Closed Ankle Fractures Research Articles

Antibiotic administration for open reduction internal fixation of closed ankle fractures: Is one preoperative dose enough?

Although preoperative antibiotics are used routinely in ankle fracture surgery, there is considerable variability in postoperative antibiotic dosing regimens amongst surgeons. The aim of this study is to compare the rate of surgical site infection (SSI) in patients receiving one dose of preoperative antibiotics to patients who received more than one dose of antibiotics. A single-center Level I Trauma Center retrospective review of patients with isolated closed ankle fractures who underwent open reduction internal fixation over a 10-year period was performed. Demographics data and risk factors were obtained from the electronic medical record. SSI was detected using a text-mining algorithm on all postoperative clinic notes. Factors associated with the development of SSI or increased antibiotic dosing were evaluated. Eight-hundred and twenty-six patients were included in the analysis. There was no correlation between infection rate and any of the potential risk factors evaluated. Two-hundred and ninety-two patients received only one dose of antibiotics preoperatively and 534 patients received more than one antibiotic dose. The rate of SSI was not significantly different between the single-dose cohort (5.8 %) and the multi-dose cohort (3.9 %) (p=0.215). Routine use of postoperative antibiotics in open reduction internal fixation of closed ankle fractures did not decrease the rate of SSI, regardless of associated comorbidities. Level of evidence: Level III (therapeutic retrospective cohort study)

Open ankle fractures in the elderly: predisposing factors and the associated mortality.

The purpose of this study was to investigate the independent effect of open ankle fractures on postoperative mortality and to identify factors leading to open ankle fractures in the elderly population. This is a retrospective case-control study of 1,045 patients aged 65years and older, with ankle fractures undergoing surgical fixation between 2010 and 2020 at three medical centers (Levels 1-2). A logistic regression analysis was used to identify risk factors for open fractures. Propensity score matching and survival analysis were used to measure the hazard of mortality attributable to open versus closed ankle fractures. There were 128 (12.2%) patients with open ankle fractures. Patients with open ankle fractures were more likely to be older, to be active smokers (OR = 1.7, p = 0.049), and tended to have a higher number of medical comorbidities including hypertension (OR = 2, p = 0.006) and chronic kidney disease (OR = 2.9, p = 0.005). Open ankle fractures were, independently of comorbid conditions and age, associated with higher risk of mortality (HR = 1.7, p = 0.03).

Evaluation of arthroscopic ankle fusion for diabetic ankle fractures

Background Ankle fractures are a very common orthopedic trauma. One in eight patients undergoing ankle fixation is diabetic. Most of these patients also have additional comorbidities including peripheral arterial disease and diabetic neuropathy. Therefore, on one hand surgical intervention can pose challenges for wound healing and risk of infection, but non-operative management increases the risk for loss of reduction and therefore stresses the condition of the surrounding soft tissue. The aim of this work was to observe the radiological and functional outcome of arthroscopic ankle fusion in diabetic ankle fractures. Methods This prospective study was carried out on 20 patients, both sexes, with clinical criteria of displaced ankle fractures in diabetics, adults, closed ankle fractures, isolated trauma, diabetic patients with neuropathy and Adelaide Fracture in the Diabetic Ankle score more than or equal 5. Results Fourteen cases had solid bony union at a mean of 27.2 weeks while six cases had stable ankles with stiff fibrous nonunion at the end of the follow up period. Two of which had a breakage of distal locking screws. However, stiff fibrous nonunion of tibio-talar joint with the foot in a stable plantigrade position was considered satisfactory and no further intervention was advised. Our limb salvage rate was 100%. No below knee amputation was done. Conclusions Ankle fractures in diabetic patients are increasingly frequently encountered in comorbid patients with suboptimal overlying soft tissue integrity. Arthroscopic assisted ankle fusion can be considered a valid primary definitive treatment option to help reduce the potential perioperative soft tissue insult and associated complications. Utilizing an arthroscopic-assisted approach to this procedure is of added benefit in allowing for articular preparation and thereby reducing the risk of non-union while also minimizing additional extensive soft tissue insult in patients with underlying soft tissue compromise.

INTRA-ARTICULAR HAEMATOMA BLOCK VERSUS PROCEDURAL SEDATION FOR MANIPULATION OF CLOSED ANKLE FRACTURE DISLOCATIONS: AN EFFICACIOUS, RESOURCE-SPARING SOLUTION?

BackgroundProcedural sedation (PS) requires two suitably qualified clinicians and a dedicated monitored bed space. We present the results of intra-articular haematoma blocks (IAHB), using local anaesthetic, for the manipulation of closed ankle fracture dislocations and compared resource use with PS.MethodsPatients received intra-articular ankle haematoma blocks for displaced ankle fractures requiring manipulation between October 2020 to April 2021. The technique used 10ml of 1% lignocaine injected anteromedially into the tibiotalar joint. Pain scores (VAS), time from first x-ray to reduction, and acceptability of reduction were recorded. A comparison was made by retrospective analysis of patients who had undergone PS for manipulation of an ankle fracture over the six month period March – August 2020.ResultsDuring the periods assessed, 25 patients received an IAHB and 28 received PS for ankle fractures requiring manipulation (mean age 57.8yr vs 55.1yr). Time from first x-ray to manipulation was 65.9 min (IAHB) vs 82.9 min (PS) (p = 0.087). In the IAHB group mean pain scores pre, during and post manipulation were 6.1, 4.7 and 2.0 respectively (‘pre’ to ‘during’ p < 0.05; ‘pre’ to ‘post’ p < 0.01). In the IAHB group, 23 (92%) had a satisfactory reduction without need of PS or general anaesthetic. In the PS group 23 (82%) had a satisfactory reduction. There was no significant difference in the number of unsatisfactory first attempt reductions between the groups. There were no cases of deep infection post operatively in either group.ConclusionIntra-articular haematoma block of the ankle appears to be an efficacious, safe and inexpensive means of providing analgesia for manipulation of displaced ankle fractures. Advantages of this method include avoiding the risks of procedural sedation, removing the requirement of designated clinical space and need for qualified clinicians to give sedation, and the ability to re-manipulate under the same block.

Ankle fracture open reduction and internal fixation in patients with cerebral palsy.

To examine patients with cerebral palsy (CP) undergoing open reduction and internal fixation (ORIF) for ankle fractures. This was a retrospective study of adult patients undergoing ankle fracture ORIF for closed, isolated ankle fractures identified in between 2010 and 2021 in the Q1 PearlDiver M151 database. Patients with CP were identified with International Classification of Diseases (ICD)-9 and ICD-10 codes, and were matched to those without 1:10 on age, sex, and Elixhauser comorbidity index (ECI). Ninety-day adverse events were assessed with multivariable logistic regression. A total of 148 993 patients with isolated ankle fracture ORIF were identified, of whom 407 (0.27%) had CP. After matching, 3863 without CP were compared to 389 with CP. Patients with CP were at increased odds of: 90-day urinary tract infection (odds ratios [OR] 6.26), pneumonia (OR 3.50), minor adverse events (OR 3.46), sepsis (OR 3.30), any adverse events (OR 3.04), emergency department visits (OR 2.28), serious adverse events (OR 1.77), and prolonged length of stay more than 4 days (OR 22.44) (p < 0.001 for all). Patients with CP undergoing ORIF for isolated, closed ankle fractures are at increased odds of several 90-day adverse events and prolonged length of stay compared to matched patients without CP.

Effect of chronic heavy tobacco smoking on ankle fracture healing

IntroductionTobacco smoking is linked to an elevated risk of osteomyelitis and delayed healing in long bone fractures. However, the impact of smoking on bone union and soft tissue recovery following ankle fractures remains unclear. This study presents a retrospective comparative analysis evaluating the effects of chronic heavy tobacco smoking on the healing process and outcomes of ankle fractures after surgical interventions. Materials and MethodsWe examined 220 consecutive cases of chronic heavy smokers (CHS) with closed ankle fractures who were referred to our unit for further treatment. A control group, consisting of 220 age- and sex-matched individuals (non-smokers with closed ankle fractures), was identified for comparative analysis. We collected clinical data, including pre-existing comorbidities, Lauge-Hansen fracture classification, necessity for surgery, and the surgical procedures performed.The primary outcomes investigated were the time required for fracture union and wound healing. Secondary outcomes included postoperative complications such as prolonged pain, bleeding, swelling, infection, compartment syndrome, and neurovascular impairment, as well as the incidence of delayed union, non-union, and the need for further intervention. Both cohorts were monitored for a minimum of 24 months. ResultsOur analysis revealed that the surgical cohort of chronic heavy smokers exhibited a statistically significant delay in fracture union compared to both the conservatively managed smokers and the control group.Further scrutiny of the surgical cohort of chronic smokers indicated a significant correlation between smoking and extended postoperative pain duration, persistent swelling at the fracture site, and both superficial and deep wound infections. Additionally, these patients experienced delays in both fracture union and wound healing when compared to the control group.Similarly, the conservatively managed chronic smokers showed a marginal increase in the incidence of post-injury pain duration, extended swelling at the fracture site, and delayed union compared to the control group. ConclusionPatients who are chronic heavy smokers and require surgical intervention for ankle fractures should be made aware of their increased risk for delayed fracture union and poor wound healing. Orthopedic surgeons should proactively encourage these patients to participate in smoking cessation programs.

Safety and Outcome Measures of Ankle Open Reduction and Internal Fixation in an Ambulatory Surgical Center

The transition of traditionally hospital-based orthopedic procedures to the ambulatory surgery center setting provides many benefits from a patient care and financial perspective. Specifically, closed ankle fractures can potentially be managed at such centers without needing hospitalization. Adding to the paucity of data, this study describes the safety, cost, and outcomes of patients undergoing ankle fracture repair in an ambulatory surgery center. A retrospective chart review of 100 patients who underwent ankle fracture open reduction and internal fixation from a single ambulatory surgery center by 1 surgeon were reviewed. Demographic data, surgical characteristics including operating time and cost were collected. Short- and long-term complications, as well as, reoperation rates were reported and functional outcomes were described. Of the 100 patients, 59% were female and the overall average age was 50 ± 16 years. The average cost per case was $8,709.63 ± 6,360.18. The short-term complication rate was 16%, with surgical site infection reported as the most common complication. No postoperative hospital admissions were reported. Planned and unplanned hardware removal was performed in 7% and 5% of patients, respectively. The delayed union rate was 13%, in which 86% shared a history of smoking. Smoking history was the only statistically significant predictor of prolonged bone healing (p = .002). This investigation demonstrates low complications rates for surgeries performed in a surgery center when compared to historical rates of those procedures performed in the hospital. These results suggest that ambulatory surgery center-based ankle fracture repair does not increase complications while may decrease overall cost when compared to ankle ORIF in a hospital setting.

THE IMPACT OF HIV INFECTION ON WOUND HEALING AND FRACTURE UNION IN PATIENTS WITH CLOSED ANKLE FRACTURES TREATED WITH A PLATE OSTEOSYNTHESIS AT A TERTIARY LEVEL HOSPITAL

Fractures of the ankle are common, and they mostly affect young adults. Wound complications are not uncommon following the fixation of these fractures. This study evaluated the impact of HIV on wound healing after plate osteosynthesis in patients with closed ankle fractures.This is an observational retrospective study of patients operated on at a tertiary level hospital. We reviewed hospital records for patients above 18 years of age who presented with wound breakdown following ankle open reduction and internal fixation. The patients’ hospital records were retrieved to identify all the patients treated for closed ankle fractures and those who developed wound breakdown. Patients with Pilon fractures were excluded. The National Health Laboratory System (NHLS) database was accessed to retrieve the CD4 count, viral load, haematology study results, and biochemistry results of these patients at the time of surgery and subsequent follow-up. The x-rays were retrieved from the electronic picture archiving system (PACS) and were assessed for fracture union at a minimum of 3 months follow-up.We reviewed the medical records of 172 patients with closed ankle fractures treated from 2018 to 2022. Thirty-one (18.0%) developed wound breakdown after surgery, and they were all tested for HIV. Most of the patients were male (58.0%), and the average age of the cohort was 43.7 years (range: 21 years to 84 years). Ten of these patients (32.2%) were confirmed HIV positive, with CD4 counts ranging from 155 to 781. Viral load levels were lower than detectable in 40% of these patients. All patients progressed to fracture union at a minimum of 3 months follow-up.We observed no difference between HIV-positive and HIV-negative patients in terms of wound breakdown and bone healing post-plate osteosynthesis for closed ankle fractures.

Inducing a Closed Ankle Fracture in a Cadaveric Model to Create Interdisciplinary Teaching Models for Preclinical Medical Students.

This paper describes a cost-effective fracture simulation that aids in preclinical learning of fracture identification. This project establishes feasibility of inducing closed fractures in a donated cadaver. The study team made an identified Weber C ankle fracture in this donor, maintaining the soft tissue envelope surrounding the fracture, using minimal materials in a stepwise process that will be reproducible across educational programs regardless of access to highly specialized equipment. The resulting fracture can be used to help students identify fractures during their preclinical education and has demonstrated educational potential for future use and adaptation.

Functional outcomes of early versus delayed fixation of closed ankle fractures assessed by objective and subjective criteria using the Olerud-Molander ankle score

Background: The incidence of ankle fractures is approximately 0.01% per year. Indications for surgical fixation include severe displacement and unstable fracture pattern. Ankle fracture is one of the most common injuries treated by an orthopaedic surgeon. Ankle injuries are usually caused by simple twisting injury to high energy injuries. Methods: This study included patients attending the OPD, emergency of Orthopaedics Department, Govt. Medical College Jammu from October 2014 to October 2016 diagnosed with closed ankle fractures. Both male and female patients between the age group of 18-60 years were treated by open reduction and internal fixation. 50 patients were divided into two equal groups (25 each) as per the timing of surgery. Group 1-cases of early internal fixation within 5 days Group 2-cases of delayed internal fixation after 5 days. Results: In subjective results, in Group I 92% of the patients had good subjective results and 8% had fair results whereas in Group II 84% had good and 16% had fair subjective result. In objective results, in group I 96% patients’ good results were obtained and 4 % patients had fair results whereas in group II 88% patients had good results and 12% patients had fair results. Conclusions: In this study the overall functional outcome was good in both the groups. Thus, we felt when immediate fixation is not possible, delayed fixation of displaced ankle fracture is a reasonable option.

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

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

EARLY WEIGHT BEARING MOBILIZATION AFTER SURGICAL FIXATION OF UNSTABLE ANKLE FRACTURES– PROSPECTIVE STUDY

Objective:The purpose of the study is to clarify outcomes of early weight bearing in lower extremity fractures treated operatively and advantage of Immediate-Early weight bearing over LWB mobilization Prospective study A total of 136 skeleta Design: Materials and methods: lly mature patients underwent ankle surgery, 33 of which were allowed immediate weightbearing as tolerated (IWBAT) in the acute postoperative period was taken into study At the scheduled follow-up, patients had wound assessment, radiogra Outcome Measures: phic analysis of fracture reduction maintenance and healing, clinical fracture healing evaluation, and complications requiring further surgery. After 6 months the patients were individually assessed using a Modied American Academy of Orthopaedic Surgeons Foot and Ankle Scale (MAAOSFS) This study Results : demonstrates that IWBAT in a certain subset of patients with stable osteosynthesis following an ankle fracture is a safe alternative to a period of protected weight-bearing. Earlier weight-bearing is associated with earlier return to full weight bearing without a reduction in functional outcome scores. IWBAT in a certain subset of patients with stable osteosynthesi Conclusions: s following an ankle fracture is a safe alternative to a period of protected weight-bearing. Earlier weight-bearing has been associated with better mobility, shorter hospital stays, and earlier return to work. Potential candidates for IWBAT are patients with closed ankle fractures, without syndesmotic disruption, and with no involvement of the tibial plafond and in whom stable xation has been achieved. Conict of Interests The authors declare that there is no conict of interests regarding the publication of this paper

Prediction of Functional Outcome of Surgical Treatment in Danis-Weber Type-C Closed Ankle Fracture Using AOFAS Ankle Hind Foot Score in a Tertiary Care Hospital

Background: Fracture of the ankle is the most common fracture involving joints. Being a weight-bearing joint maximum thrust passes through it. It is a complex weight-bearing joint and is subjected to many different types of injury. Successful treatment will allow early mobilization to avoid complications. AOFAS Ankle Hind foot score is the most commonly used tool to measure this outcome. Objective: To assess prediction of functional outcome of surgical treatment in Danis-Weber type-C closed ankle fracture using AOFAS Ankle Hind Foot Score. Methods: A prospective observational study was carried out in Monno Medical College and Hospital, Manikganj, from June 2022 to December 2022. A total of 32 patients with Danis-Weber type-C ankle fracture were taken in this study. All the patients were initially managed by analgesic and short leg posterior slab. After admission, all were treated by ORIF with small DCP for fractured fibula and ORIF by two 4mm cannulated cancellous screws for fractured medial malleolus. Operations were done within 4 days to 14 days. The average follow up was 24 weeks. The outcome was assessed by the AOFAS score. Results: The mean age was 34.68+10.79 years with a male predominance, 23 (71%). Most of the patients, 14 (44%), were service holder. Right-sided injury, 20 (63%), were more than left. The main cause of injury was RTA, 22 (69 %), and the commonest mechanism of injury was pronation external rotation, 37 (84%). Syndesmotic injury was present in 28 (88%) cases. The mean duration of hospital stay was 14+2.68 days. Superficial infection was in 2 (6%) patients. The mean AOFAS pain score at 12th and 24th weeks follow up were 29.21+6.18 and 34.3+45.64, which was significant (p-.0005). The mean duration of radiological healing was 13.34+1.56 weeks. The mean dorsiflexion and plantar flexion at 12th weeks follow up was respectively 8.81±1.59 and 43.18+4.70; and 24th weeks follow up was respectively 10.87±1.43 and 51.25+1.11, which was significant .......

EXTERNAL PNEUMATIC COMPRESSION FOR PREOPERATIVE MANAGEMENT OF SWELLING FOR ANKLE FRACTURES: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL

Patients awaiting resolution of swelling and oedema prior to ankle surgery can represent a significant burden on hospital beds. Our study assessed whether external pneumatic intermittent compression (EPIC) can reduce delays to surgery.Our prospective randomised controlled trial (n= 20) compared outcomes of patients treated with EPIC vs control group managed with ice and elevation. Included were patients aged &lt;18 years with isolated closed ankle fractures admitted for management of swelling prior to surgery. Excluded were open fractures, injuries to contralateral leg, diabetes, absent pulses, peripheral vascular disease, inability to consent, no requirement for admission. Eligible patients were randomised to active or control arms. All patients were managed initially with reduction and back slab application. Patients in active arm fitted with EPIC (Hydroven 3000) device over the back slab. Assessment by treating team determined the time at which patient is assessed ready for surgery.Patients in the treatment arm were assessed as ready for surgery sooner, (123 hrs vs 168hrs, T score = 1.925, P 0.035) and had a shorter time to surgery (167 hrs vs 216 hrs, T score = 1.748, P 0.047) Length of stay was reduced bud did not reach statistical significance. (259 hrs vs 269 hrs, T score 0.229, P 0.41)Our results showed a statistically and clinically significant reduction in time that patients were assessed ready for surgery and time to surgery in the treatment cohort. We conclude that although further data is needed to achieve an adequately powered study and assess the safety profile of the EPIC, incorporation of EPIC into routine clinical practice has the potential for significant cost savings.

Does the Level of Syndesmotic Screw Insertion Affect Clinical Outcome after Ankle Fractures with Syndesmotic Instability?

Ankle fractures are often combined with syndesmotic instability, requiring reduction and stabilization. However, the optimal level for syndesmotic screw positioning remains unclear. This study aims to evaluate the effect of different syndesmotic screw insertion levels on postoperative clinical outcomes and determine whether an optimal level exists. This retrospective study included data from 43 adult patients with acute closed ankle fractures combined with intraoperative evidence of unstable syndesmotic injuries who underwent open reduction internal fixation from January 1, 2017 to March 1, 2018 according to the inclusion and exclusion criteria. All 43 patients were divided into three groups based on the syndesmotic screw placement level: trans-syndesmotic group: screw level of 2-3cm; inferior-syndesmotic group: screw level <2cm; and supra-syndesmotic group: screw level >3cm. Clinical outcomes were measured at the final follow-up, including the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Olerud-Molander Ankle Score (OMAS), short-form 36-item questionnaire (SF-36), visual analogue scale (VAS) score and restrictions in ankle range of motion (ROM). The relationships between screw placement level and clinical outcomes were analyzed with the Kruskal-Wallis H-test and Spearman correlation analysis. The median follow-up duration was 15months (range, 10-22months). No patients developed fracture nonunion or malunion or experienced hardware failure. The outcome scoring systems showed an overall score for the entire group of 94.91 points for the AOFAS ankle-hindfoot score, 83.14 for the OMAS, 96.65 for the SF-36, 1.77 for the VAS, 9.14° for the restrictions in dorsiflexion, and 1.30° for the restrictions in plantarflexion. There were no significant differences among three groups in clinical outcomes (P > 0.05). Neither the AOFAS score nor OMAS had significant correlations with screw insertion level (P=0.825 and P=0.585, respectively). No postoperative arthritis or widening of the tibiofibular space was observed at the final follow-up. Different syndesmotic screw placement levels appear not to affect the clinical outcomes of ankle fractures with syndesmotic instability. No optimal level was observed in this study. Our findings suggest other clinically acceptable options apart from syndesmotic screw placement 2-3cm above the ankle.

A Prospective Evaluation of Opioid Utilization Following Ankle Fracture Surgery

Category: Trauma; Ankle Introduction/Purpose: There has been significant scrutiny of physicians' opioid prescribing patterns for both operative and non- operative patients. Orthopaedic surgeons are the third highest group of opioid prescribers among physicians in the United States. The wide scope of orthopaedic procedures lends to the variability and difficulty in setting forth prescribing guidelines. Recent orthopedic literature has highlighted that orthopaedic surgeons are prescribing excess narcotic medication than is needed in common orthopaedic procedures. Ankle fractures make up about 9% of all fractures, which correlates to about 400,000 per year. The purpose of this study was to assess the amount of post-operative pain medication being prescribed and how much of that medication was being consumed in patients who underwent an open reduction internal fixation (ORIF) of an ankle fracture. Methods: We identified all patients that underwent a unilateral ORIF of a closed ankle fracture. We prospectively collected data on patients at the time of surgery. Patients were identified and enrolled in the study prior to their surgical procedure, where they were instructed to bring their pain medication bottle with them to their first post-operative visit. Patients were asked about the quantity of opioids consumed. At the twelve-week post-op, the American Orthopedic Foot and Ankle Score (AOFAS) was completed by the patient. We recorded the number, dosage, and formulation of opioid medication prescribed up to 90 days after surgery using the Pennsylvania Drug Monitoring Program (PDMP) website. Using opioid equianalgesic charts, we converted dosages of opioid to a morphine milligram equivalent (MEq) to standardize prescription amounts across all patients. Descriptive statistics were calculated and reported. Categorical data were compared using chi-square tests and quantitative data were compared using independent sample t-tests. Results: 75 patients were included in our study, 45 of which were female. The mean age of the patient was 46.7 years old with a range from 17-77 years old. On average, 400MEq were prescribed to the patient after surgery. Patients consumed an average of 258 MEq within the 2 weeks following surgery, which accounted for about 65% of the initial prescription. Thirty (13.3%) patients consumed their entire first prescription. Patients who consumed the full opioid prescription were 8.7 times more likely (95% CI 2.6, 29.3, X2(1)=14.1, p&lt;0.001) to have other scripts filled in the PDMP. After adjusting for inequal variances, an independent samples t-test found that subjects that did not consume the full prescription also had statistically significantly higher functionality scores (82 vs. 70) than patients that consumed the full prescribed amount (p=0.001). Conclusion: We found the average patient consumes the equivalent of 34 pills of 5mg oxycodone after undergoing an open reduction internal fixation of an ankle fracture. Our providers over prescribed, on average, by 21 total pills. 9.3% of patients were still requiring narcotic pain medication ninety days post-operatively. Those patients who did not consume their first narcotic prescription were found to have statistically better functional outcome scores compared to those who did. Further studies should continue to assess patient characteristics, surgeon techniques, and prescribing habits to further improve post-operative pain control in patients undergoing open reduction internal fixation of ankle fractures.

845 Assessing How Effectively Ankle Fractures Are Managed in Accordance with the BOAST Guidelines at a Major Trauma Centre

Abstract Aim Ankle fractures constitute approximately 10.2% of all bony injuries. Due to pressures exerted by the COVID-19 pandemic, a series of modifications have evolved within subspecialty fracture management. The aim of our study was to evaluate our adaptations to the COVID-19 pandemic and assess our management of ankle fractures according to the BOAST guidelines. Method We performed a retrospective review of 30 skeletally mature patients with a closed ankle fracture presenting to a major tertiary centre. Our inclusion criteria comprised of the ‘BOAST guidelines for ankle fracture management’ published in 2016. Results Of the 30 patients within our cohort, 40% (n= 12) had stable ankle fractures, whereas 60% (n= 18) were unstable (based on the weber classification and evidence of syndesmotic instability). 63% (n= 10) had fracture manipulations prior to surgery. 50% (n= 5) had a documented re-examination of neurovascular status. All patients had a post reduction image. 88% (n= 16) with unstable fractures underwent operative fixation. 6 patients underwent external fixation prior to definitive management. The average time from injury to definitive fixation was 12 days with a range from 0–22 days. Only 8 patients had clear documentation of intraoperative syndesmotic stability. Conclusions The BOAST guidelines outline a range of standards that should be utilised when treating ankle fracture patients. We intend to use our study to educate healthcare professionals on the importance of accurate documentation and encourage shorter operative waiting times to improve standard of care and patient outcomes.

Surgeon volume and risk of deep surgical site infection following open reduction and internal fixation of closed ankle fracture.

Increasing evidences have shown that surgeon volume was associated with postoperative complications or outcomes in a variety of orthopaedics surgeries, but few were focused on ankle fractures. This study aimed to investigate the deep surgical site infection (DSSI) in association with the surgeon volume following open reduction and internal fixation (ORIF) of ankle fractures. This was a retrospective analysis of the prospectively collected data on patients who underwent ORIF for acute closed ankle fractures between October 2014 and June 2020. Surgeon volume was defined as the number of ORIF procedures performed within 12 months preceding the index operation. The receiver operating characteristic (ROC) curve was constructed to determine the optimal cut-off value, whereby surgeon volume was dichotomized as high or low. The outcome was DSSI within 1year postoperatively. Multivariate logistics analysis was performed to examine the DSSI in association with surgeon volume and multiple sensitivity/subgroup analyses were performed to refine the findings. Among 1562 patients, 33 (2.1%) developed a DSSI. The optimal cut-off value was 7/year. Low-volume (<7/year) was significantly associated with a 5.0-fold increased risk of DSSI (95%CI, 2.2-11.3; P < .001). Sensitivity/subgroup analyses restricted to patients aged <65 years, with or without concurrent fractures, with unimalleolar fractures, bi- or trimalleolar fractures, receiving ORIF within 14 days and those operated by ≥10-year experience surgeons showed the consistently significant results (ORs, 2.7-6.8, all P < .05). The surgeon volume of <7 cases/year is associated with an increased risk of DSSI. It is more feasible that patients with complex fractures or conditions (eg, bi- and trimalleolar or presence of concurrent fractures) are preferentially directed to high-volume and experienced surgeons.

Assessment of alternative techniques to quantify the effect of injury on soft tissue in closed ankle and pilon fractures.

IntroductionLocal soft tissue status (STS) guides the timing for definitive surgical treatment strategies of fracture fixation around the ankle joint. The aim of this study was to assess different types of new technical devices in relation to the surgical treatment in closed ankle and pilon fractures.MethodsThis study was designed as a cohort study. Adult patients admitted between February 1, 2019 and December 31, 2020 presenting with closed ankle fracture requiring surgical treatment were eligible. The exclusion criteria were previous injuries to the lower extremity, acute deep venous thrombosis, skin diseases, and delayed presentation (admission >24 hours after injury). Moderate-energy trauma includes injuries sustained during team sports, biking, and running. The primary outcome was the assessment of the degree of soft tissue involvement following closed fractures by comparing different techniques focusing on the ankle region and including ankle and pilon fractures. The variables of interest included the circumference of soft tissue swelling around the ankle, determined within a 5-mm range in the area of the medial and lateral malleolus and the bone-skin distance on a plain radiograph, determined by the largest distance from the malleolus to the border of the soft-tissue shadow. STS assessment included optical measures of local perfusion (O2C, Lea Inc. Germany) and tactile measures of mechanical characteristics (Myoton® tensiometer AS, Estonia). Measurements of Group Temp (temporary stabilization) and Group Def (definitive surgery) were taken on admission and prior to the treatment strategy decision. The contralateral non-injured ankle served as a control. The quality of assessment tools was quantified by calculating the smallest detectable change (SDC).ResultsIn total, 38 patients with a mean age of 40.4 (SD 17.8) years were included. The SDC was 3.2% (95%CI 2.5 to 3.8) for local blood flow and 1.1% (95%CI 0.4 to 1.7) for soft tissue stiffness. The circumference of the injured area at admission was significantly higher than that of the healthy site (28.2 [SD 3.4] cm versus 23.9 [SD 2.4] cm, p < 0.001). The local perfusion (blood flow 107.5 (SD 40.79 A.U. vs. 80.1 [SD 13.8] A.U., p = 0.009), and local dynamic stiffness of the skin (668.1 (SD 148.0) N/m vs 449.5 (SD 87.7) N/m, p < 0.001) were significantly higher at the injured site. In Group Temp, the local blood flow was significantly higher when compared with Group Def (109.6 [SD 39.8] vs. 94.5 [SD 13.0], p = 0.023). The dynamic stiffness of the soft tissue was significantly higher in Group Temp (679.4 N/m [SD 147.0] N/m vs. 573.0 N/m (SD 93.8) N/m, p < 0.001). The physical properties of STS were comparable among the fracture types. None of the included patients had local soft tissue complications.ConclusionClosed fractures of the ankle and the pilon are associated with an increase in local circulation and local soft tissue stiffness and tension. These changes of the STS following injury can be quantified in a standardized and reproducible manner.

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.