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Morningstar J, Lauck BJ, Bank N, Lalli T. Impact of glucagon-like peptide-1 receptor agonists on postoperative outcomes following ankle fracture open reduction and internal fixation. J Foot Ankle Surg 2025:S1067-2516(25)00140-1. [PMID: 40345639 DOI: 10.1053/j.jfas.2025.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2025] [Accepted: 05/03/2025] [Indexed: 05/11/2025]
Abstract
Glucagon-like peptide-1 receptor agonists (GLP-1RA) are quickly growing in popularity as effective tools in the management of diabetes and weight loss. Despite this increased usage, there is a paucity of literature investigating the use of GLP-1RA in patients with ankle fractures. This study aims to compare the outcomes of patients undergoing ankle fracture open reduction and internal fixation (ORIF) receiving therapy with GLP-1RA to those not receiving treatment. A retrospective analysis was performed utilizing the TriNetX research network to query patients who underwent ankle fracture ORIF between 2000-2024. Two cohorts were established according to preoperative GLP-1RA usage with 1:1 matching by propensity scores for demographics and comorbidities. Primary outcomes included the risk of postoperative complications (i.e. infection, sepsis, wound dehiscence, cellulitis, thrombosis, nonunion, reoperation, revision, etc.) at 30-days, 90-days, 1-year, and 5-years. There were 123,546 patients not taking GLP-1RA and 1,173 patients taking GLP-1RA who underwent ORIF for an ankle fracture, with propensity score matching resulting in two cohorts of 1,173 patients each. After matching, there were no significant differences in demographics or comorbidities, including a 75.6 % prevalence of diabetes mellitus and 68.7 % prevalence of overweight or obesity in both cohorts. At 30-days postoperatively, the no GLP-1RA cohort had a significantly higher rate of removal of hardware (Odds Ratio [OR] 1.953, 95 % Confidence Interval (CI) 1.062-3.591); no other complications demonstrated significant differences at 30-days, 90-days, 1-year, or 5-years postoperatively. These findings further underscore the low risk of preoperative GLP-1RA usage noted in other orthopaedic procedures.
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Affiliation(s)
- Joshua Morningstar
- Department of Orthopaedics, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Bradley J Lauck
- Department of Orthopaedics, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Nicholas Bank
- Department of Orthopaedics, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA; Case Western Reserve University School of Medicine, Clevaland, Ohio, USA
| | - Trapper Lalli
- Department of Orthopaedics, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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McDonald J, Oravic M, Wardell W, Lee W. Open Reduction and Internal Fixation vs Primary Tibiotalocalcaneal Hindfoot Nailing for Ankle Fractures in Elderly Patients: A Systematic Review and Meta-analysis. Foot Ankle Int 2025:10711007251325841. [PMID: 40219867 DOI: 10.1177/10711007251325841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2025]
Abstract
BACKGROUND Current literature lacks comprehensive information comparing primary tibiotalocalcaneal (TTC) hindfoot nailing and open reduction internal fixation (ORIF) in the ankle fractures in the elderly population. This systematic review and meta-analysis was conducted to evaluate and compare the clinical outcomes of 2 surgical techniques, primary TTC nailing and ORIF, for ankle fractures in the elderly. METHODS Our comprehensive literature review adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and used databases including PubMed, Embase, Web of Science, and the Cochrane Library. Data investigated in this study included total infection, deep infection, superficial infection, hardware problems such as painful hardware, and hardware protrusion/pullout, nonunion/delayed union, reoperation, length of stay, and return to preoperative mobility level. RESULTS Total 5 studies were included in this study. In aggregate, 127 patients (42.9%) underwent TTC nailing, whereas 169/296 patients (57.1%) underwent ORIF. A lower rate of superficial infection was reported for the TTC nailing group: 2.1% (2/95) in TTC nailing vs 10.2% (14/137) in ORIF, with a relative ratio of 0.26 (95% CI, 0.08-0.85). The other outcome measures were not significantly different between groups. CONCLUSION Based on our review of these studies that reported mostly early follow-up data, it appears that primary TTC nailing may be a viable alternative to ORIF for ankle fracture fixation in the elderly population. However, these findings should be interpreted cautiously because of heterogeneity across the included studies.
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Affiliation(s)
- John McDonald
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Michael Oravic
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - William Wardell
- Department of Orthopaedic Surgery, Guthrie Clinic, Sayre, PA, USA
| | - Wonyong Lee
- Department of Orthopaedic Surgery, Guthrie Clinic, Sayre, PA, USA
- Department of Orthopaedic Surgery and Rehabilitation, The University of Chicago, Chicago, IL, USA
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Schagemann JC, Neumann H, Schäfers J, Paech A, Wendlandt R, Oheim R, Schulz AP. Similar Clinical Outcome in Locking and Conventional Plate Osteosynthesis for the Treatment of AO 44-B2 Ankle Fractures. Foot Ankle Spec 2025; 18:209-218. [PMID: 36418935 DOI: 10.1177/19386400221136757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
IntroductionBiomechanical studies have proved that locking plates have better primary stability besides versatility regarding fracture pattern while reducing bone contact and bridging the gap, whereas conventional nonlocking plates (plus lag screw) depend on bone-plate compression. The clinical benefit of locking plates over nonlocking plates remains unanswered, however. Therefore, this retrospective cohort study was set up to test the hypothesis that the use of locking plates for unstable ankle fractures will result in fewer re-displacements, superior bony healing, and functional and clinical outcomes better than observed in the nonlocking cohort.MethodsBimalleolar ankle fractures (AO 44-B2) without syndesmotic injury treated with either a locking or a nonlocking plate were included. Groups were compared for complications, bone healing, secondary dislocation, progressions of osteoarthritis, and clinical outcome using patient-reported outcome measures.ResultsData revealed no clinical outcome differences (Olerud-Molander Ankle Score: nonlocking 88.2 ± 14.4, locking 88.8 ± 12.3, P = .69, robust two 1-sided test for equality (RTOST): P = .03; American Orthopaedic Foot and Ankle Score: nonlocking 91.2 ± 12.9, locking 91.8 ± 11.3, P = .96, RTOST: P = .04). Nevertheless, a significant postoperative progression of osteoarthritis was detected in both groups (P = .04). This was independent of implant (P = .16). Although difference was not significant, locking plates were preferred in older (P = .78) and sicker patients (P = .63) and in cases with severer osteoarthritis (P = .16), and were associated with a higher complication rate (P = .42) and secondary dislocation (nonlocking 9.4%, locking 18.2%; P = .42). Re-displacement, however, was not a compelling reason for revision.ConclusionsThe present study shows statistically significant equality of both types of implants. Contrary to our expectation, locking plates seemed to be associated with a higher risk for re-displacement. Overall, the use of either locking or nonlocking plates for unstable AO 44-B2 fractures is safe and successful despite significant progression of osteoarthritis.Level of Evidence:III, Retrospective observational cohort study.
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Affiliation(s)
- Jan C Schagemann
- Christophorus Kliniken Coesfeld, Coesfeld, Germany
- Universität zu Lübeck, Lübeck, Germany
| | | | | | | | | | - Ralf Oheim
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Arndt Peter Schulz
- Universität zu Lübeck, Lübeck, Germany
- BG Klinikum Hamburg, Hamburg, Germany
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Carver A, Choong M, Fawdry R, Boylan CT, Nanavati N. Do operative or weight-bearing delays lead to worse outcomes in ankle surgery? Foot (Edinb) 2025; 62:102159. [PMID: 40203477 DOI: 10.1016/j.foot.2025.102159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2025] [Revised: 03/18/2025] [Accepted: 03/23/2025] [Indexed: 04/11/2025]
Abstract
BACKGROUND Ankle fractures comprise 10 % of fractures seen in ED. Despite this, debate remains regarding the optimal timing of surgery and weight bearing post-operatively. There is no clear consensus whether delaying ankle ORIF leads to better outcomes. There is also debate whether early post-operative weight bearing (WB) impacts post-operative outcomes. The aim of this study was to investigate whether a delay in operation or a prolonged post-operative weight-bearing plan led to (1) increased complications and (2) poorer outcomes in patient-recorded outcome measures (PROMs). METHODS In this retrospective study, 160 patients were analysed. Primary outcomes were post-operative complications. Secondary outcomes were PROMs, using EQ-5D and MOxFQ questionnaires. Data was analysed using SPSS26. Analysis used independent two-tailed Mann-Whitney U tests for continuous data with nominal independent variables, and Kruskal-Wallace tests for ordinal independent variables. Fisher-exact tests were used for categorical variables. RESULTS Delay in operation had no statistically significant impact on overall complication rate (p = 0.482). There was no statistically significant difference in EQ-5D (p = 0.433) and MOxFQ (p = 0.325) scores regardless of delay in operation. Additionally, time spent until WB post-operatively had no statistically significant impact on overall complication rate (p = 0.634). There was no statistically significant difference in EQ-5D (p = 0.358) and MOxFQ (p = 0.089) scores regardless of post-operative WB plan. CONCLUSIONS/FINDINGS Our results suggest that a delay in ankle ORIF operation does not lead to an increase in complications or poorer PROMs post-operatively, endorsing GIRFT principles. Early post-operative WB also had no impact on complication rate or PROMs, meaning early mobilisation may accelerate patient rehabilitation, facilitate independence, and reduce prolonged inpatient hospital stay.
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Affiliation(s)
- Alexander Carver
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; The Rotherham NHS Foundation Trust, Rotherham, UK.
| | - Marc Choong
- The Rotherham NHS Foundation Trust, Rotherham, UK
| | - Robert Fawdry
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; The Rotherham NHS Foundation Trust, Rotherham, UK
| | - Conor T Boylan
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Chauhan DD, Modha N, Rushing CJ. Minimal Incision Management of Rearfoot & Ankle Trauma. Clin Podiatr Med Surg 2025; 42:139-152. [PMID: 39550089 DOI: 10.1016/j.cpm.2024.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2024]
Abstract
Minimally invasive surgery is gaining tremendous popularity in reconstructive foot and ankle surgery, as well as with trauma. Minimally invasive approaches have demonstrated equivalent to outcomes to traditional open incisional approaches with the added benefit of less risk for wound healing complications and surgical site infections. Advances in orthopedic hardware and surgical techniques are allowing minimal incision surgery for trauma to become more widespread. While there is a steeper learning curve to become proficient, minimally invasive surgery is likely to become the standard for most foot and ankle trauma cases.
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Affiliation(s)
- Dhavel D Chauhan
- Dallas Advanced Foot and Ankle Reconsruction Fellowship, Dallas, TX, USA
| | - Nehal Modha
- McKinney Footcare, 5337 West University Drive Suite 100, Mckinney, TX, USA
| | - Calvin J Rushing
- Dallas Orthopedic and Shoulder Institute, 222 South Collins Road Suite 101, Sunnyvale, TX 75182, USA.
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Boppana AV, Boppana AS, Roberts MA, Wall CJ. Hindfoot Nailing for Surgical Management of Open Ankle Fractures in the Elderly: A Systematic Review. Cureus 2024; 16:e75838. [PMID: 39822412 PMCID: PMC11735849 DOI: 10.7759/cureus.75838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2024] [Indexed: 01/19/2025] Open
Abstract
Open ankle fractures in the elderly are increasingly common, with significant morbidity and mortality. Management is challenging due to poor soft tissue conditions, comorbidities, and limited functional independence. While traditional surgical options include external fixation or open reduction and internal fixation (ORIF), hindfoot nail (HFN) fixation may offer advantages, including immediate weight-bearing and reduced immobilisation complications. However, no systematic review has assessed the outcomes of HFNs in managing open ankle fractures in this population. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Comprehensive searches of the Medline, CINAHL, Embase, and Cochrane databases were conducted on September 24, 2024, with inclusion criteria focused on studies involving HFN for open ankle fractures in patients aged ≥60 years. Outcomes included union rates, infection, complications, and functional recovery. Two reviewers independently performed data extraction and quality assessment (using the Newcastle-Ottawa Scale), with narrative synthesis due to study heterogeneity. Five retrospective studies were included where open ankle fractures were treated with HFNs. Across studies, immediate post-operative weight-bearing was allowed in most cases. Union rates ranged from 85% to 100%. Infection rates varied between 6.3% and 17.9%, with implant-related complications noted in 18.7% of cases. Functional outcomes, where reported, were moderate, with scores such as the Olerud-Molander Ankle Score (OMAS) averaging 45-57 (62 preoperatively). Mortality at six to 12 months ranged from 15% to 61%. Compared to ORIF, HFNs demonstrated no difference in union rates or complications, including deep vein thrombosis (DVT) and pulmonary embolism (PE). HFNs utilised in arthrodesis resulted in increased wound complications, and implant removal reoperations compared to ORIF (10%-20% vs. 5%-10%) in frail patients with compromised soft tissues. HFNs used for fixation only resulted in similar complication rates to ORIF. HFNs appear to be a viable option for managing open ankle fractures in elderly patients. Offering advantages such as immediate weight-bearing and reduced immobilization risks. However, higher rates of implant-related complications and variable functional outcomes warrant caution. Prospective, comparative studies are needed to better delineate the role of HFNs in this complex patient population.
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Nathe K, Bakaes Y, Giakas AM, Kung J, Gauthier C, Grabowski G, Smoker B, Boguski J, Toole W, Elliott M, Van Eck CF, Bowman E, Townsend C, Jackson JB. Open Ankle Fractures in Older Individuals: A Multi-center Study. J Foot Ankle Surg 2024; 63:631-636. [PMID: 38909963 DOI: 10.1053/j.jfas.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 05/06/2024] [Accepted: 06/08/2024] [Indexed: 06/25/2024]
Abstract
The purpose of this study is to identify demographics, etiology, comorbidities, treatment, complications, and outcomes for older patients with open ankle fractures. Patients ≥60 years old who sustained an open ankle fracture between January 1, 2004 and March 31, 2014 at 6 Level 1 trauma centers were retrospectively reviewed. Univariate analysis using chi-squared or Student's t test was performed to identify associations between preoperative variables and 2 postoperative outcomes of interest: amputation and 1-year mortality. Multivariate analysis was performed using stepwise logistical regression to identify independent predictors of postoperative amputation and 1-year mortality. Of the 162 total patients, the most common mechanism of injury was a ground-level fall (51.9%). The most common fracture types were bimalleolar fractures (52.5%) followed by trimalleolar fractures (26.5%), with 41.5% of the fractures classified as Gustilo Anderson Classification Type 2 and 38.6% classified as Type 3A. The average number of surgeries required per patient was 2.1. Complications included: 15.4% superficial infection rate, 9.9% deep infection rate, and 9.3% amputation rate. The 1-year mortality rate was 13.6% and the overall mortality rate was 25.9%. Male gender and fracture type were found to be independent predictors for amputation after surgery (p = .009, .005, respectively). Older age and having diabetes were independent predictors for 1-year mortality after surgery (p = .021, .005 respectively). Overall, open ankle fractures in older individuals were associated with high rates of amputation and mortality.
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Affiliation(s)
- Kristen Nathe
- Prisma Health Midlands Department of Orthopaedic Surgery, Columbia, SC
| | - Yianni Bakaes
- University of South Carolina School of Medicine Columbia, Columbia, SC.
| | - Alec M Giakas
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Justin Kung
- Prisma Health Midlands Department of Orthopaedic Surgery, Columbia, SC
| | - Chase Gauthier
- Prisma Health Midlands Department of Orthopaedic Surgery, Columbia, SC
| | - Gregory Grabowski
- Prisma Health Midlands Department of Orthopaedic Surgery, Columbia, SC
| | - Brice Smoker
- University of South Carolina School of Medicine Columbia, Columbia, SC
| | | | - William Toole
- University of Florida College of Medicine, Jacksonville, FL
| | - Mark Elliott
- University of Florida College of Medicine, Jacksonville, FL
| | | | - Erik Bowman
- University of Nebraska Medical Center, Omaha, NE
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Andrés-Peiró JV, Reverté-Vinaixa MM, Pujol-Alarcón O, Altayó-Carulla M, Castellanos-Alonso S, Teixidor-Serra J, Tomàs-Hernández J, Selga-Marsà J, Piedra-Calle CA, Blasco-Casado F, García-Sánchez Y, Joshi-Jubert N, Minguell-Monyart J. Predictive factors of hospital and nursing facility admission in the fixation of low-energy ankle fractures. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024:S1888-4415(24)00172-3. [PMID: 39477014 DOI: 10.1016/j.recot.2024.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2024] [Revised: 10/17/2024] [Accepted: 10/21/2024] [Indexed: 12/24/2024] Open
Abstract
INTRODUCTION Ankle fractures are increasingly common in frail patients, with hospitalization being the principal cost driver, particularly for the elderly who often need referral to nursing facilities. This study aims to identify factors affecting resource utilization per admission (hospital and nursing) in the fixation of low-energy ankle fractures. MATERIALS AND METHODS This retrospective cohort study examined patients undergoing fixation for low-energy ankle fractures. The primary outcome was the length of hospitalization. Secondary outcomes included delays in fixation and the need for referral to a nursing institution. Multiple linear and logistic regression models were used to determine predictors related to patient demographics, injury characteristics, and treatment. RESULTS We analyzed 651 patients with a median age of 58years. The median hospitalization duration was 9days, primarily before surgery. Extended hospitalization was associated with antithrombotic treatment (b=4.08), fracture-dislocation (2.26), skin compromise (7.56), complications (9.90), and discharge to a nursing center (5.56). Referral to a nursing facility occurred in 17.2%, associated with older age (OR=1.10) and an ASA score ≥III (6.96). CONCLUSIONS Prolonged hospitalization was mainly due to surgical delays and was related to fracture-dislocations, skin compromise, and complications. Older and comorbid patients were more likely to need nursing facilities, and delays in these facilities' availability contributed to extended hospital stays.
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Affiliation(s)
- J V Andrés-Peiró
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Vall d'Hebron, Barcelona, España; Cirugía Reconstructiva del Aparato Locomotor, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España; Departmento de Cirugía y Ciencias Morfológicas, Universitat Autònoma de Barcelona (UAB), Barcelona, España.
| | - M M Reverté-Vinaixa
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Vall d'Hebron, Barcelona, España; Cirugía Reconstructiva del Aparato Locomotor, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España; Departmento de Cirugía y Ciencias Morfológicas, Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - O Pujol-Alarcón
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Vall d'Hebron, Barcelona, España; Cirugía Reconstructiva del Aparato Locomotor, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - M Altayó-Carulla
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Vall d'Hebron, Barcelona, España; Cirugía Reconstructiva del Aparato Locomotor, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - S Castellanos-Alonso
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Municipal de Badalona, Badalona, Barcelona, España
| | - J Teixidor-Serra
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Vall d'Hebron, Barcelona, España; Cirugía Reconstructiva del Aparato Locomotor, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España; Departmento de Cirugía y Ciencias Morfológicas, Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - J Tomàs-Hernández
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Vall d'Hebron, Barcelona, España; Cirugía Reconstructiva del Aparato Locomotor, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - J Selga-Marsà
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Vall d'Hebron, Barcelona, España; Cirugía Reconstructiva del Aparato Locomotor, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - C A Piedra-Calle
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Vall d'Hebron, Barcelona, España; Cirugía Reconstructiva del Aparato Locomotor, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - F Blasco-Casado
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Vall d'Hebron, Barcelona, España; Cirugía Reconstructiva del Aparato Locomotor, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - Y García-Sánchez
- Cirugía Reconstructiva del Aparato Locomotor, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - N Joshi-Jubert
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Vall d'Hebron, Barcelona, España; Cirugía Reconstructiva del Aparato Locomotor, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España; Departmento de Cirugía y Ciencias Morfológicas, Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - J Minguell-Monyart
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Vall d'Hebron, Barcelona, España; Cirugía Reconstructiva del Aparato Locomotor, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España; Departmento de Cirugía y Ciencias Morfológicas, Universitat Autònoma de Barcelona (UAB), Barcelona, España
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Nian P, Elali F, Voyvodic LC, Rodriguez AN, Ng MK, Abdelgawad AA, Razi AE. 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. J Foot Ankle Surg 2024; 63:504-507. [PMID: 38679410 DOI: 10.1053/j.jfas.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/05/2024] [Accepted: 04/06/2024] [Indexed: 05/01/2024]
Abstract
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.
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Affiliation(s)
- Patrick Nian
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York, NY; State University of New York (SUNY) Downstate, School of Medicine, Brooklyn, New York, NY
| | - Faisal Elali
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York, NY; State University of New York (SUNY) Downstate, School of Medicine, Brooklyn, New York, NY
| | - Lucas C Voyvodic
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York, NY; State University of New York (SUNY) Downstate, School of Medicine, Brooklyn, New York, NY
| | - Ariel N Rodriguez
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York, NY.
| | - Mitchell K Ng
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York, NY
| | - Amr A Abdelgawad
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York, NY
| | - Afshin E Razi
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York, NY
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10
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Rushing CJ. Comparison of Ankle Fracture Fixation Using Intramedullary Fibular Nailing Versus Plate Fixation. J Foot Ankle Surg 2024; 63:546-556. [PMID: 38825307 DOI: 10.1053/j.jfas.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 05/03/2024] [Accepted: 05/11/2024] [Indexed: 06/04/2024]
Abstract
Ankle fracture fixation using intramedullary fibular (IMF) nails has been shown to allow for earlier weightbearing, reduced wound complications, better union rates, and the absence of prominent hardware, compared to plates/screw (PS) constructs. The purpose of present retrospective cohort study was to compare outcomes of patients who underwent ankle fracture fixation using an IMF nail versus PS. Demographic, clinical, and radiographic data were recorded for patients who underwent ankle fracture fixation between May 2020 and May 2022, and who were at least 1 year postoperative. Toe-touch weightbearing was permitted immediately after surgery, protected weightbearing (PWB) at postoperative week 2, and weightbearing as tolerated in a brace at week 6. Radiographs were assessed preoperatively, and at 2, 6, 12, 24, and 48 weeks postoperative. Sixty-one ankle fractures (30 IMF, 31 PS) with a mean follow up of 14.7 and 18 (range, 12 to 23) months were included. Overall, the IMF nail cohort had less pain, faster time to union (11.4 vs 13.2 weeks), and less complications (23% vs 45%), reoperations (10% vs 16%), and surgical failures (9% vs 9.7%), compared to the PS cohort. The differences were not statistically significant. The PS cohort had a higher rate of symptomatic hardware irritation (p =< .001). Tobacco use adversely effected direct osseous healing (p < .001) and increased postoperative complications (p = .050). The present study lends credence to the previously reported advantages of IMF nailing over PS fixation for ankle fractures. Ankle fracture fixation using a fourth generation, IMF nail is a viable alternative to traditional PS fixation.
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Zhang D, Litvak A, Lin N, Pirkle S, Strelzow J, Hynes K. Current Trends in the Surgical Treatment of Fibular Fractures: A National Database Study of Intramedullary vs. Plate Fixation Practice Patterns, Complications, and Cost. Adv Orthop 2024; 2024:7506557. [PMID: 39036541 PMCID: PMC11260212 DOI: 10.1155/2024/7506557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/14/2024] [Accepted: 06/24/2024] [Indexed: 07/23/2024] Open
Abstract
Existing primary evidence comparing fibular intramedullary fixation (IMF) with traditional plate fixation (PF) for the treatment of distal fibular fractures remains limited by modest sample sizes. Using a large national database, this study aims to compare use rates, fracture patterns, patient characteristics, time to surgery, complication rates, and cost between fibular IMF and PF within the United States. Adults treated with fibular IMF or PF between October 2015 and October 2021 were identified within the PearlDiver Database. The ratio of IMF-treated to PF-treated patients was tracked temporally to compare use rates. Fracture patterns were determined using fracture diagnoses within one-month preceding surgery. Further comparisons of IMF- and PF-treated groups only included patients with at least 12 months of follow-up, and patients with upper tibia or tibia shaft fractures were excluded. An analysis of cohorts matched at a 1 : 4 (IMF: PF) ratio to control for risk factors was performed to compare time to surgery, complication rates (infection, nonunion, malunion, revision, hardware removal, pulmonary embolism, and deep vein thrombosis), and cost. 39329 patients (2294 IMF and 37035 PF) were identified. IMF use trended upwards relative to PF use over time. Tibia and fibula shaft fractures were the most common injuries in IMF patients versus bimalleolar and trimalleolar fractures in PF patients. A higher proportion of IMF patients had open fractures. IMF patients were younger, with higher mean ECI, fewer female patients, and higher rates of CKD. Percutaneous approaches were more common among IMF patients. There were no significant differences in time to surgery or complication rates. IMF was less costly. The popularity of IMF trended upwards across the study period. IMF was used more commonly in injuries involving higher energy trauma and soft tissue disruption. Overall, IMF patients were younger with more comorbidities. When used in similar populations, IMF appears to be a cost-effective alternative to PF.
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Affiliation(s)
- Douglas Zhang
- The University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Audrey Litvak
- The University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Nicholas Lin
- The University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Sean Pirkle
- Department of Orthopaedics and Sports MedicineUniversity of Washington, Seattle, WA 98195, USA
| | - Jason Strelzow
- Department of Orthopaedic Surgery and Rehabilitation MedicineUniversity of Chicago Medicine, Chicago, IL 60637, USA
| | - Kelly Hynes
- Department of Orthopaedic Surgery and Rehabilitation MedicineUniversity of Chicago Medicine, Chicago, IL 60637, USA
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Samuel Z, Hong IS, Deliso M, Passannante L, Zapf CG, Tang A, Jankowski JM, Liporace FA, Yoon RS. Intramedullary Fixation Versus Plate Fixation of Distal Fibular Fractures: A Systematic Review. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202407000-00009. [PMID: 38996216 PMCID: PMC11239172 DOI: 10.5435/jaaosglobal-d-24-00119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 07/14/2024]
Abstract
INTRODUCTION The purpose of this systematic review and meta-analysis was to provide an update of the recent literature comparing clinical outcomes of surgically treated fibular fractures using intramedullary nailing (IMN) with open reduction and internal plate fixation (ORIF). METHODS A literature search reporting clinical outcomes after IMN or ORIF of the distal fibula was conducted on PubMed. Inclusion criteria consisted of original studies; studies focusing on clinical outcomes after IMN or IMN and ORIF published before May 11, 2022; studies with at least 5 patients; and studies reporting union rates, complication rates, and patient-reported outcomes such as American Orthopaedic Foot and Ankle Society (AOFAS) and Olerud-Molander scores. RESULTS Of 2,394 studies identified, a total of 29 studies (4 LOE-I, 2 LOE-II, 6 LOE-III, 17 LOE-IV) were included consisting of 1,850 IMN patients and 514 plate patients. The pooled mean age of IMN patients was 58 years (95% confidence interval [CI], 54 to 62, I2 = 42%) versus 57 years (95% CI, 53 to 62, I2 = 49%) in ORIF. Union rates for IMN patients revealed a 99% union rate (95% CI, 0.98 to 1.00, I2 = 20%) versus 97% union rate for ORIF patients (95% CI, 0.94 to 0.99, I2 = 0%). Studies that compared IMN with ORIF revealed no difference in union rates (risk ratio [RR] = 0.99, 95% CI, 0.96 to 1.02, I2 = 0%). IMN patients showed a 15% complication rate (95% CI, 0.09 to 0.23, I2 = 89%), whereas plate patients had a complication rate of 30% (95% CI, 0.18 to 0.46, I2 = 63%). When comparing studies with both treatments, IMN patients had a significantly lower risk of complications (RR = 0.49, 95% CI, 0.29 to 0.82, I2 = 50%). The IMN group trended toward a higher mean AOFAS and Olerud-Molander score than the plate group by 4.53 (95% CI, -14.58 to 23.65, I2 = 85%) and 3.54 (95% CI, -2.32 to 9.41, I2 = 76%) points, respectively. CONCLUSION Current literature reveals near equivalence in union rates and a markedly lower risk of complications when comparing IMN with plate fixation. While IMN patients had higher AOFAS and Olerud-Molander scores, these differences were not statistically significant. Notably, subgroup analyses indicated that rates of symptomatic implant and removal of implant were comparable between IMN and ORIF, which may indicate that wound-related complications were reduced in the minimally invasive IMN technique. While the high cost of IMN implants remains a barrier to their widespread adoption, the long-term benefits of reducing complications, specifically associated with wound complications in high-risk populations, may greatly improve quality of care for patients with distal fibula fractures. Additional research and cost-effectiveness analyses are warranted to fully assess the long-term benefits and economic feasibility of using IMN fixation for distal fibula fractures. LEVEL OF EVIDENCE Therapeutic Level IV.
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Affiliation(s)
- Zachariah Samuel
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Ian S. Hong
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Marisa Deliso
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Luke Passannante
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Christian G. Zapf
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Alex Tang
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Jaclyn M. Jankowski
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Frank A. Liporace
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Richard S. Yoon
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
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Andrés-Peiró JV, Pujol O, Altayó-Carulla M, Castellanos-Alonso S, Reverté-Vinaixa MM, Teixidor-Serra J, Tomàs-Hernández J, Selga-Marsà J, García-Sánchez Y, Molero-García V, Joshi-Jubert N, Minguell-Monyart J. Predictors of first-year postoperative complications after fixation of low-energy ankle fractures: A single-center, retrospective cohort study of 663 consecutive fractures. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:363-372. [PMID: 38043738 DOI: 10.1016/j.recot.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 11/19/2023] [Accepted: 11/24/2023] [Indexed: 12/05/2023] Open
Abstract
INTRODUCTION Rotational ankle fractures are common, have diverse personalities and affect both robust and fragile patients. Postoperative complications are frequent, creating a sizeable economic burden. The primary purpose of this study was to expand current knowledge on predictors of postoperative complications after low-energy ankle fracture fixation. MATERIALS AND METHODS A retrospective single-center cohort study was completed of patients undergoing internal fixation OF low-energy ankle fractures. The primary outcome was first-year postoperative complications, classified as major (surgical) or minor (non-surgical). Data on patients, their injuries, and treatments were collected. To identify potential predictors of outcomes, logistic regression methods were used, with a backward-stepwise method used for model fitting. RESULTS In total, 663 patients of median age 59 years were analyzed. We found a high rate of complications (28.4%), with wound-healing issues and infections predominant. Overall, 14.8% had minor complications, while 13.6% required an unplanned reoperation. On multivariable analysis, the most consistent predictors of complications were older age (OR=1.02 per year), longer operating time (3.32 per hour), and smoking (2.91). CONCLUSIONS Older patients and smokers who sustain fractures requiring more complex surgery are at higher risk of postoperative complications.
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Affiliation(s)
- J-V Andrés-Peiró
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.
| | - O Pujol
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - M Altayó-Carulla
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - S Castellanos-Alonso
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - M-M Reverté-Vinaixa
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - J Teixidor-Serra
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - J Tomàs-Hernández
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - J Selga-Marsà
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Y García-Sánchez
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - V Molero-García
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - N Joshi-Jubert
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - J Minguell-Monyart
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
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14
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Andrés-Peiró JV, Pujol O, Altayó-Carulla M, Castellanos-Alonso S, Reverté-Vinaixa MM, Teixidor-Serra J, Tomàs-Hernández J, Selga-Marsà J, García-Sánchez Y, Molero-García V, Joshi-Jubert N, Minguell-Monyart J. Predictors of first-year postoperative complications after fixation of low-energy ankle fractures: A single-center, retrospective cohort study of 663 consecutive fractures. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:T363-T372. [PMID: 38325573 DOI: 10.1016/j.recot.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 11/19/2023] [Accepted: 11/24/2023] [Indexed: 02/09/2024] Open
Abstract
INTRODUCTION Rotational ankle fractures are common, have diverse personalities and affect both robust and fragile patients. Postoperative complications are frequent, creating a sizeable economic burden. The primary purpose of this study was to expand current knowledge on predictors of postoperative complications after low-energy ankle fracture fixation. MATERIALS AND METHODS A retrospective single-center cohort study was completed of patients undergoing internal fixation OF low-energy ankle fractures. The primary outcome was first-year postoperative complications, classified as major (surgical) or minor (non-surgical). Data on patients, their injuries, and treatments were collected. To identify potential predictors of outcomes, logistic regression methods were used, with a backward-stepwise method used for model fitting. RESULTS In total, 663 patients of median age 59 years were analysed. We found a high rate of complications (28.4%), with wound-healing issues and infections predominant. Overall, 14.8% had minor complications, while 13.6% required an unplanned reoperation. On multivariable analysis, the most consistent predictors of complications were older age (OR: 1.02 per year), longer operating time (3.32 per hour), and smoking (2.91). CONCLUSIONS Older patients and smokers who sustain fractures requiring more complex surgery are at higher risk of postoperative complications.
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Affiliation(s)
- J-V Andrés-Peiró
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España.
| | - O Pujol
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - M Altayó-Carulla
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - S Castellanos-Alonso
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - M-M Reverté-Vinaixa
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - J Teixidor-Serra
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - J Tomàs-Hernández
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - J Selga-Marsà
- Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - Y García-Sánchez
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - V Molero-García
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - N Joshi-Jubert
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - J Minguell-Monyart
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
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Mehraban N, Lew AR, Foran IM, Lee S, Bohl DD, Hamid KS. Lateral Locking Plate Fixation of Simple Weber B Fibula Fractures Without a Lag Screw Yields Excellent Radiographic Results. Foot Ankle Spec 2024; 17:131-136. [PMID: 34747245 DOI: 10.1177/19386400211055280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The most common first-line fixation technique for simple Weber B fibula fractures is a lag screw with lateral neutralization plate. The most common surgical technique for unstable Weber B fibula fracture is one-third semi-tubular plate and cortical screws, implemented with lag screw when appropriate. However, the lag technique can be technically challenging in osteoporotic bone or within fibulas of smaller diameter, and in some cases can result in fragmentation at the fracture site, malreduction, or peroneal irritation. The purpose of this study is to examine an alternative first-line method for routine treatment of simple Weber B fibula fractures. METHODS Fifty-two consecutive patients undergoing open reduction internal fixation (ORIF) of a Weber B fibula fracture by a single surgeon were included in this retrospective study. After reduction, a lateral locking plate was applied with cortical screws proximally and locking screws distally. No screw crossed the fracture in any case. Per published precedent, nonunion was defined as either a gap of >3 mm between fracture surfaces >6 months postoperatively or a fracture line >2 to 3 mm wide and sclerosing of the fracture surfaces. Similarly, malunion was defined as one or more of the following: talar tilt >2º, talar subluxation >2 mm, or tibiofibular clear space ≥5 mm. RESULTS The mean (± standard deviation) age of the 52 included patients was 44.2 ± 16.2 years, the mean body mass index was 27.7 ± 6.6 kg/m2, and 63.5% of patients identified themselves as female sex. The mean follow-up was 6.2 (range: 1.5-15) months. In addition to undergoing fixation of the lateral malleolus, 21 patients also underwent fixation of the posterior malleolus, 27 underwent fixation of the medial malleolus, 29 underwent fixation across the syndesmosis, and 7 underwent repair of the deltoid. In all patients, bony anatomic union of the fibula and congruence of the mortise were achieved with no cases of malunion or nonunion. CONCLUSIONS The Arbeitsgemeinschaft für Osteosynthesefragen (AO) fixation technique for simple Weber B fractures with a lag screw and lateral neutralization plating has provided good outcomes for decades. We present an alternative technique for ORIF of these fractures with a lateral locking plate and no lag screw. In our series, we evaluated radiographic union and alignment as our primary outcome measures and found no cases of nonunion or malunion. Prospective cohort testing of lateral locking plates versus traditional fixation in the context of patient-centered value is warranted.Level of Evidence: Level III.
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Affiliation(s)
- Nasima Mehraban
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois (NM, ARL, IMF, SL, DDB, KSH)
| | - Alexandra R Lew
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois (NM, ARL, IMF, SL, DDB, KSH)
| | - Ian M Foran
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois (NM, ARL, IMF, SL, DDB, KSH)
| | - Simon Lee
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois (NM, ARL, IMF, SL, DDB, KSH)
| | - Daniel D Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois (NM, ARL, IMF, SL, DDB, KSH)
| | - Kamran S Hamid
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois (NM, ARL, IMF, SL, DDB, KSH)
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Xiao B, Lu M, Chen X, Qiu D, He Y, Li X. Study on the risk factors of postoperative wound complications in patients with ankle fracture. Int Wound J 2024; 21:e14845. [PMID: 38584355 PMCID: PMC10999563 DOI: 10.1111/iwj.14845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Wound complications after surgery for ankle fractures can lead to catastrophic consequences. The purpose of this study was to evaluate the risk factors of postoperative wound complications in patients with ankle fracture and to determine their effects on prognosis. 200 patients with ankle fracture treated in our hospital from October 2021 to December 2023 were analysed retrospectively. The total incidence of postoperative wound complications was 19% (38/200). Type of complications: wound edge necrosis 15 cases (39.47%), dehiscence (reopening of wound) 13 cases (34.21%), delayed healing (>30 days) 10 cases (26.32%); Univariate analysis showed that patients' age, body mass index (BMI), current smoking, alcoholism, diabetes mellitus, injury mechanism, open fracture, wound classification, higher American Society of Anesthesiologists (ASA) score and operation time were all associated with postoperative wound complications. Multivariate Logistic regression model shows: age ≥60 years old OR3.671 (1.875-5.937), BMI OR1.198 (1.143-1.324), current smoking OR2.727 (1.251-5.602), alcoholism OR1.143 (1.034-1.267), complicated with diabetes OR2.763 (1.236-4.852), injury mechanism (high vs. low and medium energy) OR2.437 (1.238-4.786), open fracture OR1.943 (1.8262.139), wound classification (II vs. I) OR4.423 (1.73511.674), ASA score (III-IV vs. I-II) OR1.307 (1.113-2.194) was an independent risk factor for postoperative wound complications in patients with ankle fracture. Further, ROC curves showed that these nine independent influences had high accuracy and validity in predicting postoperative wound complications in patients with ankle fractures. In conclusion, independent risk factors for postoperative complications of ankle fracture were age >60 years, BMI, injury mechanism, open fracture, wound classification (II vs. I), ASA score, current smoking, and alcoholism. The wound classification (II vs. I) has the highest diagnostic value.
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Affiliation(s)
- Ben Xiao
- Orthopedic DepartmentBeijing TongRen Hospital Affiliated Capital Medical UniversityBeijingChina
| | - Meng Lu
- Orthopedic DepartmentBeijing TongRen Hospital Affiliated Capital Medical UniversityBeijingChina
| | - Xiaobin Chen
- Orthopedic DepartmentBeijing TongRen Hospital Affiliated Capital Medical UniversityBeijingChina
| | - Daojing Qiu
- Orthopedic DepartmentBeijing TongRen Hospital Affiliated Capital Medical UniversityBeijingChina
| | - Yuanming He
- Orthopedic DepartmentBeijing TongRen Hospital Affiliated Capital Medical UniversityBeijingChina
| | - Xuejun Li
- Orthopedic DepartmentBeijing TongRen Hospital Affiliated Capital Medical UniversityBeijingChina
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van de Voort JC, Brekelmans W, Ritchie ED, Leijnen M. Preventing Surgical Site Infections in Geriatric Ankle Fracture Surgery with Closed-Incision Vacuum Therapy: A Pilot Study. Adv Skin Wound Care 2024; 37:1-4. [PMID: 38506586 DOI: 10.1097/asw.0000000000000124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Ankle fractures are among the most common fractures in older adult patients that need surgical treatment. The risk of surgical site infections (SSIs) after ankle fracture surgery ranges between 0.5% and 30%; SSI incidence is higher among older adults. Further, SSIs have significant consequences for subjective functional outcomes and create a need for prolonged intravenous antibiotic therapy and wound care. Accordingly, it is critical to determine risk factors for and establish optimal postoperative wound care to prevent SSIs. OBJECTIVE The aim of the pilot study was to examine the feasibility of closed-incision vacuum therapy (CIVT) to reduce rates of SSI in older adults. METHODS The authors performed a pilot study of a CIVT system in a population of 10 older adult patients after ankle fracture surgery. RESULTS Nine patients experienced uncomplicated wound healing of the lateral incision. One patient (10%) developed an SSI after premature removal of the vacuum system because of technical failure. Six weeks postoperation, overall satisfaction with the CIVT was high; none of the participants complained of incapacitating discomfort or disruptive limitations in postsurgical recovery. CONCLUSIONS The authors conclude that CIVT is a feasible, safe, and generally well-tolerated therapy to prevent SSIs in postoperative wound healing after open reduction and internal fixation in older adult patients after ankle fracture.
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Affiliation(s)
- Jan C van de Voort
- At Alrijne Hospital, Leiderdorp, the Netherlands, Jan C. van de Voort, MD, is Surgical Resident; Wouter Brekelmans, MD, is Head of the Alrijne Wound Center; and Ewan D. Ritchie, MD, and Michiel Leijnen, MD, are Trauma Surgeons
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Abstract
Successful outcomes in the surgical treatment of the fractured ankle require methods that respect the soft tissue envelope and establish a stable mortise for functional rehabilitation. Ankle fractures in patients with osteopenia and in diabetic patients with deranged bone remodeling constitute high-risk injuries that may result in catastrophic complications. These patients present unique care challenges and should not be approached in the same manner as their healthy counterparts. We present the principles of treatment in high-risk ankle fractures, operative treatment philosophy illustrating techniques frequently used at our institution, and a review of current literature.
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Affiliation(s)
- Craig E Krcal
- The CORE Institute, 18444 N 25th Avenue Suite 320, Phoenix, AZ 85023, USA; Kaiser San Francisco Bay Area Foot & Ankle Residency Program Alumni Class of 2023
| | - David R Collman
- Kaiser San Francisco Bay Area Foot & Ankle Residency Program; Department of Orthopedics, Podiatry, Injury, Sports Medicine; Kaiser Permanente San Francisco Medical Center, 450 6th Avenue, French Campus, 5th Floor, San Francisco, CA 94118, USA.
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Dhillon MS, Rajnish RK, Kumar P, Sharma S, Singh GP, Srivastava A. A comparison of outcomes of locking versus non-locking plate fixation for the distal fibula fractures: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:75-89. [PMID: 37656278 DOI: 10.1007/s00590-023-03694-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/13/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE A locking plate (LP) or non-locking plate (NLP) can be used for distal fibula fracture fixation. However, the advantages of LP over NLP in patients with distal fibula fractures are not clear. In terms of indications, the role of the two plates probably differs; however, to draw comparative conclusions, we conceptualized this systematic review and meta-analysis of studies that directly compared the two plates, wherein both groups' indications and baseline parameters were similar. METHODS An electronic literature search was performed using PubMed/Medline, Embase, Scopus, and Cochrane Library databases for studies comparing the LP versus NLP fixation for the lateral malleolus fracture. A total of 18 studies were included in qualitative and quantitative analysis. A subgroup analysis was performed for patients aged < 55 years and patients aged > 55 years. The statistical analysis was performed by Review Manager Software version 5.4.1. RESULTS A meta-analysis of 4243 fractures was performed across 18 studies. The rate of fracture union and overall complication rates did not differ between the two fixation groups with an OR of 0.71 (95% CI 0.26, 1.96, p = 0.51 and 1.11 (95% CI 0.84, 1.47, p = 0.47, respectively. There is no difference in the reoperation rate due to minor or major complications between the two groups. There was no difference in functional outcome (MD -0.85, with 95% CI -5.63, 3.93, p = 0.73), but NLP has a shorter surgical duration (MD 3.0, with 95% CI 0.26, 5.75, p = 0.03). A leave-one-out sensitivity analysis performed for overall complications affected the final outcome of the meta-analysis. CONCLUSION This meta-analysis demonstrates no clear benefit in selecting LP over NLP for the fixation of lateral malleolus fractures.
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Affiliation(s)
| | - Rajesh Kumar Rajnish
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
| | - Prasoon Kumar
- Department of Orthopaedics, PGIMER, Chandigarh, India
| | | | - Gagan Preet Singh
- Department of Orthopaedics, All India Institute of Medical Sciences, Bathinda, India
| | - Amit Srivastava
- Department of Orthopaedics, University College of Medical Sciences and GTB Hospital, Delhi, India
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Becerra E, Castro M, Ruiz-Riquelme P. Results of prophylactic simple fasciocutaneous advancement in the initial management of acute ankle fractures with high risk of operative wound complication. Foot Ankle Surg 2024; 30:37-43. [PMID: 37730458 DOI: 10.1016/j.fas.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 08/24/2023] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
Ankle fracture is the third most prevalent fracture in older adults. Wound dehiscence is the most frequent complication. Our objective is to determine the operative wound complication rate in patients with unstable ankle fracture in whom a prophylactic simple fasciocutaneous advancement was used. METHODS Prospective registry of patients with unstable ankle fracture, in whom a prophylactic fasciocutaneous advancement was performed between August 2020 and July 2021. Demographic variables, time spent in performing the flap, cost of osteosynthesis, minor and major complications of the surgical wound, readmission or reoperation were registered. RESULTS 42 older adults with ankle fracture were included. Median age 69 (60-94). 31% diabetics and 21.5% active smokers. A 40% trimalleolar fracture pattern. There were 7% of superficial complications of the surgical wound. No major complications, no reoperations. CONCLUSIONS Prophylactic fasciocutaneous advancement at the beginning of traumatological surgery is technically simple, reproducible, cheap and with low complications. LEVEL OF EVIDENCE Level IV, cross-sectional study.
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Affiliation(s)
- Eduardo Becerra
- Foot and Ankle Surgery Unit, Department of Orthopedic and Traumatology, Hospital Clínico La Florida, Santiago, Chile; Foot and Ankle Surgery Unit, Department of Orthopedic and Traumatology, Hospital Carabineros de Chile, Santiago, Chile
| | - Magdalena Castro
- School of Medicine, Finis Terrae University, Santiago, Chile; Clinical Epidemiology and Research Unit, School of Medicine, Finis Terrae University, Santiago, Chile
| | - Pablo Ruiz-Riquelme
- Foot and Ankle Surgery Unit, Department of Orthopedic and Traumatology, Hospital Clínico La Florida, Santiago, Chile; School of Medicine, Finis Terrae University, Santiago, Chile; Foot and Ankle Surgery Unit, Department of Orthopedics and Traumatology, Clinic Las Condes, Santiago, Chile.
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21
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Lickiss J, Weinraub G. Batting Cleanup: Revision of Surgical Misadventure. Clin Podiatr Med Surg 2024; 41:169-192. [PMID: 37951673 DOI: 10.1016/j.cpm.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Surgical complications are a part of every surgeon's practice. Managing your own complications or one from another provider requires carefully reviewing your patient's previous experience and surgery along with balancing their expectations. In order to provide the best treatment plan, a thorough analysis of the pre and postoperative period that contributed to the patient's outcome must be considered. Identifying what revision options are available and weighing the potential future complications that could arise from another surgery must be reviewed. Honest conversations regarding revision options and if revision surgery is even a viable option is vital for a good patient-physician relationship and outcome.
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Affiliation(s)
- Jessica Lickiss
- Orthopedics Department, Kaiser Permanente Santa Clara Residency Program, Kaiser Permanente GSAA, 2500 Merced Street, San Leandro, CA 94577, USA.
| | - Glenn Weinraub
- Orthopedics Department, Kaiser Permanente Santa Clara Residency Program, Kaiser Permanente GSAA, 2500 Merced Street, San Leandro, CA 94577, USA
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Patel S, Dionisopoulos SB, Schmalhaus MJ. Early Functional Rehabilitation in Foot and Ankle Surgery. Clin Podiatr Med Surg 2024; 41:59-71. [PMID: 37951679 DOI: 10.1016/j.cpm.2023.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
The traditional postoperative management of common foot and ankle procedures has involved a prolonged period of immobilization and nonweight bearing. The concern was loss of correction and fixation failure. However, it has been shown that a prolonged period of nonweight bearing can predispose patients possible deep vein thrombosis, disuse osteopenia, cardiovascular complications, and generalized deconditioning. The authors' institution has published studies reviewing the efficacy of early weight bearing after first metatarsophalangeal joint arthrodesis, modified Lapidus bunionectomy, and open reduction and internal fixation of ankle fractures. This article highlights the literature and rationale supporting the safety of early weight-bearing protocols.
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Affiliation(s)
- Sandeep Patel
- San Francisco Bay Area Foot and Ankle Residency, The Permanente Medical Group, Diablo Service Area, 1425 South Main Street, Walnut Creek, CA 94596, USA.
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Balziano S, Baran I, Prat D. Hindfoot nailing without joint preparation for ankle fractures in extremely elderly patients: Comparison of clinical and patient-reported outcomes with standard ORIF. Foot Ankle Surg 2023; 29:588-592. [PMID: 37468359 DOI: 10.1016/j.fas.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/25/2023] [Accepted: 07/02/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Tibiotalocalcaneal (TTC) nailing without joint preparation has been indicated as an alternative to open reduction and internal fixation (ORIF) in the treatment of unstable fragility ankle fractures. We hypothesized that primary hindfoot nailing without joint preparation, and immediate weight bearing can provide a safe and effective treatment for unstable fragility fractures of the ankle compared to ORIF. METHODS A retrospectively single-center cohort was reviewed for all surgically treated ankle fractures in patients aged 75 years and older between 2016 and 2021. The cases were grouped by the surgical technique: ORIF or TTC nailing. Diagnosis and treatment were validated by a review of the radiographs and the patients' charts. Primary outcomes included complication rates and revision rates. The PROMs questionnaires included the Foot and Ankle-Ability Measure (FAAM-ADL) and the Olerud-Molander Ankle Score (OMAS). RESULTS Forty-six cases met the inclusion criteria during the study period. Eighteen in the TTC group and 28 in the ORIF group. The average follow-up was 46.4 months (Median 49.5, SD ± 25.3). The mean age of the TTC group was significantly higher (88.6 versus 81.8, p < 0.001). The mean surgery duration and length of stay were similar. The complication rates were 50.0 % in the ORIF group (28.6 % major) versus 22.2 % in the TTC group (5.6 % major), (p = 0.060). The revision rates were 28.6 % and 11.1 % in the ORIF and TTC groups respectively (p = 0.161). The FAAM-ADL was higher in the ORIF group (62.6 % versus 32.4 %, p = 0.020), as well as the OMAS (60.0 versus 32.8, p = 0.029). CONCLUSION TTC nailing without joint preparation for unstable fragility fractures of the ankle in the extremely elderly provided a better complication profile compared to traditional ORIF. However, PROMs were inferior.
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Affiliation(s)
- Snir Balziano
- Department of Orthopaedic Surgery, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel, Affiliated with the Faculty of Medicine of Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Isaac Baran
- Department of Orthopaedic Surgery, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel, Affiliated with the Faculty of Medicine of Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Dan Prat
- Department of Orthopaedic Surgery, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel, Affiliated with the Faculty of Medicine of Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel.
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Aziz H, Trout SM, Jethanandani R, Bub CD, Collins L, Goldman AT. Postoperative Outcomes in Malleolar Fractures Fixed With a 3.5-mm Locking Compression Plate Hook Plate. Orthopedics 2023; 46:340-344. [PMID: 37052594 DOI: 10.3928/01477447-20230407-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Ankle fractures are among the most common types of fractures seen in the United States. Few studies have analyzed the use of a locking compression plate (LCP) hook plate in the fixation of malleolar fractures. The goal of this study was to analyze postoperative outcomes in malleolar fractures fixed with a 3.5-mm LCP hook plate. A cohort of 74 patients with ankle fractures treated operatively with hook plates between 2011 and 2021 by a single orthopedic surgeon was retrospectively reviewed. Time to union, duration of non-weight bearing, final range of motion, postoperative complications, demographics, and comorbidities were recorded. A total of 66 patients fulfilled our inclusion criteria. There were 5 isolated medial malleolar, 34 bimalleolar, and 27 trimalleolar fractures. There were 46 women and 20 men with a mean age of 60.9±18.9 years. Fourteen patients had diabetes, 27 had osteoporosis, and 4 were current or former tobacco users. All patients achieved union, with a mean time to union of 10.9±5.3 weeks. The mean time to weight bearing was 50.2±18.4 days. The mean length of follow-up was 8.1±5.6 months. At final follow-up, mean dorsiflexion was 9.9°±4.3° and mean plantarflexion was 14.1°±5.1°. Six patients experienced postoperative complications such as surgical site infections and posttraumatic osteoarthritis. This study demonstrates that the use of a 3.5-mm LCP hook plate in the operative fixation of malleolar fractures has a high rate of union while maintaining low rates of postoperative complications. [Orthopedics. 2023;46(6):340-344.].
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Evola FR, Di Fede GF, Evola G, Barchitta M, Agodi A, Longo G. Locking plates for distal fibula fractures in young and elderly patients: A retrospective study. World J Orthop 2023; 14:540-546. [PMID: 37485428 PMCID: PMC10359748 DOI: 10.5312/wjo.v14.i7.540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 04/16/2023] [Accepted: 06/06/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Ankle fractures are common injuries in the young and elderly populations. To prevent post-traumatic arthritis, an anatomic reconstruction of the ankle structure is mandatory. Open reduction and internal fixation is the treatment of choice among orthopaedics. Conventional plates allow stability of the fracture if bone quality is present. Locking plates might offer an advantage for the treatment of lateral malleolar fracture in patients with comminution, severe instability, distal fractures, or osteoporotic bone. Our hospital introduced a new locking plate for fracture of the distal fibula. AIM To evaluate locking plates in terms of outcomes and complications in young and elderly patients. METHODS We retrospectively reviewed a total of 67 patients treated for displaced distal fibula fractures. Demographic data, number of comorbidities, use of inter fragmentary screw, complication, time of fracture healing, partial or full weight bearing, and reoperation were recorded for all patients. Clinical outcome was assessed by the American Orthopedic Foot and Ankle Society clinical scoring system. Radiographs were obtained at 4, 8, 12, 16, 20, and 24 wk until radiographic union was obtained. RESULTS All patients displayed complete bony union on radiographic assessment, and no patients developed any serious complications. We observed two superficial infections, one delayed wound healing, and two plate intolerances. Significant differences were observed between the two age groups in terms of radiographic healing (11.9 wk in younger patients vs 13.7 wk in older patients; P = 0.011) and in the American Orthopedic Foot and Ankle Society score at 6 mo after surgery (88.2 in younger patients vs 86.0 in older patients; P = 0.001) and at 12 mo after surgery (92.6 in younger patients vs 90.0 in older patients; P = 0.000). CONCLUSION Locking plates provide a stable and rigid fixation in multifragmentary and comminuted fractures or in the presence of poor bone quality.
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Affiliation(s)
- Francesco Roberto Evola
- Department of Surgery, Division of Orthopedics and Trauma Surgery, “Cannizzaro” Hospital, Catania 95100, Italy
| | - Giovanni Francesco Di Fede
- Department of Radiodiagnostics, Division of Radiology, “S. Marta and S. Venera” Hospital, Acireale 95024, Italy
| | - Giuseppe Evola
- Department of Surgery, Division of Surgery, “Garibaldi” Hospital, Catania 95100, Italy
| | - Martina Barchitta
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, Catania 95100, Italy
| | - Antonella Agodi
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, Catania 95100, Italy
| | - Gianfranco Longo
- Department of Surgery, Division of Orthopedics and Trauma Surgery, “Cannizzaro” Hospital, Catania 95100, Italy
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Gopireddy R, T Hafez A, Khan MJ, Javed O, Omar I, Clint S. Comparison of Complications, Metalwork Removal and Cost Between Locking and Tubular Plates for Lateral Malleolus Fractures Fixation. Cureus 2023; 15:e36181. [PMID: 37065389 PMCID: PMC10103815 DOI: 10.7759/cureus.36181] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Introduction Ankle fractures are common injuries in orthopaedic practice. Open reduction with internal fixation is the main line of management of displaced ankle fractures in fit patients. The study aims to analyse the complications, re-operation rate and cost difference between one-third tubular and locking plates which are the most frequently used constructs in lateral malleolus fractures. Materials and methods The total number of presented ankle fractures from April to August during the years 2015, 2017 and 2019 to our Tertiary Hospital in the United Kingdom were screened. Data including operative fixation, plate used, complication rates, the need for revision surgery and metalwork removal were collected from the hospital's electronic Virtual Trauma Board. Patients who had less than one-year follow-up were excluded. Results A total of 174 patients were included which represents more than half of presented ankle fractures (56%) with a decline in the mean age of operated patients from 56.4 in 2015 to 46.2 in 2019. The majority of fixation used tubular plates (n=122) versus (n=52) for locking plates. Locking plate fixation doubled from 10 in 2015 to 23 in 2019. However, they only contributed to 27% of the total operated ankle fractures. Despite the initial higher complications and removal rates of locking plates in 2015 (P<0.042 and P<0.038 respectively), there was no significant difference in overall complications, revision rates, and metalwork removal between locking plates and tubular plates (p=0.084, FEp= 0.158 and p=0.096 respectively). There was an estimated extra cost of £15938.60 for the use of locking plates during the study timeline. Conclusion There was no significant difference in overall complications, revision surgery and metalwork removal between tubular and locking plates in treating lateral malleolus fractures despite the significantly higher cost of locking constructs. Further studies are needed to illustrate the trend and cost-effective analysis of the tubular and locking plates in treating ankle fractures.
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Ring A, Beutel H, Kirchhoff P, Bushart SU, Dellmann NC, Farzaliyev F. [Reconstruction of posttraumatic soft tissue defects of the ankle using free fascial flaps from the anterolateral thigh]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:136-144. [PMID: 34686888 PMCID: PMC8533668 DOI: 10.1007/s00113-021-01100-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/29/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Free fascial flaps from the anterolateral thigh (ALT) were used to reconstruct soft tissue defects after trauma to the ankle. This modification was compared to the conventional fasciocutaneous method. MATERIAL AND METHODS The defect size, the thickness of the subcutaneous fat layer on the thigh and the extent of the soft tissue covering the ankle were determined retrospectively. The evaluations were compared between fascial (Fo) and fasciocutaneous flaps (Fc). The foot and ankle outcome score (FAOS) was used. Esthetic outcome surveys were carried out. RESULTS A total of 18 isolated fractures of the ankle were evaluated. In 94% of the cases a closed soft tissue damage predominated. After fracture fixation using a plate, soft tissue defects with a mean area of 40.4 ± 13.1 cm2 (28-76 cm2) developed. The thickness of the soft tissue covering over the affected malleoli increased significantly in both groups as a result of the flap surgery (4.5 ± 0.7 vs. 21.1 ± 6.4 mm, p < 0.05). A significant difference was found when comparing the body mass index (BMI) between the groups (Fc 26.3 ± 3.4 kg/m2 vs. Fo 30.1 ± 4.2 kg/m2, p < 0.05). For both groups there was a positive correlation (r = 0.843) between the BMI and the thickness of the epifascial fat layer of the thigh. The FOAS survey revealed 75.9 ± 28.9 and 47.9 ± 32.4 points, respectively, for "function in daily life" and "foot and ankle-related quality of life". The esthetic reconstruction result was rated as "acceptable" by 55% and as "good" by 45%. DISCUSSION The modified method of a free fascial flap from the ALT can be useful in situations where a bulky flap makes it difficult to fit it into the defect.
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Affiliation(s)
- Andrej Ring
- Klinik für Plastische Chirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland.
- Ruhr-Universität Bochum, Bochum, Deutschland.
| | - Hendrik Beutel
- Klinik für Plastische Chirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland
- Ruhr-Universität Bochum, Bochum, Deutschland
| | - Pascal Kirchhoff
- Klinik für Plastische Chirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland
| | - Sebastian Ulrich Bushart
- Klinik für Plastische Chirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland
| | - Niklas-Chris Dellmann
- Klinik für Plastische Chirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland
| | - Farhad Farzaliyev
- Klinik für Allgemein‑, Viszeral und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
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Fibula Nail versus Locking Plate Fixation-A Biomechanical Study. J Clin Med 2023; 12:jcm12020698. [PMID: 36675627 PMCID: PMC9862725 DOI: 10.3390/jcm12020698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
In the treatment of ankle fractures, complications such as wound healing problems following open reduction and internal fixation are a major problem. An innovative alternative to this procedure offers a more minimally invasive nail stabilization. The purpose of this biomechanical study was to clarify whether this method was biomechanically comparable to the established method. First, the stability (range of motion, diastasis) and rotational stiffness of the native upper ankle were evaluated in eight pairs of native geriatric specimens. Subsequently, an unstable ankle fracture was created and fixed with a locking plate or a nail in a pairwise manner. The ankles showed significantly less stability and rotational stiffness properties after nail and plate fixations than the corresponding native ankles (p < 0.001 for all parameters). When comparing the two methods, both showed no differences in their range of motion (p = 0.694) and diastasis (p = 0.166). The nail also presented significantly greater rotational stiffness compared to the plate (p = 0.001). However, both fixations remained behind the native stability and rotational stiffness. Due to the comparable biomechanical properties of the nail and plate fixations, an early weight-bearing following nail fixation should be assessed on a case-by-case basis considering the severity of fractures.
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Penning D, Jonker CAL, Buijsman R, Halm JA, Schepers T. Minifragment plating of the fibula in unstable ankle fractures. Arch Orthop Trauma Surg 2023; 143:1499-1504. [PMID: 35224664 PMCID: PMC9958153 DOI: 10.1007/s00402-022-04397-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/14/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Only 6.4-17% of the load is transmitted through the fibula when weight-bearing. Plate fixation of distal fibular fractures using minifragments (≤ 2.8 mm) could lead to similar reduction with less implant removal (IR) rates, compared to small-fragment plates (3.5 mm). We hypothesized that the use of minifragment plates is at least similar in unscheduled secondary surgery. MATERIALS AND METHODS In this retrospective cohort study, all patients with surgically treated distal fibular fractures between October 2015 and March 2021 were included. Patients treated with plate fixation using minifragments and patients treated with small-fragment plates were compared regarding the following outcomes: secondary dislocation, malreduction, implant malposition, nonunion, surgical site infections (SSI) and IR. RESULTS Sixty-five patients (54.2%) received a minifragment implant (≤ 2.8 mm) and 55 patients (45.8%) received a small-fragment implant (3.5 mm). There were no patients needing secondary surgery in the minifragment group compared to 9 patients following fixation using small-fragment implants (3 with secondary dislocation, 5 with malreduction and 1 with malposition, p = 0.001). SSI rates were 3.1% for minifragment and 9.1% for small-fragment implants (p = 0.161). Implant removal was performed significantly less often following use of minifragment implants (17.8% and 53.2%, p < 0.001). CONCLUSIONS In this cohort, minifragment plate fixation for distal fibular fractures is an adequate fixation method offering stable fixation with significant lower need for implant removal and comparable complications to small-fragment plates, although an adequately powered randomized controlled study is needed for implementation in a clinical setting. LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- D. Penning
- Trauma Unit Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - C. A. L. Jonker
- Trauma Unit Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - R. Buijsman
- Department of Traumasurgery, Tergooi MC, Van Riebeeckweg 212, 1213 XZ Hilversum, The Netherlands
| | - J. A. Halm
- Trauma Unit Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - T. Schepers
- Trauma Unit Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Lu V, Tennyson M, Zhang J, Thahir A, Zhou A, Krkovic M. Ankle fusion with tibiotalocalcaneal retrograde nail for fragility ankle fractures: outcomes at a major trauma centre. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:125-133. [PMID: 34820741 PMCID: PMC8612118 DOI: 10.1007/s00590-021-03171-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/15/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE Fragility ankles fractures in the geriatric population are challenging to manage, due to fracture instability, soft tissue compromise, and patient co-morbidities. Traditional management options include open reduction internal fixation, or conservative treatment, both of which are fraught with high complication rates. We aimed to present functional outcomes of elderly patients with fragility ankle fractures treated with retrograde ankle fusion nails. METHODS A retrospective observational study was performed on patients who underwent intramedullary nailing with a tibiotalocalcaneal nail. Twenty patients met the inclusion criteria of being over sixty and having multiple co-morbidities. Patient demographics, AO/OTA fracture classification, intra-operative and post-operative complications, time to mobilisation and union, AOFAS and Olerud-Molander scores, and patient mobility were recorded. RESULTS There were seven males and thirteen females, with a mean age of 77.82 years old, five of whom are type 2 diabetics. Thirteen patients returned to their pre-operative mobility state, and the average Charlson Co-morbidity Index (CCI) was 5.05. Patients with a low CCI are more likely to return to pre-operative mobility status (p = 0.16; OR = 4.00). All patients achieved radiographical union, taking on average between 92.5 days and 144.6 days. The mean post-operative AOFAS and Olerud-Molander scores were 53.0 and 50.9, respectively. There were four cases of superficial infection, four cases of broken or loose distal locking screws. There were no deep infections, periprosthetic fractures, nail breakages, or non-unions. CONCLUSION Tibiotalocalcaneal nailing is an effective and safe option for managing unstable ankle fractures in the elderly. This technique leads to lower complication rates and earlier mobilisation than traditional fixation methods.
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Affiliation(s)
- Victor Lu
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK ,Christ’s College, St. Andrew’s Street, Cambridge, CB2 3BU UK
| | - Maria Tennyson
- Department of Trauma and Orthopaedics, Addenbrooke’s Hospital, Cambridge, CB2 0QQ UK
| | - James Zhang
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK
| | - Azeem Thahir
- Department of Trauma and Orthopaedics, Addenbrooke’s Hospital, Cambridge, CB2 0QQ UK
| | - Andrew Zhou
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK
| | - Matija Krkovic
- Department of Trauma and Orthopaedics, Addenbrooke’s Hospital, Cambridge, CB2 0QQ UK
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Giver Jensen T, Aqeel Khudhair Almadareb M, Booth Nielsen M, Jesper Hansen E, Lindberg-Larsen M. Outcome After Treatment of Distal Fibula Fractures Using One-Third Tubular Plate, Locking Compression Plate or Distal Anatomical Locking Compression Plate. J Foot Ankle Surg 2022; 62:524-528. [PMID: 36642663 DOI: 10.1053/j.jfas.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 12/02/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022]
Abstract
Surgical treatment of lateral distal fibula fractures is associated with high risk of reoperation and complications. The primary aim was to report risks of surgical site infection (SSI) and reoperation ≤1 year after treatment with one-third tubular plate, locking compression plate (LCP) or distal anatomical LCP. Secondary to investigate associations between patient, fracture and operative factors and risk of SSI and reoperation. Retrospectively, we evaluated a consecutive cohort of 588 patients having osteosynthesis of distal fibula with a one-third tubular plate (n = 417), LCP (n = 115) or distal anatomical LCP plate (n = 56) at Bispebjerg Hospital, Denmark from January 2010 to December 2015 with 1-year follow-up. The risk of SSI was 15% (95% confidence interval [CI] 12-18) after treatment with one-third tubular plate, 30% (95% CI 23-39) after LCP and 41% (95% CI 29-54) after distal anatomical LCP. We found a significant association of SSI and LCP (p = .005) and distal anatomical LCP (p < .001). Other factors associated with increased risk of SSI were age>70 years (p < .001), smoking (p = .004), DM (p = .007), surgery time ≥90 minutes (p = .006) and surgery delay of 3-6 days (p = .007). The risk of reoperation ≤1 year was 10% (95% CI 6-11) for one-third tubular plate, 21% (95% CI 14-29) for LCP and 25% (95% CI 16-38) for distal anatomical LCP. We found a significant association between distal anatomical LCP and risk of reoperation (p = .008). The only other risk factor associated with risk of reoperation was surgery delay of more than 7 days (p = .004). We conclude that LCP plate and the distal anatomical LCP plate should only be used after careful considerations.
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Affiliation(s)
- Thomas Giver Jensen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark.
| | | | - Maria Booth Nielsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Emil Jesper Hansen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark; Orthopaedic Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Peuchot H, Falguières J, Cermolacce M, Le Baron M, Flecher X. Resumption of complete weight bearing after osteosynthesis of bimalleolar fractures using locking plates. Orthop Traumatol Surg Res 2022; 108:103382. [PMID: 35908733 DOI: 10.1016/j.otsr.2022.103382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/27/2021] [Accepted: 04/25/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Bimalleolar fractures represent 9% of fractures and affect 187/100,000 people per year. The gold standard for osteosynthesis is a one-third tubular or lateral locking plate and compression screwing or use of tension band wiring, with complete weight bearing planned around the 6th week. The development of locking plates seems to allow earlier resumption of weight bearing. The objective of our study was to evaluate the clinical and radiological results after internal fixation of bimalleolar fractures using locking plates with complete weight bearing authorized from the outset. The hypothesis was that this does not predispose to cutaneous or mechanical complications. HARDWARE AND METHOD A continuous multi-operator retrospective study was performed. The clinical and radiological data of 55 patients operated on for bimalleolar fractures were collected. All underwent osteosynthesis with medial and lateral locking plates with authorization for weight bearing from the outset. RESULTS Complete weight bearing was resumed at 27.4 days 14.7 [7-60] postoperatively. No non-union or malunion was found. Two patients presented with delayed medial healing without the need for hardware removal. Two patients required removal of the lateral Plate 1 month postoperatively due to infection. Seven patients presented with discomfort related to hardware, justifying its removal at 1 year. The Kitaoka score at 1 year was 94.6 7.7 [71-100]. CONCLUSION The use of medial and lateral locking plates in bimalleolar fractures associated with complete weight bearing authorized from the outset allows complete consolidation. There was no increase in cutaneous or mechanical complications. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Henri Peuchot
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France.
| | - Julie Falguières
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France
| | - Mathieu Cermolacce
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France
| | - Marie Le Baron
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France
| | - Xavier Flecher
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France
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Indications for retrograde intramedullary screw fixation of the distal fibula: a retrospective cohort series. OTA Int 2022; 5:e216. [PMID: 36569110 PMCID: PMC9782339 DOI: 10.1097/oi9.0000000000000216] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 06/18/2022] [Indexed: 12/27/2022]
Abstract
Introduction Ankle fractures are a common orthopaedic injury that often require surgical fixation. Because the comorbid population in the United States continues to survive longer, it has become routine to treat comorbid patients with unstable ankle fractures. The literature has identified comorbidities known to increase the risk of ankle fracture complications to include age 55 years or older, body mass index >29.9, polytrauma, open fractures, diabetes mellitus, smoking, peripheral neuropathy, and alcohol use. Methods We retrospectively reviewed 37 patients who received retrograde intramedullary screw fixation of the distal fibula, all of whom had preexisting conditions known to increase the rate of postoperative complications. Results Thirty-seven patients were included in this study, of whom 36 (97.3%) went on to union. Six of 37 patients (16.2%) had complications although only one (2.7%) was due to inadequate fixation. The average time to weight-bearing as tolerated was 57.2 days (15-115 days). Two patients (5.4%) had symptomatic instrumentation requiring removal after union. Two patients (5.4%) had delayed union of the distal fibula, which responded to the use of a bone stimulator. One patient (2.7%) developed a nonunion which led to chronic subluxation of the ankle joint. One patient (2.7%) had a minor medial ankle wound complication that was treated with oral antibiotics and local wound care. Conclusions Retrograde intramedullary screw fixation of the distal fibula is a viable alternative to plate and screw fixation in patients with unstable ankle fractures who have known risk factors for increased complications. However, not all distal fibula fractures are amenable to this fixation method. Level of Evidence Level III retrospective cohort study.
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Cho BK, Kim JB, Choi SM. Efficacy of hook-type locking plate and partially threaded cancellous lag screw in the treatment of displaced medial malleolar fractures in elderly patients. Arch Orthop Trauma Surg 2022; 142:2585-2596. [PMID: 34089372 DOI: 10.1007/s00402-021-03945-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/03/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Traditionally, partially threaded cancellous lag screws (PTCS) are used for most medial malleolar fractures but are often challenging to execute in elderly patients because of the high risk of postoperative complications. Limited literature explores whether hook-type locking compression plates (LCPs) reliably offer better outcomes than PTCS in elderly patients. We aimed to compare the midterm radiologic and clinical outcomes between hook-type LCP and PTCS for medial malleolar fractures in an elderly population. METHODS We included 258 patients, aged 65 years and above, treated with either a hook-type locking plate (hook LCP group: 121 patients) or PTCS (screw group: 137 patients), and with follow-ups of at least 36 months in this retrospective study. Radiographic assessments included the union rate and interval to fracture union. Clinical assessment included the postoperative complications and revision procedures. RESULTS Although a significantly higher rate of comminuted fractures was observed in the hook LCP group than in the screw group (p < .001), no significant difference in the union rate was observed between the two groups (hook LCP group: 93.4% vs. screw group: 89.8%, p = .151), and a significantly shorter interval to union was observed in the hook LCP group (10.2 ± 7.0 vs. 12.3 ± 6.7 weeks, p = .015). There was a trend toward a lower rate of complications, including revision procedures, in the hook LCP group than in the screw group (19.9% vs. 28.5%, p = .107 and 6.6% vs. 13.8%, p = .074). CONCLUSION Hook-type LCP may be an alternative option for treating medial malleolar fractures with comminution in elderly patients.
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Affiliation(s)
- Byung-Ki Cho
- Department of Orthopaedic Surgery, School of Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Jun-Beom Kim
- Wellbone Orthopedic Clinic, Daejeon, Republic of Korea
| | - Seung-Myung Choi
- Department of Orthopedic Surgery, Eulji University School of Medicine, Uijeongbu Hospital, 712, Dongil-ro, Uijeongbu-si, Gyeonggi-do, 11759, Republic of Korea.
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Large TM, Kaufman AM, Frisch HM, Bankieris KR. High-risk ankle fractures in high-risk older patients: to fix or nail? Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04574-3. [PMID: 35947171 DOI: 10.1007/s00402-022-04574-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/31/2022] [Indexed: 11/02/2022]
Abstract
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.
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Affiliation(s)
- Thomas M Large
- Department of Orthopaedic Surgery, Emory University, Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, USA.
| | - Adam M Kaufman
- Orthopaedic Trauma Services, Mission Hospital, Asheville, NC, USA
| | - Harold M Frisch
- Orthopaedic Trauma Services, Mission Hospital, Asheville, NC, USA
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Early Return to Daily Life through Immediate Weight-Bearing after Lateral Malleolar Fracture Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19106052. [PMID: 35627586 PMCID: PMC9140336 DOI: 10.3390/ijerph19106052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/12/2022] [Accepted: 05/14/2022] [Indexed: 12/04/2022]
Abstract
Lateral malleolus fracture is one of the most common fractures. However, there is controversy regarding the rehabilitation protocols used after surgery. In particular, the initiation point for weight-bearing has not been standardized. In the present study, we investigated the prognostic difference between immediate and delayed weight-bearing on lateral malleolus fractures. The medical records of matched patients in the immediate and delayed weight-bearing groups (50 and 50, respectively) were reviewed retrospectively. All patients were treated with open reduction and internal fixation using an anatomical locking compression plate with a lag screw. In the immediate weight-bearing group (IWB), tolerable weight-bearing (i.e., what can be endured immediately after surgery with crutches) was permitted. In the delayed weight-bearing group (DWB), weight-bearing was completely restricted for 4 weeks after surgery. Ankle motion exercise was permitted in both groups, starting from the day after surgery. Radiographic assessment data and clinical outcomes were reviewed between the two groups. No significant differences in radiographic assessments and complications were found between the two groups. Significant differences in terms of a shortened length of hospital stay and time to return to work with the IWB rehabilitation protocol compared with DWB were confirmed (6.0 vs. 9.2 days, p = 0.02 and 6.1 vs. 8.3 weeks, p = 0.02, respectively). A significant difference in sport factor was observed in the Foot and Ankle Outcome Score at 3 months postoperatively (72.3 vs. 67.4, p = 0.02). We found no significant differences between the two groups concerning postoperative radiological outcomes and complications. The benefits of shortening the time to return to work and length of hospital stay associated with the IWB rehabilitation protocol were confirmed. In conclusion, immediate weight-bearing is recommended in patients with lateral malleolus fracture after anatomical reduction and firm fixation by surgery.
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Jacobsen GH, Gude MH, Viberg B, Gundtoft PH. Risk of Reoperation in Simple Ankle Fracture Surgery When Comparing Locking Plate With Nonlocking Plate. J Foot Ankle Surg 2022; 61:567-571. [PMID: 34838457 DOI: 10.1053/j.jfas.2021.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/12/2021] [Accepted: 10/05/2021] [Indexed: 02/03/2023]
Abstract
Locking plates were initially designed to provide improved stability to ankle fractures with poor bone quality but are currently widely used. The aim of this study was to compare the reoperation risk when using locking plates compared with nonlocking plates in patients with simple ankle fractures. This study was a population-based register study. Data regarding patients with AO type 44A1/2 and 44B1/2 injuries who were treated with either locking or nonlocking plates were obtained from the Danish Fracture Database. The follow-up period was 24 months. Major complications were defined as complications requiring surgical intervention, with the exception of simple hardware removal 6 weeks after primary surgery, which was defined as a minor complication. Multivariate regression analysis was performed to determine relative risk (RR), adjusted for age, sex, American Society of Anesthesiologists physical status classification (ASA)-score, and level of the surgeon's experience. A total of 2177 ankle fractures were included, among which 718 (33%) were treated with locking plates, and 1459 (67%) were treated with nonlocking plates. Data were linked with the Danish National Patient Registry to ensure complete information was obtained regarding reoperations, which were divided into major and minor complications. In both groups, the risks for major and minor complications were 3% and 22%, respectively, resulting in adjusted RRs of 1.00 (0.66; 1.66) for major reoperation comparing locking with nonlocking plates and 0.92 (0.76; 1.11) for minor reoperations. We conclude that no significant association with reoperation exists for locking compared with nonlocking plates among patients with surgically treated simple ankle fractures.
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Affiliation(s)
- Gudrun Holm Jacobsen
- Resident, Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Denmark.
| | - Mads Holm Gude
- Resident, Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Denmark
| | - Bjarke Viberg
- Consultant Associate Professor and Head of Research, Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Denmark
| | - Per Hviid Gundtoft
- Consultant, Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Denmark
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Bando K, Takegami Y, Ando T, Sugino T, Sato T, Fujita T, Imagama S. Early weight bearing and mobilization decrease perioperative complications in patients after ankle fracture; the retrospective multicenter (TRON group) study. J Orthop Sci 2022; 28:651-655. [PMID: 35370043 DOI: 10.1016/j.jos.2022.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 02/15/2022] [Accepted: 03/03/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND Open reduction and internal fixation (ORIF) for unstable ankle fractures (AF) are relatively predictable with excellent outcomes. Rehabilitation strategies are still being debated after surgical intervention for AF: non-weight bearing and cast immobilization for six weeks after the surgical repair of unstable AF or early functional treatment with partial weight bearing. This study aimed to compare early weight bearing and functional outcomes and complications. METHODS Between April 2014 and March 2019, 1421 patients with AF underwent ORIF at 11 institutions (TRON group). The patients were divided into two groups: Group E started weight bearing within six weeks after surgery, and group L started weightbearing for more than six weeks after. To adjust for baseline difference between groups, a propensity score-matched algorithm was used to match Group E with Group L in a 1:1 ratio of 294 cases each. We compared the American Orthopedic Foot and Ankle Society (AOFAS) score as the functional outcome, the rate of wound dehiscence, superficial and deep infections, blistering, nonunion, neurapraxia, and reoperation at 3, 6, and 12 months after surgery. RESULTS The mean period of non-weight bearing was significantly shorter in group E (3.68 ± 1.02 vs. 6.67 ± 1.43; P < 0.001). The mean period of cast immobilization term were shorter in group E (1.84 ± 1.35 vs. 2.65 ± 1.51; P < 0.001). There were no differences in the AOFAS score at any period. The rates of deep infection and reoperation in Group E were significantly lower than those in Group L (1.7% vs. 6.1%; P = 0.009, 2.0% vs. 7.8%; P = 0.002, respectively). There were no significant differences in superficial infection (9 vs. 15; P = 0.297), nonunion (9 vs. 15 P = 0.30), blistering (4 vs. 3; P = 1.00), neurapraxia (2 vs. 1; P = 1.00), and wound dehiscence (15 vs. 18; P = 0.72). CONCLUSIONS Although functional outcome was similar depending on whether early weight bearing was allowed, the rates of deep infection and reoperation decreased in patients with early weight bearing. We recommend early postoperative weight bearing in patients with a surgically treated AF.
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Affiliation(s)
- Kosuke Bando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Takegami
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Toshihiro Ando
- Department of Orthopedic Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takayuki Sugino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshifumi Sato
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Fujita
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Stupay KL, Miller CP, Staffa S, McTague MF, Weaver MJ, Kwon JY. Risk Factors for Aseptic Revision of Operatively Treated Ankle Fractures. Foot Ankle Int 2022; 43:378-388. [PMID: 34677113 DOI: 10.1177/10711007211050876] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Early revision rates within 12 months after ankle fracture open reduction internal fixation (AF-ORIF) are fairly low; however, they remain relevant given the volume of ankle fractures occurring annually. Understanding these rates is complex because reoperation due to technical or mechanical complications is typically reported alongside soft tissue-related problems such as symptomatic hardware, wound dehiscence, or infection. There are limited data identifying risk factors specifically for revision of ankle fracture fixation in the absence of soft tissue complications. Understanding variables that predispose to aseptic technical and mechanical failure without this confounder may provide insight and improve patient care. METHODS A retrospective cohort study was performed at 2 large academic medical centers. Research Patient Data Registry (RPDR) data available from 2002 to 2019 were used to identify patients who underwent aseptic revision of AF-ORIF within 12 months (n = 33). A control group (n = 100) was selected by identifying sequential patients who underwent AF-ORIF not requiring revision within 12 months. Multiple factors were recorded for all patients in both cohorts. Each fracture was also evaluated according to the Ankle Reduction Classification System (ARCS) of Chien et al,8 which categorizes biplanar talar displacement in relation to a central tibial plumb line into 1 of 3 grades: A (0-2 mm), B (3-10 mm), and C (>10 mm). Adapted from its original purpose of grading reduction quality, we applied ARCS to pre-reduction radiographs to assess initial fracture displacement. All variables collected were compared in univariate analysis. Variables that achieved significance in univariate comparisons were included as candidates for multivariable analysis. RESULTS Final multivariable logistic regression modeling demonstrated the following factors to independently predict the need for aseptic revision surgery: documented falls in the early postoperative period (aOR, 298; 95% CI, 15.4, 5759; P < .001), movement-altering disorders (aOR, 81.7; 95% CI, 4.12, 1620; P = .004), a nonanatomic mortise (medial clear space [MCS] > superior clear space [SCS]) on immediate postoperative imaging (aOR, 38.4; 95% CI, 5.53, 267; P < .001), initial coronal plane tibiotalar displacement >10 mm and sagittal plane tibiotalar dislocation (ARCS-C) (aOR vs ARCS-A, 25.8; 95% CI, 2.81, 237; P = .004), substance abuse (aOR, 15.7; 95% CI, 2.66, 92.8; P = .002), and polytrauma (aOR, 12.3; 95% CI, 2.02, 74.8; P = .006). CONCLUSION In this investigation we found a notable increase in risk for revision surgery after AF-ORIF for patients who had one of the following: (1) falls in the early postoperative period, (2) movement-altering disorders, (3) a nonanatomic mortise (MCS > SCS) on immediate postoperative imaging, (4) more severe initial fracture displacement, (5) substance abuse, or (6) polytrauma. Identifying these factors may allow surgeons to better understand risk and counsel patients, and may serve as future targets for intervention aimed at improving patient safety and outcomes after ankle fracture ORIF. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Kristen L Stupay
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Christopher P Miller
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Steven Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Michael F McTague
- Harvard Medical School Orthopaedic Trauma Initiative, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michael J Weaver
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - John Y Kwon
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
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An overview on the treatment and outcome factors of ankle fractures in elderly men and women aged 80 and over: a systematic review. Arch Orthop Trauma Surg 2022; 142:3311-3325. [PMID: 34546421 PMCID: PMC9522701 DOI: 10.1007/s00402-021-04161-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 09/01/2021] [Indexed: 10/27/2022]
Abstract
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.
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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. Foot Ankle Surg 2021; 27:879-883. [PMID: 33277173 DOI: 10.1016/j.fas.2020.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/13/2020] [Accepted: 11/27/2020] [Indexed: 02/04/2023]
Abstract
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.
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Spek RWA, Smeeing DPJ, van den Heuvel L, Kokke MC, Bhashyam AR, Kelder JC, Verleisdonk EJMM, Houwert RM, van der Velde D. Complications After Surgical Treatment of Geriatric Ankle Fractures. J Foot Ankle Surg 2021; 60:712-717. [PMID: 33789807 DOI: 10.1053/j.jfas.2019.12.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 12/04/2019] [Indexed: 02/03/2023]
Abstract
The incidence of geriatric ankle fractures is rising and the potential for complications is high in this population. Little is known about factors associated with increased postoperative complications after surgical fixation of ankle fractures in older-age patients. The purpose of this retrospective cohort study was to assess the epidemiology and risk factors for complications after surgically treated ankle fractures in geriatric patients. All patients who were 65 years or older and had a surgically treated ankle fracture were included. Pilon fractures, patients who were initially treated conservatively or who had less than 1 month of follow-up were excluded. Postoperative complications, demographic-, fracture- and surgical data of 282 patients were recorded from two level 2 trauma centers between 2012 and 2017. A total of 87 (30.9%) patients developed a complication, of which wound related complications were most frequently reported. Superficial and deep wound infections were observed in 27 (9.6%) and 18 (6.4%) patients, respectively. Multivariate regression analysis demonstrated increased age to be an independent predictive variable for the occurrence of postoperative complications (odds ratio 1.04; 95% confidence interval 1.00-1.09), while cast immobilization for more than 2 weeks was a protective factor for the development of wound related complications (odds ratio 0.34; 95% confidence interval 0.17-0.66). In conclusion, the incidence of postoperative complications among geriatric patients after surgical treatment of ankle fractures is high and patients should be informed accordingly.
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Affiliation(s)
- Reinier W A Spek
- Medical Student, Department of Trauma, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Diederik P J Smeeing
- Surgical Resident, Department of Surgery, Slingeland Hospital, Doetinchem, The Netherlands
| | - Linda van den Heuvel
- Physician Assistant, Department of Surgery, St Antonius Hospital, Utrecht, The Netherlands
| | - Marike C Kokke
- Trauma Surgeon, Department of Surgery, St Antonius Hospital, Utrecht, The Netherlands
| | - Abhiram R Bhashyam
- Resident, Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA
| | - Johannes C Kelder
- Medical Doctor, Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Roderick M Houwert
- Trauma Surgeon, Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Trauma Surgeon, Utrecht Trauma Center, Utrecht, The Netherlands
| | - Detlef van der Velde
- Trauma Surgeon, Department of Surgery, St Antonius Hospital, Utrecht, The Netherlands
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43
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R A, Am K, Ah M, Ck B, S R, M F. Interventional revascularization prior to operative fixation of fractures below the knee. A retrospective case series. Injury 2021; 52:1939-1943. [PMID: 34020779 DOI: 10.1016/j.injury.2021.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/08/2021] [Accepted: 04/10/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Aigner R
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, Location Marburg, Marburg, Germany
| | - König Am
- Philipps-University of Marburg, Clinic of Diagnostic and Interventional Radiology, Marburg, Germany
| | - Mahnken Ah
- Philipps-University of Marburg, Clinic of Diagnostic and Interventional Radiology, Marburg, Germany
| | - Boese Ck
- Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ruchholtz S
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, Location Marburg, Marburg, Germany
| | - Frink M
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, Location Marburg, Marburg, Germany.
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Eyre-Brook AI, Ring J, Chadwick C, Davies H, Davies M, Blundell C. A Comparison of Fibula Pro-Tibia Fixation Versus Hindfoot Nailing for Unstable Fractures of the Ankle in Those Older Than 60 Years. Foot Ankle Spec 2021; 16:135-144. [PMID: 34176315 DOI: 10.1177/19386400211017373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND 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.
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King CM, Doyle MD, Castellucci-Garza FM, Nguyentat A, Collman DR, Schuberth JM. Early Protected Weightbearing After Open Reduction Internal Fixation of Ankle Fractures With Trans-syndesmotic Screws. J Foot Ankle Surg 2021; 59:726-728. [PMID: 32057623 DOI: 10.1053/j.jfas.2020.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/26/2019] [Accepted: 01/11/2020] [Indexed: 02/03/2023]
Abstract
Traditional postoperative care after open reduction internal fixation (ORIF) of unstable ankle fractures with syndesmotic instability includes non-weightbearing for 6 to 8 weeks. However, prolonged non-weightbearing may be detrimental. The goal of this case series was to assess the outcomes of early protected weightbearing after operative treatment of acute ankle fractures with syndesmotic instability requiring screw stabilization. Fifty-eight consecutive patients, treated from January 2006 to January 2013, met the inclusion criteria with a minimum follow up of 1 year. Electronic medical records and radiographs were reviewed for patient and surgical characteristics, postoperative complications, and maintenance of reduction. Patients initiated walking at an average of 10 days (range 1 to 15) postoperatively. Surgical treatment consisted of operative reduction with standard fixation devices and 1 or 2 trans-syndesmotic screws that purchased 4 cortices. All 58 patients maintained correction after surgery when allowed to weightbear early in the postoperative recovery. Five complications (8.6%) occurred in the 58 patients, which included 3 superficial infections (5.2%) and 2 cases (3.4%) of neuritis. The maintenance of reduction and low complication rate in this study support the option of early protected weightbearing after ankle fracture ORIF with trans-syndesmotic fixation.
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Affiliation(s)
- Christy M King
- Attending Staff and Residency Director, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Foundation Hospital, Oakland, CA
| | - Matthew D Doyle
- Fellow, Silicon Valley Reconstructive Foot and Ankle Fellowship, Mountain View, CA
| | - Francesca M Castellucci-Garza
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Foundation Hospital, Antioch, CA
| | - Annie Nguyentat
- Attending Staff, Foot and Ankle Surgery, Roseville Orthopedic Surgery & Sports Medicine, Roseville, CA
| | - David R Collman
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics, Kaiser Foundation Hospital, San Francisco, CA
| | - John M Schuberth
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics, Kaiser Foundation Hospital, San Francisco, CA.
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Canton G, Sborgia A, Maritan G, Fattori R, Roman F, Tomic M, Morandi MM, Murena L. Fibula fractures management. World J Orthop 2021; 12:254-269. [PMID: 34055584 PMCID: PMC8152440 DOI: 10.5312/wjo.v12.i5.254] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/01/2021] [Accepted: 04/05/2021] [Indexed: 02/06/2023] Open
Abstract
Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.
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Affiliation(s)
- Gianluca Canton
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Andrea Sborgia
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Guido Maritan
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Roberto Fattori
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Federico Roman
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Marko Tomic
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Massimo Max Morandi
- Department of Orthopaedic Surgery, Louisiana State University Health Science Center, Shreveport, LA 71103, United States
| | - Luigi Murena
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
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47
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Beleckas CM, Szatkowski JP. Nontraditional Methods of Fibula Fixation. Orthop Clin North Am 2021; 52:123-131. [PMID: 33752833 DOI: 10.1016/j.ocl.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This article explores different nontraditional methods that could be adopted in clinical settings as alternatives to the traditional fibular fixation. Less invasive methods, such as intramedullary nail and screw fixation, might be viable alternatives for managing ankle fractures. These methods might especially benefit patients with poor soft tissue envelopes, low immunity, and poor bone quality. There is minimal soft tissue coverage for most orthopedic implants around the ankle. Various authors have highlighted the importance of minimally invasive surgery as an effective modality for ensuring superior prognosis for ankle fracture surgery or those fractures involving both the distal tibia and fibula.
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Affiliation(s)
- Casey M Beleckas
- Department of Orthopedics, Indiana University, 1801 N Senate Ave, MPC1 #535, Indianapolis, IN 46202, USA
| | - Jan P Szatkowski
- Department of Orthopedics, Indiana University, IU Health, 1801 N Senate Ave, MPC1 #535, Indianapolis, IN 46202, USA.
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Increasing age and modifiable comorbidities are associated with short-term complications after open reduction and internal fixation of ankle fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:113-119. [PMID: 33759030 DOI: 10.1007/s00590-021-02927-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Ankle fractures are common orthopedic injuries with complication rates fixation of up to 40%. Limited evidence exists in the literature regarding complications in the elderly population, and moreover, these studies frequently define elderly arbitrarily at 60-65 years old. The purpose of the present study was to utilize a large, validated database to evaluate whether there is an inflection point of age when postoperative complications after an ankle fracture significantly increase. METHODS A retrospective review of all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent fixation of an ankle fracture between 2012 and 2018 was performed. Patients were identified within the database using the Current Procedural Terminology codes. Appropriate statistical analysis was performed with p value less than 0.05 considered statistically significant. RESULTS A total of 27,633 fractures were including and comprised of 221 posterior malleolar, 1567 medial malleolar, 8495 lateral malleolar, 10,175 bimalleolar, and 7175 trimalleolar. A total of 1545 complications were encountered (5.6%). There was a statistically significant association between increasing age and complications (OR = 1.03; p < 0.001). Further analysis shows the largest spike in complications within the age 78 + bracket. There were no overall interaction effects between age and fracture subtype (p = 0.223). CONCLUSION ORIF of ankle fractures is a common orthopedic procedure performed on patients of all ages, with complications ranging in severity. In order to best counsel patients on their individual postoperative risks, large datasets are often necessary to prognosticate. This study found that postoperative complications increase with advanced age. The incidence of complications did not spike for patients around the age of 65, but rather followed an incremental linear pattern with the largest increase in odds ratio occurring at age 78 and above. Complication rate was not associated with specific fracture type based off of ICD codes.
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Sahin A, Agar A, Gulabi D, Erturk C. The Surgical Outcomes of Unstable Ankle Fractures in Patients Aged >65 Years. Geriatr Orthop Surg Rehabil 2021; 12:2151459321997765. [PMID: 33796343 PMCID: PMC7968019 DOI: 10.1177/2151459321997765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 01/27/2021] [Accepted: 02/03/2021] [Indexed: 01/02/2023] Open
Abstract
AIM To evaluate the surgical outcomes and complications of patients over 65 years of age, with unstable ankle fractures. MATERIAL AND METHOD The study included 111 patients (73F/38 M) operated on between January 2015 and February 2019 and followed up for a mean of 21.2 months (range, 6-62 months).Demographic characteristics, comorbidities, fracture type, and mechanisms of injury were evaluated. Relationships between postoperative complications and comorbidities were examined. In the postoperative functional evaluations, the AOFAS score was used and pre and postoperative mobilization (eg, use of assistive devices) was assessed. RESULTS The mean age of the patients was 70.5 ± 6.1 years (range, 65-90 years). The mechanism of trauma was low-energy trauma in 90.1% of the fractures and high-energy trauma in 9.9%. The fractures were formed with a SER injury (supination external rotation) in 83.7% of cases and bimalleolar fractures were seen most frequently (85/111, 76%).Complications developed in 16 (14.4%) patients and a second operation was performed in 11 (9.9%) patients with complications. Plate was removed and debridement was performed in 5 of 6 patients due to wound problems. Nonunion was developed in the medial malleolus in 4 patients. Revision surgery was performed because of implant irritation in 2 patients and early fixation loss in the medial malleolus fracture in one patient. Calcaneotibial arthrodesis was performed in 3 patients because of implant failure and ankle luxation associated with non-union. A correlation was determined between ASA score and DM and complications, but not with osteoporosis. The mean follow-up AOFAS score was 86.7 ± 12.5 (range, 36-100).A total of 94 (84.7%) patients could walk without assistance postoperatively and 92 (82.9%) were able to regain the preoperative level of mobilization. CONCLUSION Although surgery can be considered an appropriate treatment option for ankle fractures in patients aged >65 years, care must be taken to prevent potential complications and the necessary precautions must be taken against correctable comorbidities.
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Affiliation(s)
- Adem Sahin
- Orthopaedic and Traumatology Department, Saglik Bilimleri University, Kanuni Sultan Suleyman Training and Research Hospital, Kucukcekmece/Istanbul, Turkey
| | - Anıl Agar
- Orthopaedic and Traumatology Department, Saglik Bilimleri University, Kanuni Sultan Suleyman Training and Research Hospital, Kucukcekmece/Istanbul, Turkey
| | - Deniz Gulabi
- Orthopaedic and Traumatology Department, Saglik Bilimleri University, Kanuni Sultan Suleyman Training and Research Hospital, Kucukcekmece/Istanbul, Turkey
| | - Cemil Erturk
- Orthopaedic and Traumatology Department, Saglik Bilimleri University, Kanuni Sultan Suleyman Training and Research Hospital, Kucukcekmece/Istanbul, Turkey
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Peri-incisional perfusion does not differ between running versus interrupted Allgöwer-Donati suture technique in ankle fracture surgery: a pilot randomized controlled trial of wound perfusion. OTA Int 2021; 4:e097. [PMID: 33937719 PMCID: PMC8016606 DOI: 10.1097/oi9.0000000000000097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 11/19/2020] [Indexed: 11/27/2022]
Abstract
Objectives: To compare peri-incisional perfusion, perfusion impairment and wound closure time between the conventional interrupted Allgöwer-Donati (IAD) technique and a modified running Allgöwer-Donati (RAD) technique in ankle fracture surgery. Design: Prospective, randomized controlled clinical trial. Setting: Level I and II trauma centers. Patients: Twenty-five healthy adults with ankle fractures (AO/OTA 44-A, 44-B, or 44-C) between November 2017 and December 2018. (Of 26 patients enrolled in this study, 1 was lost to follow-up.) Intervention: Participants were randomized into the IAD or the RAD group (13 patients each). All participants were followed for at least 3 months after surgery to assess for wound complications. Main Outcome Measurements: Skin perfusion was assessed immediately after wound closure with laser-assisted indocyanine green angiography. Wound closure time, mean incision perfusion, and mean perfusion impairment were measured and compared with analysis of variance. Alpha = 0.05. Results: The RAD technique was significantly faster in terms of mean (± standard deviation) wound closure time (6.2 ± 1.4 minutes) compared with the IAD technique (7.3 ± 1.4 minutes) (P = 0.047). We found no differences in mean incision perfusion and mean perfusion impairment (all, P > 0.05). Conclusion: The IAD and RAD techniques resulted in similar peri-incisional perfusion and perfusion impairment. Closure time was significantly shorter for the RAD technique compared with the IAD technique. Level of Evidence: I
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