Ankle injuries and fractures in the obese patient

Weight-bearing timing after the operative management of ankle fractures: Single center audit and critical appraisal of literature

The postoperative weight-bearing policy following internal fixation of unstable ankle fractures varies greatly and is largely surgeon-dependent. While early weight-bearing is favoured for its superior functional and economic outcomes, late weight-bearing may be safer initially. However, consensus on the preferred treatment protocol is lacking. We audited practices at University Hospitals Leuven, Belgium, comparing them to existing literature to establish an updated protocol. In a retrospective study of 236 patients with unstable ankle fractures, we compared outcomes between early (EWB) and late weight-bearing (LWB) strategies, with or without braces and/or vacuum casts. Most patients followed a LWB protocol, while EWB was reserved for younger, lower BMI individuals. The difference in brace or vacuum cast usage was insignificant. All open fractures followed a LWB protocol. No disparities in union rates, complications, or length of stay were found between EWB and LWB. Surgical management cost €6,419 (6,921 US $) on average, with length of stay being the main cost driver. Total healthcare costs did not differ significantly between EWB and LWB. FRI was revealed in 6 cases, (1 [4%] vs. 5 [2.5%], EWB vs. LWB respectively, P=0.922) In conclusion, while no significant differences in outcomes were observed between EWB and LWB rehabilitation, differences in group characteristics may have influenced these findings. Despite limited EWB cases, it appears safe for younger patients with low BMI. Vacuum casts and braces aid in EWB. Reducing length of stay, rather than restricting orthotic use, may help control healthcare costs.

Radiographic outcomes of flexible and rigid fixation techniques of syndesmotic injuries across various body mass indices: A retrospective analysis

In the setting of ankle trauma, surgical management of syndesmosis injury involves screw fixation and suture button technique. The efficacy of flexible (suture button) versus rigid (screw) fixation in the management of syndesmotic injury has been investigated extensively in current literature. There is sparse data comparing these two techniques across different body mass indices (BMI). In this study, two fellowship-trained foot and ankle surgeons at urban level-1 trauma centers reviewed blinded post-operative ankle radiographs of BMI-stratified patients undergoing syndesmotic fixation. A total of 79 patients were included for analysis based on inclusion and exclusion criteria. There were 42 patients in the screw fixation group and 37 patients in the suture button group. The average follow-up period was 5.5 months. No significant difference was found in the average radiographic measurements when comparing the two fixation types, regardless of BMI parameters. This was consistent when analyzing individual fixation types stratified by BMI, as well as when comparing BMI groups stratified by fixation type. Additionally, the distribution of body mass index was even across both fixation types. Our study demonstrates that both fixation groups achieved comparable anatomic ankle reduction regardless of body mass index. The authors suggest expanding the indication of suture button fixation to include the higher body mass index patients.

Predisposing factors for chronic syndesmotic instability following syndesmotic fixation in ankle fracture: Minimum 5-year follow-up outcomes

BACKGROUND

This study aimed to identify risk factors for chronic syndesmotic instability following syndesmotic fixation.

METHODS

We performed a retrospective review of consecutive patients who had sustained ankle fractures requiring syndesmotic fixation. Patients available for a minimum 5 years of follow-up were classified into 2 groups according to the presence of syndesmotic instability. Statistical binary logistic regression analyses were performed to investigate the significance of various risk factors. Functional outcomes were assessed using the FAOS.

RESULTS

In total, 166 patients who met the study inclusion criteria underwent analysis. The overall postoperative instability rate was 20.5%, which was significantly affected due to BMI (p = 0.018; OR 6.72), and concomitant posterior malleolar fracture (p = 0.032, OR 2.77). The mean scores in the syndesmotic instability (SI) group were significantly lower than those in the no syndesmotic instability (NSI) group (p = 0.021).

CONCLUSIONS

Obesity and concomitant posterior malleolar fracture were significant risk factors for postoperative syndesmotic instability.

Distribution of Plantar Pressure in Soccer Players

(1) Background: The aim of this study was to evaluate differences in the static and dynamic distribution of foot pressure on the ground and to investigate the relationships between body mass index (BMI) and mean variables of plantar pressure between soccer players and their non-athlete peers. (2) Methods: The study involved 18 first-division Polish soccer players and 30 non-athlete physiotherapy students. The research experiment was conducted using the FreeMed platform. Basic descriptive statistics were calculated to summarize the variables. Additionally, in the static and dynamic tests, Spearman’s rank correlations between body mass index (BMI) and plantar load were calculated. (3) Results: Statistically significant differences between groups were observed in the loading of the dominant limb. A statistically significant correlation between BMI and loading of both limbs was found in the static test and between BMI and loading of the dominant limb in the dynamic test. (4) Conclusions: The baropodometric mat used in our study helped determine the plantar pressure distribution of soccer players and their non-athlete peers. Correlation analysis revealed that BMI was only associated with the mean plantar pressure of the dominant limb in the control group. Further research on a larger group of athletes is needed to determine how much sporting activity may affect the development to modifications within feet in soccer players.

Obesity and risk for open reduction and internal fixation of syndesmotic injuries in the setting of concomitant ankle fractures

Introduction

The association between obesity and the need for open reduction and surgical fixation of the syndesmosis in the setting of malleolar ankle fractures remains to be elucidated. Therefore, the primary objective of this study was to assess the relationship between obesity, ankle fracture complexity, and the need for open reduction and fixation of the syndesmosis.

Methods

A retrospective analysis of the NSQIP database was performed for patients undergoing surgical fixation of isolated, closed ankle fractures. Patients were grouped by fracture pattern into 6 cohorts (uni-, bi- and trimalleolar ankle fractures with or without syndesmotic injury). Demographic data was collected and compared between groups and logistic regression analyses were used to assess the relationship between body mass index (BMI) and ankle fracture pattern.

Results

A total of 15,841 patients (mean age 48.9 years) were identified for inclusion. Regression analyses revealed that BMI had a significant association with the incidence of open reduction and internal fixation of the ankle syndesmosis, but there was no association between BMI and malleolar fracture pattern.

Conclusions

This study demonstrates that elevated BMI is associated with an increased risk for open reduction and internal fixation of the syndesmosis in malleolar ankle fractures. However, obesity was not associated with ankle fracture pattern itself, whereas older age, female sex, and white race were more significant predictors of fracture complexity. This data provides a framework for further evaluation of the effect that both modifiable and non-modifiable risk factors have on fracture complexity and operative management of patients with such injuries.

Level of evidence

Case-control study. Level III.

Open pronation abduction ankle fractures associated with increased complications and patient BMI

INTRODUCTION

Pronation abduction (PA) ankle fractures are often associated with a medial tension failure wound. Though this injury pattern was defined based on the mechanism of injury, there is a paucity of literature evaluating risk factors for understanding which patients will sustain an open PA fracture. Furthermore, how patients with these types of fractures perform relative to other open ankle fractures has not been established. We hypothesized that open PA fractures are associated with obesity and increased number of reoperations.

METHODS

All patients at a single level one trauma center who received operative treatment for an ankle fracture between February 2012 to January 2019 were retrospectively identified using Current Procedural Terminology (CPT) codes. Patients with open PA ankle fractures were identified. Demographic data, body mass index, medical comorbidities, time to surgery, and reoperations were compared between open PA ankle fractures and other open ankle fracture subtypes.

RESULTS

There were 22 open PA ankle fractures and 35 other open ankle fracture subtypes. The open PA fracture group had a significantly higher median and average BMI and percentage of patients with obesity. There was no difference in number of patients requiring reoperation between the two groups. When reoperation was required, patients with open PA ankle fractures were found to undergo significantly more reoperations and were significantly more likely to require arthrodesis or below knee amputation.

CONCLUSIONS

Open PA ankle fractures are more often associated with obesity (BMI > 30 kg/m²) than are other open ankle fractures caused by a different mechanism. When reoperation does occur, patients with open PA ankle fractures require more reoperations and are more likely to require arthrodesis or below knee amputation that patients with other open ankle fracture subtypes. Early identification of those patients or injuries at increased risk of complications can help ensure optimal outcomes.

Single- vs 2-Screw Lag Fixation of the Medial Malleolus in Unstable Ankle Fractures

BACKGROUND

The purpose of this study was to determine the efficacy of medial malleolar fixation with 1 vs 2 screws.

METHODS

Between April 2013 and February 2017, 196 patients who presented at 2 hospitals within one academic institution with an unstable rotational ankle fracture with a medial fracture and were treated operatively by a trained orthopedic surgeon were identified. These patients' charts were reviewed and their injury, radiographic, surgical, and follow-up data recorded. Medial malleolus fragment size was assessed on the anteroposterior (AP) and lateral views of the initial injury radiograph. Functional outcome was assessed using Maryland Foot Score (MFS). Patients were grouped based upon the number of screws utilized to fox the medial malleolar fragment. Data were assessed using Fisher exact tests and independent t tests with SPSS, version 23.

RESULTS

Out of the 196 patients who met inclusion criteria, 47 patients (24%) were fixed with 1 medial malleolar screw and 149 patients (76%) were fixed with 2 screws. There were no differences among patients who received 1 vs 2 screws with regard to age, gender, body mass index, American Society of Anesthesiologists grade, or smoking status. The average malleolar fragment size was smaller in those treated with 1 screw on both the AP and lateral radiographic views than those with 2 screws (P = .009, P = .001, respectively). There was no difference between groups in ankle dorsiflexion or plantarflexion at 1 year postoperation (P = .451, P = .581). Patients who received 1 screw did not differ from those who received 2 screws with respect to Maryland Foot Scores (P = .924). There was no difference in rate of revision surgery or need for hardware removal between groups (P = .093). Furthermore, time to healing and postoperative complication rate did not differ between groups.

CONCLUSION

The use of a single screw for medial malleolar fixation provided stable fixation to allow ankle fracture healing, without an increase in complications. This information is especially important in situations when the fragment is too small to accommodate multiple fixation points.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Investigation of the Association Between the Acute Ankle Injury Caused by Fall From Own Height and Body Mass Index

In the emergency settings, increased body mass index (BMI) is a risk factor for traumatic orthopedic injuries. The aim of this study was to assess the association between the acute ankle injuries (sprain or fracture) and BMI. This prospective cohort study included patients ≥18 years of age with acute traumatic ankle injuries (either sprain or fracture) caused by fall from own height when walking at ground level and who received primary treatment at the emergency room of a university hospital between May and October 2017. Of the 107 patients who met the inclusion criteria, 58 (54%) patients experienced acute ankle sprains and 49 (46%) experienced acute ankle fractures. No significant association was detected between fracture severity (as assessed by the Danis-Weber classification) and BMI (p = .860). The most frequent ankle injury in patients with normal BMI was ankle sprain. In our cohort, obesity was not the primary determinant of the severity of ankle injury. However, age was a key determinant of the type of injury; patients >30 years of age were 20% more likely to suffer an ankle fracture.

Effect of Obesity on Total Ankle Arthroplasty: A Systematic Review of Postoperative Complications Requiring Surgical Revision

Total ankle arthroplasty has become an increasingly used alternative to ankle arthrodesis for the treatment of end-stage ankle arthritis. However, despite progressive technological advances and the advent of multiple commercial implant systems, some concern remains for the relatively high complication and failure rates. The objective of the present investigation was to perform a systematic review of the incidence of complications in obese patients undergoing total ankle arthroplasty. We performed a review of electronic databases with the inclusion criteria of retrospective case series, retrospective clinical cohort analyses, and prospective clinical trials with ≥15 total participants, a mean follow-up period of ≥12 months, ≥1 defined cohort with a body mass index of ≥30 kg/m², and a reported incidence rate of complications requiring revisional surgery at the final follow-up point. Four studies met our inclusion criteria, with a total of 400 implants analyzed. Of these, ≥71 (17.8%) developed a complication requiring a revisional surgical procedure. The most commonly reported surgeries were revision of the metallic components and ankle gutter debridement. It is our hope that our investigation will allow foot and ankle surgeons to more effectively communicate the perioperative risk to their patients during the education and consent process.

The association of body mass index with complications and functional outcomes after surgery for closed ankle fractures

AIMS

This study assessed the association of classes of body mass index in kg/m² (classified as normal weight 18.5 kg/m² to 24.9 kg/m², overweight 25.0 kg/m² to 29.9 kg/m², and obese ≥ 30.0 kg/m²) with short-term complications and functional outcomes three to six years post-operatively for closed ankle fractures.

PATIENTS AND METHODS

We performed a historical cohort study with chart review of 1011 patients who were treated for ankle fractures by open reduction and internal fixation in two hospitals, with a follow-up postal survey of 959 of the patients using three functional outcome scores.

RESULTS

Obese patients had more severe overall complications and higher odds of any complication than the normal weight group, with adjusted odds ratio 1.67 (95% confidence interval (CI) 1.08 to 2.59; p = 0.021) and 1.71 (95% CI 1.10 to 2.65; p = 0.016), respectively. In total 479 patients (54.6%) responded to the questionnaire. Obese patients had worse scores on the Olerud and Molander Ankle Score (p < 0.001), Self-Reported Foot and Ankle Questionnaire (p = 0.003) and Lower Extremity Functional Scale (p = 0.01) than those with normal weight. In contrast, overweight patients did not have worse functional scores than those with normal weight.

CONCLUSION

Obese patients had more complications, more severe complications, and worse functional outcomes three to six years after ankle surgery compared with those with normal weight. Cite this article: Bone Joint J 2017;99-B:1389-98.

Obese Patients Have Fewer Wound Complications Following Fixation of Ankle Fractures

Outcomes following ankle fracture surgery have been well studied; however, factors associated with surgical wound healing specifically are less clear. We aimed to study the relationship between wound healing and body mass index, as well as other variables following surgical treatment of ankle fractures. There were 127 consecutive, isolated, closed, malleolar ankle fractures treated with open reduction and internal fixation at a level-1 trauma center from 2008 to 2012. Patient, injury, and treatment variables were recorded and clinical records were reviewed to identify wound complications. There were 6 major and 18 minor wound complications. The overall rate of wound complication of any type was significantly lower in obese patients at 11.7% (7/60) compared with 25.4% (17/67, P < .05) in nonobese patients. When controlling for other variables obesity was associated with a significantly lower risk of developing a wound complication (OR 0.267, 95% CI 0.087-0.822), as was low energy mechanism (OR 0.246, 95% CI 0.067-0.906). No other covariates tested were associated with an increased risk of a wound infection. Ankle anatomy may present a unique situation whereby obesity may be protective against wound complications. Further studies are needed to confirm this clinical observation, and to demonstrate the mechanism through which this may occur.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Retrospective.

Are Routine Radiographs Needed the Day After Open Reduction and Internal Fixation Surgery for Distal Radius and Ankle Fractures: Study Protocol for a Prospective, Open Label, Randomized Controlled Trial

Background

Distal radius and ankle fractures are one of the most common operatively treated fractures. To date, there is no consensus concerning the need for a standard postoperative radiograph. This leads to undesirable practice variations. A standardized radiograph in the department of radiology would theoretically be more reproducible and operator independent than an intraoperatively obtained fluoroscopic image. However, if adequate intraoperative radiographs have been obtained, it is questionable if these postoperative radiographs are necessary and will lead to changes in the treatment strategy. If standard postoperative radiographs are no longer required, this would lead to a reduction in radiation exposure and health care costs. The hypothesis is that routine standardized postoperative radiographs do not influence the quality of care for patients operated on for either a distal radius or an ankle fracture if adequate intraoperative standardized radiographs have been obtained.

Objective

The primary aim of this study is to evaluate if there is a need for routine postoperative radiographs after an osteosynthesis of a distal radius or ankle fracture.

Methods

In a prospective, randomized controlled, open label trial based on a noninferiority design, we will enroll 332 patients. Patients will be randomized either in the control or the intervention group. The control group will be treated according to our current, standard protocol in which all patients receive a standard anterior-posterior and lateral radiograph on the first postoperative day. Patients randomized to the intervention group will be treated without a standard postoperative radiograph. All patients (N=332) will have a routine clinical and radiographic control after 6 weeks in the outpatient clinic. Primary outcome is a change in treatment plan, defined as either additional imaging or a reoperation based on the postoperative imaging. Secondary outcome measures include a 36-Item Short Form Survey, Patient-Rated Wrist Hand Evaluation, Foot and Ankle Outcome Score, Visual Analogue Scale, and the range of motion. Those questionnaires will be filled out at the 6-week outpatient control.

Results

The trial was started in August 2016, and 104 patients have been enrolled up to this point.

Conclusions

Our findings will be reported in peer-reviewed publications and may lead to a strong reduction in radiation exposure and health care costs. A preliminary, conservative estimation suggests a yearly cost saving of CHF 1.3 million in Switzerland.

Predictors of Time to Union After Operative Fixation of Closed Ankle Fractures

BACKGROUND

Ankle fractures are common and represent a significant burden to society. We aim to report the rate of union as determined by clinical and radiographic data, and to identify factors that predict time to union.

METHODS

A cohort of 112 consecutive patients with isolated, closed, operative malleolar ankle fractures treated with open reduction and internal fixation was retrospectively reviewed for time to clinical union. Clinical union was defined based on radiographic and clinical parameters, and delayed union was defined by time to union >12 weeks. Injury characteristics, patient factors and treatment variables were recorded, and statistical techniques employed included the Chi-square test, the Student's T-test, and multivariate linear regression modeling.

RESULTS

Forty-two (37.5%) of patients who achieved union did so in less than 12 weeks, and 69 (61.6%) of these patients demonstrated delayed union at a mean of 16.7 weeks (range, 12.1-26.7 weeks), and the remaining patient required revision surgery. Factors associated with higher rates of delayed union or increased time to union included tobacco use, bimalleolar fixation, and high energy mechanism (all p<0.05). In regression analysis, statistically significant negative predictors of time to union were BMI, dislocation of the tibiotalar joint, external fixation for initial stabilization and delay of definitive management (all p<0.05).

CONCLUSION

Patient characteristics, injury factors and treatment variables are predictive of time to union following open reduction and internal fixation of closed ankle fractures. These findings should assist with patient counseling, and help guide the provider when considering adjunctive therapies that promote bone healing.

LEVELS OF EVIDENCE

Prognostic, Level IV: Case series.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

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

Aims

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

Patients and Methods

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

Results

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

Conclusion

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

Association of Body Mass Index With the Pattern of Surgically Treated Ankle Fractures Using Two Different Classification Systems

The present retrospective cohort study assessed the association of body mass index (BMI) with the pattern of ankle fractures using 2 classifications systems. Of the 1011 consecutive patients who underwent surgery for ankle fractures in 2 hospitals from January 2009 to December 2011, 837 had a classifiable fracture according to 1 of 2 classification systems and complete information available for covariates. The association of BMI, adjusted for age, sex, corticosteroid use, diabetes, and smoking status with having a more proximal fibula fracture (Weber class A to C) and an increasing number of malleoli involved (uni-, bi-, or trimalleolar) was assessed using multivariable ordered logistic regression analysis. The mean age of the patients was 50.9 ± 16.9 years, and 461 (55%) were female. On multivariable analysis, BMI and male sex were associated with having a more proximal fibula fracture using the Weber classification, with an odds ratio (OR) of 1.07 (95% confidence interval [CI] 1.04 to 1.11; p < .001) per 1 kg/m² increase and OR of 2.96 (95% CI 2.13 to 4.11; p < .001) compared with female sex, respectively. Age was not associated with this fracture classification. In an analysis of uni-, bi-, and trimalleolar fractures, age per 10 years showed higher odds (OR 1.24, 95% CI 1.14 to 1.36; p < .001) and male sex lower odds compared with female sex (OR 0.36, 95% CI 0.27 to 0.48; p < .001) of having trimalleolar fractures than uni- or bimalleolar fractures. An increasing BMI did not seem to be a risk factor, although an inverse U-shaped relationship was seen between quintiles of BMI and the OR of having trimalleolar versus uni- or bimalleolar fractures. Corticosteroid use, diabetes, and smoking status were not significantly associated with the pattern of the ankle fractures using either classification system. In conclusion, an increasing BMI and male sex were risk factors for proximal fibula fractures, and female sex and age were risk factors for bi- and trimalleolar fractures.

Achilles Tendon Repair in Obese Patients Is Associated With Increased Complication Rates

Objective The objective of the present study is to utilize a national database to examine the association between obesity and postoperative complications after primary Achilles tendon repair. Methods The PearlDiver database was queried for patients undergoing primary Achilles repair using CPT 27650. Excision of a Haglund's deformity or tendon transfer were exclusion criteria. Patients were then divided into obese (body mass index [BMI] > 30 kg/m(2)) and nonobese (BMI < 30 kg/m(2)) cohorts using ICD-9 codes. Complications within 90 days postoperatively were assessed using ICD-9 and CPT codes. Results In all, 18 948 patients who underwent primary Achilles tendon repair were identified from 2005 to 2012. Overall, 2962 patients (15.6%) were coded as obese or morbidly obese. Obese patients had significantly higher rates of postoperative wound complications (odds ratio [OR] = 2.1; P < .0001), infection (OR = 1.8; P < .0001), venous thromboembolism (VTE; OR = 1.8; P = .001), and medical complications (OR = 3.9; P < .0001) compared with nonobese patients after primary Achilles tendon repair. Additionally, obese patients had a significantly lower rate of ankle stiffnesassociated with a significantly higher risk of s (OR = 0.4; P < .0001) compared with nonobese patients. Conclusion Obesity is associated with a significantly higher risk of wound complications, infection, VTE, and medical complications after primary Achilles tendon repair.

LEVELS OF EVIDENCE

Prognostic, Level II: Retrospective study.

Predictors of Adverse Events for Ankle Fractures: An Analysis of 6800 Patients

Ankle fractures are one of the most common injuries seen by orthopedic surgeons. It is therefore essential to understand the risks associated with their treatment. Using the American College of Surgeons National Surgical Quality Improvement Program(®) database from 2006 to 2013, the patient demographics, comorbidities, and 30-day complications were collected for 5 types of ankle fractures. A bivariate analysis was used to compare the patient demographics, comorbidities, and complications across all Common Procedural Terminology codes. A multivariable logistic regression model was then used to assess the odds of minor and major postoperative complications within 30 days after open treatment. A total of 6865 patients were included in the analysis. Of these patients, 2507 (36.5%) had bimalleolar ankle fractures. The overall rate of adverse events for ankle fractures was low. Bimalleolar fractures had the greatest rate of major (2.6%, n = 64), minor (3.8%, n = 94), and total (5.7%, n = 143) complications. When controlling for individual patient characteristics, bimalleolar fractures were associated with 4.92 times the odds (95% confidence interval 1.80 to 13.5; p = .002) of developing a complication compared with those with a medial malleolar fracture. The risk factors driving postoperative complications for all ankle fractures were age >65 years, obesity, diabetes, American Society of Anesthesiologists score >2, and functional status (p < .05). Although the overall rate of adverse events for ankle fractures was low, bimalleolar fractures were associated with 5 times the odds of developing a complication compared with medial malleolar fractures. Orthopedic surgeons must be aware of the risk factors that increase the rate of ankle fracture complications to improve patients' quality of care.

Treatment of Nonunions After Malleolar Fractures

Ankle fracture nonunion is a rare occurrence following closed or operative intervention. When it does occur, patients can experience debilitating symptoms that limit daily function. Malleolar nonunion can be caused by patient factors, such as smoking, malnutrition, or vascular insufficiency. Surgeon factors, such as insufficient or inappropriate operative fixation, also play a role. Several adjuncts, such as bone grafting, bone morphogenic protein, and bone stimulation, are useful in treating nonunions. Through a multimodal approach, malleolar nonunions are reliably treated with operative fixation leading to good patient outcomes with minimal complications.

Risk Factors for Open Malleolar Fractures: An Analysis of the National Trauma Data Bank (2007 to 2011)

A limited number of studies have described the epidemiology of open fractures, and the epidemiology of open ankle fractures is not an exception. Therefore, the risk factors associated with open ankle fractures have not been extensively evaluated. The frequencies and proportions of open ankle fractures among all the recorded malleolar fractures in the US National Trauma Data Bank data set from January 2007 to December 2011 were analyzed. Clinically relevant variables captured in the data set were also used to evaluate the risk factors associated with open ankle fractures, adjusting for other covariates. The entire cohort was further subdivided into "lower" and "higher" energy trauma groups and the same analysis performed for each group separately. We found that a body mass index of >40 kg/m(2) and farm location were risk factors for open ankle fractures and impaired sensorium was protective against open ankle fractures. In the "lower energy" group, male gender, alcohol use, peripheral vascular disease, other injuries, and injury occurring at a farm location were risk factors for open fractures. In the "higher energy" group, female gender, work-related injury, and injury at a farm or industry location demonstrated statistically significantly associations with open fractures.

Women with severe obesity and relatively low bone mineral density have increased fracture risk

Among women with obesity, those with the lowest bone density have the highest fracture risk. The types of fractures include any fracture, fragility-type fractures (vertebra, hip, upper arm, forearm, and lower leg), hand and foot fractures, osteoporotic, and other fracture types.

INTRODUCTION

Recent reports have contradicted the traditional view that obesity is protective against fracture. In this study, we have evaluated the relationship between fracture history and bone mineral density (BMD) in subjects with obesity.

METHODS

Fracture risk was assessed in 400 obese women in relation to body mass index (BMI), BMD, and clinical and laboratory variables.

RESULTS

Subjects (mean age, 43.8 years; SD, 11.1 years) had a mean BMI of 46.0 kg/m(2) (SD, 7.4 kg/m(2)). There were a total of 178 self-reported fractures in 87 individuals (21.8% of subjects); fragility-type fractures (hip, vertebra, proximal humerus, distal forearm, and ankle/lower leg) were present in 58 (14.5%). There were higher proportions of women in the lowest femoral neck BMD quintile who had any fracture history (41.3 vs. 17.2%, p < 0.0001), any fragility-type fractures (26.7 vs. 11.7%, p = 0.0009), hand and foot fractures (16.0 vs. 5.5%, p = 0.002), other fracture types (5.3 vs. 1.2%, p = 0.02), and osteoporotic fractures (8.0 vs. 1.2%, p < 0.0001) compared to the remaining population. The odds ratio for any fracture was 0.63 (95% CI, 0.49-0.89; p = 0.0003) per SD increase in BMD and was 4.3 (95% CI, 1.9-9.4; p = 0.003) in the lowest BMD quintile compared to the highest quintile. No clinical or biochemical predictors of fracture risk were identified apart from BMD.

CONCLUSIONS

Women with obesity who have the lowest BMD values, despite these being almost normal, have an elevated risk of fracture compared to those with higher BMD.

Effect of obesity on arthroscopic treatment of anterolateral impingement syndrome of the ankle

The present case series study was performed to evaluate the effect of obesity on the arthroscopic findings and the functional outcome after arthroscopic treatment of anterolateral impingement syndrome of the ankle. The study was conducted on 36 patients (26 were classified as obese [body mass index ≥30 kg/m(2)] and 10 as not obese [body mass index <25 kg/m(2)]) who had previously undergone arthroscopic treatment of anterolateral impingement syndrome of the ankle. The arthroscopic findings and demographic features were recorded. The patients were examined postoperatively at 6 and 12 months postoperatively, and AOFAS scores were obtained. Our data showed that obese patients had the same arthroscopic findings as nonobese patients, except for chondral lesions. At 1 year of follow-up after performing arthroscopy, the presence of obesity had no effect on the functional outcome of arthroscopic treatment of anterolateral impingement syndrome of the ankle.Obesity has no effect on the effectiveness of arthroscopic treatment.

Effect of variable body mass on plantar foot pressure and off-loading device efficacy

An increasing body of evidence has implicated obesity as having a negative effect on the development, treatment, and outcome of lower extremity pathologic entities, including diabetic foot disease. The objective of the present study was to increase the body of knowledge with respect to the effects of obesity on foot function. Specifically, we attempted to (1) describe the relationship between an increasing body mass index (BMI) on plantar foot pressures during gait, and (2) evaluate the efficacy of commonly prescribed off-loading devices with an increasing BMI. A repeated measures design was used to compare the peak plantar foot pressures under multiple test conditions, with the volunteers acting as their own controls. The primary outcome measure was the mean peak plantar pressure in the heel, midfoot, forefoot, and first metatarsal, and the 2 variables were modification of patient weight (from "normal" BMI to "overweight," "obese," and "morbidly obese") and footwear (from an athletic sneaker to a surgical shoe, controlled ankle motion walker, and total contact cast). Statistically significant increases in the peak plantar pressures were observed with increasing volunteer BMI weight class, regardless of the off-loading device used. The present investigation has provided unique and specific data with respect to the changes that occur in the peak plantar pressures with variable BMIs across different anatomic levels and with commonly used off-loading devices. From our results, we have concluded that although the plantar pressures increase with increasing weight, it appears that at least some reduction in pressure can be achieved with an off-loading device, most effectively with the total contact cast, regardless of the patient's BMI.

Obesity and people with disabilities: the implications for health care expenditures

OBJECTIVE

This study estimates additional average health care expenditures for overweight and obesity for adults with disabilities vs. without.

DESIGN AND METHODS

Descriptive and multivariate methods were used to estimate additional health expenditures by service type, age group, and payer using 2004-2007 Medical Expenditure Panel Survey data.

RESULTS

In 2007, 37% of community-dwelling Americans with disabilities were obese vs. 27% of the total population. People with disabilities had almost three times ($2,459) the additional average obesity cost of people without disabilities ($889). Prescription drug expenditures for obese people with disabilities were three times as high and outpatient expenditures were 74% higher. People with disabilities in the 45- to 64-year age group had the highest obesity expenditures. Medicare had the highest additional average obesity expenditures among payers. Among people with prescription drug expenditures, obese people with disabilities had nine times the prevalence of diabetes as normal weight people with disabilities. Overweight people with and without disabilities had lower expenditures than normal-weight people with and without disabilities.

CONCLUSIONS

Obesity results in substantial additional health care expenditures for people with disabilities. These additional expenditures pose a serious current and future problem, given the potential for higher obesity prevalence in the coming decade.

Can foot and ankle surgeons accurately estimate patient body mass index?

The body mass index (BMI) is an objective patient finding that has been established to have a negative effect on the development and outcomes of podiatric pathologic entities and interventions. The objective of the present investigation was to assess the ability of podiatric physicians to estimate the patient BMI from clinical and radiographic observation. For the clinical estimation of the patient BMI, podiatric specialists across 3 levels of experience (i.e., students, residents, and practicing clinicians) performed 294 estimations on 72 patients in 3 clinical situations (standing, sitting in a treatment chair, and lying in a hospital bed). It was more common to inaccurately estimate the patient BMI (77.9%) than it was to correctly estimate it (22.1%), with underestimations being the most common error (48.3%). The estimations were particularly inaccurate when the patients were in the common clinical situation of sitting in a treatment chair or lying in a hospital bed and with patients actually classified as obese. For the radiographic estimation of patient BMI, 150 consecutive lateral ankle radiographs were analyzed, with the ratio of the overlying soft tissue diameter to the underlying bone diameter calculated and compared. Positive, but weak, relationships were observed with these ratios. From these data, we have concluded that podiatric practitioners should perform an actual calculation of the patient BMI during the patient examination and medical decision-making process to fully appreciate the potential risks inherent to the treatment of obese patients.

The effect of obesity on early failure after operative syndesmosis injuries

OBJECTIVE

The goal of this investigation was to determine if obese patients with syndesmotic injuries have a higher incidence of early postoperative failure compared with nonobese patients.

DESIGN

Retrospective cohort study.

SETTING

Level 1 urban trauma center.

PATIENTS AND METHODS

Two hundred thirteen patients with operative syndesmotic injuries were divided into 2 cohorts: obese and nonobese. All syndesmotic injuries were confirmed by intraoperative stress testing, reduced, and stabilized with internal fixation.

INTERVENTION

Fixation of displaced syndesmosis injuries with solid 3.5- and 4.5-mm screws.

MAIN OUTCOME MEASURES

The primary outcome was early failure of fixation, defined as revision surgery within 3 months for ankle mortise and/or syndesmosis displacement.

RESULTS

Two hundred thirteen patients were identified with operative syndesmosis injuries, of which 102 (48%) were obese and 111 (52%) were nonobese. Fifteen percent (n = 15) of patients in the obese cohort sustained a failure of fixation compared with 1.8% (n = 2) of patients in the nonobese cohort (P = 0.0005). Diabetes mellitus, smoking status, and the type of construct used (eg, screw caliber, number of screws, and number of cortices) were not predictive of loss of reduction. Adjusting for injury severity, obese patients were 12 times more likely to suffer a loss of reduction compared with nonobese patients (odds ratio = 12.0, P = 0.02).

CONCLUSIONS

There is a strong association between obesity and loss of reduction after operative treatment of the syndesmosis. Further research is warranted to determine if a stronger mechanical construct or more conservative postoperative protocol can reduce the risk of loss of reduction in obese patients who sustain a syndesmotic injury.

Operative treatment of nonunion following distal fibula and medial malleolar ankle fractures

BACKGROUND

The purpose of this study was to evaluate the outcomes following operative treatment of nonunited rotational distal fibula and medial malleolar ankle fractures.

METHODS

Seventeen patients were identified as having a nonunion of a rotational ankle fracture. All patients were evaluated clinically, radiographically, and functionally with the Short Musculoskeletal Functional Assessment (SMFA) questionnaire. They were divided into lateral and medial malleolus groups and compared with 44 patients following a nonoperative (SE2/3) ankle fracture and 25 patients who underwent operative fixation of their SE4 ankle fracture for functional comparison.

RESULTS

Two of the 17 patients were excluded. The patients in the medial malleolar group were notably older than those in the other groups. Nonunions included 12 distal fibulas and 3 medial malleoli. All patients were treated with open reduction with plate and screw fixation or screw fixation alone. Adjunctive grafting was performed in all but 2 cases. The average time to healing was 5.2 months post surgery. At latest follow-up, mean 33.9 months, all nonunions had resolved. Standardized SMFA scores differed notably among the groups in the Bothersome, Emotional, and Mobility categories. There was no difference between lateral malleolar nonunion patients and surgically treated SE4 patients.

CONCLUSIONS

Reports of nonunions of fractures of lateral and medial malleoli have been rarely reported. Operative treatment of these nonunions in this study led to reliable bony healing. Patients who underwent surgery for these nonunions ultimately had similar outcomes and range of motion compared with patients who underwent operative treatment for acute ankle fractures.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

The timing of ankle fracture surgery and the effect on infectious complications; a case series and systematic review of the literature

PURPOSE

Information about the influence of delayed surgery on infectious wound complications is ambiguous. A clinical audit was performed to test the hypothesis that early surgery lowers the rate of infectious wound complications. Secondly we looked at the influence of surgical delay and complications on patient reported functional outcome.

METHODS

All consecutive, closed distal fibular fractures treated surgically with a plate were included and retrospectively analysed for the delay in operation and wound complications. In a second cohort of patients with a AO-Weber B-type ankle fracture outcome was measured using the Olerud-Molander ankle score (OMAS), the American Orthopaedic Foot and Ankle Society score (AOFAS) and a visual analog score (VAS) for overall satisfaction.

RESULTS

Patients treated within one day experienced no wound complications (zero out of 60), whereas in the delayed group 11% (16/145) did (p = 0.004). A similar significant difference was found for the patients treated within one week (2/98) versus after one week (14/107). A systematic review of the literature showed a difference in wound complications of 3.6% (early) versus 12.9% (late) (p < 0.0001). After 43 months, the median AOFAS was 11.5 points lower in the complication group, the OMAS 10 points, and the VAS 0.5 points, with all differences being statistically significant.

CONCLUSIONS

Every effort should be made to operate on closed ankle fractures as soon as reasonably possible. A delay in surgery is associated with a significant rise in infectious wound complications, which significantly lowers outcome and patient satisfaction. These fractures should preferably be treated within the first day.

Prevalence of overweight in children with bone fractures: a case control study

BACKGROUND

Children's fractures have been enlisted among orthopaedics complaints of childhood obesity. Unhealthy lifestyle behaviours may contribute to increased risk. This study described the prevalence of overweight/obesity in children and adolescents reporting a recent fracture in relation to gender, dynamic of trauma, and site of fracture.

METHODS

Four-hundred-forty-nine children and adolescents with fracture and 130 fracture-free controls were recruited from a large children's hospital. The interaction between overweight and gender, dynamic of trauma, site of fracture was explored. Sports participation, television viewing, and calcium intake were also investigated.

RESULTS

Overweight/obesity rate was increased in girls with fracture either at the upper or the lower limb (p= 0.004), while it was increased only in boys with fracture at the lower limb (p <0.02). Overweight/obesity rate did not differ between groups with low or moderate trauma. TV viewing ≥ 2 hrs was more frequent in children with fractures than controls (61.5% vs 34.5%, p =0.015) in the overweight/obese group.

CONCLUSIONS

The increased prevalence of overweight/obesity in children with fractures is related to gender and site of fracture. Higher levels of sedentary behaviours characterize overweight children reporting fractures.

Wound complications in joint arthroplasty: comparing traditional and modern methods of skin closure

Various methods of skin closure exist in joint replacement surgery. Although subcuticular skin closure techniques offer an aesthetic advantage over conventional skin stapling, no measurable differences have been reported. Furthermore, newer barbed sutures, such as the V-Loc absorbable suture (Covidien, Mansfield, Massachusetts), theoretically distribute tension evenly through the wound and help decrease knot-related complications. The purpose of this study was to evaluate whether wound complication rates were (1) lower in V-Loc closure cases as theoretically suggested, (2) lower for subcuticular closure vs staples, and (3) significantly different for knee and hip joint reconstruction.A retrospective chart review was conducted of 278 consecutive cases of primary joint reconstruction performed by a single surgeon (L.P.). The study group comprised 106 men and 161 women. Average patient age at surgery was 63 years (range, 18-92 years), and average body mass index of the cohort was 33.7 kg/m(2) (range, 25-51 kg/m(2)). Skin was closed via staple gun or subcuticular stitch (3-0 Biosyn [Covidien] vs V-Loc). Seven (3.9%) wound complications occurred in 181 cases closed with staples. Four (7.8%) wound complications occurred in 51 cases closed via subcuticular Biosyn suture. Six (13.0%) wound complications occurred in 46 cases closed with V-Loc suture. The staple group had a lower rate of complications when compared with the suture group as a whole (P=.033) and when compared specifically with the V-Loc suture group (P=.017).