Risk of Ankle Fusion or Arthroplasty After Operatively and Nonoperatively Treated Ankle Fractures: A Matched Cohort Population Study

Complications After Ankle Fracture Surgery in Finland Between 1998 and 2020

BACKGROUND

Ankle fracture is a common injury and often requires operative treatment. This study investigated short-term (≤4 months) and long-term (>4 months) complications after ankle fracture surgery in a 23-year period with use of data from a comprehensive, nationwide, individual-level register.

METHODS

Data regarding patients who underwent operative treatment for ankle fracture were collected from the Finnish Care Register for Health Care and analyzed with use of logistic and Cox regression.

RESULTS

A total of 83,666 ankle fractures were operatively treated between 1998 and 2020. Of these, 36% were lateral malleolar fractures, 7% were medial malleolar fractures, 52% were bimalleolar or trimalleolar fractures, and 5% were other types of fractures. Fifty-one percent of the fractures were in female patients. The overall rate of short-term complications was 7.2%. Specifically, infection occurred in 4.4% of cases; thromboembolic complications,1.6% of cases; mechanical complications, 0.4% of cases; and other complications, 0.9% of cases. An age of >75 years was associated with a higher rate of short-term complications than an age of 51 to 75 years, with an odds ratio of 1.53 in the multivariable analysis (95% confidence interval, 1.39 to 1.67; p < 0.001). Short-term complications were also more prevalent in patients with diabetes (with or without associated complications); chronic pulmonary, kidney, or liver disease; or peripheral vascular disease. Mortality during the first 4 months after the ankle fracture operation was 0.6%. The most common reason for reoperation in the long term (>4 months after the index procedure) was fixation device removal, with a cumulative incidence of 17% within the first 3 years postoperatively. The risk of implant removal increased in younger patients and patients with bimalleolar or trimalleolar fractures. The cumulative incidence of ankle arthrodesis and arthroplasty was low.

CONCLUSIONS

Although postoperative complications are relatively rare, their treatment can lead to considerable morbidity. The findings of this study allow us to identify patients who are prone to complications or reoperations after undergoing operative treatment for ankle fracture.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Computed tomography changes diagnosis, management and surgical planning of ankle fractures

PURPOSE

To demonstrate how the use of adjunctive Computed Tomography (CT) can modify diagnosis, treatment options, and operative planning of ankle fractures in comparison with conventional radiographs (CR) in isolation.

MATERIALS AND METHODS

A total of 53 patients diagnosed with an ankle fracture between 2011 and 2016, were assessed with CT and CR. Evaluations of the fractures using CR in isolation and CR combined with CT were compared using different readers. Fractures were assessed in terms of type, displacement, size, associated injuries, treatment, patient position and surgical planning.

RESULTS

The medial malleolus fractures characteristics (posteromedial fragment and anterior colliculus), the presence of posterior malleolus fracture and its characteristics (displacement, size, posteromedial or posterolateral segment) (ps < 0.042), syndesmosis injury (p < 0.001), and the absence of deltoid ligament lesion (p < 0.001), were more evident with the combination of CT and radiographs. There was an increase in operative indication (p = 0.007), prone positioning (p = 0.002), posterior malleolus surgical treatment (p < 0.001), posterolateral approach for the lateral malleolus (p = 0.003), and syndesmosis fixation (p = 0.020) with the association of CT and CR, among all groups of expertise, with a high interobserver reliability (> 0.75).

CONCLUSIONS

The CR may fail to demonstrate subtle lesions, such as posterior malleolus fractures and syndesmotic injuries. The CT evaluation increases the diagnostic precision and improves the quality of information the surgeon receives, what might positively affect patient care.

LEVEL OF EVIDENCE III

Retrospective Comparative Study.

Syndesmosis fixation in supination-external rotation ankle fractures. Long-Term results of a prospective randomised study

BACKROUND

The clinical relevance and treatment of syndesmosis injury in supination-external rotation (SER) ankle fractures are controversial.

METHODS

After malleolar fixation 24 SER 4 ankle fracture patients with unstable syndesmosis in external rotation stress test were randomised to syndesmosis transfixation with a screw (13 patients) or no fixation (11 patients). Mean follow-up time was 9.7 years (range, 8.9-11.0). The primary outcome measure was the Olerud-Molander Ankle Outcome Score (OMAS). Secondary outcome measures included ankle mortise congruity and degenerative osteoarthritis, 100-mm visual analogue scale for function and pain, RAND 36-Item Health Survey, and range of motion.

RESULTS

Mean OMAS in the syndesmosis transfixation group was 87.3 (SD 15.5) and in the no-syndesmosis-fixation group 89.0 (SD 16.0) (difference between means 1.8, 95% CI -10.4-14.0, P = 0.76). There were no differences between the two groups in secondary outcome measures.

CONCLUSION

With the numbers available, SER 4 ankle fractures with unstable syndesmosis can be treated with malleolar fixation only, with good to excellent long-term functional outcome.

Talus Visualization in Ankle Fractures: How Much Are We Really Seeing?

Background:

Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time.

Purpose:

To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus.

Study Design:

Descriptive laboratory study.

Methods:

Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated.

Results:

Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm² (95% CI, 13.3-14.7 cm²), while the mean area visible via an open approach was 2.1 cm² (95% CI, 0.5-3.6 cm²). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%).

Conclusion:

These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate.

Clinical Relevance:

Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.

Registries: Big data, bigger problems?

Patient registries have grown in size and number along with general computing power and digitization of the healthcare world. In contrast to databases, registries are typically patient data systematically created and collected for the express purpose of answering health-related questions. Registries can be disease-, procedure-, pathology-, or product-based in nature. Registry-based studies typically fit into Level II or III in the hierarchy of evidence-based medicine. However, a recent advent in the use of registry data has been the development and execution of registry-based trials, such as the TASTE trial, which may elevate registry-based studies into the realm of Level I evidence. Some strengths of registries include the sheer volume of data, the inclusion of a diverse set of participants, and their ability to be linked to other registries and databases. Limitations of registries include variable quality of the collected data, and a lack of active follow-up (which may underestimate rates of adverse events). As with any study type, the intended design does not automatically lead to a study of a certain quality. While no specific tool exists for assessing the quality of a registry-based study, some important considerations include ensuring the registry is appropriate for the question being asked, whether the patient population is representative, the presence of an appropriate comparison group, and the validity and generalizability of the registry in question. The future of clinical registries remains to be seen, but the incorporation of big data and machine learning algorithms will certainly play an important role.