Open Ankle Fractures Research Articles

Risk Factors for Open Malleolar Fractures: An Analysis of the National Trauma Data Bank (2007 to 2011)

A limited number of studies have described the epidemiology of open fractures, and the epidemiology of open ankle fractures is not an exception. Therefore, the risk factors associated with open ankle fractures have not been extensively evaluated. The frequencies and proportions of open ankle fractures among all the recorded malleolar fractures in the US National Trauma Data Bank data set from January 2007 to December 2011 were analyzed. Clinically relevant variables captured in the data set were also used to evaluate the risk factors associated with open ankle fractures, adjusting for other covariates. The entire cohort was further subdivided into “lower” and “higher” energy trauma groups and the same analysis performed for each group separately. We found that a body mass index of >40 kg/m2 and farm location were risk factors for open ankle fractures and impaired sensorium was protective against open ankle fractures. In the “lower energy” group, male gender, alcohol use, peripheral vascular disease, other injuries, and injury occurring at a farm location were risk factors for open fractures. In the “higher energy” group, female gender, work-related injury, and injury at a farm or industry location demonstrated statistically significantly associations with open fractures.

Contemporary demographics and complications of patients treated for open ankle fractures

Open ankle fractures are rare injuries with a high likelihood of wound complications and subsequent infections. There is limited information about the complications and outcomes of these injuries in different age groups. The aim of this study was to assess the contemporary demographics and complications related to this injury. We performed a chart review of all the 3030 patients treated for ankle fractures at a Level 1 trauma centre from 2006 to 2011. 137 (4.5%) patients had an open ankle fracture. The demographic data, injury mechanism, comorbidities, and fracture type were collected. Treatment, complications, length of stay and number of outpatient visits were also recorded. The mean age of the patients was 60 years and 56% were women. Most fractures were Weber type B with a medial sided wound (93%). Only 20% of the fractures were the result of high-energy trauma, and 31% were Gustilo grade III injuries. Immediate internal fixation was performed in 82% of patients, and the wound was primarily closed in most cases (80%). The incidence of postoperative wound necrosis and deep infection was 18% and 17%, respectively. There were more deep infections if pulsatile lavage was used during the wound debridement (p=0.029). About 14 (10%) patients required a flap reconstruction to cover the soft-tissue defect. Every other patient (54%) had a complication, and 21 patients (15%) suffered a long-term disability related to the injury. The number complications did not differ for nighttime and daytime operations (p=0.083). High-energy injuries were more common in younger patients (p<0.001) and these patients also had more lateral sided open wounds than older patients (p=0.002). Interestingly, younger patients also had significantly more complications (p=0.024), suffered more often from chronic pain (p=0.003), and required more flap reconstructions (p=0.026), reoperations (p=0.026), and outpatient clinic visits (p=0.006). Open ankle fractures have a high complication rate and often require multiple surgical procedures. In young patients these injuries are more likely to be the consequence of high-energy trauma leading to more complications and subsequently increased healthcare resource utilisation.

Open ankle fractures: who gets them and why?

Open ankle fractures present a significant clinical challenge. The management and outcome of these injuries has been extensively reported, but there have been no reports of the epidemiology and how this has changed over time. We report 178 adult patients with open ankle fractures presenting to our unit over a twenty-three year period. The study centre is the only hospital receiving adult orthopaedic trauma in the region and has a defined population. The incidence of open ankle fractures was 1.5/10(5)/year, representing 1.5% of all ankle fractures. The mean age was 55years (range 16-96), with the highest incidence occurring in women over the age of 90. The most common mechanism was a simple fall with only 26% of cases due to a motor vehicle collision (MVC). 82% of cases were isolated injuries. Social deprivation had no significant influence on the incidence, but there was a difference in the mechanism with the majority of injuries in the most deprived quintile caused by MVCs and significantly fewer due to simple falls (p=0.047). Over the twenty-three years, there was a significant increase in the mean age from 44 to 64years (p=0.03). The overall incidence remained constant over the two decades. In common with many traumatic injuries, open ankle fractures are increasingly low-energy insufficiency fractures affecting elderly patients, particularly older women. This has implications for service planning and training as well as the surgical intervention in these patients.

Long-term functional and radiographic outcomes in 243 operated ankle fractures.

BackgroundLarge comparative studies that have evaluated long-term functional outcome of operatively treated ankle fractures are lacking. This study was performed to analyse the influence of several combinations of malleolar fractures on long-term functional outcome and development of osteoarthritis.MethodsRetrospective cohort-study on operated (1995–2007) malleolar fractures. Results were assessed with use of the AAOS- and AOFAS-questionnaires, VAS-pain score, dorsiflexion restriction (range of motion) and osteoarthritis. Categorisation was determined using the number of malleoli involved.Results243 participants with a mean follow-up of 9.6 years were included. Significant differences for all outcomes were found between unimalleolar (isolated fibular) and bimalleolar (a combination of fibular and medial) fractures (AOFAS 97 vs 91, p = 0.035; AAOS 97 vs 90, p = 0.026; dorsiflexion restriction 2.8° vs 6.7°, p = 0.003). Outcomes after fibular fractures with an additional posterior fragment were similar to isolated fibular fractures. However, significant differences were found between unimalleolar and trimalleolar (a combination of lateral, medial and posterior) fractures (AOFAS 97 vs 88, p < 0.001; AAOS 97 vs 90, p = 0.003; VAS-pain 1.1 vs 2.3 p < 0.001; dorsiflexion restriction 2.9° vs 6.9°, p < 0.001). There was no significant difference in isolated fibular fractures with or without additional deltoid ligament injury. In addition, no functional differences were found between bimalleolar and trimalleolar fractures. Surprisingly, poor outcomes were found for isolated medial malleolar fractures. Development of osteoarthritis occurred mainly in trimalleolar fractures with a posterior fragment larger than 5 %.ConclusionsThe results of our study show that long-term functional outcome is strongly associated to medial malleolar fractures, isolated or as part of bi- or trimalleolar fractures. More cases of osteoarthritis are found in trimalleolar fractures.

Outcome of the management of open ankle fractures in an ortho-plastic specialist centre

IntroductionWe reviewed the functional outcome of 68 patients with open ankle fractures managed in an orthoplastic specialist centre. Materials and methodsPatients managed at Frenchay Hospital over a 6 year period were divided into 3 groups: group P were patients initially seen and managed at Frenchay Hospital (an orthoplastic specialist centre), group S were patients stabilised at a different unit and referred for definitive management, while group R were patients managed in a different unit and referred following complications.Injuries were graded using the AO score and outcome was measured using the Enneking score (both validated). Results19 patients (group P, mean age: 43 years), 26 patients (group S, mean age: 41 years) and 23 patients (group R, mean age: 41.9 years) made the cohort. 82.4% patients required free tissue transfer. Mean AO scores of groups P, S and R were 11.5, 12.3 and 9.7 (p+0.03). Mean number of procedures for P, S and R were 2.6, 3.5 and 4.2 (p=0.0006). Mean follow up time was 55.5, 61.0 and 57.0 weeks respectively (p=0.72). Mean Enneking scores for groups P, S and R were 63.3, 74.8 and 73.5 (p=0.16). ConclusionPatients from groups S and R underwent more procedures. However, a similar outcome can be achieved, highlighting the importance of managing such injuries in an orthoplastic specialist centre.

Are Low-Energy Open Ankle Fractures in the Elderly the New Geriatric Hip Fracture?

As the geriatric population in the United States continues to increase, ankle fractures in the elderly are predicted to exponentially increase in the future. As such, these injuries will become a common injury seen by physicians in various fields. Currently, no studies discussing low-energy open ankle fractures in the elderly and/or the mortality rate associated with these devastating injuries have been published. The purpose of the present study was to retrospectively review the morality rate associated with low-energy open ankle fractures in the elderly. We retrospectively identified 11 patients >60 years old who had sustained low-energy open ankle fractures and been treated at our institution. The patient demographics, mechanism of injury, wound size, medical comorbidities, treatment, follow-up data, and outcomes were recorded. Low-energy falls were defined as ground level falls from sitting or standing. The mean age of the patients was 70.72 years, with a mean body mass index of 35.93 ± 10.24. Of the 11 patients, 9 (81.81%) had ≥3 comorbidities (i.e., hypertension, diabetes, coronary artery disease, congestive heart failure, and/or chronic obstructive pulmonary disease). The mean size of the medially based ankle wound was 14.18 ± 4.12 cm; 10 (90.90%) were Gustilo and Anderson grade IIIA open ankle fractures. In our study, low-energy open ankle fractures in the elderly, very similar to hip fractures, were associated with a high mortality incidence (27.27%) at a mean of 2.67 ± 2.02 months, and 81.81% of our patients had ≥3 medical comorbidities.

Initial Management of Ankle Fractures in the Overweight and Obese: The Providence Pinch

BackgroundObese and overweight people have higher rates of ankle injury, particularly operative ankle fractures. The initial management of unstable ankle fractures includes closed reduction and splinting to limit soft tissue injury and articular cartilage damage until definitive operative fixation can be performed. Adequate reduction can be more difficult in the obese patient due to the weight and additional padding provided by the larger soft tissue envelope. DiscussionA novel technique, described herein by the authors, may be useful in obtaining a suitable reduction of the ankle in the initial management of unstable ankle fractures in the overweight and obese. ConclusionsObese patients have unique musculoskeletal injury profiles and special considerations in their management. The authors have found this technique useful in the management of their ankle fractures.

Evaluation of Lauge-Hansen Designation of Weber C Fractures

Associations between Weber C ankle fractures and pronation external rotation (PER) injuries of the Lauge-Hansen classification have often been incorrectly correlated. The purpose of the present study was to evaluate the Lauge-Hansen designation of Weber C fractures by establishing the proportion of Weber C fractures that are supination external rotation (SER), supination adduction (SA), pronation abduction (PA), PER, and hyperplantarflexion variant fractures. A clinical database of operative ankle fractures treated by the senior author (D.G.L.) was reviewed. The inclusion criteria were patient age older than 16 years, preoperative ankle radiographs, and Weber C fracture designation. A total of 132 patients met the inclusion criteria, and the proportion of PA, PER, SER, SA, and variant fractures among the Weber C fractures was analyzed. PA fractures accounted for 0.8% (n = 1), PER fractures 56.8% (n = 75), SER fractures 35.6% (n = 47), and hyperplantarflexion variant fractures 6.8% (n = 9) of the 132 Weber C fractures. Patients with Weber C-PER fractures were more commonly male (p = .005) and younger (p = .003) and demonstrated a greater fibular fracture height (p < .001) than those with Weber C-SER and Weber C-variant fractures. Our study quantitatively demonstrated that not all Weber C fractures occur secondary to pronation injuries. This distinction is important, because all pronation injuries will demonstrate medial ankle injury, but SER and variant fractures might not. We therefore recommend careful evaluation of the fibular fracture characteristics, including the direction of fracture propagation and the distance from the tibial plafond, when classifying Weber C fractures using the Lauge-Hansen system, because correct classification is vital in preparation for appropriate operative treatment.

リネゾリドが有効であった足関節開放骨折術後のMRSA 創部感染の1 例

リネゾリドが有効であった足関節開放骨折術後のMRSA 創部感染の1 例

Risk Factors for Posttraumatic Synostosis and Outcomes Following Operative Treatment of Ankle Fractures

Distal tibiofibular synostosis is a known but poorly described complication of ankle fractures. The objective of this study was to evaluate the relationship between ankle fracture fixation method and other risk factors in the development of synostosis in posttraumatic operative ankle fractures. Outcomes of patients with no synostosis, incomplete bony bridging, or complete synostosis also were compared. All operative ankle fractures from a single surgeon's prospectively collected clinical database were evaluated for the presence of distal tibiofibular synostosis not earlier than 3 months postoperatively. All fractures were treated in a fracture-specific and ligament-specific fashion. Syndesmotic screws, when used, were routinely removed no sooner than 4 months after operation. Patient demographic and medical history data as well as injury and fixation profile were evaluated. Incidence of complications was also reviewed. Foot and Ankle Outcome Score (FAOS) and range of motion (ROM) were compared between the groups. Of the 564 ankle fractures included in the study, 91 demonstrated complete synostosis and 46 demonstrated incomplete bony bridging. Multivariate analysis revealed male sex (odds ratio [OR] = 2.82, P < .001), syndesmotic screw fixation (OR = 2.46, P < .001), and tibiotalar dislocation (OR = 1.74, P = .032) to remain significant independent risk factors for the development of incomplete bony bridging or complete synostosis while adjusting for confounding risk factors. Ankles with synostosis also demonstrated significant reduction in dorsiflexion (P = .017), plantarflexion (P = .024), and inversion (P < .001), though patient-reported outcome measures were equivalent with patients without synostosis. Syndesmotic screw fixation, male sex, and tibiotalar dislocation were significant risk factors in the formation of postoperative distal tibiofibular synostosis, though patient-reported outcome measures seemed equivalent among patients with and without synostosis. Level III, case control study of prospectively collected registry data.

The perils of spinning class: An open ankle fracture following a spinning exercise session

Spinning is an increasingly popular form of cycle-based exercise. The workouts are often of high-intensity and participants are intermittently encouraged to achieve a high crank-set-cadence rate. We report a unique case of an open ankle fracture requiring free flap coverage, which highlights the potential perils of spinning class.

Risk Factors for Deep Surgical Site Infection Following Operative Treatment of Ankle Fractures

Surgical site infection is one of the most common complications following ankle fracture surgery. These infections are associated with substantial morbidity and lead to increased resource utilization. Identification of risk factors is crucial for developing strategies to prevent these complications. We performed an age and sex-matched case-control study to identify patient and surgery-related risk factors for deep surgical site infection following operative ankle fracture treatment. We identified 1923 ankle fracture operations performed in 1915 patients from 2006 through 2009. A total of 131 patients with deep infection were identified and compared with an equal number of uninfected control patients. Risk factors for infection were determined with use of conditional logistic regression analysis. The incidence of deep infection was 6.8%. Univariate analysis showed diabetes (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.0, 4.9), alcohol abuse (OR = 3.8, 95% CI = 1.6, 9.4), fracture-dislocation (OR = 2.0, 95% CI = 1.2, 3.5), and soft-tissue injury (a Tscherne grade of ≥1) (OR = 2.6, 95% CI = 1.3, 5.3) to be significant patient-related risk factors for infection. Surgery-related risk factors were suboptimal timing of prophylactic antibiotics (OR = 1.9, 95% CI = 1.0, 3.4), difficulties encountered during surgery, (OR = 2.1, 95% CI = 1.1, 4.0), wound complications (OR = 4.8, 95% CI = 1.6, 14.0), and fracture malreduction (OR = 3.4, 95% CI = 1.3, 9.2). Independent risk factors for infection identified by multivariable analyses were tobacco use (OR = 3.7, 95% CI = 1.6, 8.5) and a duration of surgery of more than ninety minutes (OR = 2.5, 95% CI = 1.1, 5.7). Cast application in the operating room was independently associated with a decreased infection rate (OR = 0.4, 95% CI = 0.2, 0.8). We identified several modifiable risk factors for deep surgical site infection following operative treatment of ankle fractures.

Risk factors for surgical site infection following operative ankle fracture fixation

Ankle fracture is a common injury and there is an increasingly greater emphasis on operative fixation. The purpose of the study was to determine the complication rate in this cohort of patients and, in doing so, determine risk factors which predispose to surgical site infection. A prospective cohort study was performed at a tertiary referral trauma center examining risk factors for surgical site infection in operatively treated ankle fractures. Univariate and multivariate analysis was performed. Female gender and advancing age were determined to be the risk factors in univariate analysis. Drain usage and peri-operative pyrexia were found to be significant for infection in multivariate analysis. This study allows surgeons to identify those at increased risk of infection and counsel them appropriately. It also allows for a high level of vigilance with regard to soft tissue handling intra-operatively in this higher risk group.

Role of Patient Information Handouts Following Operative Treatment of Ankle Fractures

Widespread evidence exists for directed patient information interventions (eg, pamphlets) in the setting of several orthopaedic conditions and interventions. Up until now, no study had assessed the role of these interventions in the management of patients following ankle fractures. Between 2005 and 2007, 40 patients who suffered an operative ankle fracture were randomized to either a standard treatment group for an ankle fracture or an enhanced information group who received an American Academy of Orthopaedic Surgeons ankle fracture information pamphlet that explained postoperative routine at our institution and a physiotherapy handout depicting a standard protocol. Study participants were followed for 3 months clinically and radiographically. At the 6-week and 3-month intervals, study participants completed the Olerud-Molander Questionnaire and 2 questions regarding their level of satisfaction. The primary outcome measure was the Likert-scale-based survey question determining the level of satisfaction with the treating staff. Participants in the enhanced information group were more satisfied with treatment at 3 months (9.2 vs 6.3; P < .001). There were significant improvements in work/activity ability at 6 weeks (P = .01), but this advantage disappeared at 3 months (P = .24). No differences in postoperative complication rates were noted. Information enhancement in the form of pamphlets can be helpful in providing patients with accessible information in the postoperative period. While they do not seem to have a sustained impact on postoperative outcomes, handouts may enhance the interaction between staff and patient at postoperative visits, improving patient satisfaction. Level I, appropriately powered randomized prospective cohort study.

Limb Salvage of Ankle Fracture Dislocation With LIMA External Fixator

Open ankle fractures with dislocation are potentially limb-threatening injuries with complications ranging from infection to amputation. External fixation has been used in trauma institutions for limb salvage, particularly in the setting of extensive soft tissue compromise. The authors present a case of an elderly woman with an open ankle fracture dislocation who underwent a staged surgical approach. A LIMA external fixator was used in conjunction with antibiotic beads and subsequent definitive open reduction with internal fixation. At 5-year follow-up, the patient demonstrated pain-free range of motion with a return to activity comparable to the preinjury state. The authors highlight the benefit of procedure staging in the presence of a severe fracture dislocation of the tibiotalar joint.

Open ankle fractures: A case series

Open ankle fractures: A case series

Evidence-based treatment of open ankle fractures

Fractures of the ankle are fairly common injuries. Open ankle fractures are much less common and associated with severe injuries to surrounding tissues. We have performed a systematic review of the literature concerning the clinical results and complication rates in the treatment of open ankle fractures. We conducted a search limited to the following databases: Pubmed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register and Embase. These were searched from 1968 to April 2010 to identify studies relating to the treatment of open ankle fractures. Fifteen articles concerning 498 patients with treatment of an open ankle fracture were identified. The number of included patients varied from 11 to 64. There were 2 prospective and 13 retrospective studies. All articles were case series and classified as Level IV evidence. In 373 cases, open ankle fractures were treated by immediate internal fixation. In 125 cases, a conservative treatment or delayed/other fixation treatment was followed. Of those patients treated by immediate internal fixation, 81% had satisfactory result. Poor results (15%) were most commonly due to non-anatomic reductions, articular surface damage or deep infection. When conservative treatment was followed, 76% had satisfactory results. The most reported complications after immediate internal fixation were deep infection (8%) and skin necrosis (14%). There is a lack of high quality literature concerning the (operative) treatment of patients with open ankle fractures. Remarkable is that most authors reported satisfactory results after performance of their treatment protocol. Based on the available literature, we formulated guidelines regarding: timing of operative treatment, wound irrigation, the role of internal fixation, wound coverage and closure, the use of antibiotics and additional therapies.

Outcomes of Ankle Fractures in Patients with Uncomplicated versus Complicated Diabetes

Patients with diabetes who sustain an ankle fracture are at increased risk for complications including higher rates of in hospital mortality, in-hospital postoperative complications, length of stay and non-routine discharges. The purpose of this study was to retrospectively compare the complications associated with operatively treated ankle fractures in a group of patients with uncomplicated diabetes versus a group of patients with complicated diabetes. Complicated diabetes was defined as diabetes associated with end organ damage such as peripheral neuropathy, nephropathy and/or PAD. Uncomplicated diabetes was defined as diabetes without any of these associated conditions. Our hypothesis was that patients with uncomplicated diabetes would experience fewer complications than those patients with complicated diabetes. We compared the complication rates of ankle fracture repair in 46 patients with complicated diabetes and 59 patients with uncomplicated diabetes and calculated odds ratios (OR) for significant findings. At a mean followup of 21.4 months we found that patients with complicated diabetes had 3.8 times increased risk of overall complications 3.4 times increased risk of a non-infectious complication (malunion, nonunion or Charcot arthropathy) and 5 times higher likelihood of needing revision surgery/arthrodesis when compared to patients with uncomplicated diabetes. Open ankle fractures in this diabetic population were associated with a three times higher rate of complications and 3.7 times higher rate of infection. Patients with complicated diabetes have an increased risk of complications after ankle fracture surgery compared to patients with uncomplicated diabetes. Careful preoperative evaluation of the neurovascular status is mandatory, since many patients with diabetes do not recognize that they have neuropathy and/or peripheral artery disease.

Immediate Internal Fixation of Open Ankle Fractures

Open ankle fractures are one of the most frequently treated open fractures. Immediate internal fixation in open ankle fractures is widely reported to produce good results, with a very low infection rate. However, there are few reports in the literature discussing distinct features of open ankle fractures. Thus, the aim of this study was to explore the injury features of such fractures and the operative technique; pilon fractures were excluded. Ninety-six patients with open ankle fractures underwent surgery between August 2001 and March 2008. Ninety-two patients were followed for an average of 35 (range, 14 to 66) months. Intravenous antibiotics were initiated in the emergency room, and wounds were copiously irrigated and thoroughly debrided in the operating room as soon as possible. Based on the fracture's classification, the extent of comminution, and the wound condition, a rational sequence of treatment for each malleolar fracture was determined. Reduction and internal fixation of the fractures were performed in turn. Primary wound healing was achieved in 65 patients. Superficial skin necrosis was seen in 19 patients, four patients had delayed wound healing and two had superficial infections. One diabetic patient developed a deep infection. The average time of fracture healing was 13 weeks. The mean AOFAS ankle-hindfoot score was 90.4 (range, 59 to 100). Compared with closed ankle fractures, open ankle fractures have some unique injury features, and correspondingly require special treatment methods with respect to soft-tissue handling, restoration of large posterior malleolar fractures, the reconstruction sequence of malleolar fractures, and the management of distal tibiofibular syndesmotic diastasis.

One year follow-up after operative ankle fractures: A prospective gait analysis study with a multi-segment foot model

Ankle fractures are one of the most common lower limb traumas. Several studies reported short- and long-term post-operative results, mainly determined by radiographic and subjective functional evaluations. Three-dimensional gait analysis with a multi-segment foot model was used in the current study to quantify the inter-segment foot motions in 18 patients 1 year after surgically treated ankle fractures. Data were compared to that from gender- and age-matched healthy controls. The correlations between Olerud/Molander ankle score and kinematics were also evaluated. Patients with ankle fractures showed less plantarflexion and smaller range of motion in the injured talocrural joint, which were believed to be a sign of residual joint stiffness after surgery and immobilization. Moreover, the forefoot segment had smaller sagittal and transverse ranges of motion, less plantarflexion and the hallux segment had less dorsiflexion and smaller sagittal range of motion. The deviations found in the forefoot segment may contribute to the compensation mechanisms of the injured ankle joint. Findings of our study show that gait analysis with a multi-segment foot model provides a quantitative and objective way to perform the dynamic assessment of post-operative ankle fractures, and makes it possible to better understand not only how the injured joint is affected, but also the surrounding joints.