Treatment of fragility ankle fractures using hindfoot nail, systemic review

The outcomes of the management of complex distal tibia and ankle fractures in elderly with tibiotalocalcaneal nail in a minimum 12-month follow-up period

PURPOSE

To evaluate the clinical outcomes of the use of tibiotalocalcaneal nail for the treatment of complex distal tibia and ankle fractures in elderly people, in a major trauma centre.

METHODS

Elderly patients (age > 65) with distal tibia or ankle fractures that underwent stabilization with a tibiotalocalcaneal nail were eligible to participate. Exclusion criteria were patients that died or were lost to follow-up and cases in which the nail was used in a chronic setting, such as malunion and non-union. Main parameters evaluated were fracture union, complications and functional outcomes. The functional outcome was assessed using the Olerud-Molander Ankle Score (OMAS). The minimum follow-up was 12 months.

RESULTS

Thirty-two consecutive patients (12 males) with a mean age of 80.2 years (range 66-98) met the inclusion criteria and formed the basis of this study. Fracture union was achieved in 93.8% of the cases at a mean time of 3.9 months (range 2-8). Two patients developed surgical site infections and underwent reoperation before union. The overall complication rate was 25.1%, while the respective reintervention rate was 18.8%. In terms of functional outcomes, the mean OMAS score was 45, ranging from 20 to 70.

CONCLUSION

Tibiotalocalcaneal nailing can be considered as an acceptable less invasive option with good functional outcomes for the treatment of complex distal tibia and ankle fractures in frail patients with problematic local soft tissues.

Epidemiology & management of complex ankle fractures in the United Kingdom: A multicentre cohort study

BACKGROUND

Patient factors are known to contribute to decision making and treatment of ankle fractures. The presence of poor baseline mobility, diabetes, neuropathy, alcoholism, cognitive impairment, inflammatory arthritis or polytrauma can result in a higher risk of failure or complications. Limited evidence is available on the optimum management for this challenging cohort of patients herein described as complex ankle fractures. This UK multicentre study assessed and evaluated the epidemiology of ankle fractures complicated by significant comorbidity and patient factors and use of specialist surgical techniques such as hindfoot nails (HFN) / tibiotalarcalcaneal (TCC) nails and enhanced open reduction and internal fixation (ORIF).

PATIENTS AND METHODS

A UK-wide collaborative study was performed of adult distal AO43/AO44 fractures, associated with 1 or more of the patient factors listed above. Primary outcomes included patient demographics, comorbidities, surgical technique and implants. Secondary outcomes included surgical complications and early post-operative weight bearing instructions. Statistical analysis was performed to assess patient and fracture characteristics on outcome, including propensity matching.

RESULTS

One-thousand three hundred and sixty patients, with at least one of the above complex factors, from 56 centres were included with a mean age of 53.1 years. 90.2% (1227) patients underwent primary fixation which included 78.9% (1073) standard open reduction internal fixations (ORIF), 3.25% (43) extended ORIF and 8.1% (111) primary HFN / TCC. Overall wound complications and thromboembolic events were similar in the hindfoot nail group and the ORIF group (11.7% vs 10.7%). Wound complications were greater in diabetic patients versus non-diabetic patients independent of fixation method (15.8% vs 9.0%). After propensity matching for comorbidities and fracture type, overall complications were lower in the hindfoot nail (11.8%) and extended ORIF groups (16.7%), than the standard ORIF group (18.6%).

CONCLUSION

Only a minority of complex ankle fractures are treated with specialised techniques (HFN/TCC or extended ORIF). Though more commonly used in older and frail patients their perceived advantages are often negated by a reluctance to bear weight early. These techniques demonstrated a better complication profile to standard ORIF but hindfoot nail with joint preparation for fusion was associated with more complications than hindfoot nail for fixation.

LEVEL OF EVIDENCE

III.

Tibiotalar nailing using an antegrade intramedullary tibial nail: a salvage procedure for unstable distal tibia and ankle fractures in the frail elderly patient

AIM

This article describes the technique of tibiotalar nailing performed using an antegrade tibial nail for salvage of distal tibia and ankle fractures in elderly patients.

MATERIALS AND METHODS

We report indications, surgical technique, and the clinical outcomes and complication rate in our series to date. A retrospective review was performed at our level 1 major trauma centre. Patient demographics, comorbidities, and 12-month post-operative course were collected. Fractures were classified using the OTA/AO and modified Gustilo-Anderson classification. Fifteen patients underwent the procedure. We present data with a minimum 12-month follow-up. The median age of the patients in this cohort was 83 years (range, 51-102). Five patients were diabetic. Six patients (6/15; 40%) presented with an open fracture.

RESULTS

At final follow-up, fourteen patients reported painless walking and had returned to baseline activity.

CONCLUSION

This technique may serve as a salvage procedure, with indications similar to those for tibio-talar-calcaneal arthrodesis. Indications would include non-constructible pilon fractures, comminuted intra-articular fractures in low-demand patients, or patients at high risk of wound complications.

LEVEL OF CLINICAL EVIDENCE

3.

Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures

PURPOSE OF REVIEW

The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities.

RECENT FINDINGS

There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.

Use of a Hindfoot Nail Without Separate Subtalar and Tibiotalar Joint Preparation to Treat Geriatric Ankle and Distal Tibia Fractures: A Case Series

Introduction

Ankle fractures in geriatric patients can be devastating injuries, as they limit an individual's mobility, autonomy, and quality of life. This study examines the functional outcomes and complications related to hindfoot nails (HFN) in geriatric patients who have suffered an ankle malleolar or distal tibia fracture.

Materials and Methods

This is a single-surgeon case-series of patients who underwent HFN for acute fixation or delayed reconstruction after an ankle or distal tibia fracture. Demographic information, comorbidities, baseline functional status, AO/OTA classification, surgical indications, need for external fixation, total operative time, length of stay (LOS), ambulation at discharge, and discharge disposition were recorded. Primary outcomes included 30-day complications, ambulation at follow-up, and time to fracture union and fusion.

Results

There were 22 patients, with average age 80.8 years. Mean LOS was 7.0 days, and 68.2% were discharged to subacute rehabilitation. Within 30 days, 1 patient developed a deep vein thrombosis and bilateral pulmonary emboli, and 2 experienced wound dehiscence requiring antibiotics. At 6-weeks, 1 patient sustained a fall with periprosthetic fracture requiring HFN revision, and another developed cellulitis necessitating hardware removal. Fracture healing was seen in 72.7% at 19.4 weeks, while radiographic fusion occurred in 18.2% at 43.0 weeks. 72.7% were ambulating with an assistive device at discharge, and 100.0% at 12-weeks post-operatively or last follow-up. Upon final examination, all patients were ambulating without pain.

Discussion

HFNs provide a reliable alternative to traditional open reduction internal fixation and have the ability to improve quality of life for geriatric patients through a faster return to weight-bearing. Additionally, radiographic fusion rates show that patients have favorable functional outcomes even without formal arthrodesis.

Conclusion

HFN is beneficial for elderly patients with low functional demand and complex medical comorbidities, as it allows for early mobility after sustaining an ankle or distal tibia fracture.

Hindfoot nailing for displaced ankle fractures in the elderly: A case-control analysis

INTRODUCTION

Management of fragility ankle fractures in the elderly poses a surgical dilemma. An alternative to open reduction and internal fixation (ORIF) with screw and plate construct in selected elderly patients who may be significantly frail and comorbid is a tibio-talo-calcaneal (TTC) or hindfoot nail. Hindfoot nailing potentially reduces the risk of wound infection and increases likelihood of earlier return to function by allowing earlier weightbearing. The aim of this study was to examine the outcomes and complications of patients who received a hindfoot nail compared to patients who underwent an ORIF.

METHODS

A retrospective review identified patients who underwent hindfoot nailing from Jan 2010 to Dec 2021. Patients aged >65-years who underwent ORIF in the same time period were concurrently identified. The patients in the ORIF group were matched with patients in the hindfoot nail group by age, gender, comorbidity according to their Charlson Comorbidity Index (CCI) and their pre-injury function by Karnofsky Performance Scale (KPS). Clinical Frailty Scale (CFS) was also collected as part of patient demographics. Outcomes examined include mortality, length of stay, operation time, return to previous mobility, wound complications, metalware failure and infections.

RESULTS

Twenty-six patients were identified in the hindfoot nail group and matched to 26 patients who underwent ORIF. Mean age was 84 and 83 years in the nail and ORIF group respectively. Overall, there were 12 and 11 complications from the hindfoot nail and ORIF group respectively with seven and two requiring return to theatre in the nail group and ORIF group (P = 0.07). The hindfoot nail group waited an average of 22 days after the operation for weightbearing compared to 59 days in the ORIF group (P < 0.001). There were no significant differences in length of stay (P = 0.58) and operation time (P = 0.19).

CONCLUSION

Hindfoot nailing was associated with an increased risk of complications and higher risk of return to the operating theatre. Despite the potential attraction of earlier weightbearing, surgeons and patients need to be aware of these potential pitfalls.

Ankle fractures of the geriatric patient: a narrative review

The present narrative review provides a summary of current concepts for the treatment of ankle fractures in elderly patients. Despite a high complication rate, open reduction and internal fixation is the gold standard for operative care. However, individual patient-based treatment decision considering the soft-tissue status, the fracture pattern, as well as the patient's mobility and comorbidities is mandatory to achieve sufficient patient outcomes. Due to high complication rates after surgery in the past, techniques such as fibular nails or minimal invasive techniques should be considered.

Open ankle fractures: Factors influencing unplanned reoperation

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.

Treatment of bimalleolar fractures in elderly

Geriatrics continues to evolve as a specialty by adapting itself to increasingly older patients. Musculoskeletal injuries are common in these patients, who can maintain their physical capacities and autonomy for a long time, but whose bone solidness is frequently reduced by osteoporosis. Falls increase with age and because of certain medical conditions. Trauma in the geriatric population involves specific risks; thus, the treatment must be adapted not only to the fracture, but to the local conditions and the patient. Ankle injuries are particularly frequent in general traumatology but even more in geriatric traumatology. They can lead to complete loss of autonomy if the treatment is delayed and/or not adapted to the local conditions or the patient. The functional prognosis is brought into play, along with the patient's life due to loss of autonomy and general complications occurring in patients who are bed-ridden. The treatment of bimalleolar ankle fractures in older adults requires rigorous analysis at all points, which starts by evaluating the cutaneous status and viability of the soft tissues upon admission. The benefit-risk balance of the various treatment options will be assessed with the main goal being that patients recover their autonomy. This article will review this topic by answering 7 questions: 1) What are the distinctive features of elderly? Dependence on others, comorbidities, bone and soft tissue fragility are the main ones, explaining these high-risk situations and frequent complications. 2) When should a bimalleolar ankle fracture be treated surgically? The surgery must be done early, preferably within 8hours of the injury occurring, once the comorbidities have been controlled. The local conditions (skin and soft tissue damage) must be evaluated carefully as they determine the treatment. Errors are not allowed in these patients, who are often fragile and in precarious health. Definitive fixation is preferred if the skin status allows it, but one must keep temporary external fixation in mind as an option. 3) Is there still a role for conservative treatment of displaced fractures? This will produce good results when it is well done; however, the indications are rare and must be selected carefully. The main risks are secondary displacement and skin lesions inside the cast, which are sources of infection. 4) Is fixation with anatomical locking plates an advance? This is definitely an advance for these fragility fractures, which are often comminuted, as it allows return to weight bearing in certain conditions. However, the implantation rules must be followed exactly, and it is preferable to use thinner plates. 5) Does transplantar Steinmann pin fixation still have a role? It has few indications, limited to salvage situations (catastrophic local conditions, very poor general condition). External tibiocalcaneal fixation, alone or in combination, is a better option. 6) Is immediate transarticular fixation with a retrograde or antegrade locked nail a reasonable option? Fixation can be done by retrograde nailing or antegrade nailing. It is proposed to patients who are not very autonomous with a poor cutaneous status and/or severe osteoporosis. It is preferable to transplantar nailing. 7) Is immediate protected weight bearing, with or without fixation, possible? This can be considered on a case-by-case basis depending on the extent of the trauma, patient compliance and treatment carried out. LEVEL OF EVIDENCE: V, Expert opinion.