Fixation Of Ankle Fractures Research Articles

Comparison of elective implant removal and complication rates between mini and small fragment implants for lateral malleolar fixation

IntroductionImplant removal after open reduction and internal fixation (ORIF) of ankle fractures is common. Mini-fragment implants have gained popularity for their smaller size, with studies showing similar load to failure to small-fragment implants. We hypothesized mini-fragment implant use for ORIF of the distal fibula is associated with a lower implant removal rate and without an increase in implant failure. MethodsIn this retrospective review study at two level-one trauma centers, adult patients (>18 years) with a lateral malleolar or bimalleolar fracture were included. Chart review was performed to determine if patients received ORIF of the distal fibula with mini-fragment implants or small-fragment implants. The primary outcome was elective implant removal of the fibular plate. Secondary outcomes included complications requiring reoperation. ResultsFive-hundred and five patients were included with a mean age of 50.6 ± 17.8 years old with a mean follow-up of was 75.7 ± 61.0 weeks. Sixty patients (11.9 %) received mini-fragment fixation. The rate of elective distal fibula implant removal for the mini-fragment group was 8.3 % (5 of 60) compared to 10.8 % (48 of 445) in the small-fragment group (p = .66). The complication rate was 6.7 % (4 of 60) for the mini fragment group versus 6.5 % (29 of 445) for the small fragment group (p = 1.00). Logistic regression demonstrated that each additional week of follow-up increased the implant removal rate with the observed odd ratio (OR) of 1.007 (95 % CI 1.002–1.012). ConclusionElective implant removal rates and complications requiring reoperation were similar between mini-fragment and small-fragment fixation of distal fibula fractures. The hypothetical benefit of low-profile mini-fragment implants should be balanced with the higher implant cost.

Key-risk factors for fracture-related infection after ankle surgery: a retrospective study

Background: Fracture-related infection (FRI) is a serious complication following ankle fracture surgery, with significant implications for patient outcomes. This study aimed to identify the key risk factors associated with FRI in a cohort of patients undergoing surgical fixation of ankle fractures. Methods: A retrospective analysis was conducted on 261 patients who underwent open reduction and internal fixation (ORIF) for ankle fractures between 2019 and 2021. Patient demographics, comorbidities, and surgical details were extracted from medical records. The primary outcome was the development of FRI within one year postoperatively. Logistic regression analysis was used to identify independent predictors of infection. Results: The mean age of the patients was 61.8 years (SD=16.5), with 69.3% being female. The overall infection rate was 8%. Significant predictors of FRI included smoking (OR=13.643, p=0.002), peripheral vascular disease (OR=17.684, p<0.001), and diabetes mellitus (OR=11.309, p=0.002). Gender, congestive heart failure, obesity, and age were not statistically significant predictors of infection. Conclusion: This study identifies smoking, peripheral vascular disease, and diabetes mellitus as significant risk factors for FRI following ankle fracture surgery. These findings underscore the importance of targeted interventions to manage these comorbidities in high-risk patients to reduce the incidence of postoperative infections. Further research is needed to explore the role of other potential factors and to develop effective prevention strategies.

No difference in early outcomes comparing intramedullary versus extramedullary fibular fixation in operative ankle fractures

IntroductionThe purpose of this study was to compare postoperative complications and outcomes of minimally invasive intramedullary fixation (IMF) versus plate fixation (PF) in the treatment of distal fibular fractures. Materials and methodsA retrospective review was performed from identifying all consecutive ankle fracture patients aged ≥18-years-old surgically managed between August 2017 to September 2022 at a tertiary care center with minimum 6 months clinical follow-up. Patients were grouped into those receiving intramedullary versus extramedullary fibular fixation. The primary outcomes were relevant demographic factors (diabetes, osteoporosis, charlson comorbidity index [CCI]), surgical time, complication rates, reoperation rates. Secondary outcomes included time to definitive fracture fixation, fracture characteristics (AO/OTA and Lauge-Hansen classification), syndesmotic instability requiring fixation and discharge disposition. ResultsForty-one IMF patients (average age 55.3 ± 18.1yrs) and 162 PF patients (47.7 ± 17.4yrs) were identified and included in this study. Within the IMF group, 25 patients received IM nailing and 16 patients received percutaneous screw fixation. A greater proportion of IMF patients had diabetes (39 % vs 22 %, p < 0.001), osteoporosis (22 % vs 3 %, p < 0.001), and moderate or severe CCI (41 % vs 23 %, p = 0.017). Surgical time was significantly reduced when using IMF technique (80.4 ± 43.1 min vs 99.1 ± 43.1 min, p = 0.012). Overall complication rates or time to complication did not differ significantly between groups (p = 0.578 and p = 0.082, respectively); however, when sub-stratified, IMF patients trended towards experiencing fewer wound related complications versus PF patients (5 % vs 9 %, p = 0.291). No IMF patients experienced deep or superficial infections and only 2 (5 %) patients experienced wound dehiscence. Reoperation rates(15 % vs 10 %, p = 0.267) and time to fracture union (2.7 ± 2.2 mos vs 3.1 ± 2.0 mos, p = 0.301) did not differ significantly. At final follow-up (IMF: 15.0 ± 12.2 mos vs PF: 28.5 ± 19.5 mos), Olerud and Molander ankle score was significantly higher in IMF compared to PF (87.1 ± 14.2 vs 76.2 ± 22.6, p = 0.002). ConclusionPatients in the IMF group at baseline had several comorbid medical conditions that put them at high risk for wound related complications, however, postoperatively they demonstrated higher functional scores and similar complication rates compared to the PF group. It is important to note, however, while we expected a higher rate of wound issues with the PF group, there were no significant differences in infection rates. Either IMF and PF is reliable for fixation and outcomes, and thus with proper soft tissue, biologically friendly technique, either IMF or PF is a reliable choice in the fixation of fibula fractures. Level of evidenceIII, retrospective cohort comparison study.

Screw and absorbable suture tension band technique for geriatric weber type A lateral malleolus fractures

PurposeThe optimal method of internal fixation for ankle fractures in geriatric patients remains debated. This study aims to assess the efficacy of the screw and absorbable suture self-compression tension band technique in treating Weber Type A lateral malleolus fractures in geriatric patients. MethodsClinical data were analyzed from 31 geriatric patients with Weber Type A lateral malleolus fractures treated between March 2018 and June 2022. All patients underwent fixation with two screws combined with an absorbable suture self-compression tension band. The cohort comprised 18 males and 13 females, with a mean age of 65.6 ± 7.3 years. The study recorded operative time, intraoperative blood loss, fracture healing time, and postoperative complications. Outcomes were evaluated using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS) for pain, and ankle range of motion (ROM). ResultsOf the 31 patients, 30 achieved primary wound healing. Follow-up periods ranged from 12 to 36 months (mean: 19.5 months). The average operative time was 44.7 ± 13.6 min, with slightly longer times for patients with additional injuries. Fracture healing time ranged from 8 to 16 weeks (mean: 12.1 weeks), with no cases of delayed healing or non-union, and no instances of fixation loosening or failure. Postoperative complications included one cases of superficial infection, one case of numbness, one case of foreign body sensation, and one case of prolonged pain. At the final follow-up, the mean AOFAS score was 89.8 ± 6.2, with VAS scores of 0 in 18 cases, 1 in 11 cases, and 2 in 2 cases. The average ROM was 65.4° ± 4.3°, resulting in a clinical satisfaction rate of 87.1 %. ConclusionThe use of screws combined with an absorbable suture self-compression tension band for treating Weber Type A lateral malleolus fractures in geriatric patients is straightforward, effective, and warrants broader adoption.

A Perioperative Prospective Study of WALANT in Open Reduction Internal Fixation of Ankle Fractures: A Malaysian Experience

A Perioperative Prospective Study of WALANT in Open Reduction Internal Fixation of Ankle Fractures: A Malaysian Experience

Factores predictivos del ingreso hospitalario y sociosanitario en la fijación de fracturas de tobillo por trauma de baja energía

IntroductionAnkle fractures are increasingly common in frail patients, with hospitalization being the principal cost driver, particularly for the elderly who often need referral to nursing facilities. This study aims to identify factors affecting resource utilization per admission (hospital and nursing) in the fixation of low-energy ankle fractures. Materials and methodsThis retrospective cohort study examined patients undergoing fixation for low-energy ankle fractures. The primary outcome was the length of hospitalization. Secondary outcomes included delays in fixation and the need for referral to a nursing institution. Multiple linear and logistic regression models were used to determine predictors related to patient demographics, injury characteristics, and treatment. ResultsWe analyzed 651 patients with a median age of 58years. The median hospitalization duration was 9days, primarily before surgery. Extended hospitalization was associated with antithrombotic treatment (b=4.08), fracture-dislocation (2.26), skin compromise (7.56), complications (9.90), and discharge to a nursing center (5.56). Referral to a nursing facility occurred in 17.2%, associated with older age (OR=1.10) and an ASA score ≥III (6.96). ConclusionsProlonged hospitalization was mainly due to surgical delays and was related to fracture-dislocations, skin compromise, and complications. Older and comorbid patients were more likely to need nursing facilities, and delays in these facilities’ availability contributed to extended hospital stays.

Weight-bearing timing after the operative management of ankle fractures: Single center audit and critical appraisal of literature

The postoperative weight-bearing policy following internal fixation of unstable ankle fractures varies greatly and is largely surgeon-dependent. While early weight-bearing is favoured for its superior functional and economic outcomes, late weight-bearing may be safer initially. However, consensus on the preferred treatment protocol is lacking. We audited practices at University Hospitals Leuven, Belgium, comparing them to existing literature to establish an updated protocol.In a retrospective study of 236 patients with unstable ankle fractures, we compared outcomes between early (EWB) and late weight-bearing (LWB) strategies, with or without braces and/or vacuum casts. Most patients followed a LWB protocol, while EWB was reserved for younger, lower BMI individuals. The difference in brace or vacuum cast usage was insignificant. All open fractures followed a LWB protocol. No disparities in union rates, complications, or length of stay were found between EWB and LWB. Surgical management cost €6,419 (6,921 US $) on average, with length of stay being the main cost driver. Total healthcare costs did not differ significantly between EWB and LWB. FRI was revealed in 6 cases, (1 [4%] vs. 5 [2.5%], EWB vs. LWB respectively, P=0.922)In conclusion, while no significant differences in outcomes were observed between EWB and LWB rehabilitation, differences in group characteristics may have influenced these findings. Despite limited EWB cases, it appears safe for younger patients with low BMI. Vacuum casts and braces aid in EWB. Reducing length of stay, rather than restricting orthotic use, may help control healthcare costs.

Predictive factors to return to sport after surgical management of ankle fractures

Achieving Return to Sport (RTS) is crucial in managing ankle fractures for athletes. This study aimed to identify RTS factors post-surgical fixation of ankle fractures. A retrospective analysis was conducted on 93 active patients with surgically treated displaced or unstable ankle fractures from January 2020 to January 2021. The median follow-up was 2.12 years. Clinical, functional, and radiographic aspects were evaluated. Among the athletes, 82.8% resumed sports post-surgery, with 26.9% returning within 3 months and 75.3% at 1 year. At 1 year, 40.9% regained their pre-injury activity level. There was a significant association between RTS and AO/OTA fracture subtype (p = 0.038). Unimalleolar fractures had the best outcomes, with 100% achieving RTS in a median of 4 months. Bimalleolar fractures had 80.77% RTS in 6 months, and trimalleolar fractures had 65.22% RTS in 8 months. AO/OTA subtypes B and C predicted lower RTS to pre-injury levels, with delayed recovery for bimalleolar and trimalleolar fractures. These findings underscore the impact of fracture severity on RTS, with more complex fractures leading to poorer and delayed recovery outcomes.Level of evidence: III

Trauma

The October 2024 Trauma Roundup360 looks at: Early versus delayed weightbearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomized controlled trial; The effect of early weightbearing and later weightbearing rehabilitation interventions on outcomes after ankle fracture surgery; Is intramedullary nailing of femoral diaphyseal fractures in the lateral decubitus position as safe and effective as on a traction table?; Periprosthetic fractures of the hip: Back to the Future, Groundhog Day, and horses for courses; Two big bones, one big decision: when to fix bilateral femur fractures; Comparison of ankle fracture fixation using intramedullary fibular nailing versus plate fixation; Unclassified acetabular fractures: do they really exist?

Radiographic Accuracy of Identifying Anterolateral Tibial Plafond Involvement in Pronation Abduction Ankle Fractures.

To evaluate the incidence of anterolateral tibial plafond involvement in pronation-abduction (PAB) ankle fractures and analyze the accuracy of radiographs in detecting anterolateral tibial plafond involvement, impaction, and predicting the need for direct visualization and an articular reduction. Design: A multi-institutional retrospective chart review. Five level 1 trauma centers in the United States. Adult patients with PAB ankle fractures (OTA/AO 44B2.3, 44C2.2, 44C2.3) from 2020-2022 were reviewed by 7 fellowship-trained orthopedic trauma surgeons. They were queried about the presence of anterolateral tibial plafond involvement and impaction, and whether they would need direct visualization and an articular reduction using both radiographs and CT. The presence of anterolateral tibial plafond impaction was tabulated separately using radiographs and CT scans. The accuracy of radiographs and changes in surgical plan after CT review were calculated using CT as the gold standard. 61 fractures in 61 patients were evaluated with CT and/or plain radiographs. Using plain radiographs, anterolateral tibial plafond involvement and impaction were identified in 61% and 36% of cases, respectively. In the 38 fractures with both plain radiographs and CT scans, anterolateral tibial plafond involvement was identified in 66% of radiographs and 74% of CT scans (p = 0.4). Plafond impaction was identified in 42% of plain radiographs and 37% of CT scans (p = 0.62). There was no difference in the rate of involvement between radiographs and CT scan. The diagnosis of anterolateral tibial plafond impaction using plain radiographs was correct in 74% of fractures when compared to CT imaging, resulting in a sensitivity of 71%, a specificity of 75%, a positive predictive value (PPV) of 62%, and a negative predictive value (NPV) of 82%. Plain radiographs correctly predicted the need for direct visualization and an articular reduction in 74% of cases and had a PPV of 59% and a NPV of 86%. Anterolateral tibial plafond involvement and impaction was present on CT in 74% and 37% of pronation-abduction (PAB) ankle fractures, respectively. Plain radiographs had higher NPV for identifying impaction and the need for articular reduction than they did sensitivity, specificity or PPV. CT is an important tool for preoperative planning that should be considered when planning for operative fixation of PAB ankle fractures. Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.

ROLE OF POSTOPERATIVE CT SCAN IN ASSESSING SYNDESMOTIC REDUCTION IN ANKLE INJURIES

Background: Accurate syndesmotic reduction is necessary for achieving joint congruity and better functional outcomes. Radiographs alone don’t suffice, and CT scans are required for the evaluation of postoperative syndesmotic reduction. Methods: All patients who underwent ankle syndesmotic reduction and fixation from December 2019 to July 2021 were taken into the study. Predefined measurements were taken in postoperative radiographs and axial CT images were taken postoperatively. Sensitivity and specificity of X-rays when compared to CT scan were evaluated. Results: Twenty eight patients were included in the study and 13 cases were found to have syndesmotic malreduction in radiographs as per TCS and TFO in AP view and TFO and MCS measurements in mortise view. Five out of 28 cases were found to have syndesmotic malreduction in CT axial cuts as per standard anterior and posterior measurements. Hence 17.85% cases were malreduced in our study as per the gold standard (CT scan). The incidence of syndesmotic malreduction after fixation was 17.85%. Radiographs had a sensitivity of 60% and specificity of 56.5% in detecting malreduction. Conclusion: CT scan is necessary to accurately diagnose syndesmotic malreduction after open reduction and internal fixation of ankle fractures with associated syndesmotic injuries.

Ankle Fractures Treated with Locked Fibular Intramedullary Nailing: Description and Outcomes of a Minimally Invasive Open Technique

OBJECTIVES: To describe and report outcomes of a minimally invasive open intramedullary (IM) fibular nailing technique for fixation of ankle fractures. METHODS: Design: Case Series Setting: Urban Level 1 trauma center Patient Selection Criteria: Adult patients with ankle fractures (OTA 44A-C) treated with locked fibular IM nailing via a minimally invasive open technique for fracture and syndesmotic reduction between 2021 and 2024. Outcome Measures and Comparisons: Quality of reduction, complications, and patient-reported outcomes (PRO). RESULTS: A total of 150 consecutive patients operated by a single surgeon were included. Mean age was 53.3 (17-97) years, and mean BMI was 30.6 ± 7.4 kg/m2. 93(62%) patients were female, and 78 (52%) patients were Caucasian. 72 (48%) patients were obese, 40 (27.7%) patients were current/former smokers, 39 (26%) patients were diabetic, and 23 (15.3%) patients had open fractures. 37 (24.7%) patients had isolated lateral malleolus fractures, 48 (32%) had bimalleolar fractures, and 65(43.3%) had trimalleolar fractures. 123 (82%) patients had 2 syndesmotic screws placed, 26 (17.3%) had 1 screw, and 1 (0.7%) had none. Quality of reduction was good for 98%, fair for 2%, and poor for none per McLennan’s criteria. 113 patients (75.3%) were followed until clinical and radiographic union for a mean of 7.6 months (range 3-22) months). 110 patients (97.3%) went on to successful clinical and radiographic union following the index procedure. No patient had a superficial surgical-site infection, and 3 (2.6%) had deep surgical-site infections. 3 patients had a loss of reduction, and 6 patients had implant failure (5 broken syndesmotic screws, and 1 medial malleolus screw). 9 (8%) patients had unplanned reoperations (3 for debridement, 2 for loss of reduction, and 4 for removal of symptomatic implants). Mean ankle range of motion at final follow-up visit was 12.9° (0-40) of dorsiflexion, 39.6° (10-70) of plantarflexion, 23.5° (5-40) of inversion, and 18.2° (5-50) of eversion. Mean PROs at final follow-up visit were: Global Physical Health: 42.4 (23.5-67.6), Global Mental Health: 47.5 (21-67.6), Physical Function: 37.5 (14.7-57.8), Pain: 54.9 (22-72) and Mobility: 36.9 (16-65.3). CONCLUSIONS: Minimally invasive open fibular IM nailing allowed for excellent reduction and results in union with low rates of complications and good patient reported outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Retrospective Cohort Analysis Comparing the Costs of Ankle Fracture Fixation in Orthopaedics and Podiatry in a U.S. Medicare Limited Data Set.

Increasing overlap exists between surgeries performed by podiatrists and orthopaedic surgeons. Large-scale cost comparisons between the two are lacking despite the current climate of cost containment in health care. Using national Medicare data, we aimed to compare per-case Medicare payments between podiatrists and orthopaedic surgeons for ankle fracture fixation. This retrospective cohort study included patients in an outpatient setting undergoing either unimalleolar, bimalleolar, or trimalleolar ankle fracture repair from the national Medicare Limited Data Set (2013-2019). Type of surgeon (podiatrist or orthopaedic surgeon) was determined using publicly available information. The primary outcome was total Medicare payments specific to the procedure, as a surrogate for cost. A subset analysis was also done to directly compare costs of orthopaedic surgeons to podiatric surgeons while excluding other fees (eg, hospital facility fees and surgery-related imaging payments). Additionally, patient demographics and hospital characteristics were compared to determine if any factors associated with costs may influence group differences. Univariable tests assessed significance of group differences. Overall, 16 927 unimalleolar, 17 244 bimalleolar, and 11 717 trimalleolar fracture repairs were included; 86.7% and 13.3%, 92.4% and 7.6%, and 92.2% and 7.8% were performed by an orthopaedic surgeon or podiatrist, respectively. Median age (70-71 years) and median Charlson-Deyo Comorbidity Index (0) did not significantly differ between patients treated by either surgeon type. Median procedure-specific Medicare payments for all 3 categories of ankle fracture repairs (uni-, bi-, trimalleolar) were significantly lower for orthopaedic surgeons compared to podiatrists: $4156 vs $4300, $4205 vs $4379, and $4396 vs $4525, respectively (all P < .001). Our investigation using a national Medicare data set (2013-2019) found that the 3 types of ankle fractures (unimalleolar, bimalleolar, and trimalleolar) performed by orthopaedic surgeons in an outpatient setting were less expensive and that cost differences do not appear to be driven by patient characteristics. These results and further research into the causes of the cost differences may help improve the cost-effectiveness of ankle fracture surgery.

Early Motion and Directed Exercise (EMADE) following ankle fracture fixation: a pragmatic randomized controlled trial.

This study aimed to compare the outcomes of two different postoperative management approaches following surgical fixation of ankle fractures: traditional cast immobilization versus the Early Motion and Directed Exercise (EMADE) programme. A total of 157 patients aged 18 years or older who underwent successful open reduction and internal fixation (ORIF) of Weber B (AO44B) ankle fractures were recruited to this randomized controlled trial. At two weeks post-surgical fixation, participants were randomized to either light-weight cast-immobilization or the EMADE programme, consisting of progressive home exercises and weekly advice and education. Both groups were restricted to non-weightbearing until six weeks post-surgery. The primary outcome was assessed using the Olerud-Molander Ankle Score (OMAS) questionnaire at 12 weeks post-surgery, with secondary measures at two, six, 24, and 52 weeks. Exploratory cost-effectiveness analyses were also performed. Overall, 130 participants returned their 12-week OMAS questionnaires. The mean OMAS was significantly higher in the EMADE group compared with the immobilized group (62.0 (SD 20.9) vs 48.8 (SD 22.5)), with a clinically meaningful mean difference of 13.2 (95% CI 5.66 to 20.73; p < 0.001). These differences were maintained at week 24, with convergence by week 52. No intervention-related adverse events, including instability, were reported. The EMADE programme demonstrated an accelerated recovery compared to traditional six-week cast immobilization for those who have undergone ORIF surgery to stabilize Weber B (AO44B) ankle fractures. The study found the EMADE intervention to be safe.

Comparing the risk of reoperation between pneumatic tourniquet and non-tourniquet use in surgical treatment of ankle fractures.

Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets. This was a population-based cohort study using data from the Danish Fracture Database with a follow-up period of 24 months. Data were linked to the Danish National Patient Registry to ensure complete information regarding reoperations due to complications, which were divided into major and minor. The relative risk of reoperations for the tourniquet group compared with the non-tourniquet group was estimated using Cox proportional hazards modelling. A total of 4,050 ankle fractures treated with open reduction and internal fixation between 15 March 2012 and 31 December 2016 were included, with 669 (16.5%) undergoing surgery with a tourniquet and 3,381 (83.5%) without a tourniquet. The overall reoperation risk was 28.2% with an adjusted relative risk of 1.46 (95% CI 0.91 to 2.32) for group comparison. The reoperation risk due to major complications was 3.1% with a tourniquet and 4.4% without a tourniquet, resulting in an adjusted relative risk of 1.45 (95% CI 0.91 to 2.32). For minor complications, there were 24.7% and 23.9% reoperations, resulting in an adjusted relative risk of 0.99 (95% CI 0.84 to 1.17). We found no significant difference in the reoperation rate when comparing ankle fractures treated surgically with and without the use of pneumatic tourniquets.

Patient reported outcomes after revision ankle fixation

BackgroundFunctional outcome following ankle fracture fixation is linked to the restoration of joint congruity, anatomic alignment and stability. If surgical fixation fails to achieve these goals, revision surgery may be indicated. This retrospective study aims to report a consecutive series of fourteen patients with a minimum of one year follow up after revision ankle fixation and describe CT scan based modified Pettrone score used to assess quality of primary fixation. MethodsBetween April 2019 and August 2021, fourteen patients underwent revision ankle fracture fixation. Patients were identified by the multidisciplinary team through a review of intra-operative radiographs. Subsequently, a CT scan-based criteria which is modification of original Pettrone criteria based on plain radiographs was applied to further assess sub-optimal fixation. Demographic, clinical, radiological and patient-reported outcome measures data were collected and examined. ResultsTwelve patients exhibited protonation type injuries according to the Lauge-Hansen classification system. Syndesmotic joint was readdressed in eleven patients. The mean duration between the index surgery and the subsequent revision surgery was 46 days (inter-quartile range – 42 days). The mean Olerud-Molander Ankle Score was calculated as 58, with an IQR of 45. Similarly, the mean EQ-5D-3L VAS score was determined to be 69, with an IQR of 35. In our series, 60 % patients reported good to excellent results using OMAS. The quality-of-life scores of in these patients were also satisfactory. ConclusionWe recommend early revision fixation should be considered when primary fixation is considered inadequate in early post-operative period. The modified Pettrone criterion can be used to assess sub-optimal fixation.

Adverse effect of smoking on surgical site infection following ankle and calcaneal fracture fixation: a meta-analysis.

Studies have reported conflicting findings on the relationship between smoking and surgical site infection (SSI) post fixation for ankle and calcaneal fractures. This meta-analysis explored the effect of smoking on SSI incidence following open reduction and internal fixation (ORIF) of these fractures. Full-text studies on smoking's influence on post-ORIF SSI rates for closed ankle and calcaneal fractures were sourced from the PubMed, Embase, and Cochrane databases, with no consideration given to language or publication date. Study quality was appraised using the Newcastle-Ottawa Scale. Odds ratios (OR) and the corresponding 95% CIs were determined using random-effects models. This meta-analysis adhered to the PRISMA guidelines and was registered with PROSPERO (CRD42023429372). The analysis incorporated data from 16 cohort and case-control studies, totaling 41 944 subjects, 9984 of whom were smokers, with 956 SSI cases. Results indicated smokers faced a higher SSI risk (OR: 1.62; 95% CI: 1.32-1.97, P < 0.0001) post ORIF, with low heterogeneity (I 2 = 26%). Smoking was identified as a significant deep SSI risk factor (OR: 2.09; 95% CI: 1.42-3.09; P = 0.0002; I 2 = 31%). However, the subgroup analysis revealed no association between smoking and superficial SSI (OR: 1.05; 95% CI: 0.82-1.33; P = 0.70; I 2 = 0%). Smoking is associated with increased SSI risk after ORIF for closed ankle and calcaneus fractures. Although no clear link was found between superficial SSI and smoking, the data underscore the negative influence of smoking on deep SSI incidence.

Surgical Outcomes of Syndesmotic Fixation of Ankle Fractures Using Syndesmotic Screws Versus Suture Button Devices.

Ankle fractures associated with disruption of the syndesmotic complex could potentially have poorer outcomes if missed or malreduced at the time of surgery.Favourable results have been reported for the suture button (SB) technique and may provide advantages over standard screw fixation of the syndesmosis, although this remains the gold standard method in many units. To compare the outcomes of syndesmotic screws (SS) with SB fixation of the syndesmosis during ankle fracture fixation at a high-volume orthopaedic department of a Scotland trauma unit. A cross-sectional, retrospective study looking at ankle fracture fixations was undertaken at the Clyde Trauma Unit, Paisley. Relevant information was obtained from electronic patient records for 457 ankle fracture patients between August 2019 and February 2022 and followed up for six months. The digital patient archive system (PACS) was used for evaluating radiographs. Patients were divided into two groups depending on whether they had an SS or SB fixation of their syndesmosis. We focused on the surgical and radiological outcomes following syndesmotic fixation as no functional scores following surgery were conducted on the patients. Out of the entire study group, 26.3% (120/457 patients) required syndesmotic fixation. Within the syndesmotic fixation group, 70.8% (85/120 patients) underwent SS fixation, and 29.2% (35/120 patients) had an SB fixation. Both groups were statistically well-matched. Additionally, 21.1% (18/85) of SS fixation went on to have a second surgical procedure (four fixation failures, five planned removals, five for pain/stiffness, two infections, and two metalwork breakage/migration), whereas 8.6% (3/35) of the SB fixation group had a secondary procedure - two for fixation failures and one for infection. We reported a higher incidence of associated syndesmotic injury in our series of 457 ankle fractures than previously described. There were significantly fewer sequelae in the SB group compared to the SS fixation group (P = 0.0464). Although we did not observe a statistically significant difference in the rate of reoperation (P = 0.1184), this is likely due to the small numbers in the SB group.Our study suggests that SB fixation may be associated with a lower rate of reoperation for post-op complications such as metalwork failure, pain, and stiffness (21.1% SS vs 8.6% SB). Regardless of the fixation method used, accurate reduction of the ankle mortice and syndesmosis is a key step to a successful surgical outcome.

Surgical Management of Complex Ankle Fractures in Patients with Diabetes: A National Retrospective Multicentre Study.

Objectives: Patients with ankle fractures associated with diabetes experience more complications following standard open reduction-internal fixation (ORIF) than those without diabetes. Augmented fixation strategies, namely extended ORIF and hindfoot nails (HFNs), may offer better results and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, we aimed to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes, including early post-operative weightbearing and surgical complications. Methods: A national multicentre retrospective cohort study was conducted between January and June 2019 in 56 centres (10 major trauma centres and 46 trauma units) in the United Kingdom; 1360 patients with specifically defined complex ankle fractures were enrolled. The patients' demographics, fixation choices and surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with and without diabetes. Results: There were 316 patients in the diabetes cohort with a mean age of 63.9 yrs (vs. 49.3 yrs. in the non-diabetes cohort), and a greater frailty score > 4 (24% vs. 14% (non-diabetes cohort) (p < 0.03)); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% an HFN, compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p < 0.02), but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications compared to non-diabetes patients, even though early-weightbearing rates were greater than for standard-ORIF. Conclusions: Ankle fractures in diabetes occur in older, frailer patients, whilst lower-than-expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weightbearing without increasing complications, in keeping with modern guidelines in ankle fracture management.

DELTOID LIGAMENT RECONSTRUCTION IN ANKLE FRACTURES: DOES IT PREVENT PES PLANUS?

IntroductionDeltoid ligament reconstruction (DLR) is an important factor in the consideration of pes planus deformity. There is little evidence in the literature determining whether DLR could mitigate the risk of patients acquiring flat foot postoperatively following deltoid ligament injury.AimOur objective was to establish if there was a difference in pes planus deformity in patients who underwent DLR during their ankle fracture fixation compared to those who did not.MethodsA retrospective analysis of post-operative weight bearing radiographs was performed of patients who underwent ankle fracture fixation. Inclusion criteria were confirmed deltoid instability presurgery without medial malleolar fracture and post operative weightbearing radiographs at least 6 weeks post-fixation. Patients were categorised into no deltoid ligament reconstruction (nDLR) and having DLR. Radiographic pes planus parameters involved Meary's Angle assessment. Other fracture morphology was classified.ResultsA total 723 ankle fractures were screened. 122 patients were included for further analysis. There were 94 patients in the nDLR group and 28 patients in DLR group. The mean Meary's Angle was 15.81 (95% CI 14.06, 17.56) degrees in the nDLR group and −.2 (95% CI −3.86, 3.82) in the DLR group. This was statistically significant (p&lt;.001). There was no significant difference in medial clear space measurements (2.90mm v 3.19mm, p = 0.145). There were significantly more pes planus patients in the nDLR than the DLR group (p&lt;.001, 90.5% vs 25%).ConclusionIn this study there was significantly greater pes planus parameters in patients not undergoing DLR. Patients undergoing DLR had on average normal parameters, whilst those not undergoing DLR had on average severe pes planus. The benefits of DLR are not only maintaining ankle stability but maintaining medial arch integrity, and this should be taken into account in a future study on DLR.