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Wang Y, Qi Y, Ma B, Wu H, Wang Y, Wei B, Wei X, Xu Y. Three-dimensional gait analysis of orthopaedic common foot and ankle joint diseases. Front Bioeng Biotechnol 2024; 12:1303035. [PMID: 38456008 PMCID: PMC10919227 DOI: 10.3389/fbioe.2024.1303035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/02/2024] [Indexed: 03/09/2024] Open
Abstract
Walking is an indispensable mode of transportation for human survival. Gait is a characteristic of walking. In the clinic, patients with different diseases exhibit different gait characteristics. Gait analysis describes the specific situation of human gait abnormalities by observing and studying the kinematics and dynamics of limbs and joints during human walking and depicting the corresponding geometric curves and values. In foot and ankle diseases, gait analysis can evaluate the degree and nature of gait abnormalities in patients and provide an important basis for the diagnosis of patients' diseases, the correction of abnormal gait and related treatment methods. This article reviews the relevant literature, expounds on the clinical consensus on gait, and summarizes the gait characteristics of patients with common ankle and foot diseases. Starting from the gait characteristics of individuals with different diseases, we hope to provide support and reference for the diagnosis, treatment and rehabilitation of clinically related diseases.
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Affiliation(s)
| | | | | | | | | | | | | | - Yongsheng Xu
- Orthopedic Center (Sports Medicine Center), Inner Mongolia People’s Hospital, Hohhot, China
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James HK, Griffin DR, Griffin J, Fisher JD, Pattison GTR. Ankle fracture internal fixation performed by cadaveric simulation-trained versus standard-trained orthopaedic trainees: a preliminary, multicentre randomized controlled trial. Bone Jt Open 2023; 4:594-601. [PMID: 37586708 PMCID: PMC10546066 DOI: 10.1302/2633-1462.48.bjo-2022-0144.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
Aims Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance. Methods We undertook a preliminary, pragmatic, single-blinded, multicentre, randomized controlled trial of cadaveric simulation versus standard training. Primary outcome was fracture reduction on postoperative radiographs. Results Overall, 139 ankle fractures were fixed by 28 postgraduate year three to five trainee surgeons (mean age 29.4 years; 71% males) during ten months' follow-up. Under the intention-to-treat principle, a technically superior fixation was performed by the cadaveric-trained group compared to the standard-trained group, as measured on the first postoperative radiograph against predefined acceptability thresholds. The cadaveric-trained group used a lower intraoperative dose of radiation than the standard-trained group (mean difference 0.011 Gym2, 95% confidence interval 0.003 to 0.019; p = 0.009). There was no difference in procedure time. Conclusion Trainees randomized to cadaveric training performed better ankle fracture fixations and irradiated patients less during surgery compared to standard-trained trainees. This effect, which was previously unknown, is likely to be a consequence of the intervention. Further study is required.
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Affiliation(s)
- Hannah K. James
- Department of Trauma & Orthopaedic Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
- Warwick Clinical Trials Unit, Warwick Medical School, Coventry, UK
| | - Damian R. Griffin
- Department of Trauma & Orthopaedic Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
- Warwick Clinical Trials Unit, Warwick Medical School, Coventry, UK
| | - James Griffin
- Warwick Clinical Trials Unit, Warwick Medical School, Coventry, UK
| | - Joanne D. Fisher
- Warwick Clinical Trials Unit, Warwick Medical School, Coventry, UK
| | - Giles T. R. Pattison
- Department of Trauma & Orthopaedic Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
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Sanchez T, Sankey T, Scheinberg MB, Schick S, Singh S, Cheppalli N, Davis C, Shah A. Factors and Radiographic Findings Influencing Patient-Reported Outcomes Following Maisonneuve Fractures. Cureus 2023; 15:e43536. [PMID: 37719488 PMCID: PMC10501688 DOI: 10.7759/cureus.43536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND This research adds to the literature by providing prognostic information for physicians and patients regarding the outcomes of operative management of Maisonneuve fractures (MFs). To date, this is the only cohort study of patient-reported outcomes measurement information systems (PROMIS) scores following surgical fixation of MF. Patient outcomes were compared focusing on the mean population with an inter-analysis using basic demographic information, radiographic findings, and patient comorbidities and their respective impact on PROMIS scores. METHODS A total of 24 patients between 2012 and 2020 met the inclusion criteria and completed PROMIS surveys at a minimum of 18 months postoperatively. Patient charts were reviewed through the electronic medical record (EMR) for demographic information and comorbidities as well as operative variables. PROMIS scores for physical function (PF), pain interference (PI), and depression were obtained via follow-up visits and phone calls. The impact of categorical variables on complications was compared using Chi-Squared tests. Variables were analyzed with a type 3 SS test to stratify independent risk factors' effect on PROMIS scores and to account for confounding variables. RESULTS PROMIS PF averaged 44.84 and was significantly affected by BMI>30 (p=.033), hypertension (HTN) (p=.026), patients with clinical anxiety or depression (p=.047), and subsequent screw removal (p=.041). PROMIS PI averaged a score of 54.57 and was significantly affected by BMI>30 (p=.0046), coronary artery disease (CAD) (p=.0123), patients with clinical anxiety or depression (p=.0206), and subsequent screw removal (p=.0039). PROMIS depression scores averaged 46.03 and were significantly affected by the presence of CAD (p=.049) and subsequent screw removal (p=.023). CONCLUSION Patient-reported outcomes following MF surgery demonstrated PROMIS scores within +/- 1 standard deviation of the population-based control, and thus many patients can reasonably expect to return to a level of function comparable to the general population. Nonetheless, the significant effects of patient comorbidities and surgical variables ought to be evaluated and utilized as prognostic indicators when managing patient expectations prior to operative treatment of an MF injury.
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Affiliation(s)
- Thomas Sanchez
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Turner Sankey
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Mila B Scheinberg
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Samuel Schick
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Swapnil Singh
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | | | - Chandler Davis
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Ashish Shah
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
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Maseda M, Konda S, Leucht P, Ganta A, Karia R, Egol K. Tibial plateau fractures in the elderly have clinical outcomes similar to those in younger patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03384-y. [PMID: 36114875 DOI: 10.1007/s00590-022-03384-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 09/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The purpose of this study was to compare outcomes following surgical treatment of tibial plateau fractures in an elderly (≥ 65y) and non-elderly (< 65) population. METHODS Patients with tibial plateau fractures were prospectively followed. Patients were included if they were operatively treated, had an Injury Severity Score of < 16, and had follow-up through 12 months. Clinical, radiographic, and functional outcomes were evaluated at the 3, 6, and 12-month follow-up points. RESULTS Mean time to radiographic fracture union was by 4.68 and 5.26 months in young and elderly patients, respectively (p = 0.25). There was no difference in self-reported baseline SMFA (p = 0.617). SMFA scores were better in younger patients at 3 months (p = 0.031), however this did not hold when multivariate modeling controlled for other factors. There was no difference at 6 and 12 months (p = 0.475, 0.392). There was no difference in range of knee motion at 3 months. At 6 and 12 months, young patients had statistically but not clinically better range of knee motion (p = 0.045, 0.007). There were no differences in overall reoperation rates, conversion arthroplasty, post-traumatic osteoarthritis or wound complications. CONCLUSIONS Age greater than 65 does not appear to portend poorer outcomes after surgical repair of a tibial plateau fracture. The complication profiles are similar. Elderly and younger patients had similar function at 12 months compared to their baseline. These data suggest that age should not be a disqualifying factor when considering whether a patient with a tibial plateau fracture should be treated operatively.
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Affiliation(s)
- Meghan Maseda
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Sanjit Konda
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
| | - Philipp Leucht
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Abishek Ganta
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
| | - Raj Karia
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10003, USA
| | - Kenneth Egol
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10003, USA.
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA.
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Penning D, Kleipool S, van Dieren S, Dingemans SM, Schepers T. The minimal clinically important difference (MCID) of the Olerud Molander Ankle Score (OMAS) in patients with unstable ankle fracture. Arch Orthop Trauma Surg 2022; 143:3103-3110. [PMID: 35821429 DOI: 10.1007/s00402-022-04533-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/18/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The Olerud Molander Ankle Score (OMAS) is a widely used validated Patient Reported Outcome Measure (PROM). For clinical research, it is important to determine the Minimal Clinically Important Difference (MCID). The objective of this study was to determine the MCID of the OMAS at several moments in the follow-up, in a cohort of patients that underwent open reduction and internal fixation of unstable ankle fractures with syndesmotic injury. MATERIALS AND METHODS Data for this descriptive study were extracted from a prospective randomized controlled trial, the RODEO trial. The Dutch version of the OMAS was completed at 3, 6 and 12-month follow-up and estimated at baseline. The used anchor-based methods were: mean change and ROC curve. The distribution-based methods were: 0.5SD and minimal detectable change (MDC). RESULTS This cohort included 148 patients. The mean OMAS score in the group with minimal improvement between 3 and 6 months was 15.0 (SD 17.5, 95%CI 9.4-20.6) and between 6 and 12 months 9.5 (SD 17.1, 95% CI 3.1-15.9). The ROC curve between 3 and 6 months resulted in a MCID of 12.5 (AUC 0.72) and between 6 and 12 months, the MCID was 7.5 (AUC 0.78). Using 0.5 SD, the MCID was 10.52 (SD 21.04) at 3 months, 11.37 (SD 22.73) at 6 months and 10.47 (SD 20.94) at 12 months. The MDC was 4.72 at 3 months, 5.20 at 6 months and 4.71 at 12 months. CONCLUSIONS The calculated MCID in patients following surgery for unstable ankle fractures ranges from 10.5 to 15.0 at 3-6-month follow-up and from 7.5 to 11.4 at 6-12-month follow-up, depending on moment and method.
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Affiliation(s)
- Diederick Penning
- Trauma Unit, Amsterdam University Medical Center, Location Meibergdreef, Amsterdam Movement Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | | | - Susan van Dieren
- Department of Clinical Epidemiology, Amsterdam University Medical Center, Location Meibergdreef, Amsterdam, The Netherlands
| | - Siem M Dingemans
- Trauma Unit, Amsterdam University Medical Center, Location Meibergdreef, Amsterdam Movement Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | | | - Tim Schepers
- Trauma Unit, Amsterdam University Medical Center, Location Meibergdreef, Amsterdam Movement Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Stowers JM, Black AT, Kavanagh AM, Mata KDL, Bohm A, Katchis SD, Weiner LS, Spielfogel W, Rahnama A. Predicting Nonunions in Ankle Fractures Using Quantitative Tibial Hounsfield Samples From Preoperative Computed Tomography: A Multicenter Matched Case Control Study. J Foot Ankle Surg 2022; 61:562-566. [PMID: 34819267 DOI: 10.1053/j.jfas.2021.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 07/12/2021] [Accepted: 10/05/2021] [Indexed: 02/06/2023]
Abstract
The aim of this study is to use tibial Hounsfield unit measurements from preoperative computed tomography scans of ankle fractures to predict delayed union and nonunion. We hypothesize that patients with lower Hounsfield unit averages, an indirect measure of lower bone mineral density, in the distal tibia are more likely to develop delayed union and nonunion complications after ankle fracture surgery. Patient data from January 2010 to January 2020 were retrospectively analyzed from 2 institutions. Exposure cases of delayed union or nonunion that had preoperative computed tomography were compared to 5 controls matched for sex, age, and classification. 3 measurements were taken from the tibia on axial computed tomography and averaged to create a summative measure for overall bone health. Statistical analysis was used to analyze the relationship between the groups. 19 exposure patients were compared to 95 control patients. There were 16 females and 3 males in the exposure group aged from 30 to 88 years. Average follow-up was 1.6 years. The average exposure and control Hounsfield measurements were 186 (161-210) and 258 (248-269), respectively. Significant differences were found for all measured averages. This is the first study to our knowledge relating preoperative tibial Hounsfield measurements to healing rates of ankle fractures. Measurements taken from any of the 3 sites or the average could be an indicator of overall bone health. Using this technique on preoperative imaging will help surgeons adjust their perioperative planning for patients at higher risk for delayed union and nonunion.
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Affiliation(s)
- Jered M Stowers
- ACFAS Surgical Fellow, Foot and Ankle Institute Fellowship, Indianapolis, IN.
| | - Alexandra T Black
- ACFAS Surgical Fellow, Foot and Ankle Specialists of Central Ohio Foot and Ankle Surgery Fellowship, Columbus, OH
| | - Amber M Kavanagh
- Resident Physician, Department of Plastics Surgery, Medstar Georgetown University Hospital, Washington, DC
| | - Karla De La Mata
- Resident Physician, Department of Podiatric Surgery, Northwell Lenox Hill Hospital, New York, NY
| | - Andrew Bohm
- Biostatistician, Department of Orthopedics, Lenox Hill Hospital Northwell Health, New York, NY
| | - Stuart D Katchis
- Section Chief Foot and Ankle, Department of Orthopedics, Lenox Hill Hospital Northwell, New York, NY
| | - Lon S Weiner
- Program Director, Department of Orthopedics, Lenox Hill Hospital Northwell, New York, NY
| | - William Spielfogel
- Chief of Podiatry, Department of Orthopedics, Lenox Hill Hospital Northwell, New York, NY
| | - Ali Rahnama
- Fellowship Trained Foot and Ankle Surgeon Assistant Professor, Georgetown University, School of Medicine, Washington, DC
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Stupay KL, Miller CP, Staffa S, McTague MF, Weaver MJ, Kwon JY. Risk Factors for Aseptic Revision of Operatively Treated Ankle Fractures. Foot Ankle Int 2022; 43:378-388. [PMID: 34677113 DOI: 10.1177/10711007211050876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Early revision rates within 12 months after ankle fracture open reduction internal fixation (AF-ORIF) are fairly low; however, they remain relevant given the volume of ankle fractures occurring annually. Understanding these rates is complex because reoperation due to technical or mechanical complications is typically reported alongside soft tissue-related problems such as symptomatic hardware, wound dehiscence, or infection. There are limited data identifying risk factors specifically for revision of ankle fracture fixation in the absence of soft tissue complications. Understanding variables that predispose to aseptic technical and mechanical failure without this confounder may provide insight and improve patient care. METHODS A retrospective cohort study was performed at 2 large academic medical centers. Research Patient Data Registry (RPDR) data available from 2002 to 2019 were used to identify patients who underwent aseptic revision of AF-ORIF within 12 months (n = 33). A control group (n = 100) was selected by identifying sequential patients who underwent AF-ORIF not requiring revision within 12 months. Multiple factors were recorded for all patients in both cohorts. Each fracture was also evaluated according to the Ankle Reduction Classification System (ARCS) of Chien et al,8 which categorizes biplanar talar displacement in relation to a central tibial plumb line into 1 of 3 grades: A (0-2 mm), B (3-10 mm), and C (>10 mm). Adapted from its original purpose of grading reduction quality, we applied ARCS to pre-reduction radiographs to assess initial fracture displacement. All variables collected were compared in univariate analysis. Variables that achieved significance in univariate comparisons were included as candidates for multivariable analysis. RESULTS Final multivariable logistic regression modeling demonstrated the following factors to independently predict the need for aseptic revision surgery: documented falls in the early postoperative period (aOR, 298; 95% CI, 15.4, 5759; P < .001), movement-altering disorders (aOR, 81.7; 95% CI, 4.12, 1620; P = .004), a nonanatomic mortise (medial clear space [MCS] > superior clear space [SCS]) on immediate postoperative imaging (aOR, 38.4; 95% CI, 5.53, 267; P < .001), initial coronal plane tibiotalar displacement >10 mm and sagittal plane tibiotalar dislocation (ARCS-C) (aOR vs ARCS-A, 25.8; 95% CI, 2.81, 237; P = .004), substance abuse (aOR, 15.7; 95% CI, 2.66, 92.8; P = .002), and polytrauma (aOR, 12.3; 95% CI, 2.02, 74.8; P = .006). CONCLUSION In this investigation we found a notable increase in risk for revision surgery after AF-ORIF for patients who had one of the following: (1) falls in the early postoperative period, (2) movement-altering disorders, (3) a nonanatomic mortise (MCS > SCS) on immediate postoperative imaging, (4) more severe initial fracture displacement, (5) substance abuse, or (6) polytrauma. Identifying these factors may allow surgeons to better understand risk and counsel patients, and may serve as future targets for intervention aimed at improving patient safety and outcomes after ankle fracture ORIF. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Kristen L Stupay
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Christopher P Miller
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Steven Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Michael F McTague
- Harvard Medical School Orthopaedic Trauma Initiative, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michael J Weaver
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - John Y Kwon
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Gait Alterations in Adults after Ankle Fracture: A Systematic Review. Diagnostics (Basel) 2022; 12:diagnostics12010199. [PMID: 35054366 PMCID: PMC8774579 DOI: 10.3390/diagnostics12010199] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/24/2021] [Accepted: 12/26/2021] [Indexed: 12/04/2022] Open
Abstract
(1) Background: Ankle fracture results in pain, swelling, stiffness and strength reduction, leading to an altered biomechanical behavior of the joint during the gait cycle. Nevertheless, a common pattern of kinematic alterations has still not been defined. To this end, we analyzed the literature on instrumental gait assessment after ankle fracture, and its correlation with evaluator-based and patient-reported outcome measures. (2) Methods: We conducted a systematic search, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, of articles published from January 2000 to June 2021 in PubMed, Embase and PEDro on instrumental gait assessment after ankle fracture. (3) Results: Several changes in gait occur after ankle fracture, including a reduction in step length, swing time, single support time, stride length, cadence, speed and an earlier foot-off time in the affected side. Additionally, trunk movement symmetry (especially vertical) is significantly reduced after ankle fracture. The instrumental assessments correlate with different clinical outcome measures. (4) Conclusions: Instrumental gait assessment can provide an objective characterization of the gait alterations after ankle fracture. Such assessment is important not only in clinical practice to assess patients’ performance but also in clinical research as a reference point to evaluate existing or new rehabilitative interventions.
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Abstract
Objectives: To assess the patient and injury characteristics that impact functional outcomes after ankle fracture. Design: Retrospective study. Setting: Urban level I trauma center. Patients/Participants: One thousand patients underwent fixation of ankle fracture (AO/OTA 44) between 2006 and 2015. Four hundred sixteen completed functional outcome surveys by telephone or mail at a mean of 5.9 years after injury. Intervention: Open reduction internal fixation. Main outcome measure: Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA). Results: Mean age was 46.7 years, with 46.2% male. Higher (worse) FFI scores were seen in tobacco users (38.9 vs 30.1), recreational drug users (45.9 vs 32.7), and the morbidly obese (52.0 vs 30.6), all P < .005. Higher (worse) SMFA dysfunction and bothersome scores were also seen in these groups, and in females and alcohol users. Multiple regression analysis identified female gender, obesity, tobacco and alcohol use, complications, secondary procedures, and multiple additional injuries as independent predictors of higher scores (all P < .04). Fracture patterns, open fracture, and development of arthritis had no impact on FFI or SMFA scores. Conclusion: Patient characteristics, not under surgeon-control, such as female sex, obesity, and substance use, appear to contribute to patient-reported functional outcome scores more than injury characteristics. Level of Evidence: Level 3, prognostic
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Simske NM, Hermelin MJ, Vallier HA. Impact of Psychosocial and Economic Factors on Functional Outcomes After Operative Calcaneus Fractures. J Orthop Trauma 2021; 35:e423-e428. [PMID: 33967225 DOI: 10.1097/bot.0000000000002082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To report functional outcome scores after operative intraarticular calcaneus fracture and to determine risk factors associated with worse outcomes. DESIGN Retrospective study. SETTING Urban Level 1 trauma center. PATIENTS AND PARTICIPANTS Ninety-six patients with 114 calcaneus fractures treated by a single surgeon over a 14-year period. INTERVENTION Surgical treatment with open reduction and internal fixation with lateral extensile approach or percutaneous reduction and fixation. MAIN OUTCOME MEASUREMENTS Functional outcome scores as assessed by the Musculoskeletal Function Assessment (MFA) and the Foot Function Index (FFI) after mean 56 months follow-up. RESULTS Seventy-two patients (75%) completed functional outcome questionnaires. Patients with functional outcome data were more often employed (86% vs. 67%, P = 0.07), but were no different in terms of age, sex, medical history, mechanism of injury, or injury characteristics. The mean FFI score was 30 (range: 2-89), and the mean MFA score was 28 (range: 2-80). One-third of patients reported scores >30 on the FFI, MFA, or both. Age, sex, tobacco use, mechanism of injury, fracture pattern, open injury, and postoperative infection were not associated with outcome scores. Alcohol abuse and failure to return to work were associated with worse (higher) FFI scores. Alcohol abuse, psychiatric illness, unemployment (before and after injury), polytrauma, and posttraumatic osteoarthrosis were associated with worse (higher) MFA scores. CONCLUSIONS Polytrauma, alcohol abuse, psychiatric illness, work status, and posttraumatic osteoarthrosis were predictors of poor functional outcomes. The findings of this study add to previous literature that has demonstrated the importance of social, behavioral, and environmental factors on recovery after orthopaedic injury. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Natasha M Simske
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
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11
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Abstract
BACKGROUND Several studies have reported on potential negative predictive factors of functional outcomes after ankle fracture fixation. However, there is minimal patient-reported data on long-term outcomes. This study aimed to evaluate potential risk factors leading to a poor patient-reported functional outcome at 2 and 5 years following ankle fracture fixation. METHODS We conducted a prospective cohort study over a 5-year period on patients undergoing open reduction and internal fixation for unstable ankle fractures. Patient demographics, medical comorbidities, fracture pattern, and fixation quality were recorded and analyzed. Patients were followed up at 2 and 5 years. Data collected include the Olerud-Molander Ankle Score (OMAS), Lower Extremity Functional Scale (LEFS), ongoing issues, and the need for further intervention. A P value <.05 was considered statistically significant. RESULTS Out of 180 patients, follow-up data were available for 82 (46%) patients at 2 years and 94 (52%) patients at 5 years. At 2 years, age ≥60 years was a predictor of worse LEFS, while a body mass index ≥30 was a predictor of worse OMAS. Severely deformed ankle at presentation showed worse OMAS and LEFS score. However, these predictive factors were not significant at 5 years. An anatomically reduced ankle fracture fixation was more likely to have a better functional outcome at the 2- and 5-year follow-ups. A reduction in OMAS at 2 years was predictive of possible ongoing issues following surgery, which in turn increased the odds of worsening OMAS at 5 years. CONCLUSION Achieving adequate fracture reduction during fixation is crucial for better ankle functional recovery postinjury. In this cohort, we found that patients who undergo ankle fracture fixation will have an ongoing negative impact on their functional and physical capacity at both 2 and 5 years postoperatively. Appropriate patient counseling is necessary to prepare them for the expected functional outcomes. LEVEL OF EVIDENCE Level II, prognostic.
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Affiliation(s)
- Han Hong Chong
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Pranav Mishra
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Paul Rai
- University Hospitals of Leicester NHS Trust, Leicester, UK
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12
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Gregersen MG, Molund M. Weightbearing Radiographs Reliably Predict Normal Ankle Congruence in Weber B/SER2 and 4a Fractures: A Prospective Case-Control Study. Foot Ankle Int 2021; 42:1097-1105. [PMID: 34261365 DOI: 10.1177/10711007211027286] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In Weber B/SER2-4 ankle fractures, assessment with weightbearing radiographs to ascertain stability of the ankle mortise has been advised. However, no previous studies report whether this method leads to preservation of normal ankle congruence. The purpose is to evaluate equivalence of ankle congruence of injured ankles after fracture union, vs the uninjured side, for stable SER2 and partially unstable SER4a fracture types. METHODS We conducted a prospective case-control study designed as an equivalence trial to evaluate if weightbearing radiographs predict whether stable/SER2 and partially unstable/SER4a Weber B ankle fractures reach union with preserved normal tibiotalar congruence and without a concomitant increase of treatment failure. A total of 149 patients with a Weber B fracture stable on weightbearing radiographs were recruited into the trial. All participants were treated with a functional orthosis and weightbearing allowed. Results from gravity stress radiographs classified ankles as SER2 or SER4a fracture types. We defined an equivalence margin in medial clear space difference of 1.0 mm. We also evaluated the reliability of obtaining measurements from weightbearing radiographs. RESULTS No differences in medial clear space between the injured and uninjured ankles were observed after fracture union for the SER2 group (mean difference 0.1 mm, 95% confidence interval [CI] -0.3, 0.0; P = .056), or the SER4a group (mean difference 0.0 mm (95% CI -0.1, 0.1; P = .797). No between-group differences were observed (mean difference 0.0 mm, 95% CI -0.2, 0.2; P = .842). These findings were consistent with equivalence. CIs for the intraclass correlation coefficients indicated excellent reliability. CONCLUSION Assessment of stability of Weber B SER2/4a ankle fractures, with weightbearing radiographs, also predicts preservation of normal ankle congruence in those deemed stable, with no difference between SER2 and SER4a fracture types. Further, excellent reproducibility of the method of obtaining medial clear space measurements was demonstrated. LEVEL OF EVIDENCE Level III, case-control.
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Affiliation(s)
- Martin G Gregersen
- Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, Grålum, Norway
| | - Marius Molund
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
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Park YU, Kim SJ, Kim HN. Minimally invasive plate osteosynthesis using the oblong hole of a locking plate for comminuted distal fibular fractures. J Orthop Surg Res 2021; 16:281. [PMID: 33906661 PMCID: PMC8077965 DOI: 10.1186/s13018-021-02441-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background Nonunion is a rare complication for distal fibular fractures. However, when there is a high degree of comminution, nonunion may occur. In this article, we describe a novel technique that uses the oblong hole of a locking plate to lengthen the fibula for fracture reduction. This technique is straightforward and allows for easy control of the comminuted fracture to restore length and rotation at the time of plate application without opening the fracture site. Methods Thirty-five consecutive patients, who were treated with the minimally invasive plate osteosynthesis (MIPO) technique for comminuted distal fibular fractures were retrospectively studied. The study included 19 men and 16 women, with a mean age of 47.0 years (range, 20 to 72). There were 3 lateral malleolar fractures with deltoid injury, 11 bimalleolar fractures, 7 trimalleolar fractures, and 14 distal tibiofibular fractures. The quality of fracture reduction was assessed by comparing the radiologic parameters (fibular length, talocrural angle, and medial clear space) between the affected ankle and the contralateral uninjured ankle. Results Two patients were not reachable and 5 declined to visit the clinic. For these 7 patients, the latest outcomes that were measured prospectively were used. Postoperative radiographs showed well-aligned ankle mortise, with fibular length restoration. The mean Olerud-Molander ankle score was 82.1 ± 10.7 at a mean of 27.2 months (range, 12 to 58). There was one case of nonunion and one case of superficial peroneal nerve injury. Conclusion The MIPO technique, using the oblong hole of a locking plate, achieved satisfactory restoration of length and rotation, bone union, and clinical outcomes for the comminuted distal fibular fractures.
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Affiliation(s)
- Young Uk Park
- Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Sung Jae Kim
- Department of Orthopedic Surgery, Dongtan Sacred Hospital, Hallym University, Hwaseong, South Korea
| | - Hyong Nyun Kim
- Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1, Dalim-1dong, Youngdeungpo-gu, Seoul, 150-950, Republic of Korea.
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Balaji G, Bhukya S, Nema S, Rajeswari M, Vellaipandi V. Predictors of Functional Outcome in Unstable Ankle Fractures Treated Surgically - A Prospective Cohort Study. Malays Orthop J 2021; 15:85-92. [PMID: 33880153 PMCID: PMC8043639 DOI: 10.5704/moj.2103.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: Unstable ankle injuries require anatomical reduction and stabilisation for optimal outcome. In spite of adequate care, a few patients have poor outcome. In this study, we assessed the risk factors that predict the clinical outcomes in surgically treated unstable ankle fractures. Material and methods: This prospective cohort study was conducted on 68 patients who underwent surgical management for an unstable ankle injury. Demographic details, fracture type and associated medical comorbidities were recorded. Pre-operative radiographic assessment was done for all patients. At the end of one year follow-up, clinical (American Orthopaedic foot and ankle society-AOFAS and Olerud-Molander ankle - OMAS) scores and radiological parameters were assessed and analysed. Results: Fracture dislocation (0.008), diabetes mellitus (0.017), level of alchohol consumption (0.008) and pre-operative talocrural angle (TCA) > 100° (0.03) were significant predictors of poor outcomes as per AOFAS. Fracture dislocation (0.029), diabetes mellitus (0.004), pre-operative TCA > 100° (0.009), female gender (0.001), age more than 60 years (0.002) and open injuries (0.034) had significantly poor outcome as per OMAS. Other parameters (smoking, hypertension, classification, syndesmotic injury, medial clear space and tibiofibular overlap) did not affect the outcome significantly. Conclusion: Our study showed that poor outcome predictors in unstable ankle fractures are age >60 years, female gender, diabetes mellitus, alcohol consumption, fracture dislocation, open fractures and pre-op TCA >100°.
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Affiliation(s)
- G Balaji
- Department of Orthopaedics Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - S Bhukya
- Department of Orthopaedics Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - S Nema
- Department of Orthopaedics Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - M Rajeswari
- Department of Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - V Vellaipandi
- Department of Orthopaedics, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
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Lobo S, Zargaran D, Zargaran A. The 50 most cited articles in ankle surgery. Orthop Rev (Pavia) 2021; 12:8593. [PMID: 33585022 PMCID: PMC7874954 DOI: 10.4081/or.2020.8593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/24/2020] [Indexed: 12/25/2022] Open
Abstract
This paper aims to establish a ranking of the 50 most cited research articles pertaining to ankle surgery in the field of orthopaedics. In addition, the demographic features such as the date of publications, location of primary author and country of the publisher were all analysed. Studies similar to these have been completed in other subspecialties, however we were not able to find studies relevant to ankle surgery. The Web of Science Cor Collection Database was utilised to identify the target articles. The most cited article was cited 394 times and the least was cited 120 times, and the majority of articles were published in the United States of America. This research will benefit the scientific community in identifying popular research topics, identifying lacking fields and identifying key hubs in the field of ankle surgery.
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Dwivedi R, Karki A, Bhattarai R, Rijal B. Functional Outcome Estimation of Bimalleolar Ankle Fractures Treated by Open Reduction and Internal Fixation at a Tertiary Care Center: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc 2020; 58:740-743. [PMID: 34504356 PMCID: PMC7654478 DOI: 10.31729/jnma.5532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction: Ankle fractures account for about 9% of all fractures in adults. Open reduction and internal fixation is the preferred treatment for such injuries. However, surgery is not free of complications, and outcomes following surgery are not always satisfactory. Therefore, this study aimed to estimate the functional outcomes of bimalleolar ankle fractures treated by open reduction and internal fixation. Methods: This descriptive, cross-sectional study was carried out at a tertiary care center in the western region of Nepal among the patients with bimalleolar ankle fractures from March 2017 to August 2020 after approval from the Institutional review committee. Convenience sampling was done to reach the sample size. Twenty-nine cases were included in the study. Data were recorded in proforma and data analysis was done in the statistical package for social sciences (SPSS 16.0). The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used to assess the final outcome. Results: At the final evaluation mean AOFAS ankle-hindfoot score was 89.86 (±7.95). According to the AOFAS ankle-hindfoot score, there were 19 excellent (65.51%), six good (20.68%), and four fair (13.79%) results. Complications in the form of superficial infection were seen in four (13.79%) cases. Conclusions: Functional outcomes following surgical treatment of bimalleolar ankle fractures are mostly excellent to good and complications following surgery are few, therefore, surgery is a better option of treatment in bimalleolar ankle fractures.
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Affiliation(s)
- Rajeev Dwivedi
- Department of Orthopedics, Lumbini Medical College and Teaching Hospital, Tansen, Palpa, Nepal
| | - Ankit Karki
- Department of Orthopedics, Lumbini Medical College and Teaching Hospital, Tansen, Palpa, Nepal
| | - Roshan Bhattarai
- Department of Orthopedics, Lumbini Medical College and Teaching Hospital, Tansen, Palpa, Nepal
| | - Badri Rijal
- Department of Orthopaedics, National Trauma Centre, Kathmandu, Nepal
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Simske NM, Benedick A, Audet MA, Vallier HA. Ankle fractures in patients over age 55 years: Predictors of functional outcome. OTA Int 2020; 3:e080. [PMID: 33937704 PMCID: PMC8023118 DOI: 10.1097/oi9.0000000000000080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 03/12/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To identify predictors of functional outcomes following treatment of ankle fracture in patients 55 years or older. SETTING Level 1 Trauma Center. PATIENTS/PARTICIPANTS Four hundred twenty-nine patients with torsional ankle fractures (44A-C): 233 patients (54%) were ages 55 to 64, 25% were between the ages 65 and 74; 21% were 75 years or older. INTERVENTION Operative or nonoperative management of ankle fracture. MAIN OUTCOME MEASURE Early complications were assessed for all patients after minimum of 6 months, and functional outcome scores as assessed by the Foot Function Index (FFI; n = 166, 39%) and Short Musculoskeletal Function Assessment (SMFA; n = 168, 39%) after median 57 months follow-up. RESULTS Surgical management was elected in 67% of patients. Nonoperative management became more common with advancing age and was associated with fewer unplanned operations (12% vs 3%, P < .01) and complications (21% vs 13%, P = .07). African American race was associated with worse pain on the FFI (P = .002) and BMI was associated with worse (higher) scores on all categories of the FFI and SMFA (all P < .05). Diabetes, neuropathy, and mental illness were also predictive of worse scores on various categories of both surveys. Assistive device use or nonambulatory status at the time of injury was associated with worse disability/dysfunction, activity, and mobility scores on both the FFI and SMFA (all P > 15, P < .05). Sex, Hispanic ethnicity, tobacco use, open fracture, dislocation, fracture pattern, and operative management were not independent predictors in this regression model. CONCLUSIONS Baseline health and ambulatory capacity at injury were more predictive of outcomes following ankle fracture than were fracture characteristics or type of treatment.
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Affiliation(s)
- Natasha M Simske
- MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, Ohio
| | - Alex Benedick
- MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, Ohio
| | - Megan A Audet
- MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, Ohio
| | - Heather A Vallier
- MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, Ohio
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Simske NM, Audet MA, Kim CY, Vallier HA. Open ankle fractures are associated with complications and reoperations. OTA Int 2019; 2:e042. [PMID: 33937670 PMCID: PMC7997115 DOI: 10.1097/oi9.0000000000000042] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 06/22/2019] [Indexed: 01/14/2023]
Abstract
Objectives: To assess clinical and functional outcomes after open versus closed ankle fracture. Design: Retrospective comparative study. Location: Level 1 Trauma Center. Patients/Participants: 1303 patients treated for ankle fractures (Weber B and C) between 2003 and 2015. One hundred sixty-five patients (12.7%) presented with open fracture and 1138 (87.3%) with closed fracture. Intervention: Surgical or conservative management of ankle fracture. Main Outcome Measure: Rates of complications and reoperations. Patient-reported functional outcomes were assessed with the Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA), after a minimum of 12 months. Results: Mean age was 46 years and 49% of patients were male. Higher mean age was associated with open injuries (51 vs 45 years, P < 0.001), and fractures were increasingly open with aging. Open fractures were associated with high-energy mechanisms: 44% following motor vehicle or motorcycle collisions, although the majority of open fractures in patients >65 years occurred after ground-level fall. Complications occurred more often after open fracture (33% vs 11%) and necessitated more secondary procedures (19% vs. 7%), both P < 0.001. Multivariate regression analysis identified open fracture as a predictor of complications and of worse scores on the activity categories of both the FFI and SMFA. Conclusion: Open fractures occurred more often after high energy mechanisms, and were generally more complex than closed fractures. Advanced age was common among open fracture patients, likely contributing to higher complication and secondary procedure rates. Greater morbidity after open ankle fractures was associated with minor differences on activity functions of the FFI and SMFA. Level of Evidence: Level 3, prognostic
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Affiliation(s)
- Natasha M Simske
- MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
| | - Megan A Audet
- MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
| | - Chang-Yeon Kim
- MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
| | - Heather A Vallier
- MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
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van Hoeve S, Houben M, Verbruggen JPAM, Willems P, Meijer K, Poeze M. Gait analysis related to functional outcome in patients operated for ankle fractures. J Orthop Res 2019; 37:1658-1666. [PMID: 29920765 PMCID: PMC6618247 DOI: 10.1002/jor.24071] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 06/03/2018] [Indexed: 02/04/2023]
Abstract
Ankle fractures are among the most common lower limb fractures. Associations between postoperative radiographic results and clinical outcome have been found, but less is known about the relevant ankle biomechanics. This study analyzed ankle kinematics, radiographic findings, and patient-reported outcome measures (PROM) in patients treated for ankle fractures. The hypothesis was that patients after ankle fracture surgery had less flexion/extension in the ankle compared to healthy subjects and that fracture severity had significant influence on kinematics and patient satisfaction. Thirty-three patients (n = 33 feet) operated for ankle fractures were recruited. Ankle kinematics were analyzed using the Oxford Foot model, and results were compared with an age-matched healthy control group (11 patients, 20 feet). In addition, patients were divided by fracture (severity) classification and kinematic results were correlated with PROM and radiographic findings. Patients treated for ankle fracture showed lower walking speed (p < 0.001) when asked to walk in preferred normal speed. When compared at equal speed, significantly less range of motion (ROM) between the hindfoot and tibia in the sagittal plane (flexion/extension) during loading and push-off phases (p = 0.003 and p < 0.001) was found in patients after ankle fractures compared to healthy subjects. Lowest ROM and poorest PROM results were found for patients with trimalleolar ankle fractures. There was a significant correlation between ROM (flexion/extension) during the push-off phase and SF-36 physical functioning (r2 = 0.403, p = 0.027) and SF-36 general health (r2 = 0.473, p = 0.008). Fracture severity was significantly correlated with flexion/extension ROM in the ankle during both loading and push-off phases (r2 = -0.382, p = 0.005, and r2 = -0.568, p < 0.001) and was also significantly correlated with PROM. This study found that patients with ankle fractures had significantly altered ankle kinematics compared to healthy subjects. The poorest results were found among patients with trimalleolar fractures. Weak to strong significant correlations were found between fracture severity, ankle kinematics, and PROM. © 2019 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 37:1658-1666, 2019.
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Affiliation(s)
- Sander van Hoeve
- Division of Trauma Surgery, Department of SurgeryMaastricht University Medical CenterP. Debyelaan 25, PO Box 5800Maastricht6202 AZThe Netherlands
| | - Michael Houben
- Division of Trauma Surgery, Department of SurgeryMaastricht University Medical CenterP. Debyelaan 25, PO Box 5800Maastricht6202 AZThe Netherlands
| | - Jan P. A. M. Verbruggen
- Division of Trauma Surgery, Department of SurgeryMaastricht University Medical CenterP. Debyelaan 25, PO Box 5800Maastricht6202 AZThe Netherlands
| | - Paul Willems
- Department of Movement SciencesMaastricht University Medical CenterP. Debyelaan 25, PO Box 616Maastricht6200 MDThe Netherlands,School for Nutrition and Translational Research in MetabolismNUTRIMPO Box 616Maastricht6200 MDThe Netherlands
| | - Kenneth Meijer
- Department of Movement SciencesMaastricht University Medical CenterP. Debyelaan 25, PO Box 616Maastricht6200 MDThe Netherlands,School for Nutrition and Translational Research in MetabolismNUTRIMPO Box 616Maastricht6200 MDThe Netherlands
| | - Martijn Poeze
- Division of Trauma Surgery, Department of SurgeryMaastricht University Medical CenterP. Debyelaan 25, PO Box 5800Maastricht6202 AZThe Netherlands,School for Nutrition and Translational Research in MetabolismNUTRIMPO Box 616Maastricht6200 MDThe Netherlands
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Quested R, Wiltshire D, Sommerville S, Lutz M. The impact of preexisting disease on outcomes of simple orthopaedic trauma: A prospective cohort study. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2019. [DOI: 10.1016/j.jotr.2018.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Background: This article describes a prospective cohort study trial which aims to determine what risk factors might be associated with increased levels of pain, disability and psychological distress following simple orthopaedic trauma. Methods: Patients were recruited from two large tertiary referral hospitals. Outcome measures were return to work, measurement of the visual analogue scale for pain and the SF 12 physical component score (PCS) and mental health component score. Results: Fifty-five participants were recruited. Overall, participants had significant improvement in their levels of pain, and all who were working before the injury returned to work. Those with a preexisting disease had a significantly lower ( p = 0.007) initial PCS with no significant changes in either mental health component score or PCS. Conclusions: Differences in outcomes were observed in patients with and without preexisting disease.
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Affiliation(s)
- Rachele Quested
- University of Queensland, School of Medicine, Herston, Brisbane, Australia
| | - Danielle Wiltshire
- Ipswich General Hospital, Chelmsford Ave, Ipswich, Queensland, Australia
| | - Scott Sommerville
- University of Queensland, School of Medicine, Herston, Brisbane, Australia
| | - Michael Lutz
- University of Queensland, School of Medicine, Herston, Brisbane, Australia
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21
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Meijer DT, Gevers Deynoot BDJ, Stufkens SA, Sierevelt IN, Goslings JC, Kerkhoffs GMMJ, Doornberg JN. What Factors Are Associated With Outcomes Scores After Surgical Treatment Of Ankle Fractures With a Posterior Malleolar Fragment? Clin Orthop Relat Res 2019; 477:863-869. [PMID: 30624323 PMCID: PMC6437353 DOI: 10.1097/corr.0000000000000623] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 12/06/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Psychosocial factors, such as depression and catastrophic thinking, might account for more disability after various orthopaedic trauma pathologies than range of motion and other impairments. However, little is known about the influence of psychosocial aspects of illness on long-term symptoms and limitations of patients with rotational-type ankle fractures, including a posterior malleolar fragment. Knowledge of the psychosocial factors associated with long-term outcome after operative treatment of trimalleolar ankle fractures might improve recovery. QUESTIONS/PURPOSES (1) Which factors related to patient demographics, physical exam, diagnosis, or psychological well-being (in particular, depression), if any, are associated with better or worse scores on validated lower-extremity outcomes instruments after surgical treatment for rotational ankle fractures (including a posterior malleolar fragment) at long-term followup? METHODS Between 1974 and 2002, 423 patients underwent open reduction internal fixation for rotational ankle fractures with posterior malleolar fragments according to the basic principles of the AO (Arbeitsgemeinshaft für Osteosynthesfragen). Minimum followup for inclusion here was 10 years (range, 12.5-39.4 years). When posterior malleolar fragments involved more than 25% of the articular surface as assessed on plain lateral radiographs, the fracture was generally fixed with AP or posterior-anterior (PA) screws. Of those treated surgically during the period in question, 319 were lost to followup, had too much missing data to include, or declined to participate in this study (or could not because of reasons of mental illness) (68%), leaving 104 (32%) for analysis in this retrospective study. Independent observers not involved in patient care measured disability using the patient-based Foot and Ankle Ability Measure questionnaire and using the subscale Activities in Daily Living (ADL) and pain score of the Foot and Ankle Outcome Score. General physical and mental health status was evaluated using the SF-36. Depressive symptoms were measured with the Center for Epidemiologic Studies-Depression scale score (range, 0-60 points). A score above 16 indicated a depressive disorder. Misinterpretation or overinterpretation of nociception was measured with the Pain Catastrophizing Scale score. Scores above 13.9 were considered abnormal. Statistical analyses included uni- and multivariate regression analysis. In general, patients in this series reported good to excellent outcomes; the mean ± SD scores were 91 ± 15 for Foot and Ankle Ability Measure, 93 ± 16 for Foot and Ankle Outcome Score (ADL), 91 ± 15 for Foot and Ankle Outcome Score (pain), 49 ± 9 for SF-36 mental component score, and 52 ± 9 for SF-36 physical component score. RESULTS Implant removal (β = -8.199, p < 0.01) was associated with worse Foot and Ankle Ability Measure scores. Better flexion/extension arc (β = 0.445, p < 0.01) and lower Center for Epidemiologic Studies-Depression scores (β = -0.527, p < 0.01) were associated with better Foot and Ankle Ability Measure scores. Osteoarthritis (β = -4.823, p < 0.01) was associated with worse Foot and Ankle Outcome Score (pain) scores. Better flexion/extension arc (β = 0.454, p < 0.01) and lower Center for Epidemiologic Studies-Depression scores (β = -0.596, p < 0.01) were associated with better Foot and Ankle Outcome Score (pain) scores. Better flexion/extension arc (β = -0.431, p < 0.01) and lower Center for Epidemiologic Studies-Depression scores (β = -0.557, p < 0.01) were associated with better Foot and Ankle Outcome Score (ADL) scores. Finally, we found that a better inversion/eversion arc (β = 0.122, p = 0.024) was associated with better SF-36 physical component score and that a lower Center for Epidemiologic Studies-Depression score (β = -0.567, p < 0.01) was associated with better SF-36 mental component score. CONCLUSIONS Psychological aspects of recovery from musculoskeletal injury merit greater attention, perhaps even over objective, unmodifiable predictors. A mean of 24 years after surgical treatment of ankle fractures with a posterior malleolar fragment, patient-reported outcome measures have little to do with pathophysiology; they mostly reflect impairment and depression symptoms. Further research is needed to determine whether early indentification and treatment of at-risk patients based on psychosocial factors can improve long-term outcomes. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Diederik T Meijer
- D. T. Meijer, B. D. J. G. Deynoot, S. A. Stufkens, G. M. M. J. Kerkhoffs, J. N. Doornberg, Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, The Netherlands D. T. Meijer, Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands I. N. Sierevelt, Slotervaart Center of Orthopedic Research and Education, Department of Orthopaedic Surgery, Medical Centre Slotervaart, Amsterdam, The Netherlands J. C. Goslings, Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands G. M. M. J. Kerkhoffs, Academic Center for Evidence-based Sports Medicine, Amsterdam Collaboration for Health and Safety in Sports, IOC Research Center, Amsterdam, The Netherlands J. N. Doornberg, Flinders University, Adelaide, Australia
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Won SH, Chung CY, Park MS, Lee SY, Suh YS, Lee KM. Characteristics of and Factors Contributing to Immediate Postoperative Pain After Ankle Fracture Surgery. J Foot Ankle Surg 2019; 57:890-893. [PMID: 29880320 DOI: 10.1053/j.jfas.2018.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Indexed: 02/03/2023]
Abstract
To build an appropriate strategy of pain management after ankle fracture surgery, surgeons need to know the characteristics of postoperative ankle pain and its contributing factors. The aim of the present study was to investigate the maximum pain period after ankle fracture surgery and the factors affecting postoperative pain using a linear mixed model when patient-controlled analgesia (PCA) was used as a basic modality. A total of 219 adult patients (108 males and 111 females; mean age 51.2 ± 15.9 years) who had undergone operative treatment for ankle fractures were included. Data on fracture severity, causes of injury, interval between injury and surgery, anesthesia method, American Society of Anesthesiologists classification, and operative time were collected. Pain intensity was measured using an 11-point pain intensity numerical rating scale preoperatively and postoperatively every 8 hours. Intravenous PCA was prescribed to all patients. The chronologic pattern of postoperative pain and factors affecting it were statistically analyzed using a linear mixed model. Maximum postoperative pain was observed at 8 hours postoperatively, and the maximum pain numerical rating scale score was 3.92, measured at 8-hour intervals. The severity of fracture (p = .01) was the only significant factor contributing to postoperative pain after ankle fracture surgery on multivariate analysis. Clinicians should consider the chronologic pattern of postoperative pain after ankle fracture surgery during postoperative pain management. Interventions for pain control, in addition to PCA, might be needed at ~8 hours postoperatively, especially for those with severe ankle fractures.
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Affiliation(s)
- Sung Hun Won
- Assistant Professor, Department of Orthopaedic Surgery, Soon Chun Hyang University Hospital, Seoul, Korea
| | - Chin Youb Chung
- Professor, Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, Korea
| | - Moon Seok Park
- Clinical Professor, Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, Korea
| | - Seung Yeol Lee
- Clinical Associate Professor, Department of Orthopaedic Surgery, Ewha Woman's University Mokdong Hospital, Seoul, Korea
| | - You Sung Suh
- Resident, Department of Orthopaedic Surgery, Ewha Woman's University Mokdong Hospital, Seoul, Korea
| | - Kyoung Min Lee
- Clinical Associate Professor, Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, Korea.
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Weber AC, Hull MG, Johnson AJ, Henn RF. Cost analysis of ankle syndesmosis internal fixation. J Clin Orthop Trauma 2019; 10:173-177. [PMID: 30705555 PMCID: PMC6349602 DOI: 10.1016/j.jcot.2017.08.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/08/2017] [Accepted: 08/17/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Unstable ankle syndesmosis injuries are common, and the optimal surgical fixation is controversial. The two main options for stabilization of syndesmotic injuries are suture button fixation and screw fixation. Suture button fixation has a higher initial cost, but may have a lower hardware removal rate. The purpose of this study was to compare the costs of syndesmotic fixation. METHODS A cost analysis was performed at a single university-affiliated hospital. Variables included the number of suture buttons, the number and type of syndesmosis screws used, and the frequency of hardware removal and operative time required for hardware removal. There were four clinical scenarios evaluated: (A) one suture button versus one cortical screw; (B) two suture buttons versus two cortical screws; (C) one suture button versus one locking screw; (D) two suture buttons versus two locking screws. Suture button removal rate was assumed to be 0% in the analysis. RESULTS Cost equivalence was achieved at an 18 to 53% syndesmotic screw removal rate depending on the fixation construct used and the amount of time required for hardware removal. When the syndesmosis screws were removed 100% of the time, suture button fixation was more economical by $85,000-$194,656 per 100 ankles. When hardware was never removed, suture button fixation was more expensive by $169,844-$295,500 per 100 ankles. CONCLUSION This study demonstrates that the costs associated with syndesmosis fixation are more dependent on the rate of hardware removal than the type of hardware utilized. Routine removal of syndesmosis screws is clearly less economical than suture button fixation.
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Affiliation(s)
| | | | | | - R. Frank Henn
- Corresponding author at: University of Maryland, Department of Orthopaedics, 2200 Kernan Drive, Baltimore, Maryland, United States.
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Corey RM, Cannada LK, Bledsoe G, Israel H. Biomechanical evaluation of medial malleolus fractures treated with headless compression screws. J Clin Orthop Trauma 2019; 10:310-314. [PMID: 30828200 PMCID: PMC6383165 DOI: 10.1016/j.jcot.2018.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/15/2018] [Accepted: 04/19/2018] [Indexed: 10/17/2022] Open
Abstract
PURPOSE The gold standard for fixation of medial malleolus fractures has yet to be determined. Most agree the best results of displaced unstable ankle fractures are with open reduction and internal fixation. Hardware irritation necessitating screw removal is a known complication. An alternative fixation method of medial malleolar fractures has been described using headless compression screws. There are currently no biomechanical studies that assess the stability of this method. The purpose of the study is to complete a biomechanical evaluation of partially threaded cancellous screws (PT) and headless compression screws (HC) in an external rotation ankle fracture model. METHODS Composite polyurethane sawbone models of tibia were obtained. A custom jig was created to ensure identical osteotomies. The models were fixed with either two partially threaded cancellous screws or two headless compression screws. The models were fitted into the Material Test System (MTS) machine and the force transducer was programed to apply axial offset. The two constructs were loaded until 5 mm of displacement occurred, our defined point of failure. The amount of force (Newtons) necessary to create fracture line displacement was recorded for each model. RESULTS The axial rotational force to create facture displacement between 1 mm and 3 mm, between 1 mm and 5 mm, and between 3 mm and 5 mm were statistically significant (p < 0.05) for both models. The mean axial rotational force measured in Newtons at 1 mm, 3 mm, and 5 mm of displacement for the PT was 149.32, 244.19 and 477.76 respectively. The mean axial rotational force measured in Newtons at 1 mm, 3 mm, and 5 mm of displacement for the HC was 152.05, 224.07, and 498.31 respectively. CONCLUSION No statistically significant difference was found between the biomechanical properties of partially threaded cancellous screws and headless compression screws used in the fixation of medial malleolus fractures. These results support HC screws as a viable alternative in a biomechanical model of medial malleolus fractures.
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Affiliation(s)
- Robert M. Corey
- Department of Orthopaedics, Saint Louis University, United States
| | - Lisa K. Cannada
- Department of Orthopaedics, Saint Louis University, United States,Corresponding author at: Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 3635 Vista Avenue, 7th Floor Desloge Towers, St. Louis, MO, 63110, United States.
| | - Gary Bledsoe
- Parks College of Engineering, Saint Louis University, United States
| | - Heidi Israel
- Department of Orthopaedics, Saint Louis University, United States
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Johnson JD, Chachula LA, Bickley RJ, Anderson CD, Ryan PM. Return to Duty Following Open Reduction and Internal Fixation of Unstable Ankle Fractures in the Active Duty Population. Mil Med 2018; 184:e381-e384. [DOI: 10.1093/milmed/usy325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/29/2018] [Accepted: 10/29/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- John D Johnson
- Department of Surgery, Orthopaedic Service, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI
| | - Laura A Chachula
- Department of Surgery, Orthopaedic Service, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI
| | - Ryan J Bickley
- Department of Surgery, Orthopaedic Service, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI
| | - Claude D Anderson
- Department of Surgery, Orthopaedic Service, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI
| | - Paul M Ryan
- Department of Surgery, Orthopaedic Service, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI
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Schray D, Ehrnthaller C, Pfeufer D, Mehaffey S, Böcker W, Neuerburg C, Kammerlander C, Zeckey C. Outcome after surgical treatment of fragility ankle fractures in a certified orthogeriatric trauma center. Injury 2018; 49:1451-1457. [PMID: 30041983 DOI: 10.1016/j.injury.2018.06.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/21/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Orthogeriatric ankle fractures seem to play an essential role in terms of quality of life in the elderly. Knowledge of the outcome after orthogeriatric ankle fractures is sparse. The present study investigates the outcome after surgically treated ankle fractures at a certified orthogeriatric trauma center. MATERIAL & METHODS A retrospective observational study was performed investigating the outcome of surgically treated ankle fractures in orthogeriatric patients between 2015-2017. Outcome parameters included but were not limited to the EQ-5D 3 L, Barthel Index, Karlsson Score and the Charlson Comorbidity Index. Housing situation and mobility were evaluated and potential associations to the fracture pattern and the related treatment strategy were investigated. RESULTS In total, 58 patients were included (age 77.7 ± 6,2 years). The majority were AO-44 B2 fractures (72%). General outcome was related to the Parker score; a Parker Score of 9 prior surgery was independently associated with an improved outcome according to the EQ-5D 3 L and Barthel Index. Patients under 80 years of age also had better results. Place of residence did not significantly change after surgery. Neither different types of implants nor initial use of an external fixator (e.g. open fractures) did influence outcome. A wound healing impairment was found in 10% of our patients whereas the overall unplanned reoperation rate was 7%. Overall complication rate was 20%, one-year mortality was 10%. CONCLUSIONS Surgically treated ankle fractures in the elderly which are treated in a certified geriatric fracture center seem to have limited negative effect on their quality of life. We did not observe the otherwise often demonstrated high mortality rates, but still nearly half of the patients demonstrated perioperative complications, which emphasizes the need for optimal perioperative care at an orthogeriatric trauma center. Since there was a reasonable number of patients with wound healing issues this study supports the idea of a staged protocol using external fixation with secondary ORIF.
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Affiliation(s)
- D Schray
- Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Germany
| | - C Ehrnthaller
- Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Germany
| | - D Pfeufer
- Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Germany
| | - S Mehaffey
- Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Germany
| | - W Böcker
- Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Germany
| | - C Neuerburg
- Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Germany
| | - C Kammerlander
- Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Germany.
| | - C Zeckey
- Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Germany
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Functional Outcomes and Quality of Life After Ankle Fracture Surgically Treated: A Systematic Review. J Sport Rehabil 2018; 27:274-283. [DOI: 10.1123/jsr.2016-0199] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Context:Ankle fractures (AFs) are the most common fractures of the lower limbs found in emergency services. Approximately 53% of these fractures are unstable and treated surgically.Objective:To conduct a systematic review evaluating functional outcomes and quality of life of patients with AFs surgically treated.Evidence Acquisition:A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. Five electronic databases were searched, without any limit on publication dates. Only patients with an unstable AF that was surgically treated were included; functional outcomes and the quality of life were controlled by the 36-Item Short-Form Health Survey instrument.Evidence Synthesis:Five studies were included in the analysis, including 267 patients. The values of the Physiotherapy Evidence Database scale ranged between a minimum of 5 and a maximum of 7 points. Patients with surgically treated AF reported less functionality and physical capacity compared with the nonfractured population. Some patients experienced vitality, emotional, and mental health limitations for a long period. Most surgically treated patients reported no pain and a good health and social status.Conclusion:Limitations in functionality and physical capacity represent the main threats to health-related quality of life in patients with surgically treated AFs.
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Abstract
The indications for arthroscopy have expanded over the years. Arthroscopic-assisted open reduction internal fixation in the setting of acute trauma is gaining popularity with foot and ankle surgeons. It serves to facilitate direct visualization of fracture fragments and allows for precise articular reduction with minimal soft tissue insult. Current evidence reports a high incidence of chondral injury with ankle fractures. Arthroscopy performed at the time of open reduction internal fixation allows for joint inspection and potential treatment of these posttraumatic defects.
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Marin C, Luyten FP, Van der Schueren B, Kerckhofs G, Vandamme K. The Impact of Type 2 Diabetes on Bone Fracture Healing. Front Endocrinol (Lausanne) 2018; 9:6. [PMID: 29416527 PMCID: PMC5787540 DOI: 10.3389/fendo.2018.00006] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/05/2018] [Indexed: 12/14/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a chronic metabolic disease known by the presence of elevated blood glucose levels. Nowadays, it is perceived as a worldwide epidemic, with a very high socioeconomic impact on public health. Many are the complications caused by this chronic disorder, including a negative impact on the cardiovascular system, kidneys, eyes, muscle, blood vessels, and nervous system. Recently, there has been increasing evidence suggesting that T2DM also adversely affects the skeletal system, causing detrimental bone effects such as bone quality deterioration, loss of bone strength, increased fracture risk, and impaired bone healing. Nevertheless, the precise mechanisms by which T2DM causes detrimental effects on bone tissue are still elusive and remain poorly studied. The aim of this review was to synthesize current knowledge on the different factors influencing the impairment of bone fracture healing under T2DM conditions. Here, we discuss new approaches used in recent studies to unveil the mechanisms and fill the existing gaps in the scientific understanding of the relationship between T2DM, bone tissue, and bone fracture healing.
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Affiliation(s)
- Carlos Marin
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Prometheus—Division of Skeletal Tissue Engineering Leuven, KU Leuven, Leuven, Belgium
- Biomaterials—BIOMAT, Department of Oral Health Sciences, KU Leuven, Leuven, Belgium
| | - Frank P. Luyten
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Prometheus—Division of Skeletal Tissue Engineering Leuven, KU Leuven, Leuven, Belgium
| | - Bart Van der Schueren
- Clinical and Experimental Endocrinology, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Greet Kerckhofs
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Prometheus—Division of Skeletal Tissue Engineering Leuven, KU Leuven, Leuven, Belgium
| | - Katleen Vandamme
- Prometheus—Division of Skeletal Tissue Engineering Leuven, KU Leuven, Leuven, Belgium
- Biomaterials—BIOMAT, Department of Oral Health Sciences, KU Leuven, Leuven, Belgium
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May JD, Morris MWJ. Mobile phone generated vibrations used to detect diabetic peripheral neuropathy. Foot Ankle Surg 2017; 23:281-284. [PMID: 29202988 DOI: 10.1016/j.fas.2016.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/27/2016] [Accepted: 08/08/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND In the current United Kingdom population the incidence of diabetic peripheral neuropathy is increasing. The presence of diabetic neuropathy affects decision making and treatment options. This study seeks to evaluate if the vibrations generated from a mobile phone can be used to screen patients for diabetic peripheral neuropathy. METHODS This study comprised of 61 patients; a control group of 21 patients; a lower limb injury group of 19 patients; a diabetic peripheral neuropathy group of 21 patients. The control and injury group were recruited randomly from fracture clinics. The diabetic peripheral neuropathy group were randomly recruited from the diabetic foot clinic. The 61 patients were examined using a 10g Semmes-Weinstein monofilament, a 128Hz tuning fork and a vibrating mobile phone. The points tested were, index finger, patella, lateral malleoli, medial malleoli, heel, first and fifth metatarsal heads. RESULTS The most accurate location of all the clinical tests was the head of the 1st metatarsal at 0.86. The overall accuracy of the tuning fork was 0.77, the ten gram monofilament 0.79 and the mobile phone accuracy was 0.88. The control group felt 420 of 441 tests (95%). The injury group felt 349 of 399 tests (87%). The neuropathic group felt 216 of 441 tests (48%). There is a significant difference in the number of tests felt between the control and both the injury and neuropathic groups. p<0.0001 using N-1 Two Proportion Test. CONCLUSION A mobile phone is an accurate screening tool for diabetic peripheral neuropathy. The most accurate location to test for diabetic peripheral neuropathy is the head of the 1st metatarsal. Screening for diabetic peripheral neuropathy in the index finger and patella were inaccurate. An injury to the lower limb affects the patient's vibration sensation, we would therefore recommend screening the contralateral limb to the injury. LEVEL OF EVIDENCE This study represents level II evidence of a new diagnostic investigation.
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Affiliation(s)
- Jonathan David May
- Speciality Registrar 6 Trauma and Orthopaedics, Sheffield Teaching Hospitals, Chesterfield Royal Foundation Hospital Trust, United Kingdom.
| | - Matthew William John Morris
- Consultant Orthopaedic and Trauma Surgeon, Special Interest in Foot and Ankle surgery, Chesterfield Royal Foundation Hospital Trust, United Kingdom.
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Functional outcomes following surgical-site infections after operative fixation of closed ankle fractures. Foot Ankle Surg 2017; 23:311-316. [PMID: 29202994 DOI: 10.1016/j.fas.2016.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 10/05/2016] [Accepted: 10/16/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND To compare the functional outcomes between patients with and without postoperative surgical-site infection (SSI) after surgical treatment in closed ankle fractures. METHODS Retrospective cohort study with prospective follow-up. Of 1011 treated patients, 959 were eligible for inclusion in a postal survey. Functional outcomes were assessed using three self-reported questionnaires. RESULTS In total 567 patients responded a median of 4.3 years (range 3.1-6.2 years) after surgery. In total 29/567 had an SSI. The mean Olerud and Molander Ankle Score was 19.8 points lower for patients with a deep SSI (p=0.02), the Lower Extremity Functional Scale score was 10.2 points lower (p<0.01) and the Self-Reported Foot & Ankle Questionnaire score was 5.0 points higher (p=0.10) than for those without an SSI, after adjusting for age, sex, smoking status, diabetes, physical status, fracture classification and duration of surgery. CONCLUSIONS Patients with a deep SSI had worse long-term functional outcomes than those without an SSI.
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Stavem K, Naumann MG, Sigurdsen U, Utvåg SE. The association of body mass index with complications and functional outcomes after surgery for closed ankle fractures. Bone Joint J 2017; 99-B:1389-1398. [PMID: 28963162 DOI: 10.1302/0301-620x.99b10.bjj-2016-1038.r1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 04/03/2017] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- K Stavem
- Akershus University Hospital, Lørenskog, Norway
| | | | - U Sigurdsen
- Akershus University Hospital, Lørenskog, Norway
| | - S E Utvåg
- Akershus University Hospital, Lørenskog, Norway
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Stavem K, Naumann MG, Sigurdsen U, Utvåg SE. Determinants of Health Status Three to Six Years After Surgical Treatment of Closed Ankle Fracture and Comparison with the General Population: A Historical Cohort Study. JB JS Open Access 2017; 2:e0019. [PMID: 30229223 PMCID: PMC6133095 DOI: 10.2106/jbjs.oa.17.00019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: The purposes of the present study were to identify the determinants of health status 3 to 6 years after open reduction and internal fixation (ORIF) for the treatment of closed ankle fracture and to compare the health status of patients who had undergone this procedure with that in the general population after adjusting for sociodemographic variables, body mass index (BMI), and smoking status. Methods: The present study was a historical cohort study combined with a postal survey. In total, 1,149 patients who underwent ORIF for the treatment of closed ankle fractures at 2 hospitals were eligible for chart review; 959 with low-energy fractures were eligible for a postal survey, and 471 (49%) responded to the Short Form Health Survey-36 (SF-36) health status questionnaire and provided data on BMI. Determinants of the physical functioning (PF), physical component summary (PCS), and mental component summary (MCS) scores of the SF-36 were analyzed by means of multivariable linear regression analysis. The health status of patients with an ankle fracture (n = 471) was compared with that in a sample of the general population (n = 5,396) by means of multivariable regression. Results: Age, American Society of Anesthesiologists (ASA) class III, and complications following surgery were associated with PF and PCS scores, and a BMI of ≥30 kg/m2 and current smoking status was associated with PF and MCS scores. However, the PF, PCS, and MCS scores of patients with ankle fractures did not differ from those of the general population, with unstandardized regression coefficients of 0.25 (95% confidence interval [CI], –1.67 to 2.16; p = 0.80), 0.67 (95% CI, –0.35 to 1.70; p = 0.199), and –0.57 (95% CI, –1.63 to 0.49; p = 0.29), respectively. Conclusions: Age, ASA class III, and complications following surgery were associated with PF and PCS scores at 3 to 6 years after surgery for the treatment of closed ankle fractures. However, the health status of patients with ankle fractures did not differ from that in the general population after adjusting for differences in demographic variables, BMI, and smoking status. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Knut Stavem
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Health Services Research Unit (K.S.), Medical Division, Department of Pulmonary Medicine (K.S.), and Department of Orthopaedics (U.S. and S.E.U.), Akershus University Hospital, Lørenskog, Norway
| | | | - Ulf Sigurdsen
- Health Services Research Unit (K.S.), Medical Division, Department of Pulmonary Medicine (K.S.), and Department of Orthopaedics (U.S. and S.E.U.), Akershus University Hospital, Lørenskog, Norway
| | - Stein Erik Utvåg
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Health Services Research Unit (K.S.), Medical Division, Department of Pulmonary Medicine (K.S.), and Department of Orthopaedics (U.S. and S.E.U.), Akershus University Hospital, Lørenskog, Norway
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Seidel A, Krause F, Weber M. Weightbearing vs Gravity Stress Radiographs for Stability Evaluation of Supination-External Rotation Fractures of the Ankle. Foot Ankle Int 2017; 38:736-744. [PMID: 28511569 DOI: 10.1177/1071100717702589] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Isolated lateral malleolar fractures may result from a supination-external rotation (SER) injury of the ankle. Stable fractures maintain tibiotalar congruence due to competent medial restraints and can be treated nonoperatively with excellent functional results and long-term prognosis. Stability might be assessed with either stress radiographs or weightbearing radiographs. METHODS A consecutive series of patients with closed SER fractures (presumed AO 44-B1) were prospectively enrolled from 2008 to 2015. Patients with clearly unstable fractures (medial clear space more than 7 mm) on the initial nonweightbearing radiograph were excluded and operated on. All other patients were examined with a gravity stress and a weightbearing anteroposterior radiograph. Borderline instability of the fracture was assumed when the medial clear space was 4 to 7 mm. Those were treated nonoperatively. RESULTS Of 104 patients with isolated lateral malleolar fractures of the SER type, 14 patients were treated operatively because of clear instability (displacement) on the initial radiographs. Of the nonoperative patients, 44 patients demonstrated borderline instability on the gravity stress but stability on the weightbearing radiograph ("gravity borderline"); the remaining 46 were stable in both tests ("gravity stable"). At an average follow-up of 23 months, no significant differences were seen in the American Orthopaedic Foot & Ankle Society hindfoot score (92 points gravity-borderline group vs 93 points gravity-unstable group), the Foot Functional Index score (11 vs 10 points), the Short Form 36 (SF-36) physical component (86 vs 85 points), and SF-36 mental component (84 vs 81 points). Radiographically, all fractures had healed with anatomic congruity of the ankle. CONCLUSION Weightbearing radiographs provided a reliable basis to decide about stability and nonoperative treatment in isolated lateral malleolar fractures of the SER type with excellent clinical and radiographic outcome at short-term follow-up. Gravity stress radiographs appear to overrate the need for operative treatment. LEVEL OF EVIDENCE Level III, prospective comparative study.
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Affiliation(s)
- Angela Seidel
- 1 Department of Orthopaedic Surgery and Traumatology, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian Krause
- 1 Department of Orthopaedic Surgery and Traumatology, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Weber
- 2 Department of Orthopaedic Surgery and Traumatology, Orthosiloah, Siloah Hospital, Guemligen, Switzerland
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Switaj PJ, Fuchs D, Alshouli M, Patwardhan AG, Voronov LI, Muriuki M, Havey RM, Kadakia AR. A biomechanical comparison study of a modern fibular nail and distal fibular locking plate in AO/OTA 44C2 ankle fractures. J Orthop Surg Res 2016; 11:100. [PMID: 27628500 PMCID: PMC5024498 DOI: 10.1186/s13018-016-0435-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 08/18/2016] [Indexed: 12/21/2022] Open
Abstract
Background A lateral approach with open reduction and internal fixation with a plate is a very effective technique for the majority of distal fibular fractures. However, this open approach for ankle fixation may be complicated by wound dehiscence and infection, especially in high-risk patients. An alternative to plating is an intramedullary implant, which allows maintenance of length, alignment, and rotation and which allows for decreased soft tissue dissection. While there has been clinical data suggesting favorable short-term outcomes with these implants, there is no current biomechanical literature investigating this technology in this particular fracture pattern. This study sought to biomechanically compare an emerging technology with an established method of fixation for distal fibular fractures that traditionally require an extensive exposure. Methods Ten matched cadaveric pairs from the proximal tibia to the foot were prepared to simulate an Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 44C2 ankle fracture and randomized to fixation with a distal fibular locking plate or intramedullary fibular rod. A constant 700-N axial load was applied, and all specimens underwent testing for external rotation stiffness, external rotation cyclic loading, and torque to failure. The syndesmotic diastasis, stiffness, torque to failure, angle at failure, and mode of failure were obtained from each specimen. Results There was no significant difference in syndesmotic diastasis during cyclic loading or at maximal external rotation between the rod and plate groups. Post-cycle external rotation stiffness across the syndesmosis was significantly higher for the locking plate than the fibular rod. There was no significant difference between the rod and plate in torque at failure or external rotation angle. The majority of specimens had failure at the syndesmotic screw. Conclusions In the present cadaveric study of an AO/OTA 44C2 ankle fracture, a modern fibular rod demonstrated less external rotation stiffness while maintaining the syndesmotic diastasis to within acceptable tolerances and having similar failure characteristics.
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Affiliation(s)
- Paul J Switaj
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA.
| | - Daniel Fuchs
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Mohammed Alshouli
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Avinash G Patwardhan
- Musculoskeletal Biomechanics Research Laboratory, Edward Hines Jr. VA Hospital, Chicago, IL, USA
| | - Leonard I Voronov
- Musculoskeletal Biomechanics Research Laboratory, Edward Hines Jr. VA Hospital, Chicago, IL, USA
| | - Muturi Muriuki
- Musculoskeletal Biomechanics Research Laboratory, Edward Hines Jr. VA Hospital, Chicago, IL, USA
| | - Robert M Havey
- Musculoskeletal Biomechanics Research Laboratory, Edward Hines Jr. VA Hospital, Chicago, IL, USA
| | - Anish R Kadakia
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
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36
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Suciu O, Onofrei RR, Totorean AD, Suciu SC, Amaricai EC. Gait analysis and functional outcomes after twelve-week rehabilitation in patients with surgically treated ankle fractures. Gait Posture 2016; 49:184-189. [PMID: 27434488 DOI: 10.1016/j.gaitpost.2016.07.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 07/05/2016] [Accepted: 07/07/2016] [Indexed: 02/02/2023]
Abstract
Ankle fractures are the most common type of lower extremity fractures. The objective of our study was to analyse the changes of temporal and spatial gait parameters and functional outcomes in patients with bimalleolar fractures who followed surgery and rehabilitation compared to healthy controls. 49 patients with ankle fractures and 21 age-matched healthy volunteers were recruited. There were two assessments for the study group: T1 - once weight-bearing was allowed and T2 - twelve weeks after exercise-based rehabilitation programme. Each evaluation consisted in a functional questionnaire (Olerud-Molander Ankle Score-OMAS) and temporal and spatial gait parameters analysis. The gait parameters were analysed using a Zebris FDM platform. 30 patients completed the final assessment and their data were analysed. In T1 assessment there were significant differences in all temporal and spatial gait parameters between the patients group and controls. In T2 evaluation step time in affected ankle and non-affected ankle, swing time and stance time on affected ankle, stride time and cadence showed no significant differences in patients compared with controls. The within-group analysis showed significant differences in all temporal and spatial gait parameters except for single support time on non-affected ankle after rehabilitation. The OMAS improved significantly from T1 to T2 in all subscales except for squatting. Median value of OMAS improved from 60 (35-90) to 95 (55-100). Our study revealed significant improvements of all temporal and spatial gait parameters, as well as of the functional outcome in patients with surgically treated ankle fractures after twelve-week rehabilitation.
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Affiliation(s)
- Oana Suciu
- Department of Rehabilitation, Physical Medicine and Rheumatology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania.
| | - Roxana Ramona Onofrei
- Department of Rehabilitation, Physical Medicine and Rheumatology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania.
| | - Alina Daniela Totorean
- Department of Rehabilitation, Physical Medicine and Rheumatology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania.
| | - Silviu Cristian Suciu
- Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.
| | - Elena Constanta Amaricai
- Department of Rehabilitation, Physical Medicine and Rheumatology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania.
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Elbaz A, Mor A, Segal G, Bar D, Monda MK, Kish B, Nyska M, Palmanovich E. Lower Extremity Kinematic Profile of Gait of Patients After Ankle Fracture: A Case-Control Study. J Foot Ankle Surg 2016; 55:918-21. [PMID: 27267411 DOI: 10.1053/j.jfas.2016.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Indexed: 02/03/2023]
Abstract
The present study examined the differences in the lower extremity gait kinematic profile of patients recovering from ankle fracture compared with healthy controls. In addition, we inquired whether the profile would differ among fracture severity groups. A total of 48 patients participated in the present prospective, case-control study. The gait of 24 patients recovering from an ankle fracture injury and 24 healthy matched controls was examined using an inertial measurement unit sensor system. The following gait parameters were evaluated: knee range of motion (ROM) during the swing phase, maximum knee flexion angle during stance, thigh and calf ROM, and stride duration. Statistically significant differences were found between the ankle fracture group and the control group for all parameters. The patients with ankle fracture had a lower knee ROM during swing phase compared with the control group (mean ± standard deviation 43.0° ± 15.5° compared with 66.7° ± 5.1°, respectively; p < .001). The maximum knee flexion angle during stance was lower in the patients with ankle fracture than in the control group (mean ± standard deviation 10.5° ± 6.1° compared with 21.2° ± 4.5°, respectively; p < .001). Patients with ankle fracture also had lower gait cycle thigh and calf ROM angles (p < .001) and a longer stride duration (p < .001) compared with the control group. No statistically significant differences were found among the severity groups. These results suggest that the gait kinematic characteristics vary between healthy people and patients recovering from an ankle fracture injury during the short-term period after injury.
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Affiliation(s)
- Avi Elbaz
- AposTherapy Research Group, Herzliya, Israel
| | - Amit Mor
- AposTherapy Research Group, Herzliya, Israel.
| | - Ganit Segal
- AposTherapy Research Group, Herzliya, Israel
| | - Dana Bar
- AposTherapy Research Group, Herzliya, Israel
| | - Maureen K Monda
- University College of London Institute of Orthopaedics and Musculoskeletal Science, London, UK
| | - Benjamin Kish
- Department of Orthopedic Surgery, Meir Medical Center, Kfar-Saba, Israel
| | - Meir Nyska
- Department of Orthopedic Surgery, Meir Medical Center, Kfar-Saba, Israel
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Varenne Y, Curado J, Asloum Y, Salle de Chou E, Colin F, Gouin F. Analysis of risk factors of the postoperative complications of surgical treatment of ankle fractures in the elderly: A series of 477 patients. Orthop Traumatol Surg Res 2016; 102:S245-8. [PMID: 27033839 DOI: 10.1016/j.otsr.2016.03.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/24/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The surgical strategy of ankle fractures in elderly subjects is controversial because of the high rate of local and general complications. The goal of this study was to identify the risk factors of complications of ankle fractures in elderly subjects. MATERIALS AND METHODS Four hundred and seventy-seven patients operated between 2008 and 2014 were included in this retrospective study. The minimum age was 60 years old for women and 70 for men. Patients presenting with a pilon fracture or with less than 3 months of follow up were excluded. A clinical evaluation of autonomy based on the Parker score and a radiographic assessment were performed preoperatively and during follow up The characteristics of the fracture, comorbidities and the type of internal fixation used were reported. RESULTS This series included 384 women (81%), mean age 74 years old (60-99). Most fractures were Weber type B (n=336). Four hundred and thirty-one patients (90.4%) received so-called standard internal fixation and 46 patients (9.6%) received so-called atypical fixation. The rate of general complications was 4.6%, and local complications was 23.9%. Univariate analysis of the risk factors of general complications identified 2 significant criteria: age older than 80 (OR=3.46, P=0.012) and more than 2 comorbidities 2 (OR=10.6, P<0.0001). Univariate analysis of risk factors of local complications identified 2 criteria: an open fracture (OR=4.90, P=0.0016) and age over 80 (OR=1.85, P=0.024). Multivariate analysis of risk factors of local complications confirmed the relationship with open fractures (OR=4.67, P<0.001). DISCUSSION The results of the management of ankle fractures in elderly subjects is satisfactory. The use of standard internal fixation techniques is recommended. The risk of complications increases with age, the severity of the fracture and the number of associated diseases. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Y Varenne
- Clinique Chirurgicale de Chirurgie Orthopédique et Traumatologique, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France.
| | - J Curado
- Service d'Orthopédie-Traumatologie, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France
| | - Y Asloum
- Service d'Orthopédie-Traumatologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - E Salle de Chou
- Service d'Orthopédie-Traumatologie, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France
| | - F Colin
- Clinique Chirurgicale de Chirurgie Orthopédique et Traumatologique, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - F Gouin
- Clinique Chirurgicale de Chirurgie Orthopédique et Traumatologique, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
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Gonzalez TA, Macaulay AA, Ehrlichman LK, Drummond R, Mittal V, DiGiovanni CW. Arthroscopically Assisted Versus Standard Open Reduction and Internal Fixation Techniques for the Acute Ankle Fracture. Foot Ankle Int 2016; 37:554-62. [PMID: 26660864 DOI: 10.1177/1071100715620455] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ankle fractures represent one of the most common orthopaedic injuries requiring operative treatment. Although open reduction and internal fixation (ORIF) of ankle fractures leads to good results in most patients, poor functional outcomes continue to be reported in some patients for whom anatomic reduction was achieved. It has been theorized that these lesser outcomes may in part be due to a component of missed intra-articular injury that reportedly ranges between 20% and 79%, although to date the true explanation for this subset of lower functional outcomes remains unknown. Such concerns have recently spawned novel techniques of arthroscopically assisted ankle fracture assessment in hopes of enabling better detection and treatment of concomitant intra-articular ankle injuries. The purpose of this systematic review was to summarize the literature comparing standard ORIF to arthroscopically assisted ORIF (AAORIF) for ankle fractures. METHODS A systematic review of the English literature was performed using the PubMed database to access all studies over the last 50 years that have documented the functional outcomes of acute ankle fracture management using either a traditional ORIF or an AAORIF technique in the adult population. Relevant publications were analyzed for their respective Levels of Evidence as well as any perceived differences reported in operative time, outcomes, and complications. RESULTS A total of only 14 ORIF and 4 AAORIF papers fit the criteria for review. There is fair quality (grade B) evidence to support good to excellent outcomes following traditional ORIF of malleolar fractures. There is fair-quality (grade B) evidence that ankle arthroscopy can be successfully employed for identification and treatment of intra-articular injuries associated with acute ankle fractures, but insufficient (grade I) evidence examining the functional outcomes and complication rates after treatment of these injuries and little documentation that this approach portends any improvement in patient outcome over historical techniques. There is also insufficient (grade I) evidence from 2 prospective randomized studies and 1 case-control study to provide any direct comparative data on functional outcomes, complication rates or total operative time between AAORIF and ORIF for the treatment of acute ankle fractures. CONCLUSIONS Ankle arthroscopy is a valuable tool in identifying and treating intra-articular lesions associated with ankle fractures. The presence of such intra-articular pathology may lead to the unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions therefore has the potential to improve patient outcomes. To date, however, currently available literature has not shown that treatment of these intra-articular injuries provides any improvement in outcomes over standard ORIF, and few prospective randomized controlled studies have been performed comparing these 2 operative techniques-rendering any suggestion that AAORIF improves clinical outcomes over traditional ORIF difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct before we can advocate its routine use in these patients. LEVEL OF EVIDENCE Level II, systematic review.
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Affiliation(s)
- Tyler A Gonzalez
- Harvard Combined Orthopaedic Residency Program, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Alec A Macaulay
- Harvard Combined Orthopaedic Residency Program, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Lauren K Ehrlichman
- Harvard Combined Orthopaedic Residency Program, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Rosa Drummond
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Vaishali Mittal
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Chief, Foot and Ankle Service and Fellowship Program, Massachusetts General Hospital, Director, MGH Comprehensive Foot and Ankle Center, Waltham, MA, USA Foot and Ankle Service, Newton-Wellesley Hospital, Newton, MA, USA
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40
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Abstract
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.
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Affiliation(s)
- Brian M Capogna
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, New York University Langone Medical Center, 301 E17th Street, New York, NY 10003, USA
| | - Kenneth A Egol
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, New York University Langone Medical Center, 301 E17th Street, New York, NY 10003, USA.
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Reaming Does Not Affect Functional Outcomes After Open and Closed Tibial Shaft Fractures: The Results of a Randomized Controlled Trial. J Orthop Trauma 2016; 30:142-8. [PMID: 26618662 PMCID: PMC4761270 DOI: 10.1097/bot.0000000000000497] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We sought to determine the effect of reaming on 1-year 36-item short-form general health survey (SF-36) and short musculoskeletal function assessment (SMFA) scores from the Study to Prospectively Evaluate Reamed Intramedullary Nails in patients with Tibial Fractures. DESIGN Prospective randomized controlled trial.1319 patients were randomized to reamed or unreamed nails. Fractures were categorized as open or closed. SETTING Twenty-nine academic and community health centers across the US, Canada, and the Netherlands. PATIENTS/PARTICIPANTS One thousand three hundred and nineteen skeletally mature patients with closed and open diaphyseal tibia fractures. INTERVENTION Reamed versus unreamed tibial nails. MAIN OUTCOME MEASUREMENTS SF-36 and the SMFA. Outcomes were obtained during the initial hospitalization to reflect preinjury status, and again at the 2-week, 3-month, 6-month, and 1-year follow-up. Repeated measures analyses were performed with P < 0.05 considered significant. RESULTS There were no differences between the reamed and unreamed groups at 12 months for either the SF-36 physical component score [42.9 vs. 43.4, P = 0.54, 95% Confidence Interval for the difference (CI) -2.1 to 1.1] or the SMFA dysfunction index (18.0 vs. 17.6, P = 0.79. 95% CI, -2.2 to 2.9). At one year, functional outcomes were significantly below baseline for the SF-36 physical componentf score, SMFA dysfunction index, and SMFA bothersome index (P < 0.001). Time and fracture type were significantly associated with functional outcome. CONCLUSIONS Reaming does not affect functional outcomes after intramedullary nailing for tibial shaft fractures. Patients with open fractures have worse functional outcomes than those with a closed injury. Patients do not reach their baseline function by 1 year after surgery. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
Diabetes is associated with a number of lower extremity orthopedic conditions and complications including fractures, Charcot neuroarthropathy, plantar ulcers, and infection. These complications are of significant clinical concern in terms of morbidity, mortality, and socioeconomic costs. A review of each condition is discussed, with particular emphasis on the clinical importance, diagnostic considerations, and orthopedic treatment recommendations. The goal of the article is to provide a clinical picture of the challenges that orthopedic surgeons confront, and highlight the need for specific clinical guidelines in diabetic patients.
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Affiliation(s)
- Daniel J Gehling
- Department of Orthopaedic Surgery, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States.
| | - Beata Lecka-Czernik
- Department of Orthopaedic Surgery, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States; Department of Physiology and Pharmacology, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States; Center for Diabetes and Endocrine Research, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States
| | - Nabil A Ebraheim
- Department of Orthopaedic Surgery, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States
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Sculco PK, Lazaro LE, Little MM, Berkes MB, Warner SJ, Helfet DL, Lorich DG. Dislocation is a risk factor for poor outcome after supination external rotation type ankle fractures. Arch Orthop Trauma Surg 2016; 136:9-15. [PMID: 26506829 DOI: 10.1007/s00402-015-2353-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Ankle fractures are one of the most common fractures requiring surgical treatment. Ankle fracture-dislocations are significant injuries to the osseous and soft tissue envelope, but studies focused on the effect of dislocation on radiographic and functional outcomes are lacking. The objective of this study was to evaluate the effect of dislocations on postoperative outcomes in SER IV ankle fracture patients. MATERIALS AND METHODS From 2004 through 2010, all operative SER IV ankle fractures treated by a single surgeon were enrolled in a prospective database. SER IV ankle fractures were separated into two groups based on clinical or radiographic evidence of dislocation. The primary and secondary functional outcomes measures were the Foot and Ankle Outcome Score (FAOS) and ankle and subtalar range of motion (ROM) with a minimum of 1-year follow-up, respectively. RESULTS 108 patients with SER IV ankle fractures were identified, with 73 in the non-dislocation group (68%) and 35 patients in the dislocation group (32%). Patient demographics and co-morbidities were similar between the two groups. The incidence of open fractures and the application of an external fixator were significantly higher in the dislocation group (p = 0.037 and p = 0.003, respectively). The dislocation group showed a significant decrease in the accuracy of articular reduction (p = 0.003). At a mean follow-up of 21 months, ankle fracture-dislocation patients had increased pain (p = 0.005) and decreased activities of daily living (p = 0.014) on FAOS outcome measures and significantly worse ankle and subtalar ROM. CONCLUSIONS The results of this study suggest that concurrent dislocation at time of ankle fracture is associated with worse radiographic and functional outcomes, but not an increase in superficial or deep infection. The results from this study may be helpful in counseling patients regarding expected clinical outcomes after ankle fracture-dislocation and in the surgical management of this complex injury.
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Affiliation(s)
- Peter K Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Lionel E Lazaro
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Milton M Little
- Orthopaedic Trauma Service, Cedar Sinai Medical Center, Los Angeles, CA, USA
| | | | - Stephen J Warner
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - David L Helfet
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Dean G Lorich
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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Jones CB, Gilde A, Sietsema DL. Treatment of Syndesmotic Injuries of the Ankle: A Critical Analysis Review. JBJS Rev 2015; 3:01874474-201510000-00001. [PMID: 27490790 DOI: 10.2106/jbjs.rvw.n.00083] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Clifford B Jones
- The CORE Institute, Center for Orthopedic Research and Education, 18444 North 25th Avenue, Suite 320, Phoenix, AZ 85023
| | - Alex Gilde
- Grand Rapids Medical Education Partners Orthopaedic Residency Program, 1000 Monroe Avenue N.W., Grand Rapids, MI 49503
| | - Debra L Sietsema
- The CORE Institute, Center for Orthopedic Research and Education, 18444 North 25th Avenue, Suite 320, Phoenix, AZ 85023
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Switaj PJ, Mendoza M, Kadakia AR. Acute and Chronic Injuries to the Syndesmosis. Clin Sports Med 2015; 34:643-77. [DOI: 10.1016/j.csm.2015.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Chen Y, Zhang K, Qiang M, Li H, Dai H. Comparison of plain radiography and CT in postoperative evaluation of ankle fractures. Clin Radiol 2015; 70:e74-82. [PMID: 26055409 DOI: 10.1016/j.crad.2015.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 03/25/2015] [Accepted: 04/20/2015] [Indexed: 10/23/2022]
Abstract
AIM To compare postoperative plain radiographs with computed tomography (CT) post-processing images in evaluating the quality of anatomical reduction and internal fixation of ankle fractures. MATERIALS AND METHODS A total of 168 patients who sustained closed ankle fracture and were treated with open reduction and internal fixation in East Hospital were reviewed. Postoperative plain radiographs and CT post-processing images were evaluated. The observation was performed under volume-rendering mode and multiplanar reconstruction mode. The assessment was performed by two independent orthopaedic surgeons. The inter- and intra-observer variations were analysed by kappa statistics. The differences between plain radiographs and CT post-processing images were compared using χ(2) test (McNemar's test). RESULTS Inter- and intra-observer agreement was almost perfect (0.813-1.000) using CT post-processing images, which was higher than that using plain radiographs (0.323-0.848). More non-anatomical reduction could be recognised in the supination-external rotation (SER), supination-adduction (SAD), pronation-external rotation (PER), and overall groups (p<0.05) and more poor internal fixation could be recognised in the SER, SAD, and overall groups (p<0.05) using CT post-processing images than using radiographs. CONCLUSION More residual articular step, fracture fragment displacement, and poor internal fixation could be detected by CT post-processing images than plain radiographs.
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Affiliation(s)
- Y Chen
- Department of Orthopedic Trauma, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, 200120 Shanghai, China.
| | - K Zhang
- Department of Orthopedic Trauma, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, 200120 Shanghai, China
| | - M Qiang
- Department of Orthopedic Trauma, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, 200120 Shanghai, China
| | - H Li
- Department of Orthopedic Trauma, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, 200120 Shanghai, China
| | - H Dai
- Department of Orthopedic Trauma, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, 200120 Shanghai, China
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Veen EJD, Zuurmond RG. Mid-term results of ankle fractures with and without syndesmotic rupture. Foot Ankle Surg 2015; 21:30-6. [PMID: 25682404 DOI: 10.1016/j.fas.2014.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 08/28/2014] [Accepted: 09/04/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUNDS This study investigated the effect of short term removal of syndesmotic screws on the ankle function after 6 years, as there still exists controversy on the duration of screw stabilization. METHODS Patients with an ankle fracture who received surgery between 1998 and 2004 were reviewed. One group was composed of patients with an ankle fracture needing a syndesmotic repair with screws. The second was composed of operated patients that did not need syndesmotic repair. The primary scoring used was the Olerud-Molander Ankle Score (OMAS). RESULTS A total of 59 patients were studied with comparable characteristics, with no significant difference on the OMAS after 6 years between the repair group (81.9) and the non-repair group (90.4). On additional clinical scoring groups remained the same. Joint degeneration was seen in both groups (86.7% vs. 55.5%). CONCLUSIONS Patients with ankle fractures using syndesmotic repair and screw removal after 8 weeks and operated patients without syndesmotic injury have comparable results after 6 years.
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Affiliation(s)
- Egbert J D Veen
- Department of Orthopaedic Surgery and Traumatology, Isala Clinics, PO Box 10400, 8000 GK Zwolle, The Netherlands.
| | - Rutger G Zuurmond
- Department of Orthopaedic Surgery and Traumatology, Isala Clinics, PO Box 10400, 8000 GK Zwolle, The Netherlands
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49
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Boyle MJ, Gao R, Frampton CMA, Coleman B. Removal of the syndesmotic screw after the surgical treatment of a fracture of the ankle in adult patients does not affect one-year outcomes. Bone Joint J 2014; 96-B:1699-705. [DOI: 10.1302/0301-620x.96b12.34258] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Our aim was to compare the one-year post-operative outcomes following retention or removal of syndesmotic screws in adult patients with a fracture of the ankle that was treated surgically. A total of 51 patients (35 males, 16 females), with a mean age of 33.5 years (16 to 62), undergoing fibular osteosynthesis and syndesmotic screw fixation, were randomly allocated to retention of the syndesmotic screw or removal at three months post-operatively. The two groups were comparable at baseline. One year post-operatively, there was no significant difference in the mean Olerud–Molander ankle score (82.4 retention vs 86.7 removal, p = 0.367), the mean American Orthopedic Foot and Ankle Society ankle-hindfoot score (88.6 vs 90.1, p = 0.688), the mean American Academy of Orthopedic Surgeons foot and ankle score (96.3 vs 94.0, p = 0.250), the mean visual analogue pain score (1.0 vs 0.7, p = 0.237), the mean active dorsiflexion (10.2° vs 13.0°, p = 0.194) and plantar flexion (33.6° vs 31.3°, p = 0.503) of the ankle, or the mean radiological tibiofibular clear space (5.0 mm vs 5.3 mm, p = 0.276) between the two groups. A total of 19 patients (76%) in the retention group had a loose and/or broken screw one year post-operatively. We conclude that removal of a syndesmotic screw produces no significant functional, clinical or radiological benefit in adult patients who are treated surgically for a fracture of the ankle. Cite this article: Bone Joint J 2014;96-B:1699–1705.
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Affiliation(s)
- M. J. Boyle
- Middlemore Hospital, Department
of Orthopaedic Surgery, Private Bag 93311, Otahuhu, Auckland
1640, New Zealand
| | - R. Gao
- Middlemore Hospital, Department
of Orthopaedic Surgery, Private Bag 93311, Otahuhu, Auckland
1640, New Zealand
| | - C. M. A. Frampton
- The University of Otago , Department
of Medicine, PO Box 4345, Christchurch, New Zealand
| | - B. Coleman
- Middlemore Hospital, Department
of Orthopaedic Surgery, Private Bag 93311, Otahuhu, Auckland
1640, New Zealand
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Segal G, Elbaz A, Parsi A, Heller Z, Palmanovich E, Nyska M, Feldbrin Z, Kish B. Clinical outcomes following ankle fracture: a cross-sectional observational study. J Foot Ankle Res 2014; 7:50. [PMID: 25478013 PMCID: PMC4252004 DOI: 10.1186/s13047-014-0050-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 11/07/2014] [Indexed: 11/12/2022] Open
Abstract
Background The purpose of the current study was to examine objective and subjective differences between three severity groups of ankle fractures patients compared to healthy controls. Methods This was a case-controlled study. 92 patients with an ankle fracture injury of which 41 patients were eligible to participate in the study. 72 healthy people served as controls. All patients underwent a computerized gait test, completed self-assessment questionnaires (The Foot and Ankle Outcome Score (FAOS) and the SF-36), evaluated with the American Foot and Ankle Score (AOFAS) form and completed the 6-min walk test. The control group performed a computerized gait test and completed the SF-36 health survey. Results All ankle fracture patients presented compromised gait patterns and limb symmetry compared to controls (p < 0.05). Ankle fracture patients also had lower SF-36 scores compared to controls (p < 0.05). Significant differences were found between the unimalleolar group compared to the bimalleolar and trimalleolar groups in most parameters, except for the FAOS scores. There were no significant differences between the bimalleolar fracture group and the trimalleolar fracture groups. Conclusions Although all fracture severity classification groups presented a compromised gait pattern and worse clinical symptoms compared to controls, it seems that patients with a unimalleolar fracture is a different group compared to bimalleolar and trimalleolar fracture. Furthermore, it seems that bimalleolar fracture and trimalleolar fracture affect the gait pattern and clinical symptoms to an equal extent, at least in the short-term. Trial registration NCT01127776.
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Affiliation(s)
- Ganit Segal
- AposTherapy Research Group, 1 Abba Even Blvd, Herzliya, 46733 Israel
| | - Avi Elbaz
- AposTherapy Research Group, 1 Abba Even Blvd, Herzliya, 46733 Israel
| | - Alon Parsi
- AposTherapy Research Group, 1 Abba Even Blvd, Herzliya, 46733 Israel
| | - Ziv Heller
- Department of Orthopedic Surgery, Meir Medical Center, Kfar-Saba, Israel
| | | | - Meir Nyska
- Department of Orthopedic Surgery, Meir Medical Center, Kfar-Saba, Israel
| | - Zeev Feldbrin
- Department of Orthopaedic Surgery, Wolfson Medical center, Holon, Israel, affiliated to the Sacker Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Benjamin Kish
- Department of Orthopedic Surgery, Meir Medical Center, Kfar-Saba, Israel
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