Fixation Of Ankle Fractures Research Articles

Outcomes of Posterior Malleolar Fixation in Ankle Fractures in A Major Trauma Centre

Category:Ankle; TraumaIntroduction/Purpose:Ongoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. These injuries require careful evaluation of the bony and ligamentous structures with theoretical benefits of posterior malleolar fixation now widely accepted as restoration of articular congruity, restoration of fibular length and stabilisation of the syndesmosis. Surgical and patient report outcomes are varied in the literature with analysis limited by the lack of standardisation in functional outcomes and small patient populations. Posterior malleolar fixation does extend operative time and potentially increases complication rate. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation in the setting of a major trauma centre. Our hypothesis is that posterior malleolus fixation leads to improved clinical outcomes.Methods:A total of 320 patients were identified with operatively treated ankle fractures involving a posterior malleolus component, between January 2012 and January 2018, with minimum 2 year follow-up. Patient electronic records were assessed for demographic data including age, gender, mechanism of injury, co-morbidities and smoking status. Pre-operative imaging, including CT was used to evaluate the nature of the injury and classify the posterior malleolar fracture according to the Mason classification. One hundred and sixty patients underwent posterior malleolus fixation as part of their surgery and 160 patients did not. The Manchester-Oxford Foot Questionnaire (MOXFQ) at final follow-up, was the primary patient outcome measure.Complications were noted to be minor (superficial infection or delayed wound healing) or major (DVT/PE, deep infection, chronic regional pain syndrome (CRPS), arthrofibrosis, further intervention for post-traumatic arthritis, hardware failure or irritation). All cause reoperation rates were also noted.Results:Fixation of the posterior malleolus was associated with a statistically significant improvement in patient outcomes. Mean MOXFQ score in the unfixed posterior malleolus group was 24.03 (0 - 62), compared to 20.10 (0 - 67) in the fixed posterior malleolus group (p =0.04). Outcomes were worse with increasing size of posterior malleolar fragment. When compared with either posterior malleolus fixation alone or syndesmotic stabilisation alone, poorer outcomes were seen when the posterior malleolus fixed with additional syndesmotic stabilisation, with mean MOXFQ scores of 21.73 (0-60), p =0.057. Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%), p=0.03). Re-operation rate was double (34/160 (21.2%) vs 16/160 (10%), p = 0.03). The main cause of this was hardware related issues.Conclusion:This pragmatic study is one of the largest published series that assesses patient reported outcomes in posterior malleolar fixation. The key finding is that posterior malleolar fixation is associated with a statistically significant improvement in patient reported outcome scores. However, the overall complication rate was 10.7% higher in the fixation group and the risk of reoperation was over double. Further research should focus on high quality randomised controlled trials with long term follow-up to assess long term impacts of this complex ankle injury pattern.

The Intercalary Fragment in Posterior Malleolus Fractures: Characterization and Significance

Category:TraumaIntroduction/Purpose:Methods of fixation in ankle fractures involving the posterior malleolus have become increasingly scrutinized. With the increase in computed tomography (CT), an intercalary fracture fragment (ICF) adjacent to the posterior malleolus has often been described. Treatment of this intercalary comminution remains controversial. The primary goal of this study was to compare clinical and radiographic outcomes in patients who had direct reduction and fixation of this fragment compared to those where the ICF was removed or not reduced prior to posterior malleolus fixation.Methods:This retrospective study included 249 trimalleolar and posterior pilon ankle fractures grouped into those who had the ICF reduced and fixed (n=74) and those where the ICF was not directly addressed or excised (n=175). CT scans were evaluated for size and location of the ICF. Demographic, radiographic and intraoperative variables were collected and analyzed. The Kellgren and Lawrence classification system was utilized to grade severity of post-traumatic arthritis during the follow up period. Chart review was performed assessing time to weightbearing, repeat surgeries and post-operative complications.Results:For the group which had the ICF reduced and fixed, follow up radiographs demonstrated significantly worse Kellgren- Lawrence scores compared to the group that did not specifically reduce the ICF (p< 0.05). There was also a higher rate of repeat surgery in the group which had the ICF fixed, although not meeting statistical significance. There were no differences in size or location of the ICF fragment between groups. The average overall time to weightbearing amongst all patients was 9.7 +- 3.8 weeks. There was no significant difference between time to weightbearing between groups (p = 0.6). There was no significant difference in need for secondary surgeries or post-operative deep and superfical infections.Conclusion:With the widespread utilization of CT-scans for preoperative planning of ankle fractures involving the posterior malleolus, there has been greater discussion surrounding the optimal management of the ICF when present. In our study, the primary aim was to explore radiographic changes in patients after direct reduction and fixation of this ICF compared to those without ICF fixation. We demonstrated significantly worse radiographic outcomes following attempted direct reduction and fixation of the ICF. Our results suggest that while concentric joint reduction and syndesmosis stabilization are of utmost importance, attempting to reduce and fix the ICF may lead to worse radiographic outcomes.

Utilization of Arthroscopy During Ankle Fracture Fixation among Early Career Surgeons: An Evaluation of the American Board of Orthopedic Surgery Part II Database

Category:Ankle; Arthroscopy; TraumaIntroduction/Purpose:Rotational ankle fractures are common injuries associated with high rates of intra-articular injury. Traditional ankle fracture open reduction and internal fixation (ORIF) techniques provide limited capacity for evaluation of intra- articular pathology. Ankle arthroscopy represents a minimally invasive technique to directly visualize the articular cartilage and syndesmosis while aiding with reduction and allowing joint debridement, loose body removal, and treatment of chondral injuries. The purpose of this study was to evaluate temporal trends in concomitant ankle arthroscopy during ankle fracture ORIF surgery amongst early-career orthopaedic surgeons while examining the influence of subspecialty fellowship training on utilization.Methods:The American Board of Orthopedic Surgery (ABOS) Part II database was queried to identify all candidates performing at least one ankle fracture ORIF (Current Procedural Terminology [CPT] codes 27766, 27769. 27784, 27792, 27814, 27822, 27823, 27829, 27846, 27848) from examination years 2010 to 2019. All ORIF cases were examined to identify those that carried a concomitant CPT code for ankle arthroscopy (CPT codes 29891, 29892, 29894, 29895, 29897, 29898, 29899). Concomitant ankle arthroscopy cases were categorized by candidates self-reported fellowship training status and examination year. Descriptive statistics were performed to report relevant data and linear regression analyses were utilized to assess temporal trends in concomitant ankle arthroscopy with ORIF for ankle fractures. Statistical significance was defined as p<0.05.Results:There were 36,113 cases of ankle fracture ORIF performed of which 388 cases (1.1%) were performed with concomitant ankle arthroscopy. Ankle fracture ORIF was most frequently performed by trauma fellowship trained Part II candidates (n=8,888; 24.6%), followed by sports medicine (n=7,493; 20.8%) and foot and ankle (n=6,563; 18.2%). Arthroscopy was most frequently utilized by foot and ankle fellowship trained surgeon (293/ 6,270 cases; 4.5%) followed by sports medicine (29/7,464 cases; 0.4%) and trauma (4/8,884 cases; 0.1%). With respect to total arthroscopic cases, 75.5% were performed by foot and ankle fellowship trained surgeons while only 1.0% was performed by trauma trained candidates. Ankle arthroscopy utilization significantly increased from 3.65 cases per 1,000 ankle fractures in 2010 to 13.91 cases per 1,000 ankle fractures in 2019 (p=0.010). Specifically, foot and ankle fellowship trained surgeons demonstrated a significant increase in arthroscopy utilization during ankle fracture ORIF over time (p<0.001; OR: 1.101; CI: 1.054-1.151).Conclusion:Ankle arthroscopy utilization during ankle fracture ORIF has increased ten-fold over the past decade. Foot and ankle fellowship trained surgeons contribute most significantly to this trend.

The Effectiveness of Perioperative Parecoxib Intravenous Administration in Foot and Ankle Surgery: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial

Category:Trauma; AnkleIntroduction/Purpose:Parecoxib is indicated for the short-term treatment of postoperative pain in adults. A systematic review assessed the analgesic efficacy of single dose intravenous (IV) or intramuscular (IM) parecoxib in acute postoperative pain and concluded that parecoxib is an effective analgesic in the postoperative setting in adults. However, little is known about its effectiveness in the perioperative intravenous administration in foot and ankle surgery. The present study conducts a double- blinded prospective randomized controlled trial via an 'intention-to-treat analysis' principle to compare the effectiveness of perioperative parecoxib versus placebo in patients with unstable ankle fractures who have surgical indications.Methods:A total of 40 patients undergoing open reduction and internal fixation of the unstable ankle fractures were randomly allocated either to Group A (parecoxib 40 mg IV 30 min before surgery and then an additional 40 mg every 12 hours for 48 hours after surgery [n=20]) or Group B (placebo (saline) [n=20]). The baseline data were recorded in each patient. The efficacy of pain control was assessed by total morphine used, pain intensity (at rest/ambulation) and pain relief (at rest/ambulation) using the verbal numerical rating score (VNRS) from 0 (no pain) to 10 (worst imaginable pain) and the verbal numerical rating percentage (VNRP) from 0 (no relief) to 100 (best relief) respectively, as well as each patient's subjective rating of the medication. The patients' subjective rating of the medication used the classifications of 'excellent', 'good', 'fair', or 'poor'. When the patients were moved to the post-anesthesia care unit (PACU) after surgery, the study procedure was to record the time as 0. The data were then recorded at 0, 4, 12, 24, and 48 hours after surgery by trained personnel. The overall adverse effects experienced by patients were reported in both groups. All outcomes were recorded by trained personnel who were blind to the patient group allocation. All surgeons, anesthesiologists, and patients involved in the process were also blind to the group allocations. The outcomes including efficacy, patients' subjective ratings of the medication, and overall adverse effects were statistically compared between the two groups.Results:From a total of 40 patients in the study, four patients were excluded by the study criteria. The remaining 36 patients continued in the study. The mean age of patients was 49.3 +/- 18.0 years. No significant difference was found regarding the mean age of patients between the two groups (p-value > 0.05). Male patients appeared more frequently in the saline group than the parecoxib group (p-value = 0.018). For the main outcomes, there were no significant differences between the two groups in terms of the pain intensity, pain relief, patients' subjective ratings of the medication at both preoperative and postoperative periods, total quantity of morphine used, and side effects and acute complications of surgery (p-values > 0.05).Conclusion:Based on the results of the present study, the perioperative administration of parecoxib could not significantly improve postoperative pain control as defined by the reduction in opioid requirements, lower pain scores, higher pain relief, and higher patients' subjective ratings of the medication when compared to the placebo. Male predominance was significantly found in the placebo group. This may have influenced the level of pain tolerance between the two groups. This may also affect the results as no significant differences of pain parameters between the two groups in the study. Further study with larger numbers of patients is still necessary to clarify the role of preemptive parecoxib on ankle fracture surgery.

Posterior malleous fixation in trimalleolar ankle fractures using anterior to posterior screw versus posterolateral plate

Introduction: Posterior malleolar fractures are observed in approximately 7%-44% of all ankle fractures. Due to the important biomechanical function of the posterior tibial margin in weight-bearing and ankle stability, the affected ankle is prone to degenerative ankle arthritis. In ankle fractures involving the posterior malleolus, the issue of which type of fractures require posterior malleolus fixation is still controversial, suggesting that a trans-syndesmotic fixation may be adequate instead of posterior malleolar fixation. Objective: This study compares the anterior to posterior screw versus posterolateral plate for posterior malleous fixation in trimalleolar ankle fractures. Material and Methods: This study was conducted in patients with trimalleolar ankle fracture admitted in a tertiary level health care centre.It is a Prospective, randomized comparative study. Patients were randomized into two groups by using computerized random no. table and subsequent pt. was allocated in alternative groups /In group A fixed with anterior to posterior screw was done by an identified orthopedic surgeon. In group open reduction internal fixation with posterolateral plate fixation. Patients were examined for clinical and radiological, union, bone strength, weight bearing, deformity and range of motion at 2wks, 6wks, till 6 months. Results: Forty six patients were evaluated in this study and were divided in two groups accordingly. Group A = Anterior to posterior leg screw and Group B = Postero-lateral Plate. Evidence of union in X-ray seen after 18.80±1.92 weeks of operation in group-A and 20.16±2.01 weeks in group-B. In terms of functional result, 28.00% patients were excellent, 58.00% patients were good and 14.00% patients were poor in group-A. 40.00% patients treatment results were excellent, 50.00% patients treatment results were good and 10.00% patients treatment results were poor in group-B. Conclusion: These results demonstrate that posterior malleolar fracture fixation is closely related to successful radiological and functional outcomes after trimalleolar fractures. Transyndesmal screw fixation may not be needed in the cases where the posterior malleolar fracture fixated. For these reasons, we recommend that all posterior malleolar fractures have to be fixed regardless of size.

The Incidence of Deltoid Ligament Interposition in Bimalleolar Equivalent Ankle Fractures

Category:AnkleIntroduction/Purpose:When performing surgical fixation of bimalleolar equivalent ankle fractures, there has been considerable debate regarding fixation of the deltoid ligament. Many surgeons would agree that deltoid ligament repair should be undertaken if there is radiographic evidence of medial interposition of the deep deltoid. The incidence of deltoid ligament interposition has not been addressed in current literature. This study aims to assess the incidence of deltoid interposition in bimalleolar equivalent ankle fractures to provide further guidance on the importance of acute deltoid ligament repair.Methods:Over a five year time frame, 49 bimalleolar equivalent ankle fractures were repaired in 30 males and 19 females with a mean age, 37 (15-73) years. There was no exclusion criteria and patients were consecutively enrolled if they sustained a bimalleolar equivalent ankle fracture.Results:During this time frame, 49 patients who sustained a bimalleolar equivalent ankle fracture underwent surgical fixation with routine repair of the deltoid ligament. 18 patients (36.73%) had deltoid interposed within the medial gutter. 13 patients (26.53%) had an osteochondral defect.Conclusion:The incidence of deltoid interposition seen with medial exploration within this cohort was 37%. While the benefits of deltoid ligament repair are still controversial, persistent medial gutter soft tissue interposition could lead to symptoms of impingement or even result in persistent medial widening. This study supports increased scrutiny to the relationship of the medial gutter and deltoid ligament in acute bimalleolar equivalent ankle fractures.

Recovery Position vs Prone Position in the Surgical Treatment of Trimalleolar Ankle Fractures Using Posterolateral and Medial Approach

Category:TraumaIntroduction/Purpose:Posterolateral (PL) and medial approaches have been increasingly used for open reduction and internal fixation (ORIF) of trimalleolar ankle fractures. Traditionally this procedure is performed on the prone position. Nevertheless, this position itself has been related to general complications as brachial plexus injury and postoperative visual loss. Moreover, the prone position can provide difficult access for medial malleolar reduction. Recovery position was recently described as an alternative but its results have not been evaluated yet. This study aimed to compare the results using recovery position (RP) versus prone position in the surgical treatment of trimalleolar fractures.Methods:A retrospective analytic study was conducted in a Level 1 trauma center, analyzing patients who underwent ORIF for trimalleolar ankle fractures using posterolateral and medial approaches over 3 years. 58 ankles were divided according to the position used in the surgical fixation: Group 1 positioned in RP (27 ankles), and group 2 positioned in prone (31 ankles). Demographics, surgical time, hospital stay, quality of reduction, surgical site complications and re- interventions were compared between both groups. Statistical analysis was performed with Shapiro-Wilks test to assess normality in distribution, Chi-square test, and t-student test for group differences in parametric variables as Fisher's exact test and Mann-Whitney U test in non- parametric variables with a p-value set at 0.05.Results:Median age was 47 years old (IQR 40-58). Both groups were similar regarding age (p=0.794), gender (p=0.902), and posterior malleolus Haraguchi (p=0.064) and Bartonicek-Rammelt (p=0.055) classifications. Surgical median time was 115 (IQR 100-130) and 100 (IQR 75-129) minutes for RP and prone groups respectively (p=0,085), Both groups showed similar rates of lateral, posterior and medial malleolus insufficient reduction (Table attached). Median hospital stay was 4 (IQR 2-9 and 2-7 for RP and prone respectively) days for both (p=0,86) (Table attached). Surgical site complications and re-interventions were similar between both groups (p=0.349 and p=1.0 respectively).Conclusion:The RP showed similar results than the prone position while providing an accessible simultaneous approach to the posterolateral and medial regions of the ankle.

A Prospective, Randomized, Controlled, Two-Center, International Trial Comparing the Fibular Nail With Open Reduction and Internal Fixation for Unstable Ankle Fractures in Younger Patients.

To compare the outcome of fibular nailing with plate fixation for unstable fractures of the ankle in a cohort of patients under the age of 65 years. 2 international university trauma centers. One hundred twenty-five patients who were 18-64 years of age with an acute unstable fracture of the ankle were included in the study. Patients were randomized to fixation with a fibular nail (n = 63) or plate (n = 62) and were reviewed at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. The primary outcome measure was the Olerud and Molander score at 1 year. Secondary outcomes were the rates of complications and reinterventions. There was no difference between the 2 groups with respect to the primary outcome measure [mean Olerud and Molander score 78.4 in the nail group vs. 80.2 in the plate group (P = 0.621)]. Wound infections occurred in 2 patients who were treated with a nail and 9 patients who were treated with a plate, but this did not reach statistical significance. No difference was seen in the overall rate of complications and reinterventions between groups [28.6% in the nail group vs. 29% in the plate group (P = 0.955)]. In younger patients with ankle fractures, no difference was found in the patient-reported outcome between fibular nail and plate fixation at 1 year after surgery. The fibular nail is an effective and safe option for the stabilization of ankle fractures in younger patients, although the benefits associated with reduced wound complications are not as apparent as for elderly patients. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Cost of Operative Fixation of Ankle Fractures: Comparing Orthopaedics and Podiatry

Category:Trauma; OtherIntroduction/Purpose:Ankle fractures pose a unique situation as both podiatrists and orthopaedic surgeons are licensed to treat them. Despite increasing emphasis on value-based medical care, there are few cost analyses focused on the treatment of ankle fractures. The goal of this study is to determine if there are cost differences between an orthopaedic surgeon and podiatrist to operatively manage an ankle fracture.Methods:Retrospective cohort study of patients who underwent ankle fracture fixation over a 22 month period at an academic level 1 trauma center. Patient data was subcategorized by surgeon type and treatment groups. Four treatment groups were included: lateral malleolus open reduction and internal fixation (ORIF), bimalleolar/trimalleolar ORIF (no posterior malleolus fixation), lateral malleolus ORIF with syndesmotic fixation, bimalleolar/trimalleolar ORIF (no posterior malleolus fixation) with syndesmotic fixation. Primary outcome was total (OR time cost + Implant cost) cost per case.Results:A total of 134 cases met criteria. Eighty-five cases were treated by a total of 4 orthopaedic surgeons while 49 were treated by 8 podiatrists. There was significantly longer OR time (minutes) for lateral malleolus ORIF (111 vs 134.92), lateral malleolus ORIF with syndesmotic fixation (130.53 vs 156.7), and bimalleolar/trimalleolar ORIF (no posterior malleolus fixation) with syndesmotic fixation (162.13 vs 208) when podiatry was the treating team. Average total cost per case was significantly more for lateral malleolus ORIF (+$1188.45), lateral malleolus ORIF with syndesmotic fixation (+$2259.16), and bimalleolar/trimalleolar ORIF with syndesmotic fixation (+$2837.29) when podiatry was the treating team.Conclusion:Lateral malleolus ORIF, lateral malleolus ORIF with syndesmotic fixation, and bimalleolar/trimalleolar ORIF with syndesmotic fixation costs less per case when performed by an orthopaedic surgeon based on OR time costs and implant costs.

Risk Factors for Aseptic Revision of Surgically-Treated Ankle Fractures

Category:Trauma; AnkleIntroduction/Purpose:Early revision rates within 12 months after ankle fracture open reduction internal fixation (ORIF) are fairly low, however remain relevant given the sheer volume of ankle fractures which occur each year. Understanding these rates is complex because reoperation due to technical or mechanical complications - such as malunion, inadequate reduction or fixation failure - are typically reported alongside returns to the operating room for soft-tissue related problems like wound dehiscence or infection. There is limited data identifying risk factors specifically for revision of ankle fracture fixation in the absence of soft-tissue complications. Understanding variables which predispose to aseptic technical and mechanical failure without this confounder may provide insight and improve patient care.Methods:The purpose was to identify risk factors for aseptic revision of ankle fracture within ORIF 1 year of primary operation. A retrospective cohort study was performed at two large academic medical centers. Research Patient Data Registry (RPDR) data available from 2002-2019 was used to identify patients who underwent aseptic revision of ankle fracture ORIF within 12mo of their primary ORIF. Patients were excluded if <18yo at primary surgery, or if indications for return to the operating room included surgical management of a dehisced wound or deep infection. A control group was selected by identifying sequential patients who underwent ankle fracture ORIF which did not require revision within 12mo. Primary and revision surgeon characteristics, patient demographics, comorbidities, fracture characteristics, surgical techniques and post-operative events were recorded and compared in univariate analysis. Variables which achieved significance in univariate comparisons were included as candidates for multivariable analysis.Results:33 patients were identified for the Revision group. 100 patients were identified for the Control group (Power = 80% for detecting moderate differences). Groups did not differ in age or gender. Final multivariable logistic regression modeling, adjusting for all other variables within the multivariable analysis, demonstrated the following factors to be independently associated with an increased risk of revision surgery: Documented falls in the early post-operative period (aOR: 298; 95% CI: 15.4, 5759; P<0.001), Movement-altering disorders (aOR=81.7; 95% CI: 4.12, 1620; P=0.004), a non-anatomic mortise (MCS > SCS) on immediate post- operative imaging (aOR=28.4; 95% CI: 5.53, 267; P<0.001), more severe initial fracture displacement (ARCS Type C) (aOR vs Type A =25.8; 95% CI: 2.81, 237; P=0.004), Substance abuse (aOR=15.7; 95% CI: 2.66, 92.8; P=0.002), and polytrauma (aOR=12.3; 95% CI: 2.02, 74.8; P=0.006).Conclusion:Six factors were found to be predictive of the need for aseptic revision: Documented falls in the early post- operative period (aOR: 298), movement-altering disorders (aOR=81.7), a non-anatomic mortise (MCS > SCS) on immediate post- operative imaging (aOR=28.4), more severe initial fracture displacement (ARCS Type C) (aOR=25.8), substance abuse (aOR=15.7) and polytrauma (aOR=12.3). Identifying these factors may allow surgeons to better counsel their patients and discuss risk during the informed consent process. These may also serve as future targets for intervention aimed at improving patient safety and outcomes follow ankle fracture ORIF.

Does Time to Intervention Affect Patient Reported Outcomes after Ankle Fracture?

Category:AnkleIntroduction/Purpose:Advances in surgical technique and technology have allowed orthopedic surgeons to attempt early operative fixation of closed ankle fractures. Little is known about the modifiable factors impacting the recovery of these patients and how early operative intervention affects patient reported outcomes. This study aims to determine if early surgical treatment can be performed safely without increasing a patient’s risk for postoperative wound complications and how time to surgery affects both clinical and patient reported outcomes.Methods:A review of 311 patients records who underwent open reduction and internal fixation (ORIF) for an ankle fracture between July 1st, 2011 and July 1st, 2018 at a single academic center was conducted. Medical records were reviewed. Patients were contacted for collection of PROMIS Physical function, PROMIS Pain Interference, and the Foot Function Index. Patients with open fractures, high energy fractures with ipsilateral lower extremity injuries, pilon fractures, revision cases, non-respondents to the patient reported outcomes survey, and those lost to follow-up prior to radiographic evidence of union or non-union were excluded. After exclusions, 86 patients were then stratified by time to surgery after injury and injury classification. A linear regression model was constructed for each outcome instrument with the covariates of age, BMI, diabetes, smoking status, union, wound complication, time from surgery, and severe injuries by the Lauge-Hansen classification.Results:The delayed union, nonunion, and wound complication rate was similar regardless of timing of operative intervention (p=.470, p=.149, & p=.578, respectively). At a median of 4.5 (2.0 IQR) years postoperatively, outcomes scores were as follows (median (IQR)): PROMIS Physical Function 47.9 (11.2), PROMIS Pain Interference 50.1 (17.4), FFI Pain 26.0 (52.0), FFI Disability 17.0 (49), FFI Activity Limitation 3.0 (22.0), and FFI Total 20.0 (41.5). Time to intervention was not found to have an independent effect on any outcome score. Severe injuries by the Lauge-Hasen classification were found to be independent predictors of PROMIS physical function -6.3 (Unstandardized beta, 95% CI -11.5 to -1.1). Diabetes had a significant independent effect on PROMIS pain interference 52.4 (Unstandardized beta, 95% CI 24.3 to 80.5).Conclusion:Early surgical intervention did not significantly delayed union rate, nonunion rate, wound complications, or patient reported outcomes instruments. Severity of injury classification has a significant independent effect on patient’s physical function. Notably, this effect is above the minimal clinically important difference for PROMIS physical function. Overall, the intermediate term outcomes of ankle fracture fixation indicate patients are within one standard deviation of the population mean in terms of pain and physical function. Surgeons should be aware timing of intervention did not have an effect on outcomes scores at intermediate term follow-up.

Can Reducing Implant Costs Increase Revenue for Surgically Treated Ankle Fractures: Time-Driven Activity-Based Costing for 1-Year Episode of Care.

The purpose of this study was to investigate whether decision-making regarding implant selection affects the reimbursement margins for the surgical fixation of ankle fractures. All ankle fractures treated between 2010 and 2017 within a single-insurer database were identified via Current Procedural Terminology codes by review of electronic medical record. Implant cost was determined via the implant record cross-referenced with the single contract institutional charge master database. The Time-Driven Activity-Based Costing (TDABC) technique was used to determine the costs of care during all activities throughout the 1-year episode of care. Statistical analysis consisted of multiple linear regression and goodness-of-fit analyses. In all, 249 patients met inclusion criteria. Implant costs ranged from $173 to $3944, averaging $1342 ± $751. The TDABC-estimated cost of care ranged from $1416 to $9185, averaging $3869 ± $1384. Finally, the total reimbursed cost of care ranged between $1335 and $65 645, averaging $13 954 ± $9445. The implant costs occupied an estimated 34.7% of the TDABC-estimated cost of care per surgical encounter. Implant cost, as a percentage of the overall TDABC, was estimated as 36.2% in the inpatient setting and 33% in the outpatient setting, which was the second highest percentage behind surgical costs in both settings. We found a significant increase in net revenue of $1.93 for each dollar saved on implants in the outpatient setting, whereas the increase in net revenue per dollar saved of $1.03 approached significance in the inpatient setting. There is a direct relationship between intraoperative decision-making, as evidenced by implant choices, and the revenue generated by surgical fixation of ankle fractures. Intraoperative decision-making that is cognitive of implant cost can facilitate adoption of institutional cost containment measures and prompt increased healthcare value. Level III: Retrospective cohort study.

Treatment of perioperative swelling by rest, ice, compression, and elevation (RICE) without and with additional application of negative pressure (RICE+) in patients with a unilateral ankle fracture: study protocol for a monocentric, evaluator-blinded randomized controlled pilot trial

BackgroundEdema is commonly seen after surgical fixation of ankle fractures. Rest, ice, compression, and elevation (RICE) is an established combination to prevent swelling but hardly able to stimulate lymphatic resorption. Recently, an epicutaneously applied negative pressure suction apparatus (LymphaTouch®) has been introduced to stimulate lymphatic flow. While postoperative recovery, soft tissue, and osseous healing as well as functional outcome are probably linked to the amount of postoperative swelling, estimates on this relative to prevention (RICE) or prevention + stimulated resorption (RICE+) of fluid are scarce.Methods and analysisThis is a single-center, evaluator-blinded randomized pilot trial to investigate postoperative swelling in adults requiring surgical fixation of a closed unilateral ankle fracture. A total of 50 patients will be recruited and randomly assigned to RICE or RICE+ prior to surgery. All patients will undergo evaluator-blinded measurements of the ankle volume the day before surgery and subsequently from the evening of the 2nd postoperative day every 24 h until discharge. RICE will be initiated right after surgery and continued until discharge from the hospital in all patients. Additional application of negative pressure therapy (RICE+) will be initiated on the morning of the 2nd postoperative day and repeated every 24 h until the time of discharge from the hospital. Outcome measures are (i) the relative amount and the time course of the postoperative swelling, (ii) the demand for analgesic therapy (type and amount) together with the perception of pain, (iii) the rate of complications, and (iv) mobility of the ankle joint and the recovery of walking abilities during a 12-weeks follow-up period. Serum and urine samples taken prior to sugery and during postoperative recovery will allow to evaluate the ratio of naturally occurring stable calcium isotopes (δ44/42Ca) as a marker of skeletal calcium accrual.Ethics and disseminationThe protocol was approved by the institutional Ethics Committee (Rostock University Medical Center, Rostock, Germany) in accordance with the Declaration of Helsinki (approval number: A 2020-0092). The results of this study will be actively disseminated through scientific publications and conference presentations.Trial registrationDRKS, DRKS00023739. Registered on 14 December 2020

Venous thromboembolism in patients with surgically treated ankle fractures.

In patients with rotational ankle fracture, we compare the rate of venous thromboembolism development between patients who received chemoprophylaxis vs those patients that received none. Retrospective cohort study. Level I trauma center. Between 2014 and 2018, we identified 483 patients with rotational ankle fracture that had no VTE risk factors, were under 70years of age, and had an isolated injury. Chemoprophylaxis vs no chemoprophylaxis after open reduction internal fixation of a rotational ankle fracture. Development of VTE was the primary outcome. Secondary outcomes included wound problems, infection, hematoma, or non-union. There were 313 patients that received no prophylaxis and 170 patients that received chemoprophylaxis after operative fixation of an isolated ankle fracture. Demographics including age, gender, body mass index, and ASA class were similar between groups. The rate of DVT/PE was 3.5% in those without DVT prophylaxis, and 4.1% in those on DVT prophylaxis with no significant differences found (p = 0.8). There was no significant difference in wound complication (no VTE prophylaxis-3.7% vs VTE prophylaxis-2.5%, p = 0.7) or infection rates (no VTE prophylaxis-3.8% vs VTE prophylaxis 4.1%, p = 1.0) between groups. No difference was detected in the rate of symptomatic DVT or PE in patients based on chemoprophylaxis. Our results support the conclusion that the use of chemoprophylaxis may remain surgeon preference and based on patient risk factors for VTE development. Level III-retrospective cohort study.

Rehabilitation after ankle fracture fixation

Rehabilitation after ankle fracture fixation

Risk Factors for Aseptic Revision of Operatively Treated Ankle Fractures.

Early revision rates within 12 months after ankle fracture open reduction internal fixation (AF-ORIF) are fairly low; however, they remain relevant given the volume of ankle fractures occurring annually. Understanding these rates is complex because reoperation due to technical or mechanical complications is typically reported alongside soft tissue-related problems such as symptomatic hardware, wound dehiscence, or infection. There are limited data identifying risk factors specifically for revision of ankle fracture fixation in the absence of soft tissue complications. Understanding variables that predispose to aseptic technical and mechanical failure without this confounder may provide insight and improve patient care. A retrospective cohort study was performed at 2 large academic medical centers. Research Patient Data Registry (RPDR) data available from 2002 to 2019 were used to identify patients who underwent aseptic revision of AF-ORIF within 12 months (n = 33). A control group (n = 100) was selected by identifying sequential patients who underwent AF-ORIF not requiring revision within 12 months. Multiple factors were recorded for all patients in both cohorts. Each fracture was also evaluated according to the Ankle Reduction Classification System (ARCS) of Chien et al,8 which categorizes biplanar talar displacement in relation to a central tibial plumb line into 1 of 3 grades: A (0-2 mm), B (3-10 mm), and C (>10 mm). Adapted from its original purpose of grading reduction quality, we applied ARCS to pre-reduction radiographs to assess initial fracture displacement. All variables collected were compared in univariate analysis. Variables that achieved significance in univariate comparisons were included as candidates for multivariable analysis. Final multivariable logistic regression modeling demonstrated the following factors to independently predict the need for aseptic revision surgery: documented falls in the early postoperative period (aOR, 298; 95% CI, 15.4, 5759; P < .001), movement-altering disorders (aOR, 81.7; 95% CI, 4.12, 1620; P = .004), a nonanatomic mortise (medial clear space [MCS] > superior clear space [SCS]) on immediate postoperative imaging (aOR, 38.4; 95% CI, 5.53, 267; P < .001), initial coronal plane tibiotalar displacement >10 mm and sagittal plane tibiotalar dislocation (ARCS-C) (aOR vs ARCS-A, 25.8; 95% CI, 2.81, 237; P = .004), substance abuse (aOR, 15.7; 95% CI, 2.66, 92.8; P = .002), and polytrauma (aOR, 12.3; 95% CI, 2.02, 74.8; P = .006). In this investigation we found a notable increase in risk for revision surgery after AF-ORIF for patients who had one of the following: (1) falls in the early postoperative period, (2) movement-altering disorders, (3) a nonanatomic mortise (MCS > SCS) on immediate postoperative imaging, (4) more severe initial fracture displacement, (5) substance abuse, or (6) polytrauma. Identifying these factors may allow surgeons to better understand risk and counsel patients, and may serve as future targets for intervention aimed at improving patient safety and outcomes after ankle fracture ORIF. Level III, retrospective cohort study.

345 A Novel Fixation Method for Unstable Ankle Fractures in The Elderly with Poor Quality Skin, Via Dual Percutaneous Tibiotalar Cannulated Screws

Abstract Introduction The incidence of ankle fractures is highest in the elderly population due to poor bone quality. Osteoporosis and poor overlying skin increase risk of infection, wound breakdown, and fixation failure. This ultimately results in worse functional outcomes. This retrospective case-series describes a novel dual percutaneous tibiotalar cannulated screw fixation method, for managing unstable ankle fractures, in high-risk elderly patient with low functional demand. Method Six elderly patients were identified between January 2019-2020 who underwent dual tibiotalar cannulated screw fixation for unstable ankle fractures. Pre-operative and post-operative pain and mobility scores were obtained via telephone consultation and case-note review. Radiographs were analysed pre-operatively for fracture type and post-operatively for complications such as, talar shift. Wound Infection post-operatively was monitored. Results The mean age was 86.8 with an average ASA grade of three. Functional outcomes were excellent with 83.3% of patients remaining ambulatory with no post-operative pain at an average follow-up of 10.25 months. Three patients (50%) had excellent post-operative radiographs with evidence of union and no talar shift. Two patients (33.3%) had either non-union or minor talar shift, and one patient (16.7%) had multiple radiological complications likely due to delayed fixation. All three patients remained ambulatory and had minimal post-operative pain. There were no reports of soft tissue injury or infection due to the surgery. Conclusions Dual percutaneous tibiotalar cannulated screws can be used to manage unstable ankle fractures in the low demand elderly patient, with poor skin quality. Function outcomes were good with satisfactory post-operative mobility and minimal pain in the majority of cases.

862 A Retrospective Audit on Management of Ankle fracture In a District General Hospital in South east England

Abstract Aim Ankle fractures are common injuries encountered by orthopaedic surgeons on a daily basis. Primary aim of the audit is to compare management of ankle fracture in Ashford and St Peter’s Hospital under NHS trust with the BOAST guidelines. As a secondary objective, quality of life of patients less than 60 years of age is assessed in order to review the specificity of timing of surgery as mentioned in the guidelines. Method An audit was conducted among patients who have undergone open reduction and internal fixation for ankle fracture during a period of one year in Ashford and St. Peter’s hospital. BOAST guidelines was kept as a standard to compare the management practice in the trust. Quality of life is assessed with the help of COST (Chertsey Outcome Scoring for Trauma) scoring method. Results Trust showed good compliance with the guidelines regarding documentation and reviewing patients within 6 weeks’ time. Only 45% of the patients, less than 60 years old had surgery within 24 hours. The average COST score does not show any significant difference between those who had surgery within 24 hours and after that. Conclusions To conclude, trust showed good compliance in certain aspects like documentation and reviewing patients, but the surgery was delayed up to 19 days for patients less than 60 years of age. The average COST score showed that there are no functional benefits for patients who had surgery on an early date. So, the specificity of timing in the BOAST guideline is questionable.

Assessment of operative outcome of ankle fractures: A clinical study

Background: Ankle fractures are one of the most common fractures presenting in public hospitals. Most of the studies report the short term functional outcome post-ankle fracture surgery. Hence; the present study was undertaken for assessing operative outcome of ankle fractures. Materials and methods: A total of 40 patients operatively treated for an unstable ankle fracture were entered into a database and prospectively followed. The postoperative protocol was standardized for all patients. Complete demographic and clinical details of all the patients were obtained. Baseline characteristics, complications, additional surgery, functional status and the American Orthopaedic Foot and Ankle Society score (AOFAS) were assessed. The intervention chosen was open reduction and internal fixation of unstable ankle fractures. Functional outcome was evaluated.Results: Level of pain decreased consistently over the 3-, 6-, and 12-month follow-up periods in both study groups as measured by the AOFAS questionnaire. At 3 months, 6 months and 12 months follow-up, mean AOFAS score was 75.5, 80.3 and 85.3 respectively. Conclusion: Patients undergoing operative fixation of unstable ankle fractures showed reasonable functional result at the 1-year follow-up.

Geriatric Ankle Fracture: Robust Fixation Versus Hindfoot Nail.

The incidence of geriatric ankle fractures is increasing in step with the current aging population. Special considerations must be taken into account when treating geriatric patients due to increased medical comorbidities, worse soft tissue envelope, poor bone quality, and the needs for early mobilization. The orthopaedic surgeon must have a variety of surgical options to treat fractures in the elderly population based on patient-specific needs. This article uses a case-based approach to discuss relevant considerations when selecting between hindfoot fusion nail and robust open reduction and internal fixation for geriatric ankle fractures.