Ankle Open Reduction Internal Fixation Research Articles

Effect of Obesity on Short- and Long-Term Complications After Ankle Fracture Fixation.

This study evaluated the relationship between obesity and postoperative complications in patients undergoing ankle open reduction internal fixation (ORIF). Retrospective cohort study. PearlDiver-Mariner All-Payor Database. Patients who underwent ankle ORIF from 2010 to 2021 and had a minimum of 2 years of follow-up were identified using Current Procedural Terminology, ICD-9, and ICD-10 codes. Patients were stratified by body mass index into nonobese, obese, morbidly obese, and super-obese groups. Complication rates, including 90-day readmissions, infection, and post-traumatic osteoarthritis, were compared between obesity groups. Patients were additionally compared with a 1:1 matched analysis that controlled for demographics and comorbidities. A total of 160,415 patients undergoing ankle ORIF from 2010 to 2021 were identified. The cohort consisted mostly of females (64.8%) and the average age was 52.5 (SD 18.4) years. There were higher rates of 90-day readmissions, UTIs, DVT/PE, pneumonia, superficial infections, and acute kidney injuries in patients with increasing levels of obesity (P < 0.001). There were increased odds of nonunion and post-traumatic arthritis in the matched analysis at 2 years in the obesity group [OR: 2.36, 95% confidence interval (CI): 1.68-3.31, P < 0.001; OR: 2.18, 95% CI: 1.77-2.68, P < 0.001, respectively]. Postoperative medical complication rates in patients undergoing ankle ORIF, including infection, are higher in obese patients, even in the 1:1 matched analysis that controlled for demographic and comorbidity factors. Rates of nonunion and post-traumatic arthritis were higher in obese patients, as well. As such, it is important for surgeons to provide appropriate education regarding the risks after ankle ORIF in patients with obesity. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparing immediate and delayed weight bearing in patients with ankle open reduction internal fixation–A protocol for feasibility randomised controlled trial

IntroductionUncertainty 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. Method32 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. ResultsNot applicable.This pilot RCT will endeavour to optimise standard rehabilitation protocols post ankle ORIF.

Weight Changes after Ankle Fracture Surgery: A Retrospective Cohort Study

Background: Recovery from open reduction internal fixation of the ankle frequently involves a decrease in activity level and some limitations in weightbearing. The purpose of this study was to evaluate weight changes during the postoperative period following ankle fracture surgery. Methods: Hospital billing records were retrospectively reviewed to identify all patients who underwent open reduction internal fixation of bimalleolar and trimalleolar ankle fractures at our hospital system between January 1, 2018 and June 30, 2021. Weight data from outpatient encounters coinciding with the 3-month, 6-month, and 1-year postoperative time points were recorded and analyzed. Results: 56 patients had complete weight data. The mean age at surgery was 44.6±16.2 years. There were 27 women and 29 men. At time of surgery, the mean weight was 197.2.3±53.9 lbs and BMI was 30.3±7.1 kg/m2. At 1 year postoperative, the mean weight was 219.2±51.6 lbs and BMI was 33.8±7.0 kg/m2, representing statistically significant increases of 22.0 lbs and 3.4 BMI points compared to preoperative (p=0.0491 and 0.0330, respectively). On subgroup analysis of different preoperative BMI groups (&lt;25, 25-29, 30-34, and ≥35), only those patients with a pre-operative BMI of &lt;25 experienced statistically significant increases in weight and BMI, 27.9 lbs and 4.8 kg/m2 respectively (p=0.029 and p=0.001). Conclusion: This is the first study to evaluate weight changes following ankle fracture. This study showed that at 1 year patients recovering from ankle open reduction internal fixation gain an average of 22 lbs and 3.4 BMI points. Patients with a pre-operative BMI of &lt;25 are subject to statistically significant increases in weight. We recommend monitoring patients’ weight and counseling them on the risks of weight gain. Further research is necessary to better characterize the risk of weight gain following orthopedic surgery. Level of Evidence: 4 (retrospective cohort)

Adverse Events After Ankle Fracture Open Reduction Internal Fixation Among Patients With and Without Documented Cannabis and Tobacco Use.

Ankle fractures are common orthopaedic injuries that may be indicated for open reduction internal fixation (ORIF). Although the negative impact of tobacco use on perioperative outcomes of ankle fracture ORIF has been described, the potential impact of cannabis use on related outcomes is not as well established. Retrospective database study of adult patients undergoing ankle ORIF for closed, isolated, ankle fractures from the 2010-2021 Q1 PearlDiver M151 data set. Subcohorts without and with cannabis and/or tobacco use were identified based on coding and matched based on patient age, sex, and Elixhauser Comorbidity Index (ECI) scores to yield groups of nonusers, tobacco users, tobacco and cannabis users, and cannabis users. Ninety-day adverse events were assessed between matched subcohorts with multivariable logistic regression controlling for age, sex, and ECI. A total of 149 289 patients met study inclusion criteria for whom tobacco only use was documented for 14 989 (10.0%), tobacco and cannabis use for 2726 (1.8%), and cannabis only use for 867 (0.6%). Matching yielded 823 for each group. On multivariable analyses, isolated tobacco users were at higher odds of 90-day urinary tract infections (UTIs) (odds ratio [OR] 2.64), minor adverse events (OR 2.33), all-cause adverse events (OR 2.17), readmissions (OR 1.85), and severe adverse events (OR 1.84). Tobacco and cannabis comorbid users were at a marginally higher odds of 90-day UTI (OR 2.82), minor adverse events (OR 2.51), readmissions (OR 2.39), and any adverse events (OR 2.22). Cannabis only users were not at greater odds of 90-day adverse events relative to nonusers. Patients with tobacco use (alone or with cannabis) were at greater odds of 90-day adverse events following ankle fracture ORIF, but cannabis only users were not. Level III, Retrospective database study.

Attitudes and Practices Surrounding Opioid Prescriptions following Open Reduction Internal Fixation of Distal Radius and Ankle Fractures: A Survey of the Canadian Orthopaedic Association Membership.

The past two decades have seen a significant increase in consequences associated with nonmedical misuse of prescription opioids, such as addiction and unintentional overdose deaths. This study aimed to use an electronic survey to assess attitudes and opioid-prescribing practices of Canadian orthopaedic surgeons and trainees following open reduction internal fixation (ORIF) of distal radius and ankle fractures. This study was the first to assess these factors following ORIF of distal radius and ankle fractures using a survey design. A 40-item survey was developed focusing on four themes: respondent demographics, opioid-prescribing practice, patients with substance use disorders, and drug diversion. The survey was distributed among members of the Canadian Orthopaedic Association. Descriptive statistics were used to summarize respondent demographics and outcomes of interest. A Chi-square test was used to determine if proportion of opioid prescriptions between attending surgeons and surgeons in training was equal. 191 surveys were completed. Most respondents prescribed 10-40 tabs of immediate-release opioids, though this number varied considerably. While most respondents believed patients consumed only 40-80% of the prescribed opioids (73.6%), only 28.7% of respondents counselled patients on safe storage/disposal of leftover opioids. 30.5% of respondents felt confident in their knowledge of opioid use and mechanisms of addiction. Most respondents desired further education on topics such as procedure-based opioid-prescribing protocols (74.2%), alternative pain management strategies (69.7%), and mechanisms of opioid addiction (49.0%). The principle finding of this study is the lack of a standardized approach to postoperative prescribing in distal radius and ankle fractures, illustrated by the wide range in number of opioids prescribed by Canadian orthopaedic surgeons. Our data suggest a trend towards overprescription among respondents following distal radius and ankle ORIF. Future studies should aim to rationalize interventions targeted at reducing postoperative opioid prescribing for common orthopaedic trauma procedures.

Republication of "Primary Ankle Arthrodesis vs ORIF for Severely Comminuted Pilon Fractures: A Comparative Retrospective Study".

The treatment for highly comminuted pilon fractures remains controversial. The goal of this retrospective cohort study was to compare functional outcomes of primary arthrodesis of the tibiotalar joint (fusion) and open reduction internal fixation (ORIF). Patients who underwent primary ORIF or fusion for pilon fractures at our institution since 2000 were identified by Current Procedural Terminology (CPT) code. Inclusion criteria for the ORIF cohort were patients with an AO/Orthopaedic Trauma Association type C3 pilon fracture. Additional inclusion criteria for the fusion cohort were patients whose fractures were deemed non-reconstructable by the treating surgeon. Outcome assessment was determined by the Foot and Ankle Outcome Score (FAOS) and Short Form 36-item health survey (SF-36), time to radiographic union or fusion, and wound-healing complications at a minimum of 2 years after their surgery. Nineteen ORIF and 16 fusion patients completed the study's outcome assessments. A higher rate of nonunion was observed in patients treated by primary ORIF than primary fusion (5/19 vs 1/16). Posttraumatic arthritis was observed in 11 of 19 primary ORIF patients. Primary fusion patients exhibited increased symptoms, pain, and physical role limits but were equivalent to primary ORIF patients on all other functional metrics examined. Primary ankle arthrodesis achieves a lower rate of nonunion and comparable functional outcomes to ORIF in patients with severely comminuted pilon fractures. The higher rate of nonunion observed in the primary ORIF group suggests that primary fusion should be considered an effective procedure for severe injuries to decrease the need for further operative intervention. Therapeutic Level III, retrospective cohort.

Patient-reported Outcomes of Revision Ankle Open Reduction Internal Fixation

Ankle fractures may require revision surgery for malunion or suboptimal joint congruence results after initial surgical or nonsurgical treatment. There is limited literature on the outcomes of patients undergoing such revision surgery for ankle fracture malunion. In this retrospective case series, we determined clinical and functional outcomes of revision ankle open reduction internal fixation (ORIF) for 7 patients with ankle fracture malunion through patient-reported and radiographic outcomes. Patient-reported Outcomes Measurement Information System physical function and pain interference scores prerevision and postrevision procedure were obtained from 7 patients treated from January 2017 to October 2020. Postoperative complications including persistent pain, infection, hardware removal, hardware failure, and conversion to ankle arthrodesis were analyzed. Seven patients who underwent revision ORIF surgery for ankle fracture malunion between January 2017 and October 2020 were included. The average age was 46.3 12.2 years old; 85.7% of the patients were female; 14.3% were male. The average amount of time between revision ORIF procedure and collection of postoperative Patient-Reported Outcomes Measurement Information System scores was 19.3±5.9 months. Each of the 7 patients showed an increase in physical function after revision surgery (average preoperative physical function score: 30.7; average postoperative physical function score: 48.9). All patients showed a decrease in pain after revision surgery (average preoperative pain interference score: 64.8; average postoperative pain interference score: 55.7). Of the 7 participants who underwent revision ORIF, a majority did not experience any complications at least 1 year postprocedure, including infection, reoperation, or hardware removal. One participant underwent hardware removal for persistent pain and developed overlying cellulitis. For patients with ankle fracture malunion without significant post-traumatic degenerative changes of the ankle joint, revision ankle ORIF can be an effective method for improving physical function, decreasing pain, and preserving ankle joint motion. Level of Evidence: Level IV—case series.

Assessing technical skill in ankle fracture surgery from the postoperative radiograph : pilot development and validation of a final product analysis core outcome set.

AimsTo identify a core outcome set of postoperative radiographic measurements to assess technical skill in ankle fracture open reduction internal fixation (ORIF), and to validate these against Van der Vleuten’s criteria for effective assessment.MethodsAn e-Delphi exercise was undertaken at a major trauma centre (n = 39) to identify relevant parameters. Feasibility was tested by two authors. Reliability and validity was tested using postoperative radiographs of ankle fracture operations performed by trainees enrolled in an educational trial (IRCTN 20431944). To determine construct validity, trainees were divided into novice (performed < ten cases at baseline) and intermediate groups (performed ≥ ten cases at baseline). To assess concurrent validity, the procedure-based assessment (PBA) was considered the gold standard. The inter-rater and intrarater reliability was tested using a randomly selected subset of 25 cases.ResultsOverall, 235 ankle ORIFs were performed by 24 postgraduate year three to five trainees during ten months at nine NHS hospitals in England, UK. Overall, 42 PBAs were completed. The e-Delphi panel identified five ‘final product analysis’ parameters and defined acceptability thresholds: medial clear space (MCS); medial malleolar displacement (MMD); lateral malleolar displacement (LMD); tibiofibular clear space (TFCS) (all in mm); and talocrural angle (TCA) in degrees. Face validity, content validity, and feasibility were excellent. PBA global rating scale scores in this population showed excellent construct validity as continuous (p < 0.001) and categorical (p = 0.001) variables. Concurrent validity of all metrics was poor against PBA score. Intrarater reliability was substantial for all parameters (intraclass correlation coefficient (ICC) > 0.8), and inter-rater reliability was substantial for LMD, MMD, TCA, and moderate (ICC 0.61 to 0.80) for MCS and TFCS. Assessment was time efficient compared to PBA.ConclusionAssessment of technical skill in ankle fracture surgery using the first postoperative radiograph satisfies the tested Van der Vleuten’s utility criteria for effective assessment. 'Final product analysis' assessment may be useful to assess skill transfer in the simulation-based research setting.Cite this article: Bone Jt Open 2022;3(6):502–509.

Cost and safety of inpatient versus outpatient open reduction internal fixation of isolated ankle fractures.

Background:As health care shifts to value-based models, one strategy within orthopedics has been to transition appropriate cases to outpatient or ambulatory settings to reduce costs; however, there are limited data on the efficacy and safety of this practice for isolated ankle fractures. The purpose of this study was to compare the cost and safety associated with inpatient versus outpatient ankle open reduction internal fixation (ORIF).Methods:All patients who underwent ORIF of isolated closed ankle fractures at 2 affiliated hospitals between April 2016 and March 2017 were identified retrospectively. Demographic characteristics, including age, gender, comorbidities and injuryspecific variables, were collected. We grouped patients based on whether they underwent ankle ORIF as an inpatient or outpatient. We determined case costing for all patients and analyzed it using multivariate regression analysis.Results:A total of 196 patients (125 inpatient, 71 outpatient) were included for analysis. Inpatients had a significantly longer mean length of stay than outpatients (54.3 h [standard deviation (SD) 36.3 h] v. 7.5 h [SD 1.7 h], p < 0.001). The average cost was significantly higher for the inpatient cohort than the outpatient cohort ($4137 [SD $2285] v. $1834 [SD $421], p < 0.001). There were more unimalleolar ankle fractures in the outpatient group than in the inpatient group (42 [59.2%] v. 41 [32.8%], p < 0.001). Outpatients waited longer for surgery than inpatients (9.6 d [SD 5.6 d] v. 2.0 d [SD 3.3 d], p < 0.001). Fourteen patients (11.2%) in the inpatient group presented to the emergency department or were readmitted to hospital within 30 days of discharge, compared to 5 (7.0%) in the outpatient group (p = 0.3).Conclusion:In the treatment of isolated closed ankle fractures, outpatient surgery was associated with a significant reduction in length of hospital stay and overall case cost compared to inpatient surgery, with no significant difference in readmission or reoperation rates. In medically appropriate patients, isolated ankle ORIF can be performed safely in an ambulatory setting and is associated with significant cost savings.

A cost analysis of ankle fractures treated by orthopedic surgeons with or without foot and ankle fellowship training at ambulatory surgery centers and hospitals.

Introduction:Ankle fractures are commonly treated by orthopedic surgeons. Fellowship versus non-fellowship training often adds a different perspective, use of specialty-specific implants, comfort with outpatient procedures, and may contribute to cost differences between surgeons. To assess the impact of fellowship training on the value of care provided, the difference in cost of ankle fracture open reduction internal fixation procedures between foot and ankle trained orthopedic surgeons and non-foot and ankle trained orthopedic surgeons over the past 10 years was retrospectively evaluated. We additionally evaluated the cost differences of ankle fracture open reduction internal fixations between hospitals, hospital-owned ambulatory surgery centers, and physician-owned ambulatory surgery centers. The study also assessed the costs effects of inpatient versus outpatient procedures and ankle open reduction internal fixation procedure volume of the surgeon observed within the timeframe of the study.Methods:Patient data was collected from electronic medical records and billing documents for patients who underwent an ankle open reduction internal fixation procedure performed by an orthopedic surgeon in our hospital system and local hospital-owned ambulatory surgery centers between the years 2010 and 2020. Data were also collected from a physician-owned ambulatory surgery center for patients who underwent an ankle open reduction internal fixation procedure performed by an orthopedic surgeon between the years 2015 and 2020. Statistical analyses were performed to observe potential cost differences among all variables.Results:Procedures performed by fellowship-trained orthopedic surgeons were significantly less costly than those performed by non-foot and ankle trained orthopedic surgeons when performed at ambulatory surgery centers but not at hospitals. Procedures performed at ambulatory surgery centers were found to be significantly less costly than those performed at hospitals. In addition, it was noted that procedures performed at hospital-owned ambulatory surgery centers were less costly than physician-owned ambulatory surgery centers. It was also found that procedure cost decreased with an increase in surgeon volume.Conclusion:An ankle fracture open reduction internal fixation performed by a foot and ankle trained orthopedic surgeon in a hospital-owned ambulatory surgery center is the lowest cost option available, and an increase in volume of open reduction internal fixations is associated with a further decrease in cost when within our hospital system between the years 2010 and 2020.

Peripheral Nerve Blocks Associated With Shorter Length of Stay Without Increasing Readmission Rate for Ankle Open Reduction Internal Fixation in the Outpatient Setting: A Propensity-Matched Analysis

Peripheral nerve blocks (PNB) have become an important modality for pain management in ankle fracture surgery. Previous studies have reported their efficacy, but concerns with rebound pain and readmissions have been cited as possible deterrents. The purpose of this study was to evaluate the effects of PNB on hospital length of stay (LOS), narcotic intake, visual analog scale (VAS) for pain, and associated complications in patients undergoing outpatient ankle open reduction internal fixation (ORIF). Adult patients undergoing ankle ORIF were matched 2:1 (no block:block) using propensity-score matching. Preoperative patient characteristics and postoperative outcomes were compared between cohorts. VAS and total narcotic intake were evaluated for each of the first 3 postoperative 8-hour shifts. Narcotic medication was converted to morphine milligram equivalents (MME). Thirty-two patients who received PNB were matched to 64 patients who did not. The PNB group had lower VAS and MME during each of the 8-hour shifts after surgery: 0 to 8 hours (VAS 1.8 vs 6.3; MME 10.6 vs 77.9; p < .001), 8 to 16 hours (VAS 1.2 vs 5.9; MME 9.2 vs 28.2; p < .001), 16 to 24 hours (VAS 3.7 vs 6.2; MME 13.2 vs 24.2; p = .006 and 0.019). PNB had a shorter LOS (average 16.7 hours vs 26.8 hours; p < .001). There were no differences in rates of ED presentations after discharge, hospital readmissions, or complications between cohorts. Peripheral nerve blocks after ankle ORIF are associated with shorter hospital LOS, lower VAS, and reduced narcotic intake without increasing rates of ED visits, hospital readmissions, or complications.

Arthroscopic Findings During Routine Ankle ORIF: What is Being Missed?

The aim of study is to document our experience and intra-articular findings at time of routine ankle arthroscopy during ankle open reduction internal fixation (ORIF) and to contribute to the growing body of literature that shows this to be a safe and effective treatment. This is a retrospective review of ankle fractures who were treated with ORIF and arthroscopy by a single surgeon. The patients’ charts including operative reports, office notes, and images were reviewed to identify intra-articular pathology and fracture type. Analysis was performed with regard to fracture type, presence and location of osteochondral lesions, presence of loose-body, syndesmotic injury, and deltoid injury. Fifty-seven ankle fractures were identified and met inclusion criteria. 84.2% of the fractures had intra-articular pathology, most commonly a syndesmotic injury followed by loose joint body and osteochondral defect. Orthopedic surgeons with any arthroscopic prowess should consider arthroscopic evaluation during ankle fracture ORIF, particularly pronation external rotation and supination external rotation patterns. The benefits include a more detailed examination of associated injuries and possible treatment of pathology at the time of arthroscopy. This is a safe and effective compliment to routine ORIF for ankle fractures.

Effect of Applying Postoperative Nursing Instructions 0nAnkle Open Reduction Internal Fixation Surgery Patients.

AbstractBackground: Fractures of the ankle are one of the most common lesions the orthopedic surgeon handles. Aim: to evaluate the effect of applying postoperative nursing instructions on ankle open reduction internal fixation (ORIF) surgery patients. Research design: Quasi experimental research design was utilized in this study. Setting: This study was performed in trauma units (male and female) and orthopedic clinic at Assiut University Hospital. Sample: This study included a convenient sample of (60 patients). Tool I: Interview questionnaire sheet Tool II: Patient complications assessment sheet. Results: In lateral wound ,it was found that one quarter of control group had normal healing while more than two fifth in study group . In medial wound healing it was found that more than one third of control group had normal healing while majority in study group. Conclusion: The present study revealed that providing patients with post-operative nursing instructions were represented of great value in wound healing and reduction other complications (residual pain, Malunion, infection, deformity). Recommendations: the present study should be replicated on larger study populations for generalization of the results.

Spinal Anesthesia Associated With Increased Length of Stay Compared to General Anesthesia for Ankle Open Reduction Internal Fixation: A Propensity-Matched Analysis

General and spinal anesthesia are both utilized for patients undergoing open reduction internal fixation of the ankle, but there are little data comparing early complication rates. The purpose of this study was to compare duration of surgery, length of stay, and rates of postoperative adverse events within 30 days in patients undergoing open reduction internal fixation of ankle fracture using spinal versus general anesthesia. Adult patients who underwent open reduction internal fixation of a closed ankle fracture from 2012 to 2016 were retrospectively identified from American College of Surgeons National Surgical Quality Improvement Program. Duration of surgery, length of stay, 30-day adverse events, and unplanned readmissions were compared between patients who received general anesthesia and spinal anesthesia. Propensity adjustment with respect to known risk factors for complications and adjunctive regional block was used to match patients. Of the 10,795 patients included after applying the inclusion and exclusion criteria, 9862 (91.36%) received general anesthesia and 933 (8.64%) received spinal anesthesia. Using propensity-scored matching, 841 patients in the spinal cohort were matched to 3364 patients in the general cohort. Spinal anesthesia was associated with increased length of stay (+0.5 days, 95% confidence interval 0.23-0.77, p < .001). There were no differences in the rates of major/minor complications, mortality, transfusions, unplanned readmissions, or duration of surgery. General anesthesia is predominantly used for fixation of ankle fractures. While spinal anesthesia is associated with lower complication rates in hip and knee surgery, we found that it is associated with increased length of stay in patients undergoing open reduction internal fixation of the ankle within 30 days of surgery.

Immediate Weight-Bearing and Range of Motion After Internal Fixation of Selected Malleolar Fractures: A Retrospective Controlled Study.

We studied the safety of immediate weight-bearing as tolerated (IWBAT) and immediate range of motion (IROM) after open reduction internal fixation (ORIF) of selected malleolar ankle fractures (defined as involving bony or ligamentous disruption of 2 or more of the malleoli or syndesmosis without articular comminution) and attempted to identify risk factors for complications. Retrospective case-control study. Level 1 Urban Trauma Center and multiple community hospitals, orthopedic specialty hospitals, and outpatient surgicenters within one metropolitan area. Of 268 patients at our level 1 trauma center who underwent primary ORIF of a selected malleolar fracture from 2013 to 2018, we identified 133 (49.6%) who were selected for IWBAT and IROM. We used propensity score matching to identify 172 controls who were non-weight-bearing (NWB) and no range of motion for 6 weeks postoperatively. The groups did not differ significantly in age, body mass index, Charleston Comorbidity Index, smoking status, diabetes status, malleoli involved, percentages undergoing medial malleolus (60.9% IWBAT vs. 51.7% NWB), posterior malleolus (24.1% IWBAT, 26.7% NWB), or syndesmosis fixation (41.4% IWBAT, 42.4% NWB, P = 0.85). IWBAT and IROM after ankle ORIF versus NWB for 6 weeks. Postoperative complications, including delayed wound healing, superficial or deep infection, and loss of reduction. There was no significant difference in total complications (P = 0.41), nonoperative complications (P = 0.53), or operative complications, including a loss of reduction (P = 0.89). We did not identify any factors associated with an increased complication risk, including posterior malleolus or syndesmosis fixation, diabetes, age, or preinjury-assisted ambulation. We failed to demonstrate a difference in complications in general and loss of reduction in particular when allowing immediate weight-bearing/ROM in selected cases of operatively treated malleolar fractures, suggesting this may be safe. Future prospective randomized studies are necessary to determine if immediate weight-bearing/ROM is safe and whether it offers any benefits to patients with operatively treated malleolar fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

2.4mm Non-Cannulated Screws are Non-Inferior to 4.0mm Cannulated Screws for Medial Malleolar Fixation in Unstable Ankle Fractures

Category:Ankle; TraumaIntroduction/Purpose:Ankles fractures are the third most common adult fractures, representing significant cost to society. This makes the effectiveness of ankle open reduction internal fixation (ORIF) an important area for study. The majority of existing literature on medial malleolus fracture fixation involves biomechanical testing in synthetic bone or cadaveric models. We sought to compare the clinical efficacy of medial malleolar fixation with 2.4mm non-cannulated screws to 4.0mm cannulated screws by evaluating rates of loss of reduction and hardware failure.Methods:We performed a propensity-score-matched retrospective cohort study on patients who underwent ORIF of an unstable ankle fracture with fixation of the medial malleolus with either 2.4mm non-cannulated (N=51 ankles in 51 patients) or 4.0mm cannulated (N=60 ankles in 60 patients) screws. Vertically oriented medial malleolus fractures or those in which additional fixation was used were excluded. We identified post-operative complications and compared follow-up radiographs with immediate post-operative radiographs for signs of hardware failure or loss of reduction. Mean age was 50.2 years (SD 13.9). There was no significant difference between groups in age, BMI, Charleston Comorbidity Index (CCI), smoking or diabetes status. The 2.4mm patients were more likely to require syndesmosis fixation (56.9% 2.4mm, 30.0% 4.0mm, p=0.007) but not posterior malleolus fixation (25.5% 2.4mm, 28.3% 4.0mm, p=0.831). Most medial malleoli were fixed with 2 screws (1 screw 9.8%, 2 screws 90.2%2.4mm, 1 screw 7.0%, 2 screws 93.0% 4.0mm, p=0.60).Results:There was no significant difference in total complications (7.8% 2.4mm, 15.0% 4.0mm, p=0.375), operative complications (5.9% 2.4mm, 5.0% 4.0mm, p=1.00), loss of medial reduction (3.9% 2.4mm, 6.7% 4.0mm, p=0.69), or medial hardware breakage (2.0% 2.4mm, 0% 4.0mm, p=0.45). The two patients in the 2.4mm screw group with loss of medial malleolus fixation were noncompliant with non-weight bearing restrictions and failed by screw backing out, while the 4 patients in the 4.0mm group failed by medial fracture fragment displacement around stable screws. The 4.0mm group had more nonoperative complications (0% 2.4mm, 10.0% 4.0mm, p=0.031); one of these was delayed union of the medial malleolus, while the remainder were delayed lateral wound healing or sural or superficial peroneal distribution paresthesias, which appeared unrelated to medial fixation type.Conclusion:When used for medial malleolus fixation in unstable ankle fractures, 2.4mm non-cannulated screws do not have higher rates of loss of reduction or hardware failure compared to 4.0mm cannulated screws. Given their decreased cost and equivalent ease of insertion, surgeons should consider their use when fixing unstable ankle fractures.

Arthroscopic Findings During Routine Ankle ORIF: What is Being Missed?

Category:Ankle; Arthroscopy; TraumaIntroduction/Purpose:Ankle fractures are among the most common operatively treated injuries by orthopedic surgeons. However, up to 20% of patients will have continued pain and poor patient reported outcomes despite good/excellent radiographic results. Ankle fractures typically occur with varying degrees of intra-articular and soft tissue injury which can include ligamentous injury, loose bodies, and chondral lesions. The aim of study is to document intra-articular findings with ankle arthroscopy prior to ankle open reduction internal fixation (ORIF) and to contribute to the growing body of literature that shows this to be a safe adjunct to fracture fixation.Methods:IRB approval was obtained prior to chart review. This is a retrospective review of ankle fractures that were treated with arthroscopy and ORIF by a single surgeon. Between August 2016 and July 2018 Operative reports, office notes, and images were reviewed to identify intra-articular pathology and fracture type. Analysis was performed with regard to fracture type, presence and location of osteochondral lesions, presence of loose-body, syndesmotic injury, and deltoid injury.Results:Fifty-seven ankle fractures were identified that met inclusion criteria. 84.2% of the fractures had intra-articular pathology, most commonly a syndesmotic injury followed by loose joint body and osteochondral defect.Conclusion:Arthroscopic evaluation during ankle fracture ORIF, particularly pronation external rotation and supination external rotation patterns give a more detailed examination of associated pathology. Arthroscopy at the time of ankle fracture fixation is a safe adjunct and should be considered a potential compliment to routine ORIF of ankle fractures.

Overlapping Surgery for Ankle Fractures: Is It Safe?

To determine whether the practice of overlapping surgery influenced patient safety after open reduction internal fixation (ORIF) for ankle fractures. Retrospective case-control. Level 1 Academic Midwest trauma center. All patients who underwent ankle fracture ORIF by a single surgeon were eligible for our study, with 478 total patients. Cases that were overlapping were compared against cases that were not overlapping. Cases were defined as overlapping if there was greater than 30 minutes of overlap between procedural times. Patient complications were recorded up to a year from the index surgery. Unexpected return to surgery. There were 478 ankle fracture ORIF patients, 238 with at least 3 months follow-up; 124 (52%) in the overlapping group and 114 (48%) in the nonoverlapping group. There was no difference in the rate of unexpected return to surgery (P = 0.76), infection (P = 0.52), readmission (P = 0.96), painful implant (P = 0.62), malunion (P = 0.27), nonunion (P = 0.52), or arthritis (P = 0.39) between the overlapping and nonoverlapping groups. There were 467 isolated ankle fractures used for time analysis. Average procedure time was 26 minutes longer for the overlapping group than the nonoverlapping group (P < 0.01). Overlapping surgery causes increased operative time for ankle ORIF, but there was no apparent increased risk to the patients for short-term complications. The need for graduated resident responsibility required by ACGME guidelines need to be weighed against the decreased efficiency of operating room time. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tibiotalocalcaneal Fusion With Antibiotic Cement-Coated Nails for Refractory Deep Infection After Ankle ORIF.

Deep infection after open reduction internal fixation (ORIF) of ankle fractures represents a challenge to the orthopaedic surgeon, particularly in patients in whom conventional surgical treatments have failed. The aim of this study was to assess the results of a modified technique of tibiotalocalcaneal fusion using a retrograde locked intramedullary nail covered in cement with antibiotics. Six patients treated using the authors' technique were analyzed retrospectively. All patients had deep infection after ankle osteosynthesis and several surgical procedures (debridement, external fixation, etc) had failed. Radiographs were analyzed to confirm the healing of the bone. Outcome was measured by maintained construct stability and eradication of infection (no clinical signs of infection and normal values of laboratory markers). The average age of the series was 64.2 (range, 50-75) years, and the average follow-up period was 19.5 (range, 8-41) months. Tibiotalocalcaneal stability and eradication of the infection were achieved in all patients, along with the normalization of clinical and radiologic parameters. In the patient who underwent a talectomy, one of the calcaneal locking screws broke, with no clinical repercussions. Tibiotalocalcaneal fusion with antibiotic cement-coated retrograde nails was useful in providing clinically acceptable results in the control of chronic infection in complex patients after the failure of previous surgeries. Level IV, therapeutic study.

Surgical Games: A Simulation-Based Structured Assessment of Orthopedic Surgery Resident Technical Skill

Simulation-based education and objective evaluation of surgical skill have been incorporated into many surgical training programs. We describe the development and implementation of a timed, multitask, station-based Surgical Games to evaluate orthopedic resident surgical skills. Participants in the study were postgraduate-year 2 to 5 orthopedic surgery residents from a single institution. Residents completed 4-timed simulated tasks: cadaveric carpal tunnel release (CTR), Sawbones model of total knee arthroplasty (TKA), Sawbones model of ankle fracture open reduction internal fixation (ORIF), and knee arthroscopy simulator (KAS) of removal of loose body. Evaluations were performed using standardized score sheets by attending surgeons. Resident performance was analyzed by postgraduate-year and number of weeks of prior task-related residency training. A total of 32 residents were assessed at the 4 stations. Total scores were significantly different for CTR (p = 0.006), TKA (p = 0.05), and the KAS (p = 0.004) by year of training, but not for the ankle ORIF task. Residents with more task-specific experience performed significantly better on the KAS (p < 0.001), TKA (p = 0.002), and CTR (p = 0.02) tasks but not on the ankle ORIF task (p = 0.1). Overall, residents rated the exercise valuable to their education with mean scores of 3.9 ± 0.54 on a 5-point Likert Scale. This Surgical Games exercise provided an objective evaluation of surgical skill that correlated with year-in-training and prior experience in skill-specific rotations for the KAS, TKA, and CTR tasks. This surgical skills assessment provided an opportunity for effective structured feedback and identification of areas for improvement.