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Tye C, Alkhabbaz O, Miaw W, Park K, Newman S, Barcak E. Outcomes of Patients Treated for Open Pilon Fractures at a County Hospital. Foot Ankle Spec 2025:19386400251316921. [PMID: 39927489 DOI: 10.1177/19386400251316921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2025]
Abstract
INTRODUCTION Open pilon fractures represent a challenging injury for both patients and physicians. Patients must contend with prolonged non-weightbearing, wound complications, and the possibility of post-traumatic arthritis. Surgeons also deal with a fracture which is difficult to treat and that is prone to poor outcomes. To better understand these challenging injuries and identify details that may portend better patient outcomes, we performed a retrospective review of open pilon fractures treated at a level 1 trauma county hospital by orthopedic trauma-trained surgeons. MATERIALS AND METHODS A search was performed for patients treated for open pilon fractures at our institution. Demographics and fracture information for each patient, as well as pre and postoperative details for each patient, were collected. We also identified complications such as infection, nonunion, and the need for additional surgeries in patients. Patients were then compared to one another, and they were also stratified according to their Gustilo-Anderson classification of open fracture to identify differences. RESULTS Patients in our study who sustained type 3 open injuries were older, more often required additional surgeries, sustained nonunion of their fracture, became infected or underwent amputation than patients with type 1 and 2 injuries. 20% of all patients with type 3 open injuries underwent 4 or more additional procedures, while only 13% did not require additional surgery. In contrast, over half of all patients with type 1 and 2 open injuries did not require any additional surgeries. CONCLUSIONS Despite following currently recommended guidelines for the treatment of open pilon fractures, these injuries are still prone to complications. Elderly patients and those with type 3 injuries are especially at high risk for negative postoperative outcomes due to the increased severity of soft-tissue damage. Further research is necessary to identify optimal protocols for these devastating injuries, especially in vulnerable populations. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Cooper Tye
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas
| | - Omar Alkhabbaz
- Texas College of Osteopathic Medicine, The University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas
| | - Wesley Miaw
- Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, Texas
| | - Kyung Park
- Department of Clinical Research, John Peter Smith Health Network, Fort Worth, Texas
| | | | - Eric Barcak
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas
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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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Doxey SA, Sorich MM, Abraham SC, Switzer JA, Cunningham BP, McKee MD, Myeroff CM. Iatrogenic open humeral shaft fractures following functional bracing. Arch Orthop Trauma Surg 2024; 144:2539-2546. [PMID: 38743112 DOI: 10.1007/s00402-024-05369-4] [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: 02/22/2024] [Accepted: 05/05/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION The treatment of closed humeral shaft fractures tends to be successful with functional bracing. Treatment failure due to iatrogenic conversion to an open fracture has not been described in the literature. We present a case series of patients that experienced open humeral shaft fractures after initially being treated with functional bracing for closed humeral shaft fractures and describe what factors are associated with this complication. MATERIALS AND METHODS This was a retrospective case series performed at three level 1 trauma centers across North America. All nonoperatively treated humeral shaft fractures were reviewed from 2001 to 2023. Patients were included if they sustained a humeral shaft fracture, > 18 years old, were initially treated non-operatively with functional bracing which subsequently converted to an open fracture. Eight patients met inclusion criteria. All included patients were eventually treated with irrigation, debridement, and open reduction and internal fixation. Outcomes assessed included mortality rate, time until the fracture converted from closed to open, need for further surgery, and bony union. Descriptive statistics were used in analysis. RESULTS The eight included patients on average were 65 ± 21.4 years old and had a body mass index (BMI) of 25.6 ± 5.2. Six patients were initially injured due to a fall. Time until the fractures became open on average was 5.2 ± 3.6 weeks. Three patients (37.5%) died within 1.8 ± 0.6 years after initial injury. The average Charlson Comorbidity Index (CCI) score was 4.5 ± 3.4. Three patients (37.5%) had dementia. Common characteristics among this cohort included a history of visual disturbances (50.0%), cerebrovascular accident (50.0%), smoking (50.0%), and alcohol abuse (50.0%). CONCLUSION Conversion from a closed to open humeral shaft fracture after functional bracing is a potentially devastating complication. Physicians should be especially cognizant of patients with a low BMI, history of falling or visual disturbance, dementia, age ≥ 65, decreased sensorimotor protection, and significant smoking or alcohol history when choosing to use functional bracing as the final treatment modality. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Stephen A Doxey
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, 6500 Excelsior Boulevard, St. Louis Park, MN, 55426, USA
| | - Megan M Sorich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sarah C Abraham
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN, USA
| | - Julie A Switzer
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, 6500 Excelsior Boulevard, St. Louis Park, MN, 55426, USA
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA.
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, 6500 Excelsior Boulevard, St. Louis Park, MN, 55426, USA.
| | - Michael D McKee
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ, USA
- Department of Orthopaedic Surgery, Banner University Medical Center, Phoenix, AZ, USA
| | - Chad M Myeroff
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN, USA
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Noorlander-Borgdorff MP, Şekercan A, Young-Afat DA, Bouman M, Botman M, Giannakópoulos GF. Nationwide study on open tibial fractures in the Netherlands: Incidence, demographics and level of hospital care. Injury 2024; 55:111487. [PMID: 38490848 DOI: 10.1016/j.injury.2024.111487] [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: 12/04/2023] [Revised: 02/02/2024] [Accepted: 02/25/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVES Open tibial fractures are relatively common injuries following traffic accidents. The vulnerability of the soft tissues surrounding the tibia increases the susceptibility to complications, including infection and nonunion. To minimize complications, a multidisciplinary, timely approach is crucial. To date, the Dutch incidence and level of hospital treatment remain unknown due to a lack of condition-specific nationwide registries. This study aimed to estimate the incidence and management of open tibial fractures in the Netherlands, providing essential information for public health policymaking and guideline development. METHODS The 2018 and 2019 Dutch National Hospital Care Basic Registration data, provided by the Dutch Hospital Data Foundation, were utilized to identify all patients admitted to Dutch hospitals with tibial fractures. Incidence rates, patient demographics, primary diagnoses, fracture classification, level of hospital, and length of hospital stays were analyzed using descriptive statistics. RESULTS 1,079 ICD-10 codes for closed and open tibial fractures were identified in patients that were admitted to a Dutch hospital. Thirty-four percent were classified as open tibial fractures, accounting for an estimated incidence rate of 1.1 per 100,000 person-years (95 % CI 0.97-1.12). When categorized by age, the calculated incidence rate was higher in males for all age categories up until the age of 70. Notably, the overall highest incidence rate was found for females aged 90 and above (6.6 per 100,000 person-years). Open tibial fractures were predominantly treated in general or top clinical hospitals (comprising 69 % of open all tibia fractures). Notably, the minority (31 %) presented at university medical centers, all Level-1 trauma centers, equipped with orthoplastic teams. CONCLUSION This is the first study to report the nationwide incidence rate of open tibial fractures in the Netherlands; 34 % of tibial fractures were registered as open. Notably, a limited proportion of open tibial fractures underwent treatment within Level-1 trauma centers. Consequently, in the majority of cases, the implementation of an orthoplastic team approach was unattainable. This study underscores the need for more comprehensive data collection to assess and improve the current treatment landscape.
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Affiliation(s)
- M P Noorlander-Borgdorff
- Trauma Unit, Department of Surgery. Amsterdam UMC, Location AMC, Amsterdam, the Netherlands; Department of Plastic, Reconstructive, and Hand Surgery. Amsterdam UMC, Amsterdam, the Netherlands; Amsterdam Movement Sciences, Musculoskeletal Health, Amsterdam, the Netherlands.
| | - A Şekercan
- Trauma Unit, Department of Surgery. Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - D A Young-Afat
- Department of Plastic, Reconstructive, and Hand Surgery. Amsterdam UMC, Amsterdam, the Netherlands
| | - M Bouman
- Department of Plastic, Reconstructive, and Hand Surgery. Amsterdam UMC, Amsterdam, the Netherlands
| | - M Botman
- Department of Plastic, Reconstructive, and Hand Surgery. Amsterdam UMC, Amsterdam, the Netherlands
| | - G F Giannakópoulos
- Trauma Unit, Department of Surgery. Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
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Resad Ferati S, Ganta A. Classification of open tibia fractures: the rationale for a new classification system. OTA Int 2024; 7:e318. [PMID: 38840710 PMCID: PMC11149748 DOI: 10.1097/oi9.0000000000000318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 06/07/2024]
Abstract
Open tibial shaft fractures are one of the most common long bone injuries encountered. Current existing classifications are designed to characterize the nature of the injury and guide clinical decision making. However, despite these advancements, there are areas in our current classification system that can be improved to not only make reliability more producible but also create prognostic factors that can help guide treatment.
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Affiliation(s)
| | - Abhishek Ganta
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
- Jamaica Hospital Medical Center, Queens, NY
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Nohmi S, Suzuki M, Aburakawa K, Araki R. "Fix and flap" for an open fracture of the tibia in a 97-year-old patient: A case report of early internal fixation and free flap reconstruction. Int J Surg Case Rep 2023; 110:108733. [PMID: 37647757 PMCID: PMC10509864 DOI: 10.1016/j.ijscr.2023.108733] [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: 07/12/2023] [Revised: 08/22/2023] [Accepted: 08/25/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION The incidence of open fractures in super-old patients has increased. "Fix and flap" procedures using early internal fixation and free flap reconstruction in super-old patients are rarely reported. PRESENTATION OF CASE A 97-year-old woman presented to our emergency department after a car accident. She was diagnosed with an open fracture of the lower leg, and the open wound could not be closed after debridement. The tibia was fixed using an intramedullary nail on the day of injury, and the open wound was closed using a free latissimus dorsi myocutaneous flap on the sixth day. The flap was engrafted at the 1-year follow-up after the injury, and the patient was able to walk using a cane. DISCUSSION To facilitate flap elevation and shorten the operative time, a flap with fewer vascular variants should be selected, and flow-through anastomosis that does not obstruct peripheral blood flow with a high patency rate is preferable. Reconstructive free flap surgery is preferably performed within 1 week of the initial injury to prevent fibrosis or scarring of recipient vessels. CONCLUSION The "fix and flap" procedure, composed of early internal fixation and free flap reconstruction, is possible even in super-old patients through careful considerations of flap selection, methods of anastomosis of blood vessels, and timing of surgery. However, it is necessary to determine whether the affected limb can be preserved or amputated, and prolonged treatment must be avoided.
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Affiliation(s)
- Shuya Nohmi
- Department of Orthopaedic Surgery, Misawa City Hospital, 164-65 Horiguchi, Misawa, Misawa-shi, Aomori 033-0022, Japan.
| | - Masahiro Suzuki
- Department of Orthopaedic Surgery, Towada City Central Hospital, 14-8 Nishi12-bancho, Towada-shi, Aomori 034-0093, Japan
| | - Kotaro Aburakawa
- Department of Orthopaedic Surgery, Aomori Prefectural Central Hospital, 2-1-1 Higashitsukurimichi, Aomori-shi, Aomori 030-8553, Japan
| | - Ryo Araki
- Department of Orthopaedic Surgery, Hachinohe City Hospital, 3-1-1 Tamukai, Hachinohe-shi, Aomori 031-8555, Japan
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Sagerfors M, Jakobsson H, Wretenberg P, Brus O, Möller M. Treatment and outcome of AO/OTA type C distal radius fractures: 12 199 fractures from the Swedish Fracture Register. Acta Orthop Belg 2023; 89:241-247. [PMID: 37924540 DOI: 10.52628/89.2.11473] [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: 11/06/2023]
Abstract
The aim of this study was to examine the epidemiology, treatment, and patient-reported outcome of AO/OTA type C distal radius fractures (DRF) using data from a large national fracture register. We used prospectively collected data from the Swedish Fracture Register covering all AO/OTA type C DRFs registered between April 2012 and December 2018. Data on fracture type, epidemiology, trauma-mechanism, and treatment had been recorded by the treating physician. Patients had been sent an outcome questionnaire including EQ-VAS, EQ-5D, and the SMFA at the time of injury and 12 months after. A total of 12 199 cases with AO/OTA type C fracture were identified. AO/OTA type C1 fracture was most common, with 5400 cases, followed by AO type C2 with 4304 and AO/OTA type C3 with 2495. Cast treatment and surgical treatment with volar locking plate fixation were the most common treatments. Patient-reported outcome measures worsened significantly one year after the fracture, and 56% reported moderate problems with pain and discomfort one year after the fracture. Patients treated with a volar plate reported a significantly larger deterioration in EQ-5D outcome compared to patients treated with a cast. No treatment method was found to be superior. A good outcome after a type C fracture is possible, but many patients do not recover completely. Our findings indicate a relatively better self-reported outcome for patients treated with a cast, but as treatment was not randomized the clinical relevance is unclear.
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Lukina Y, Safronova T, Smolentsev D, Toshev O. Calcium Phosphate Cements as Carriers of Functional Substances for the Treatment of Bone Tissue. MATERIALS (BASEL, SWITZERLAND) 2023; 16:4017. [PMID: 37297151 PMCID: PMC10254876 DOI: 10.3390/ma16114017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/14/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023]
Abstract
Interest in calcium phosphate cements as materials for the restoration and treatment of bone tissue defects is still high. Despite commercialization and use in the clinic, the calcium phosphate cements have great potential for development. Existing approaches to the production of calcium phosphate cements as drugs are analyzed. A description of the pathogenesis of the main diseases of bone tissue (trauma, osteomyelitis, osteoporosis and tumor) and effective common treatment strategies are presented in the review. An analysis of the modern understanding of the complex action of the cement matrix and the additives and drugs distributed in it in relation to the successful treatment of bone defects is given. The mechanisms of biological action of functional substances determine the effectiveness of use in certain clinical cases. An important direction of using calcium phosphate cements as a carrier of functional substances is the volumetric incorporation of anti-inflammatory, antitumor, antiresorptive and osteogenic functional substances. The main functionalization requirement for carrier materials is prolonged elution. Various release factors related to the matrix, functional substances and elution conditions are considered in the work. It is shown that cements are a complex system. Changing one of the many initial parameters in a wide range changes the final characteristics of the matrix and, accordingly, the kinetics. The main approaches to the effective functionalization of calcium phosphate cements are considered in the review.
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Affiliation(s)
- Yulia Lukina
- National Medical Research Center for Traumatology and Orthopedics Named after N.N. Priorov, Ministry of Health of the Russian Federation, Priorova 10, 127299 Moscow, Russia;
- Faculty of Digital Technologies and Chemical Engineering, Mendeleev University of Chemical Technology of Russia, Miusskaya pl. 9, 125047 Moscow, Russia
| | - Tatiana Safronova
- Department of Chemistry, Lomonosov Moscow State University, Building 3, Leninskie Gory 1, 119991 Moscow, Russia;
- Department of Materials Science, Lomonosov Moscow State University, Building 73, Leninskie Gory 1, 119991 Moscow, Russia;
| | - Dmitriiy Smolentsev
- National Medical Research Center for Traumatology and Orthopedics Named after N.N. Priorov, Ministry of Health of the Russian Federation, Priorova 10, 127299 Moscow, Russia;
| | - Otabek Toshev
- Department of Materials Science, Lomonosov Moscow State University, Building 73, Leninskie Gory 1, 119991 Moscow, Russia;
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Friedman LGM, Zachos TA, Sanchez D, Tawari A, Kempegowda H, Ryan S, Michalowski A, Horwitz DS. Open lower extremity fractures in the geriatric population. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:401-408. [PMID: 35034183 DOI: 10.1007/s00590-022-03209-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Open fractures in the elderly are distinct compared to younger populations. The purpose of this study is to follow a series of open fractures of the lower extremity in the geriatric population to better prognosticate outcomes. METHODS We performed a retrospective chart review of patients over the age of 65 years old who were treated for an open, lower extremity fracture across two level I trauma medical systems. Patients were included if they had documented wound healing problems in the postoperative period, or 6 months of follow-up, or if they had a definitive radiographic outcome. Sixty-four patients were included of an average age of 76.23, of whom 73.4% were female. RESULTS The fracture types were midshaft femur in 3, distal femur in 9, patella in 2, proximal tibia in 3, proximal fibula in 1, midshaft tibia in 14, distil tibia in 8, ankle in 23, and talar neck/calcaneus in 1. Forty-two fractures were the result of low energy mechanism and 22 fractures were from high energy mechanism. Fourteen fractures were type 1, 32 were type 2, 11 were type 3A, 6 were type 3B, and 1 was type 3C. At final follow-up, 13 wounds were well healed, 39 wounds were healed following a delay of more than 6 weeks to achieve healing, 3 were infected, 3 had been treated with amputation, 2 had chronic ulceration, 2 with active draining, and 2 had draining sinuses. DISCUSSION Open lower extremity fractures are serious injuries with high rates of morbidity. Such risks are even higher in the geriatric population, particularly with regard to wound healing. This study provides important prognostic information in counseling geriatric patient with an open lower extremity fracture, as well as informs treatment in terms of wound surveillance and care in the postoperative period.
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Affiliation(s)
- Lisa G M Friedman
- Geisinger Medical Center, 100 N. Academy Ave., Danville, PA, 17822, USA.
| | | | - Daniela Sanchez
- School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Akhil Tawari
- Thunga Hospitals, SRCC Children's Hospital, Mumbai, India
| | | | - Scott Ryan
- Tufts University Medical Center, Boston, MA, USA
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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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Jaibaji M, Sohatee M, Watkins C, Qasim S, Fearon P. Open ankle fractures: Factors influencing unplanned reoperation. Injury 2022; 53:2274-2280. [PMID: 35397874 DOI: 10.1016/j.injury.2022.03.047] [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: 03/06/2022] [Accepted: 03/22/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Ankle fractures are amongst the most common open fracture injuries presenting to major trauma centres (MTC) and their management remains a topic of debate. Incidence is increasing particularly in the elderly population however the optimal surgical approach and risk factors for unplanned reoperation remain scarce. We therefore conducted a retrospective case study to analyse our institution's outcomes as well as identify risk factors for early unplanned reoperation. MATERIALS AND METHODS Sixty-five consecutive open ankle fractures were identified using our institutional database between July 2016 and July 2020. Medical records and operation notes were reviewed to identify patient age at injury, Sex, co-morbidities and other co-morbidities, fracture configuration, extent of soft tissue injury, fixation type and post-operative complications. The data was categorised into four groups for analysis, 1) age, 2) AO-OTA classification 3) Sex 4) Gustilo-Anderson grade. Statistical analysis was undertaken to identify predictors of unplanned reoperation. RESULTS The mean age of patients at the time of injury was 60.8. Unplanned reoperation rate was 17.5%. Age and Gustilo-Anderson classification grade were both statistically significant predictors of unplanned reoperation. AO-OTA classification, Sex and Diabetes were not statistically significant factors associated with unplanned reoperation. CONCLUSION Age and quality of soft tissue envelope are significant risk factors for unplanned reoperation. Patients with these risk factors may benefit from an alternative surgical approach.
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Affiliation(s)
- Monketh Jaibaji
- Health Education England North East, Newcastle Upon Tyne, United Kingdom.
| | - Mark Sohatee
- Health Education England North East, Newcastle Upon Tyne, United Kingdom
| | - Christopher Watkins
- Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Sultan Qasim
- Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Paul Fearon
- Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
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Abstract
OBJECTIVE The aim of this study was to assess the outcomes of open lower limb fractures in patients aged 65 and over. The primary outcome was mortality at 30 days, and the secondary outcome was reoperation. METHODS This study retrospectively identified patients aged 65 and over, presenting with an open tibia or ankle fracture, over a two-year period. Patient demographics, injury characteristics and surgical interventions were documented. The 30-day and one-year mortality was recorded, as well as any complications encountered. RESULTS There were 88 patients included in the study, with a mean age of 78 years and 66% of patients were female. Of this cohort, 67 patients (76%) had low energy injuries and 64 patients (73%) had Gustillo-Anderson type IIIB injuries. Treatment consisted of a one-stage surgical procedure in 49 patients (56%) and a two-stage procedure in 37 patients (42%), with two patients dying before definitive treatment. Primary wound closure was performed in 23 patients (26%), four patients (5%) had a split skin graft alone, 35 patients (40%) had local flaps, 21 patients (24%) were managed with free flaps and three patients (3%) had primary below knee amputations. The 30-day mortality rate was 10%, the one-year mortality rate was 19% and the reoperation rate was 8%. CONCLUSION Open lower limb fractures in the elderly are a life and limb threatening injury, with a similar demographic and mortality profile to hip fracture. This study demonstrates that limb salvage can be achieved in 93% of cases, with treatment performed as a one-stage procedure in 56% of cases.
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Lee A, Geoghegan L, Nolan G, Cooper K, Super J, Pearse M, Naique S, Hettiaratchy S, Jain A. Open tibia/fibula in the elderly: A retrospective cohort study. JPRAS Open 2022; 31:1-9. [PMID: 34805472 PMCID: PMC8585579 DOI: 10.1016/j.jpra.2021.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/07/2021] [Indexed: 12/17/2022] Open
Abstract
The incidence of open tibia/fibula fractures in the elderly is increasing, but current national guidelines focus on the aggressive treatment of high-energy injuries in younger patients. There is conflicting evidence regarding whether older age affects treatment provision and outcomes in open fractures. The aim of this study was to determine if elderly patients are sustaining a different injury to younger patients and how their treatment and outcomes differ. This may have implications for future guidelines and verify their application in the elderly. In this retrospective single centre cohort study (December 2015-July 2018), we compared the injury characteristics, operative management and outcomes of elderly (≥65 years) and younger (18-65 years) patients with open tibia/fibula fractures. An extended cohort examined free flap reconstruction. In total, 157 patients were included. High-energy injuries were commoner in younger patients (88% vs 37%; p<0.001). Most were Gustilo-Anderson IIIb in both age groups. Elderly patients waited longer until debridement (21:19 vs 19:00 h) and had longer inpatient stays (23 vs 15 days). There was no difference in time to antibiotics, operative approach or post-operative complications. Despite the low-energy nature of elderly patients' injuries, the severity of soft tissue insult was equivalent to younger patients with high-energy injuries. Our data suggest that age and co-morbidities should not prohibit lower limb reconstruction. The current application of generic guidelines appears suitable in the elderly, particularly in the acute management. We suggest current management pathways and targets be reviewed to reflect the greater need for peri-operative optimisation and rehabilitation in elderly patients.
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Affiliation(s)
- Alice Lee
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Luke Geoghegan
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Grant Nolan
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Kerri Cooper
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Jonathan Super
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Michael Pearse
- Department of Orthopaedic Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Satyajit Naique
- Department of Orthopaedic Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Shehan Hettiaratchy
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Abhilash Jain
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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Sagerfors M, Jakobsson H, Thórdardóttir Á, Wretenberg P, Möller M. Distal radius fractures in the superelderly: an observational study of 8486 cases from the Swedish fracture register. BMC Geriatr 2022; 22:140. [PMID: 35183121 PMCID: PMC8857784 DOI: 10.1186/s12877-022-02825-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 02/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background The distal radius fracture (DRF) is the most common fracture in adults. With an ageing population, the number of wrist fractures in the superelderly (≥ 80 years) is expected to rise. Optimal treatment for displaced DRFs remains controversial, especially in the superelderly group. In addition, basic knowledge of the outcome after a DRF in this heterogenic group is lacking. The aim of this study was to study injury characteristics, treatment and outcome of DRFs in superelderly patients using data from a large national register. Methods We used prospectively collected data from the Swedish Fracture Register. All distal radius fractures registered between April 2012 and December 2018 in patients ≥ 80 years of age were included. Data on epidemiology, fracture type, trauma mechanism and treatment are registered by the physician treating the patient. Patients are also sent a subjective outcome questionnaire including EQ-5D, EQ-VAS and Short Musculoskeletal Function Assessment questionnaire (SMFA-score) at the time of injury and after 12 months. The 12-month questionnaire was sent to those who had completed the questionnaire at the time of injury. A Mann–Whitney U-test was used to assess differences between treatment methods. Results Mean age for this population was 86 years (80–105 years), a majority of the patients were female (86.7%). The dominating injury mechanism was a simple fall (74.6%) in the patient’s residence. The majority of fractures were AO type A (70%) followed by AO type C (20.9%) and type B (8.6%). The incidence of open fractures was significantly higher in females (2.6%) compared to males (1.5%). A majority of the fractures were treated with a cast (87.5%) with volar locking plate as the second most common treatment method (6.6%). Patient-reported outcome measures (PROMs) EQ-5D, EQ-VAS and the Arm Hand Function Index of the SMFA-score deteriorated somewhat one year after injury compared to pre-injury. PROMs did not correlate to treatment with cast or a volar plate. Conclusions This nationwide register study provides detailed data on DRFs in the superelderly regarding epidemiology, treatment and self-reported outcome. A good self-reported outcome is possible, but many patients do not recover completely. PROMs did not correlate to type of treatment. The frequency of open fractures was significantly higher in females. The reason for this is unclear but different skin thickness in older males versus females may be one explanation.
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Affiliation(s)
- Marcus Sagerfors
- Department of Orthopedics and Hand Surgery, Faculty of Medicine and Health, Örebro University, 70182, Örebro, SE, Sweden.
| | - Hugo Jakobsson
- Department of Orthopedics and Hand Surgery, Faculty of Medicine and Health, Örebro University, 70182, Örebro, SE, Sweden
| | - Ásgerdur Thórdardóttir
- Department of Orthopedics and Hand Surgery, Faculty of Medicine and Health, Örebro University, 70182, Örebro, SE, Sweden
| | - Per Wretenberg
- Department of Orthopedics and Hand Surgery, Faculty of Medicine and Health, Örebro University, 70182, Örebro, SE, Sweden
| | - Michael Möller
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
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Pflüger P, Braun KF, Mair O, Kirchhoff C, Biberthaler P, Crönlein M. Current management of trimalleolar ankle fractures. EFORT Open Rev 2021; 6:692-703. [PMID: 34532077 PMCID: PMC8419795 DOI: 10.1302/2058-5241.6.200138] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus. Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons. In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint. In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care. This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives. Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138
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Affiliation(s)
- Patrick Pflüger
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Karl-Friedrich Braun
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Traumatology and Reconstructive Surgery including Department of Orthopedic Surgery, Charite Universitätsmedizin Berlin, Berlin, Germany
| | - Olivia Mair
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Chlodwig Kirchhoff
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Moritz Crönlein
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
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Kamin K, Kleber C, Marx C, Schaser KD, Rammelt S. [Minimally invasive fixation of distal fibular fractures with intramedullary nailing]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 33:104-111. [PMID: 33728477 DOI: 10.1007/s00064-021-00702-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Minimally invasive osteosynthesis of distal fibula fractures serves as a biomechanically stable and soft-tissue-friendly fixation method in the case of an unstable fracture, poor bone quality, and/or critical soft tissue conditions with restoration of the length, axis and rotation of the distal fibula as well as stabilization of the ankle mortise. The goal is to reduce and stabilize the distal fibular fracture in a quick and stable manner that protects the soft tissues in ankle fractures. INDICATIONS Unstable malleolar fractures and fracture dislocations; fibular fractures in combination with distal tibia fractures; critical soft tissue conditions around the ankle. CONTRAINDICATIONS No consent to surgery by the patient. Overall critical (life-threatening) general condition preventing surgery to the extremities. Very narrow medullary canal of the fibula (less than 3 mm, depending on the implant). SURGICAL TECHNIQUE Percutaneous placement of a guidewire into the distal fibular tip, opening the medullary canal and drilling the medullary canal in the distal fragment. Reduction of the axis by introduction of the fibular nail, with additional percutaneous use of reduction clamps for restoration of fibular length and rotation, if necessary. Placement of distal locking screws over the targeting device while maintaining rotation and length, in addition proximal static locking is mandatory to maintain the length of the fibula. In case of residual syndesmotic instability after fracture fixation, syndesmotic screws are inserted through the fibular nail via the aiming device. POSTOPERATIVE MANAGEMENT Following surgery, rest and elevation of the injured leg, and local cooling are indicated. Subsequently, mobilization with partial weight bearing (15-20 kg) in an ankle foot orthosis or plaster/cast for 6 weeks. RESULTS Minimally invasive fibular fixation with an intramedullary nail results in a significantly lower rate of wound healing complications compared with lateral plating. Reported union rates range from 97.4 to 100% with current nail designs. The quality of reduction and functional outcome is comparable to that after plate fixation. A certain learning curve has to be respected.
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Affiliation(s)
- Konrad Kamin
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - Christian Kleber
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Christine Marx
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Klaus-Dieter Schaser
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Stefan Rammelt
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
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17
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Pley C, Purohit K, Krkovic M, Abdulkarim A. A health economic analysis of the management of open lower limb fractures in the elderly. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2020; 30:1383-1391. [PMID: 32519071 PMCID: PMC7680339 DOI: 10.1007/s00590-020-02713-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/31/2020] [Indexed: 11/16/2022]
Abstract
AIM The aim of this study was to investigate the financial implications of the inpatient management of open lower limb fractures in adults over 65 years old. Further, the study compares the calculated cost to the income received by the hospital for these patients and to the existing body of literature. METHODS This study employed direct inpatient costing analysis to estimate the cost of treating the open lower limb fractures incurred by 58 patients over the age of 65 years treated in our centre (Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust) between March 2014 and March 2019. RESULTS The median cost of inpatient care calculated in this study was £20,398 per patient, resulting in a financial loss to the hospital of £5113 per patient. When the results were disaggregated by sex, the median cost for an open lower limb fracture in a male patient was £20,886 compared to £19,304 in a female patient. Data were also disaggregated by the site of injury, which produced a median cost for an open femur fracture of £23,949, and £24,549 and £15,362 for open tibia and ankle fractures, respectively. CONCLUSION This study provides a valuable estimate of the expense of treating open lower limb fractures in patients over the age of 65 years in a Major Trauma Centre in England. The study highlights the large losses incurred by hospitals in treating these cases, and supports revision of the remuneration structures in the National Health Service to adequately cover their cost.
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Affiliation(s)
- Caitlin Pley
- School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Katie Purohit
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
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Yanagisawa Y, Watanabe Y, Yamazaki M. Successful treatment of an open tibial fracture in a 102-year-old woman: a case report. J Rural Med 2020; 15:221-224. [PMID: 33033546 PMCID: PMC7530588 DOI: 10.2185/jrm.2020-019] [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: 04/22/2020] [Accepted: 05/07/2020] [Indexed: 11/27/2022] Open
Abstract
Introduction: As the average life expectancy is increasing, the number of patients aged >100 years who have fragility fractures will increase in the future. In female patients, the incidence of open fractures increases with age. Case Presentation: We present the case of a 102-year-old woman with open tibial and fibular diaphyseal fractures (Gustilo-Anderson classification type IIIb) treated with temporary external fixation, advancement flap, and negative pressure wound therapy in the first-stage surgery and treatment, and open reduction and internal fixation with skin grafting in the second-stage surgery. Open wound and bone healing were attained. Conclusion: Surgery should not be denied on the basis of age alone. Medical evaluation should focus on identifying risk factors, assessing risk in detail, optimizing status, predicting complications, and making the appropriate surgical plan for the patient status. Moreover, in the present case, meticulous postoperative management was the main reason for the successful surgical treatment.
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Affiliation(s)
| | - Yu Watanabe
- Department of Orthopaedic Surgery, University of Tsukuba, Japan
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19
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Quatman CE, Villarreal ME, Cochran A. Incisional Negative Pressure Wound Therapy Following Surgical Repair of Lower Extremity Fractures. JAMA 2020; 323:513-514. [PMID: 32044926 DOI: 10.1001/jama.2019.22531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Carmen E Quatman
- Department of Orthopedic Surgery, Ohio State University, Columbus
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20
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Gustilo-Anderson type III tibial fractures have poor functional outcomes in patients over 75 years. J Clin Orthop Trauma 2020; 11:S71-S75. [PMID: 31992921 PMCID: PMC6978180 DOI: 10.1016/j.jcot.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/06/2019] [Accepted: 06/07/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Previous outcome studies in open tibial fractures have commonly assessed young patients and there is a paucity of data regarding outcomes in the elderly. The aim of this study is to assess functional outcomes for patients over 75 years with Gustilo-Anderson Grade III open tibial fractures, including mobility and residential status. METHODS Outcomes for all patients over 75 years admitted with grade III open tibial fractures to a UK level 1 trauma centre during a 5-year period (January 2010-May 2015) were analysed. Long-term follow up of surviving patients (median 44 months post injury) was undertaken in February 2016. RESULTS Twenty-nine patients (24 female, 5 male - median 85 years) were included. Prior to injury 48% (n = 14) patients were independently mobile and 45% (n = 13) were living at home without care. Two-thirds of injuries were low energy; all patients sustained a grade III open tibial fracture. The 12-month mortality rate was 28% (n = 8) and mortality at long-term follow-up 48% (n = 14). From pre-injury to long-term 8% (n = 1) patients did not change mobility status, 75% (n = 9) reduced by one grade (e.g. independent to walking aid) and 16% (n = 2) by two grades. Fifty eight percent (n = 7) of patients retained residential status, 17% (n = 2) reduced by one grade and 25% (n = 3) by two grades. CONCLUSION Grade III open tibial fractures are a significant injury in the elderly associated with poor outcomes with respect to return to mobility and pre-injury residential status. Our results suggest that a greater emphasis on intensive rehabilitation should be considered in this patient group.
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21
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Hoffmeyer P, Miozzari H, Holzer N. Non-hip/non-vertebral fractures - How to treat best? Best Pract Res Clin Rheumatol 2019; 33:236-263. [PMID: 31547981 DOI: 10.1016/j.berh.2019.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.
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Affiliation(s)
- Pierre Hoffmeyer
- Swiss Foundation for Innovation and Training in Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1205, Switzerland.
| | - Hermes Miozzari
- Department of Orthopaedics, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1205, Switzerland.
| | - Nicolas Holzer
- Department of Orthopaedics, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1205, Switzerland.
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22
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Abstract
INTRODUCTION It is accepted that the incidence of fractures in patients aged ≥ 65 years is increasing but little is known about which fractures are becoming more common in this group of patients. Virtually all research has concentrated on the classic fragility fractures of the proximal femur, proximal humerus, pelvis, spine and distal radius but it is likely that other fractures are becoming more common. METHODS We have examined two prospectively collected databases 10 years apart to see which fractures are becoming more common in ≥ 65 year old patients. We compared the fractures to look for epidemiological differences over the 10-year period and we compared the epidemiology of the fractures that had increased in incidence with equivalent fractures in the < 65 year old population. RESULTS Analysis shows that in older female patients fractures of the clavicle, finger phalanges, ankle and metatarsus are increasing in incidence. In males there is an increasing incidence of fractures of the proximal humerus, distal humerus, metacarpus, pelvis, femoral diaphysis, distal tibia and ankle. In females the basic epidemiology of fractures in the ≥ 65 year old population was very similar to the fractures seen in younger females and we believe that the increasing incidence of fractures in the future will mainly be low velocity fractures following falls. In older males however, it is apparent that there is a much wider variation in the causes of fracture. DISCUSSION We believe that the changes in fracture epidemiology in older patients relate to improved health and longevity and analysis of our population during the study period shows significant social changes which are associated with increased longevity and improved health. It is probable that fractures in older patients will continue to increase in incidence and that other fractures that are now commonly seen in middle-aged patients will be seen in older patients. Surgeons will have to treat more complex fractures in older males than in older females and it is likely that there will be a higher incidence of open and multiple fractures. Appropriate management techniques will need to be established.
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Noblet TM, Jackson PC, Foster P, Taylor DM, Harwood PJ, Wiper JD. Managing soft tissues in severe lower limb trauma in an ageing population. Injury 2018; 49:1197-1202. [PMID: 29588023 DOI: 10.1016/j.injury.2018.03.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 02/22/2018] [Accepted: 03/07/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE With an ageing population, the incidence of trauma in those aged over 65 years is increasing. Strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures in the UK is described by the BOAST4 guidelines (from the British Orthopaedic Association and British Association of Plastic & Aesthetic Surgeons). It is not clear to what extent these are appropriate for older patients. We describe our experience of managing elderly patients presenting with open tibial fractures. METHOD Patients were identified via prospectively collected national and departmental databases. These data were supplemented by review of the patient records and radiographs. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long-term outcomes. RESULTS Between January 2013 and June 2016, 74 patients aged over 65 years were admitted with open lower limb fractures. 54 of these were open tibial fractures and these patients formed the study group. 19 patients required soft-tissue reconstruction for Gustilo and Anderson IIIB tibial fractures (age range, 67-95 years). In these patients, there were 7 midshaft (AO 42), 1 proximal (AO 41), and 11 distal (AO 43) fractures. 13 patients were treated with internal fixation and 6 with circular frames. The median length of hospital stay was 27 days (range, 4-85). 14 patients received loco-regional flaps and 5 underwent free tissue transfer with one requiring preoperative femoral angioplasty. There were no flap losses. Four patients had fasciocutaneous flaps, 3 tibialis anterior transposition, 2 an extensor digitorum brevis flap, 1 a hemisoleus flap, and 4 were skin grafted. All patients went on to unite and return to their premorbid weight-bearing status (4 using walking frames, 3 using sticks, and 12 walking independently). CONCLUSION Although the literature suggests a significantly higher complication rate in elderly patients with open fractures, we have demonstrated comparable rates of flap survival and bony union to those observed in younger patients. Challenges are presented in terms of patient physiology and these must be carefully managed pre- and postoperatively. These challenges are reflected in prolonged hospital stays.
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Affiliation(s)
- Timothy M Noblet
- Limb Reconstruction Unit, Leeds General Infirmary, Leeds, West Yorkshire, United Kingdom.
| | - Philippa C Jackson
- Limb Reconstruction Unit, Leeds General Infirmary, Leeds, West Yorkshire, United Kingdom
| | - Patrick Foster
- Limb Reconstruction Unit, Leeds General Infirmary, Leeds, West Yorkshire, United Kingdom
| | - David Martin Taylor
- Limb Reconstruction Unit, Leeds General Infirmary, Leeds, West Yorkshire, United Kingdom
| | - Paul J Harwood
- Limb Reconstruction Unit, Leeds General Infirmary, Leeds, West Yorkshire, United Kingdom
| | - Jay D Wiper
- Limb Reconstruction Unit, Leeds General Infirmary, Leeds, West Yorkshire, United Kingdom
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24
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Winkler D, Goudie ST, Court-Brown CM. The changing epidemiology of open fractures in vehicle occupants, pedestrians, motorcyclists and cyclists. Injury 2018; 49:208-212. [PMID: 29153449 DOI: 10.1016/j.injury.2017.11.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIMS To investigate the changing epidemiology of open fractures in vehicle occupants, pedestrians, motorcyclists and cyclists. MATERIALS AND METHODS Data on all non-spinal open fractures admitted to the Royal Infirmary of Edinburgh after a road traffic accident between 1988 and 2010 were collected and analysed to provide information about the changing epidemiology in different patient groups. Demographic information was collected on all patients with the severity of injury being analysed with the Injury Severity Score (ISS), Musculoskeletal Index (MSI) and the number of open fractures. The severity of the open fractures was analysed using the Gustilo classification. The 23-year study period was divided into four shorter periods and the results were compared. RESULTS There were 696 patients treated in 23 years. Analysis showed that the incidence of RTA open fractures initially fell in both males and females and continued to fall in females during the 23 years. In males it levelled off about 2000. The age of the female patients also fell during the study period but it did not change in males. The only patient group to show an increased incidence of open fractures were cyclists. In vehicle occupants the incidence fell throughout the study period but it levelled off in pedestrians and motorcyclists. There was no difference in the severity of injury in any group during the study period. The most severe open fractures were those of the distal femur and femoral diaphysis although open tibial diaphyseal fractures were the most common fracture in all patient groups. CONCLUSIONS Improved car design and road safety legislation has resulted in a reduction in the incidence of open fractures in vehicle occupants, pedestrians and motorcyclists. The most obvious group to have benefitted from this are older female pedestrians. The only group to show an increase in age during the study period were male motorcyclists.
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Affiliation(s)
- Dennis Winkler
- University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stuart T Goudie
- Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
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25
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Batta V, Sinha S, Trompeter A. Temporary Fixation Using a Long Femoral-tibial Nail to Treat a Displaced Medial Tibial Plateau Fracture in a 90-year-old Patient: A Case Report. J Orthop Case Rep 2017; 7:36-38. [PMID: 29181350 PMCID: PMC5702701 DOI: 10.13107/jocr.2250-0685.840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Tibial plateau fractures are complex injuries in the elderly population. When traditional methods of fixation are not suitable, an alternative method needs to be chosen for a favorable outcome. We demonstrate a previously undescribed treatment for displaced tibial plateau fractures in the very elderly with poor soft-tissue integrity. Case Report A 90-year-old woman suffered an open, Gustilo Grade IIIA, displaced fracture of the tibial plateau. An intramedullary knee arthrodesis, the femoral-tibial nail was used to temporarily stabilize her fracture. She was able to weight bear immediately postfixation. Conclusion A long femoral-tibial nail allows favorable fracture and soft tissue healing, ease of nursing and immediate full weight-bearing. It shows good promise and should be considered as a management option when traditional methods are not applicable in select patients.
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Affiliation(s)
- V Batta
- Department of Trauma and Orthopaedic Surgery, Luton and Dunstable Hospital, Luton, LU4 0DZ, United Kingdom
| | - S Sinha
- Department of Trauma and Orthopaedics, St Richard's Hospital, Chichester, PO19 6SE, United Kingdom
| | - A Trompeter
- Department of Trauma and Orthopaedic Surgery, St George's Hospital, Tooting, London, SW17 0QT, United Kingdom
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Wood AM, Robertson GAJ, MacLeod K, Porter A, Court-Brown CM. Epidemiology of open fractures in sport: One centre’s 15-year retrospective study. World J Orthop 2017; 8:545-552. [PMID: 28808625 PMCID: PMC5534403 DOI: 10.5312/wjo.v8.i7.545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 03/19/2017] [Accepted: 04/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To describe the epidemiology of sport-related open fractures from one centre’s adult patient population over a 15-year period.
METHODS A retrospective review of a prospectively-collected database was performed: The database contained information all sport-related open fractures, sustained from 1995 to 2009 in the Edinburgh, Mid and East Lothian Populations.
RESULTS Over the 15-year period, there were 85 fractures recorded in 84 patients. The annual incidence of open sport-related fractures was 0.01 per 1000 population. The mean age at injury was 29.2 years (range 15-67). There were 70 (83%) males and 14 females (17%). The 6 most common sports were soccer (n = 19, 22%), rugby (n = 9, 11%), cycling (n = 8, 9%), hockey (n = 8, 9%); horse riding (n = 6, 7%) and skiing (n = 6, 7%). The five most common anatomical locations were finger phalanges (n = 30, 35%); tibial diaphysis (n = 19, 23%); forearm (n = 12, 14%); ankle (n = 7, 8%) and metacarpals (n = 5, 6%). The mean injury severity score was 7.02. According to the Gustilo-Anderson classification system, 45 (53%) fractures were grade 1; 28 (33%) fractures were grade 2; 8 (9%) fractures were grade 3a; and 4 (5%) fractures were grade 3b. Out of the total number of fractures, 7 (8%) required plastic surgical intervention as part of management. The types of flaps used were split skin graft (n = 4), fasciocutaneous flaps (n = 2); and adipofascial flap (n = 1).
CONCLUSION We analysed the epidemiology of open fractures secondary to sport in one centre over a 15-year period. Soccer and rugby were the most common causative sports while fractures of the finger phalanx and of the tibial diaphysis were the most common sites. Open fractures are uncommon in sport; however, when they are sustained they usually occur on muddy sport fields or forest tracks and therefore must be treated appropriately. It is important that clinicians and sports therapists have knowledge of these injuries, in order to ensure they are managed optimally.
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Abstract
The incidence and severity of ankle fractures in elderly patients is increasing steadily. These injuries are challenging to treat and prone to complications. Individual fracture treatment is tailored depending on bone quality, skin conditions, comorbidities, and functional demand of the patient. This article provides a review of current techniques to obtain stable fixation despite poor bone quality. To avoid complications, it is imperative to consider and treat comorbidities such as diabetes and osteoporosis. In the absence of severe systemic comorbidities, the results after open reduction and internal fixation of malleolar fractures in patients above and below 60 years of age are nearly identical, while nonoperative treatment of unstable fractures leads to significantly inferior outcomes. Therefore, the general indications for surgery in elderly patients should not differ from those in younger patients. However, it is essential to detect severe conditions such as Charcot neuro-osteoarthropathy because these require a completely different treatment regime, and standard internal fixation will invariably fail in these patients. Cite this article: Rammelt S. Management of ankle fractures in the elderly. EFORT Open Rev 2016;1:239-246. DOI: 10.1302/2058-5241.1.000023.
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Affiliation(s)
- Stefan Rammelt
- University Center of Orthopaedics & Traumatology, University Hospital Carl Gustav Carus, Dresden, Germany
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Abstract
Fractures in the elderly are increasing in incidence and becoming a major health issue in many countries. With an increasing number of the elderly living to an older age, the problems associated with fractures will continue to increase. We describe the epidemiology of fractures in the elderly and identify six fracture patterns in the population of patients who are sixty-five years of age or older. We also analyzed multiple fractures and open fractures in the elderly and we show that both increase in incidence with older age. The incidence of open fractures in elderly women is equivalent to that in young men. Many factors, including patient socioeconomic deprivation, increase the incidence of fractures in the elderly. More than 90% of fractures follow low-energy falls and the mortality is considerable. Mortality increases with older age and medical comorbidities, but there is also evidence that it relates to premature discharge from the hospital.
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Ovaska MT, Madanat R, Mäkinen TJ. Predictors of Postoperative Wound Necrosis Following Primary Wound Closure of Open Ankle Fractures. Foot Ankle Int 2016; 37:401-6. [PMID: 26830839 DOI: 10.1177/1071100715609182] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most open malleolar ankle fracture wounds can be closed primarily after meticulous debridement. However, the development of wound necrosis following operative treatment of open malleolar ankle fractures can have catastrophic consequences. The aim of this study was to identify risk factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. METHODS A total of 137 patients with open malleolar ankle fractures were identified. The open fracture wound was primarily closed in 110 of 137 (80%) patients, and postoperative wound necrosis occurred in 18 (16%) of these patients. These patients were compared to the open fracture patients without wound necrosis. Twenty possible risk factors for the development of wound necrosis were studied with logistic regression analysis. RESULTS The variables that were independently associated with an increased risk for postoperative wound necrosis included ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery. CONCLUSIONS Our study showed that ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery were the most important factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. The findings warrant a further study specifically comparing primary and delayed wound closure in patients with Gustilo grade III open malleolar ankle fractures and different ASA classes. Also, the role of pulsatile lavage should be re-evaluated. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Mikko T Ovaska
- Department of Orthopaedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Rami Madanat
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Tatu J Mäkinen
- Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
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Ovaska MT, Madanat R, Honkamaa M, Mäkinen TJ. Contemporary demographics and complications of patients treated for open ankle fractures. Injury 2015; 46:1650-5. [PMID: 25935358 DOI: 10.1016/j.injury.2015.04.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 04/10/2015] [Indexed: 02/02/2023]
Abstract
Open ankle fractures are rare injuries with a high likelihood of wound complications and subsequent infections. There is limited information about the complications and outcomes of these injuries in different age groups. The aim of this study was to assess the contemporary demographics and complications related to this injury. We performed a chart review of all the 3030 patients treated for ankle fractures at a Level 1 trauma centre from 2006 to 2011. 137 (4.5%) patients had an open ankle fracture. The demographic data, injury mechanism, comorbidities, and fracture type were collected. Treatment, complications, length of stay and number of outpatient visits were also recorded. The mean age of the patients was 60 years and 56% were women. Most fractures were Weber type B with a medial sided wound (93%). Only 20% of the fractures were the result of high-energy trauma, and 31% were Gustilo grade III injuries. Immediate internal fixation was performed in 82% of patients, and the wound was primarily closed in most cases (80%). The incidence of postoperative wound necrosis and deep infection was 18% and 17%, respectively. There were more deep infections if pulsatile lavage was used during the wound debridement (p=0.029). About 14 (10%) patients required a flap reconstruction to cover the soft-tissue defect. Every other patient (54%) had a complication, and 21 patients (15%) suffered a long-term disability related to the injury. The number complications did not differ for nighttime and daytime operations (p=0.083). High-energy injuries were more common in younger patients (p<0.001) and these patients also had more lateral sided open wounds than older patients (p=0.002). Interestingly, younger patients also had significantly more complications (p=0.024), suffered more often from chronic pain (p=0.003), and required more flap reconstructions (p=0.026), reoperations (p=0.026), and outpatient clinic visits (p=0.006). Open ankle fractures have a high complication rate and often require multiple surgical procedures. In young patients these injuries are more likely to be the consequence of high-energy trauma leading to more complications and subsequently increased healthcare resource utilisation.
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Affiliation(s)
- Mikko T Ovaska
- Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland.
| | - Rami Madanat
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Maija Honkamaa
- Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
| | - Tatu J Mäkinen
- Mount Sinai Hospital and University of Toronto Toronto, ON, Canada
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