Early versus delayed treatment of severe ankle fractures: a comparison of results

Temporary immobilization methods for closed low-energy ankle fracture-dislocations: comparative analysis of a retrospective cohort

PURPOSE

Ankle fracture-dislocations (AFD) often necessitate staged management involving temporary external fixation (EF) due to mechanical instability or blistering. However, limited literature exists on the optimal temporary immobilization method for low-energy closed AFD. This study compared baseline patient and fracture characteristics, along with clinical and radiological outcomes between AFD initially immobilized with EF versus splinting.

METHODS

A retrospective cohort study was conducted involving patients with AFD temporarily immobilized using EF or splinting, followed by definitive open reduction and internal fixation. Quality of reduction (QOR) was assessed for each patient post-initial immobilization and after the definitive surgery.

RESULTS

The study encompassed 194 patients: 138 treated with a splint (71.1%) and 56 (28.9%) with EF. Secondary loss of reduction had occurred in three patients who were splinted (2.2%). The mean ages in the EF and splint groups were 63.2 and 56.1 years, respectively (p = 0.01). Posterior malleolus fracture (PMF) and blisters were more prevalent in EF patients (69.6% vs. 43.5% for PMF and 76.8% vs. 20.3% for blisters, respectively; p = 0.05 and p < 0.01). Postoperative complication rates were 8.9% for EF versus 10.9% for splinting (p = 0.69). Satisfactory final QOR was attained in 79.8% of patients treated with a splint versus 64.3% with EF (p = 0.02).

CONCLUSION

Patients immobilized by EF presented with poorer baseline characteristics and had more unstable injuries. Nevertheless, postoperative complication rates were comparable. Thus, EF appears to be a valuable tool for standardizing outcomes in AFD patients with a less favorable prognosis.

Temporary Cast Application in Dislocated Ankle Fractures Leads to High Rates of Secondary Loss of Reduction: Does the Lauge-Hansen Injury Type Matter?

BACKGROUND

For the temporary treatment of ankle fracture dislocations (AFDs), previous studies indicate higher rates of secondary loss of reduction (LOR) with splint immobilization, prompting consideration for expanding indications for external fixation (ExFix). However, these studies did not investigate the influence of fracture morphology to further improve patient selection. The aim of this study was to investigate the influence of Lauge-Hansen injury type on the LOR rate in bimalleolar or trimalleolar AFDs for temporary cast vs ExFix immobilization.

METHODS

In this retrospective cohort study, patients with isolated AFD cases treated at our institution from 2011 to 2020 were reviewed. Inclusion criteria required radiographs depicting initial dislocation and appropriate reduction after Cast or ExFix immobilization. Exclusion criteria encompassed concomitant injuries, open fractures, conservative management as well as surgery performed within 48 hours or at a different facility. Patients were grouped by temporary treatment (Cast or ExFix). The primary endpoint was LOR prior to definitive surgery across various Lauge-Hansen types.

RESULTS

The LOR rate was significantly higher in the cast group (40/152, 26.3%) compared to the ExFix group (5/191, 2.6%; P < .0001). In the cast group, LOR was associated with an increase in time to definitive surgery by a mean of 3 days (P < .002). During cast treatment, LOR was significantly more likely for pronation abduction (P = .001) and supination external rotation injuries (P < .0001), whereas no significant differences were observed for pronation external rotation (P = .006), supination adduction (P > .99), and fractures not classifiable (P > .99).

CONCLUSION

In cases of AFDs resulting from supination external rotation or pronation abduction trauma according to the Lauge-Hansen classification, especially in the setting of an additional posterior malleolar fracture, primary application of external fixation should be considered to reduce the risk for secondary loss of reduction.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Timing of Olecranon Fracture Fixation Does Not Affect Early Complication or Reoperation Rates

Purpose

Surgical fixation of olecranon fractures can lead to soft-tissue complications and return to the operating room for hardware removal. While some risk factors of complications after olecranon fracture fixation have been described, the effects of fixation timing on complications and reoperation have not been evaluated. The purpose of the present study was to assess whether the timing of olecranon fracture fixation affects complication and reoperation rates.

Methods

All patients who underwent olecranon fracture open reduction and internal fixation at a single level 1 trauma center from January 2012 to February 2022 were included in the study. A retrospective review was performed to evaluate patients for inclusion and to identify patient demographic factors, medical comorbidities, concomitant injuries, mechanism of injury, and time to fixation. Operative and clinical notes were evaluated to identify fixation type and outcomes of interest. Patients were stratified into early, standard, and delayed fixation groups (0-3 days, 4-14 days, and >14 days, respectively) for independent analyses, and Fisher's exact test was used to identify differences in complications and reoperations between groups. Multivariate analysis was used to assess associations between patient demographic factors, complication rates, and time to surgery.

Results

A total of 97 patients met inclusion criteria of having an olecranon open reduction and internal fixation and had a minimum follow-up of at least 10 weeks, with an average follow-up of 7.1 months. The average time to surgery in the overall cohort was 9.3 days. There were no differences in the number of total complications and rate of reoperation among the three cohorts. Smoking was found to be significantly associated with total complications, while open fracture was significantly associated with reoperation. Polytrauma and open fracture were significantly associated with earlier operation, while smoking was significantly associated with delayed fixation.

Conclusions

The timing of fixation of displaced olecranon fractures does not significantly increase the rate of early complications or reoperation.

Type of study/level of evidence

Symptom Prevalence Study III.

The Impact of Surgical Timing After Ankle Fracture on Clinical and Long-Term Patient Reported Outcomes

The goal of this study is to evaluate the effect of time-to-surgery following closed ankle fractures on long-term patient reported outcomes, fracture healing, and wound complications. To date, little research has been done focusing on the impact "time to definitive fixation" has on patient reported outcomes. We performed a retrospective analysis of 215 patient records who underwent open reduction and internal fixation (ORIF) for an ankle fracture from July 2011 to July 2018. A total of 86 patients completed the patient reported outcome measurement information systems (PROMIS) survey at long-term follow-up. Primary outcomes were the rate of delayed union, postoperative wound complications, patient reported outcome measurement information system (PROMIS) pain interference (PI), and physical function (PF) scores. No differences were found when comparing time to surgery on a continuous scale with rates of delayed union, nonunion, or wound complications (p = .84, .47, and .63, respectively). PROMIS scores were collected at a median of 4.5 years (2.0 interquartile range (IQR), range 2.5-12.3) postoperatively. The time from ankle fracture to surgery was independently associated with worse PROMIS PI scores (unstandardized β 0.38, 95% CI 0.07-0.68) but not PROMIS PF scores. Severe Lauge-Hansen injuries were independently associated with decreased PROMIS PF scores (unstandardized β -7.02, 95% CI -12.0 to -2.04). Increased time to surgical intervention and severe Lauge-Hansen injuries were independently associated with worse long-term patient reported outcomes. Surgical timing did not impact union rates or wound complications. Surgeons should be aware that delaying ankle fracture repair beyond 12 days after injury may negatively affect long-term patient reported pain scores.

The Wait Time for Surgery Following Injury Affects Functional Outcomes and Complications After an Ankle Fracture: A Propensity Score-Matched Multicenter Study, the TRON Study

BACKGROUND

The present study aimed to evaluate the hypothesis that a 1-week extension of the waiting period to perform surgery for ankle fracture might affect postoperative results and complications.

METHODS

We used our multicenter database named TRON (Trauma Research Group of Nagoya). In all, 779 patients who underwent surgery for ankle fracture, who had no comorbidities were eligible. After exclusion, we analyzed 596 patients. We divided the patients into 2 groups according to whether they were operated on within 7 days after the injury with propensity score matching.

RESULTS

The operative time of the delayed operation group (DO group) was significantly longer than that of the early operation group (EO group) (115.87 ± 56.59 vs 85.93 ± 34.58 minutes; P < .001). The rate of infection in the DO group was significantly higher than that of the EO group (16 patients [6.5%] vs 4 patients [1.6%]; P = .016).

CONCLUSION

Waiting for more than a week to perform ankle surgery may lead to longer operative times and increased infection rates.

LEVELS OF EVIDENCE

III.

Development of a nomogram to predict surgical site infection after open reduction and internal fixation for closed pilon fracture: a prospective single-center study

BACKGROUND

To explore the risk factors and develop a nomogram in order to predict surgical site infection (SSI) after open reduction and internal fixation (ORIF) for closed pilon fractures (CPF).

METHODS

A prospective cohort study with one-year follow-up was carried out in a provincial trauma center. From January 2019 to January 2021, 417 adult patients with CPFs receiving ORIF were enrolled. A Whitney U test or t test, Pearson chi-square test, and multiple logistic regression analyses were gradually used for screening the adjusted factors of SSI. A nomogram model was built to predict the risk of SSI, and the concordance index (C-index), the receiver operating characteristic (ROC) curve, calibration curve and decision curve analysis (DCA) were used for evaluating the prediction performance and consistency of the nomogram model. The bootstrap method was employed to test the validity of the nomogram.

RESULTS

The incidence of SSI after ORIF for CPFs was 7.2% (30/417): 4.1% (17/417) of superficial SSIs and 3.1% (13/417) of deep SSIs. The most common pathogenic bacteria were Staphylococcus aureus (36.6%, 11/30). The multivariate analysis showed tourniquet use, longer preoperative stay, lower preoperative albumin (ALB), higher preoperative body mass index (BMI) and hypersensitive C-reactive protein (Hs-CRP) were independent risk factors of SSI. Additionally, the C-index and bootstrap value of the nomogram model were 0.838 and 0.820, respectively. Finally, the calibration curve indicated that the actual diagnosed SSI had good consistency with the predicted probability, and the DCA showed that the nomogram had clinical value.

CONCLUSIONS

Tourniquet use, longer preoperative stay, lower preoperative ALB, higher preoperative BMI and Hs-CRP were five independent risk factors of SSI after closed pilon fractures treated by ORIF. These five predictors are shown on the nomogram, with which we may be able to further prevent the CPS patients from SSI. Trial registration NO 2018-026-1, October /24/2018, prospectively registered. The study was registered in October 24, 2018. The study protocol was designed based on the Declaration of Helsinki and admitted by the Institutional Review Board. The ethics committee approved the study on factors related to fracture healing in orthopedic surgery. Data analyzed in the present study were acquired from the patients who underwent open reduction and internal fixation from January 2019 to January 2021.

Percutaneous Reduction and Provisional Pinning of the Distal Fibula: A Novel Way to Maintain Fibular Length in Temporary Stabilization

Ankle fractures are commonly observed by orthopaedic trauma surgeons, foot and ankle surgeons, and general orthopaedists with more than 135,000 fractures surgically treated every year in the United States. 1 The soft tissue envelope surrounding the osseous anatomy of the ankle is limited and many injuries, including those that result from higher injury mechanisms and/or those occurring in hosts with vascular and metabolic comorbidities may benefit from a delay in definitive fixation; this may minimize risks of wound healing issues and fracture-related infection. 2,3 Open fractures may benefit from temporizing fixation after debridement and irrigation for the same reasons. 4-6 The benefits of temporizing external fixation in pilon fractures has been recognized for decades. 7 The use of ankle-spanning external fixation for ankle fractures and dislocations has become more frequently used to maintain coronal and sagittal alignment of the ankle mortise as a bridge to definitive fixation. 8-10 However, standard ankle-spanning external fixation techniques do not always directly restore fibular length and rotation, especially in fracture patterns with syndesmotic disruption and/or segmental fibular comminution. Some authors have advocated for limited internal fixation of fibula fractures at time of external fixation application to address this problem, 7 but this still necessitates a surgical approach through a traumatized soft tissue envelope and potentially compromises posterolateral and anterolateral approaches that could be used to address associated Volkman or Chaput fragments. Delayed distal fibular open reduction and internal fixation of shortened fractures has frustrated orthopaedic surgeons for decades and techniques such as "push-pull" screws 11 and extensive soft tissue dissection 12 are often necessary to restore anatomic fibular reduction of length and rotation. Given these challenges, the senior author began to use a technique of percutaneous reduction and buried provisional pinning of the distal fibula to the talus for fibula fractures with persistent shortening after ankle-spanning external fixation of injuries not deemed appropriate for immediate open reduction and internal fixation. We aim to report early results and describe this novel, low-cost surgical technique.

Comparing Temporary Immobilization Using Cast and External Fixator in Unimalleolar Ankle Fracture Dislocations: A Retrospective Case Series

Studies have reported a high percentage of ankle fracture dislocations with secondary loss of reduction during primary treatment with a splint or cast. This study aimed to assess the rate of secondary loss of reduction in unimalleolar ankle fracture dislocations treated primarily with a cast or external fixator, identify the potential influence of fracture morphology, and investigate the potential implications. Unimalleolar ankle fracture dislocations with and without posterior malleolar fracture between 2011 and 2020 were included. Patients were categorized into two groups, depending on the method of temporary treatment. Fracture morphology, time to definitive surgery, and soft-tissue complications were compared. Of 102 patients, loss of reduction tended to occur more often in the cast group (17.3%) than in the external fixator group (6.0%). The presence of a posterior malleolar fracture did not have a significant influence on loss of reduction in cast immobilization; however, the fragment proved to be significantly bigger in cases with loss of reduction. No statistically significant differences in soft tissue complications or time to definitive surgery were found. Surgeons should consider the application of interval external fixation in the primary treatment of unimalleolar ankle fracture dislocations with additional posterior malleolar fractures.

Comparison of complications of early and delayed open reduction and internal fixation for treating pilon fracture: A protocol of systematic review and meta-analysis

BACKGROUND

Tibial Pilon fractures are severe fractures accompanied by soft tissue injury. Although open reduction and internal fixation (ORIF) are effective in treating Pilon fractures, there is a controversy over time to surgery due to reported postoperative complications. However, there is no systematic review evaluating the difference of postoperative complications between early and delayed ORIF for treating pilon fractures.

METHODS

Relevant literature written in English will be searched through PubMed, Cochrane Library, Embase, MEDLINE, and Web of Science. The study aims to compare the effects and complications of early and delayed ORIF for treating fresh pilon fractures in adult patients. The primary outcome will be infection rate, fracture union time, nonunion and malunion rate. And the secondary outcome will be metalwork removal, amputation, and ankle function grade. Two reviewers will independently assess the eligibility of the studies according to the pre-defined inclusion and exclusion criteria. A meta-analysis for the available data will be conducted using Revman 5.3. To measure effect size, odds ratios (ORs) and mean difference will be used for dichotomous and continuous data, respectively. Statistical heterogeneity will be explored. And a random-effects model or a fixed-effects will be used in pooled data on the basis of the existence or absence of heterogeneity. Subgroup analysis will be conducted to identify sources of heterogeneity and sensitivity analysis to test the results' robustness. We will assess the risk of bias by four different quality assessment tools according to the study design. Publication bias will be evaluated by funnel plot. The study data will be stored in the Open Science Framework website.

PROSPERO REGISTRATION NUMBER

CRD42020207465.

Pre-operative physiotherapy following unilateral ankle fractures at a tertiary hospital in South Africa: Perceptions of patients and nurses

Background

Ankle fractures are a common injury because of an increase in levels of physical activity, as well as senescence worldwide. Ankle fractures often require surgical management for optimal stabilisation. Pre-operative physiotherapy is necessary to prepare patients for early mobilisation and home discharge. There is a lack of information on the influence of pre-operative physiotherapy on post-operative rehabilitation success, as well as timeous discharge, in patients with ankle fractures.

Objectives

To explore the perceptions of patients receiving pre-operative physiotherapy care following a unilateral ankle fracture and the perceptions of nursing staff managing these patients at a tertiary hospital in South Africa.

Method

A descriptive qualitative design, using semi-structured interviews, including both patients with unilateral ankle fractures and nurses caring for these patients, was adopted. Interviews were recorded and verbatim transcriptions were analysed utilising thematic analysis.

Results

Four overarching themes emerged: the perceived benefits of pre-operative physiotherapy; inhibitors to physiotherapy rehabilitation; hidden enablers to pre-operative physiotherapy and future initiatives for rehabilitation.

Conclusion

The perceived benefits included improved functional independence and safety of patients, as well as reduced burden of care for nurses. Patients also believed that pain and fear were two inhibitors to physiotherapy. Furthermore, nurses identified that organisational limitations, such as short-staffing and inadequately trained staff, inhibited pre-operative physiotherapy and continuity of care. Early post-operative discharge was a crucial hidden enabler to the pre-operative physiotherapy protocol. Recommendations included improved health education; the potential role of nursing staff as facilitators in pre-operative rehabilitation and regular, pre-operative in-patient monitoring of physiotherapy intervention.

Clinical implications

Health education was perceived to have improved patient safety and compliance which subsequently reduced patient safety incidences as well as served as a risk mitigation measure. Furthermore, gait training and muscle strengthening exercises was perceived to have resulted in safe, independent mobility to ensure prompt discharge home. Consequently, a reduced post-operative length of in hospital stay results in major cost savings per patient as well as improved access and bed availability. Future studies may need to explore the effects of pre-operative physiotherapy on post-operative success and return to pre-injury activity.

Temporizing External Fixation vs Splinting Following Ankle Fracture Dislocation

BACKGROUND

Closed reduction and splinting followed by outpatient management is standard of care for temporizing most ankle fractures. However, ankle fracture-dislocation potentially warrants a different approach based on the propensity for loss of reduction. The purpose of this study was to determine the rate of complications associated with closed reduction and splinting of unstable ankle fracture-dislocations. Further, we sought to determine the efficacy of immediate external fixation as an alternative to splinting in cases too swollen for acute operation.

METHODS

This retrospective chart review analyzed all ankle-fracture dislocations that came through a large health care system from 2008 to 2018. Patients managed with acute open reduction internal fixation (ORIF) and open fractures were excluded. In patients managed late, the cohorts were divided into those temporized with closed reduction/splinting vs external fixation. Reduction quality and splint technique were additionally assessed in splinted patients. A total of 354 closed ankle fracture-dislocations were identified: 298 patients (84%) underwent ORIF within 48 hours and were excluded; 28 (15 female/13 male, average age 46.8 years) were placed in an external fixator and 28 (22 female/6 male, average age 57.2 years) were reduced, splinted, and discharged.

RESULTS

At follow-up, 14 of the patients (50%) in the splint group developed loss of reduction and 5 of these patients (17.6%) developed anteromedial skin necrosis from skin tenting. None of the patients in the ex-fix group developed loss of reduction or skin necrosis. The rate of redislocation and the rate of development of skin necrosis was statistically higher in cases temporized with a splint versus an external fixator (P < .01 and P = .05, respectively).

CONCLUSION

We found that in ankle fracture-dislocations not treated with acute ORIF, splint immobilization was associated with an increased risk of complications, including redislocation and skin necrosis, when compared to a temporizing external fixator.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Timing of Open Reduction and Internal Fixation of Ankle Fractures

Background. Unstable ankle fractures are treated with open reduction internal fixation (ORIF) to prevent posttraumatic arthritis. Typically, ORIF is performed as an ambulatory surgery several days to a few weeks after injury. It is unclear what effect this delay may have on functional outcome. This study aimed to assess the effect of timing of ankle ORIF on wound complications and functional outcome. Methods. A retrospective review of 121 patients who underwent ankle ORIF was performed. A total of 58 patients had a follow-up of at least 24 months. Time between injury and surgery greater than 14 days was defined as "delayed." Demographic variables, injury characteristics, length of surgery, and postoperative stay were documented. Comparison of demographic variables, wound complications, and functional outcome determined by Foot and Ankle Outcome Score (FAOS) was performed. Results. 118 patients were included. The duration between injury and surgery was 6 days in the "early" group and 19 days in the "delayed" group. There were no significant differences in demographic variables, injury characteristics, and length of surgery between the groups. Wound complications in the early and delayed groups were 5% and 11.8%, although this difference was not statistically significant. Among 58 patients who had a follow-up of at least 24 months, the median follow-up time was 38 (range, 24-76) months. Each subscale of FAOS demonstrated no significant difference. Conclusion. Ankle ORIF more than 14 days after injury did not significantly increase the rate of wound complication, nor did it impair ultimate functional outcome in this group. Levels of Evidence: Level III.

The Use of Modern Intramedullary Nailing in Distal Fibula Fracture Fixation

Background. Lateral malleolus (LM) fixation is necessary for unstable ankle fractures. Traditional fixation relies on the use of plates through a lateral incision, wound healing can be an issue for such incisions. A novel intramedullary (IM) fixation device has been developed that can be placed through a minimal incision. The purpose of this study was to demonstrate the clinical efficacy of this device. Methods. A retrospective analysis was performed on patients who received IM fixation for isolated fibula, bimalleolar (BM), and trimalleolar (TM) fractures. Pertinent demographic information, operative factors, complications, and clinical outcomes were recorded. Results. Sixteen patients were included in the study with an average age of 59 years (range 35-86 years). Six patients presented with isolated LM fractures, four patients had a BM fracture with a syndesmotic injury, 2 patients sustained a LM fracture with an associated syndesmotic injury, 2 patients had a BM fracture, and 2 patients had a TM fracture with a syndesmotic injury. There was a 100% healing rate of the lateral malleolus without any cases of malunion or shortening. There were no cases of sural nerve or peroneal tendon injuries, nor any wound complications found. Conclusion. These findings demonstrate the safe and efficacious use of a novel intramedullary fixation device for fibula fractures with lower wound complications compared with published outcomes found with lateral fibular plating. The features of this device allow for reliable fixation of the fibula, maintaining length and minimizing wound issues. Levels of Evidence: Level IV: Case series.

Delayed Internal Fixation of Distal Radius and Bimalleolar Ankle Fractures Does Not Increase Surgical Time

Introduction:

It is commonly believed that delay in fracture fixation of more than two weeks results in increased Surgical Time (ST), due to scar and callus formation at the fracture site. Reducing ST can lower hospital costs and decrease radiation exposure.

Methods and Results:

A retrospective chart review was conducted to investigate whether early fracture care (up to 2 days after injury) results in decreased ST and radiation exposure compared to delayed fracture care (> 14 days after injury) for distal radius and bimalleolar ankle fractures. A total of 581 radius and ankle fractures that underwent surgical fixation between 2014 and 2017 were identified from the OR registry. Cases with only a single volar locking plate for the distal radius and constructs consisting of 2 medial malleolar screws, third tubular plate, and up to 1 syndesmotic screw for the ankle were included. The mean ST for distal radius cases done up to 2 days after injury was significantly greater than ST for distal radius cases done > 14 days after injury (125.78±29.75 minutes versus 105.83±24.82 minutes respectively , p=0.06). The mean ST for ankle fracture cases done less than 2 days did not differ from ST for ankle fracture cases done > 14 days after injury (140.86±28.15 minutes versus 173.22±39.98 minutes respectively, p=0.06).

Conclusion:

There was no significant difference in radiation exposure. Delaying surgery for distal radius and bimalleolar ankle fractures > 14 days after injury does not seem to significantly affect the duration of surgery or radiation exposure.

A Retrospective Case Series of Carbon Fiber Plate Fixation of Ankle Fractures

Distal fibula fractures represent a common problem in orthopaedics. When fibula fractures require operative fixation, implants are typically made from stainless steel or titanium alloys. Carbon fiber implants have been used elsewhere in orthopaedics for years, and their advantages include a modulus of elasticity similar to that of bone, biocompatibility, increased fatigue strength, and radiolucency. This study hypothesized that carbon fiber plates would provide similar outcomes for ankle fracture fixation as titanium and steel implants. A retrospective chart review was performed of 30 patients who underwent fibular open reduction and internal fixation (ORIF). The main outcomes assessed were postoperative union rate and complication rate. The nonunion or failure rate for carbon fiber plates was 4% (1/24), and the union rate was 96% (23/24). The mean follow-up time was 20 months, and the complication rate was 8% (2/24). Carbon fiber plates are a viable alternative to metal plates in ankle fracture fixation, demonstrating union and complication rates comparable to those of traditional fixation techniques. Their theoretical advantages and similar cost make them an attractive implant choice for ORIF of the fibula. However, further studies are needed for extended follow-up and inclusion of larger patient cohorts.

LEVELS OF EVIDENCE

Level IV: Retrospective Case series.

The role of diabetes mellitus and BMI in the surgical treatment of ankle fractures

BACKGROUND

Open reduction and internal fixation is the standard treatment for displaced ankle fractures. However, the presence of comorbidities such as diabetes mellitus and body mass index (BMI) are associated with poor bone quality, and these factors may predict the development of postoperative complications. The study aim was to assess the role of diabetes mellitus and BMI in wound healing in patients younger than 65 years who were surgically treated for malleoli fractures.

METHODS

Ninety patients, aged from 18 to 65 years old, with surgically treated ankle fracture, were retrospectively enrolled. Patients were classified in two groups: patient with diabetes and patients without diabetes (insulin-dependent and noninsulin dependent). All patients were assessed for wound complications, Visual Analogue Scale and Foot and Ankle Disability Index (FADI) were assessed for all patients. Logistic regression was used to identify the risk of wound complications after surgery using the following factors as explanatory variables: age, gender, duration of surgery, BMI, hypercholesterolemia, smoking history, diabetes mellitus, and high blood pressure.

RESULTS

In total, 38.9% of patients showed wound complications. Of them, 17.1% were nondiabetics and 82.9% were diabetics. We observed a significant association between DM and wound complications after surgery (P = .005). Logistic regression analysis revealed that DM (P < .001) and BMI (P = .03) were associated with wound complications. The odds of having a postoperative wound complication were increased 0.16 times in the presence of diabetes and 1.14 times for increasing BMI.

CONCLUSION

This study showed that diabetes mellitus and higher BMI delay the wound healing and increase the complication rate in young adult patients with surgically treated bimalleolar fractures.

Outpatient Management of Ankle Fractures

Interest in outpatient orthopedic surgery has been fueled by provider desire to control costs and development of rapid recovery protocols. Open reduction and internal fixation (ORIF) is a commonly elected treatment strategy for ankle fracture that may be performed in an outpatient setting. Lessons on cost-savings of the outpatient model in orthopedics can be learned in total joint replacement and spine surgery. Moreover, in properly selected patients, outpatient ORIF has been shown to be comparably safe. Reasons for admission of the surgically managed patient with ankle fractures, including concern for surgical delay and additional social factors, warrant further investigation.

Economic Burden of Inpatient Admission of Ankle Fractures

BACKGROUND

Ankle fractures are among the most prevalent traumatic orthopaedic injuries. A large proportion of patients sustaining operative ankle fractures are admitted directly from the emergency department prior to operative management. In the authors' experience, however, many closed ankle injuries may be safely and effectively managed on an outpatient basis. The aim of this study was to characterize the economic impact of routine inpatient admission of ankle fractures.

METHODS

A retrospective review of all outpatient ankle fracture surgery performed by a single foot and ankle fellowship-trained surgeon at a tertiary level academic center in 2012 was conducted to identify any patients requiring postoperative inpatient admission. The National Inpatient Sample was queried for operative management of lateral malleolus, bimalleolar, and trimalleolar ankle fractures in 2012 with regard to national estimates of total volume and length of stay by age. The maximum allowable Medicare inpatient facility reimbursements for diagnosis related group 494 and Medicare outpatient facility reimbursements for Current Procedural Terminology codes 27792, 27814, and 27822 were obtained from the Medicare Acute Inpatient Prospective Pricer and the Medicare Outpatient Pricer Code, respectively. Private facility reimbursement rates were estimated at 139% of inpatient Medicare reimbursement and 280% of outpatient reimbursement, as described in the literature. Surgeon and anesthesiologist fees were considered similar between both inpatient and outpatient groups. A unique stochastic decision-tree model was derived from probabilities and associated costs and evaluated using modified Monte Carlo simulation.

RESULTS

Of 76 lateral malleolar, bimalleolar, and trimalleolar ankle fracture open reduction internal fixation cases performed in 2012 by the senior author, 9 patients required admission for polytrauma, medical comorbidities, or age. All 67 outpatients were discharged home the day of surgery. In the 2012 national cohort analyzed, 48,044 estimated inpatient admissions occurred postoperatively for closed ankle fractures. The median length of stay was 3 days for each admission and was associated with an estimated facility reimbursement ranging from $12,920 for Medicare reimbursement of lateral malleolus fractures to $18,613 for private reimbursement of trimalleolar fractures. Outpatient facility reimbursements per case were estimated at $4,125 for Medicare patients and $11,459 for private insurance patients. Nationally, annual inpatient admissions accounted for $796,033,050 in reimbursements, while outpatient surgery would have been associated with $419,327,612 for treatment of these same ankle fractures.

CONCLUSION

In the authors' experience, closed lateral malleolus, bimalleolar, and trimalleolar fractures were safely and effectively treated on an outpatient basis. Routine perioperative admission of patients sustaining ankle fractures likely results in more than $367 million of excess facility reimbursements annually in the United States. Even if a 25% necessary admission rate were assumed, routine inpatient admission of ankle fractures would result in a $282 million excess economic burden annually in the United States. Although in certain cases, inpatient admission may be necessary, with value-based decision making becoming increasingly the responsibility of the orthopaedic surgeon, understanding the implications of inpatient stays for ankle fracture surgery can ultimately result in cost savings to the US health care system and patients individually.

LEVEL OF EVIDENCE

Level III, comparative series.

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.

Can intermittent pneumatic compression (IPC) reduce time to surgery for malleolar fractures?

BACKGROUND

Surgery of malleolar fractures are often delayed due to oedema of the ankle. The use of intermittent pneumatic compression (IPC) is thought to reduce oedema of the fracture site and thereby time to surgery in patients with malleolar fractures.

PURPOSE

To investigate the influence of IPC on the time from admission to surgery in adult patients with internal fixated primary malleolar fractures.

METHODS

February 1st 2013 IPC was introduced as a standard treatment for all patients admitted with a malleolar fracture. Data was retrieved from the hospital database 2 years prior and after the introduction date. The patients were found using ICD-10 diagnoses codes (DS825-8) in combination with NOMESCO procedure codes (KNHJ40-3, KNHJ60-3, KNHJ70-3, KNHJ80-3). One reviewer examined all the journals and classified the x-ray images by the AO classification. The primary outcome measure was time from diagnosis to surgery.

RESULTS

74 patients in the IPC cohort and 113 in the non-IPC cohort were included in the study. Time from admission to surgery was 21.9 (10.8-45.0) hours in the control group and 22.1 (8.9-41.2) hours in the IPC group. The difference is not statistically significant (p=0.420). A subgroup analysis divided the patients operated before and after 24h from admission. The median (IQR) time to surgery for patients operated before 24h was 10.9 (6.4-16.9) hours for the control group and 9.9 (5.8-20.1) hours in the IPC group (p=0.989). The median (IQR) time to surgery for patients operated after 24h was 21.5 (4.1-57.0) hours for the control group and 18.4 (7.4-32.3) hours in the IPC group (p=0.353).

INTERPRETATION

There was no benefit from IPC on time to surgery in patients with acute primary malleolar fracture in a cohort with a mean surgical delay less than 24h.

Associations of timing of surgery with postoperative length of stay, complications, and functional outcomes 3-6 years after operative fixation of closed ankle fractures

AIMS

To evaluate the associations of timing of surgery with postoperative length of stay (LOS), complications, and functional outcomes 3-6 years after open reduction and internal fixation (ORIF) in closed ankle fractures.

PATIENTS AND METHODS

Historical cohort study by chart review of 1011 patients for postoperative LOS and complications; 959 individuals were invited to participate in a postal survey with functional outcomes questionnaires. Complications were classified as perioperative, early, or late. The associations with time from trauma to surgery (<8h, 8h to 6days, >6days) were assessed with (1) postoperative LOS using multivariable random-effects negative binomial regression, (2) complications using multivariable binary and multinomial logistic regression, and (3) three different functional outcomes using multivariable linear regression.

RESULTS

The mean patient age was 51.4 (range 18-94) years, 556 (55%) were female, and 567 individuals (59%) responded to the questionnaire. There were no statistically significant associations between time to surgery and either postoperative LOS or complications after adjusting for several patient and fracture characteristics. Patients operated on >6days after the trauma had significantly worse scores on the Olerud and Molander Ankle Score (OMAS) (p=0.039) and somewhat worse, but non-significant, scores on the Lower Extremity Functional Scale (LEFS; p=0.573) and the Self-Reported Foot and Ankle Score (SEFAS) scale (p=0.161) than those operated on <8h after trauma.

CONCLUSION

In ankle-fracture surgery, there was no apparent association between timing of surgery and postoperative LOS or complications. A delay of surgery for 8h to 6days resulted in similar functional outcomes after 3-6 years suggesting there may be a safe window of time for surgery of up to 6days after trauma that can be used to plan and perform the final ORIF.

Vascular Impulse Technology versus elevation in the treatment of posttraumatic swelling of extremity fractures: study protocol for a randomized controlled trial

BACKGROUND

Fractures of the extremities are often complicated by a variable degree of swelling secondary to hemorrhage and soft tissue injury. Patients typically require up to 7 days of inpatient bed rest and elevation to reduce swelling to an acceptable level for operative treatment with internal fixation. Alternatively, an intermittent pneumatic compression device, such as the Vascular Impulse Technology (VIT) system, can be used at the injured extremity to reduce the posttraumatic swelling. The VIT system consists of a pneumatic compressor that intermittently rapidly inflates a bladder positioned under the arch of the hand or the foot, which results in compression of the venous hand or foot plexus. That intermittent compression induces an increased venous velocity and aims to reduce the soft tissue swelling of the affected extremity.

METHODS/DESIGN

The VIT study is a prospective, monocenter, randomized controlled trial to compare the VIT system with elevation in the treatment of posttraumatic swelling in the case of a fracture of the upper and lower extremity. This study will include 280 patients with fractures of the upper and the lower extremity with nine different injury types. For each of the nine injury types a separate randomization to the two intervention groups (VIT group or control group) will be performed. The primary outcome parameter is the time taken for the swelling to resolve sufficiently to permit surgery. A separate analysis for each of the nine injury types will be performed.

DISCUSSION

In the proposed study, the effectiveness of the VIT system in the treatment of posttraumatic swelling of upper and lower extremity fractures will be evaluated.

TRIAL REGISTRATION

German Clinical Trial Register, No. DRKS00010510 . Registered on 17 July 2016.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Early versus late surgery for closed ankle fractures

PURPOSE

To compare the outcome after early versus late surgery for closed ankle fractures in terms of the length of hospital stay and infection rate.

METHODS

Records of 95 men and 119 women aged 14 to 92 (mean, 46) years who underwent open reduction and internal fixation for ankle fractures during three 6-month periods in 2004, 2007, and 2010 were reviewed. 82 and 132 patients underwent surgery <24 hours and >24 hours after presentation, respectively. The most common reason for delayed surgery was unavailability of the operation theatre, followed by delayed admission to the fracture clinic and excess soft tissue swelling.

RESULTS

Patient and injury characteristics of the 3 study periods were comparable (p=0.399). The early and late surgery groups were comparable in proportions of various fracture patterns but not in patient age (40 vs. 49 years, p=0.002). The mean postoperative length of hospital stay was shorter in the early surgery group (2.9 vs. 5.5 days, p=0.009). The 2 groups did not differ significantly in the infection rate (7% vs. 11%, p=0.589) or the need for additional surgery (3.7% vs. 5.3%, p=0.63).

CONCLUSION

Patients with delayed surgery for ankle fracture had a longer postoperative length of hospital stay. Surgery should be performed within 24 hours of injury to minimise the length of hospital stay.

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

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

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

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

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Home therapy pathway - safe and streamlined method of initial management of ankle fractures

BACKGROUND

Ankle fractures requiring operative fixation often swell up after 24h and surgery during this period is not feasible as there are several associated risks including infection and wound breakdown. The affected limb is kept elevated usually in hospital and once the swelling has sufficiently subsided then the operation takes place. We conducted a study looking at the impact of a home therapy ankle pathway on the length of stay and safety of patients with ankle fractures requiring surgical fixation.

METHODS

The length of stay of a control group was studied from December 2009 to March 2010. The home therapy ankle pathway was then introduced in August 2010. If patients could not have their operation within 24h then they were placed in a Plaster of Paris back slab in casualty with the ankle reduced, limb care advice given - elevation, cooling and DVT thromboprophylaxis - and the patient was discharged home on crutches after a slot was determined on the trauma list typically six days later. The patient was also given an emergency contact number in case an untoward event occurred, and they were called at least once during their home stay by hospital staff to ensure all was well. Patients who were unsafe to be discharged on home therapy were admitted. This cohort of patients was studied between August 2010 and December 2011 RESULTS: In the control group, 49 ankle fractures required operative intervention. The mean pre-operative length of stay was 2.88 days and the mean post op length of stay was 5 days. Between August 2010 and December 2011, after implementation of the pathway, 176 ankle fractures requiring operative treatment presented to the orthopaedic department. Of these, 105 were eligible for home therapy on the ankle pathway prior to surgery. The average pre-operative length of stay on the pathway was 0.17 days. The average post op length of stay was 1.72 days (P<0.001 in all modalities). Home therapy was carried out for an average of 6.63 days. Challenges of home therapy included persistent swelling and blistering (11), loss of reduction (4), poor pain management whilst at home (4) and cancellation due to lack of availability of a theatre slot (6).

CONCLUSION

With patients in whom it is indicated, the home therapy ankle pathway has proved to be a safe and resource sparing method of managing ankle fractures prior to surgery.

Impact of intermittent pneumatic foot pumps on delay to surgery following ankle fracture

BACKGROUND

Ankle fractures requiring open reduction and internal fixation (ORIF) are common and place considerable burden on inpatient beds. ORIF cannot be performed once the associated swelling is too excessive to permit tension-free wound closure. Where ORIF cannot be performed before the onset of swelling in the first 24-48h, patients typically require up to 7 days of inpatient bed-rest and elevation to reduce swelling to an acceptable level for ORIF. The primary aim of this study was to determine whether delay to ORIF could be reduced with the pre-operative application of an intermittent pneumatic foot pump (IPF). These devices were designed as anti-embolic adjuncts, but have also been shown to be effective in the reduction of swelling. We compared 12 patients managed with an IPF to 12 matched historical controls who were not. No previous studies have addressed this question in unselected patients requiring ankle ORIF.

METHODS

We performed a retrospective, controlled, before and after study of 24 patients who underwent ankle ORIF at our orthopaedic unit. Foot pumps were applied in the Accident and Emergency Department to ankle fracture patients requiring admission, and kept in place until ORIF. Data was collected from patient case notes for all patients. Patients were matched for age, gender, American Society of Anaesthesiologists (ASA) Grade, and pre-injury mobility. The primary outcome measure was time to surgery. We also recorded total hospital stay, and calculated cost savings.

RESULTS

Patients managed with IPFs had a statistically significant 50% reduction in time from presentation to surgery compared to those managed without (p=0.024), and had a reduced hospital stay (p=0.116). This resulted in a net saving of £10,480 (£953 per patient).

CONCLUSIONS

We conclude that foot pumps reduce the time to surgery and total hospital stay of patients requiring ankle ORIF, and are cost effective.

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.

Increased rates of wound complications with locking plates in distal fibular fractures

INTRODUCTION

There is a growing use of locking compression plates in fracture surgery. The current study was undertaken to investigate the wound complication rates of locking versus non-locking plates in distal fibular fractures.

PATIENTS AND METHODS

During a 6-year study period all consecutive, closed distal fibular fractures treated with either a locking or a non-locking plate were included and retrospectively analysed for complication related to the fibula.

RESULTS

A total of 165 patients received a one-third tubular plate and 40 patients were treated with a locking plate. The two groups were comparable with respect to patient characteristics (age, gender, smokers and diabetics), injury characteristics (affected side, fracture dislocations, number of fractured malleoli and classification) and operation characteristics (surgical delay and duration, use of a tourniquet and plate length). The wound complication rate was 5.5% in the conventional plating group, and 17.5% in the locking plate group (p=0.019). This difference was largely due to an increase in major complications, for which removal of the plate was necessary (p=0.008).

CONCLUSION

There is a significant increase in wound complications in distal fibular fractures treated with a locking compression plate. In light of the current study, we would caution against the application of the currently used locking compression plates in the treatment of distal fibular fractures.

Surgical versus nonsurgical treatment of the SE4-equivalent ankle fracture: a retrospective functional outcome study

Treatment of Lauge-Hansen supination-eversion (SE)4-equivalent ankle fractures is controversial. This retrospective study conducted at a level-I trauma center compared the clinical outcome of nonsurgical vs open management of these fractures. One thousand eight ankle fractures treated between 1998 and 2003 were reviewed. Forty-three patients who met the criteria for a SE4-equivalent ankle fracture were identified. Average patient age of 23 men and 20 women was 42 years (range, 18-84 years). Olerud Molander ankle scores were recorded. Medical records and radiographs of all patients were reviewed. Average follow-up was 20 months.Twenty-six patients were treated nonsurgically, with an average ankle score of 84 ± 4. Seventeen patients treated surgically had an average ankle score of 63 ± 5. The difference is statistically significant (unpaired t test, P=.0035). There was no difference between open vs closed treatment in maintaining a reduction. To investigate the reason for poor results in the surgical group, we sought an association between functional ankle score and common covariables and found that age and preoperative radiographic grading were important variables for ankle score. Patients younger than 30 years had an average ankle score of 85, whereas those older than 50 years had an average score of 61 (P<.001). Type 1 fractures (medial clear space >5 mm in stress view only) had an average ankle score of 89, type 2 (medial clear space >5 mm but <10 mm) an average score of 76, and type 3 (medial clear space >10 mm or presented with fracture dislocation and/or syndesmosis injury) an average score of 61. Our data support that type 1 and 2 fractures can effectively be treated nonsurgically.

An innovative and cost-effective way of managing ankle fractures prior to surgery--home therapy

INTRODUCTION

Ankle fractures are common injuries affecting all age groups and constitute a large proportion of the orthopaedic trauma case load. Patients are usually admitted directly to the ward from the emergency department and a large number of bed-days are spent waiting for the ankle swelling to subside prior to surgery. We audited current practice and then implemented a home therapy programme (HTP). The purpose of the study was to assess the pioneering HTP with respect to cost effectiveness, length of stay and patient satisfaction.

PATIENTS AND METHODS

If HTP criteria were met, patients with reduced, unstable ankle fractures were taught safe mobilisation by physiotherapists in the emergency department. They were then discharged home to ice and elevate their ankle in a plaster backslab. A provisional operation date was allocated on discharge. They were admitted to hospital the day of surgery and then discharged home when safe and comfortable.

RESULTS

Forty-three consecutive patients met our inclusion criteria and underwent surgical fixation of unstable ankle fractures over a 3-month period (February-April 2008). The average length of hospital stay was 8 days (range, 1-18 days), 4.5 days pre-operatively and 3.5 days postoperatively. Patients were frustrated and dissatisfied with the whole process. In total, 177 patients underwent surgical fixation of unstable ankle fractures over an 11-month period (November 2008 to October 2009) and, of these, 59 met the home therapy criteria. The average length of hospital stay was 2.4 days, 1 day pre-operatively (range, 0-4 days) and 1.4 days postoperatively (range, 0-5 days). All HTP patients expressed satisfaction with the process. Over the course of the HTP, 354 bed-days were saved which equates to a saving of £81,774. The annual estimated cost saving is £90,000.

CONCLUSIONS

The home therapy programme has proved effective in reducing hospital stay both pre- and postoperatively. It is cost-effective and well received by patients.

The factors associated with prolonged inpatient stay after surgical fixation of acute ankle fractures

In order to identify specific factors associated with prolonged inpatient stay following surgical correction of acute ankle fracture, we conducted a retrospective cohort study of patients who underwent acute ankle fracture repair, comparing length of hospital stay to the reason for delay of surgery (logistical versus clinical), type of fracture, and age. Our findings showed that delay in surgical repair beyond 24 hours following presentation to the emergency department was associated with a statistically significant overall longer length of stay, in comparison to patients who underwent surgery within the first 24 hours (P = .022). Delay due to clinical reasons statistically significantly increased the length of stay (P = .004), whereas those due to purely logistical reasons also prolonged the stay, although this association was not statistically significant in our study (P = .086). We also observed a statistically significant positive correlation between age and length of stay (P </= .001, Spearman's rho = 0.55). Interestingly, patients with a trimalleolar fracture showed a shorter length of stay if the repair was delayed, although this could not be shown to be statistically significant. The results of this investigation indicate that length of hospital stay following ankle fracture is increased by delaying surgical repair of the ankle greater than 24 hours from the time that the patient presents to the emergency department, as well as increased patient age.

Cost benefit with early operative fixation of unstable ankle fractures

INTRODUCTION

Ankle fractures are common and many require surgical intervention. It has been well documented that a delay in fracture fixation results in increased length of hospital stay and increased complication rate. Initial delay can also allow swelling or blistering to develop which may necessitate a further delay in operative fixation for up to 1 week. The aim of the current study was to review the length of hospital in-patient stay for operative ankle fractures over the previous 12-month period at our hospital and compare this to the length of hospital stay following the introduction of a fast-track system for the fixation of these fractures (all fractures fixed within 48 h).

PATIENTS AND METHODS

A retrospective review of all ankle fractures managed by open reduction and internal fixation over a 12-month period was undertaken. A protocol was then agreed to openly reduce and fix these fractures at the earliest possible opportunity over the next 6-month period. We then collected the data on all ankle fractures that needed open reduction and internal fixation over this 6-month period. The pre-protocol and post-protocol groups were then compared for total hospital length of stay and complication rate.

RESULTS

In the 12-month retrospective review, there were 83 ankle fractures that required surgical intervention. Sixty-two of these had surgery within 48 h (mean length of stay, 5.4 days), and 21 had surgery after 48 h (mean length of stay, 9.5 days). There were 39 ankle fractures in the post-protocol group who all had surgery within 48 h (mean length of stay, 5 days). There was no increase in complication rate after implementation of the fast-track system.

CONCLUSIONS

This study shows that early operative intervention for ankle fractures reduces the length of hospital stay. Intensive physiotherapy and co-ordinated discharge planning are also essential ingredients for early discharge. Early operative fixation for unstable ankle fractures has substantial cost-saving implications with no increase in complication rate.

Complications of open reduction and internal fixation of ankle fractures

This article discusses the complications after open reduction and internal fixation of ankle fractures. Complications are classified as perioperative (malreduction, inadequate fixation, and intra-articular penetration of hardware), early postoperative (wound edge dehiscence, necrosis, infection and compartment syndrome), and late (stiffness, distal tibiofibular synostosis, degenerative osteoarthritis, and hardware related complications). Emphasis is placed on preventive measures to avoid such complications.

Foot and ankle fractures in the industrial setting

Fractures of the ankle and foot are common in the worker. Proper initial assessment and treatment can result in a functional recovery that is prompt and complete in many cases. Many fractures, however, have a poor long-term prognosis and prolonged recovery. Frank initial discussions with the patient and case manager can help the system better manage the patient's future.

Timing of operative intervention in the management of acutely fractured ankles and the cost implications

A study of the length of the time between the diagnosis of an ankle fracture and operative intervention and the length of subsequent hospital stay was undertaken. The delay in operative fixation beyond 24 h from injury was associated with a lengthening of stay. The cost implication of a longer stay was assessed. Eighty-seven patients with 87 fractures fulfilled the inclusion criteria of having an acute closed fracture of the ankle requiring open reduction and internal fixation (ORIF). There were 34 unimalleolar, 35 bimalleolar and 18 trimalleolar fractures. Only 47 (54%) of the patients were operated on within 24 h of injury, even though 74 had presented by 6 h and a further five by 24 h. The mean inpatient stay was 9.6 days for this early operation group. The patients who had their operation delayed were in hospital for a mean of 14 days, a significant difference (P<0.0001) (using Wilcoxon's Signed Rank test). The cost per patient per day of an acute trauma bed is estimated at pound sterlings 225. This translates into an average cost of pound sterlings 990 more per patient whose operation is delayed. We recommend that policies be put in place to provide early operative intervention for patients with fractured ankles as this would result in significant financial savings.