Open Reduction And Internal Fixation Of Ankle Fractures Research Articles

Ankle Arthroscopy for Diagnosis and Treatment of Full Thickness Cartilage Lesions in the Setting of Ankle Fracture

Category: Ankle, Arthroscopy, Sports Introduction/Purpose: Ankle fractures treated with anatomic open reduction and internal fixation (ORIF) can still be associated with poor clinical outcomes. The presence of radiographically occult intra-articular chondral injury is a known entity, however the clinical relevance in the setting of ankle fractures is not well established. The purpose of this study aims to evaluate the prevalence of chondral lesions, in particular full thickness talar dome lesions, with concurrent arthroscopy in acute ankle fracture ORIF and determine if there is a correlation with patient and fracture characteristics. In addition, we aimed to evaluate the treatment effect on clinical outcomes to establish the role of concurrent arthroscopy in ankle fracture management. Methods: A retrospective chart review was conducted from prospectively collected registry data at the investigators’ institution from 2011 to 2016. All patients that underwent an acute ankle fracture ORIF with concurrent arthroscopy were identified. Patients with concomitant injuries were excluded. Baseline patient and fracture characteristics were recorded. Fracture type by the Lauge-Hansen classification as well as by anatomic location were determined. Charts were reviewed to determine the prevalence and grade of chondral lesions. The treatment performed for each chondral lesion was determined. Clinical outcomes with a minimum of one year follow up were assessed using the Foot and Ankle Outcome Score (FAOS). Results: One hundred and sixteen consecutive patients undergoing acute ankle fracture ORIF with concurrent arthroscopy were included. A chondral lesion was identified in 78% (90/116). Of those, a Grade IV full thickness talar dome chondral lesion was identified in 43% (39/90). Patient age was a significant predictor, with patients less than thirty being less likely to have a chondral injury compared to those greater than thirty (59% vs 85%, p=0.0077). Of the patients that sustained a dislocation at the time of injury, 100% had a chondral lesion which was statistically significant (p=0.039). Patients with complete syndesmosis disruption and instability were also more likely to have a chondral lesion (96% vs 73%, p=0.013). Patients with chondral lesions had statistically significant worse clinical outcomes than those without (Table). Conclusion: Arthroscopy performed concomitantly with ankle ORIF is useful in diagnosing chondral injuries. In particular, full thickness talar dome chondral lesions are quite common. Increased fracture severity, as indicated by the presence of a dislocation at presentation, and a syndesmotic injury may be more likely to present with a chondral lesion and thus should raise suspicion and prompt evaluation. The presence of a concurrent talar chondral injury has a negative impact on clinical outcomes. Concurrent arthroscopy allows for simultaneous diagnosis and acute treatment of full thickness talar lesions.

Effectiveness of arthroscopically assisted surgery for ankle fractures

Category: Ankle, Arthroscopy, Trauma Introduction/Purpose: This meta-analysis was performed to determine whether the arthroscopically assisted open reduction and internal fixation (ORIF) for ankle fractures is more beneficial than the conventional ORIF. Methods: Articles in electronic medial databases were searched between March 1983 and August 2016, including Pubmed and SCOPUS. We included the studies with comparative design comparing the surgical outcomes between the arthroscopically assisted ORIF for ankle fractures and the conventional ORIF. Finally, two RCTs and two retrospective comparative studies were included for analysis. Mean and standard deviation (SD) of postoperative functional scores, number of subjects, and P-values were extracted from the studies. In addition, postoperative follow-up period, fracture type, and study quality were collected. Results: The pooled effect size of the four studies 0.535 (95% CI, 0.247 to 0.823) in Hedges’s g, which favored the arthroscopically assisted ORIF over conventional ORIF. There was no evidence of publication bias in funnel plot and in Egger’s test (p=0.534). Conclusion: The arthroscopically assisted ORIF for ankle fractures were more beneficial than the conventional ORIF in the current evidences. However, since it needs more medical cost and longer operation time, possible additional complications and cost effectiveness are to be validated in future studies.

Effectiveness of arthroscopically assisted surgery for ankle fractures: A meta-analysis

IntroductionThis meta-analysis was performed to determine whether the arthroscopically assisted open reduction and internal fixation (ORIF) for ankle fractures is more beneficial than the conventional ORIF. MethodsArticles in electronic medial databases were searched between March 1983 and August 2016, including Pubmed and SCOPUS. We included the studies with comparative design comparing the surgical outcomes between the arthroscopically assisted ORIF for ankle fractures and the conventional ORIF. Finally, two RCTs and two retrospective comparative studies were included for analysis. Mean and standard deviation (SD) of postoperative functional scores, number of subjects, and P-values were extracted from the studies. In addition, postoperative follow-up period, fracture type, and study quality were collected. ResultsThe pooled effect size of the four studies 0.535 (95% CI, 0.247–0.823) in Hedges’s g, which favored the arthroscopically assisted ORIF over conventional ORIF. There was no evidence of publication bias in funnel plot and in Egger’s test (p=0.534). ConclusionThe arthroscopically assisted ORIF for ankle fractures were more beneficial than the conventional ORIF in the current evidences. However, since it needs more medical cost and longer operation time, possible additional complications and cost effectiveness are to be validated in future studies.

High Prevalence of Chronic Pain With Neuropathic Characteristics After Open Reduction and Internal Fixation of Ankle Fractures.

Unstable ankle fractures require treatment with open reduction and internal fixation (ORIF). Long-term functional outcome is satisfying in most patients; however, a number of patients have persistent complaints. Superficial nerve complications following ankle surgery may be the cause of chronic pain and disability. In this observational retrospective survey, a cohort of 527 women and men, who underwent ORIF in the period from January 2007 to January 2014, were invited to an online questionnaire. Pain symptoms were assessed using the McGill Pain Questionnaire (MPQ) and the Douleur Neuropathic en 4 Questions (DN4) Questionnaire. Descriptive statistics were used to present patient characteristics; a logistic regression model was used to analyze prognostic factors of neuropathic pain. A total of 271 patients completed the questionnaire. Mean follow-up period was 5.8 years (±1.9). Persistent neuropathic pain symptoms were present in 61 of all patients, and 51 of these patients reported an impaired quality of life caused by their symptoms. In univariate analysis, the following parameters were associated with neuropathic pain: age, hypertension, a thyroid disorder, lower back pain, fracture dislocations, and late complications such as nonunion, posttraumatic arthritis, or osteochondral injury. In multivariate analysis, an age between 40 and 60 years was found to be a significant predictor of neuropathic pain. Hypertension, dislocation, and late complications were significant predictors of persistent pain without neuropathic characteristics. The present study demonstrated a prevalence of persistent neuropathic pain symptoms after ORIF for ankle fractures in 23% of the respondents, which caused an impaired health-related quality of life. We identified 4 significant predictors of chronic and neuropathic pain after ORIF. This knowledge may aid the treating surgeon to identify patients who are at increased risk of persistent postoperative neuropathic pain and may affect the treatment of pain in these patients. Level IV, retrospective case series.

The NFL Orthopaedic Surgery Outcomes Database (NO-SOD)

Background: Injuries are inherent to the sport of American football and often require operative management. Outcomes have been reported for certain surgical procedures in professional athletes in the National Football League (NFL), but there is little information comparing the career effect of these procedures. Purpose: To catalog the postoperative outcomes of orthopaedic procedures in NFL athletes and to compare respective prognoses and effects on careers. Study Design: Case series; Level of evidence, 4. Methods: Athletes in the NFL undergoing procedures for anterior cruciate ligament (ACL) tears, Achilles tendon tears, patellar tendon tears, cervical disc herniation, lumbar disc herniation, sports hernia, knee articular cartilage repair (microfracture technique), forearm fractures, tibial shaft fractures, and ankle fractures were identified through team injury reports or other public records. Game and performance statistics during the regular season were collected before and after surgery. Statistical analysis was performed with significance accepted as P < .05. Results: A total of 559 NFL athletes were included. Overall, 79.4% of NFL athletes returned to play after an orthopaedic procedure. Forearm open reduction and internal fixation (ORIF), sports hernia repair, and tibia intramedullary nailing (IMN) led to significantly higher return-to-play (RTP) rates (90.2%-96.3%), while patellar tendon repair led to a significantly lower rate (50%) (P < .001). Athletes undergoing ACL reconstruction (ACLR), Achilles tendon repair, patellar tendon repair, and ankle fracture ORIF had significant declines in games played at 1 year and recovered to baseline at 2 to 3 years after surgery. Athletes undergoing ACLR, Achilles tendon repair, patellar tendon repair, and tibia IMN had decreased performance in postoperative season 1. Athletes in the Achilles tendon repair and tibia IMN cohorts recovered to baseline performance, while those in the ACLR and patellar tendon repair cohorts demonstrated sustained decreases in performance. Conclusion: ACLR, Achilles tendon repair, and patellar tendon repair have the greatest effect on NFL careers, with patellar tendon repair faring worst with respect to the RTP rate, career length after surgery, games played, and performance at 1 year and 2 to 3 years after surgery.

Minimally Invasive Versus Open Distal Fibular Plating for AO/OTA 44-B Ankle Fractures.

Open reduction and internal fixation (ORIF), the standard treatment for unstable ankle fractures, has well-known wound complications. Minimally invasive surgery (MIS) has been proposed to decrease these complications. The objectives of this study were to describe an algorithm of MIS for fibular plating and compare the radiographic restoration of fibular anatomy, functional outcomes, and complications between ORIF and MIS for ankle fractures. This retrospective study included 71 patients with AO/OTA 44-B ankle fractures treated by a single surgeon. ORIF group consisted of 34 patients (54.5-month follow-up) and MIS group was composed of 37 patients (55.9-month follow-up). Among 37 MIS patients, 13 patients were treated with minimally invasive percutaneous plate osteosynthesis and 24 patients with minimally invasive trans-fracture approach according to our MIS algorithm. Operative outcomes were evaluated and compared between the 2 groups by radiographic measurements, functional assessment, and complications. The MIS group had less blood loss but longer operative time and greater exposure to fluoroscopy. Radiographic measurements revealed similar union time, fibular length, talocrural angle, medial clear space, and tibiofibular clear space in both groups. Lower visual analogue pain score was observed in the MIS group in the early postoperative period. At last follow-up, there were no significant differences regarding pain score, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and range of motion between the 2 groups. Total complication rate was significantly higher in the ORIF group. Patients with AO/OTA 44-B fractures treated with MIS fibular plating achieved similar radiographic and functional outcomes but had less pain in the early postoperative period and fewer wound complications compared with those treated with ORIF. Level III, retrospective comparative study.

Arthroscopically Assisted Versus Standard Open Reduction and Internal Fixation Techniques for the Acute Ankle Fracture.

Ankle fractures represent one of the most common orthopaedic injuries requiring operative treatment. Although open reduction and internal fixation (ORIF) of ankle fractures leads to good results in most patients, poor functional outcomes continue to be reported in some patients for whom anatomic reduction was achieved. It has been theorized that these lesser outcomes may in part be due to a component of missed intra-articular injury that reportedly ranges between 20% and 79%, although to date the true explanation for this subset of lower functional outcomes remains unknown. Such concerns have recently spawned novel techniques of arthroscopically assisted ankle fracture assessment in hopes of enabling better detection and treatment of concomitant intra-articular ankle injuries. The purpose of this systematic review was to summarize the literature comparing standard ORIF to arthroscopically assisted ORIF (AAORIF) for ankle fractures. A systematic review of the English literature was performed using the PubMed database to access all studies over the last 50 years that have documented the functional outcomes of acute ankle fracture management using either a traditional ORIF or an AAORIF technique in the adult population. Relevant publications were analyzed for their respective Levels of Evidence as well as any perceived differences reported in operative time, outcomes, and complications. A total of only 14 ORIF and 4 AAORIF papers fit the criteria for review. There is fair quality (grade B) evidence to support good to excellent outcomes following traditional ORIF of malleolar fractures. There is fair-quality (grade B) evidence that ankle arthroscopy can be successfully employed for identification and treatment of intra-articular injuries associated with acute ankle fractures, but insufficient (grade I) evidence examining the functional outcomes and complication rates after treatment of these injuries and little documentation that this approach portends any improvement in patient outcome over historical techniques. There is also insufficient (grade I) evidence from 2 prospective randomized studies and 1 case-control study to provide any direct comparative data on functional outcomes, complication rates or total operative time between AAORIF and ORIF for the treatment of acute ankle fractures. Ankle arthroscopy is a valuable tool in identifying and treating intra-articular lesions associated with ankle fractures. The presence of such intra-articular pathology may lead to the unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions therefore has the potential to improve patient outcomes. To date, however, currently available literature has not shown that treatment of these intra-articular injuries provides any improvement in outcomes over standard ORIF, and few prospective randomized controlled studies have been performed comparing these 2 operative techniques-rendering any suggestion that AAORIF improves clinical outcomes over traditional ORIF difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct before we can advocate its routine use in these patients. Level II, systematic review.

Patient-Based and Surgical Risk Factors for 30-Day Postoperative Complications and Mortality After Ankle Fracture Fixation.

The purpose was to calculate the incidence rates and determine risk factors for 30-day postoperative mortality and morbidity after ankle fracture open reduction and internal fixation (ORIF). The NSQIP database was queried to identify patients undergoing ankle fracture ORIF from 2006 to 2011, with extraction patient-based or surgical variables and a 30-day clinical course. Multivariable logistic regression analysis identified significant predictors on outcome measures. Mean age was 50.3 (±18.2) years while diabetes mellitus (12.8%) and body mass index ≥40 kg/m(2) (9.2%) were documented from a total of 3328 patients identified. The 30-day mortality rate was 0.30%, and complications occurred in 5.1%. Chronic obstructive pulmonary disease [odds ratio (OR): 4.23, 95% confidence interval (CI): 1.19-15.06] and a nonindependent functional status before surgery (OR: 2.25, 95% CI: 1.13-4.51) were the sole independent predictors of mortality and major local complications, respectively. Major local complications occurred in 2.2% of patients, and significant predictors were peripheral vascular disease (OR: 6.14; 95% CI: 1.95-19.35), open wound (OR: 5.04; 95% CI: 2.25-11.27), nonclean wound classification (OR: 3.02; 95% CI: 1.31-6.93), and smoking (OR: 2.85; 95% CI: 1.42-5.70). Independent predictors of hospital stay >3 days were cardiac disease, age 70 years or older, open wound, partially/totally dependent functional status, American Society of Anesthesiologists (ASA) classification ≥3, body mass index ≥40 kg/m(2), bimalleolar or trimalleolar ankle fracture pattern, female sex, and diabetes. Chronic obstructive pulmonary disease increased the risk of mortality after ankle fracture ORIF. Risk factors for postoperative complications included peripheral vascular disease, open wound, nonclean wound classification, age 70 years or older, and ASA classification ≥3. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Injury to the Posterior Tibial Tendon After Open Reduction Internal Fixation of the Medial Malleolus.

The management of ankle fractures with open reduction and internal fixation (ORIF) has been a proven method to help prevent deformity and posttraumatic arthritis. The incidence of continued ankle pain due to retained hardware after ORIF of ankle fractures has been documented. The goal of this study was to determine if the starting point for medial malleolus screw placement is associated with posterior tibial tendon (PTT) damage when performing ORIF of the medial malleolus. Patients that had ORIF of the medial malleolus and subsequent repair of the PTT with medial malleolar hardware removal were identified. Zones were established and labeled 1 through 3 as described in the literature. This template was used as an overlay on lateral ankle radiographs to analyze the position and assign zones to the medial malleolus screws. Fifteen patients met the inclusion criteria. Three screws were found in zone 1, 11 in zone 2, and 1 in zone 3. The middle and posterior zones (zones 2 and 3) contained 80% of the screws, which may potentially cause risk to the PTT. We conclude that there is an increased probability that medial malleolar hardware in zones 2 and 3 can compromise the PTT. Therapeutic, Level IV: Case series.

Morbidity and readmission after open reduction and internal fixation of ankle fractures are associated with preoperative patient characteristics.

Ankle fractures are common and can be associated with severe morbidity. Risk factors for short-term adverse events and readmission after open reduction and internal fixation (ORIF) of ankle fractures have not been fully characterized. The purpose of our study was to determine patient rates and risk factors for (1) any adverse event; (2) severe adverse events; (3) infectious complications; and (4) readmission after ORIF of ankle fractures. Patients who underwent ORIF for ankle fracture from 2005 to 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP(®)) database using International Classification of Diseases, 9(th) Revision and Current Procedural Terminology codes. Patients with missing perioperative data were excluded from this study. Patient characteristics were tested for association with any adverse event, severe adverse events, infectious complications, and readmission using bivariate and multivariate logistic regression analyses. Of the 4412 patients identified, 5% had an adverse event. Any adverse event was associated with insulin-dependent diabetes mellitus (IDDM; odds ratio [OR], 2.05; 95% confidence interval [CI], 1.35-3.1; p = 0.001), age ≥ 60 years (OR, 1.97; 95% CI, 1.22-3.2; p = 0.006), American Society of Anesthesiologists classification ≥ 3 (OR, 1.69; 95% CI, 1.2-2.37; p = 0.002), bimalleolar fracture (OR, 1.6; 95% CI, 1.08-2.37; p = 0.020), hypertension (OR, 1.47; 95% CI, 1.04-2.09; p = 0.031), and dependent functional status (OR, 1.47; 95% CI, 1.02-2.14; p = 0.040) on multivariate analysis. Severe adverse events occurred in 3.56% and were associated with ASA classification ≥ 3 (OR, 2.01; p = 0.001), pulmonary disease (OR, 1.9; p = 0.004), dependent functional status (OR, 1.8; p = 0.005), and hypertension (OR, 1.65; p = 0.021). Infectious complications occurred in 1.75% and were associated with IDDM (OR, 3.51; p < 0.001), dependent functional status (OR, 2.4; p = 0.002), age ≥ 60 years (OR, 2.28; p = 0.028), and bimalleolar fracture (OR, 2.19; p = 0.030). Readmission occurred in 3.17% and was associated with ASA classification ≥ 3 (OR, 2.01; p = 0.017). IDDM was associated with an increased rate of adverse events after ankle fracture ORIF, whereas noninsulin-dependent diabetes mellitus was not. IDDM management deserves future study, particularly with respect to glycemic control, a potential confounder that could not be assessed with the ACS-NSQIP registry. Increased ASA class was associated with readmission, and future prospective investigations should evaluate the effectiveness of increasing the discharge threshold, discharging to extended-care facilities, and/or home nursing evaluations in this at-risk population. Level III, prognostic study.

Hardware Related Pain and Hardware Removal after Open Reduction and Internal Fixation of Ankle Fractures

Objectives: To assess the incidence of hardware related pain after open reduction and internal fixation (ORIF) after ankle fractures through functional outcomes scores in patients with or without hardware related pain. Design: Retrospective study. Setting: Regional trauma center. Patients: One hundred and seventy six patients undergoing ORIF of an ankle fracture with a minimal follow up of 18 months were sent questionnaires. In total, 80 responding patients were available for analysis. Main Outcome Measurements: Visual Analog Pain Score, Foot and Ankle Outcome Score (FAOS). Results: In seventeen patients (21%), the hardware was removed because of pain. In another seventeen patients (21%), the hardware was not removed, but pain was reported. Patients with hardware related pain had significantly worse functional outcome scores than patients without hardware related pain. After elective hardware removal, pain reduction was achieved in 71 % of the patients. Mean Visual Analog Score was 7.0 before and 3.9 after elective hardware removal for pain. Conclusions: Hardware related pain is a significant issue after ORIF of ankle fractures. Patients with hardware related pain have significantly worse functional outcome scores. Although pain reduction is achieved in 71% of the patients after elective hardware removal, a substantial number of patients have persistent complaints. Patients should be well informed about the expectations and risks of elective hardware removal.

Compartment syndrome of the foot secondary to fixation of ankle fracture—A case report

Compartment syndrome in the leg after open reduction and internal fixation (ORIF) of ankle fractures is rare. Compartment syndrome in the foot after ORIF of ankle fractures has not been reported before. A high degree of vigilance must be exercised when managing these fractures in order to avoid complications and morbidity. We report a case in which a bimalleolar fracture of the left ankle resulted in compartment syndrome of the foot.

Early versus delayed surgery for ankle fractures: a comparison of results

A retrospective review of closed ankle fractures treated using open reduction and internal fixation (ORIF) was undertaken. The aim was to investigate if the timing of surgery had any influence upon soft tissue complications and hospital stay. Sixty-two patients, 31 men and 31 women, were reviewed. Twenty-four (39%) underwent the surgery within 24 h (average 17.5 h) of injury, while the other 38 (61%) were operated at an average of 3.1 (2–9) days. The average length of stay (LOS) was 7.1 (range 2–15) days in patients who had the surgery within 24 h of injury as compared to 10.6 (range 4–64) days in those who had their surgery after 24 h of injury. The post-operative stay was 6.3 days as compared to 7.5 days in the two groups respectively. Fourteen complications were seen, including six infections all of which occurred in patients who underwent surgery after 24 h of injury. Three cases with delayed wound healing were also noted. A significantly higher complication rate was noted in patients aged 70 years or older (6/11). We conclude that delay in ORIF of ankle fractures is associated with increased complication, increased morbidity and increased hospital stay. These fractures should be surgically fixed within 24 h.

Use of a synthetic bone void filler to augment screws in osteopenic ankle fracture fixation

Sufficiently stable constructs may be difficult to obtain with ankle fractures in patients with severe osteopenic bone. Augmentation of the osteosynthesis with a new synthetic bone void filler may help to solve this problem, and it can improve the clinical outcome. A prospective, open-label study was performed in two surgical clinics in Norway. In 37 of 42 selected patients with Weber type B ankle fractures showing clinical and radiologic signs of osteopenic bone, at least one screw was found to be stripping during open reduction and internal fixation (ORIF). All the stripped screws were augmented with the bone void filler, and tightness was assessed clinically afterwards. All patients were followed up for 2 years. Successful healing of the fracture after 3 months and absence of radiographic movement of the augmented screws were assessed relative to the plate and the bone. Safety was assessed by recording adverse events and abnormal haematology findings. All 86 augmented screws were clinically tight after augmentation. After 3 months, all fractures healed, and 1 augmented and 1 non-augmented screw appeared to be radiographically loose. After 2 and 6 months, respectively, deep wound infections occurred in 2 patients (5%), necessitating antibiotic treatment, revision surgery and implant removal. After 2 years, all patients had resumed their normal daily activities, and none of the augmented screws showed signs of loosening. Augmentation of bone screws with this new synthetic bone void filler was an effective means of gaining screw anchorage. Screw stabilisation with the new synthetic bone void filler proved to be safe and effective in the ORIF of ankle fractures in patients with osteopenic bone.

Internal fixation of ankle fractures in the very elderly

The management of ankle fracture in the elderly remains controversial. A review of the early results of open reduction and internal fixation (ORIF) in 74 patients over the age of 70 years (average 76 years) was undertaken to identify the early complications, length of stay, return to pre-injury mobility and residential status. This revealed 1% deep infection, 9% delayed wound healing, 5% malunion, and 3% mortality. In 12% of patients, soft bone and comminution precluded fixation of one malleolus. The average length of stay for patients who walked with Zimmer frame (116±65 days) before injury was significantly longer than those who walked independently or with sticks (19±15 days; P<0.01). The inability of the patients to weight-bear early led to lengthy hospital stays and difficult socio-economic problems. However, the majority (85%) of patients regained their pre-injury mobility and residential status. We conclude that ORIF of ankle fractures in the elderly carries a significant risk of wound edge necrosis with delayed wound healing but the incidence of deep infection is relatively low. Poor bone quality presents technical difficulties but the majority of patients can expect good outcome.