Operative Treatment Of Ankle Fractures Research Articles

Return to Play Rates Following Operative Ankle Fractures Differ Between High- and Low-Performing National Football League Athletes.

This study investigated predictive factors for return to play among National Football League athletes after operative treatment of ankle fractures and the impacts of these injuries on career longevity and player performance. Athletes who underwent surgery to repair ankle fractures from the 2013 to 2017 seasons were identified from injury reserve lists and press releases. Demographics and season metrics were collected before and after the injury. Statistical analysis assessed for differences in recorded variables between injured and uninjured players. Thirty-one players met study inclusion criteria. Twenty-two (71%) athletes successfully returned to play. Players who did not return showed no significant differences (P>.05) in position, age, body mass index, number of games or seasons played preinjury, or snaps per game the season prior to injury and had a significantly lower (42.6%, P=.013) preinjury season approximate value (SAV) compared with returning players. Returning athletes showed no significant differences (P>.05) in SAV or snaps per game compared with their preinjury season or with uninjured controls. A high preinjury SAV is associated with successful return to play. No difference in game time or performance metrics was detectable between returning players and uninjured controls, or between preinjury and postinjury seasons. [Orthopedics. 2024;47(1):22-27.].

Effect of Postoperative Immobilization Time on PROMIS Scores and Clinical outcomes in Ankle Fracture Patients.

Ankle fractures are among the most common injuries treated by orthopaedic surgeons, yet little guidance exists in postoperative protocols for ankle fractures concerning time of immobilization. Here, we aim to investigate the association between early mobilization and patient-reported outcomes. Our null hypothesis was that no difference in Patient-Reported Outcomes Measurement Information System (PROMIS) scores would be identified in patients when comparing the effect of time of immobilization. A retrospective review identified ankle fractures that underwent surgical fixation between 2015 and 2020 at a level 1 trauma center and its associated facilities. One hundred nineteen patients from 9 providers met inclusion criteria for our final analysis. Forty-seven patients were immobilized for <6 weeks (early) and 68 patients were immobilized for ≥6 weeks (late). Our primary outcome measures included the PROMIS questionnaire, time of immobilization, and time to full weightbearing. Our secondary outcome measures included time to return to work, wound complications (infection, delayed healing), and complications associated with fracture fixation (loss of reduction, delayed union, reoperation, hardware failure). Repeated measures analysis of variance as well as linear mixed outcome regression were used to predict each of the PROMIS outcomes of anxiety, depression, physical function, and pain interference. Each model included the predictors of age, sex, race, body mass index (BMI), diabetes, rheumatoid arthritis, smoking status, payor, provider, time to radiographic union, time to return to work, time to full weightbearing, and early vs late immobilized groups. We found no differences in PROMIS scores between mobilization groups even when controlling for possible confounders such as age, BMI, rheumatoid arthritis, smoking status, and diabetes mellitus (P > .05). Furthermore, we found no differences in complications associated with fracture fixation (P > .05). Across our cohort, lower physical function scores were associated with higher BMI, increasing age, and longer time to return to work/play (P < .05). Our analysis further showed that depression, anxiety, pain interference, and physical function levels improve as a function of time (P < .05). Higher BMI was also noted to have a significant impact on PROMIS depression and anxiety when controlling for other variables. African Americans had greater pain interference scores (P < .05). Our study suggests that early mobilization in a walker boot after operative treatment of ankle fractures is a safe alternative to casting in non-neuropathic patients. When considering operative treatment of ankle fractures, factors such as increasing age and BMI are likely to negatively affect postoperative anxiety, physical function, and depression PROMIS scores regardless of immobilization time. Level III, retrospective cohort study.

Effect of Postoperative Immobilization Time on PROMIS Scores and Clinical Outcomes in Ankle Fracture Patients

Category:Ankle; TraumaIntroduction/Purpose:Ankle fractures are among the most common injuries that Orthopaedic Surgeons treat; yet, little guidance exists in postoperative protocols for ankle fractures concerning time of immobilization and weightbearing. Results from previous studies have been mixed; demonstrating improved outcomes, no difference in outcome, or poorer outcomes including increased wound complications in patients who are mobilized early. Here, we aim to investigate the association between early immobilization and patient reported outcomes. Our null hypothesis was that no difference in PROMIS scores would be identified in patients when comparing the effect of time of immobilization and time of weightbearing.Methods:A chart review identified ankle fractures that underwent surgical fixation between 2015 and 2020 at a level 1 trauma center and its associated facilities. One-hundred nineteen patients from 8 providers met inclusion criteria for our final analysis. Fifty patients were immobilized for <6 weeks and 69 patients were immobilized for at least 6 weeks. Our primary outcome measures included the PROMIS questionnaire, time of immobilization, and time to full weightbearing. Our secondary outcome measures included time to return to work, wound complications (infection, delayed healing), and complications associated with fracture fixation (loss of reduction, delayed union, reoperation, hardware failure). Repeated-measures ANOVAs were used to predict each of the PROMIS outcomes of anxiety, depression, physical function, and pain interference. Each model included the predictors of age, sex, race, BMI, payor, provider, time to radiographic union, time to return to work, time to full weightbearing, and early vs late immobilized groups.Results:There were no differences in PROMIS scores between mobilization groups and time to full weightbearing (p>0.05). Furthermore, there were no differences in wound complications nor complications associated with fracture fixation (p>0.05). Across our cohort, physical function scores were negatively impacted by higher BMI, increasing age and longer time to return to work/play (p<0.05). Our analysis further showed that depression, anxiety, pain interference and physical function levels improve as a function of time (p<0.05). African Americans showed more pain interference than other groups of patients (p<0.05). No difference in PROMIS scores were identified between treating providers (p>0.05).Conclusion:In this study, the null hypothesis was accepted. Data from our analysis shows no significant differences between the early and late mobilization and weightbearing groups in terms of PROMIS outcomes nor with wound complications and complications associated with fracture fixation. Our study does suggest that early mobilization after operative treatment of ankle fractures is safe and results in similar patient reported outcomes with no increased risk of complication. We did find that African American patients experienced more pain that other groups and we aim to further explore this topic to find potential modalities to address this disparity.

Short-term results of gait analysis with the Heidelberg foot measurement method and functional outcome after operative treatment of ankle fractures

BackgroundAnkle fractures are common fractures in trauma surgery. Several studies have compared gait patterns between affected patients and control groups. However, no one used the Heidelberg Foot Measurement Method in combination with statistical parametric mapping of the entire gait cycle in this patient cohort. We sought to identify possible mobility deficits in the tibio-talar joint and medial arch in patients after ankle fractures as a sign of stiffness and pain that could result in a pathological gait pattern. We focused on the tibio-talar flexion as it is the main movement in the tibio-talar joint. Moreover, we examined the healing progress over time.MethodsFourteen patients with isolated ankle fractures were included prospectively. A gait analysis using the Heidelberg Foot Measurement Method was performed 9 and 26 weeks after surgery to analyse the tibio-talar dorsal flexion, the foot tibia dorsal flexion, the subtalar inversion and the medial arch as well as the cadence, the walking speed and the ground reaction force. The American Orthopedic Foot & Ankle Society ankle hindfoot score was used to obtain clinical data. Results were compared to those from 20 healthy participants. Furthermore, correlations between the American Orthopedic Foot & Ankle Society hindfoot score and the results of the gait analysis were evaluated.ResultsStatistical parametric mapping showed significant differences for the Foot Tibia Dorsal Flexion for patients after 9 weeks (53–75%: p = 0.001) and patients after 26 weeks (58–70%: p = 0.011) compared to healthy participants, respectively. Furthermore, significant differences regarding the tibio-talar dorsal flexion for patients 9 weeks after surgery (15–40%: p < 0.001; 56,5–70%: p = 0.007; 82–88%: p = 0.033; 97–98,5%: p = 0.048) as well as patients after 26 weeks (62,5–65%: p = 0.049) compared to healthy participants, respectively. There were no significant differences looking at the medial arch and the subtalar inversion. Moreover, significant differences regarding the ground reaction force were found for patients after 9 weeks (0–17%: p < 0.001; 21–37%: p < 0.001; 41–54%: p < 0.001; 60–64%: p = 0.013) as well as patients after 26 weeks (0–1,5%: p = 0.046; 5–15%: p < 0.001; 27–33%: p = 0.001; 45–49%: p = 0.005; 57–59%: p = 0.049) compared to healthy participants, respectively. In total, the range of motion in the tibio-talar joint and the medial arch was reduced in affected patients compared to healthy participants. Patients showed significant increase of the range of motion between 9 and 26 weeks.ConclusionsThis study shows, that patients affected by ankle fractures show limited mobility in the tibio-talar joint and the medial arch when compared to healthy participants. Even though the limitation of motion remains at least over a period of 26 weeks, a significant increase can be recognized over time. Furthermore, if we look at the absolute values, the patients’ values tend to get closer to those of the control group.Trial registrationThis study is registered at the German Clinical Trials Register (DRKS00023379).

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.

Do Early Weight-Bearing and Range of Motion Affect Outcomes in Operatively Treated Ankle Fractures: A Systematic Review and Meta-Analysis.

This systematic review was performed to answer the following questions: (1) Does early weight-bearing (WB) after ankle fracture (AF) open reduction internal fixation (ORIF) affect outcomes? (2) Does early WB after AF ORIF cause an increase in complications? (3) Does early ankle motion after AF ORIF affect outcomes? and (4) Does early ankle motion after AF ORIF cause an increase in complications? Articles from 1970 to 2020 were found using the PubMed database. Level I studies of adult patients with operatively treated ankle fractures were selected. A total of 1130 cases across 20 studies fit the participant criteria. Studies were reviewed for data pertaining to the current study questions. The meta-analysis used logistic regression and standardized mean difference. Based on the current literature, early WB in operative ankle fractures with stable fixation showed no difference in outcomes when compared with delayed WB protocols. Early WB after ORIF did not significantly increase complications. Early ankle motion after AF ORIF did not have significant standardized mean differences between range of motion and immobilization outcomes. Early range of motion before wound healing may lead to an increase in complications [pooled odds ratio: 3.11, 95% confidence interval (CI): 1.64-5.90] but did not show an increase in infection. The authors recommend that early WB at 2 weeks postoperatively can be safely considered for ankle fractures when stable fixation has been obtained. Early ankle motion before wound healing is not recommended due to increased wound complications, without improvement in long-term results. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Early Weightbearing Versus Nonweightbearing After Operative Treatment of an Ankle Fracture: A Multicenter, Noninferiority, Randomized Controlled Trial

Background: Acute ankle fractures can occur during sports activities, and unstable ankle fractures are commonly treated operatively. However, controversy exists about the optimal time to allow weightbearing. Hypothesis: Early weightbearing after the stable fixation of an ankle fracture is not inferior to nonweightbearing in terms of ankle function assessed at 12 months after injury. Study design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 258 patients were assessed for eligibility. Of these patients, 194 were randomly allocated to either the early weightbearing group (95 patients who were allowed weightbearing at 2 weeks postoperatively) or the nonweightbearing group (99 patients who were not allowed weightbearing until 6 weeks postoperatively). The primary outcome measure was the mean difference in the Olerud-Molander ankle score (OMAS) between the groups, assessed at the 12-month follow-up examination. The secondary outcome measures were the time to return to preinjury activities and patients’ subjective satisfaction. Complications such as hardware loosening or failure, fracture displacement, and nonunion were evaluated. Results: The mean difference in the OMAS for the early weightbearing group compared with the nonweightbearing group was 1.6 (95% CI, –1.9 to 5.0) in the intention-to-treat analysis. The lower limit of the 95% CI (–1.9) exceeded the noninferiority margin of –8, indicating that early weightbearing was not inferior to nonweightbearing. The difference in the proportion of patients who were satisfied or very satisfied with their treatment was not statistically significant (84.3% vs 76.2%; P = .19); however, the time taken to return to preinjury activities was shorter with early weightbearing than with nonweightbearing (9.1 ± 3.0 vs 11.0 ± 3.0 weeks; P < .001). No cases of nonunion were observed in either group. Conclusion: Early weightbearing after the operative treatment of an unstable ankle fracture was not inferior to nonweightbearing in terms of OMAS assessed at 12 months after injury. The patients’ subjective satisfaction was similar between the groups, although the time taken to return to preinjury activities was shorter in the early weightbearing group. Registration: NCT02029170 (ClinicalTrials.gov identifier).

Operative Treatment of Ankle Fractures: Predictive Factors Affecting Outcome.

PurposeSurgical management of ankle fractures has been extensively studied in literature but studies investigating validated clinical results are lacking and controversial. The purpose of this study was to evaluate functional and health-related quality of life (HRQL) outcomes after surgically treated ankle fractures and to detect some of their predictors.MethodsTwo hundred sixty-six skeletally mature patients who underwent surgery for an isolated ankle fracture from 2006 to 2017 were retrospectively identified from our hospital records and included in the study. All patients were evaluated at one, three, six and 12 months post-injury with clinical and radiographic examination. Outcome measures recorded at final two years minimum follow-up included patient-reported pain, patient satisfaction, functional (American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score) and quality of life (Short Form (SF) 36 score) status.ResultsPatient satisfaction score was 8.4 out of 10, Visual Analogue Scale mean score was 2.3, complication rate was 36.5% and mean AOFAS ankle-hindfoot score was 87.3. Mean SF36-physical summary score was 77.9 and SF36-mental summary score was 81.1. The injury demonstrated a significant effect on physical function, role-physical, bodily pain and social functioning SF-36 subdomains. Functional outcome was significantly related to occupation, syndesmotic lesion, number of fractured malleoli and delay to surgery. Main predictors of quality of life were age, occupation, cause of injury, syndesmotic lesion, number of fractured malleoli and waiting time to surgery.ConclusionsAnkle fractures have a considerable impact on functional and quality of life status of patients. Occupation, presence of syndesmotic injury, Pott's classification and surgery delay must be considered as predictors of final outcome.

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

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

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

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

Techniques and Considerations for the Operative Treatment of Ankle Fractures in the Elderly.

* In managing fragility fractures about the ankle, nonoperative treatment should be considered with the caveat that soft-tissue integrity is of the utmost importance.* Consultation with medical and nutritional services for the comanagement of elderly patients with a fragility ankle fracture improves outcomes.* Soft-tissue preservation in the elderly is optimized with the judicious use of a tourniquet.* In elderly patients, a congruent ankle joint with axial alignment and stability should be emphasized over achieving anatomic articular reduction.* Less invasive surgical techniques, such as percutaneously placed anterior-to-posterior screws for posterior malleolar fractures and intramedullary fibular fixation, should be considered in the elderly.* Construct stability in elderly patients is maximized with the use of lateral locking plates, tibia-pro-fibula screws, and bicortical medial malleolar screws.* The use of external fixation with hydroxyapatite-coated pins should be considered in the treatment algorithm for fragility ankle fractures in elderly patients.

The Influence of Obesity on Ankle Fracture Treatment

Category: Ankle Introduction/Purpose: Obesity is a public health concern in the United States, with an overall prevalence of greater than one-third. From a surgical perspective, obesity may increase risk for postoperative complications, including delayed wound healing, infection or compromise of fixation/repair constructs. The purpose of this study was to retrospectively review outcomes data from the American College of Surgeons: National Surgical Quality Improvement Program (NSQIP) to delineate the impact that obesity has on operative treatment of ankle fractures. Methods: Perioperative data was collected from patients undergoing operative intervention for distal fibular or bimalleolar ankle injuries. Patients were identified from the 2006-2015 NSQIP database using current procedural terminology (CPT) codes. Obese (body mass index&gt;30 kg/m2) and non-obese (body mass index&lt;30 kg/m2) cohorts were identified to elucidate the influence of obesity on perioperative /postoperative complications after undergoing operative treatment for distal fibular or bimalleolar ankle injuries. Univariate and multivariate logistic regression models were created to identify independent risk factors for complications. Results: Our study identified a total of 8,377 patients including, 4,357 undergoing surgical bimalleolar ankle fracture repair and 4,020 patients undergoing surgical repair of distal fibular ankle fracture. Obese patients undergoing surgical repair of either distal fibular or bimalleolar ankle fractures were more likely to have a longer length of hospital stay (p &lt; 0.05). Patients undergoing distal fibular fixation were found have a longer operative time. Analysis using logistic regression demonstrated no significant association obesity and DVT/sepsis (bimalleolar ankle fracture fixation) and re-operation/deep incisional SSI/wound complication/UTI (distal fibular ankle fracture fixation) Obesity was not determined to be associated with postoperative complications following distal fibular nor bimalleolar ankle fracture repair. ankle fracture repair. Conclusion: This study demonstrated that, after adjusting for potential confounders, obesity is not significantly associated with adverse outcomes following bimalleolar or distal fibular ankle fracture repair. Further analysis demonstrated that operative time and length of stay are lengthened in ankle fracture fixation in obese patients.

New Persistent Opioid Use Following Operative Treatment of Ankle Fractures Compared to Nonoperatively Treated Fractures

Category: Trauma Introduction/Purpose: Chronic opioid use is a major public health concern in the United States. Orthopaedic surgeons prescribe 8% of narcotics in the U.S. while only comprising 2.5% of U.S. physicians. Understanding that neither the amount nor duration of opioid prescription correlates with patient satisfaction, orthopaedic surgeons have a unique opportunity to play a prominent role in the solution. In order to address and mitigate this epidemic, it is important to first understand rates of new persistent opioid use following specific orthopaedic procedures and to identify patient-specific risk factors. Methods: Using a widely accepted insurance claims database, we identified patients who underwent surgical treatment of common ankle fractures patterns (bimalleolar, trimalleolar, and isolated distal fibula) between January 2008 and December 2016. None had an opioid prescription filled in the period of 12 months to 15 days prior to treatment (defined as “opioid naïve”). Opioid naïve patients who underwent closed treatment of a distal fibula fracture served as a comparative group. We evaluated peri-treatment and post-treatment opioid prescription fulfillment. The primary outcome, new persistent opioid use, was defined as opioid prescription fulfillment between 91 and 180 days after the procedure. Logistic regression was used to evaluate the effect of patient factors, including surgery type, age, gender, median household income, mental health and pain disorders on the likelihood of new persistent use. Results: There was no significant difference in new persistent opioid use rates overall following surgical treatment of ankle fractures (8.4%) compared to closed fibula fracture treatment (7.4%), and all treatment groups demonstrated high rates of new persistent use. Two surgically treated fracture subtypes, treatment of bimalleolar ankle fractures and treatment of trimalleolar ankle fractures with fixation of posterior lip, demonstrated significantly higher new persistent opioid use rates (Figure). Rates were significantly increased among patients who received an opioid dose prescribed in the peri-treatment period that was in the top 25th percentile of total oral morphine equivalents. Patient-specific factors which were associated with new persistent opioid use included certain mental health disorders, comorbid conditions, arthritis, tobacco use, female gender, and household income greater than $100,000. Conclusion: Chronic opioid use, even in opioid naïve patients, is a major problem following orthopaedic procedures. To decrease the rate of chronic opioid use, it is important to first understand and define the rate of persistent use following these procedures. The overall new persistent opioid use following surgical fixation of ankle fractures was similar to the rate of persistent use in patients who underwent closed treatment of a fibula fracture. Understanding these high persistent use rates and the risk factors that may play a role in this problem provides a foundation upon which to address this sometimes lethal public health problem.

The Influence of Diabetes Mellitus on Ankle Fracture Treatment

Category: Trauma Introduction/Purpose: Diabetes mellitus is an epidemic affecting millions of individuals in the United States. This presents a challenging clinical problem from a surgical perspective, because of concerns for postoperative complications, including delayed wound healing, infection or compromise of fixation/repair constructs. The goal of this paper was to retrospectively review outcomes data from the American College of Surgeons: National Surgical Quality Improvement Program (ACS-NSQIP) to delineate more clearly the impact that diabetes has on operative treatment of ankle fractures, including bimalleolar and lateral malleolar injuries. Methods: Patients were identified from the 2006-2015 ACS-NSQIP database. Diabetic and non-diabetic cohorts were evaluated to compare demographics, comorbidities, perioperative details and 30-day outcomes. Univariate analysis was performed using chi-squared or Fisher’s exact and Wilcoxon signed-rank tests. A multivariate logistic regression model was created to identify independent risk factors for complications. Odds ratios were computed at the 95% confidence interval. Results: There were a total of 3745 (bimalleolar injuries [1579], lateral malleolar injuries [2166]) patients identified. With regard to treatment of distal fibular or bimalleolar injuries, diabetic patients were more likely to have a longer length of hospital stay (p &lt; 0.05). Based on multivariate analysis, diabetic patients undergoing operative fixation of bimalleolar injuries are at higher risk for superficial incisional surgical site infection (SSI) (OR 3.26; p=0.01), any complication (OR 1.73; p&lt;0.001), myocardial infarction (OR 10.89; p=0.046), and readmission (OR 2.38; p=0.01). In the setting of lateral malleolar fracture operative fixation, diabetic patients were at higher risk for any complication (OR 2.48; p=0.002), return to OR for unexpected complications (OR 5.88; p&lt;0.001), and urinary tract infection (OR 4.72; p=0.03) Conclusion: Based on upon the results of this study, diabetic patients are at higher risk for postoperative complications after ankle fracture fixation, namely infection and re-operation and readmission to the hospital within 30 days after surgery. This information can help clinicians guide patients appropriately prior to surgery.

Ankle Fracture Complications in the Elderly

Category: Trauma Introduction/Purpose: In the geriatric patient population, pre-existing medical conditions and poor bone quality often make operative fixation of unstable ankle fractures and fracture-dislocations more challenging. The objective of this study was to characterize the complications that occurred following operative fixation of these injuries at our institution and to determine whether complication rates were higher in our geriatric patient population (65 years and older) as compared to our younger patient population. We hypothesized that complication rates in the geriatric population would be significantly higher relative to complication rates in the younger population. We also hypothesized that in elderly patients, the soft tissue envelope would be less forgiving and require significantly more time for swelling to decrease to a level considered appropriate for definitive surgical fixation to occur. Methods: With IRB approval, a review of medical records for patients diagnosed with ankle fractures or fracture-dislocations and operated on between January of 2015 and December of 2016 was performed. Major complications were defined as any adverse outcomes requiring further surgical intervention such as irrigation and debridement for infection or exposed hardware, nonunion, major hardware failure, or amputation. Minor complications included other adverse outcomes which did not require further surgical intervention such as wound dehiscence, loss of reduction, or delayed union. Data were compared for statistically significant (p&lt;0.05) differences. Results: Medical record review produced 110 patients meeting criteria for inclusion with a mean follow-up of 179 days (range, 0 to 601 days). No significant (p&gt;0.08) differences were noted in rates of major, minor, or total complications between geriatric and younger patients treated at our institution (Fig. 1). An analysis of patient characteristics, demonstrated a significantly (p=0.035) higher proportion of trimalleolar ankle fractures within the geriatric population, but the proportions of other injury types were not significantly (p&gt;0.198) different between age groups. Prevalence of tobacco use, alcohol use, illicit drug use, or diabetes mellitus was not found to be significantly different (p&gt;0.058) between age groups. No significant (p=0.12) difference was found in time from injury to definitive surgical treatment between age groups. Conclusion: Complication rates following operative treatment of ankle fractures and fracture-dislocations were not significantly higher in our geriatric patient population, although the incidence of minor complications in the geriatric population was markedly increased relative to the younger population. A lack of significant difference in time from injury to definitive surgical treatment between age groups suggests that geriatric patients may not require a prolonged time for soft tissue swelling to decrease prior to surgery. Further study with a larger sample size is needed to determine if these findings are clinically significant.

Outcome following operative treatment of ankle fractures in Indian population

Outcome following operative treatment of ankle fractures in Indian population

Ankle fracture: The operative outcome of 30 patients

Background & Objectives: Ankle fractures are the most common injuries treated by orthopaedic surgeons. However very few investigators have examined the functional recovery following operative treatment of ankle fractures. Anatomic restoration with open reduction and internal fixation is the goal of management in ankle fractures. The purpose of this study is to analyse the functional outcome following operative treatment of ankle fractures using subjective as well as objective criteria. Methods: 30 patients with ankle fractures who fulfilled the inclusion criteria were included in the study. All patients underwent surgical fixation of the fractures. The follow-up assessment which consisted of subjective (Pain, Walking, activity, Radiographs, Ankle and Subtalar Joint function) and objective (Ankle-Hindfoot Scoring System) evaluations, were performed at 6 weeks, 3 months and 9 months postoperatively. Results: Out of 30 patients, the commonest injury pattern seen was supination external rotation followed by pronation external rotation. The most common modality of fixation for the lateral malleolus was 1/3rd tubular plate and for the medial malleolus was 4 mm cannulated cancellous screws with washer, K-wire and tension band wiring and for the posterior malleolus fixation with lag screws and Syndesmotic screws for syndesmotic injuries. At 6 weeks follow-up of 60% (n=19) had complications of persistent swelling and residual pain, Which improved significantly in function from 3rd month to 9 month postoperatively. However subjective radiographic assessment shows statistically significant improvement. The mean Ankle-Hindfoot Scoring System was statistically significant 50.5±18.7 at 3rd month post-op and, 85.1±14.2 at 9th month post-op. Age was a significant predictor of final outcome, with younger patients having a better functional outcome. Conclusions: Anatomical reduction of ankle fracture results in good functional outcome postoperatively. Early treatment without delay, anatomic reduction and fracture fixation, stringent postoperative mobilization and rehabilitation should help improve outcome in an operated ankle fracture.

Syndesmotic screw fixation in tibiofibular diastasis

In chronic instability of syndesmosis, osteoarthritis and poor functional outcome were seen more prevalently. To avoid diastasis of ankle joint, the affected distal tibiofibular syndesmosis should be restored. We evaluated the clinical and radiological results of operative treatment of ankle fractures in patients who required syndesmotic stabilization. Twenty-one patients operated for ankle fracture were evaluated. Patients were followed up for 12 to 81 months, with a mean value of 49 months. Anteroposterior (AP), lateral, and mortise radiographs were taken at the follow-up period, and AP tibiofibular distance, lateral fibular distance, and medial mortise distance were measured on the preoperative, postoperative, and last follow-up radiographs. At the last follow-up, patients were evaluated clinically with Hannover scoring system. The decrease in AP tibiofibular distance was statistically significant postoperatively in Weber Type B and C fractures. The mean preoperative AP tibiofibular distance which was 7.1 mm decreased to 3.6 mm after operation. There was no statistically significant relation between the amount of decrease and fracture type, either Weber B or C. At the same time, the AP tibiofibular distance did not change at the last follow-up. At the last follow-up clinical evaluation, patient scores were ranging from 74 to 94, with a mean value of 86, which was designated as a fair result. In ankle fractures, if diastasis of distal tibiofibular joint is present, syndesmosis should be fixed for both Weber Type B and C fractures. The most important predictor of good clinical outcome is accurate reduction of the syndesmosis.

Ankle fractures: Getting it right first time

IntroductionAnkle fractures are common injuries presenting to trauma departments and ankle open reduction and internal fixation (ORIF22ORIF: Open Reduction Internal Fixation.) is one of the first procedures targeted in early orthopaedic training. Failure to address the fracture pattern with the appropriate surgical technique and hardware may lead to early failure, resulting in revision procedures or premature degenerative change. Patients undergoing revision ORIF are known to be at much greater risk of complications and many of these secondary procedures may be preventable. MethodA retrospective analysis of all patients attending our unit for ankle ORIF over a two year period was undertaken. Patients were identified from our Bluespier database and a review of x-rays was undertaken. All patients undergoing re-operation within eight weeks of the primary procedure were studied. The cause of primary failure was established and potential contributing patient and surgical factors were recorded. Results236 patients undergoing ankle ORIF were identified. 13 patients (5.5%) returned to theatre for a secondary procedure within eight weeks. Within this group, seven (54%) patients returned for treatment of a neglected or under treated syndesmotic injury, three (23%) for complete failure of fixation, two (15%) with wound problems and one (8%) for medial malleolus mal-reduction. Of the patient group, five (39%) were known type 2 diabetics. Consultants performed two (15%) procedures, supervised registrars five (39%) and unsupervised registrars six (46%) operations. ConclusionErrors are being made at all levels of training in applying basic principles such as restoring fibula length and screening the syndesmosis intra-operatively. Appropriate placement and selection of hardware is not always being deployed in osteopenic bone resulting in premature failure of fixation and fracture patterns are not being fully appreciated. Patients are undergoing preventable secondary procedures in the operative treatment of ankle fractures.

Lower Complication Rate Following Ankle Fracture Fixation by Orthopaedic Surgeons Versus Podiatrists

Category: Ankle, Trauma Introduction/Purpose: Although the scope of practice for orthopaedic surgeons and podiatrists have considerable overlap in many foot and ankle pathologies, there are significant differences between the training for each surgical specialty that may affect patient outcomes. The purpose of this study was to evaluate complication rates following fixation of ankle fractures based on provider type. Our hypothesis was that patients with ankle fractures treated by orthopaedic surgeons would have lower complication rates compared to patients treated by podiatrists. Methods: This was a retrospective cohort study of data extracted from the Humana Claims database for 15,067 patients who underwent ankle fracture fixation between 2007 and 2015. Procedure type was identified by Current Procedural Terminology (CPT) codes. Patient data was subcategorized by surgeon type (orthopaedic surgeon versus podiatrist) and whether the patient underwent operative treatment for a single malleolus fracture (CPT 27766, 27792) versus a bimalleolar or a trimalleolar fracture (CPT 27814, 27822, 27823). The primary outcome was postoperative complications within 3 months including malunion, infection, or deep vein thrombosis (DVT). Secondary outcomes included reoperation rates for implant removal or irrigation and debridement. Complications were identified by International Classification of Disease-9 (ICD-9) codes and reoperations were identified by CPT codes. Chi-squared tests were used to determine differences in complication rates between surgeon types. The Charlson comorbidity index (CCI) was used to compare populations based on medical risk factors for complications. Results: 14,222 patients with ankle fractures were treated by orthopaedic surgeons and 845 patients were treated by podiatrists. Operative treatment by orthopaedists was associated with lower DVT (p&lt;0.02) and malunion (p&lt;0.02) rates among all types of ankle fractures. There were no differences in complications for patients with single malleolar fractures, although higher rates of implant removal (p&lt;0.01) were noted in patients treated by orthopaedic surgeons. For bimalleolar or trimalleolar fractures, treatment by an orthopaedic surgeon was associated with lower DVT (p&lt;0.03) and malunion (p&lt;0.04) rates. No differences were observed in rates of infection or need for irrigation and debridement based on surgeon type (Table 1). Patients treated by orthopaedic surgeons versus podiatrists were also noted to have a similar median CCI at 2.0 and 2.5, respectively. Conclusion: Operative treatment of ankle fractures by orthopaedic surgeons is associated with lower rates of certain postoperative complications compared with podiatrists. Malunion, in particular, is a surgeon related variable that has a significant impact on functional outcome in unstable ankle fracture patients. The specific reasons for the difference in malunion rates is likely multifactorial, and unable to be answered using this dataset, but warrants further investigation. Our findings have important implications for patients who must choose a surgeon to manage their operative ankle fracture, as well as policy makers who determine scope of practice in orthopaedic surgeons and podiatrists alike.