Fixation Of Ankle Fractures Research Articles

In Silico Analysis of Bone Tension During Fixation of the Medial Malleolus Fracture After Ankle Joint Endoprosthesis.

Total ankle arthroplasty (TAR) is a procedure alternative to arthrodesis which enables the biomechanical stabilization of the ankle joint. The procedure is associated with a high risk of complications, including fractures of the medial malleolus. In this study, the finite element method (FEM), based on CT examinations, was used to model the ankle fracture fixation after TAR. Three types of fracture stabilization were considered: screw, Blount staple, and both screw and Blount staple. In the in silico model, the maximum stress tension was found at prosthetic junctions with the base, cone, and talar components of the tibial prosthesis. When the fracture was stabilized with the Blount staple, tension along the cone of the tibial component was about 12% of the maximum tension. Stabilizations with the screw alone or Blount staple combined with a screw on the medial side of the cone induced tension in the immediate vicinity twice as high. In the area of the medial malleolus, the tension was alike for both types of stabilization. The tension was lowest when using the Blount staple alone. We conclude that, contrary to the hitherto clinical routine of using screws, fracture fixation using the Blount staple leads to the lowest bone tension around the fixation of the medial malleolus fracture after ankle joint endoprosthesis.

Arthroscopically Assisted Treatment of Complex Ankle Fractures: Intra-articular Findings and 1-Year Follow-Up

Especially after complex ankle fractures, patients regularly suffer from residual symptoms, presumably due to occult intra-articular injuries. The aim of this study was to evaluate the intra-articular lesions, identify fractures specifically at risk for these, and assess the results after arthroscopically assisted open reduction and internal fixation of complex ankle fractures after 1 year. The primary outcome was the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. Secondary outcome parameters were the Olerud and Molander Ankle Score (OMAS), Tegner activity scale, arthroscopic findings, functional assessment, and complications. Thirty-two patients (56% female) were enrolled. Chondral lesions were detected in 91%. Full-thickness lesions treated by microfracturing were observed in 0% of unimalleolar, 43% of bimalleolar, and 40% of trimalleolar fractures. After 1 year, the median (interquartile range) AOFAS was 94 (9) and OMAS was 90 (10) for all patients. When analyzing factors possibly influencing the outcome, age, sex, smoking, grading for surgical procedures according to the American Society of Anesthesiologists, fracture type (uni-, bi-, or trimalleolar), severity of chondral lesions graded according to the International Cartilage Repair Society (grade <4 versus grade 4), and syndesmotic instability had no significant influence on the outcome. The only variable significantly influencing the AOFAS (p = .004) and OMAS (p < .001) was body mass index (BMI; rs = –0.522 and –0.606, respectively), with a higher BMI resulting in inferior outcome scores. Complications were observed in 3 patients, 2 with superficial skin necrosis at the posterolateral incision and 1 nonunion of the medial malleolus. Taken together, these data show that intra-articular injuries were common in ankle fractures. Bi- and trimalleolar fractures were particularly at risk for full-thickness lesions. A higher BMI tended to result in inferior outcome scores. Arthroscopically assisted open reduction and internal fixation led to good to excellent results in all but 1 patient.

Refining Risk-Adjustment of 90-Day Costs Following Surgical Fixation of Ankle Fractures: An Analysis of Medicare Beneficiaries

As the current healthcare model transitions from fee-for-service to value-based payments, identifying cost-drivers of 90-day payments following surgical procedures will be a key factor in risk-adjusting prospective bundled payments and ensuring success of these alternative payment models. The 5% Medicare Standard Analytical Files data set for 2005–2014 was used to identify patients undergoing open reduction and internal fixation (ORIF) for isolated unimalleolar, bimalleolar, and trimalleolar ankle fractures. All acute care and post–acute care payments starting from day 0 of surgery to day 90 postoperatively were used to calculate 90-day costs. Patients with missing data were excluded. Multivariate linear regression modeling was used to derive marginal cost impact of patient-level (age, sex, and comorbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy, and syndesmotic fixation), and state-level factors on 90-day costs after surgery. A total of 6499 patients were included in the study. The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 ± $1060. Individuals aged <65 or ≥70 years had significantly higher costs. Procedure-level factors associated with significant marginal cost increases were inpatient surgery (+$5577), trimalleolar fracture (+$1082), and syndesmotic fixation (+$2822). The top 5 comorbidities with the largest marginal cost increases were chronic kidney disease (+$8897), malnutrition (+$7908), obesity (+$5362), cerebrovascular disease/stroke (+$4159), and anemia (+$3087). Higher costs were seen in Nevada (+$6371), Massachusetts (+$4497), Oklahoma (+$4002), New Jersey (+$3802), and Maryland (+$3043) compared with Michigan. With the use of a national administrative claims database, the study identifies numerous patient-level, procedure-level, and state-level factors that significantly contribute to the cost variation seen in 90-day payments after ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in patients with fractures.

Role of Hypoalbuminemia as an Independent Predictor of 30-Day Postoperative Complications Following Surgical Fixation of Ankle Fractures

Malnutrition is known to be negatively associated with outcomes after multiple orthopedic procedures. We hypothesized that admission albumin levels, as a marker for malnutrition, would correlate with postoperative outcomes. The purpose of this study was to investigate this relationship following surgery for ankle fracture. This is a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients undergoing operative fixation of an ankle fracture were identified. A total of 6138 patients with albumin available for analysis were identified. Baseline patient information, preoperative serum albumin levels, 30-day postoperative complications, readmission, reoperation, and length of stay data were then collected. Poisson regression with robust error variance was performed to assess the effect of preoperative serum albumin level on postoperative outcomes. The mean albumin level was 3.86 g/dL and 20.3% (1246/6138) of patients with available albumin levels were hypoalbuminemic. Multivariate analysis revealed that an albumin level <3.5 g/dL was an independent risk factor for complications (relative risk [RR], 1.42; 95% confidence interval [CI], 1.13-1.78; P = .002) and readmission (RR, 1.54; 95% CI, 1.13-2.08; P = .006). Additionally, when analyzed as a continuous variable, albumin level was negatively correlated with risk of mortality (RR, 0.37; 95% CI, 0.19-0.72; P = .003). Patients with hypoalbuminemia also had significantly longer lengths of stay (4.5 vs 2.1 days; P < .001). While complication rates after fixation of ankle fractures remain low, hypoalbuminemia was a predictor of postoperative course. Malnutrition, therefore, may help inform the decision between surgical and conservative management of patients with ankle fractures potentially amenable to nonoperative management. Additionally, hypoalbuminemia should trigger heightened awareness and prophylactic therapy where appropriate. Level III, comparative study.

PO 18198 - Treatment of distal tibiofibular syndesmosis injury in ankle fractures with suture button

Introduction: Distal tibiofibular syndesmosis (DTFS) injuries in ankle fractures are conventionally treated by DTFS fixation with stabilizing screws. However, screws may cause problems due to their inherent rigidity. Therefore, the popularity of fixation devices that allow DTFS mobility has increased. The objective of the present study is to describe the outcomes of the surgical treatment of ankle fractures with DTFS injury using suture button syndesmosis fixation. Methods: Forty-four patients surgically treated with a suture button for ankle fractures associated with DTFS injury were retrospectively analyzed. The mean follow-up time was 14.7 months. Patient functioning was assessed using the American Orthopedic Foot and Ankle Society (AOFAS) score, the visual analog scale (VAS), the rate of complications and the need for reoperation. Results: The mean AOFAS score at the last follow-up visit was 92 (35-100). The mean VAS was 0.8 (0-7). Eight patients (18%) developed complications, the most common of which were posttraumatic osteoarthrosis and peroneal tendinopathy. Reoperations were performed in 6 patients (13.5%) and included orthopedic hardware removal, peroneal tenoplasty, neurolysis or distal tibiofibular arthrodesis. Only one patient was unable to resume previous activities. Conclusion: Suture button is a reliable alternative for DTFS fixation in ankle fractures, providing excellent functional outcomes with a low rate of complications. This device has the theoretical advantage of allowing physiological mobility of the distal tibiofibular joint and generally requires no subsequent orthopedic hardware removal.

Sterility of 3D-Printed Orthopedic Implants Using Fused Deposition Modeling.

The use of 3-dimensional (3D) printing in orthopedics is developing rapidly and impacting the areas of preoperative planning, surgical guides, and simulation. As this technology continues to improve, the greatest impact of 3D printing may be in low- and middle-income countries where surgical items are in short supply. This study investigated sterility of 3D-printed ankle fracture fixation plates and cortical screws. The hypothesis was that the process of heated extrusion in fused deposition modeling printing would create sterile prints in a timely fashion that would not require postproduction sterilization. A free computer-assisted design program was used to design the implant models. One control group and 8 study groups were printed. Print construct, orientation, size, and postproduction sterilization differed among the groups. Sterility was assessed using thioglycollate broth cultures at 24 hours, 48 hours, and 7 days. Positive growth was speciated for aerobic and anaerobic bacteria. Print time and failed prints were recorded. Control samples were 100% positive for bacterial growth. All test samples remained sterile at all time points (100%). Speciation of control samples was obtained, and Staphylococcus was the most common species. Print times varied; however, no print time exceeded 6.75 minutes. Eighteen prints (17%) failed in the printing process. These findings demonstrate an intrinsic sterilization process associated with fused deposition modeling 3D printing and indicate the feasibility of 3D-printed surgical implants and equipment for orthopedic applications. With future research, 3D-printed implants may be a treatment modality to assist orthopedic surgeons in low- and middle-income countries. [Orthopedics. 2020; 43(1): 46-51.].

Variation in Implant Selection for Ankle Fractures: Identifying Cost Drivers.

Implant selection is the first opportunity for surgeons to control costs of fracture fixation. The current literature has demonstrated surgeons' poor understanding of implant costs. Our study evaluated implant cost variability for surgically treated ankle fractures and distal tibia fractures. Our hypothesis was that significant cost variation exists among providers. The goal was to identify cost drivers and determine whether specialty training is linked to implant selection. A retrospective 2010-2017 chart review was performed for 1281 patients at a Level I trauma center. Patients were excluded for skeletal immaturity, open fractures, polytrauma, and concurrent surgeries. Variables were assessed included age, sex, body mass index, OTA/AO classification, Weber classification, 1-year reoperation status, surgeon specialty, and use of syndesmotic screws, locking plates, and cannulated screws. Construct cost was determined by using electronic medical record implant model numbers cross-referenced with the chargemaster database. Statistical analysis involved intergroup comparative tests, regression analysis, and goodness-of-fit analyses. Implant cost was different among OTA patterns (P < 0.01), highest among 43C ($3771) and lowest with 44A ($819). Construct costs of OTA 43 fractures varied from $2568 to 3771, whereas OTA 44 ranged from $819 to $1474. Costs were comparable across Weber patterns (P = 0.15), with Weber B having the highest ($1494). Costs were highest among reconstructive, podiatry, and spine surgeons, with mean costs of $1804, $1404, and $1396, respectively. Traumatologist constructs had the lowest overall price ($987). A total of 433 (33.8%) procedures used locking plates with 512 (40.0%) using at least one cannulated screw. Locking plates averaged a larger total implant cost ($1947) than nonlocking plates ($1313) but had a comparable reoperation rate (18.5% vs. 17.7%, P = 0.81). Use of a cannulated screw presented a higher total cost ($2008 vs. $1435) with comparable reoperation rates (17.4% vs. 18.8%, P = 0.72). A total of 401 (31.5%) patients received syndesmotic fixation and a significantly higher reoperation rate (17.0% vs. 11.0%, P < 0.01). Overall, 199 patients underwent elective hardware removal, 23 were infected, 7 required revision, and 3 were identified with a nonunion. Our study demonstrated significant variability in implant costs for ankle fracture fixation and identified the key cost drivers as locking plates and cannulated screws. Surgical management of ankle fractures could be an ideal setting to pilot economic alignment between physicians and hospitals to drive value. Level III. Retrospective Cohort.

Fibular nailing for fixation of ankle fractures in patients at high risk of surgical wound infection

BackgroundPostoperative infection is a severe complication after operative treatment of ankle fractures, associated with age, comorbidities, and severe soft tissue injuries. We assessed the efficacy of intramedullary fibular nailing for treating ankle fractures in patients at high risk of wound complications. Methods41 high-risk patients were included in the study. We retrospectively reviewed the medical records to assess the risk profile, the treatment data, and possible infections and re-operations. After a minimum of 2 years eight patients had died, three had advanced-staged dementia and two were lost to follow-up. Remaining 28 patients reported the functional outcome and QoL through patient-reported questionnaires. Radiographs and cone-beam computed tomography were performed, as well as range-of-motion was measured. ResultsNo surgical wound infections were found. The mean Olerud-Molander score was 67 points (SD 28 [20–100]). The osteoarthritis stages and the range-of-motion were significantly different between the injured and uninjured ankles, but we detected no significant effect on the QoL. ConclusionIntramedullary fibular fixation appeared to be a safe treatment choice for ankle fractures in high-risk patients. Level of evidenceIV

Efficacy of Multimodal Analgesic Injections in Operatively Treated Ankle Fractures: A Randomized Controlled Trial.

Pain management following surgical treatment of an ankle fracture is an under-studied area of clinical practice. The present study evaluated the efficacy of a multimodal surgical-site injection as an adjunct to postoperative pain management in patients with an operatively treated, closed, rotational ankle fracture. Patients indicated for operative fixation of a rotational ankle fracture were randomized to receive multimodal surgical-site injection (ropivacaine 200 mg, epinephrine 0.6 mg, and morphine 5 mg) or no injection (control). Visual analog scale (VAS) pain and opioid consumption data were collected every 4 hours until discharge from the hospital. Length of stay and discharge destination were recorded. Patients were sent automated text messages to report VAS pain and opioid usage during the first 2 weeks after discharge. One hundred patients (49 injection and 51 control) were enrolled. Demographic data were similar between the 2 groups. Mean VAS scores over the first 24 and 48 hours postoperatively were slightly lower in the injection group (42 ± 3 and 41 ± 3, respectively) compared with the control group (52 ± 3 and 50 ± 3, respectively; p = 0.01 and p < 0.01, respectively). The median opioid usage, in terms of morphine equivalent dose, was similar over the first 24 hours between the injection group (25.5; range, 0 to 74.7) and the control group (28.3; range, 2.5 to 91.0; p = 0.35). The median opioid usage from recovery room admission to discharge was also similar between the injection group (29.0; range, 0 to 85.3) and the control group (32.7; range, 4.3 to 215.0; p = 0.35). There were no differences in outpatient VAS scores or opioid consumption during the first 2 weeks postoperatively as assessed with use of automated text messaging. Median length of stay was 22.3 hours (range, 1.7 to 182.3 hours) for the injection group and 22.5 hours (range, 2.2 to 123.3 hours) for the control group (p = 0.71). The response rate for the post-discharge automated text messages was 85.1%. Complication rates were similar. The use of multimodal surgical-site injections in operatively treated rotational ankle fractures is associated with a reduction in immediate in-hospital pain scores that is statistically significant but below the minimal clinically important difference. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Variability in the Reporting Terminology of Adverse Events and Complications in Ankle Fracture Fixation: A Systematic Review.

Classification systems for the reporting of surgical complications have been developed and adapted for many surgical subspecialties. The purpose of this systematic review was to examine the variability and frequency of reporting terms used to describe adverse events and complications in ankle fracture fixation. We hypothesized that the terminology used would be highly variable and inconsistent, corroborating previous results that have suggested a need for standardized reporting terminology in orthopedics. Ankle fracture outcome studies meeting predetermined inclusion and exclusion criteria were selected for analysis by 2 independent observers. Terms used to define adverse events and complications were identified and recorded. Discrepancies were resolved by consensus with the aid of a third observer. All terms were then compiled and assessed for variability and frequency of use throughout the studies involved. Reporting terminology was subsequently grouped into 10 categories. In the 48 studies analyzed, 301 distinct terms were utilized to describe complications or adverse events. Of these terms, 74.4% (224/301) were found in a single study each. Only 1 term, "infection," was present in 50% of studies, and only 19 of 301 terms (6.3%) were used in at least 10% of papers. The category that was most frequently reported was "infection," with 89.6% of studies reporting on this type of adverse event using 25 distinct terms. Other categories were "wound healing complications" (72.9% of papers, 38 terms), "bone/joint complications" (66.7% of papers, 35 terms), "hardware/implant complications" (56.3% of papers, 47 terms), "revision" (56.3% of papers, 35 terms), "cartilage/soft tissue injuries" (45.8% of papers, 31 terms), "reduction/alignment issues" (45.8% of papers, 29 terms), "medical complications" (43.8% of papers, 32 terms), "pain" (29.2% of papers, 16 terms), and "other complications" (20.8% of papers, 13 terms). There was a 78.6% interobserver agreement in the identification of terms across the 48 studies included. The reporting terminology utilized to describe complications and adverse events in ankle fracture fixation was found to be highly variable and inconsistent. This variability prevents accurate reporting of complications and adverse events and makes the analysis of potential outcomes difficult. The development of standardized reporting terminology in orthopedics would be instrumental in addressing these challenges and allow for more accurate and consistent outcome reporting. Level III; systematic review of Level III studies and above.

Effect of the Strengthening Opioid Misuse Prevention (STOP) Act on Opioid Prescription Practices After Ankle Fracture Fixation.

Background:In North Carolina, the Strengthen Opioid Misuse Prevention Act of 2017 (STOP Act) went into effect on January 1, 2018, intending to increase oversight over opioid prescriptions. This study compares postoperative narcotic prescription practices following operative fixation of ankle fractures before and after the STOP Act.Methods:This study was a retrospective review of patients 18 years and older who underwent operative fixation of ankle fractures between January 1 and June 30, 2017 (before STOP Act), and between January 1 and June 30, 2018 (after STOP Act). Variables of interest included demographics, amount of opioids prescribed postoperatively, number of prescription refills, and number of pain-related calls or visits to the emergency department (ED) or clinic after surgery. This study assessed 71 patients in the Pre group and 47 patients in the Post group.Results:There was a statistically significant decrease in the average number of postoperative narcotic pills prescribed after the STOP Act (52.7 vs 76.2, P < .001). There was also a statistically significant decrease in the average number of prescription refills (0.6 vs 1.0, P = .037). There were no significant changes in pain-related clinic calls (35.2% Pre vs 34.0% Post, P = .896), pain-related clinic visits ahead of schedule (4.2% Pre vs 6.4% Post, P = .681), or pain-related ED visits (2.8% Pre vs 10.6% Post, P = .113).Conclusion:In the postoperative period after operative fixation of ankle fractures, the volume of narcotic prescriptions decreased after the new legislation, without an associated strain on medical resources.Level of Evidence:Level III, therapeutic, comparative study.

PULMONARY EDEMA AND HEMOPTYSIS AFTER AN ORTHOPEDIC SURGERY

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Negative pressure pulmonary edema(NPPE) is an acute respiratory failure usually caused after a strong inspiratory effort generated against an obstructed upper airway[1]. CASE PRESENTATION: A 29-year-old man was admitted to the hospital for an elective open reduction with internal fixation of left bimalleolar ankle fracture. The surgery was uneventful. After extubation, he became hypoxic and started coughing up bloody phlegm without evidence of vomiting. He was afebrile, HR 96, RR 22 and BP 146/96. Chest x-ray showed bilateral alveolar consolidations in the upper and mid zones(Fig1). He was given Lasix 40 mg IV once and was transferred to the ICU. He was hemodynamically stable on high-flow oxygen. Arterial blood gas was showing pH of 7.41, PO2 98, pCO2 46 and HCO3 28.4. There was no evidence of swelling in the posterior pharynx. Lung exam showed good air entry on both sides, bilateral crepitations without wheezes. Laboratory work was unremarkable. Echocardiogram revealed normal ejection fraction, no significant valvular heart disease. He made a strong inspiratory effort after extubation due to upper airway laryngospasm and developed NPPE with alveolar hemorrhage. He was started on steroids. CT chest with contrast showed bilateral ground-glass opacities with alveolar infiltration in parenchymal hemorrhagic pattern(Fig2). He was continued on supportive treatment. Hemoptysis resolved in a day. He was transitioned to nasal cannula. Follow up chest x-ray showed significant improvement in alveolar infiltrates(Fig3). He was discharged home after a 48-h stay in the hospital. DISCUSSION: In adults, the most reported causes of airway obstruction leading to NPPE are in the context of laryngospasm following surgery[2]. The incidence of NPPE is as low as 0.1% of laryngospasm cases [3]. The first case of NPPE was reported and published in 1973 by Capitano and Kirkpatrick. There was a question whether NPPE was a result of high vessel permeability or hydrostatic pressure edema formation[1]. The high negative intrathoracic pressure generated to overcome the upper airway obstruction can reach -140 cm H2O[1]. The hydrostatic pressure in the pulmonary capillaries increases, the rate of interstitial fluid accumulation outgrows the capacity of the lymphatic drainage and fluid floods into the alveoli. Stress fracture can develop in the pulmonary capillaries leading to high permeability edema and blood-tinged secretions. Most cases of NPPE resolve in 24-48h. Diuretics have been used to hasten the resolution of the pulmonary edema. Beta agonist improves the clearance of the fluid by increasing active cation transport. In case of severe obstruction, cricothyroidotomy or tracheostomy can been used. Sedating and paralyzing the patient prevent more laryngospasm or biting of the endotracheal tube. CONCLUSIONS: NPPE is an entity not frequent encountered, but life threatening if not recognized or managed appropriately. Reference #1: M. Bhattacharya, R. H. Kallet, L. B. Ware, and M. A. Matthay, “Negative-Pressure Pulmonary Edema,” Chest, vol. 150, no. 4, pp. 927–933, Oct. 2016. Reference #2: A. Udeshi, S. M. Cantie, and E. Pierre, “Postobstructive pulmonary edema,” J. Crit. Care, vol. 25, no. 3, p. 538.e1-538.e5, 2010. Reference #3: B. Bhaskar and J. F. Fraser, “Negative pressure pulmonary edema revisited: Pathophysiology and review of management,” Saudi J. Anaesth., vol. 5, no. 3, pp. 308–313, 2011. DISCLOSURES: No relevant relationships by Arul Chandran, source=Web Response No relevant relationships by Michele Obeid, source=Web Response

A New Intraoperative Measurement that Predicts Ankle Syndesmotic Joint Malreduction

Category:Ankle, TraumaIntroduction/Purpose:Distal tibio-fibular syndesmotic reduction (SR) is an independent predictor of good functional outcome following ankle surgery. Classic intraoperative fluoroscopic parameters have shown to be poor predictors of distal SR. Syndesmotic malreduction (S-MR) has been reported up to 52% of surgically treated patients. Grenier et al proposed the Anteroposterior Tibio Fibular Ratio (APTF) to evaluate normal sagittal syndesmotic anatomy, showing good interobserver agreement and high correlation between both sides in normal ankles. We propose the use of the comparative APTF index (cAPTF), calculated as the absolute difference of APTF index between the normal and surgically treated ankle, to guide intraoperative sagittal SR. The aim of this study was to determine the capability of the intraoperative cAPTF to predict S-MR.Methods:Prospective observational study. Patients who required syndesmotic fixation for an unstable ankle fracture and who had a contralateral healthy ankle were prospectively enrolled. Intraoperative APTF was measured under fluoroscopy in both ankles according to Grenier et al and the cAPTF was calculated. No surgeons were informed of APTF measurements during the procedure. Bilateral postoperative CT was obtained, and quality of SR was evaluated using the method described by Dikos et al. To estimate the discriminatory power of the cAPTF, a receiver operative characteristic (ROC) curve was obtained and the area under the curve was calculated. Youden index was used to determine the ideal cAPTF cut-off value for S-MR and its sensitivity, specificity, positive likelihood ratio (LR+) and negative probability (LR-) were calculated.Results:Forty-seven patients were enrolled. Sixteen (34%) had S-MR on the postoperative CT. The cAPTF varied between 0.005 and 0.435. The cAPTF cut-off value to predict S-MR was 0.161. A cAPTF value greater than 0.161 had Sensitivity 100%; specificity 94%; LR+ 15.50; and LR- 0.06, for predicting malreduction of the syndesmosis.The area under the ROC curve was 0.99.Conclusion:Intraoperative cAPTF index demonstrated excellent discriminatory power for predicting syndesmotic malreduction. We propose the routine use of this new method to improve the results of syndesmotic reduction.

Posterior Approaches to the Ankle: An Analysis of 3 Approaches for Access to the Posterior Distal Tibia

Category:Ankle, TraumaIntroduction/Purpose:With the increase in the use of CT scanning and fragment specific fixation for complex ankle fractures, utilisation of multiple surgical approaches has increased. The posterolateral approach has been advocated by many, however in our experience, a large proportion of these fractures are not attainable by this approach. Our aim in this study was to analyse three posterior ankle approaches to find their use and efficacy in accessing the posterior tibia in the fixation of posterior malleolar fractures.Methods:We examined 5 fresh frozen cadaveric lower limbs. Three posterior ankle approaches (posterolateral (PL), posteromedial (PM) and medial posteromedial (MPM) approaches were performed, using a consistent repeatable incision of 7 cm extended proximal from the palpable distal extent of the medial malleolus. In both the PL and PM approaches, the flexor hallucis longus (FHL) was taken medially. In the MPM approach, the access was anterior to tibialis posterior (TP).K-wires were then placed parallel to one another at the 4 extremities of the approach. The ankles were imaged using an image intensifier and the distances measured.Our database of 172 consecutively treated posterior malleolar fractures in our department, was used to analyse the fracture fragment size and compare these fracture patterns to the approaches. The fractures were categorised using the Mason and Molloy classification. Only type 2 and 3 fractures were included, leaving 101 in the study.Results:On radiographic analysis, the type 2B and type 3 fractures incorporate 100% and 83% of the posterior width of the tibia respectively. Considering the PL approach only allows access to 40% of the posterior width of the tibia, another approach is required for these fracture patterns. Only 65% of fractures could be adequately exposed using the PL incision. In comparison, 78% of fractures could be exposed using the PM incision.The MPM incision gave the largest area for access to the posterior tibia, however it did not allow access to the constant posterolateral fragment. Only 35% of patients had posteromedial fractures that could be dealt with using the MPM incision, thus its usage is primarily as a supplementary incision, in conjunction with the PL incision.Conclusion:We conclude that the most commonly used approach (the PL approach) gives the least amount of access to the posterior tibia. In comparison to fracture fragment size, almost half of fractures would not be adequately exposed through the PL approach, and if fixing such fractures the surgeon should be comfortable with multiple approaches.

Association between socioeconomic deprivation and surgical complications in adults undergoing ankle fracture fixation: a population-based analysis

Few studies have investigated the outcomes of surgical fracture care among socially deprived patients despite the increased incidence of fractures and the inequality of care received in this group. We evaluated whether socioeconomic deprivation affected the complications and subsequent management of marginalized/homeless patients following surgery for ankle fracture. In this retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, we evaluated 45 444 patients who underwent open reduction and internal fixation (ORIF) for ankle fracture performed by 710 different surgeons between Jan. 1, 1994, and Dec. 31, 2011. Multivariable logistic regression models were used to assess the association between deprivation and shorter-term outcomes within 1 year (implant removal, repeat ORIF, irrigation and débridement owing to infection, and amputation). Multivariable Cox proportional hazards models were used to assess longer-term outcomes up to 20 years (ankle fusion and ankle arthroplasty). A higher level of deprivation was associated with an increased risk of irrigation and débridement (quintile 5 v. quintile 1: odds ratio [OR] 2.14, 95% confidence interval [CI] 1.25–3.67, p = 0.0054) and amputation (quintile 4 v. quintile 1: OR 3.56, 95% CI 1.01–12.4, p = 0.0466). It was more common for less deprived patients to have their hardware removed (quintile 5 v. quintile 1: OR 0.822, 95% CI 0.76–0.888, p < 0.0001). There was no correlation between marginalization and subsequent revision ORIF, ankle fusion, or ankle arthroplasty. Marginalized patients are at a significantly increased risk of infection and amputation following surgical treatment of ankle fractures. However, these complications are still extremely uncommon among this group. Socioeconomic deprivation should not prohibit marginalized patients from receiving surgery for unstable ankle fractures.

Risk Factors for Recurrent Syndesmotic instability after Syndesmotic Screw Fixation in Rotational Ankle Fractures

Category:AnkleIntroduction/Purpose:Rotational ankle fractures often have unstable syndesmotic injuries the require reduction and stabilization. Though multiple studies have focused on methods to assess accurate syndesmotic reduction, fairly high rates of recurrent syndesmosis diastasis were reported. However, there was no study to investigate possible risk factors for syndesmosis widening after surgical fixation. The purpose of this study was to identify the risk factors for recurrent syndesmosis widening after screw fixation. We hypothesized that risk factors for recurrence syndesmosis widening could be identified from patient demographic, intraoperative variables and the extent of the pathologic condition associated with fractures.Methods:We performed a retrospective review between 2009 and 2015 of consecutive patients who had sustained rotational ankle fractures with intraoperative evidence of syndesmotic instability requiring syndesmotic reduction and stabilization. The exclusion criteria included syndesmosis screws placed for diabetic neuropathy, skeletal immaturity, tibial pilon fractures, polytrauma, open fracture. Patients were sorted into 2 groups according to the presence of recurrent syndesmosis instability which was defined as a difference in the tibiofibular distance of =2 mm between the injured and uninjured ankles on CT at postoperative 1 year and a positive external rotation test. Furthermore, the statistical analysis by binary logistic regression analysis included the significance of various risk factors including age at surgery, sex, diabetes, smoking, body mass index (BMI), dominant side, type of fracture, associated fracture, initial tibiofibular distance on CT, number and size of screws, cortices. The functional outcomes were assessed with the Foot and Ankle Outcome Score (FAOS).Results:A total 126 patients met the study inclusion criteria and underwent analysis. The overall postoperative recurrent instability rate was 25.4% (without recurrence group: 94 patients, recurrence group: 32). It was significantly affected by the BMI (p=0.018; adjusted odds ratio, OR, = 30, 6.21) and concomitant posterior malleolar fracture (p=0.040, adjusted OR 3.31). The other variables were not found to be significant risk factors. There was a significant improvement in the mean clinical scores at one years postoperatively (both p < 0.001), but the mean scores in the group with recurrence were significantly lower than those in the group without recurrence (p=0.021)Conclusion:Among the risk factors, obesity and concomitant posterior malleolar fracture were significant risk factors for the recurrent syndesmotic instability after syndesmotic screw fixation. The overall results suggest meticulous attention to concomitant posterior malleolar fracture, especially in obese patients.

Outcomes of Bridge Plating Versus Standard Fixation in Geriatric Ankle Fractures

Category:Ankle, TraumaIntroduction/Purpose:Ankle fractures represent one of the most common injuries encountered by foot and ankle specialists. Internal fixation of the lateral malleolus can be achieved by several different techniques, most commonly by lag screw and neutralization plating. However, ankle fractures in older patients often present technical challenges as osteoporotic bone is more commonly encountered which may require bridge plating techniques. This study compares outcomes in patients over age 50 years who underwent ORIF of the lateral malleolus with either a bridge plate or lag screw and neutralization plate technique.Methods:This retrospective study evaluated 56 patients with closed ankle fractures, aged over 50 years who underwent open reduction internal fixation of the lateral malleolus. These were divided into two groups: 36 patients had fixation with one or more lag screws and a neutralization plate, and 20 patients had fixation with a bridge plate technique. Fractures were stabilized with lag screw fixation when feasible, while bridge plating was utilized in patients where lag screw fixation was not possible. SF-36 scores were attained at a minimum one-year post-op. Final radiographs and complications were recorded.Results:The lag group had a mean age of 63 years, 17% men, 61% with syndesmotic screw fixation, and 56% with medial malleolus fixation. The bridge group had a mean age of 65 years, 15% men, 60% with syndesmotic screw fixation, and 70% with medial malleolus fixation. At minimum one-year, SF-36 physical component summary score was 74.2 ± 19.4 in the lag group vs 63.2 ± 24.8 in the bridge plate group (p=0.049). The SF-36 mental component summary score was 89.2 ± 12 in the lag group vs 75.5 ± 22.7 in the bridge plate group (p=0.009). One patient in each group required return to the OR for irrigation and debridement for infection. No patients experienced fixation failure and all fractures demonstrated union on final radiograph.Conclusion:In the present study of patients over age 50 years who underwent ORIF of an ankle fracture, as compared with bridge plating, lag screw and neutralization plating is associated with superior one-year SF-36 physical and mental summary scores with similar rates of complications. However, additional research is needed to determine to what degree this difference is causative or correlative with confounding variables as fixation technique was not found to be an independent predictor of SF-36 outcomes in this small cohort.

Outcomes of Primary Tibiotalocalcaneal Nailing for Complicated Diabetic Ankle Fractures

Category:Trauma, Ankle, Ankle ArthritisIntroduction/Purpose:Ankle fractures in complicated diabetic patients (i.e. presence of neuropathy, nephropathy, or peripheral vascular disease) have significantly increased rates of complications with markedly worse functional outcomes. Current management advocates for operative intervention due to high rates of fracture reduction loss and Charcot arthropathy in those treated nonoperatively. Tibiotalocalcaneal (TTC) nails have been reported in the literature as a salvage option when initial ankle stabilization has failed. We hypothesize that the minimally invasive, robust construct that primary TTC fixation with an intramedullary nail offers will result in high rates of limb salvage, acceptable rates of complications, and nominal loss of function.Thus, the purpose of this study was to evaluate the outcomes of primary TTC intramedullary nailing for definitive treatment of neuropathic ankle fractures.Methods:This was an IRB approved retrospective study of 27 complicated diabetic patients who underwent TTC nailing of their ankle fracture as a primary treatment without formal joint preparation. The study was undertaken at an urban Level 1 trauma center. Complicated diabetes was defined as having one or more of the following formal diagnoses: neuropathy (20 patients), nephropathy (4), PVD (3). Mean clinical follow up was 888 days (range 21-2843 days). Patients were screened for associated risk factors such as open fracture, neuropathy, nicotine and alcohol abuse, obesity and elevated Hba1c. Data was also collected on surgical complications such as superficial and deep infection, wound dehiscence, amputation, revision fixation, hardware failure, malunion, nonunion. Outcomes were measured in length of hospital stay, loss of ambulatory level, and time to death.Results:The mean age was 66 (32-92) years with an average BMI of 38 (21-68). Six of 27 fractures were open and 20 of 27 patients were neuropathic. Mean hemoglobin A1C was 7.4 (5.5-13). Average hospital stay was 6 days (0-22). The average patient was fully weight bearing at 6 weeks (1-17). Two patients underwent removal of hardware, due to pain and proximal screw failure respectively. One patient required formal arthrodesis. There were no malunions, symptomatic nonunions, or instances of Charcot arthropathy. Two patients underwent repeat debridement for infection, resulting in antibiotic nail placement and above knee amputation respectively. A total of eight patients had died by final follow up (mean 1048 days) from index procedure. Overall, mean ambulatory status was maintained.Conclusion:Primary tibiotalocalcaneal nailing is a viable alternative to previously described methods of fixation of complicated diabetic ankle fractures. With high limb salvage rates, early weight bearing, maintained ambulatory status and low rates of return to the operating room, our technique can be considered an applicable approach to increase overall survivability of threatened limbs and lives with acceptably low complications.

Refining Risk-Adjustment of 90-day Costs Following Surgical Fixation of Ankle Fractures: Implications for a Bundled Payment Model

Category:TraumaIntroduction/Purpose:Current literature revolving around understanding cost-determinants of 90-day payments following ankle fractures is limited to single-institution studies. As the current healthcare model transitions from fee-for-service to value- based payments, risk-adjustment of 90-day payments will be a key factor driving success of these bundled payment models. The current study, utilizes a national Medicare database, to understand patient-level, procedure-level and state-level variation in 90-day payments following open reduction internal fixation (ORIF) of isolated ankle fractures.Methods:The 2005-2014 5% Medicare SAF (Standard Analytical Files) database was queries using Current Procedural Terminology codes to identify patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (27766, 27769, 27792), bi-malleolar (27814) and tri-malleolar (27822, 27823) ankle fractures. Patients with polytrauma or those undergoing a concurrent surgical fixation of the upper extremity, hip, femur, knee or tibia were removed from the study to capture a relevant cohort of isolated ankle fracture patients. All payments starting from day 0 of surgery up to day 90 post-operatively were used to calculate 90-day costs. Patients with missing data were excluded. Multi-variate linear regression modeling was used to derive marginal cost-impact of patient-level (age, gender, co-morbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy and syndesmotic fixation) and state-level factors on 90-day costs following surgery.Results:Following application of inclusion/exclusion criteria, a total of 6,499 patients were included in the study. The risk- adjusted 90-day price of a non-geriatric (age<65) female patient undergoing outpatient ORIF for a closed uni-malleolar ankle fracture was $8,915 ± $1,054. Individuals aged 65-69 vs. <65 had significantly lower costs (-$1,967). Procedure-level factors associated with significant marginal cost-increases were inpatient surgery (+$5,577), tri-malleolar fracture (+$1,082) and syndesmotic fixation (+$2,822). The top 5 co-morbidities with largest marginal cost-increases were chronic kidney disease (+$8,897), malnutrition (+$7,908), obesity (+$5,362), cerebrovascular disease/stroke (+$4,159) and anemia (+$3,087). Significant state-level variation in 90-day costs was seen with Nevada (+$6,371), Massachusetts (+$4,497), Oklahoma (+$4,002), New Jersey (+$3,802) and Maryland (+$3,043) having the highest marginal cost-increase and Idaho (-$6,025) having the lowest.Conclusion:Using a national administrative claims database, the study identifies numerous patient-level, procedure-level and state-level factors that significantly contribute to the cost-variation seen in 90-day payments following ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in fracture patients.

Octogenarian and Nonagenarians Are at a Higher Risk for Experiencing Adverse 30-Day Outcomes Following ORIF for Ankle Fractures

Category:Ankle, TraumaIntroduction/Purpose:Despite an increasing number of elderly individuals undergoing surgical fixation for ankle fractures, few studies have investigated peri-operative outcomes and safety of surgery in an octogenarian and nonagenarian population (age >=80 years). Past literature has shown octogenarians to be a potentially vulnerable population that have drastically different adverse outcomes and higher resource utilization as compared to individuals below the age of 80 years.Methods:The 2012-2017 American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) was queried using Current Procedural Terminology codes for patients undergoing open reduction internal fixation (ORIF) for isolated uni-malleolar (CPT-27766, CPT-27769, CPT-27792), bi-malleolar (CPT-27814) and tri-malleolar (CPT-27822, CPT-27823) ankle fractures. The study cohort was divided into three distinct groups for comparisons (Age <65 years, Age 65-79 years and Age=>80 years/octogenarians + nonagenarians). Multi-variate regression analyses were used to compare the independent effect of varying age groups on 30-day post-operative outcomes while controlling for differences in baseline clinical characteristics (age, gender, sex, race, fracture type/severity, open vs. closed fracture, admission status, BMI, co-morbidities, functional health status, ASA group and operative time). For comparison purposes, Age<65 years was taken as reference group in multi-variate regression models.Results:A total of 19,585 patients were included – out of which 1,033 (5.3%) were octogenarians/nonagenarians (=>80 years). Following multivariate analysis, individuals aged =>80 years were at a significantly higher risk of 30-day wound complications (OR 1.84; p=0.019), pulmonary complications (OR 3.88; p<0.001), renal complications (OR 1.96; p=0.015), septic complications (OR 3.72; p=0.002), urinary tract infections (OR 2.24; p<0.001), bleeding requiring transfusion (OR 1.90; p=0.025), mortality (OR 7.44; p<0.001), readmissions (OR 1.65; p=0.004) and non-home discharge (OR 13.91; p<0.001). Individuals between the age of 65-79 years only had a higher risk of pulmonary complications (OR 2.30; p=0.004), urinary tract infections (OR 2.24; p<0.001), readmissions (OR 1.41; p=0.005) and non-home discharges (OR 3.55; p<0.001), with the effect sizes being small as compared to age >=80 years group.Conclusion:Based on the findings, it appears that octagenarians and nonagenarians (age =>80) are a fundamentally distinct and vulnerable age group that is at a higher risk of complications, readmissions, mortality and non-home discharges as compared to other geriatric (65-79 years) and non-geriatric (<65 years) patients. Providers should understand the importance of pre-operative counselling and risk-stratification in this vulnerable patient population.