Operative fixation of unstable ankle fractures in patients aged over 80 years

Comparison of Patient Demographics and Risk of Surgical Site Infections Following Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures: A Nationwide Analysis of a Private Payor

Surgical site infections (SSIs) are a notable complication following open reduction and internal fixation (ORIF) for ankle fractures. The purpose of this study was to (1) compare baseline demographics of patients who did and did not develop SSIs within 90 days following ORIF for trimalleolar ankle fractures and (2) identify risk factors associated with SSIs in this setting. A retrospective analysis from 2010 to 2020 was completed using a national administrative database. The study group consisted of patients who underwent ORIF for trimalleolar ankle fractures and developed SSIs within 90 days postoperatively. Patients without SSIs served as the comparison cohort. Baseline demographics of the two cohorts were compared utilizing Pearson's Chi-Square Analyses. A multivariate binomial logistic regression model determined the association of various comorbidities on developing SSIs in this setting. Out of a total sample of 22,118 patients, 1000 individuals (4.52%) developed SSIs. The study revealed that the SSI cohort exhibited a greater burden of comorbidities, as evidenced by significant differences in various individual comorbidities and average Elixhauser-Comorbidity Indices scores. The most strongly associated risk factors for the development of SSIs following ORIF for trimalleolar ankle fractures were peripheral vascular disease (OR: 1.53, p < .0001), diabetes mellitus (OR: 1.26, p = .0010), iron deficiency anemia (OR: 1.24, p = .0010), male sex (OR: 1.22, p = .0010), and tobacco use (OR: 1.15, p = .0010). This study identified several patient risk factors that were associated with developing SSIs after ORIF for trimalleolar ankle fractures, recognizing potential patient-directed interventions that may reduce the rate of SSIs in this setting.

Evaluating Fibular Intramedullary Nails vs Traditional Plating in Geriatric Ankle Fractures: A 12-Year Single-Center Retrospective Study

BACKGROUND

This study evaluates the outcomes of fibular intramedullary nails (IMNs) compared to traditional plates and screws (PS) in the surgical treatment of unstable ankle injuries in patients aged ≥65 years.

METHOD

We conducted a retrospective study involving 32 elderly patients with unstable ankle fractures treated with IMNs from 2010 to 2022. A comparison was made with 125 case-control patients treated with PS during the same period. Outcomes compared included postoperative wound and nonwound complications, surgical reduction, union rates, implant removal rates, and the Olerud Molander Ankle Score (OMAS) at a minimum follow-up of 2 years.

RESULTS

The IMN group had a higher incidence of high-energy injuries, open fractures, concomitant surgery, and perioperative transfusion requirements than the PS group. Additionally, the IMN group developed fewer wound-related (3.1% vs 20% in the PS group, P = .043) and non-wound-related complications (18.8% vs 39.2% in the PS group, P = .030). Both groups had similar initial weightbearing restrictions, fracture union times, mean OMAS scores, rates of malunion or nonunion, and delayed implant removal times. Notably, there were significant differences in the quality and adequacy of mortise alignment between the groups (good: 53.1% in IMN group vs 79.2% in PS group, fair: 46.9% in IMN group vs 20.8% in PS group, P = .006).

CONCLUSION

Although the IMN group had an inferior outcome in the quality and adequacy of mortise reduction compared with the PS group, elderly patients with ankle fractures treated with IMN showed comparable functional outcomes to those treated with PS but with lower complication rates. Future research in this area will provide vital information for developing optimal treatment strategies, thereby improving the overall care of elderly patients with ankle fractures.

Risk factors for fracture-related infection after ankle fracture surgery

INTRODUCTION

Ankle fracture surgery comes with a risk of fracture-related infection (FRI). Identifying risk factors are important in preoperative planning, in management of patients, and for information to the individual patient about their risk of complications. In addition, modifiable factors can be addressed prior to surgery. The aim of the current paper was to identify risk factors for FRI in patients operated for ankle fractures.

METHODS

A cohort of 1004 patients surgically treated for ankle fractures at Haukeland University Hospital in the period of 2015-2019 was studied retrospectively. Patient charts and radiographs were assessed for the diagnosis of FRI. Binary logistic regression was used in analyses of risk factors. Regression coefficients were used to calculate the probability for FRI based on the patients' age and presence of one or more risk factors.

RESULTS

FRI was confirmed in 87 (9%) of 1004 patients. Higher age at operation (p < .001), congestive heart failure (CHF), p = 0.006), peripheral artery disease (PAD, p = 0.001), and current smoking (p = .006) were identified as risk factors for FRI. PAD and CHF were the risk factors displaying the strongest association with FRI with an adjusted odds ratio of 4.2 (95% CI 1.8-10.1) and 4.7 (95% CI 1.6-14.1) respectively.

CONCLUSION

The prevalence of FRI was 9% after surgical treatment of ankle fractures. The combination of risk factors found in this study demonstrate the need for a thorough, multidisciplinary, and careful approach when faced with an elderly or frail patient with an ankle fracture. The results of this study help the treating surgeons to inform their patients of the risk of FRI prior to ankle fracture surgery.

LEVEL OF EVIDENCE

Level III retrospective case-control study.

Elective Foot and Ankle Procedures in the Patients Greater than 65 Years of Age: Worth the Mobility Gains

Chronic, non-traumatic pathologies of the foot and ankle can be mobility-limiting for patients of all ages. The objective of this study was to compare postoperative changes in LifeSpace Mobility Assessment (LSA) scores of adult and elderly patients following elective foot and ankle surgery. A prospective study of 184 patients undergoing elective ankle, hindfoot, and midfoot procedures conducted by one surgeon between 2015 and 2019 was undertaken. Patient-reported LSA scores were collected at preoperative, 6-month, and 12-month follow-up. Patient data was compared using an independent sample t-test for continuous, normally distributed data and a chi-squared or Fischer's exact test for categorical data. Alpha and beta were .05 and .8. Patients were divided based on age. 140 patients were observed in the younger (<65) group, 44 patients were observed in the elderly (≥65) group. The average LSA score of elderly patients at the preoperative visit was 58.3 (SD 38.0) vs 79.3 (SD 38.8) in the younger cohort (P = .041). Both patient cohorts saw decreased mobility at 3-month postoperative visits but surpassed preoperative mobility scores by 6 months and 1 year postop. No difference in average mobility score was observed between young (85.6, SD 36.1) and elderly (90.1, SD 34.3) cohorts at 1-year follow up. Given the increased rates of perioperative comorbidities and the heightened risks of intraoperative complications, physicians may be more inclined to manage elderly patients with longer periods of conservative treatment for similar pathologies. However, these results imply that elderly patients experience similar improvements after surgery to younger cohorts and should not be excluded from surgical consideration. Our results, in tandem with literature showing the deleterious effects of decreased mobility in the elderly, suggest that the discussion to pursue or hold surgical correction of chronic foot and ankle disease in patients over age 65 must consider the mobility benefits of surgery.

Retrograde tibiotalocalcaneal nailing for the treatment of acute ankle fractures in the elderly: a systematic review and meta-analysis

Introduction

Methods

Results

Conclusion

High-risk ankle fractures in high-risk older patients: to fix or nail?

INTRODUCTION

Optimal treatment of high-risk ankle fractures in older, comorbid patients is unknown. Results of open reduction internal fixation (ORIF) versus tibiotalocalcaneal (TTC) fusion nailing for the treatment of high-risk geriatric ankle fractures were investigated.

MATERIALS AND METHODS

Results of ORIF versus TTC fusion nailing were evaluated via retrospective case-control cohort study of 60 patients over age 50 with an open ankle fracture or one with at least 50% talar subluxation and at least 1 high-risk comorbidity: diabetes mellitus (DM), peripheral vascular disease, immunosuppression, active smoking, or a BMI > 35. The primary outcome was reoperation rate within 1-year post-surgery. Secondary outcomes include infection, peri-implant fracture, malunion/nonunion, mortality, length of stay, disposition, and hospital acquired complications.

RESULTS

Mean age was 71 (ORIF) and 68 (TTC). 12/47 (25.5%) ORIF cases were open fractures versus 4/14 (28.6%) with TTC. There were no significant differences between ORIF and TTC in 1-year reoperation rates (17% vs 21.4%), infection rates (12.8% vs 14.3%), or union rates (76.% vs 85.7%), respectively. One TTC patient sustained a peri-implant fracture treated nonoperatively. There were no significant differences in medical risk factors between groups other than a higher rate of DM in the TTC group, 42.6% vs 78.6%, p = 0.02. Incomplete functional outcome data in this challenging patient cohort precluded drawing conclusions.

CONCLUSION

ORIF and TTC fusion nailing result in comparable and acceptable reoperation, infection, and union rates in treating high-risk ankle fractures in patients over 50 with at least 1 major comorbidity for increased complications; further study is warranted.

Comparing the 30-Day Complications Between Smokers and Nonsmokers Undergoing Surgical Fixation of Ankle Fractures

Background:

There have been conflicting reports regarding the effect of smoking on complications after surgical treatment of ankle fractures. This study aimed at identifying the complications for which smokers and subgroups of smokers are at a higher risk compared to nonsmokers when undergoing surgery for fixation of rotational ankle fractures.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program data set from 2008 to 2019 was used to compare the 30-day wound, cardiac, renal, and infectious complications, related readmissions, and return to the operating room between the 2 cohorts.

Results:

Of 33 741 patients included, 25 642 (76.0%) were nonsmokers and 8099 (24.0%) were smokers. Multivariate analysis showed that smokers were at a higher risk for deep wound infection (OR 2.34, 95% CI 1.48-3.69, P < .001), wound dehiscence (OR 2.43, 95% CI 1.56-3.77, P < .001), related return to the operating room (OR 1.69, 95% CI 1.36-2.11, P < .001), and related readmissions (OR 1.67, 95% CI 1.32-2.09, P < .001). Smokers at an increased risk for deep infection included patients between 50 and 59 years (OR 5.75, 95% CI 1.78-18.5, P = .003), who were Black (OR 4.24, 95% CI 1.04-17.23, P = .044), who had body mass index (BMI) 35 to 39.9 (OR 3.73, 95% CI 1.46-9.50, P = .006), or operative times between 60 and 90 minutes (OR 3.64, 95% CI 1.79-7.39, P < .001). Smoker subgroups at a higher risk for wound dehiscence included patients between 50 and 59 years (OR 9.86, 95% CI 3.29-29.53, P < .001), with operative times between 90 and 120 minutes (OR 4.88, 95% CI 1.89-12.58, P < .001), with BMI 30 to 34.9 (OR 3.06, 95% CI 1.45-6.45, P = .003) and who underwent spinal/epidural anesthesia (OR 9.31, 95% CI 2.31-37.58, P = .002).

Conclusion:

Smokers were at an increased risk for deep wound infection, wound dehiscence, related reoperations, and related readmissions after ankle fracture surgery. Certain subgroups were at an even higher risk for these complications.

Level of Evidence:

Level III, retrospective cohort study.

An overview on the treatment and outcome factors of ankle fractures in elderly men and women aged 80 and over: a systematic review

INTRODUCTION

This article is a systematic review of the literature on elderly aged 80 and over with an ankle fracture. Low energy trauma fractures are a major public health burden in developed countries that have aged populations. Ankle fractures are the third most common fractures after hip and wrist fractures. The purpose of this review is to provide an overview of the treatments and the used outcome factors.

METHODS

PubMed, Embase, Cochrane Library, and CINAHL were searched to retrieve relevant studies. Studies published in English or Dutch concerning the treatment of ankle fractures in patients aged 80 and over were included.

RESULTS

Initially 2054 studies were found in the databases. After removing duplicate entries, 1182 remained. Finally, after screening six studies were included, of which three cohorts studies and three case series. Six different treatments were identified and described; ORIF, transarticular Steinmann pin, plaster cast with or without weight-bearing, Gallagher nail and the TCC nail. Furthermore, 32 outcome factors were identified.

DISCUSSION

The various studies show that practitioners are careful with early weight-bearing. However, if we look closely to the results and other literature, this seems not necessary and it could potentially be of great value to implement early weight-bearing in the treatment. Furthermore, quality of life seems underreported in this research field.

CONCLUSIONS

ORIF with plaster cast and permissive weight-bearing should be considered for this population since it seems to be a safe possibility for a majority of the relatively healthy patients aged 80 and over. In cases where surgery is contra-indicated and a plaster cast is the choice of treatment, early weight-bearing seems to have a positive influence on the outcome in the very old patient.

Comparison study of patient demographics and risk factors for surgical site infections following open reduction and internal fixation for lateral malleolar ankle fractures within the medicare population

BACKGROUND

The purpose of this study was to analyze a comprehensive database to 1) compare patient demographic profiles; and 2) identify patient-related risk factors for surgical site infections (SSIs) following open reduction and internal fixation (ORIF) for lateral malleolar ankle fractures.

METHODS

Patients treated with ORIF for lateral malleolar ankle fractures that developed SSIs within 1-year following the procedure were identified. Study group demographics were compared to a control cohort and risks for developing SSI were calculated using multivariate logistic regression analysis.

RESULTS

There were statistically significant differences between the control group and patients with SSIs. The study showed that morbidly obese patients, peripheral vascular disease, and electrolyte/fluid imbalance were the greatest risk factors for developing SSIs following ORIF for lateral malleolar fractures.

CONCLUSION

The study is useful as it can allow orthopaedists to optimize these high-risk patients to potentially mitigate this adverse event.

Acute Hindfoot Nailing for Ankle Fractures: A Systematic Review of Indications and Outcomes

OBJECTIVES

To assess the complication rate of hindfoot nailing of acute fractures involving the tibiotalar joint, and mortality, patient-reported outcome measures, and return to preinjury activities.

DATA SOURCES

MEDLINE; EMBASE.

STUDY SELECTION

A systematic literature search for articles in English was completed using MEDLINE and EMBASE databases on April 23, 2020. Original research articles that assessed patients with acute intra-articular fractures of the ankle joint (malleolar ankle fractures and/or pilon fractures) that were treated with a locked hindfoot intramedullary nail, inserted retrograde through the plantar surface of the foot, were selected for inclusion. Case reports (≤4 patients), studies with nonlocked implants, and non-English studies were excluded.

DATA EXTRACTION AND SYNTHESIS

A validated data extraction form was used, which included study demographics (authors, journal, date of publication, and study design), patient characteristics, implant type, and reported outcomes. Risk of bias for each included study was evaluated using the Institute of Health Economics Quality Appraisal Checklist for case series and the Risk of Bias in randomized trials tool, where appropriate. The best evidence was summarized and weighted mean values were provided when appropriate.

RESULTS

Ten case series and one randomized controlled trial were included. The overall quality of studies was poor with considerable bias. The majority of studies included elderly patients (weighted mean age 75.5 years) with diabetes (42% of patients). Overall complication rate was 16% with an 8% major complication rate (deep infection, malunion, nonunion, implant failure) and an overall infection rate of 6.2%. Pooled mortality rate was 27% with fracture union rates from 88% to 100%. Mean proportion of patients able to return to preinjury level of activity was 85%.

CONCLUSIONS

Hindfoot nailing of acute ankle and pilon fractures in elderly patients and patients with diabetes is associated with complication rates comparable with other methods of fixation. Issues with elimination of subtalar joint motion and implant complications secondary to poor implant fixation persist. The literature to date has composed of primarily Level IV studies with considerable bias. Further research is necessary to clarify the role of hindfoot nailing of acute ankle and pilon fractures.

LEVEL OF EVIDENCE

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

Interventional revascularization prior to operative fixation of fractures below the knee. A retrospective case series

AIMS

The goal of the current study was to describe the results of an innovative standardized approach to prevent wound complications in patients with PAD sustaining fractures below the knee.

PATIENTS AND METHODS

In this retrospective case series, patients submitted to our institution with fractures below the knee, which were treated with endovascular recanalization of relevant stenosis or occlusions prior to definitive open reduction and fracture fixation between January 2015 and December 2019 were included.

RESULTS

Overall 23 patients (mean age 77 ± 9.8 years) were included in the current case series. In five patients (21.7 %) PAD was previously diagnosed. Endovascular interventions were performed 6.9 ± 2.5 days after fracture event and 2.5 ± 1.3 days prior to definitive surgical fixation of the lower limb fracture. After intervention 2 patients had one vessel, 10 patients two vessels and 11 patients three vessels for arterial perfusion of the lower limb. No interventional- radiology procedure related complications were observed. In this case series only two wound infections (8.7 %) occurred.

CONCLUSION

Endovascular intervention prior to surgical fixation resulted in a low complication rate after surgical fixation of fractures below the knee in patients with PAD. These results emphasize the crucial role of limb perfusion for adequate wound healing in lower limb fractures. Therefore, examination of limb perfusion should be an integral part of preoperative preparation of patients at high risk for PAD presenting with fractures below the knee. Endovascular recanalization seems to be an appropriate method to prevent wound complications.

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

BACKGROUND

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

METHOD

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

CONCLUSION

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

LEVELS OF EVIDENCE

Level III.

The influence of smoking on foot and ankle surgery: a review of the literature

The effect of tobacco smoking on foot and ankle procedures is likely to be more pronounced when compared to other orthopaedic surgery. This is due to the peripheral nature of the vasculature involved. This paper reviews the current clinical evidence on the effects of smoking foot and ankle surgery. In the trauma setting, the evidence suggests that wound complications and non-unions are significantly higher in the smoking population. In the elective setting there is a significantly increased risk of non-union in ankle and hindfoot arthrodeses in smokers. In the setting of diabetes, ulceration rate in smokers is higher and there may be a higher risk of amputation.

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

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

Prevention of postoperative surgical wound complications in ankle and distal tibia fractures: results of Incisional Negative Pressure Wound Therapy

BACKGROUND AND AIM OF THE WORK

complications in surgical wound healing represent the main postoperative complication in ankle and distal tibia fractures. Whereas the use of Incisional Negative Pressure Wound Therapy (INPWT) is recognized to have a role in wound complications prevention in prosthetic surgery, literature about its use in trauma surgery is scarce. The aim of this study was to compare the effectiveness of INWPT with a conventional dressing in order to prevent surgical wound complications in ankle and distal tibia fractures.

METHODS

The study population included patients over 65 years as well as patients under 65 years considered at risk for wound complications (smokers, obese, affected by diabetes), who underwent ORIF for bi/tri-malleolar ankle fractures or distal tibia (pilon) fractures. After surgery, patients were randomized to receive a conventional dressing or INPWT. Complications in surgical wound healing were classified in major (requiring surgical intervention) and minor complications.

RESULTS

65 patients were included in the study. The rate of minor and major complications between the two groups was not significantly different, although a positive trend towards a lower minor complications rate was noted in the INPWT group (12.6% vs 34.7%). No complications or complaints were reported for the INPWT device.

CONCLUSIONS

INPWT proved to be safe, well-tolerated and showed promising results in preventing surgical wound complications in ankle and distal tibia fractures.

Ankle fractures in the elderly: Current concepts

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.

Mortality and Morbidity of Surgical Management of Geriatric Ankle Fractures

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.

Risk factors for periprosthetic joint infection following total ankle replacement

BACKGROUND

Identifying preoperative patient characteristics that correlate with an increased risk of periprosthetic joint infection (PJI) following total ankle replacement (TAR) is of great interest to orthopaedic surgeons, as this may assist with appropriate patient selection. The purpose of this study is to systematically review the literature to identify risk factors that are associated with PJI following TAR.

METHODS

Utilizing the terms "(risk factor OR risk OR risks) AND (infection OR infected) AND (ankle replacement OR ankle arthroplasty)" we searched the PubMed/MEDLINE electronic databases. The quality of the included studies was then assessed using the AAOS Clinical Practice Guideline and Systematic Review Methodology. Recommendations were made using the overall strength of evidence.

RESULTS

Eight studies met the inclusion criteria. A limited strength of recommendation can be made that the following preoperative patient characteristics correlate with an increased risk of PJI following TAR: inflammatory arthritis, prior ankle surgery, age less than 65 years, body mass index less than 19, peripheral vascular disease, chronic lung disease, hypothyroidism, and low preoperative AOFAS hindfoot scores. There is conflicting evidence in the literature regarding the effect of obesity, tobacco use, diabetes, and duration of surgery.

CONCLUSIONS

Several risk factors were identified as having an association with PJI following TAR. These factors may alert surgeons that a higher rate of PJI is possible. However, because of the low level of evidence of reported studies, only a limited strength of recommendation can be ascribed to regard these as risk factors for PJI at this time.

Comparison of risk factors for postoperative complications across age groups in patients undergoing ORIF of the ankle

INTRODUCTION

Risk factors associated with various adverse outcomes for patients undergoing open reduction and internal fixation (ORIF) of the ankle, and how these risks differ between younger and older patient populations, has not been clearly established. Objective quantitative data may aid physicians in surgical decision making, individualizing postoperative management, and targeting interventions for reducing postoperative comorbidity. The purpose of this study is to compare the incidence of and risk factors for adverse postoperative outcomes following ORIF of ankle fractures across patient age groups.

MATERIALS AND METHODS

Charts of patients age 18 years and older who underwent open reduction and internal fixation (ORIF) for any closed, non-polytraumatic, non-pilon ankle fracture at a single institution between the years 2008 and 2018 were reviewed. Demographic information, comorbidities, and postoperative outcomes were collected. Relative risks for adverse outcomes were calculated and compared between patients younger than 50 and patients 50 years and older.

RESULTS

A total of 886 patients were included, 375 (42.3%) of which were over age 50. In both age groups, risk of infection was significantly increased among patients with hypertension, although risk among older patients (RR = 3.52, p = 0.004) was greater than that among younger patients (RR = 2.46, p = 0.017). In patients younger than 50, significant risk of wound dehiscence was associated with tobacco use (RR = 3.39, p = 0.022), substance use (RR = 3.07, p = 0.020), and CHF (RR = 12.77, p < 0.001). Risk of implant failure was significantly increased among younger patients with HIV (RR = 4.33, p = 0.026), CHF (RR = 10.54, p < 0.001), and CKD (RR = 10.54, p < 0.001), and among older patients with HTN (RR = 4.51, p = 0.006), CHF (RR = 5.83, p < 0.001), and tobacco use (RR = 3.82, P = 0.001).

CONCLUSION

Patients undergoing ORIF of the ankle should be well-informed of the potential risks of surgery as they pertain to specific comorbidities. Multidisciplinary approaches are warranted for appropriate management of patients with multiple comorbidities.

Third day laboratory follow-up: mandatory for surgical site infections of tibial plateau fractures

INTRODUCTION

Tibial plateau fractures are common fractures in adults and can be extremely challenging for surgeons. State-of-the-art therapy is open reduction and internal fixation (ORIF), although major complications of ORIF are surgical site infections (SSIs). This is especially critical on the proximal tibia, which is only sparsely covered by soft tissue and has a close relation to the knee joint. We analyzed SSIs after ORIF to correlate established laboratory parameters to the occurrence of SSIs.

METHODS

A monocentric case-control study in a Level 1 Trauma Center was conducted. Data were acquired from electronic medical records from 2011 until 2016. White blood cell count (WBC) and C-reactive protein (CRP) were used as laboratory parameters and statistically analyzed.

RESULTS

In total, 97 patients were included, with four patients suffering from SSIs. Patients with SSIs had a significantly increased WBC count and CRP levels on the third postoperative day. Infection was diagnosed after rehospitalization, 12 ± 4 weeks after initial surgery. Furthermore, a large bony destruction through trauma coincides with a rise of WBC count with no influence on CRP level.

CONCLUSION

We highly recommend a laboratory analysis with WBC count and CRP on the third day after ORIF. Patients with a CRP level above 100 mg/l should be closely watched, even if laboratory parameters few days later are adequate-since a one-time increase above this landmark might be a hint regarding the development of a SSI.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Operative Ankle Fractures

OBJECTIVES

To investigate the ability of a validated geriatric trauma risk prediction tool to stratify hospital quality metrics and inpatient cost for middle-aged and geriatric patients admitted from the emergency department for operative treatment of an ankle fracture.

DESIGN

Prospective cohort study.

SETTING

Single Academic Medical Center.

PATIENTS

Patients 55 years of age and older who sustained a rotational ankle fracture and who were treated operatively during their index hospitalization.

INTERVENTION

Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle Aged (STTGMA), using patient demographics, injury severity, and functional status. Patients were stratified into groups based on scores to create a minimal-, low-, moderate-, and high-risk cohort.

MAIN OUTCOME MEASUREMENTS

Length of stay, complications, need for intensive care unit-/step-down unit-level care, discharge location, and index admission costs.

RESULTS

Fifty ankle fracture patients met inclusion criteria. The mean length of stay was 7.8 ± 5.2 days with a significant difference among the 4 risk groups (4.6-day difference between low and high risk). 73.1% of minimal-risk patients were discharged home compared with 0% of high-risk patients. There was no difference in complication rate or in need for intensive care unit-level care between groups. However, high-risk patients had a mean total inpatient cost 2 times greater than that of minimal-risk patients.

CONCLUSION

The Score for Trauma Triage in Geriatric and Middle-Aged tool is able to meaningfully stratify older patients with ankle fracture who require operative fixation regarding hospital quality metrics and cost. This information may allow for efficient targeted reductions in costs while optimizing outcomes.

LEVEL OF EVIDENCE

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

Incidence and risk factors for surgical site infection after open reduction and internal fixation of ankle fracture: A retrospective multicenter study

Information on surgical site infection (SSI) after surgical treatment of ankle fracture is limited and remains controversial. The purpose of the present study was to determine the incidence and risk factors for SSI after open reduction and internal fixation (ORIF) of ankle fracture. Patients who underwent ORIF for ankle fracture at 3 centers between January 2015 and December 2016 were included. The potential risk factors for SSI included demographic variables, including age, sex, body mass index (BMI), hypertension, diabetes mellitus, heart disease, smoking, and excessive alcohol intake; blood test variables including preoperative white blood cell count, neutrophil count, red blood cell count, hemoglobin, total protein, albumin and globulin; injury- and surgery-related variables, including duration of operation (minutes), intraoperative blood loss, surgeon level, fracture site, accompanied dislocation, use of a drainage tube, and antibiotic use. Factors related with SSI occurrence were investigated by univariate analysis, and then by multivariate analysis. During hospitalization, 4.37% (66/1511) of patients developed SSI, which was deep in 1.32% (20/1510) and superficial in 3.05% (46/1510). The most common causative agent was polymicrobial (causing approximately half of all SSIs), followed by methicillin-resistant Staphylococcus aureus (MRSA). Multivariate analysis revealed that the significant risk factors for SSI occurrence were open injury, advanced age, incision cleanliness II - IV, high-energy injury, more experienced surgeon level, greater BMI, chronic heart disease, history of allergy, and preoperative neutrophil count > 75%. Preoperative preventative measures should be taken in patients with these conditions to lower the incidence of SSI after ORIF of ankle fracture.

LEVEL OF EVIDENCE

Level III - Retrospective Comparative Study.

Surgical site infection following open reduction and internal fixation of a closed ankle fractures: A retrospective multicenter cohort study

BACKGROUND

Identification of risk factors for surgical site infection (SSI) after surgical ankle fractures was important, but related evidence was inadequate. This study was conducted to investigate the incidence and risk factors for SSI after open reduction and internal fixation (ORIF) of a closed ankle fractures.

METHODS

Patients who underwent ORIF for a closed ankle fractures at 3 centers between July 2015 and January 2017 were included. Electronic medical recordings (EMR) and Picture Archiving and Communication Systems (PACS) were inquired for information on patients' clinical and radiographic characteristics. The potential factors include 4 aspects: demographics, injury-related, surgery-related and biochemical indictors. Factors related with SSI were analyzed by univariate and further by multivariate logistic regression model.

RESULTS

During the hospitalization, 3.7% (46/1247) of patients developed SSI, with 1.12% (14/1247) for deep and 2.57% (32/1247) for superficial SSI. Approximately half of SSIs were caused by Methicillin-resistant Staphylococcus aureus (MRSA). After adjustment for confounding factors, higher body mass index (BMI), surgeon level (residents or treating surgeon), surgical duration>130mins, delayed surgery, preoperative TP < 60 g/L were significant risk factor or predictors for SSI occurrence.

CONCLUSIONS

After comprehensive evaluation of patients medical conditions, immediate operation by a surgeon with more expertise could effectively reduce SSI occurrence.

Is It Worth Discriminating Against Patients Who Smoke? A Systematic Literature Review on the Effects of Tobacco Use in Foot and Ankle Surgery

Although numerous studies have linked smoking with lower extremity wound and bone healing complications, a comprehensive study on the effects of smoking in foot and ankle surgery has not yet been reported. The purpose of the present study was to report the results of our systemic literature review, identifying the effects of tobacco use on common foot and ankle procedures. The systematic literature review was performed according to guidelines set by the PRIMSA statement (Preferred Reporting Items for Systematic Review and Meta-Analyses). Smoking, as a single risk factor, was analyzed and used to compare adverse outcomes in the postoperative setting of foot and ankle surgery. We reviewed 528 abstracts that met our initial identification criteria. After an extensive review process, 46 of the articles (8.71%) met the eligibility requirements to be included in the present study. Distal bunionectomy with osteotomy, first metatarsophalangeal joint arthrodesis, Lapidus bunionectomy, toe amputation, transmetatarsal amputation, Syme's amputation, open reduction internal fixation (ORIF) of calcaneal fractures, ankle fracture ORIF, pilon fracture ORIF, subtalar arthrodesis, rearfoot arthrodesis, tibiocalcaneal arthrodesis, ankle arthrodesis, total ankle arthroplasty, and plastic surgery procedures and their respective negative association with smoking was identified and described in our review. Our systematic literature review revealed that procedures involving arthrodesis, fracture ORIF, and plastic surgery were associated with negative outcomes in smokers. Procedures that did not involve osseous unions such as total ankle arthroplasty and amputations did not appear to have negative outcomes associated with smoking.

Percutaneous screw fixation of unstable ankle fractures in patients with poor soft tissues and significant co-morbidities

INTRODUCTION

We describe a minimally invasive technique to stabilise unstable ankle fractures by inserting a 100mm screw up the fibula medullary canal along with percutaneous screw fixation of the medial malleolus if required. This technique is utilised in patients with poor soft tissues and significant co-morbidities where the fracture cannot be adequately controlled by a cast alone.

PATIENTS AND METHODS

Retrospective review of 23 patients the average age being 70 years (29-89) and 74% had significant co-morbidities. Postoperative radiographs were examined for adequacy of reduction using the method described by Mclenna and Ungersma. Patient based functional and health questionnaires were performed, reviewed and scored.

RESULTS

Six patients were lost during the follow-up period due to death caused by issues unrelated to the ankle fracture. There were no reported intraoperative complications, no postoperative wound infections and no non-unions. There was two complications one loss of fixation, and another required removal of the screw due to irritation. Radiographic reduction was good in 52%, fair in 44% and poor in 4%. Patient questionnaire results were 70 (20-100) for the Abbreviated Olerud and Molander score and the SF-12 physical component score was 42 and mental component was 44.

CONCLUSIONS

With appropriate patient selection percutaneous screw fixation is an excellent technique supplementing cast immobilisation of unstable ankle fractures with poor soft tissues.

The impact of lifestyle risk factors on the rate of infection after surgery for a fracture of the ankle

Aims

Lifestyle risk factors are thought to increase the risk of infection after acute orthopaedic surgery but the evidence is scarce. We aimed to investigate whether smoking, obesity and alcohol overuse are risk factors for the development of infections after surgery for a fracture of the ankle.

Patients and Methods

We retrospectively reviewed all patients who underwent internal fixation of a fracture of the ankle between 2008 and 2013. The primary outcome was the rate of deep infection and the secondary outcome was any surgical site infection (SSI). Associations with the risk factors and possible confounding variables were analysed univariably and multivariably with backwards elimination.

Results

A total of 1043 patients were included; 64 (6.1%) had a deep infection and 146 (14.0%) had SSI. Obesity was strongly associated with both outcomes (odds ratio (OR) 2.21, p = 0.017 and OR 1.68, p = 0.032) in all analyses. Alcohol overuse was similarly associated, though significant only in unadjusted analyses. Surprisingly, smoking did not yield statistically significant associations with infections.

Conclusion

These findings suggest that obesity and possibly alcohol overuse are independent risk factors for the development of infection following surgery for a fracture of the ankle. This large study brings new evidence concerning these common risk factors; although prospective studies are needed to confirm causality. Cite this article: Bone Joint J 2017;99-B:225–30.

Relationship of Prolonged Operative Time and Comorbidities With Complications After Geriatric Ankle Fractures

BACKGROUND

The incidence of geriatric ankle fractures has increased during the last few decades. In contrast to younger patients, increased complication rates have been observed. Thus, the goal of the present study was to identify risk factors for perioperative complications following open reduction and internal fixation of geriatric ankle fractures.

METHODS

Two hundred thirty-seven patients over the age of 65 years (mean, 72.5 ± 6.1 years) treated for ankle fractures in our institution between 2004 and 2014 were included. Complications associated with operative treatment as well as complications requiring revision surgery were analyzed. In a multivariate analysis, risk factors were determined.

RESULTS

In 68 patients (28.7%), 74 complications were documented. The most common complications were impaired wound healing and operative site infections. The multivariate analysis revealed that the operative time was the only independent risk factor for the development of a complication. The operative time as well as the presence of an open fracture represented risk factors for needing revision surgery. Comorbidities did not influence the development of complications.

CONCLUSION

The operative management of geriatric ankle fractures was associated with a high complication rate. In the present study, the operative time was the only modifiable factor for the development of a complication that required revision surgery. During preoperative preparation, we believe that perfusion of the affected limb should be optimized to reduce the incidence of wound complications.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

IV.

Patient-Based and Surgical Risk Factors for 30-Day Postoperative Complications and Mortality After Ankle Fracture Fixation

OBJECTIVE

The purpose was to calculate the incidence rates and determine risk factors for 30-day postoperative mortality and morbidity after ankle fracture open reduction and internal fixation (ORIF).

METHODS

The NSQIP database was queried to identify patients undergoing ankle fracture ORIF from 2006 to 2011, with extraction patient-based or surgical variables and a 30-day clinical course. Multivariable logistic regression analysis identified significant predictors on outcome measures.

RESULTS

Mean age was 50.3 (±18.2) years while diabetes mellitus (12.8%) and body mass index ≥40 kg/m(2) (9.2%) were documented from a total of 3328 patients identified. The 30-day mortality rate was 0.30%, and complications occurred in 5.1%. Chronic obstructive pulmonary disease [odds ratio (OR): 4.23, 95% confidence interval (CI): 1.19-15.06] and a nonindependent functional status before surgery (OR: 2.25, 95% CI: 1.13-4.51) were the sole independent predictors of mortality and major local complications, respectively. Major local complications occurred in 2.2% of patients, and significant predictors were peripheral vascular disease (OR: 6.14; 95% CI: 1.95-19.35), open wound (OR: 5.04; 95% CI: 2.25-11.27), nonclean wound classification (OR: 3.02; 95% CI: 1.31-6.93), and smoking (OR: 2.85; 95% CI: 1.42-5.70). Independent predictors of hospital stay >3 days were cardiac disease, age 70 years or older, open wound, partially/totally dependent functional status, American Society of Anesthesiologists (ASA) classification ≥3, body mass index ≥40 kg/m(2), bimalleolar or trimalleolar ankle fracture pattern, female sex, and diabetes.

CONCLUSIONS

Chronic obstructive pulmonary disease increased the risk of mortality after ankle fracture ORIF. Risk factors for postoperative complications included peripheral vascular disease, open wound, nonclean wound classification, age 70 years or older, and ASA classification ≥3.

LEVEL OF EVIDENCE

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

Morbidity and Mortality Associated with Geriatric Ankle Fractures: A Medicare Part A Claims Database Analysis

BACKGROUND

The purpose of this study was to examine the incidence of adverse events in elderly patients who required inpatient admission after sustaining an ankle fracture and to consider these data in relation to geriatric hip fracture and other geriatric patient admissions.

METHODS

A retrospective cohort study of patients admitted with an ankle fracture, a hip fracture, or any other diagnosis was performed with the Medicare Part A database for 2008. The primary outcome measure was the one-year mortality rate, examined with multivariate analysis factoring for both patient age and preexisting comorbidity. Secondary outcome measures analyzed additional morbidity as reflected by length of stay, discharge disposition, readmissions, and medical complications.

RESULTS

There were 19,648 patients with ankle fractures, 193,980 patients with hip fractures, and 5,801,831 patients with other admitting diagnoses. Significant differences (p < 0.001) were noted in both age and comorbidity status between the group with ankle fractures and the group with hip fractures. The one-year mortality after admission was 11.9% for patients with ankle fracture, 28.2% for patients with hip fracture, and 21.5% for patients with any other admission. Upon using multivariate analysis to account for both age and comorbidity, the hazard ratio for one-year mortality associated with fracture was 1.088 for patients with hip fracture and 0.557 for patients with ankle fracture.

CONCLUSIONS

Even after selecting for admitted patients and accounting for both age and comorbidity, geriatric patients with ankle fractures were found to have a lower one-year morbidity compared with geriatric patients who had sustained a hip fracture or alternative admitting diagnoses. Geriatric patients with ankle fractures are likely healthier and more active in ways that are not captured by simply accounting for age and comorbidity. These findings may support more aggressive definitive management of such injuries in this population.

LEVEL OF EVIDENCE

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

External fixation in the elderly

Orthopaedic trauma is an increasingly common problem in geriatric patients. As demands of daily life and recreational activities are increasing in these patients, surgeons need to be able to manage geriatric fractures to achieve good functional results. Reduced bone quality in the elderly presents a considerable challenge and may preclude the use of established surgical stabilisation techniques that are performed in younger trauma patients. Furthermore, pre-existing medical conditions and considerable comorbidities in the elderly could complicate standard surgical procedures that younger patients would be offered. In this respect, application of external fixators represents a validated, minimally-invasive treatment opportunity. This review article summarises the use of external fixation in geriatric trauma patients for wrist fractures, proximal femoral fractures, pelvic fractures, and ankle fractures. Modern modifications, like pin coating with hydroxyapatite, and aspects of pin care will be discussed.

Occupational Outcomes and Return to Running Following Internal Fixation of Ankle Fractures in a High-Demand Population

BACKGROUND

Literature evaluating surgical outcomes after ankle fixation in an active patient population is limited. This study determined occupational outcomes and return to running following ankle fracture fixation in a military cohort.

METHODS

All service members undergoing ankle fracture fixation at a single military hospital from August 2007 to August 2012 were reviewed. Univariate analysis determined the association between patient demographic information, type of fracture fixation, and the development of posttraumatic ankle arthritis and functional outcomes, including medical separation, return to running, and reoperation. Seventy-two primary ankle fracture fixation procedures were performed on patients with mean age of 29.1 years. The majority of patients were male (88%), were 25 years of age or older (61%), were of junior rank (57%), underwent unimalleolar fracture fixation (78%), and did not require syndesmotic fixation (54%). The average follow-up was 35.9 months.

RESULTS

The mean time to radiographic union was 8.6 weeks. Twelve service members (17%) were medically separated from the military due to refractory pain following ankle fracture fixation with a minimum of 2-year occupational follow-up. Among military service members undergoing ankle fracture fixation, 64% returned to running. Service members with higher occupational demands had a statistical trend to return to running (odds ratio [OR] 2.49; 95% CI, 0.93-6.68). Junior enlisted rank was a risk factor for medical separation (OR 11.00; 95% CI, 1.34-90.57). Radiographic evidence of posttraumatic ankle osteoarthritis occurred in 8 (11%) service members.

CONCLUSIONS

At mean 3-year follow-up, 83% of service members undergoing ankle fracture fixation remained on active duty or successfully completed their military service, while nearly two-thirds returned to occupationally required daily running.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Operative versus nonoperative treatment of geriatric ankle fractures: a Medicare Part A claims database analysis

BACKGROUND

The incidence of ankle fractures is increasing in the geriatric population, and several studies suggest them to be the third most common extremity fracture in this age group. Previous work has reflected relatively low complication rates during operative treatment. Little is known, however, about the association between these injuries and overall mortality, nor whether operative intervention has any effect on mortality. We hypothesized that geriatric ankle fractures would be correlated with an elevated mortality rate and that operative intervention would be associated with a reduced mortality when compared to nonoperative management.

METHODS

Following Institutional Review Board approval we retrospectively assessed all relevant 2008 part A inpatient claims from the Medicare database. We queried diagnosis codes for ankle fractures, and then excluded any patients whose age was less then 65 or had an admission related to an ankle fracture during the previous year. Operative patients were then identified by their ICD-9 procedure codes occurring within 30 days of their initial diagnosis code; all other patients were presumed to be treated without operative intervention, thereby creating 2 groups for comparison. We then analyzed this database for specific variables including overall mortality, length of stay, age distribution, and other demographical characteristics. Groups were compared with Elixhauser and Deyo-Charlson scores to determine the level of comorbidities in each group. Multivariate logistic regression analysis was used to determine if operative intervention had a protective effect.

RESULTS

In all, 19 648 patients with an ankle fracture were identified. Of those, 15 193 underwent operative intervention (77.3% ) and 4455 were treated nonoperatively (22.7% ). The mean ages for nonoperative and operative intervention were 80.9 and 76.5, respectively (P < .0001). The average length of stay for nonoperative management was 4.5 days, while operative intervention resulted in a length of stay of 4.6 days (P = .43). One-year mortality was 21.5% for the nonoperative group and 9.1% for the operative group (P < .0001). The mean Elixhauser score for the nonoperative group was 2.5 and 2.2 for the operative group (P < .0001). The mean Deyo-Charlson score was 1.3 and 1.0 for the nonoperative and operative groups, respectively (P < .0001). Multivariate logistic regression analysis demonstrated an odds ratio of 0.534 of death within 1 year for patients undergoing operative intervention as compared to nonoperative intervention (95% CI 0.483-0.591, P < .0001).

CONCLUSION

The incidence of geriatric ankle fractures continue to increase as our population continues to grow older. A significantly larger number of those patients were treated with operative intervention, at a ratio of approximately 3:1 versus nonoperative management. Despite a relatively low overall reported complication rate with treatment of these injuries, they are associated with substantially increased 1-year mortality in both patient groups. Compared to the operative group, the nonoperative cohort demonstrated a 2-fold elevated mortality rate, although this may be related to them being an arguably more frail population as suggested by both comorbidity indexes. In spite of the difference in comorbidities, logistic regression analysis demonstrated operative intervention to have a protective effect.

LEVEL OF EVIDENCE

Level III, comparative series.

Management of complex fibular fractures: double plating of fibular fractures

Complex fibular fractures as a result of either high-energy mechanisms or advanced age can be difficult to manage as significant comminution can preclude standard operative techniques. Furthermore, the maintenance of osseous reduction postoperatively throughout convalescence can present an equivalent challenge. Strict weightbearing restrictions in the elderly and the noncompliant postoperatively convey an additional risk of potential failure. We present a technique that has offered additional reassurance in these instances. We retrospectively evaluated 25 consecutive patients who had undergone this fibular double plating technique and evaluated the patient outcomes to determine whether this technique conferred any additional risk when weighed against its benefits. All 25 patients underwent benign postoperative courses. No additional operations were performed as a result of this technique. No patient undergoing this technique complained of any hardware irritation, and no hardware removal was required. This double plating technique may confer additional stability to fracture patterns that are inherently unstable. It does not appear to increase the incidence of hardware removal or irritation, and patient morbidity remained low. Based on our results, we advocate this technique especially for comminuted fracture patterns.

Management in high-risk patients

Injuries to the foot and ankle are often missed or underestimated in patients with polytrauma and are a source of long-term limitations. Injures below the knee are among the highest causes for unemployment, longer sick leave, more pain, more follow-up appointments, and decreased overall outcome. As mortalities decrease for patients with polytrauma a greater emphasis on timely diagnosis and treatment of foot and ankle injuries is indicated. Geriatric patients represent nearly one-quarter of trauma admissions in the United States. This article discusses perioperative management and complications associated with foot and ankle injuries in polytrauma, and in diabetic and geriatric patients.

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

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

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

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

Cigarette smoking increases complications following fracture: a systematic review

BACKGROUND

Smoking has been suggested to increase the rate of perioperative complications including soft-tissue complications, to decrease the rate of fracture union, and to prolong healing time. The purpose of our study was to systematically evaluate and analyze the literature regarding the relationship between smoking and healing following operative treatment of long-bone fractures.

METHODS

We searched the MEDLINE, Embase, and Cochrane databases by pairing the search terms "smoking," "tobacco," and "nicotine" with the terms "fracture," "nonunion," delayed union," and "healing." Articles and citations were evaluated for relevance. Inclusion and exclusion criteria were established to maintain data quality for analysis. Relevant information was independently extracted and compared to ensure agreement. The methodological quality of the studies was determined. A random-effects model was used. The adjusted odds ratios (ORs) and frequency-weighted means for the primary and secondary outcome measures were calculated.

RESULTS

Our initial search identified 7110 articles. Of the 237 articles that underwent further evaluation of the abstract, nineteen (seven prospective and twelve retrospective cohort studies) were included. The adjusted OR of nonunion in the smoking group compared with the nonsmoking group was 2.32 (95% confidence interval [CI], 1.76 to 3.06; p < 0.001). An increased nonunion rate was observed in smokers with a tibial fracture (OR, 2.16; 95% CI, 1.55 to 3.01; p < 0.001) and those with an open fracture (OR, 1.95; 95% CI, 1.3 to 2.9; p < 0.001). For all fractures, the mean healing time was longer for smokers (30.2 weeks; 95% CI, 22.7 to 37.7 weeks) than for nonsmokers (24.1 weeks; 95% CI, 17.3 to 30.9 weeks) (p = 0.18). Trends toward more superficial and deep infections of postoperative or traumatic wounds in smokers were noted; however, the differences in superficial and deep infection rates were not significant (p = 0.13 and p = 0.33, respectively).

CONCLUSIONS

Smoking significantly increased the risk of nonunion of fractures overall, tibial fractures, and open fractures. Nonsignificant trends toward increased time to union in all fractures and toward increased postoperative rates of superficial and deep infections were noted in smokers compared with nonsmokers.

Early complications of surgery in operative treatment of ankle fractures in those over 60: a review of 186 cases

INTRODUCTION

Ankle fractures are among the most common injuries of the lower extremity encountered by orthopaedic surgeons. With increasing population age and osteoporosis, the prevalence of these fractures is expected to increase. The aim of this study was to evaluate complications and the need for revision surgery after the surgical treatment of ankle fractures in patients over 60 years of age. We report the outcomes of 186 consecutive patients who underwent operative treatment for rotational ankle fractures in our institution from 2007 to 2010.

MATERIALS AND METHODS

Data were collected retrospectively for the purpose of this study. The outcome measures included minor complications which did not need further surgical intervention, that is, superficial wound infections, delayed wound healing, prominent implants and skin irritation, and major complications that prompted surgical intervention (due to deep wound infection, loosening of implants or loss of fixation). Medical complications were also recorded. Long-term complications (postoperative osteoarthritis) were not assessed in this study. Logistic regression analysis and Fisher's exact test were used to identify factors predicting higher risk of complications.

RESULTS

The average age was 70.67 years (standard deviation (SD) 7.40). There were 132 (71%) females and 54 (29%) males. The overall rate of complications was 21.5% with 10.8% of them being major complications prompting surgical intervention for wound washout, removal of implants and revision of fixation. Statistical analysis showed that smoking, age, diabetes, local factors (osteopaenia, peripheral neuropathy, peripheral vascular disease, lymphoedema and venous insufficiency) and modified Charlson score were significantly associated with occurrence of complications. Gender had a marginally significant effect. Coronary artery disease and fracture type (Weber classification) did not have a significant effect on the outcome.

DISCUSSION AND CONCLUSION

Our data show that surgical treatment of ankle fractures in the elderly is associated with a high rate of complications. The factors predicting a high rate of complications include smoking, age, diabetes, local factors and a higher modified Charlson score. It is important to bear the factors in mind whilst deciding whether surgical treatment should be used in the treatment of such fractures in the elderly and explains these to patients at the time of obtaining consent. Further large-scale studies are needed to validate the predictive value of the suggested modified Charlson score.

Incidence and risk factors for acute infection after proximal humeral fractures: a multicenter study

BACKGROUND

The rate of acute infection after surgery for proximal humeral fractures is not known. The aims of this study were to report the incidence and to analyze the risk factors for infection after proximal humeral fracture treatment.

MATERIALS AND METHODS

We report a retrospective multicenter study of 452 proximal humeral fractures. Data were modeled by use of univariate and/or linear regression analyses to determine the odds ratio (OR). A logistic regression analysis was used to check for demographic and other characteristics with the potential to confound a true association between risk factors and infection.

RESULTS

The mean age was 62.1 years, and 314 patients were female patients. Of the patients, 18 (4%) had an acute infection. The factors that correlated with infection were length of surgery (OR, 1.009; P = .05), preoperative skin preparation with chlorhexidine gluconate (OR, 0.13; P = .008), and prophylactic antibiotic (OR, 10.73; P = .03). The delay to surgery was close to achieving significance (OR, 1.71; P = .06).

CONCLUSION

This study suggests that washing the shoulder with chlorhexidine gluconate and avoiding the use of first-generation cephalosporin in favor of more effective prophylactic therapy are effective at reducing the risk of infection after treatment for proximal humeral fractures.

A biomechanical evaluation of locked plating for distal fibula fractures in an osteoporotic sawbone model

BACKGROUND

Supination external rotation (SER) injuries are commonly fixed with a one third tubular neutralization plate. This study investigated if a combination locked plate with additional fixation options was biomechanically superior in osteoporotic bone and comminuted fracture models.

METHODS

Using an osteoporotic and a comminuted Sawbones model, SER injuries were fixed with a lag screw for simple oblique fibula fractures, and either a one third tubular neutralization plate or a locking plate. Samples were tested in stiffness, peak torque, displacement at failure, and torsion fatigue.

RESULTS

There was no statistically significant difference in biomechanical testing for fractures treated with a lag screw and plate. For comminuted fractures, locked plating demonstrated statistically significant stiffer fixation.

CONCLUSION

A combination locked plate is biomechanically superior to a standard one third tubular plate in comminuted SER ankle fractures. There was no biomechanical superiority between locked and one third tubular plates when the fracture was amenable to a lag screw.

A Locking Contoured Plate for Distal Fibular Fractures: Mechanical Evaluation in an Osteoporotic Bone Model Using Screws of Different Length

Osteoporotic bone with poor mechanical capacity provides limited stability after fixation of ankle fractures. Stabilization with an implant providing increased fixation strength in osteoporotic bone could reduce failure rates of fixation and allow a more functional treatment. The purpose of this study was to evaluate a locking contoured plate for fixation of distal fibular fractures in comparison with a conventional contoured plate in an osteoporotic bone model. Eighty cylinders of osteoporotic bone surrogates were fixed with the two plates. We performed torque-to-failure and cyclic testing experiments using screws of different length with a Zwick/Roell testing machine. The locking system showed higher torque-to-failure and maximum torque levels as compared with the conventional plate in torque-to-failure experiments and torsional cyclic testing. The locking contoured plate provides improved fixation strength in the osteoporotic bone model. The locking system may be appropriate for fixation of distal fibular fractures, especially in osteoporotic bone with poor mechanical capacity.

Management of high-energy foot and ankle injuries in the geriatric population

By the year 2035 almost 20% of the US population of 389 million people will be 65 years and older. What this group has, compared with aged populations in the past, is better health, more mobility, and more active lifestyles. From January 1989 through December 2010, a total of 494 elderly patients with 536 foot and ankle injuries were identified. Within this group, 237 (48%) patients with 294 injuries were sustained as a result of a high-energy mechanism. These mechanisms consisted of 170 motor vehicle accidents, 30 as a result of high (not ground level) energy falls, 2 from industrial accidents, and 35 classified as other, which included sports, blunt trauma, bicycle, airplane or boating accidents, crush injuries, and injuries resulting from a lawn mower. The injuries produced were 17 metatarsal fractures, 9 Lisfranc injuries, 10 midfoot (navicular, cuneiform, or cuboid) fractures, 23 talus fractures, 63 calcaneal fractures, 73 unimalleolar, bimalleolar, or trimalleolar ankle fractures, 45 pilon fractures, and 3 pure dislocations of the foot or ankle. Overall, 243 (83%) of these injuries underwent surgical fixation and data have shown that when surgery is used to manage high-energy injuries of the foot and ankle in the elderly individuals, the complications and outcomes are similar to those seen in younger patients. Therefore, the decision for surgical intervention for high-energy injuries of the foot and ankle should be based primarily on the injury pattern and not solely on the age of the patient.

Comparison of supination external rotation type IV ankle fractures in geriatric versus nongeriatric populations

BACKGROUND

Geriatric patients' (defined as those older than 65 years old) inherent comorbidities, functional limitations, and bone quality present obstacles to successful clinical outcomes for operatively treated supination external rotation (SER) ankle fractures. We retrospectively reviewed a prospectively collected series of SER injuries between 2004 and 2010. This is a comparison of the radiographic and clinical outcomes of our geriatric (27 patients) and nongeriatric (81 patients) populations. We hypothesized that geriatric patients would have worse outcomes when compared to nongeriatric patients.

METHODS

All SER ankle fractures (176) treated by a single surgeon were enrolled in a prospective database. All patients fulfilled inclusion criteria (108) consisting of 1 year of having clinical follow-up, postoperative radiographs, and Foot & Ankle Outcome Scores (FAOS). The primary outcome evaluated was functional outcome as exhibited by the FAOS. The secondary outcomes included adequacy of reduction, loss of reduction, postoperative complications (wound complications, infection, pain-driven hardware removal), and range of motion.

RESULTS

Despite significantly higher rates of diabetes (P < .001) and peripheral vascular disease (P < .001), there were statistically significantly better FAOS outcomes in the symptoms subcategory among the geriatric population. There was no significant difference in the articular reduction, syndesmotic reduction, wound complications, postoperative infections, or range of motion between these groups.

CONCLUSION

Geriatric patients exhibited equivalent complication rates, radiographic outcomes, and functional outcomes compared to nongeriatric patients in this series. Anatomic fixation and soft tissue management counter the inherent risks of operative intervention in geriatric populations that report higher rates of comorbidities. This study supports aggressive fracture- and ligament-specific operative intervention in geriatric patients presenting with unstable SER injuries.

Osteoporotic ankle fractures

Ankle fractures are one of the most common injuries in the elderly and their incidence is anticipated to increase over the next 20 years. Appropriate management of ankle fractures in this population requires an understanding of the issues unique to the elderly. Osteoporosis must be considered when counseling patients about their ankle fracture. Good outcomes can be achieved with surgical fixation of ankle fractures in the elderly. Postoperative complications are higher in patients with diabetes and peripheral vascular disease, and in patients who smoke. This article reviews how to evaluate and treat ankle fractures in elderly patients with osteoporosis, evaluates the outcomes, and discusses surgical techniques.