searched from the earliest available date until 16th July 2020.

STUDY SELECTION

Prognostic factors studies recruiting adults of age 18 years or older with a radiologically confirmed ankle fracture, and evaluating function, symptoms and quality of life by patient reported outcome measures, were included.

STUDY APPRAISAL/SYNTHESIS METHODS

Risk of bias of individual studies was assessed by the Quality in Prognostic Factors Studies tool. Correlation coefficients were calculated and data were analysed using narrative synthesis.

RESULTS

Fifty-one phase 1 explanatory studies with 6177 participants met the inclusion criteria. Thirty-one studies were rated as high risk of bias using the Quality in Prognostic Factors Studies tool. There was low quality evidence that age, body mass index, American Society of Anesthesiologists classification and pre-injury mobility were associated with function, and low to moderate quality evidence that age, smoking and American Society of Anesthesiologists classification were associated with quality of life. No person characteristics were associated with symptoms and no fracture characteristics were associated with any outcomes.

CONCLUSION

There was low to moderate quality evidence that person characteristics may be associated with patient reported function and quality of life following ankle fracture.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020184830.

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.

Gait Alterations in Adults after Ankle Fracture: A Systematic Review

(1) Background: Ankle fracture results in pain, swelling, stiffness and strength reduction, leading to an altered biomechanical behavior of the joint during the gait cycle. Nevertheless, a common pattern of kinematic alterations has still not been defined. To this end, we analyzed the literature on instrumental gait assessment after ankle fracture, and its correlation with evaluator-based and patient-reported outcome measures. (2) Methods: We conducted a systematic search, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, of articles published from January 2000 to June 2021 in PubMed, Embase and PEDro on instrumental gait assessment after ankle fracture. (3) Results: Several changes in gait occur after ankle fracture, including a reduction in step length, swing time, single support time, stride length, cadence, speed and an earlier foot-off time in the affected side. Additionally, trunk movement symmetry (especially vertical) is significantly reduced after ankle fracture. The instrumental assessments correlate with different clinical outcome measures. (4) Conclusions: Instrumental gait assessment can provide an objective characterization of the gait alterations after ankle fracture. Such assessment is important not only in clinical practice to assess patients’ performance but also in clinical research as a reference point to evaluate existing or new rehabilitative interventions.

Determinants of functional outcome following ankle fracture

Objectives:

To assess the patient and injury characteristics that impact functional outcomes after ankle fracture.

Design:

Retrospective study.

Setting:

Urban level I trauma center.

Patients/Participants:

One thousand patients underwent fixation of ankle fracture (AO/OTA 44) between 2006 and 2015. Four hundred sixteen completed functional outcome surveys by telephone or mail at a mean of 5.9 years after injury.

Intervention:

Open reduction internal fixation.

Main outcome measure:

Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA).

Results:

Mean age was 46.7 years, with 46.2% male. Higher (worse) FFI scores were seen in tobacco users (38.9 vs 30.1), recreational drug users (45.9 vs 32.7), and the morbidly obese (52.0 vs 30.6), all P < .005. Higher (worse) SMFA dysfunction and bothersome scores were also seen in these groups, and in females and alcohol users. Multiple regression analysis identified female gender, obesity, tobacco and alcohol use, complications, secondary procedures, and multiple additional injuries as independent predictors of higher scores (all P < .04). Fracture patterns, open fracture, and development of arthritis had no impact on FFI or SMFA scores.

Conclusion:

Patient characteristics, not under surgeon-control, such as female sex, obesity, and substance use, appear to contribute to patient-reported functional outcome scores more than injury characteristics.

Level of Evidence:

Level 3, prognostic

Quality of life and complications in elderly patients after pronation rotation type III ankle fractures treated with a cast and early weight-bearing

Background

Early weight-bearing is becoming increasingly common because it can positively affect the quality of life of patients. Therefore, the efficacy and safety of this conservative treatment should be assessed for different types of ankle fractures. The goal of this study was to compare early weight-bearing and non-weight-bearing in terms of effectiveness and safety in patients with pronation rotation type III ankle fractures treated nonsurgically.

Methods

A prospective multicenter cohort study was conducted over two years. Elderly patients with a nondisplaced pronation rotation type III ankle fracture were included. The main variables were the Barthel Index and SF-12 scores. The patients completed the questionnaires at six weeks, one year and two years. We also compared the complications associated with the two interventions.

Results

30 patients were included in the weight-bearing group, while 32 patients were included in the non-weight-bearing (WB) group. The mean ages were 82.6 ± 2.6 years and 83.1 ± 2.6 years, respectively. Quality of life, measured with the SF-12 scale, increased significantly in both the short and long term in the WB group (53.5 ± 5.8 points vs 65.2 ± 4.4 points at 6 weeks and 70.1 ± 4.2 points vs. 80.9 ± 3.7 points at 2 years; p<0.001). The WB group also showed a higher quality of life, as measured by the Barthel Index (54.5 ± 5.2 points vs. 64.3 ± 4.0 points at 6 weeks and 71.0 ± 4.3 points vs. 80.7 ± 3.4 points at 2 years; p<0.001).

Conclusions

Elderly patients with pronation rotation type III fractures could benefit from an early weight-bearing protocol in terms of quality of life and functionality.

Patient Outcomes Following Ankle Fracture Fixation

BACKGROUND

Several studies have reported on potential negative predictive factors of functional outcomes after ankle fracture fixation. However, there is minimal patient-reported data on long-term outcomes. This study aimed to evaluate potential risk factors leading to a poor patient-reported functional outcome at 2 and 5 years following ankle fracture fixation.

METHODS

We conducted a prospective cohort study over a 5-year period on patients undergoing open reduction and internal fixation for unstable ankle fractures. Patient demographics, medical comorbidities, fracture pattern, and fixation quality were recorded and analyzed. Patients were followed up at 2 and 5 years. Data collected include the Olerud-Molander Ankle Score (OMAS), Lower Extremity Functional Scale (LEFS), ongoing issues, and the need for further intervention. A P value <.05 was considered statistically significant.

RESULTS

Out of 180 patients, follow-up data were available for 82 (46%) patients at 2 years and 94 (52%) patients at 5 years. At 2 years, age ≥60 years was a predictor of worse LEFS, while a body mass index ≥30 was a predictor of worse OMAS. Severely deformed ankle at presentation showed worse OMAS and LEFS score. However, these predictive factors were not significant at 5 years. An anatomically reduced ankle fracture fixation was more likely to have a better functional outcome at the 2- and 5-year follow-ups. A reduction in OMAS at 2 years was predictive of possible ongoing issues following surgery, which in turn increased the odds of worsening OMAS at 5 years.

CONCLUSION

Achieving adequate fracture reduction during fixation is crucial for better ankle functional recovery postinjury. In this cohort, we found that patients who undergo ankle fracture fixation will have an ongoing negative impact on their functional and physical capacity at both 2 and 5 years postoperatively. Appropriate patient counseling is necessary to prepare them for the expected functional outcomes.

LEVEL OF EVIDENCE

Level II, prognostic.

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.

Measuring recovery after open lower limb fractures: combined objective functional tests and global perceived recovery outperform narrower metrics and a standard generic patient reported outcome measure

BACKGROUND

Open lower limb fractures are serious injuries requiring combined ortho-plastic surgery and have significantly worse outcomes than similar closed fractures. There is little objective published data to determine which functional outcome measures best reflect progress or completeness of physical recovery. Our hypothesis was that objective measures combining strength, mobility and balance would better reflect recovery than isolated parameters (e.g. range of motion ROM) and would compare well to patients' perceived recovery.

METHODS

Adult open lower limb fracture patients were reviewed 6 and 12 weeks, 6, 9 and 12 months post-injury. The mechanism, injury pattern, age, gender and treatment were recorded. Isolated parameter objective functional outcome measures (OFOMs) (ROM and MRC strength grade) were compared to combined OFOMs (timed up and go, comfortable gait speed and fast gait speed, Edgren Side Step Test (TUAG, CGS, FGS, ESST) and Single Leg balance. Patient reported outcomes were recorded (Global Perceived Effect (GPE) score and Disability Rating Index (DRI)). Statistical analysis used non-parametric tests (e.g. Spearman correlation) compared each with time since injury.

RESULTS

Sixty-eight patients (54 male) with a median age of 45(20-75) years. Of the 19 isolated OFOMs, only knee flexion and ankle plantar flexion ROM and strength improved with time (Spearman correlation p = 0.042, 0.008, 0.032, 0.036 respectively). TUAG, ESST, CGS, FGS and GPE scores showed significant improvement (Spearman correlation p < 0.001). Patients' estimation of recovery paralleled these measures (Spearman correlation p < 0.001) with all but 2 patients achieving the minimum clinical important difference in DRI by 12 months compared to baseline. However, the GPE score had a higher proportion of improving responses than DRI at each time-point.

DISCUSSION

Functional recovery is a key determinant in patients returning to work, providing for themselves and their family or resuming independent living for older patients. This study has demonstrated time-related improvements in combined OFOMs measuring mobility, strength, agility and balance paralleling patients' perception of recovery in the 12 months after open lower limb fractures. Over the same time-frame, the simple GPE score compared favourably with the DRI. Such parameters could become part of a defined core outcomes set. Focussing rehabilitation towards these combined OFOMs may help hasten recovery.

TRIAL REGISTRATION

South West Wales REC 06/WMW02/10).

Traditional Approach vs Posterior Approach for Ankle Fractures Involving the Posterior Malleolus

BACKGROUND

In the past, posterior malleolus fragments (PMFs) commonly have been indirectly reduced and fixed when fragments involve 25% or more of the tibial articular surface, while smaller fragments were left unfixed. The posterior approach has become increasingly popular and allows fixation of even smaller fragments. This study compares clinical outcome for the 2 treatment strategies.

METHODS

Patients with ankle fractures involving a PMF treated from 2014 to 2016 were eligible for inclusion. Patients were allocated to group A (treated with a posterior approach) or group B (treated with the traditional approach) according to the treatment given. A one-to-one matching of patients from each group based on the size of the PMF was performed. Patient charts were reviewed, and outcome evaluation was performed clinically, radiographically, and by patient-reported outcome measures (PROMs; Self-Reported Foot and Ankle Score, RAND-36, visual analog scale [VAS] of pain, and VAS of satisfaction). Forty-three patients from each group were matched. Median follow-up was 26 (interquartile range [IQR], 19-35) months postoperatively.

RESULTS

The median PMF size was 17% (IQR, 12-24) in both groups, and they reported similar results in terms of PROMs. Fixation of the PMF was performed in 42 of 43 (98%) patients in group A and 7 of 43 (16%) patients in group B (P < .001). The former group more frequently got temporary external fixation (56% vs 12%, P < .01) and less frequently had syndesmotic fixation (14% vs 49%, P < .01), and they had less mechanical irritation and hardware removal but more noninfectious skin problems (28% vs 5%, P < .01). Median time from injury to definitive surgery (8 vs 0 days, P < .001) and median length of stay (12 vs 3 days, P < .001) were longer in group A.

CONCLUSION

Comparison of treatment strategies for ankle fractures involving the posterior malleolus showed similar results between patients treated with a traditional approach and a posterior approach.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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°.

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.

Progressive functional exercise versus best practice advice for adults aged 50 years or over after ankle fracture: protocol for a pilot randomised controlled trial in the UK - the Ankle Fracture Treatment: Enhancing Rehabilitation (AFTER) study

INTRODUCTION

Ankle fractures result in significant morbidity in adults, with prognosis worsening with increasing age. Previous trials have not found evidence supporting supervised physiotherapy sessions, but these studies have not focused on older adults or tailored the exercise interventions to the complex needs of this patient group. The Ankle Fracture Treatment: Enhancing Rehabilitation study is a pilot randomised controlled trial to assess feasibility of a later definitive trial comparing best-practice advice with progressive functional exercise for adults aged 50 years and over after ankle fracture.The main objectives are to assess: (i) patient engagement with the trial, measured by the participation rate of those eligible; (ii) establish whether the interventions are acceptable to participants and therapists, assessed by intervention adherence levels, participant interviews and a therapist focus group; (iii) participant retention in the trial, measured by the proportion of participants providing outcome data at 6 months; (iv) acceptability of measuring outcomes at 3 and 6 month follow-up.

METHODS AND ANALYSIS

A multicentre pilot randomised controlled trial with an embedded qualitative study. At least 48 patients aged 50 years and over with an ankle fracture requiring surgical management, or non-operative management by immobilisation for at least 4 weeks, will be recruited from a minimum of three National Health Service hospitals in the UK. Participants will be allocated 1:1 via a central web-based randomisation system to: (i) best-practice advice (one session of face-to-face self-management advice delivered by a physiotherapist and up to two optional additional sessions) or (ii) progressive functional exercise (up to six sessions of individual face-to-face physiotherapy). An embedded qualitative study will include one-to-one interviews with up to 20 participants and a therapist focus group.

ETHICS AND DISSEMINATION

Hampshire B Research Ethics Committee (18/SC/0281) gave approval on 2^nd July 2018.

TRIAL REGISTRATION NUMBER

ISRCTN16612336.

Validation of the Western Ontario and McMaster Universities Osteoarthritis Index in Patients Having Undergone Ankle Fracture Surgery

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) is a patient-reported outcome measure (PROM) that is widely used to evaluate the pain, stiffness, and physical function of patients with osteoarthritis of the hip and knee. Although the WOMAC has also been used for patients after foot and ankle surgery, it has not been validated for this purpose. A total of 130 patients with surgically treated ankle fractures completed the WOMAC, Visual Analogue Scale Foot and Ankle (VAS FA), Lower Extremity Functional Scale (LEFS), 15D Health-Related Quality-of-Life Questionnaire (15D), and Visual Analog Scale for General Health (VAS general health) after foot and ankle surgery. The structural validity of the WOMAC was assessed by using Cronbach's α, and convergent validity was tested between the WOMAC and reference outcome measures. Cronbach's α for the index score was 0.98 and 0.95, 0.86, and 0.98 for the Pain, Stiffness, and Physical Function subscales, respectively. The Spearman correlation coefficients were ‒0.84, ‒0.74, ‒0.58, and 0.55 for the VAS-FA, LEFS, 15D, and VAS general health, respectively. The relationships with the VAS-FA, LEFS, 15D, and VAS general health were strong. All relationships were statistically significant (p < .001). The WOMAC provides valid scores for assessing pain, stiffness, and physical function in patients having undergone ankle fracture surgery.

Predicting patient-reported and objectively measured functional outcome 6 months after ankle fracture in people aged 60 years or over in the UK: prognostic model development and internal validation

OBJECTIVE

To predict functional outcomes 6 months after ankle fracture in people aged ≥60 years using post-treatment and 6-week follow-up data to inform anticipated recovery, and identify people who may benefit from additional monitoring or rehabilitation.

DESIGN

Prognostic model development and internal validation.

SETTING

24 National Health Service hospitals, UK.

METHODS

Participants were the Ankle Injury Management clinical trial cohort (n=618) (ISRCTN04180738), aged 60-96 years, 459/618 (74%) female, treated surgically or conservatively for unstable ankle fracture. Predictors were injury and sociodemographic variables collected at baseline (acute hospital setting) and 6-week follow-up (clinic). Outcome measures were 6-month postinjury (primary) self-reported ankle function, using the Olerud and Molander Ankle Score (OMAS), and (secondary) Timed Up and Go (TUG) test by blinded assessor. Missing data were managed with single imputation. Multivariable linear regression models were built to predict OMAS or TUG, using baseline variables or baseline and 6-week follow-up variables. Models were internally validated using bootstrapping.

RESULTS

The OMAS baseline data model included: alcohol per week (units), postinjury EQ-5D-3L visual analogue scale (VAS), sex, preinjury walking distance and walking aid use, smoking status and perceived health status. The baseline/6-week data model included the same baseline variables, minus EQ-5D-3L VAS, plus five 6-week predictors: radiological malalignment, injured ankle dorsiflexion and plantarflexion range of motion, and 6-week OMAS and EQ-5D-3L. The models explained approximately 23% and 26% of the outcome variation, respectively. Similar baseline and baseline/6 week data models to predict TUG explained around 30% and 32% of the outcome variation, respectively.

CONCLUSIONS

Predictive accuracy of the prognostic models using commonly recorded clinical data to predict self-reported or objectively measured ankle function was relatively low and therefore unlikely to be beneficial for clinical practice and counselling of patients. Other potential predictors (eg, psychological factors such as catastrophising and fear avoidance) should be investigated to improve predictive accuracy.

TRIAL REGISTRATION NUMBER

ISRCTN04180738; Post-results.

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.

Adverse Radiographic Outcomes Following Operative Treatment of Medial Malleolar Fractures

BACKGROUND

We initiated a retrospective study on ankle fractures to assess (1) the time needed for fracture union; (2) the incidence of adverse radiographic outcomes (AROs); (3) factors that might lead to AROs; and (4) whether AROs were associated with worse function and higher incidence of post-trauma osteoarthritis (PTOA).

METHODS

From 2007 to 2016, a total of 296 patients (169 women, 127 men; average age, 48.6 years; range, 20-84) were diagnosed with a medial malleolar fracture, whether isolated or in the setting of bi- or trimalleolar fractures, and underwent open reduction and internal fixation (ORIF) or percutaneous screw fixation (PSF). The interval to fracture union, radiographic outcomes, American Orthopaedic Foot & Ankle Society (AOFAS) score at 6 months postoperatively, and the incidence of PTOA were recorded. Risk factors were identified both in univariate and multivariate analysis. The average follow-up period was 52.0 months (range, 12-118).

RESULTS

The incidence of delayed union, nonunion, and malunion were 20.3%, 3.7%, and 4.4%, respectively. The interval to fracture union was 10.3 ± 6.4 weeks. In the multivariate analysis, the risk factors for AROs were tobacco use, vertical fractures, interposed soft tissue, and fair/poor reduction. Patients with AROs had significantly worse AOFAS score at 6 months postoperatively ( P < .001) and higher incidence of PTOA ( P < .001).

CONCLUSION

AROs of medial malleolar fractures have an underestimated incidence rate and are associated with worse ankle function and higher incidence of PTOA. Risk factors including tobacco use, vertical fractures, interposed soft tissue, poor/fair reduction should be prudently taken into consideration when treating medial malleolar fractures.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years

BACKGROUND

Close contact casting (CCC) may offer an alternative to open reduction and internal fixation (ORIF) surgery for unstable ankle fractures in older adults.

OBJECTIVES

We aimed to (1) determine if CCC for unstable ankle fractures in adults aged over 60 years resulted in equivalent clinical outcome compared with ORIF, (2) estimate cost-effectiveness to the NHS and society and (3) explore participant experiences.

DESIGN

A pragmatic, multicentre, equivalence randomised controlled trial incorporating health economic evaluation and qualitative study.

SETTING

Trauma and orthopaedic departments of 24 NHS hospitals.

PARTICIPANTS

Adults aged over 60 years with unstable ankle fracture. Those with serious limb or concomitant disease or substantial cognitive impairment were excluded.

INTERVENTIONS

CCC was conducted under anaesthetic in theatre by surgeons who attended training. ORIF was as per local practice. Participants were randomised in 1 : 1 allocation via remote telephone randomisation. Sequence generation was by random block size, with stratification by centre and fracture pattern.

MAIN OUTCOME MEASURES

Follow-up was conducted at 6 weeks and, by blinded outcome assessors, at 6 months after randomisation. The primary outcome was the Olerud-Molander Ankle Score (OMAS), a patient-reported assessment of ankle function, at 6 months. Secondary outcomes were quality of life (as measured by the European Quality of Life 5-Dimensions, Short Form questionnaire-12 items), pain, ankle range of motion and mobility (as measured by the timed up and go test), patient satisfaction and radiological measures. In accordance with equivalence trial US Food and Drug Administration guidance, primary analysis was per protocol.

RESULTS

We recruited 620 participants, 95 from the pilot and 525 from the multicentre phase, between June 2010 and November 2013. The majority of participants, 579 out of 620 (93%), received the allocated treatment; 52 out of 275 (19%) who received CCC later converted to ORIF because of loss of fracture reduction. CCC resulted in equivalent ankle function compared with ORIF at 6 months {OMAS 64.5 points [standard deviation (SD) 22.4 points] vs. OMAS 66.0 points (SD 21.1 points); mean difference -0.65 points, 95% confidence interval (CI) -3.98 to 2.68 points; standardised effect size -0.04, 95% CI -0.23 to 0.15}. There were no differences in quality of life, ankle motion, pain, mobility and patient satisfaction. Infection and/or wound problems were more common with ORIF [29/298 (10%) vs. 4/275 (1%)], as were additional operating theatre procedures [17/298 (6%) vs. 3/275 (1%)]. Malunion was more common with CCC [38/249 (15%) vs. 8/274 (3%); p < 0.001]. Malleolar non-union was lower in the ORIF group [lateral: 0/274 (0%) vs. 8/248 (3%); p = 0.002; medial: 3/274 (1%) vs. 18/248 (7%); p < 0.001]. During the trial, CCC showed modest mean cost savings [NHS mean difference -£644 (95% CI -£1390 to £76); society mean difference -£683 (95% CI -£1851 to £536)]. Estimates showed some imprecision. Incremental quality-adjusted life-years following CCC were no different from ORIF. Over common willingness-to-pay thresholds, the probability that CCC was cost-effective was very high (> 95% from NHS perspective and 85% from societal perspective). Experiences of treatments were similar; both groups endured the impact of fracture, uncertainty regarding future function and the need for further interventions.

LIMITATIONS

Assessors at 6 weeks were necessarily not blinded. The learning-effect analysis was inconclusive because of limited CCC applications per surgeon.

CONCLUSIONS

CCC provides a clinically equivalent outcome to ORIF at reduced cost to the NHS and to society at 6 months.

FUTURE WORK

Longer-term follow-up of trial participants is under way to address concerns over potential later complications or additional procedures and their potential to impact on ankle function. Further study of the patient factors, radiological fracture patterns and outcomes, treatment responses and prognosis would also contribute to understanding the treatment pathway.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN04180738.

FUNDING

The National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 75. See the NIHR Journals Library website for further project information. This report was developed in association with the National Institute for Health Research Oxford Biomedical Research Unit funding scheme. The pilot phase was funded by the AO Research Foundation.

Cross-Sectional Study to Assess the Functional Outcome of Neglected Bimalleolar Fracture

INTRODUCTION

Ankle fracture is the most common intra-articular fracture of a weight-bearing joint and accounts for 9% of all fractures. Ankle fractures are classified into 3 subgroups: unimalleolar, bimalleolar, and trimalleolar fractures. Accurate reduction and stable internal fixation is necessary in bimalleolar fractures; otherwise, it may lead to posttraumatic painful restriction of movements or osteoarthritis. The purpose of this study is to assess the functional outcome and results of treatment of neglected bimalleolar fracture.

MATERIALS AND METHODS

Seventeen neglected bimalleolar fracture patients were treated with open reduction and internal fixation. Patients were followed-up at 1, 2, and 5 years and functional ability was assessed by using the modified Weber Rating Scale.

RESULTS

The mean age of patients was 41.4 ± 13.28 years. After 2 year of surgery, 13 out of 17 patients showed excellent results and 4 patients had fair results.

CONCLUSION

Good to excellent functional results were observed after long-term follow-up in neglected bimalleolar fracture treated with open reduction and internal fixation, and we advise surgical intervention in all such patients.

LEVELS OF EVIDENCE

Therapeutic, Level III: Retrospective Cohort study.

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.

Reduced Physical Activity in People Following Ankle Fractures: A Longitudinal Study

STUDY DESIGN

Longitudinal observational cohort.

BACKGROUND

The impact of ankle fracture on physical activity and sitting time and the course of recovery of physical activity are unclear.

OBJECTIVES

To assess the course of recovery of physical activity after ankle fracture and the extent to which this population may be less physically active and more sedentary than the general population.

METHODS

A cohort of individuals with ankle fracture was derived from a randomized trial and assessed with the International Physical Activity Questionnaire-Short Form (IPAQ-SF) at immobilization removal and 1, 3, and 6 months later. Total metabolic equivalent (MET) minutes per week were calculated to evaluate the course of recovery of physical activity. Sitting time (minutes per day) and the percentage of those who met the World Health Organization physical activity guidelines were calculated. Normative data were derived from a population-based cohort study that assessed physical activity using the IPAQ-SF.

RESULTS

In people with ankle fracture (n = 214), physical activity increased in the first month (from a median of 99 at immobilization removal to 979 MET min/wk) and leveled off by 6 months (1386 MET min/wk). Only 22% of the ankle fracture cohort met World Health Organization guidelines at immobilization removal, compared to 80% of the cohort from the general population (P<.001). This difference diminished over time. Sitting time in the ankle fracture cohort was higher than population norms at all time points (P<.001).

CONCLUSION

People with ankle fracture are less physically active and more sedentary than the general population. Strategies to increase physical activity must be considered. LEVEL OF EVIDENCE Prognosis, level 4.

Manual Physical Therapy Following Immobilization for Stable Ankle Fracture: A Case Series

STUDY DESIGN

Case series.

BACKGROUND

Ankle fractures commonly result in persistent pain, stiffness, and functional impairments. There is insufficient evidence to favor any particular rehabilitation approach after ankle fracture. The purpose of this case series was to describe an impairment-based manual physical therapy approach to treating patients with conservatively managed ankle fractures.

CASE DESCRIPTION

Patients with stable ankle fractures postimmobilization were treated with manual physical therapy and exercise targeted at associated impairments in the lower limb. The primary outcome measure was the Lower Extremity Functional Scale. Secondary outcome measures included the ankle lunge test, numeric pain-rating scale, and global rating of change. Outcome measures were collected at baseline (performed within 7 days of immobilization removal) and at 4 and 12 weeks postbaseline.

OUTCOMES

Eleven patients (mean age, 39.6 years; range, 18-64 years; 2 male), after ankle fracture-related immobilization (mean duration, 48 days; range, 21-75 days), were treated for an average of 6.6 sessions (range, 3-10 sessions) over a mean of 46.1 days (range, 13-81 days). Compared to baseline, statistically significant and clinically meaningful improvements were observed in Lower Extremity Functional Scale score (P = .001; mean change, 21.9 points; 95% confidence interval: 10.4, 33.4) and in the ankle lunge test (P = .001; mean change, 7.8 cm; 95% confidence interval: 3.9, 11.7) at 4 weeks. These changes persisted at 12 weeks.

DISCUSSION

Statistically significant and clinically meaningful improvements in self-reported function and ankle range of motion were observed at 4 and 12 weeks following treatment with impairment-based manual physical therapy. All patients tolerated treatment well. Results suggest that this approach may have efficacy in this population.

LEVEL OF EVIDENCE

Therapy, level 4.

Clinical outcomes following ankle fracture: a cross-sectional observational study

Background

The purpose of the current study was to examine objective and subjective differences between three severity groups of ankle fractures patients compared to healthy controls.

Methods

This was a case-controlled study. 92 patients with an ankle fracture injury of which 41 patients were eligible to participate in the study. 72 healthy people served as controls. All patients underwent a computerized gait test, completed self-assessment questionnaires (The Foot and Ankle Outcome Score (FAOS) and the SF-36), evaluated with the American Foot and Ankle Score (AOFAS) form and completed the 6-min walk test. The control group performed a computerized gait test and completed the SF-36 health survey.

Results

All ankle fracture patients presented compromised gait patterns and limb symmetry compared to controls (p < 0.05). Ankle fracture patients also had lower SF-36 scores compared to controls (p < 0.05). Significant differences were found between the unimalleolar group compared to the bimalleolar and trimalleolar groups in most parameters, except for the FAOS scores. There were no significant differences between the bimalleolar fracture group and the trimalleolar fracture groups.

Conclusions

Although all fracture severity classification groups presented a compromised gait pattern and worse clinical symptoms compared to controls, it seems that patients with a unimalleolar fracture is a different group compared to bimalleolar and trimalleolar fracture. Furthermore, it seems that bimalleolar fracture and trimalleolar fracture affect the gait pattern and clinical symptoms to an equal extent, at least in the short-term.

Trial registration

NCT01127776.

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.

Weight-bearing ankle dorsiflexion range of motion-can side-to-side symmetry be assumed?

CONTEXT

In clinical practice, the range of motion (ROM) of the non involved side often serves as the reference for comparison with the injured side. Previous investigations of non-weight-bearing (NWB) ankle dorsiflexion (DF) ROM measurements have indicated bilateral symmetry for the most part. Less is known about ankle DF measured under weight-bearing (WB) conditions. Because WB and NWB ankle DF are not strongly correlated, there is a need to determine whether WB ankle DF is also symmetrical in a healthy population.

OBJECTIVE

To determine whether WB ankle DF is bilaterally symmetrical. A secondary goal was to further explore the correlation between WB and NWB ankle DF ROM.

DESIGN

Cross-sectional study.

SETTING

Training facility of the Israeli Defense Forces.

PATIENTS OR OTHER PARTICIPANTS

A total of 64 healthy males (age = 19.6 ± 1.0 years, height = 175.0 ± 6.4 cm, and body mass = 71.4 ± 7.7 kg).

MAIN OUTCOME MEASURE(S)

Dorsiflexion ROM in WB was measured with an inclinometer and DF ROM in NWB was measured with a universal goniometer. All measurements were taken bilaterally by a single examiner.

RESULTS

Weight-bearing ankle DF was greater on the nondominant side compared with the dominant side (P < .001). Non-weight-bearing ankle DF was not different between sides (P = .64). The correlation between WB and NWB DF was moderate, with the NWB DF measurement accounting for 30% to 37% of the variance of the WB measurement.

CONCLUSIONS

Weight-bearing ankle DF ROM should not be assumed to be bilaterally symmetrical. These findings suggest that side-to-side differences in WB DF may need to be interpreted while considering which side is dominant. The difference in bilateral symmetry between the WB and NWB measurements, as well as the only moderate level of correlation between them, suggests that both measurements should be performed routinely.

Reliability and validity of a weight-bearing measure of ankle dorsiflexion range of motion

PURPOSE

To examine reliability and validity of the Lunge Test (LT) of dorsiflexion range of motion and determine the impact of different approaches to obtain a score on these parameters.

METHODS

Fifty-three patients with ankle injury/dysfunction provided initial assessment data for cross-sectional convergent and known-groups validity analysis with the Pearson coefficient (r) and paired t-test, respectively; data after 4-8 weeks of treatment for longitudinal validity analysis with coefficient r; and data 3 days later for test-retest reliability using the intra-class correlation coefficient (ICC) and minimal detectable change (MDC). LT scores were determined for the affected leg only (LTAff) and for the difference between the two limbs (LTDiff). Two strategies were used to calculate LT scores: a single series and the mean of three series of lunges. LTs were correlated with the Lower Extremity Functional Scale and Global Foot and Ankle Scale.

RESULTS

Reliability coefficients were high (ICC=0.93-0.99). The MDC=1.0/1.5 cm, LTAff/LTDiff, respectively. Cross-sectional validity was confirmed for LTDiff (r=-0.40 to -0.50). Between-limb differences (p<0.05) supported known-groups validity. Longitudinal validity was supported for both LT change scores (r=0.39-0.63). The number of series of lunges used did not impact results.

CONCLUSIONS

A single series of lunges produces a reliable LT score. From a validity perspective, clinicians should use LTDiff on initial assessment and either LT to assess change.

Predicting functional recovery after acute ankle sprain

Introduction

Ankle sprains are among the most common acute musculoskeletal conditions presenting to primary care. Their clinical course is variable but there are limited recommendations on prognostic factors. Our primary aim was to identify clinical predictors of short and medium term functional recovery after ankle sprain.

Methods

A secondary analysis of data from adult participants (N = 85) with an acute ankle sprain, enrolled in a randomized controlled trial was undertaken. The predictive value of variables (age, BMI, gender, injury mechanism, previous injury, weight-bearing status, medial joint line pain, pain during weight-bearing dorsiflexion and lateral hop test) recorded at baseline and at 4 weeks post injury were investigated for their prognostic ability. Recovery was determined from measures of subjective ankle function at short (4 weeks) and medium term (4 months) follow ups. Multivariate stepwise linear regression analyses were undertaken to evaluate the association between the aforementioned variables and functional recovery.

Results

Greater age, greater injury grade and weight-bearing status at baseline were associated with lower function at 4 weeks post injury (p<0.01; adjusted R square=0.34). Greater age, weight-bearing status at baseline and non-inversion injury mechanisms were associated with lower function at 4 months (p<0.01; adjusted R square=0.20). Pain on medial palpation and pain on dorsiflexion at 4 weeks were the most valuable prognostic indicators of function at 4 months (p< 0.01; adjusted R square=0.49).

Conclusion

The results of the present study provide further evidence that ankle sprains have a variable clinical course. Age, injury grade, mechanism and weight-bearing status at baseline provide some prognostic information for short and medium term recovery. Clinical assessment variables at 4 weeks were the strongest predictors of recovery, explaining 50% of the variance in ankle function at 4 months. Further prospective research is required to highlight the factors that best inform the expected convalescent period, and risk of recurrence.

Factors associated with mobility outcomes in older people post-ankle fracture: an observational cohort study focussing on peripheral vessel function

INTRODUCTION

There are increasing numbers of older persons sustaining ankle fractures. This injury often results in a degree of functional limitation, particularly in older patients. There is currently limited research into factors associated with mobility outcomes.

DESIGN

Observational cohort study.

SETTING

Hospital Trauma Department, UK.

PARTICIPANTS

Persons aged 60 years or over who sustained an unstable ankle fracture with no established peripheral arterial disease pre-injury.

METHODS

This study investigated the association between ankle-brachial pressure index (ABPI) and extended timed 'up and go' (TUG) measures. Associations between TUG outcomes and age, pre-morbid functional mobility (Olerud-Molander Ankle Score) and fracture severity (number of malleoli injured) were also explored.

ANALYSIS

Complete cases (n=76; 84% of cohort) were entered into univariate and multivariate linear regression.

RESULTS

No association was found between ABPI and TUG at 6 months in unadjusted and adjusted analyses. Pre-morbid functional mobility (B=-0.34, 95% confidence interval (CI) -0.45 to -0.23, p<0.001) and age (B=0.46, 95% CI 0.25-0.66, p<0.001) were associated with extended TUG values (r2=0.53, p<0.001). Fracture severity was not a significant independent predictor variable.

CONCLUSIONS

Peripheral vessel function and fracture severity may have a limited independent influence on mobility outcome after ankle fracture in those patients who do not have established pre-injury peripheral arterial disease. Age and pre-morbid mobility gave an indication of mobility outcome, but a substantial amount of variance remains unexplained. Limitations of this study, including missing data and potential residual confounding, indicate the need for caution in generalising these results. The study provides a basis on which to plan larger studies of the factors associated with mobility outcome after ankle fracture in older populations.

CT assessment of the prevalence of retinacular injuries associated with hindfoot fractures

OBJECTIVE

To determine the incidence of injuries to the flexor and peroneal retinacula in hindfoot fractures as demonstrated on ankle computed tomography (CT).

MATERIALS AND METHODS

Study patients were identified via review of CT records at a single institution. CT scans were retrospectively reviewed and compared with surgical reports.

RESULTS

Hindfoot fractures undergoing CT showed flexor retinacular injuries in 23.7% of cases and peroneal retinacular injuries in 10.2%. The posterior tibial tendon was partly torn in 4.2% of cases, and entrapped between fracture fragments in 16.1%. The peroneal tendon was rarely injured, being entrapped in 1.7% of cases. Pilon, distal tibial shaft, malleolar, talar, and calcaneal fractures were all associated with retinacular injuries. CT findings correlated well with surgical findings; there were no false-positive CT findings, and only 1 false-negative finding, a posterior tibial tendon that was entrapped at surgery, but in a normal position on the CT.

CONCLUSIONS

Retinacular injuries are commonly demonstrated on CT in patients with ankle fractures. The contribution of these injuries to fracture outcomes is unknown.

Weightbearing and nonweightbearing ankle dorsiflexion range of motion: are we measuring the same thing?

BACKGROUND

Ankle dorsiflexion range of motion has been measured in weightbearing and nonweightbearing conditions. The different measurement conditions may contribute to inconsistent conclusions regarding the role of ankle dorsiflexion in several pathologic conditions. The purpose of this study was to examine the relationship between ankle dorsiflexion range of motion as measured in weightbearing and nonweightbearing conditions.

METHODS

We compared ankle dorsiflexion range of motion as measured in a weightbearing versus a nonweightbearing position in 43 healthy volunteers. Measurements were taken separately by two examiners.

RESULTS

Weightbearing and nonweightbearing ankle dorsiflexion measurements produced significantly different results (P < .0001). The two measurements correlated moderately (r = 0.6 and r = 0.64 for examiners 1 and 2, respectively; P < .001).

CONCLUSIONS

Weightbearing and nonweightbearing ankle dorsiflexion measurements produce significantly different results and only a moderate correlation, suggesting that these two measurements should not be used interchangeably as measures of ankle dorsiflexion range of motion.

Life impact of ankle fractures: qualitative analysis of patient and clinician experiences

BACKGROUND

Ankle fractures are one of the more commonly occurring forms of trauma managed by orthopaedic teams worldwide. The impacts of these injuries are not restricted to pain and disability caused at the time of the incident, but may also result in long term physical, psychological, and social consequences. There are currently no ankle fracture specific patient-reported outcome measures with a robust content foundation. This investigation aimed to develop a thematic conceptual framework of life impacts following ankle fracture from the experiences of people who have suffered ankle fractures as well as the health professionals who treat them.

METHODS

A qualitative investigation was undertaken using in-depth semi-structured interviews with people (n=12) who had previously sustained an ankle fracture (patients) and health professionals (n=6) that treat people with ankle fractures. Interviews were audio-recorded and transcribed. Each phrase was individually coded and grouped in categories and aligned under emerging themes by two independent researchers.

RESULTS

Saturation occurred after 10 in-depth patient interviews. Time since injury for patients ranged from 6 weeks to more than 2 years. Experience of health professionals ranged from 1 year to 16 years working with people with ankle fractures. Health professionals included an Orthopaedic surgeon (1), physiotherapists (3), a podiatrist (1) and an occupational therapist (1). The emerging framework derived from patient data included eight themes (Physical, Psychological, Daily Living, Social, Occupational and Domestic, Financial, Aesthetic and Medication Taking). Health professional responses did not reveal any additional themes, but tended to focus on physical and occupational themes.

CONCLUSIONS

The nature of life impact following ankle fractures can extend beyond short term pain and discomfort into many areas of life. The findings from this research have provided an empirically derived framework from which a condition-specific patient-reported outcome measure can be developed.

Evidence-based treatment for ankle injuries: a clinical perspective

The most common ankle injuries are ankle sprain and ankle fracture. This review discusses treatments for ankle sprain (including the management of the acute sprain and chronic instability) and ankle fracture, using evidence from recent systematic reviews and randomized controlled trials. After ankle sprain, there is evidence for the use of functional support and non-steroidal anti-inflammatory drugs. There is weak evidence suggesting that the use of manual therapy may lead to positive short-term effects. Electro-physical agents do not appear to enhance outcomes and are not recommended. Exercise may reduce the occurrence of recurrent ankle sprains and may be effective in managing chronic ankle instability. After surgical fixation for ankle fracture, an early introduction of activity, administered via early weight-bearing or exercise during the immobilization period, may lead to better outcomes. However, the use of a brace or orthosis to enable exercise during the immobilization period may also lead to a higher rate of adverse events, suggesting that this treatment regimen needs to be applied judiciously. After the immobilization period, the focus of treatment for ankle fracture should be on a progressive exercise program.

EXACT: exercise or advice after ankle fracture. Design of a randomised controlled trial

Background

Ankle fractures are common. Management of ankle fractures generally involves a period of immobilisation followed by rehabilitation to reduce pain, stiffness, weakness and swelling. The effects of a rehabilitation program are still unclear. However, it has been shown that important components of rehabilitation programs may not confer additional benefits over exercise alone. The primary aim of this trial is to determine the effectiveness and cost-effectiveness of an exercise-based rehabilitation program after ankle fracture, compared to advice alone.

Methods/Design

A pragmatic randomised trial will be conducted. Participants will be 342 adults with stiff, painful ankles after ankle fracture treated with immobilisation. They will be randomly allocated using a concealed randomisation procedure to either an Advice or Rehabilitation group. Participants in the Advice group will receive verbal and written advice about exercise at the time of removal of immobilisation. Participants in the Rehabilitation group will be provided with a 4-week rehabilitation program that is designed, monitored and progressed by a physiotherapist, in addition to verbal and written advice. Outcomes will be measured by a blinded assessor at 1, 3 and 6 months. The primary outcomes will be activity limitation and quality-adjusted life years.

Discussion

This pragmatic trial will determine if a rehabilitation program reduces activity limitation and improves quality of life, compared to advice alone, after immobilisation for ankle fracture.

A clinical pathway for management of fractured ankles can be used to identify course of recovery and resource use

Carolyn Page, Kim Brock, Susan Black

Aims: This article describes a study investigating the use of a clinical pathway for the management of fractured ankles and seeking to identify the usual course of recovery for patients treated according to the pathway for both conservative and surgical management.

Methods: The study was a prospective, observational cohort study The participants were 63 patients who had sustained a fractured ankle and could weight bear The outcome measures were the Ankle Lunge Test (ALT), Lower Extremity Functional Scale, swelling, and 10m walk test.

Findings: Compliance in documenting key items of assessment on the pathway ranged between 52% and 91%. Adherence to recommended interventions was above 60% for most recommendations.

The number of weeks attending physiotherapy had a mean of 6.6 (SD 3.3). There was a correlation of r = 0.44 between ALT at week 1 and week of discharge (p > 0.01), with those having poor ALT results more likely to have prolonged treatment. The surgically treated group had a significantly poorer ALT at week one (p < 0.01), continued to make slower recovery at week three (p < 0.001) and, overall, had a significantly longer period of physiotherapy.

Conclusions: A structured clinical pathway for fractured ankles is an effective and efficient way to collect data on this population and has the capacity to detect patients that fail to progress as normal.

Pain and dorsiflexion range of motion predict short- and medium-term activity limitation in people receiving physiotherapy intervention after ankle fracture: an observational study

QUESTION

What predicts short - and medium term activity limitation in people after ankle fracture?

DESIGN

Inception cohort observational study.

PARTICIPANT

Adults with ankle fracture recruited within days following cast removal from physiotherapy departments of teaching hospital in Sydney, Australia.

OUTCOME MEASURES

The predictive value of variables that were injury-related (fracture management, fracture severity, angle of the ankle during cast immobilisation, and time from cast removal to baseline) and performance-related (activity limitation, pain, mobility and dorsiflexion range of motion measured soon after cast removal) were examined in one dataset (n = 150) using univariate linear regression. Significant variables (p <or = 0.20) were further examined with a multivariate linear model. A clinical prediction rule was derived then validated using data from an independent dataset (n = 94).

RESULTS

Fracture management, fracture severity, baseline activity limitation, pain, mobility and dorsiflexion had significant but weak univariate associations with activity limitation. Only pain and dorsiflexion range of motion contributed independently to the clinical prediction rule. When applied to the validation data, the rule explained 12% of the short-term and 9% of the medium-term variance in activity limitation.

CONCLUSION

Performance-related variables were stronger predictors than injury-related variables. A clinical prediction rule consisting of pain and dorsiflexion range of motion explained a small amount of variance in short- and medium-term activity limitation, suggesting that it may be appropriate to identify people with high levels of pain and restricted dorsiflexion after ankle fracture and target intervention accordingly.

The lower extremity functional scale has good clinimetric properties in people with ankle fracture

BACKGROUND

There is limited information on the clinimetric properties of questionnaires of activity limitation in people after ankle fracture.

OBJECTIVE

The purpose of this study was to investigate the clinimetric properties of the Lower Extremity Functional Scale, an activity limitation questionnaire, in people with ankle fracture.

DESIGN

This was a measurement study using data collected from 2 previous randomized controlled trials and 1 inception cohort study.

METHODS

Participants with ankle fracture (N=306) were recruited within 7 days of cast removal. Data were collected at baseline and at short- and medium-term follow-ups. Internal consistency and construct validity were assessed using Rasch analysis. Concurrent validity, responsiveness, and floor and ceiling effects were evaluated.

RESULTS

The Lower Extremity Functional Scale demonstrated high internal consistency (alpha > .90). The variance in activity limitation explained by the items was high (98.3%). Each item had a positive correlation with the overall scale, and most items supported the unidimensionality of the scale. These findings suggest that the scale has high internal consistency and construct validity. The scale also demonstrated high concurrent validity and responsiveness in the short term and no floor or ceiling effects. However, the scale would benefit from more-challenging items, as evident at the medium-term follow-up.

LIMITATIONS

This was a secondary analysis of existing data sets.

CONCLUSION

The Lower Extremity Functional Scale is a useful tool to monitor activity limitation in people with ankle fracture up to the short-term follow-up. More- difficult items may need to be added to improve the responsiveness of the scale for longer-term follow-up.

Passive dorsiflexion flexibility after cast immobilization for ankle fracture

Ankle fracture is frequently managed with cast immobilization, but immobilization may produce ankle contracture (loss of flexibility). We aimed to quantify recovery of ankle dorsiflexion flexibility in people treated with cast immobilization after ankle fracture, and to determine if initial orthopaedic management was associated with recovery. Ankle flexibility was measured in 150 people with plantarflexion contracture who had been referred for outpatient physical therapy following cast immobilization for ankle fracture. We obtained measurements using an instrumented footplate within 5 days of cast removal and then 4 weeks and 3 months later. Data were compared with published normative data. Both stiffness and the torque corresponding to the peak dorsiflexion angle at baseline decreased during the 3 month recovery period, but recovery was still incomplete 3 months after cast removal. Surgical fixation was associated with higher stiffness, preload and torque values. Passive ankle flexibility does not return to normal values within 3 months of cast removal after ankle fracture. Recovery of normal ankle dorsiflexion flexibility typically takes longer than the initial period of immobilization.

Effectiveness of joint mobilisation after cast immobilisation for ankle fracture: a protocol for a randomised controlled trial [ACTRN012605000143628]

Background

Passive joint mobilisation is a technique frequently used by physiotherapists to reduce pain, improve joint movement and facilitate a return to activities after injury, but its use after ankle fracture is currently based on limited evidence. The primary aim of this trial is to determine if adding joint mobilisation to a standard exercise programme is effective and cost-effective after cast immobilisation for ankle fracture in adults.

Methods/Design

Ninety participants will be recruited from the physiotherapy departments of three teaching hospitals and randomly allocated to treatment or control groups using a concealed procedure. All participants will perform an exercise programme. Participants in the treatment group will also receive joint mobilisation twice a week for four weeks. Blinded follow-up assessments will be conducted four, 12 and 24 weeks after randomisation. The primary outcome measures will be the Lower Extremity Functional Scale and the Assessment of Quality of Life. Secondary outcomes will include measures of impairments, activity limitation and participation. Data on the use of physiotherapy services and participants' out-of-pocket costs will be collected for the cost-effective and cost-utility analyses. To test the effects of treatment, between-group differences will be examined with analysis of covariance using a regression approach. The primary conclusions will be based on the four-week follow-up data.

Discussion

This trial incorporates features known to minimise bias. It uses a pragmatic design to reflect clinical practice and maximise generalisability. Results from this trial will contribute to an evidence-based approach for rehabilitation after ankle fracture.