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Mason B, Jafarian Tangrood Z, Sharr J, Powell A. Comparing immediate and delayed weight bearing in patients with ankle open reduction internal fixation-A protocol for feasibility randomised controlled trial. Contemp Clin Trials Commun 2024; 39:101304. [PMID: 38826866 PMCID: PMC11141276 DOI: 10.1016/j.conctc.2024.101304] [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: 11/14/2023] [Revised: 01/14/2024] [Accepted: 05/12/2024] [Indexed: 06/04/2024] Open
Abstract
Introduction Uncertainty regarding the timing of weight bearing following ankle open reduction internal fixation (ORIF) in patients with different ankle fracture patterns remains. Traditional rehabilitation methods, including six weeks of non-weight bearing (NWB), is still a common approach in many hospitals, while some previous evidence has shown immediate weight bearing (IWB) to be beneficial. Method 32 adult participants with unimalleolar, bimalleolar or trimalleolar ankle fractures and stable fixation following ankle ORIF will be randomly allocated to either Immediate Weight Bearing (IWB) or Delayed Weight Bearing (DWB) groups. Stability of fixation is a subjective assessment made by the operating surgeon at the completion of fixation and is independent of fracture pattern. Participants in the IWB group will be allowed to weight bear as tolerated within 24 h, while participants in the DWB group will remain non-weight bearing for six weeks. Participants' data including Olerud and Molander Ankle Score, Self-Reported Foot and Ankle Score, SF-36 health survey, time to return to work will be collected. X-rays will be assessed by orthopaedic team members for fixation-related complications including reduction loss, malreduction/malunion, implant failure and non-union. Participants data will be collected at six weeks, three and six-months post-surgery. We will determine the feasibility of a full RCT through assessing the recruitment rate, adherence rate, and drop-out rate. Results Not applicable.This pilot RCT will endeavour to optimise standard rehabilitation protocols post ankle ORIF.
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Affiliation(s)
- Blare Mason
- Division of Orthopaedic Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Zohreh Jafarian Tangrood
- Department of Orthopedic Surgery and Musculoskeletal Research, University of Otago, Christchurch, New Zealand
| | - Jonathan Sharr
- Division of Orthopaedic Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Andrew Powell
- Division of Orthopaedic Surgery, Christchurch Hospital, Christchurch, New Zealand
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Xiao B, Lu M, Chen X, Qiu D, He Y, Li X. Study on the risk factors of postoperative wound complications in patients with ankle fracture. Int Wound J 2024; 21:e14845. [PMID: 38584355 PMCID: PMC10999563 DOI: 10.1111/iwj.14845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Wound complications after surgery for ankle fractures can lead to catastrophic consequences. The purpose of this study was to evaluate the risk factors of postoperative wound complications in patients with ankle fracture and to determine their effects on prognosis. 200 patients with ankle fracture treated in our hospital from October 2021 to December 2023 were analysed retrospectively. The total incidence of postoperative wound complications was 19% (38/200). Type of complications: wound edge necrosis 15 cases (39.47%), dehiscence (reopening of wound) 13 cases (34.21%), delayed healing (>30 days) 10 cases (26.32%); Univariate analysis showed that patients' age, body mass index (BMI), current smoking, alcoholism, diabetes mellitus, injury mechanism, open fracture, wound classification, higher American Society of Anesthesiologists (ASA) score and operation time were all associated with postoperative wound complications. Multivariate Logistic regression model shows: age ≥60 years old OR3.671 (1.875-5.937), BMI OR1.198 (1.143-1.324), current smoking OR2.727 (1.251-5.602), alcoholism OR1.143 (1.034-1.267), complicated with diabetes OR2.763 (1.236-4.852), injury mechanism (high vs. low and medium energy) OR2.437 (1.238-4.786), open fracture OR1.943 (1.8262.139), wound classification (II vs. I) OR4.423 (1.73511.674), ASA score (III-IV vs. I-II) OR1.307 (1.113-2.194) was an independent risk factor for postoperative wound complications in patients with ankle fracture. Further, ROC curves showed that these nine independent influences had high accuracy and validity in predicting postoperative wound complications in patients with ankle fractures. In conclusion, independent risk factors for postoperative complications of ankle fracture were age >60 years, BMI, injury mechanism, open fracture, wound classification (II vs. I), ASA score, current smoking, and alcoholism. The wound classification (II vs. I) has the highest diagnostic value.
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Affiliation(s)
- Ben Xiao
- Orthopedic DepartmentBeijing TongRen Hospital Affiliated Capital Medical UniversityBeijingChina
| | - Meng Lu
- Orthopedic DepartmentBeijing TongRen Hospital Affiliated Capital Medical UniversityBeijingChina
| | - Xiaobin Chen
- Orthopedic DepartmentBeijing TongRen Hospital Affiliated Capital Medical UniversityBeijingChina
| | - Daojing Qiu
- Orthopedic DepartmentBeijing TongRen Hospital Affiliated Capital Medical UniversityBeijingChina
| | - Yuanming He
- Orthopedic DepartmentBeijing TongRen Hospital Affiliated Capital Medical UniversityBeijingChina
| | - Xuejun Li
- Orthopedic DepartmentBeijing TongRen Hospital Affiliated Capital Medical UniversityBeijingChina
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Andrés-Peiró JV, Pujol O, Altayó-Carulla M, Castellanos-Alonso S, Reverté-Vinaixa MM, Teixidor-Serra J, Tomàs-Hernández J, Selga-Marsà J, García-Sánchez Y, Molero-García V, Joshi-Jubert N, Minguell-Monyart J. Predictors of first-year postoperative complications after fixation of low-energy ankle fractures: A single-center, retrospective cohort study of 663 consecutive fractures. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024:S1888-4415(24)00056-0. [PMID: 38325573 DOI: 10.1016/j.recot.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 11/19/2023] [Accepted: 11/24/2023] [Indexed: 02/09/2024] Open
Abstract
INTRODUCTION Rotational ankle fractures are common, have diverse personalities and affect both robust and fragile patients. Postoperative complications are frequent, creating a sizeable economic burden. The primary purpose of this study was to expand current knowledge on predictors of postoperative complications after low-energy ankle fracture fixation. MATERIALS AND METHODS A retrospective single-center cohort study was completed of patients undergoing internal fixation OF low-energy ankle fractures. The primary outcome was first-year postoperative complications, classified as major (surgical) or minor (non-surgical). Data on patients, their injuries, and treatments were collected. To identify potential predictors of outcomes, logistic regression methods were used, with a backward-stepwise method used for model fitting. RESULTS In total, 663 patients of median age 59 years were analysed. We found a high rate of complications (28.4%), with wound-healing issues and infections predominant. Overall, 14.8% had minor complications, while 13.6% required an unplanned reoperation. On multivariable analysis, the most consistent predictors of complications were older age (OR: 1.02 per year), longer operating time (3.32 per hour), and smoking (2.91). CONCLUSIONS Older patients and smokers who sustain fractures requiring more complex surgery are at higher risk of postoperative complications.
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Affiliation(s)
- J-V Andrés-Peiró
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España.
| | - O Pujol
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - M Altayó-Carulla
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - S Castellanos-Alonso
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - M-M Reverté-Vinaixa
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - J Teixidor-Serra
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - J Tomàs-Hernández
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - J Selga-Marsà
- Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - Y García-Sánchez
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - V Molero-García
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - N Joshi-Jubert
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - J Minguell-Monyart
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, España; Departmeng of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
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Li Q, Wang X, Wang Y, Liu F, Fu B. A unilateral external fixator combined with bone transport and tibio-talar fusion for the treatment of severe postoperative infection of peri-ankle fractures: retrospective analysis of 32 cases. J Orthop Surg Res 2024; 19:110. [PMID: 38308313 PMCID: PMC10837972 DOI: 10.1186/s13018-024-04586-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/26/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND To investigate the clinical effects of a unilateral external fixator combined with bone transport and tibio-talar fusion in the treatment of severe postoperative infection of peri-ankle fractures. METHODS The clinical data of 32 patients (22 men and 10 women) with severe postoperative infection of peri-ankle fractures were retrospectively analyzed. Patients' age ranged from 26 to 62 (mean, 42 ± 9.5) years old. The types of fractures were distal tibia fracture (25 cases), distal tibia and fibula fracture (5 cases), and talus fracture (2 cases). All patients underwent treatment with unilateral external fixation combined with bone transport and tibio-talar fusion. 6 patients with severe infection received two-stage treatment involving focal debridement and external fixation, osteotomy, and bone transport. The remaining 26 patients underwent debridement, external fixation, and osteotomy simultaneously. The length of bone transport, total fixation time of the external fixator, and postoperative complications were recorded for all patients. The efficacy of the treatment was assessed using the American Association of Foot and Ankle Society (AOFAS) ankle-hindfoot score. RESULTS Patients were followed up for 16-36 months, with an average follow-up time of 24 months. The length of tibia bone transport ranged from 5 to 15 cm, with a mean length of 8.5 cm. The external fixator was applied for 12-24 months, with an average duration of 16 months. One patient suffered from refracture at tibio-talar fusion site, and one patient had external fixation pin-tract infection. No complications, such as recurrent infections (especially the MRSA infection), poor mineralization, refracture, iatrogenic nerve damage or fusion failure, were found in the remaining patients. The preoperative AOFAS ankle-hindfoot function score was 40.0 ± 3.8 (range, 30-52) points, and it increased to 75.0 ± 3.0 (range, 67-78) points at the last follow-up. CONCLUSION A unilateral external fixator combined with bone transport and tibio-talar fusion is an effective method for treating severe postoperative infection of peri-ankle fractures. This approach is capable of reconstructing large bone defects that remain after clearing the infected lesion. Additionally, it provides stability to the ankle, enhances ankle-hindfoot function, and improves the patient's quality of life.
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Affiliation(s)
- Qinghu Li
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Xin Wang
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Yonghui Wang
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Fanxiao Liu
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Baisheng Fu
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China.
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Abstract
Successful outcomes in the surgical treatment of the fractured ankle require methods that respect the soft tissue envelope and establish a stable mortise for functional rehabilitation. Ankle fractures in patients with osteopenia and in diabetic patients with deranged bone remodeling constitute high-risk injuries that may result in catastrophic complications. These patients present unique care challenges and should not be approached in the same manner as their healthy counterparts. We present the principles of treatment in high-risk ankle fractures, operative treatment philosophy illustrating techniques frequently used at our institution, and a review of current literature.
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Affiliation(s)
- Craig E Krcal
- The CORE Institute, 18444 N 25th Avenue Suite 320, Phoenix, AZ 85023, USA; Kaiser San Francisco Bay Area Foot & Ankle Residency Program Alumni Class of 2023
| | - David R Collman
- Kaiser San Francisco Bay Area Foot & Ankle Residency Program; Department of Orthopedics, Podiatry, Injury, Sports Medicine; Kaiser Permanente San Francisco Medical Center, 450 6th Avenue, French Campus, 5th Floor, San Francisco, CA 94118, USA.
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Becerra E, Castro M, Ruiz-Riquelme P. Results of prophylactic simple fasciocutaneous advancement in the initial management of acute ankle fractures with high risk of operative wound complication. Foot Ankle Surg 2024; 30:37-43. [PMID: 37730458 DOI: 10.1016/j.fas.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 08/24/2023] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
Ankle fracture is the third most prevalent fracture in older adults. Wound dehiscence is the most frequent complication. Our objective is to determine the operative wound complication rate in patients with unstable ankle fracture in whom a prophylactic simple fasciocutaneous advancement was used. METHODS Prospective registry of patients with unstable ankle fracture, in whom a prophylactic fasciocutaneous advancement was performed between August 2020 and July 2021. Demographic variables, time spent in performing the flap, cost of osteosynthesis, minor and major complications of the surgical wound, readmission or reoperation were registered. RESULTS 42 older adults with ankle fracture were included. Median age 69 (60-94). 31% diabetics and 21.5% active smokers. A 40% trimalleolar fracture pattern. There were 7% of superficial complications of the surgical wound. No major complications, no reoperations. CONCLUSIONS Prophylactic fasciocutaneous advancement at the beginning of traumatological surgery is technically simple, reproducible, cheap and with low complications. LEVEL OF EVIDENCE Level IV, cross-sectional study.
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Affiliation(s)
- Eduardo Becerra
- Foot and Ankle Surgery Unit, Department of Orthopedic and Traumatology, Hospital Clínico La Florida, Santiago, Chile; Foot and Ankle Surgery Unit, Department of Orthopedic and Traumatology, Hospital Carabineros de Chile, Santiago, Chile
| | - Magdalena Castro
- School of Medicine, Finis Terrae University, Santiago, Chile; Clinical Epidemiology and Research Unit, School of Medicine, Finis Terrae University, Santiago, Chile
| | - Pablo Ruiz-Riquelme
- Foot and Ankle Surgery Unit, Department of Orthopedic and Traumatology, Hospital Clínico La Florida, Santiago, Chile; School of Medicine, Finis Terrae University, Santiago, Chile; Foot and Ankle Surgery Unit, Department of Orthopedics and Traumatology, Clinic Las Condes, Santiago, Chile.
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Cervera-Garvi P, Galan-Hurtado MH, Marchena-Rodriguez A, Chicharro-Luna E, Guerra-Marmolejo C, Diaz-Miguel S, Ortega-Avila AB. Transcultural Adaptation and Validation of the Spanish Version of the Visual Analogue Scale for the Foot and Ankle (VASFA). J Clin Med 2023; 13:213. [PMID: 38202220 PMCID: PMC10779598 DOI: 10.3390/jcm13010213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/24/2023] [Accepted: 12/25/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The main aim of this study is to perform a cross-cultural adaptation and validation of the Visual Analogue Scale for the Foot and Ankle (VASFA) questionnaire, creating a Spanish-language version (VASFA-Sp), and to determine the measurement properties of this instrument. METHODS VASFA was cross-culturally translated into Spanish following the guidelines of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). The study sample was composed of 228 participants who were recruited from February to May 2022. All were at least 18 years old, gave signed informed consent to take part and properly completed the Foot and Ankle Ability Measures-Sp and VASFA-Sp questionnaires. Cronbach's alpha and test/re-test reliability values were calculated. Structural validity was assessed via exploratory factor analysis. RESULTS The 228 patients included in the final analysis presented the following characteristics: 35.53% were male and 64.47% were female; the mean age was 35.95 (18-81) years; and the mean body mass index was 23.79. Internal consistency was excellent. The Cronbach's alpha for VASFA-Sp was 0.96 and the intraclass correlation coefficient was 0.932 (95% CI; 0.84 to 0.97). Exploratory factor analysis identified one main factor. CONCLUSIONS VASFA-Sp is a reliable, valid and sensitive questionnaire that is suitable for measuring perceived foot and ankle function impairment in a Spanish-speaking population.
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Affiliation(s)
- Pablo Cervera-Garvi
- Department of Nursing and Podiatry, Faculty of Health Sciences, Ampliación de Campus de Teatinos, University of Malaga, Arquitecto Francisco Penalosa 3, 29071 Málaga, Spain; (P.C.-G.); (M.H.G.-H.); (C.G.-M.); (S.D.-M.); (A.B.O.-A.)
| | - Maria Hermas Galan-Hurtado
- Department of Nursing and Podiatry, Faculty of Health Sciences, Ampliación de Campus de Teatinos, University of Malaga, Arquitecto Francisco Penalosa 3, 29071 Málaga, Spain; (P.C.-G.); (M.H.G.-H.); (C.G.-M.); (S.D.-M.); (A.B.O.-A.)
| | - Ana Marchena-Rodriguez
- Department of Nursing and Podiatry, Faculty of Health Sciences, Ampliación de Campus de Teatinos, University of Malaga, Arquitecto Francisco Penalosa 3, 29071 Málaga, Spain; (P.C.-G.); (M.H.G.-H.); (C.G.-M.); (S.D.-M.); (A.B.O.-A.)
| | - Esther Chicharro-Luna
- Department of Behavioural and Health Sciences, Nursing Area, Faculty of Medicine, Miguel Hernandez University, San Juan de Alicante, 03550 Alicante, Spain;
| | - Cristina Guerra-Marmolejo
- Department of Nursing and Podiatry, Faculty of Health Sciences, Ampliación de Campus de Teatinos, University of Malaga, Arquitecto Francisco Penalosa 3, 29071 Málaga, Spain; (P.C.-G.); (M.H.G.-H.); (C.G.-M.); (S.D.-M.); (A.B.O.-A.)
| | - Salvador Diaz-Miguel
- Department of Nursing and Podiatry, Faculty of Health Sciences, Ampliación de Campus de Teatinos, University of Malaga, Arquitecto Francisco Penalosa 3, 29071 Málaga, Spain; (P.C.-G.); (M.H.G.-H.); (C.G.-M.); (S.D.-M.); (A.B.O.-A.)
| | - Ana Belen Ortega-Avila
- Department of Nursing and Podiatry, Faculty of Health Sciences, Ampliación de Campus de Teatinos, University of Malaga, Arquitecto Francisco Penalosa 3, 29071 Málaga, Spain; (P.C.-G.); (M.H.G.-H.); (C.G.-M.); (S.D.-M.); (A.B.O.-A.)
- Biomedical Research Institute (IBIMA), 29590 Malaga, Spain
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Andrés-Peiró JV, Pujol O, Altayó-Carulla M, Castellanos-Alonso S, Reverté-Vinaixa MM, Teixidor-Serra J, Tomàs-Hernández J, Selga-Marsà J, García-Sánchez Y, Molero-García V, Joshi-Jubert N, Minguell-Monyart J. Predictors of first-year postoperative complications after fixation of low-energy ankle fractures: A single-center, retrospective cohort study of 663 consecutive fractures. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023:S1888-4415(23)00259-X. [PMID: 38043738 DOI: 10.1016/j.recot.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 11/19/2023] [Accepted: 11/24/2023] [Indexed: 12/05/2023] Open
Abstract
INTRODUCTION Rotational ankle fractures are common, have diverse personalities and affect both robust and fragile patients. Postoperative complications are frequent, creating a sizeable economic burden. The primary purpose of this study was to expand current knowledge on predictors of postoperative complications after low-energy ankle fracture fixation. MATERIALS AND METHODS A retrospective single-center cohort study was completed of patients undergoing internal fixation OF low-energy ankle fractures. The primary outcome was first-year postoperative complications, classified as major (surgical) or minor (non-surgical). Data on patients, their injuries, and treatments were collected. To identify potential predictors of outcomes, logistic regression methods were used, with a backward-stepwise method used for model fitting. RESULTS In total, 663 patients of median age 59 years were analyzed. We found a high rate of complications (28.4%), with wound-healing issues and infections predominant. Overall, 14.8% had minor complications, while 13.6% required an unplanned reoperation. On multivariable analysis, the most consistent predictors of complications were older age (OR=1.02 per year), longer operating time (3.32 per hour), and smoking (2.91). CONCLUSIONS Older patients and smokers who sustain fractures requiring more complex surgery are at higher risk of postoperative complications.
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Affiliation(s)
- J-V Andrés-Peiró
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.
| | - O Pujol
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - M Altayó-Carulla
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - S Castellanos-Alonso
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - M-M Reverté-Vinaixa
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - J Teixidor-Serra
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - J Tomàs-Hernández
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - J Selga-Marsà
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Y García-Sánchez
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - V Molero-García
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - N Joshi-Jubert
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - J Minguell-Monyart
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
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9
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Hawkins J, Andrews NA, Sankey MT, Sanchez T, Young S, Agarwal A, McGwin G, Shah A. The Impact of Surgical Timing After Ankle Fracture on Clinical and Long-Term Patient Reported Outcomes. J Foot Ankle Surg 2023; 62:701-706. [PMID: 37003858 DOI: 10.1053/j.jfas.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/27/2023] [Accepted: 02/19/2023] [Indexed: 04/03/2023]
Abstract
The goal of this study is to evaluate the effect of time-to-surgery following closed ankle fractures on long-term patient reported outcomes, fracture healing, and wound complications. To date, little research has been done focusing on the impact "time to definitive fixation" has on patient reported outcomes. We performed a retrospective analysis of 215 patient records who underwent open reduction and internal fixation (ORIF) for an ankle fracture from July 2011 to July 2018. A total of 86 patients completed the patient reported outcome measurement information systems (PROMIS) survey at long-term follow-up. Primary outcomes were the rate of delayed union, postoperative wound complications, patient reported outcome measurement information system (PROMIS) pain interference (PI), and physical function (PF) scores. No differences were found when comparing time to surgery on a continuous scale with rates of delayed union, nonunion, or wound complications (p = .84, .47, and .63, respectively). PROMIS scores were collected at a median of 4.5 years (2.0 interquartile range (IQR), range 2.5-12.3) postoperatively. The time from ankle fracture to surgery was independently associated with worse PROMIS PI scores (unstandardized β 0.38, 95% CI 0.07-0.68) but not PROMIS PF scores. Severe Lauge-Hansen injuries were independently associated with decreased PROMIS PF scores (unstandardized β -7.02, 95% CI -12.0 to -2.04). Increased time to surgical intervention and severe Lauge-Hansen injuries were independently associated with worse long-term patient reported outcomes. Surgical timing did not impact union rates or wound complications. Surgeons should be aware that delaying ankle fracture repair beyond 12 days after injury may negatively affect long-term patient reported pain scores.
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Affiliation(s)
- Jacob Hawkins
- Orthopaedic Resident, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Nicholas A Andrews
- Orthopaedic Resident, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew T Sankey
- Orthopaedic Research Fellow, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Thomas Sanchez
- Orthopaedic Research Fellow, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Sean Young
- Research Fellow, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Abhinav Agarwal
- Assistant Professor, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Gerald McGwin
- Professor, Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Ashish Shah
- Associate Professor, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL.
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Ahearn B, Mueller C, Boden S, Mignemi D, Tenenbaum S, Bariteau J. Republication of "Assessment of Recovery From Geriatric Ankle Fracture Using the Life Space Mobility Assessment (LSA): A Pilot Study". FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231195327. [PMID: 37655945 PMCID: PMC10467179 DOI: 10.1177/24730114231195327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Abstract
Background The Life Space Assessment (LSA) is a validated outcomes measure that aims to assess the level of mobility and physical functioning within one's own environment following a medical event. We sought to study the recovery of geriatric ankle fracture patients utilizing the LSA. We hypothesized that the LSA would provide improved assessment of these patients and help identify key differences in operative and nonoperatively treated patients. Methods Prospective observational study of geriatric patients age 65 years and older with an ankle fracture with 1-year follow-up. Operative versus nonoperative intervention was determined by the attending physician on a patient-specific basis. The LSA, Short Form-36 (SF-36), and visual analog pain scale (VAPS) were administered at predetermined intervals postinjury and scores were analyzed for significance. Results 20 patients were enrolled in this study. 11 underwent surgery whereas 9 were treated nonoperatively. Regardless of treatment, the preinjury LSA score was 86.7. This significantly dropped to 20.6 at 6 weeks and recovered to 73.6 at 12 months. In the operative cohort, the LSA scores preinjury were 91.4 and improved to 87.6 after 1 year. The nonoperative group recorded 80.9 preinjury and only improved to 59.5 at 1 year (P = 0.007). There was no statistically significant difference when comparing the results of the SF-36 and VAPS to the LSA. Conclusion The LSA was effective in assessing recovery in geriatric ankle fracture patients. A severe deficit in mobility was seen for the first 6 months of recovery regardless of treatment. Operative patients ultimately returned to their baseline LSA at 1 year while nonoperative patients did not. Outcomes from the VAS and SF-36 mirrored the LSA but were not found to be statistically significant. Level of Evidence Level II.
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Affiliation(s)
- Briggs Ahearn
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Claire Mueller
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephanie Boden
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Danielle Mignemi
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Shay Tenenbaum
- Orthopaedic Attending with Chaim Sheba Medical Center at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jason Bariteau
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
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Bando K, Takegami Y, Ando T, Sugino T, Sato T, Fujita T, Imagama S. Early weight bearing and mobilization decrease perioperative complications in patients after ankle fracture; the retrospective multicenter (TRON group) study. J Orthop Sci 2022; 28:651-655. [PMID: 35370043 DOI: 10.1016/j.jos.2022.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 02/15/2022] [Accepted: 03/03/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND Open reduction and internal fixation (ORIF) for unstable ankle fractures (AF) are relatively predictable with excellent outcomes. Rehabilitation strategies are still being debated after surgical intervention for AF: non-weight bearing and cast immobilization for six weeks after the surgical repair of unstable AF or early functional treatment with partial weight bearing. This study aimed to compare early weight bearing and functional outcomes and complications. METHODS Between April 2014 and March 2019, 1421 patients with AF underwent ORIF at 11 institutions (TRON group). The patients were divided into two groups: Group E started weight bearing within six weeks after surgery, and group L started weightbearing for more than six weeks after. To adjust for baseline difference between groups, a propensity score-matched algorithm was used to match Group E with Group L in a 1:1 ratio of 294 cases each. We compared the American Orthopedic Foot and Ankle Society (AOFAS) score as the functional outcome, the rate of wound dehiscence, superficial and deep infections, blistering, nonunion, neurapraxia, and reoperation at 3, 6, and 12 months after surgery. RESULTS The mean period of non-weight bearing was significantly shorter in group E (3.68 ± 1.02 vs. 6.67 ± 1.43; P < 0.001). The mean period of cast immobilization term were shorter in group E (1.84 ± 1.35 vs. 2.65 ± 1.51; P < 0.001). There were no differences in the AOFAS score at any period. The rates of deep infection and reoperation in Group E were significantly lower than those in Group L (1.7% vs. 6.1%; P = 0.009, 2.0% vs. 7.8%; P = 0.002, respectively). There were no significant differences in superficial infection (9 vs. 15; P = 0.297), nonunion (9 vs. 15 P = 0.30), blistering (4 vs. 3; P = 1.00), neurapraxia (2 vs. 1; P = 1.00), and wound dehiscence (15 vs. 18; P = 0.72). CONCLUSIONS Although functional outcome was similar depending on whether early weight bearing was allowed, the rates of deep infection and reoperation decreased in patients with early weight bearing. We recommend early postoperative weight bearing in patients with a surgically treated AF.
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Affiliation(s)
- Kosuke Bando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Takegami
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Toshihiro Ando
- Department of Orthopedic Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takayuki Sugino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshifumi Sato
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Fujita
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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12
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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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Cinats DJ, Kooner S, Johal H. Acute Hindfoot Nailing for Ankle Fractures: A Systematic Review of Indications and Outcomes. J Orthop Trauma 2021; 35:584-590. [PMID: 34369457 DOI: 10.1097/bot.0000000000002096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess the complication rate of hindfoot nailing of acute fractures involving the tibiotalar joint, and mortality, patient-reported outcome measures, and return to preinjury activities. DATA SOURCES MEDLINE; EMBASE. STUDY SELECTION A systematic literature search for articles in English was completed using MEDLINE and EMBASE databases on April 23, 2020. Original research articles that assessed patients with acute intra-articular fractures of the ankle joint (malleolar ankle fractures and/or pilon fractures) that were treated with a locked hindfoot intramedullary nail, inserted retrograde through the plantar surface of the foot, were selected for inclusion. Case reports (≤4 patients), studies with nonlocked implants, and non-English studies were excluded. DATA EXTRACTION AND SYNTHESIS A validated data extraction form was used, which included study demographics (authors, journal, date of publication, and study design), patient characteristics, implant type, and reported outcomes. Risk of bias for each included study was evaluated using the Institute of Health Economics Quality Appraisal Checklist for case series and the Risk of Bias in randomized trials tool, where appropriate. The best evidence was summarized and weighted mean values were provided when appropriate. RESULTS Ten case series and one randomized controlled trial were included. The overall quality of studies was poor with considerable bias. The majority of studies included elderly patients (weighted mean age 75.5 years) with diabetes (42% of patients). Overall complication rate was 16% with an 8% major complication rate (deep infection, malunion, nonunion, implant failure) and an overall infection rate of 6.2%. Pooled mortality rate was 27% with fracture union rates from 88% to 100%. Mean proportion of patients able to return to preinjury level of activity was 85%. CONCLUSIONS Hindfoot nailing of acute ankle and pilon fractures in elderly patients and patients with diabetes is associated with complication rates comparable with other methods of fixation. Issues with elimination of subtalar joint motion and implant complications secondary to poor implant fixation persist. The literature to date has composed of primarily Level IV studies with considerable bias. Further research is necessary to clarify the role of hindfoot nailing of acute ankle and pilon fractures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- David J Cinats
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA
| | - Sahil Kooner
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada; and
| | - Herman Johal
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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Pflüger P, Wurm M, Biberthaler P, Pförringer D, Crönlein M. [Analysis of 6851 foot and ankle injuries from 2010-2017 in an emergency department]. Unfallchirurg 2021; 125:801-810. [PMID: 34591136 PMCID: PMC9515139 DOI: 10.1007/s00113-021-01081-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2021] [Indexed: 11/30/2022]
Abstract
Hintergrund Sprunggelenk- und Fußverletzungen gehören zu den häufigsten Krankheitsbildern in der Traumatologie. Ziel dieser Studie war es, die demografischen Veränderungen von Patienten mit Fuß- und Sprunggelenkverletzungen, das zeitliche Auftreten und die Entwicklung über die Jahre in einer Notaufnahme zu untersuchen. Material und Methoden Retrospektive Datenauswertung von Patienten, welche aufgrund einer Fuß- und Sprunggelenkverletzung in der Notaufnahme im Zeitraum von 2010 bis 2017 behandelt wurden. Die Patienten wurden mittels ICD-Codes identifiziert und die demografischen Veränderungen, das zeitliche Auftreten und die Entwicklung über die Jahre analysiert. Mittels Quantil-Quantil-Diagramm wurden kontinuierliche Variablen auf Normalverteilung getestet und, falls zutreffend, mittels t‑Test oder nichtparametrischem Mann-Whitney-U-Test auf Signifikanz überprüft. Ergebnisse Insgesamt wurden 6581 Fuß- und Sprunggelenkverletzungen in die Analyse eingeschlossen. Das mittlere Alter von Patienten mit einer Fußfraktur war 39 ± 17,4 Jahre und mit einer Sprunggelenkfraktur 47 ± 19,2 Jahre (p < 0,001). Ligamentäre Verletzungen des Sprunggelenks traten insbesondere bei jüngeren Patienten in den Sommermonaten auf. Die Altersverteilung bei Sprunggelenkfrakturen zeigte für Männer einen Häufigkeitsgipfel zwischen dem 30. und 39. Lebensjahr und bei Frauen ein vermehrtes Auftreten ab dem 50. Lebensjahr. In der Altersgruppe zwischen 65 und 75 Jahren stellten Trimalleolarfrakturen die zweithäufigste Sprunggelenkfraktur dar. Frakturen des Fußes betrafen am häufigsten Patienten im Alter von 20 bis 29 Jahren, wobei bei Frauen ein 2. Häufigkeitsgipfel zwischen dem 50. und 59. Lebensjahr zu beobachten war. Schlussfolgerung Ligamentäre Verletzungen des Sprunggelenks sind häufige Krankheitsbilder in der Notaufnahme und betreffen v. a. jüngere Patienten. Sprunggelenkfrakturen zeigten für Frauen eine bimodale Altersverteilung, und insbesondere Bi- und Trimalleolarfrakturen waren vermehrt bei Frauen ab dem 65. Lebensjahr zu beobachten. Aufgrund der erhöhten Prävalenz von Fuß- und Sprunggelenkfrakturen bei älteren Frauen sollte in diesem Patientenkollektiv eine weitere Osteoporoseabklärung veranlasst werden.
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Affiliation(s)
- Patrick Pflüger
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland.
| | - Markus Wurm
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Peter Biberthaler
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Dominik Pförringer
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Moritz Crönlein
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
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15
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Womble TN, Comadoll SM, Dugan AJ, Davenport DL, Ali SZ, Srinath A, Matuszewski PE, Aneja A. Is supplemental regional anesthesia associated with more complications and readmissions after ankle fracture surgery in the inpatient and outpatient setting? Foot Ankle Surg 2021; 27:581-587. [PMID: 32917527 DOI: 10.1016/j.fas.2020.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/14/2020] [Accepted: 07/31/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is concern that regional anesthesia is associated with increased risk of complications, including return to the hospital for uncontrolled pain once the regional anesthetic wears off. METHODS Retrospective database review of patients who underwent open reduction and internal fixation of a closed ankle fracture from 2014-16 who received general anesthesia alone (GA) or general anesthesia plus regional anesthesia (RA). RESULTS 9459 patients met inclusion criteria. Patients in the RA group had significantly longer operative duration in both inpatient (GAI=71min vs RAI=79min, p=0.002) and outpatient setting (GAO=66min vs RAI=72min, p<0.001), lower overall LOS (GA=1.7 days vs RA=1.1 days, p<0.001), and higher readmission rate for pain (RAO=4 [0.3%] vs GAO=1 [0.0%], p=0.007). CONCLUSIONS Patients who received supplemental regional anesthesia had shorter hospital LOS, increased operative time, and increased readmission rates for rebound pain. However, the small number of patients needing readmission are not clinically significant demonstrating that regional anesthesia is safe, effective and readmission for rebound pain should not be a concern. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Tanner N Womble
- School of Medicine, University of Kentucky, Lexington, KY, USA
| | - Shea M Comadoll
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Adam J Dugan
- Department of Biostatistics, University of Kentucky College of Public Health, Lexington, KY, USA
| | - Daniel L Davenport
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Syed Z Ali
- Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Arjun Srinath
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Paul E Matuszewski
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA.
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16
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Kulakli-Inceleme E, Tas DB, Smeeing DP, Houwert RM, van Veelen NM, Link BC, Iselin LD, Knobe M, Babst R, Beeres FJ. Tibiotalocalcaneal Intramedullary Nailing for Unstable Geriatric Ankle Fractures. Geriatr Orthop Surg Rehabil 2021; 12:21514593211020705. [PMID: 34211800 PMCID: PMC8216405 DOI: 10.1177/21514593211020705] [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: 11/10/2021] [Revised: 03/29/2021] [Accepted: 05/04/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tibiotalocalcaneal (TTC) intramedullary nailing has been suggested as an alternative to open reduction and internal fixation (ORIF) for the primary treatment of unstable fragility ankle fractures with a poor soft tissue envelope. This study aims to investigate the clinical efficacy of TTC intramedullary nail fixation for the primary treatment of unstable ankle fractures in frail elderly patients with poor soft tissue condition, by assessing the number of postoperative complications and the patient-reported functional outcomes. METHODS A retrospective cohort study was performed including patients with an unstable ankle fracture treated between 2015 and 2019 with TTC stabilization using a retrograde intramedullary hindfoot nail that was inserted without joint preparation and allowing immediate weight-bearing postoperatively. The primary outcome was the total number of postoperative complications. RESULTS A total of 10 patients were included out of 365 operatively treated ankle fractures. The mean age was 85.2 years (range 66-92) with a mean follow-up of 11.2 months (range 6-16). Fracture types included AO/OTA 44-B2 (n = 1), 44-B3 (n = 6), 44-C1 (n = 2) and 44-C3 (n = 1). Postoperative complications were observed in 4 patients (40%), including 3 nonunions, 2 implant related complications and 1 wound infection. No wound healing disorder or below-the-knee amputation was observed. Four patients (40%) deceased between post-operative 6 to 16 months due to medical conditions unrelated to surgery. The mean Foot and Ankle Outcome Score was 52.6 (range 44.2-73.8). CONCLUSION Hindfoot nailingis a viable treatment option in selected high-risk patients with an advanced age, unstable ankle fractures with significant bone loss, poor soft tissue condition and/or severely impaired pre-injury mobility. In a frail geriatric population, hindfoot nailing may be a safe alternative fixation method with a low risk of wound complication or major amputation. However, unprepared joint may lead to symptomatic nonunion after TTC intramedullary nailing.
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Affiliation(s)
- Elif Kulakli-Inceleme
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
- These two co-authors contributed equally
| | - David B. Tas
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- These two co-authors contributed equally
| | | | - Roderick M. Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Utrecht Traumacenter, Utrecht, The Netherlands
| | - Nicole M. van Veelen
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Bjoern-Christian Link
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Lukas D. Iselin
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Frank J.P. Beeres
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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17
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Canton G, Sborgia A, Maritan G, Fattori R, Roman F, Tomic M, Morandi MM, Murena L. Fibula fractures management. World J Orthop 2021; 12:254-269. [PMID: 34055584 PMCID: PMC8152440 DOI: 10.5312/wjo.v12.i5.254] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/01/2021] [Accepted: 04/05/2021] [Indexed: 02/06/2023] Open
Abstract
Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.
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Affiliation(s)
- Gianluca Canton
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Andrea Sborgia
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Guido Maritan
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Roberto Fattori
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Federico Roman
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Marko Tomic
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Massimo Max Morandi
- Department of Orthopaedic Surgery, Louisiana State University Health Science Center, Shreveport, LA 71103, United States
| | - Luigi Murena
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
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Increasing age and modifiable comorbidities are associated with short-term complications after open reduction and internal fixation of ankle fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:113-119. [PMID: 33759030 DOI: 10.1007/s00590-021-02927-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Ankle fractures are common orthopedic injuries with complication rates fixation of up to 40%. Limited evidence exists in the literature regarding complications in the elderly population, and moreover, these studies frequently define elderly arbitrarily at 60-65 years old. The purpose of the present study was to utilize a large, validated database to evaluate whether there is an inflection point of age when postoperative complications after an ankle fracture significantly increase. METHODS A retrospective review of all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent fixation of an ankle fracture between 2012 and 2018 was performed. Patients were identified within the database using the Current Procedural Terminology codes. Appropriate statistical analysis was performed with p value less than 0.05 considered statistically significant. RESULTS A total of 27,633 fractures were including and comprised of 221 posterior malleolar, 1567 medial malleolar, 8495 lateral malleolar, 10,175 bimalleolar, and 7175 trimalleolar. A total of 1545 complications were encountered (5.6%). There was a statistically significant association between increasing age and complications (OR = 1.03; p < 0.001). Further analysis shows the largest spike in complications within the age 78 + bracket. There were no overall interaction effects between age and fracture subtype (p = 0.223). CONCLUSION ORIF of ankle fractures is a common orthopedic procedure performed on patients of all ages, with complications ranging in severity. In order to best counsel patients on their individual postoperative risks, large datasets are often necessary to prognosticate. This study found that postoperative complications increase with advanced age. The incidence of complications did not spike for patients around the age of 65, but rather followed an incremental linear pattern with the largest increase in odds ratio occurring at age 78 and above. Complication rate was not associated with specific fracture type based off of ICD codes.
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19
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Ochman S, Raschke MJ. [Ankle fractures in older patients : What should we do differently?]. Unfallchirurg 2021; 124:200-211. [PMID: 33566120 DOI: 10.1007/s00113-021-00953-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 02/07/2023]
Abstract
As a result of the demographic developments ankle fractures in older patients are part of routine trauma surgery. Due to comorbidities, such as diabetes mellitus, reduced bone quality and limited compliance in follow-up treatment, these fractures are prone to complications. The primary goal in the treatment of older patients with ankle fractures is to maintain mobility. In contrast to young patients most fractures are unstable pronation-abduction injuries. In the diagnostics the recognition and optimization of factors influencing the outcome, such as the blood perfusion and the generous use of computed tomography (CT) are recommended. As in the case of younger patients, conservative treatment is reserved for stable fracture forms and, if there are contraindications, should also be initiated in the case of unstable injuries. The choice of approaches is different for surgical treatment, which is adapted to the soft tissues, if necessary minimally invasive and increasingly carried out by a posterolateral approach. The initial transfixation can reduce soft tissue problems. Special surgical techniques and implants that provide a high level of stability, such as dorsal plate positioning, hook plates, angular stable plate systems and intramedullary systems as well as additional options, such as tibia pro fibula constructs are used. Primary retrograde nail arthrodesis is reserved as a salvage procedure only for exceptional cases. As part of the follow-up treatment, an interdisciplinary approach with respect for and optimization of concomitant diseases seems to make sense.
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Affiliation(s)
- Sabine Ochman
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert Schweitzer Campus 1, Gebäude W1, Waldeyerstr. 1, 48149, Münster, Deutschland.
| | - Michael J Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert Schweitzer Campus 1, Gebäude W1, Waldeyerstr. 1, 48149, Münster, Deutschland
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Jupiter DC, Hsu ES, Liu GT, Reilly JG, Shibuya N. Risk Factors for Short-Term Complication After Open Reduction and Internal Fixation of Ankle Fractures: Analysis of a Large Insurance Claims Database. J Foot Ankle Surg 2021; 59:239-245. [PMID: 32130984 DOI: 10.1053/j.jfas.2019.08.003] [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] [Received: 06/10/2019] [Revised: 08/06/2019] [Accepted: 08/11/2019] [Indexed: 02/03/2023]
Abstract
Although fractures of the ankle are common injuries treated by surgical podiatrists and orthopaedic surgeons specializing in foot and ankle surgery, postoperative complications can occur, often imposing an economic burden on the patient. As health care in the United States moves toward value-based care, cost reduction has primarily focused on reducing complications and unplanned episodes of care. We used a large modern database of insurance claims to examine patterns of complications after open reduction internal fixation of ankle fractures, identifying diabetes mellitus and history of myocardial infarction as risk factors for postoperative infection within 30 days of surgery. Lateral malleolar repair was less likely to lead to infection, or need for repeated surgery, than was medial malleolar fracture repair. Diabetes mellitus, neuropathy, and chronic obstructive pulmonary disease were associated with development of postoperative cellulitis. Patients with a history of cerebrovascular accident were more likely to return to the emergency department or to have a pulmonary embolism. Male sex, presence of lupus, and increased age were associated with repeat surgery.
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Affiliation(s)
- Daniel C Jupiter
- Associate Professor, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX; Assistant Professor, Department of Orthopedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX.
| | - En Shuo Hsu
- Associate Professor, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - George Tye Liu
- Associate Professor, Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - John G Reilly
- Medical Student, Texas A&M, College of Medicine, Bryan, TX
| | - Naohiro Shibuya
- Professor, Texas A&M University, College of Medicine, Temple, TX; Chief, Section of Podiatry, Surgical Services, Central Texas Veterans Affairs Health Care System, Temple, TX; Staff, Department of Surgery, Baylor Scott & White Health, Temple, TX
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21
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Xia D, Zhang Y, Ou T, Wang Y, Hao Z, Zhou P, Xu S. Combination of mini locking plate and nitinol arched shape-memory connector for purely lateral malleolus fractures: technique and clinical results. ANNALS OF TRANSLATIONAL MEDICINE 2021; 8:1573. [PMID: 33437772 PMCID: PMC7791235 DOI: 10.21037/atm-20-4055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Lateral malleolus fractures occur frequently. The common techniques for fixing purely lateral malleolus fractures are often challenging, owing to the extent of soft tissue damage and fracture non-union. Herein, we report a new treatment that entails minimally invasive insertion and continuous compression of the broken ends as a novel technique, and evaluate its clinical results. Methods This study enrolled 21 patients (13 males and 8 females; mean age 32.06±3.45 years, range 23–69 years) with purely lateral malleolus fractures. Each patient underwent open reduction treatment with a mini locking plate for internal fixation and compression of the fracture end with an Arched Shape-Memory Connector (ASC). The clinical assessments were made using the American Orthopedic Foot and Ankle Society (AOFAS) scores, which were recorded at the final follow-up visit. Results The patients were followed for an average of 14.7±1.2 months (range, 12–18 months). None of the patients showed surgical failure, and all of the purely lateral malleolus fractures healed in an average of 12.6±1.5 weeks (range, 10–16 weeks). The mean AOFAS score was 88.94 (range, 83–90). Conclusions The new treatment had beneficial outcomes for purely lateral malleolus fractures. Mini locking plates are minimally invasive for surgical intervention, and combined with continuous concentrated compression with an ASC to accelerate osseous healing, they aid in restoration of function and enable early rehabilitation with a low incidence of postoperative complications.
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Affiliation(s)
- Demeng Xia
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China.,Department of Orthopaedics, The Naval Hospital of Eastern Theater Command of PLA, Zhoushan, China
| | - Yuntong Zhang
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China.,Department of Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Tianle Ou
- Department of Clinical Medicine, The Naval Medical University, Shanghai, China
| | - Yang Wang
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zichen Hao
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Panyu Zhou
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China.,Department of Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Shuogui Xu
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China.,Department of Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, China
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22
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Abstract
Ankle fractures remain the third most common musculoskeletal injury in the elderly population. The presence of osteoporosis, significant multiple comorbidities and limited functional independence makes treatment of such injuries challenging. Early studies highlighted high rates of post-operative complications and poor outcomes after surgical intervention. With advances in surgical techniques and a greater understanding of multi-disciplinary team (MDT)-driven peri-operative care and rehabilitation, evidence now appears to suggest improved outcomes for operative management. Approaches must be adapted according to co-morbidities, baseline function and patient wishes. This review article aims to discuss contemporary treatment strategies and the complex challenges associated with the management of the elderly ankle fracture.
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De Las Heras Romero J, Lledó Alvarez A, Torres Sánchez C, Luna Maldonado A. Operative Treatment of Ankle Fractures: Predictive Factors Affecting Outcome. Cureus 2020; 12:e11016. [PMID: 33094040 PMCID: PMC7574997 DOI: 10.7759/cureus.11016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Purpose Surgical management of ankle fractures has been extensively studied in literature but studies investigating validated clinical results are lacking and controversial. The purpose of this study was to evaluate functional and health-related quality of life (HRQL) outcomes after surgically treated ankle fractures and to detect some of their predictors. Methods Two hundred sixty-six skeletally mature patients who underwent surgery for an isolated ankle fracture from 2006 to 2017 were retrospectively identified from our hospital records and included in the study. All patients were evaluated at one, three, six and 12 months post-injury with clinical and radiographic examination. Outcome measures recorded at final two years minimum follow-up included patient-reported pain, patient satisfaction, functional (American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score) and quality of life (Short Form (SF) 36 score) status. Results Patient satisfaction score was 8.4 out of 10, Visual Analogue Scale mean score was 2.3, complication rate was 36.5% and mean AOFAS ankle-hindfoot score was 87.3. Mean SF36-physical summary score was 77.9 and SF36-mental summary score was 81.1. The injury demonstrated a significant effect on physical function, role-physical, bodily pain and social functioning SF-36 subdomains. Functional outcome was significantly related to occupation, syndesmotic lesion, number of fractured malleoli and delay to surgery. Main predictors of quality of life were age, occupation, cause of injury, syndesmotic lesion, number of fractured malleoli and waiting time to surgery. Conclusions Ankle fractures have a considerable impact on functional and quality of life status of patients. Occupation, presence of syndesmotic injury, Pott's classification and surgery delay must be considered as predictors of final outcome.
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Affiliation(s)
| | - Ana Lledó Alvarez
- Regional Statistical Center, Treasury and Public Administration Council, Murcia, ESP
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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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25
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Bohl DD, Idarraga AJ, Holmes GB, Hamid KS, Lin J, Lee S. Validated Risk-Stratification System for Prediction of Early Adverse Events Following Open Reduction and Internal Fixation of Closed Ankle Fractures. J Bone Joint Surg Am 2019; 101:1768-1774. [PMID: 31577682 DOI: 10.2106/jbjs.19.00203] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND As orthopaedic surgery moves toward bundled payments, there is growing interest in identifying patients at high risk of early postoperative adverse events. The purpose of this study was to develop and validate a risk-stratification system for the occurrence of early adverse events among patients treated with open reduction and internal fixation (ORIF) for a closed fracture of the ankle. METHODS Patients undergoing ORIF for a closed ankle fracture during the period of 2006 to 2017, as documented by the American College of Surgeons National Surgical Quality Improvement Program, were identified. For the 60% of patients randomly selected as the development cohort, multivariate Cox proportional hazards modeling was used to identify factors that were independently associated with the occurrence of adverse events (including events such as reoperation, surgical site infection, and pulmonary embolism). On the basis of these results, a nomogram analysis was used to generate a point-based risk-stratification system. To evaluate the validity of the point-based system, the system was applied to the remaining 40% of patients constituting the validation cohort and tested for its ability to predict adverse events. RESULTS Of the 7,582 patients in the development cohort, 455 developed an adverse event (estimated adverse event risk of 6%). On the basis of Cox proportional-hazards regression, patients were assigned points for each of the following significant risk factors: +1 point for age of 40 to 59 years, +3 points for age of 60 to 79 years, +5 points for age of ≥80 years, +1 point for female sex, +2 points for chronic obstructive pulmonary disease (COPD), +2 points for insulin-dependent diabetes, +3 points for anemia, and +4 points for end-stage renal disease. The validation cohort included 5,263 patients. Among this second cohort, the risk-stratification system predicted the risk of early adverse events (p < 0.001; Harrell C = 0.697). CONCLUSIONS The occurrence of early adverse events following ORIF for closed ankle fractures was associated with greater age, female sex, COPD, insulin-dependent diabetes, anemia, and end-stage renal disease. We present and validate a simple point-based risk-stratification system to predict the risk of early adverse events. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel D Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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26
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Wolfstadt JI, Pincus D, Kreder HJ, Wasserstein D. Association between socioeconomic deprivation and surgical complications in adults undergoing ankle fracture fixation: a population-based analysis. Can J Surg 2019; 62:320-327. [PMID: 31550093 DOI: 10.1503/cjs.012018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background Few studies have investigated the outcomes of surgical fracture care among socially deprived patients despite the increased incidence of fractures and the inequality of care received in this group. We evaluated whether socioeconomic deprivation affected the complications and subsequent management of marginalized/homeless patients following surgery for ankle fracture. Methods In this retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, we evaluated 45 444 patients who underwent open reduction and internal fixation (ORIF) for ankle fracture performed by 710 different surgeons between Jan. 1, 1994, and Dec. 31, 2011. Multivariable logistic regression models were used to assess the association between deprivation and shorter-term outcomes within 1 year (implant removal, repeat ORIF, irrigation and débridement owing to infection, and amputation). Multivariable Cox proportional hazards models were used to assess longer-term outcomes up to 20 years (ankle fusion and ankle arthroplasty). Results A higher level of deprivation was associated with an increased risk of irrigation and débridement (quintile 5 v. quintile 1: odds ratio [OR] 2.14, 95% confidence interval [CI] 1.25–3.67, p = 0.0054) and amputation (quintile 4 v. quintile 1: OR 3.56, 95% CI 1.01–12.4, p = 0.0466). It was more common for less deprived patients to have their hardware removed (quintile 5 v. quintile 1: OR 0.822, 95% CI 0.76–0.888, p < 0.0001). There was no correlation between marginalization and subsequent revision ORIF, ankle fusion, or ankle arthroplasty. Conclusion Marginalized patients are at a significantly increased risk of infection and amputation following surgical treatment of ankle fractures. However, these complications are still extremely uncommon among this group. Socioeconomic deprivation should not prohibit marginalized patients from receiving surgery for unstable ankle fractures.
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Affiliation(s)
- Jesse Isaac Wolfstadt
- From the Granovsky Gluskin Division of Orthopaedics, Mount Sinai Hospital, Toronto, Ont. (Wolfstadt); the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Wolfstadt, Pincus, Kreder, Wasserstein); the Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Pincus, Kreder, Wasserstein); the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Pincus, Kreder); and ICES, Toronto, Ont. (Pincus, Kreder)
| | - Daniel Pincus
- From the Granovsky Gluskin Division of Orthopaedics, Mount Sinai Hospital, Toronto, Ont. (Wolfstadt); the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Wolfstadt, Pincus, Kreder, Wasserstein); the Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Pincus, Kreder, Wasserstein); the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Pincus, Kreder); and ICES, Toronto, Ont. (Pincus, Kreder)
| | - Hans J. Kreder
- From the Granovsky Gluskin Division of Orthopaedics, Mount Sinai Hospital, Toronto, Ont. (Wolfstadt); the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Wolfstadt, Pincus, Kreder, Wasserstein); the Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Pincus, Kreder, Wasserstein); the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Pincus, Kreder); and ICES, Toronto, Ont. (Pincus, Kreder)
| | - David Wasserstein
- From the Granovsky Gluskin Division of Orthopaedics, Mount Sinai Hospital, Toronto, Ont. (Wolfstadt); the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Wolfstadt, Pincus, Kreder, Wasserstein); the Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Pincus, Kreder, Wasserstein); the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Pincus, Kreder); and ICES, Toronto, Ont. (Pincus, Kreder)
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Abstract
The number of ankle fractures in elderly patients is increasing. The aim of treatment of ankle fractures in the elderly is to guarantee a possible unlimited autonomy and quality of life for patients. This is achieved by minimization of the complications and impairments after ankle joint fractures. Decisive for the further course is the initial treatment. The results are essentially determined by the soft tissue management, reduction and stable osteosynthesis; however, an orthogeriatric co-management with the implementation of treatment paths and standard operating procedures is recommended. The advantages of an interdisciplinary cooperation of trauma surgeons and geriatricians are obvious in this situation.
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Lower Complication Rate Following Ankle Fracture Fixation by Orthopaedic Surgeons Versus Podiatrists. J Am Acad Orthop Surg 2019; 27:607-612. [PMID: 30601371 DOI: 10.5435/jaaos-d-18-00630] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Increased overlap in the scope of practice between orthopaedic surgeons and podiatrists has led to increased podiatric treatment of foot and ankle injuries. However, a paucity of studies exists in the literature comparing orthopaedic and podiatric outcomes following ankle fracture fixation. METHODS Using an insurance claims database, 11,745 patients who underwent ankle fracture fixation between 2007 and 2015 were retrospectively evaluated. Patient data were analyzed based on the provider type. Complications were identified by the International Classification of Diseases, Ninth Revision, codes, and revision surgeries were identified by the Current Procedural Terminology codes. Complications analyzed included malunion/nonunion, infection, deep vein thrombosis, and rates of irrigation and débridement. Risk factors for complications were compared using the Charlson Comorbidity Index. RESULTS Overall, 11,115 patients were treated by orthopaedic surgeons and 630 patients were treated by podiatrists. From 2007 to 2015, the percentage of ankle fractures surgically treated by podiatrists had increased, whereas that treated by orthopaedic surgeons had decreased. Surgical treatment by podiatrists was associated with higher malunion/nonunion rates among all types of ankle fractures. No differences in complications were observed in patients with unimalleolar fractures. In patients with bimalleolar or trimalleolar fractures, treatment by a podiatrist was associated with higher malunion/nonunion rates. Patients treated by orthopaedic surgeons versus podiatrists had similar comorbidity profiles. DISCUSSION Surgical treatment of ankle fractures by orthopaedic surgeons was associated with lower rates of malunion/nonunion when compared with that by podiatrists. The reasons for these differences are likely multifactorial but warrants further investigation. Our findings have important implications in patients who must choose a surgeon to surgically manage their ankle fracture, as well as policymakers who determine the scope of practice. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Operative Ankle Fractures. J Orthop Trauma 2019; 33:312-317. [PMID: 30664055 DOI: 10.1097/bot.0000000000001446] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To investigate the ability of a validated geriatric trauma risk prediction tool to stratify hospital quality metrics and inpatient cost for middle-aged and geriatric patients admitted from the emergency department for operative treatment of an ankle fracture. DESIGN Prospective cohort study. SETTING Single Academic Medical Center. PATIENTS Patients 55 years of age and older who sustained a rotational ankle fracture and who were treated operatively during their index hospitalization. INTERVENTION Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle Aged (STTGMA), using patient demographics, injury severity, and functional status. Patients were stratified into groups based on scores to create a minimal-, low-, moderate-, and high-risk cohort. MAIN OUTCOME MEASUREMENTS Length of stay, complications, need for intensive care unit-/step-down unit-level care, discharge location, and index admission costs. RESULTS Fifty ankle fracture patients met inclusion criteria. The mean length of stay was 7.8 ± 5.2 days with a significant difference among the 4 risk groups (4.6-day difference between low and high risk). 73.1% of minimal-risk patients were discharged home compared with 0% of high-risk patients. There was no difference in complication rate or in need for intensive care unit-level care between groups. However, high-risk patients had a mean total inpatient cost 2 times greater than that of minimal-risk patients. CONCLUSION The Score for Trauma Triage in Geriatric and Middle-Aged tool is able to meaningfully stratify older patients with ankle fracture who require operative fixation regarding hospital quality metrics and cost. This information may allow for efficient targeted reductions in costs while optimizing outcomes. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Merrill RK, Ferrandino RM, Hoffman R, Shaffer GW, Ndu A. Machine Learning Accurately Predicts Short-Term Outcomes Following Open Reduction and Internal Fixation of Ankle Fractures. J Foot Ankle Surg 2019; 58:410-416. [PMID: 30803914 DOI: 10.1053/j.jfas.2018.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Indexed: 02/03/2023]
Abstract
Ankle fractures are common orthopedic injuries with favorable outcomes when managed with open reduction and internal fixation (ORIF). Several patient-related risk factors may contribute to poor short-term outcomes, and machine learning may be a valuable tool for predicting outcomes. The objective of this study was to evaluate machine-learning algorithms for accurately predicting short-term outcomes after ORIF for ankle fractures. The Nationwide Inpatient Sample and Nationwide Readmissions Database were queried for adult patients ≥18 years old who underwent ORIF of an ankle fracture during 2013 or 2014. Morbidity and mortality, length of stay >3 days, and 30-day all-cause readmission were the outcomes of interest. Two machine-learning models were created to identify patient and hospital characteristics associated with the 3 outcomes. The machine learning models were evaluated using confusion matrices and receiver operating characteristic area under the curve values. A total of 16,501 cases were drawn from the Nationwide Inpatient Sample and used to assess morbidity and mortality and length of stay >3 days, and 33,504 cases were drawn from the Nationwide Readmissions Database to assess 30-day readmission. Older age, Medicaid, Medicare, deficiency anemia, congestive heart failure, chronic lung disease, diabetes, hypertension, and renal failure were the variables associated with a statistically significant increased risk of developing all 3 adverse events. Logistic regression and gradient boosting had similar area under the curve values for each outcome, but gradient boosting was more accurate and more specific for predicting each outcome. Our results suggest that several comorbidities may be associated with adverse short-term outcomes after ORIF of ankle fractures, and that machine learning can accurately predict these outcomes.
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Affiliation(s)
- Robert K Merrill
- Orthopedic Surgery Resident, Department of Orthopedic Surgery, Albert Einstein Medical Center, Philadelphia, PA.
| | - Rocco M Ferrandino
- Ear Nose and Throat Resident, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan Hoffman
- Orthopedic Surgery Resident, Department of Orthopedic Surgery, Albert Einstein Medical Center, Philadelphia, PA
| | - Gene W Shaffer
- Orthopedic Surgeon, Department of Orthopedic Surgery, Albert Einstein Medical Center, Philadelphia, PA
| | - Anthony Ndu
- Orthopedic Surgeon, Department of Orthopedic Surgery, Albert Einstein Medical Center, Philadelphia, PA
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31
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Hsu RY, Ramirez JM, Blankenhorn BD. Surgical Considerations for Osteoporosis in Ankle Fracture Fixation. Orthop Clin North Am 2019; 50:245-258. [PMID: 30850082 DOI: 10.1016/j.ocl.2018.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
As the geriatric population and associated ankle fractures continues to increase, fracture surgeons should be prepared to surgically manage osteoporotic ankle fractures. There are abundant challenges in management, soft tissue care, and fixation of ankle fractures with poor bone quality especially in elderly patients who have difficulty limiting weight bearing. This article summarizes several different surgical techniques that can be used to optimize outcomes of these fractures.
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Affiliation(s)
- Raymond Y Hsu
- Department of Orthopedic Surgery, The Warren Alpert Medical School at Brown University, 1 Kettle Point Avenue, East Providence, RI 02915, USA.
| | - Jose M Ramirez
- Department of Orthopedic Surgery, The Warren Alpert Medical School at Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Brad D Blankenhorn
- Department of Orthopedic Surgery, The Warren Alpert Medical School at Brown University, 1 Kettle Point Avenue, East Providence, RI 02915, USA
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Abousayed MM, Johnson CK, Moral M, Sternbach S, Rosenbaum AJ. Trends in Urgent Care Utilization Following Ankle Fracture Fixation. Foot Ankle Int 2019; 40:218-223. [PMID: 30354487 DOI: 10.1177/1071100718804178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: The Centers for Medicare and Medicaid services (CMS) have implemented initiatives to improve postdischarge care and reduce unnecessary readmissions. Readmissions within 30 days are frequent and represent an economic burden on both patients and the healthcare system. The aim of this study was to evaluate the frequency and causes for urgent care visits within 30 days of discharge after ankle open reduction and internal fixation (ORIF) and determine factors correlated with such visits. METHODS: This was a retrospective analysis of prospectively collected data. All patients who underwent ankle ORIF at our institution between July 1, 2016, and June 30, 2017, were included. Patients were identified using Current Procedural Terminology (CPT) codes for ankle ORIF. Patients' demographics including age, sex, race, body mass index, occupation, insurance payer, and comorbidities were documented. RESULTS: Thirty-five patients (10.51%) had urgent care visits within 30 days of discharge. Patients presented at a mean of 11.8 days after the day of surgery. Sixteen patients (45.71%) had cast/splint-related issues, 7 (20%) presented with pain, and 7 (20%) with increased operative site drainage. Univariate analysis demonstrated a statistically significant association between postoperative urgent care visits and patients with diabetes ( P = .03) or underlying psychiatric disorders ( P = .03). CONCLUSION: In this population study of patients undergoing ankle fracture surgery, we found that the rate of urgent care visits within 30 days of discharge exceeded the rate of inpatient readmission. Additionally, patients with diabetes and psychiatric disorders were significantly more likely to present to an urgent care facility postoperatively, potentially accounting for increased expenditures of the healthcare system. LEVEL OF EVIDENCE: Level III, comparative series.
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Affiliation(s)
| | | | - Muhammad Moral
- 1 Division of Orthopedic Surgery, Albany Medical College, Albany, NY, USA
| | - Sarah Sternbach
- 1 Division of Orthopedic Surgery, Albany Medical College, Albany, NY, USA
| | - Andrew J Rosenbaum
- 2 Director of Orthopedic Research, Division of Orthopedic Surgery, Albany Medical College, Albany, NY, USA
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Yasui Y, Shimozono Y, Hung CW, Marangon A, Wollstein A, Gianakos AL, Murawski CD, Kennedy JG. Postoperative Reoperations and Complications in 32,307 Ankle Fractures With and Without Concurrent Ankle Arthroscopic Procedures in a 5-Year Period Based on a Large U.S. Healthcare Database. J Foot Ankle Surg 2019; 58:6-9. [PMID: 30243789 DOI: 10.1053/j.jfas.2018.03.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Indexed: 02/03/2023]
Abstract
Residual symptoms often persist even after successful operative reduction and internal fixation (ORIF) of ankle fractures. Concurrent ankle arthroscopic procedures (CAAPs) have been proposed to improve clinical outcomes; however, a dearth of evidence is available supporting this practice. The purpose of the present study was to investigate the reoperation and complication rates after ORIF of ankle fractures with and without CAAPs. Reoperations and complications after ORIF of ankle fractures were identified using the PearlDiver database from January 2007 to December 2011. The CAAPs included bone marrow stimulation, debridement, synovectomy, and unspecified cartilage procedures. Reoperation procedures consisted of ankle fracture repeat fixation, arthroscopic procedures, osteochondral autograft transfers, and ankle arthrodesis. Of the 32,307 patients who underwent ankle fracture fixation, 248 received CAAP and 32,059 did not. No significant difference was found in the reoperation rate between the 2 groups (7.7% versus 8.6%; odds ratio 0.89; 95% confidence interval 0.55 to 1.42; p = .61). Of the 248 patients in the CAAP group, 19 (7.7%) underwent reoperation, of which 13 (68.4%) were arthroscopic debridement and 6 were either ankle refixation or osteochondral autograft transfer. For the non-CAAP group, 3021 reoperation procedures were performed, consisting of ankle refixation in 83.2%, arthroscopic procedures in 14.3%, and ankle arthrodesis in 2.5%. The complication rate in the non-CAAP group included wound dehiscence in 2.4%, wound surgery in 0.4%, deep vein thrombosis in 0.8%, and pulmonary embolism in 0.4%. No complications were detected in the CAAP group. Ankle fracture fixation with CAAPs did not increase the postoperative reoperation rate compared with ankle fracture fixation without CAAPs.
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Affiliation(s)
- Youichi Yasui
- Orthopaedic Surgeon, Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | | | - Chun Wai Hung
- Medical Student, New York Medical College, Valhalla, NY
| | | | - Adi Wollstein
- Medical Student, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | | | - John G Kennedy
- Attending Orthopaedic Surgeon, Hospital for Special Surgery, New York, NY.
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Meng J, Sun T, Zhang F, Qin S, Li Y, Zhao H. Deep surgical site infection after ankle fractures treated by open reduction and internal fixation in adults: A retrospective case-control study. Int Wound J 2018; 15:971-977. [PMID: 30091528 PMCID: PMC7949792 DOI: 10.1111/iwj.12957] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/02/2018] [Accepted: 06/05/2018] [Indexed: 01/17/2023] Open
Abstract
Information on ankle fractures is limited. The purpose of this study was to investigate the incidence and risk factors for deep surgical site infection (DSSI) after open reduction and internal fixation (ORIF). Adult patients who underwent ORIF for an ankle fractures at 3 level-I centres between January 2013 and June 2017 were included. Data on demographic, injury-related, and surgery-related variables and biochemical indexes from the laboratory were collected from patients' electronic medical records. Univariate analysis and multivariate logistic regression analysis model were used to perform the data analysis through SPSS 19.0. Within 1-year postoperatively, 2.83% (74/2617) of cases developed DSSI, with the earliest occurring at the 4th and latest at 147th day. Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and methicillin-susceptible Staphylococcus aureus were the top 3 bacteria, causing 73% (37/51) of all the cases. Age (45-64 and ≥65 years), current smoking status, chronic heart disease, lower preoperative albumin level, open injury, and prolonged surgical duration were identified to be independently associated with DSSI occurrence. Preoperative active supplementation of nutrition, immediate smoking cessation, and optimisation of an operative plan for the reduction of surgical duration were feasible measures for DSSI prevention following ORIF of ankle fractures.
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Affiliation(s)
- Jinghong Meng
- Department of Rheumatology and ImmunologyThe 3rd Hospital of Hebei Medical UniversityShijiazhuangPR China
| | - Tao Sun
- Department of Bone TumorThe 3rd Hospital of Hebei Medical UniversityShijiazhuangPR China
| | - Fengqi Zhang
- Department of Foot and Ankle SurgeryThe 3rd Hospital of Hebei Medical UniversityShijiazhuangPR China
| | - Shiji Qin
- Department of Foot and Ankle SurgeryThe 3rd Hospital of Hebei Medical UniversityShijiazhuangPR China
| | - Yansen Li
- Department of Foot and Ankle SurgeryThe 3rd Hospital of Hebei Medical UniversityShijiazhuangPR China
| | - Haitao Zhao
- Department of Foot and Ankle SurgeryThe 3rd Hospital of Hebei Medical UniversityShijiazhuangPR China
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Assessment of Recovery From Geriatric Ankle Fracture Using the Life Space Mobility Assessment (LSA). FOOT & ANKLE ORTHOPAEDICS 2018. [DOI: 10.1177/2473011418795160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The Life Space Assessment (LSA) is a validated outcomes measure that aims to assess the level of mobility and physical functioning within one’s own environment following a medical event. We sought to study the recovery of geriatric ankle fracture patients utilizing the LSA. We hypothesized that the LSA would provide improved assessment of these patients and help identify key differences in operative and nonoperatively treated patients. Methods: Prospective observational study of geriatric patients age 65 years and older with an ankle fracture with 1-year follow-up. Operative versus nonoperative intervention was determined by the attending physician on a patient-specific basis. The LSA, Short Form–36 (SF-36), and visual analog pain scale (VAPS) were administered at predetermined intervals postinjury and scores were analyzed for significance. Results: 20 patients were enrolled in this study. 11 underwent surgery whereas 9 were treated nonoperatively. Regardless of treatment, the preinjury LSA score was 86.7. This significantly dropped to 20.6 at 6 weeks and recovered to 73.6 at 12 months. In the operative cohort, the LSA scores preinjury were 91.4 and improved to 87.6 after 1 year. The nonoperative group recorded 80.9 preinjury and only improved to 59.5 at 1 year ( P = 0.007). There was no statistically significant difference when comparing the results of the SF-36 and VAPS to the LSA. Conclusion: The LSA was effective in assessing recovery in geriatric ankle fracture patients. A severe deficit in mobility was seen for the first 6 months of recovery regardless of treatment. Operative patients ultimately returned to their baseline LSA at 1 year while nonoperative patients did not. Outcomes from the VAS and SF-36 mirrored the LSA but were not found to be statistically significant. Level of Evidence: Level II.
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McDonald E, Winters B, Nicholson K, Shakked R, Raikin S, Pedowitz DI, Daniel JN. Effect of Postoperative Ketorolac Administration on Bone Healing in Ankle Fracture Surgery. Foot Ankle Int 2018; 39:1135-1140. [PMID: 29972028 DOI: 10.1177/1071100718782489] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In an effort to minimize narcotic analgesia and its potential side effects, anti-inflammatory agents offer great potential provided they do not interfere with bone healing. The safety of ketorolac administration after foot and ankle surgery has not been well defined in the current literature. The purpose of this study was to report clinical healing and radiographic outcomes for patients treated with a perioperative ketorolac regimen after open reduction and internal fixation (ORIF) of ankle fractures. METHODS A retrospective review was performed on all patients that received perioperative ketorolac at the time of lateral malleolar, bimalleolar, and trimalleolar ankle ORIF by a single surgeon between 2010 and 2016 with minimum 4 months follow-up. Patients received 20 tablets of 10 mg ketorolac Q6 hours. Radiographs were evaluated independently by 2 blinded fellowship-trained orthopedic foot and ankle surgeons to assess for radiographic healing. A total of 281 patients were included, with a median age of 51 years and 138 males (47%). Statistical analysis consisted of a linear mixed-effects regression. RESULTS In all, 265/281 (94%) were clinically healed within 12 weeks and 261/281 (92%) were radiographically healed within 12 weeks. Within the group of patients that did not heal within 12 weeks, mean time to clinical healing was 16.9 weeks (range = 14-25 weeks), and mean time to radiographic healing was 17.1 weeks (range = 14-25 weeks). In patients taking ketorolac, there were no cases of nonunion in our series (n = 281) and no significant difference found between fracture patterns and healing or complications ( P = .500). CONCLUSIONS Perioperative ketorolac use was associated with a high rate of fracture union by 12 weeks. This is the first study to examine the effect of ketorolac on radiographic time to union of ankle fractures. Additional studies are necessary to determine whether ketorolac helps reduce opioid consumption and improve pain following ORIF of ankle fractures. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Elizabeth McDonald
- 1 The Rothman Institute, Philadelphia, PA, USA.,2 Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Comparison of Open Reduction and Internal Fixation Versus Closed Reduction and Percutaneous Fixation for Medial Malleolus Fractures. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2018; 1:e048. [PMID: 30211366 PMCID: PMC6132344 DOI: 10.5435/jaaosglobal-d-17-00048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Indexed: 11/18/2022]
Abstract
Introduction Surgical treatment of medial malleolus (MM) fractures can be performed through open or percutaneous approaches, although comparisons between these two approaches have not been undertaken. In this study, we compared patients with MM fractures treated with closed reduction and percutaneous fixation (CRPF) with patients treated with traditional open reduction and internal fixation (ORIF). Methods A group of 165 consecutive patients underwent surgical fixation of a closed MM fracture from 2011 to 2015 at a single institution. Thirty-one underwent CRPF and 134 underwent ORIF. Patient demographics, injury characteristics, treatment methods, and outcome variables were recorded through review of patient charts, radiographs, and surgical reports. Results The rate of MM fracture comminution was higher in the ORIF group compared with the CRPF group (9.7% vs 27.6%; P = 0.04). All other patient and injury variables were similar between the two groups. There was no statistically significant difference observed between the CRPF and ORIF groups regarding outcomes, including nonunion, malunion, time to union, rate of hardware removal, and wound complications. Discussion Both CRPF and ORIF resulted in acceptable radiographic outcomes and low complication rates for the treatment of MM fractures.
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Keene DJ, Mistry D, Nam J, Tutton E, Handley R, Morgan L, Roberts E, Gray B, Briggs A, Lall R, Chesser TJ, Pallister I, Lamb SE, Willett K. The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years. Health Technol Assess 2018; 20:1-158. [PMID: 27735787 DOI: 10.3310/hta20750] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Close contact casting (CCC) may offer an alternative to open reduction and internal fixation (ORIF) surgery for unstable ankle fractures in older adults. OBJECTIVES We aimed to (1) determine if CCC for unstable ankle fractures in adults aged over 60 years resulted in equivalent clinical outcome compared with ORIF, (2) estimate cost-effectiveness to the NHS and society and (3) explore participant experiences. DESIGN A pragmatic, multicentre, equivalence randomised controlled trial incorporating health economic evaluation and qualitative study. SETTING Trauma and orthopaedic departments of 24 NHS hospitals. PARTICIPANTS Adults aged over 60 years with unstable ankle fracture. Those with serious limb or concomitant disease or substantial cognitive impairment were excluded. INTERVENTIONS CCC was conducted under anaesthetic in theatre by surgeons who attended training. ORIF was as per local practice. Participants were randomised in 1 : 1 allocation via remote telephone randomisation. Sequence generation was by random block size, with stratification by centre and fracture pattern. MAIN OUTCOME MEASURES Follow-up was conducted at 6 weeks and, by blinded outcome assessors, at 6 months after randomisation. The primary outcome was the Olerud-Molander Ankle Score (OMAS), a patient-reported assessment of ankle function, at 6 months. Secondary outcomes were quality of life (as measured by the European Quality of Life 5-Dimensions, Short Form questionnaire-12 items), pain, ankle range of motion and mobility (as measured by the timed up and go test), patient satisfaction and radiological measures. In accordance with equivalence trial US Food and Drug Administration guidance, primary analysis was per protocol. RESULTS We recruited 620 participants, 95 from the pilot and 525 from the multicentre phase, between June 2010 and November 2013. The majority of participants, 579 out of 620 (93%), received the allocated treatment; 52 out of 275 (19%) who received CCC later converted to ORIF because of loss of fracture reduction. CCC resulted in equivalent ankle function compared with ORIF at 6 months {OMAS 64.5 points [standard deviation (SD) 22.4 points] vs. OMAS 66.0 points (SD 21.1 points); mean difference -0.65 points, 95% confidence interval (CI) -3.98 to 2.68 points; standardised effect size -0.04, 95% CI -0.23 to 0.15}. There were no differences in quality of life, ankle motion, pain, mobility and patient satisfaction. Infection and/or wound problems were more common with ORIF [29/298 (10%) vs. 4/275 (1%)], as were additional operating theatre procedures [17/298 (6%) vs. 3/275 (1%)]. Malunion was more common with CCC [38/249 (15%) vs. 8/274 (3%); p < 0.001]. Malleolar non-union was lower in the ORIF group [lateral: 0/274 (0%) vs. 8/248 (3%); p = 0.002; medial: 3/274 (1%) vs. 18/248 (7%); p < 0.001]. During the trial, CCC showed modest mean cost savings [NHS mean difference -£644 (95% CI -£1390 to £76); society mean difference -£683 (95% CI -£1851 to £536)]. Estimates showed some imprecision. Incremental quality-adjusted life-years following CCC were no different from ORIF. Over common willingness-to-pay thresholds, the probability that CCC was cost-effective was very high (> 95% from NHS perspective and 85% from societal perspective). Experiences of treatments were similar; both groups endured the impact of fracture, uncertainty regarding future function and the need for further interventions. LIMITATIONS Assessors at 6 weeks were necessarily not blinded. The learning-effect analysis was inconclusive because of limited CCC applications per surgeon. CONCLUSIONS CCC provides a clinically equivalent outcome to ORIF at reduced cost to the NHS and to society at 6 months. FUTURE WORK Longer-term follow-up of trial participants is under way to address concerns over potential later complications or additional procedures and their potential to impact on ankle function. Further study of the patient factors, radiological fracture patterns and outcomes, treatment responses and prognosis would also contribute to understanding the treatment pathway. TRIAL REGISTRATION Current Controlled Trials ISRCTN04180738. FUNDING The National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 75. See the NIHR Journals Library website for further project information. This report was developed in association with the National Institute for Health Research Oxford Biomedical Research Unit funding scheme. The pilot phase was funded by the AO Research Foundation.
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Affiliation(s)
- David J Keene
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Julian Nam
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Elizabeth Tutton
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Royal College of Nursing Research Institute, University of Warwick, Coventry, UK
| | - Robert Handley
- Oxford Trauma Service, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lesley Morgan
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Emma Roberts
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Bridget Gray
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Briggs
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Tim Js Chesser
- Department of Orthopaedic Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Ian Pallister
- Department of Orthopaedic Surgery, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Sarah E Lamb
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Keith Willett
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Sun Y, Wang H, Tang Y, Zhao H, Qin S, Xu L, Xia Z, Zhang F. Incidence and risk factors for surgical site infection after open reduction and internal fixation of ankle fracture: A retrospective multicenter study. Medicine (Baltimore) 2018; 97:e9901. [PMID: 29443762 PMCID: PMC5839807 DOI: 10.1097/md.0000000000009901] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
UNLABELLED Information on surgical site infection (SSI) after surgical treatment of ankle fracture is limited and remains controversial. The purpose of the present study was to determine the incidence and risk factors for SSI after open reduction and internal fixation (ORIF) of ankle fracture. Patients who underwent ORIF for ankle fracture at 3 centers between January 2015 and December 2016 were included. The potential risk factors for SSI included demographic variables, including age, sex, body mass index (BMI), hypertension, diabetes mellitus, heart disease, smoking, and excessive alcohol intake; blood test variables including preoperative white blood cell count, neutrophil count, red blood cell count, hemoglobin, total protein, albumin and globulin; injury- and surgery-related variables, including duration of operation (minutes), intraoperative blood loss, surgeon level, fracture site, accompanied dislocation, use of a drainage tube, and antibiotic use. Factors related with SSI occurrence were investigated by univariate analysis, and then by multivariate analysis. During hospitalization, 4.37% (66/1511) of patients developed SSI, which was deep in 1.32% (20/1510) and superficial in 3.05% (46/1510). The most common causative agent was polymicrobial (causing approximately half of all SSIs), followed by methicillin-resistant Staphylococcus aureus (MRSA). Multivariate analysis revealed that the significant risk factors for SSI occurrence were open injury, advanced age, incision cleanliness II - IV, high-energy injury, more experienced surgeon level, greater BMI, chronic heart disease, history of allergy, and preoperative neutrophil count > 75%. Preoperative preventative measures should be taken in patients with these conditions to lower the incidence of SSI after ORIF of ankle fracture. LEVEL OF EVIDENCE Level III - Retrospective Comparative Study.
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Affiliation(s)
- Yaning Sun
- Department of Foot and Ankle Surgery, the Third Hospital of Hebei Medical University
| | - Huijuan Wang
- Department of Histology and Embryology, Hebei Medical University, Shijiazhuang
| | - Yuchao Tang
- Department of Foot and Ankle Surgery, the Third Hospital of Hebei Medical University
| | - Haitao Zhao
- Department of Foot and Ankle Surgery, the Third Hospital of Hebei Medical University
| | - Shiji Qin
- Department of Foot and Ankle Surgery, the Third Hospital of Hebei Medical University
| | - Lihui Xu
- Department of Foot and hand Surgery, Xingtai People‘s Hospital, Xingtai
| | - Zhiyong Xia
- Department of Orthopedics 4, Handan Branch of the Jizhong Energy Fengfeng Group General Hospital, Handan, Hebei, China
| | - Fengqi Zhang
- Department of Foot and Ankle Surgery, the Third Hospital of Hebei Medical University
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Jordan RW, Chapman AWP, Buchanan D, Makrides P. The role of intramedullary fixation in ankle fractures - A systematic review. Foot Ankle Surg 2018; 24:1-10. [PMID: 29413767 DOI: 10.1016/j.fas.2016.04.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 04/06/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ankle fractures are one of the most commonly occurring fractures in the elderly population. The overall incidence has been reported to be up to 184 fractures per 100,000 persons per year, of which 20-30% occur in the elderly. Medical co-morbidities, osteoporosis, suboptimal skin quality and poor toleration of non-weight bearing status all contribute to difficulties in managing these injuries in this population. Intramedullary implants are advantageous as they utilise smaller incisions, minimise soft tissue disruption and may allow early weight bearing. This systematic review aims to analyse the use of both fibula nails and talo-tibial-calcaneal (TTC) implants in the management of fragility ankle fractures. METHODS We conducted a systematic review of the literature using the online databases Medline and EMBASE on 26th December 2015. Only studies assessing ankle fractures that were treated with either an intramedullary fibula nail or TTC implant were included. Studies must have reported complications, patient mobility status or a functional outcome measure. Studies were excluded if the intramedullary device utilised was an adjunct to plate fixation or where a variety of surgical treatments were included in the study. The included studies were appraised with respect to a validated quality assessment scale. RESULTS Our search strategy produced 350 studies although only 17 studies met inclusion criteria; ten assessed a fibula nail and seven assessed a standard hindfoot nail, a TTC implant. 15 studies were case series, the overall quality of the studies was low and only one randomised controlled trial was reviewed. The mean Olerud and Molander Ankle Score for fibula nail studies ranged from 58 to 97 and the complication rate from 0 to 22%. Two comparative studies reported a statistically significant increase in complication rate with plate fixation but similar functional outcomes. Studies assessing TTC implants reported a mean Olerud and Molander Ankle Score of 50-62 and complication rate from 18 to 22.6%. CONCLUSION The studies reviewed suggest that fibula nails may be capable of producing similar functional outcomes with lower rates of complications to plate fixation. TTC implants produce lower functional outcomes but this may be acceptable in a subgroup of patients at high risk or with reduced pre-injury mobility. However, the low quality of evidence reviewed, the variation in patients included, implant used and outcome scores measured restricts the ability to draw definitive conclusions. Further comparative studies are required to explore the role of these implants further.
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Affiliation(s)
- R W Jordan
- University Hospital, Coventry and Warwickshire, United Kingdom.
| | - A W P Chapman
- University Hospital, Coventry and Warwickshire, United Kingdom
| | | | - P Makrides
- Birmingham Heartlands Hospital, United Kingdom
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Sun R, Li M, Wang X, Li X, Wu L, Chen Z, Chen K. Surgical site infection following open reduction and internal fixation of a closed ankle fractures: A retrospective multicenter cohort study. Int J Surg 2017; 48:86-91. [PMID: 29050964 DOI: 10.1016/j.ijsu.2017.10.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/20/2017] [Accepted: 10/02/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Identification of risk factors for surgical site infection (SSI) after surgical ankle fractures was important, but related evidence was inadequate. This study was conducted to investigate the incidence and risk factors for SSI after open reduction and internal fixation (ORIF) of a closed ankle fractures. METHODS Patients who underwent ORIF for a closed ankle fractures at 3 centers between July 2015 and January 2017 were included. Electronic medical recordings (EMR) and Picture Archiving and Communication Systems (PACS) were inquired for information on patients' clinical and radiographic characteristics. The potential factors include 4 aspects: demographics, injury-related, surgery-related and biochemical indictors. Factors related with SSI were analyzed by univariate and further by multivariate logistic regression model. RESULTS During the hospitalization, 3.7% (46/1247) of patients developed SSI, with 1.12% (14/1247) for deep and 2.57% (32/1247) for superficial SSI. Approximately half of SSIs were caused by Methicillin-resistant Staphylococcus aureus (MRSA). After adjustment for confounding factors, higher body mass index (BMI), surgeon level (residents or treating surgeon), surgical duration>130mins, delayed surgery, preoperative TP < 60 g/L were significant risk factor or predictors for SSI occurrence. CONCLUSIONS After comprehensive evaluation of patients medical conditions, immediate operation by a surgeon with more expertise could effectively reduce SSI occurrence.
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Affiliation(s)
- Ran Sun
- Department of Joint Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China.
| | - Mingqiao Li
- Department of the Orthopaedics, The Second People' Hospital of Hengshui, Hengshui, Hebei, 053000, PR China.
| | - Xiaofeng Wang
- Department of Joint Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China.
| | - Xiaodong Li
- Department of Orthopaedics, Handan Central Hospital, Handan, Hebei, 056002, PR China.
| | - Lumei Wu
- Department of Joint Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China.
| | - Zheng Chen
- Department of Joint Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China.
| | - Kang Chen
- Department of Joint Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, PR China.
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Rate of and Risk Factors for Intermediate-Term Reoperation After Ankle Fracture Fixation: A Population-Based Cohort Study. J Orthop Trauma 2017; 31:e315-e320. [PMID: 28614147 DOI: 10.1097/bot.0000000000000920] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Establish baseline rates of and risk factors for reoperation within 1 or 2 years of ankle open reduction internal fixation (ORIF). DESIGN Retrospective, population-based cohort study. SETTING Two hundred two hospitals in Ontario, Canada (approximate population 13.6 million in 2014). PATIENTS/PARTICIPANTS Forty five thousand four hundred forty-four patients who underwent ankle ORIF performed by 710 different surgeons between January 1, 1994, and December 31, 2011. MAIN OUTCOME MEASUREMENTS Intermediate-term reoperation because of isolated implant removal, repeat ORIF, irrigation and debridement (I&D) for infection, or amputation. Multivariable logistic regression related potential prognostic factors (patient, provider, and injury) to reoperation. RESULTS There were 8906 patients who underwent at least one subsequent operation (19.6%). The most common procedure was isolated implant removal (18.1%); odds of removal being higher for females [odds ratio (OR), 1.53; 95% confidence interval (CI), 1.45-1.62; P < 0.001]. N = 674 patients (1.5%) underwent reoperation for another reason. The odds of repeat ORIF and I&D infection were greater for open fractures (OR 2.17; 95% CI, 1.22-3.86; P = 0.008 and OR 3.12; 95% CI, 1.94-5.03; P < 0.001). Odds of amputation was highest for diabetics (OR 7.42; 95% CI, 3.73-14.86; P < 0.001). CONCLUSIONS Isolated implant removal accounts for the vast majority of intermediate-term reoperations after ankle ORIF. Reoperation for other reasons (repeat ORIF, I&D, or amputation) was extremely rare, even among the highest risk patients. Concerns regarding reoperation for these reasons should not preclude operative treatment in any patient, provider, or injury group we considered. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Matson AP, Hamid KS, Adams SB. Predictors of Time to Union After Operative Fixation of Closed Ankle Fractures. Foot Ankle Spec 2017; 10:308-314. [PMID: 27872379 DOI: 10.1177/1938640016677813] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ankle fractures are common and represent a significant burden to society. We aim to report the rate of union as determined by clinical and radiographic data, and to identify factors that predict time to union. METHODS A cohort of 112 consecutive patients with isolated, closed, operative malleolar ankle fractures treated with open reduction and internal fixation was retrospectively reviewed for time to clinical union. Clinical union was defined based on radiographic and clinical parameters, and delayed union was defined by time to union >12 weeks. Injury characteristics, patient factors and treatment variables were recorded, and statistical techniques employed included the Chi-square test, the Student's T-test, and multivariate linear regression modeling. RESULTS Forty-two (37.5%) of patients who achieved union did so in less than 12 weeks, and 69 (61.6%) of these patients demonstrated delayed union at a mean of 16.7 weeks (range, 12.1-26.7 weeks), and the remaining patient required revision surgery. Factors associated with higher rates of delayed union or increased time to union included tobacco use, bimalleolar fixation, and high energy mechanism (all p<0.05). In regression analysis, statistically significant negative predictors of time to union were BMI, dislocation of the tibiotalar joint, external fixation for initial stabilization and delay of definitive management (all p<0.05). CONCLUSION Patient characteristics, injury factors and treatment variables are predictive of time to union following open reduction and internal fixation of closed ankle fractures. These findings should assist with patient counseling, and help guide the provider when considering adjunctive therapies that promote bone healing. LEVELS OF EVIDENCE Prognostic, Level IV: Case series.
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Affiliation(s)
- Andrew P Matson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Kamran S Hamid
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Ziegler P, Schlemer D, Flesch I, Bahrs S, Stoeckle U, Werner S, Bahrs C. Quality of life and clinical-radiological long-term results after implant-associated infections in patients with ankle fracture: a retrospective matched-pair study. J Orthop Surg Res 2017; 12:114. [PMID: 28716100 PMCID: PMC5513114 DOI: 10.1186/s13018-017-0608-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 07/01/2017] [Indexed: 11/25/2022] Open
Abstract
Background Ankle fractures are frequently occurring injuries. Despite the relatively simple operative technique, patients often suffer from postoperative complications. Little is known about postoperative treatment of implant-associated infections of the ankle. Therefore, this study shows and evaluates a treatment algorithm in long- and short-term outcomes compared to infection-free patients. Methods Data from patients of over 20 years of a level 1 trauma center and university hospital was retrospectively analyzed including age, gender, comorbidities, smoking status, fracture classification, number of revisions, length of in-patient stay due to fracture and infection, and results of microbiological specimen with the length of antibiotic treatment. Moreover, present long-term outcome was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, the Ankle Osteoarthritis Score, and the Short Form 36 score and compared to a matched-pair infection-free patient cohort. Results Forty-four patients could be retrospectively evaluated (51% male, 49% women, mean age 46 ± 17 years). Most of the cases were Weber B fractures (38%) following an in-patient stay from 51 ± 4.3 days after primary treatment and 77 ± 10.0 days after secondary treatment in our hospital. Microbiological specimen showed in 77% Staphylococcus aureus with following intravenous antibiotic treatment for 13.9 ± 3.1 days in mean. Common comorbidities/risk factors were cardiovascular disease (28%), smoking (15%), and diabetes (18%). Cure of infection and clinical and radiographic osseous consolidation could be documented for all cases. Patients with implant-associated infections had significantly more risk factors than infection-free patients (1.1/0.33; p = .02 per patient). The matched-pair group showed significantly better long-term outcome in mean regarding the Ankle Osteoarthritis Score (2.0 ± 1.2/13.9 ± 4.7) and AOFAS hindfoot score (96.7 ± 1.9/87.3 ± 3.4). Conclusion Immediate revision surgery with aggressive debridement, microbiological diagnostics, antibiotic therapy, and use of a drain until osseous consolidation is reached with following removal of the implant in patients with implant-associated infections after ankle fracture and open reduction internal fixation lead to cure of infection and fair long-term outcome in all cases. Special care must be taken of risk factors like diabetes and smoking. Trial registration 24/2008BO2
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Affiliation(s)
- Patrick Ziegler
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, University of Tübingen, Schnarrenbergstr 95, 72076, Tuebingen, Germany
| | - Donat Schlemer
- Department of Orthopedics, Traumatology and Sports Medicine, Bogenhausen, Kliniken München GmbH, Englschalkinger Str. 77, 81925, Munich, Germany
| | - Ingo Flesch
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, University of Tübingen, Schnarrenbergstr 95, 72076, Tuebingen, Germany
| | - Sonja Bahrs
- Department of Diagnostic and Interventional Radiology, University of Tübingen, Hoppe-Seyler-Str. 3, D-72076, Tübingen, Germany.
| | - Ulrich Stoeckle
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, University of Tübingen, Schnarrenbergstr 95, 72076, Tuebingen, Germany
| | - Sebastian Werner
- Department of Diagnostic and Interventional Radiology, University of Tübingen, Hoppe-Seyler-Str. 3, D-72076, Tübingen, Germany
| | - Christian Bahrs
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, University of Tübingen, Schnarrenbergstr 95, 72076, Tuebingen, Germany
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Kadakia RJ, Ahearn BM, Schwartz AM, Tenenbaum S, Bariteau JT. Ankle fractures in the elderly: risks and management challenges. Orthop Res Rev 2017; 9:45-50. [PMID: 30774476 PMCID: PMC6209347 DOI: 10.2147/orr.s112684] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Ankle fractures are the third most common osseous injury in the elderly, behind hip and distal radius fractures. While there is a rich history of clinical advancement in the timing, technique, perioperative management, and associated risks of hip fractures, similar evaluations are only more recently being undertaken for ankle fractures. Traditionally, elderly patients were treated more conservatively; however, nonoperative management has been found to be associated with increased mortality. As such, older and less healthy patients have become operative candidates. The benefits of geriatric/orthopedic inpatient comanagement that have been well elucidated in the hip fracture literature also seem to improve outcomes in elderly patients with ankle fractures. One of the orthopedist’s roles is to recognize the complexities of osteoporotic bone fixation and optimize wound healing potential. Though the immediate cost of this surgical approach is inevitably higher, the ultimate cost of long-term care has been found to be substantially reduced. It is important to consider the mortality and morbidity benefits and cost reductions of operative intervention and proper inpatient care of geriatric ankle fractures when they present to the emergency department or the office.
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Affiliation(s)
- Rishin J Kadakia
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA,
| | - Briggs M Ahearn
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA,
| | - Andrew M Schwartz
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA,
| | - Shay Tenenbaum
- Department of Orthopedic Surgery, Chaim Sheba Medical Center at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jason T Bariteau
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA,
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Abstract
INTRODUCTION This study sought to assess and compare long-term functional and clinical outcomes in patients with tibial plateau fractures that are treated nonsurgically. METHODS Over a period of 8 years, 305 consecutive tibial plateau fractures were treated by three surgeons at a single institution and followed prospectively in an Institutional Review Board-approved study. Overall, 41 patients (13%) were treated nonsurgically and 37 were available for follow-up. Indications for nonsurgical management were minimal fracture displacement or preclusion of surgery because of comorbidities. A series of univariate retrospective analyses were used to identify individual risk factors potentially predictive of Short Musculoskeletal Functional Assessment scores. RESULTS Thirty-seven patients were included with a mean follow-up of 21 ± 14.9 months. Overall, 59% of patients (n = 22) attained good to excellent functional outcomes. In patients for whom surgery was precluded because of comorbidities, outcome scores were significantly poorer (38.8 ± 23.0 versus 12.7 ± 14.2; P = 0.001). Surgery precluded by a factor other than minimal fracture displacement predicted poor outcome (P = 0.002). DISCUSSION Carefully selected patients with minimally displaced tibial plateau fractures can expect good to excellent outcomes when treated nonsurgically. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Abstract
INTRODUCTION Ankle fractures are the third most common orthopaedic injury seen in the geriatric patient. Studies have identified mortality benefits with operative management, but treatment must be considered on a case-by-case basis. In the era of value-based analysis, a thorough of understanding of outcomes and costs of treatment is required. The purpose of this study was to analyze the inpatient and readmission costs associated with operative and nonoperative management of geriatric ankle fractures. METHODS Patients were identified using diagnosis codes for ankle fractures from all 2008 Part A Medicare claims. Patients younger than 65 years and those who sustained an ankle fracture during the previous year were excluded. Operative patients were then identified by ICD-9 procedure codes. Other variables collected included age, comorbidities, and the incidence of hospital readmissions. Inpatient costs were determined using Medicare reimbursement data. RESULTS A total of 19 648 patients with ankle fractures were identified. Of these, 15 193 (77.3%) underwent operative intervention. The mean cost for initial fracture admission was $5097.20 for nonoperative management compared with $8798.10 for operative management ( P < .05). The mean inpatient costs associated with readmission for nonoperative intervention was $5161.50 and for operative treatment, it was $5071.40 ( P > .05). The reimbursement for hospital readmissions for both groups combined for approximately $29.7 million. The total cost of initial treatment plus readmission for both treatment groups combined was approximately $185 million. DISCUSSION The total expenditure estimate of $185 million in this study has likely increased given the steady growth of the geriatric population. Expenditures associated with these readmissions was approximately $30 million-nearly a sixth of total costs. Future work must focus on determining which patients will benefit from operative intervention and optimizing care to decrease readmissions and their associated cost in this growing cohort of patients. LEVELS OF EVIDENCE Therapeutic, Level III: Retrospective study.
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Affiliation(s)
- Rishin J Kadakia
- Department of Orthopaedics, Emory University, Atlanta, Georgia (RJK, BMA, JTB).,Chaim Sheba Medical Center Department of Orthopaedic Surgery, Ramat Gan, Israel (ST)
| | - Briggs M Ahearn
- Department of Orthopaedics, Emory University, Atlanta, Georgia (RJK, BMA, JTB).,Chaim Sheba Medical Center Department of Orthopaedic Surgery, Ramat Gan, Israel (ST)
| | - Shay Tenenbaum
- Department of Orthopaedics, Emory University, Atlanta, Georgia (RJK, BMA, JTB).,Chaim Sheba Medical Center Department of Orthopaedic Surgery, Ramat Gan, Israel (ST)
| | - Jason T Bariteau
- Department of Orthopaedics, Emory University, Atlanta, Georgia (RJK, BMA, JTB).,Chaim Sheba Medical Center Department of Orthopaedic Surgery, Ramat Gan, Israel (ST)
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Weinraub GM, Levine P, Shi E, Flowers A. Comparison of Medial Malleolar Fracture Healing at 8 Weeks After Open Reduction Internal Fixation Versus Percutaneous Fixation: A Retrospective Cohort Study. J Foot Ankle Surg 2017; 56:277-281. [PMID: 28087232 DOI: 10.1053/j.jfas.2016.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Indexed: 02/03/2023]
Abstract
Unstable medial malleolar fractures are treated with either standard open reduction internal fixation (ORIF) or a percutaneous approach. The percutaneous approach avoids the potentially excessive soft tissue dissection associated with an open approach but can also result in inadequate anatomic reduction. No studies have compared the incidence of radiographic healing of medial malleolar fractures between an open approach and percutaneous fixation. A retrospective comparative study was performed at a single institution across multiple sites. Electronic medical records and digital radiographs were reviewed for 845 patients who had undergone either ORIF or percutaneous screw fixation (PSF) of a medial malleolar fracture. The interval to fracture healing was measured. Logistic regression analysis was used. Of the 490 included patients, 458 (93.44%) underwent standard ORIF and 32 (6.53%) underwent PSF. Patients who underwent ORIF were 5 times more likely to have a healed fracture at 8 weeks than were patients who had undergone PSF (p < .001). Compared with standard ORIF, PSF of medial malleolar fractures leads to an increased risk of an unhealed fracture at 8 weeks. This was likely due to a combination of soft tissue interposition within the fracture site and inadequate fluoroscopic reliability, leading to poor anatomic reduction and inaccurate fixation.
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Affiliation(s)
- Glenn M Weinraub
- Attending Physician, Department of Orthopaedic Surgery, The Permanente Medical Group, San Leandro, CA
| | - Patrick Levine
- Resident Physician, Kaiser Permanente South Bay Consortium, Santa Clara, CA
| | - Eric Shi
- Resident Physician, Kaiser Permanente South Bay Consortium, Santa Clara, CA.
| | - Aarron Flowers
- Resident Physician, Kaiser Permanente South Bay Consortium, Santa Clara, CA
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Ashman BD, Kong C, Wing KJ, Penner MJ, Bugler KE, White TO, Younger ASE. Fluoroscopy-guided reduction and fibular nail fixation to manage unstable ankle fractures in patients with diabetes. Bone Joint J 2016; 98-B:1197-201. [PMID: 27587520 DOI: 10.1302/0301-620x.98b9.37140] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 05/04/2016] [Indexed: 11/05/2022]
Abstract
Aims Patients with diabetes are at increased risk of wound complications after open reduction and internal fixation of unstable ankle fractures. A fibular nail avoids large surgical incisions and allows anatomical reduction of the mortise. Patients and Methods We retrospectively reviewed the results of fluoroscopy-guided reduction and percutaneous fibular nail fixation for unstable Weber type B or C fractures in 24 adult patients with type 1 or type 2 diabetes. The re-operation rate for wound dehiscence or other indications such as amputation, mortality and functional outcomes was determined. Results Two patients developed lateral side wound infection, one of whom underwent wound debridement. Three other patients required re-operation for removal of symptomatic hardware. No patient required a below-knee amputation. Six patients died during the study period for unrelated reasons. At a median follow-up of 12 months (7 to 38) the mean Short Form-36 Mental Component Score and Physical Component Score were 53.2 (95% confidence intervals (CI) 48.1 to 58.4) and 39.3 (95% CI 32.1 to 46.4), respectively. The mean Visual Analogue Score for pain was 3.1 (95% 1.4 to 4.9). The mean Ankle Osteoarthritis Scale total score was 32.9 (95% CI 16.0 to 49.7). Conclusion Fluoroscopy-guided reduction and fibular nail fixation of unstable ankle fractures in patients with diabetes was associated with a low incidence of wound and overall complications, while providing effective surgical fixation. Cite this article: Bone Joint J 2016;98-B:1197–1201.
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Affiliation(s)
- B. D. Ashman
- University of British Columbia, 3114
- 910 West 10th Avenue, Vancouver, BC, V5Z
1M9, Canada
| | - C. Kong
- University of British Columbia, 3114
- 910 West 10th Avenue, Vancouver, BC, V5Z
1M9, Canada
| | - K. J. Wing
- University of British Columbia, St.
Paul’s Hospital, 530 – 1144 Burrard Street, Vancouver, BC, V6Z
2A5, Canada
| | - M. J. Penner
- University of British Columbia, St.
Paul’s Hospital, 530 – 1144 Burrard Street, Vancouver, BC, V6Z
2A5, Canada
| | - K. E. Bugler
- The Royal Infirmary of Edinburgh, Little
France Crescent, Edinburgh, Scotland, EH16
4SA, UK
| | - T. O. White
- The Royal Infirmary of Edinburgh, Little
France Crescent, Edinburgh, Scotland, EH16
4SA, UK
| | - A. S. E. Younger
- University of British Columbia, St.
Paul’s Hospital, 530 – 1144 Burrard Street, Vancouver, BC, V6Z
2A5, Canada
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