Osteoporotic Ankle Fractures Research Articles

Clinical Efficacy of Distal Tibial Hounsfield Unit for the Diagnosis of Osteoporosis in Ankle Fractures

Category: Trauma; Ankle Introduction/Purpose: Ankle fracture is one of the most common fractures over the age of 50 years. However, there is a lack of research on osteoporotic ankle fractures compared to other osteoporotic fractures. Recently, some studies have been published that Hounsfield Unit(HU) measuring bone attenuation from CT scan is used for assessing the bone density of not only the hip and spine but also extremities such as the distal radius and proximal humerus. This study aims to evaluate the correlation between HU of distal tibia without ankle fracture and DEXA-BMD and determine the cut-off value of HU for osteoporosis diagnosis. Additionally, this study determines whether the HU of the distal tibia obtained from the preoperative CT scan of ankle fractures helps evaluate patients with osteoporotic ankle fractures. Methods: From June 2016 to August 2020, We retrospectively studied foot and ankle traumatic patients who are postmenopausal women or men over 50 years. They conducted a foot or ankle CT scan containing the axial images of the distal tibia and DEXA- BMD within three months. Patients with open fractures with severe displacement or arthritic change were excluded. The mean HU was obtained from two sequential axial images of the distal tibial metaphysis's largest region of interest (ROI), more than 1cm proximal to the tibial plafond. We divided the patients into Group A without ankle fractures and Group B with distal tibia or fibula fractures in the ankle. The correlation analysis was done between the distal tibial HU and DEXA-BMD. We obtained the cut-off value of the distal tibial HU for osteoporosis using receiver operating characteristic(ROC) curves and compared the results between the two groups. Results: Group A was 38 cases(mean age 69.9), and Group B was 59 (mean age 71.0). There were no statistical differences in patients' characteristics, the mean distal tibial HU, bone density, T-score, and rate of osteoporosis in BMD. All HU values in both groups showed excellent inter- and intra-observer reliability(All intraclass coefficients>0.9). Both groups had significant correlations between the distal tibial HU and DEXA-BMD, especially in the femur neck and L3 spine(r=0.706, 0.622, p< 0.001 in Group A, r=0.625,0.499, p< 0.001 in Group B). The cut-off value for osteoporosis of the distal tibial HU was 153.15(sensitivity 73.9%, specificity 86.7%; area under the curve(AUC) 0.841, 95% CI 0.716-0.965, p< 0.001) in Group A. The cut-off value of Group B was 167.35(sensitivity 66.7%, specificity 75.9%; AUC 0.737, 95% CI 0.610-0.865, p=0.002). Conclusion: The distal tibial HU values on the axial images on the CT showed a significant correlation with the central bone of DEXA-BMD. The distal tibial HU value showed excellent reliability with or without fracture. HU value can be easily obtained using a preoperative ankle CT scan without additional cost & radiation exposure to patients with ankle fractures. Therefore, it can help treat osteoporotic ankle fractures by screening for osteoporosis and deciding the fixation method of surgery.

Tibiotalocalcaneal nailing for osteoporotic ankle fractures in the frail patient: a narrative review with a clinical score proposal for the decision-making process.

Osteoporotic ankle fractures result from mechanical forces that would not ordinarily result in fracture, known as ‘low-energy’ trauma, such as those equivalent to a fall from a standing height or less.Osteoporotic ankle fractures in frail patients are becoming more and more frequent in daily practice and represent a therapeutic challenge for orthopaedic surgeons.The main problems with frail patients are the poor condition of the soft tissues around the ankle, dependence for activities of daily living and high comorbidity.The decision to operate on these patients is complex because conservative treatment is poorly tolerated in unstable fractures and conventional open reduction and internal fixation is associated with a high rate of complications.The authors conducted a narrative review of the literature on primary tibiotalocalcaneal nailing of ankle fractures in frail patients and categorized the different factors to consider when treatment is indicated for this conditon. Difficulty of ambulation, age over 65 years old, deteriorated baseline state and instability of the fracture were the most frequently considered factors.Finally, the authors propose an easy and quick clinical scoring system to help in the decision-making process, although further comparative studies are required to explore its validity.

Three internal fixation methods for Danis-Weber-B distal fibular fractures: A biomechanical comparison in an osteoporotic fibula model

A common agreement for the surgical treatment of osteoporotic ankle fractures has not been defined yet although locking plates are preferred for fractures with poor bone quality. This study aims to evaluate the mechanical stability of locked and conventional plates on osteoporotic Danis-Weber-B-fibula fracture models.Fractured custom-made osteoporotic fibulae were treated with neutralization plate plus lag screw, locking plate plus lag screw, or a standalone locking plate. Load until failure was applied mimicking single-leg stance. Stiffness, failureload, and interfragmentary movements were investigated.Stiffness, failureload and axial fragment movement showed no significant differences among groups. Shear movements and fragment rotation around the shaft of the neutralization plate were on average twice as high as those of the locking plates.Although no superiority was shown for overall mechanical performance, the locking plate groups exhibited higher shear and rotational stability than the neutralization plate.

Fibula pro-tibia vs standard locking plate fixation in an ankle fracture saw bone model.

BACKGROUNDLocking plate fixation in osteoporotic ankle fractures may fail due to cut-out or metalwork failure. Fibula pro-tibia fixation was a technique prior to the advent of locking plates that was used to enhance stability in ankle fractures by achieving tri or tetra-cortical fixation. With locking plates, the strength of this fixation construct can be further enhanced. There is lack of evidence currently on the merits of tibia-pro-fibula augmented locking plate fixation of unstable ankle fractures.AIMTo assess if there is increased strength to failure, in an ankle fracture saw bone model, with a fibula pro-tibia construct when compared with standard locking plate fixation.METHODSTen osteoporotic saw bones with simulated supination external rotation injuries were used. Five saw bones were fixed with standard locking plates whilst the other 5 saw bones were fixed with locking plates in a fibula pro-tibia construct. The fibula pro-tibia construct involved fixation with 3 consecutive locking screws applied across 3 cortices proximally from the level of the syndesmosis. All fixations were tested in axial external rotation to failure on an electromagnetic test frame (MTS 858 Mini-Bionix test machine, MTS Corp, Eden Praire, MN, United States). Torque at 30 degrees external rotation, failure torque, and external rotation angle at failure were compared between both groups and statistically analyzed.RESULTSThe fibula pro-tibia construct demonstrated a statistically higher torque at 30 degrees external rotation (4.421 ± 0.796 N/m vs 1.451 ± 0.467 N/m; t-test P = 0.000), as well as maximum torque at failure (5.079 ± 0.694N/m vs 2.299 ± 0.931 N/m; t-test P = 0.001) compared to the standard locking plate construct. The fibula pro-tibia construct also had a lower external rotation angle at failure (54.7 ± 14.5 vs 67.7 ± 22.9).CONCLUSIONThe fibula pro-tibia locking plate construct demonstrates biomechanical superiority to standard locking plates in fixation of unstable ankle fractures in this saw bone model. There is merit in the use of this construct in patients with unstable osteoporotic ankle fractures as it may aid improved clinical outcomes.

Efficacy of open reduction and internal fixation in management of senile osteoporotic ankle fractures

Objective To explore the efficacy of open reduction and internal fixation in the treatment of senile osteoporotic ankle fractures. Methods A retrospective case series study was conducted to analyze the data of 26 elderly patients with osteoporotic ankle fractures which all caused by sprain from June 2012 to June 2018 in Changhai Hospital, including 10 male and 16 female patients aged from 60 to 93 years (mean, 69.72 years). In these 26 patients, three had medial malleolus fractures, four had lateral malleolus fractures, six had double ankle fractures and 13 had cotton's fractures. According to the Lauge-Hansen type, all 26 patients can be classified into four types: 5 with supination external rotation type, 4 supination adduction type, 16 with pronation-external rotation type and 1 with pronation abduction type. All the patients received open reduction and internal fixation. Plate fixation was used for lateral and posterior malleolus fractures, plate fixation and cannulated screws were applied to fix the comminuted posterior malleolus fracture while in the comminuted internal malleolus fracture, the steel plate was used only when needed. Early professional functional rehabilitation training and active anti-osteoporosis treatment were applied. All the operation time and bleeding volume were recorded, and the reduction of fracture plus the healing of wounds were observed. At last follow-up, American Orthopedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Scale was used to evaluate the treatment effect and the Visual Analogue Scale (VAS)to evaluate the therapeutic effect and the subjective satisfaction of the patients. Complications were recorded as well. Results All patients were followed up for 12-48 months (mean, 23.6 months). Operation time ranged from 30 to 95 minutes (mean, 70 minutes) and bleeding volume ranged from 10 to 150 ml (mean, 70 ml). All patients got satisfied reduction of fracture within 25 patients' incision healing in first intention, although one has fat liquefaction. AOFAS Ankle Hindfoot Scale improved from preoperative (84.4±10.8)points to (31.9±11.4)points at last follow-up (P<0.01), and the results were excellent in five patients, good in 17, fair in three and poor in one, with the excellent and good rate of 85%. VAS improved from preoperative(1.85±0.73)points to (9.23±0.28)points at last follow-up (P<0.01). Among 26 patients, 5 with ankle stiffness of different degree recovered after rehabilitation care, and 2 with internal malleolus fractures had bone displacement when receiving rehabilitation care, with no side effect on basic function. No serious complications such as wound infection or skin necrosis were found. Conclusion For osteoporotic ankle fractures in the elderly, open reduction and internal fixation can promote functional recovery and relieve pain. Key words: Ankle injuries; Osteoporotic fractures; Fracture fixation, internal

Acute Retrograde Tibiotalocalcaneal Nailing for Osteoporotic Ankle Fractures in Fragile Patients

Category:Ankle, TraumaIntroduction/Purpose:With the rising aging of the population, osteoporotic ankle fractures represent a frequent scenario in daily practice. The coexistence of comorbidities such as poorly controlled diabetes mellitus, vascular insufficiency, and poor condition of the surrounded soft tissues, means that conventional open reduction and internal fixation methods often fail. On the other hand, conservative or orthopaedic treatments in such population are badly tolerated. Our study aims to study the short- term outcome of retrograde tibiotalocalcaneal (TTC) nailing in a selected series of fragile patients.Methods:This study included 15 patients who underwent primary retrograde TTC nailing from January 2016 to July 2018. The mean age of the patients was 83,5 years (range, 75 to 88), and the mean follow-up period was 11,5 months (range, 6 to 24 months) with no patient lost to follow-up. All patients but one were diabetic; 2 were non-ambulatory; and 13 walked with walking aids. The authors implemented a primary nailing without addressing tibiotalar or subtalar joint and without using a tourniquet. Complete weight bearing was allowed early as tolerated. Alignment and healing of the fracture were evaluated. American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score were recorded preoperatively and at the final follow-up.Results:One of the patients died 8 months after the treatment. Radiographic healing of the fractures were identified in 100% of the cases. In 2 cases, a complete arthrodesis of the ankle joint was achieved by simple nail reaming (Figure 1). No infection or any scarring problems was recorded. Of the 13 patients who walked with difficulty, 4 remained prostrate to a wheelchair, but the rest maintained their previous autonomy. The mean AOFAS score improved from 48 (range, 14 to 71) preoperatively to 71 (range, 44 to 81) postoperatively.Conclusion:In the view of these results, we suggest that primary retrograde TTC nailing is a valid option in selected patients with fragility ankle fractures, high comorbidity, poor condition of the soft tissues and with difficulties to walk before the fracture. This option allows an early full weight bearing, avoids complications due to joint off-loading, and achieves acceptable functional results.

The result of the treatment in osteoporotic ankle fractures with small fragment using claw plate in elderly

Category: Ankle, Trauma Introduction/Purpose: Osteoporotic fractures in ankle have often included small bone fragments and were very unstable. There had been tried to fix them for anatomical reduction, using variable methods. However, it was not easy to keep the reduction, especially in elderly. The purpose of this study was to evaluate the results of the treatment in ankle fractures with small fragment using claw plate in elderly. Methods: The nineteen patients with ankle fractures, which included the small fragments, from january 2012 to july, 2014 were evaluated retrospectively. All patients were more than 65 years and had osteoporosis. The authors have been tried to fix it using claw plate in all cases. The mean follow up period was 15 months(range, 12month to 18month). The claw plate was designed to catch the small fragment and made of tubular plate or locking tubular plate with bending it after cutting the distal end of them. It had two different hooks to keep the reduction and the fragment. Functional outcome scores were obtained using Olerud Molander Ankle score(OMA), VAS, and American Orthopedic Foot and Ankle Society (AOFAS) score at 2, 3, 6, 9, 12 month after the operation, when each patient underwent a physical examination and radiography. There was evaluated statistically by SPSS 19.0 Results: There were no complication, such as metal failure and loss of reduction. AOFAS score improved from 56.4±3.1 at 2 month to 93±1.5 at 12 month(p=0.01). The VAS improved from 6.2±0.9 at 2 month to 1.2±0.8 at 12 month(p=0.001). OMA score improved from 15.5±0.2 at 2 month to 75±2.5 at 12 month (p=0.001). There was significant difference, statistically. There was obstained the bony union in 3 months after the operation in all cases Conclusion: We suggested that the claw plate is the alternative method to fix the osteoporotic ankle fracture with small fragments in elderly, without complications

The result of the treatment in osteoporotic ankle fractures with small fragment using claw plate

The result of the treatment in osteoporotic ankle fractures with small fragment using claw plate

Optimizing stabilization in osteoporotic ankle fractures

Optimizing stabilization in osteoporotic ankle fractures

Osteoporotic Ankle Fractures: An Approach to Operative Management

The incidence of osteoporosis is increasing as the elderly population grows. Because these patients remain active, fragility fractures of the ankle are becoming more common. The literature indicates a relatively high complication rate for non-operative management of ankle fractures in this patient cohort, leading surgeons to face challenges unique to patients with poor bone and skin quality. This article discusses techniques to address osteoporotic ankle fractures and reviews the current literature relevant to this issue.

Trans-Syndesmotic Fibular Plating for Fractures of the Distal Tibia and Fibula With Medial Soft Tissue Injury

This report presents a retrospective review of several cases of distal fractures of the tibia and fibula with significant injury to the medial soft tissues treated either primarily or in staged fashion with fixed-angle trans-syndesmotic fixation. This fixation strategy was used in an effort to minimize further surgical trauma and implant load in the zone of soft tissue injury. Ten patients were identified between September 2002 and November 2010 who presented to a level I trauma center with fractures of the distal tibia and fibula associated with open medial wounds (9 patients) or extensive closed medial degloving injury (1 patient). They were all treated with trans-syndesmotic plating of the distal fibula. Two patients were lost to follow-up after initial treatment, and an additional 2 patients had follow-up durations of only 6.5 and 3 months, respectively. This left 6 patients with an average of 23.3 months of follow-up (range: 14-36 months). Radiographs and medical records were reviewed, and clinical and radiographic results were evaluated. All 6 patients had radiographic evidence of bony healing and had resumed weight bearing. Two patients required additional bone graft surgery to encourage healing, 1 of whom also required free-flap coverage as a component of the nonunion repair. One patient resumed weight bearing earlier than instructed and experienced mild but acceptable loss of reduction. No patients developed wound infections of either the medial traumatic or lateral surgical wounds, although, as noted above, 1 of the patients with a nonunion required medial free-flap coverage as a component of the nonunion repair because of incompetent medial soft tissues. Trans-syndesmotic fixation has previously been described as providing enhanced fixation of diabetic and osteoporotic ankle fractures but has not, to our knowledge, been described for the treatment of higher energy traumatic injuries. Specifically, the valgus distal tibial fracture, frequently associated with medial traction wounds, can present challenges to the treating surgeon in terms of obtaining adequate fixation although minimizing wound complications associated with the soft tissue injury. In a select subset of injuries, trans-syndesmotic fixation can provide a viable means of obtaining and maintaining either definitive fixation or enhancing the provisional fixation supplied by spanning external fixation.

(iii) The osteoporotic ankle fracture

Conservative management of osteoporotic ankle fractures is associated with high displacement rates and elderly patients are often unable to restrict their weight bearing, leading to longer hospital stays. Operative surgery is challenging and may lead to loss of reduction or implant failure from screw ‘cut out’. This paper describes some of the operative techniques in this difficult group of patients.

Percutaneous Gallagher nail stabilisation for fragility ankle fracture

Osteoporotic fragility fractures of the ankle in the elderly present a difficult challenge for the orthopaedic surgeon. There is a high incidence of complications with both operative and non-operative treatment. We have treated nine such fractures by closed reduction and percutaneous ankle stabilisation using a transarticular Gallagher nail introduced via the calcaneum and directed through the talar dome into the tibia. The median patient age was 81 years (range 60–101 years). Mean duration of patient follow-up was 34 months. All the fractures maintained satisfactory alignment and healed without delay. Pain-free transfer with assistance was possible in all patients by 8 weeks post-operatively. Nails were removed in eight patients. Six patients returned to pre-fracture mobility status. Union was achieved in eight cases. No wound complications occurred. Gallagher nail percutaneous trans-calcaneal stabilisation provides a means of sole definitive fixation in the management of unstable osteoporotic ankle fractures in the elderly.

Comparison of Augmentation Methods for Internal Fixation of Osteoporotic Ankle Fractures

Internal fixation of osteoporotic ankle fractures is associated with failure of fixation. This study compared different augmentation methods biomechanically. In nine paired fresh-frozen cadaver legs, an identical supination-external rotation type II ankle fracture was created. Fractures were stabilized using an eight-hole locking plate. In four pairs, two screws were inserted across the syndesmosis for purchase in the tibial metaphysis. One leg from each pair was randomly selected for injection of calcium sulphate-calcium phosphate graft into the screw holes. Each leg was mounted to an MTS machine in a custom loading frame. Axial cyclic loading to body weight was performed to measure displacement at the fracture site, followed by rotational loading to failure simulating a supination external rotation injury. Data were analyzed using a two-way paired t-test and ANOVA. The specimens used had a mean bone mineral density of 0.49 +/- 0.15 (SD) g/cm(2), and a mean age of 83 +/- 12 years. In the biomechanical tests, there were no significant differences between augmented and non-augmented locking plates without the tibia-pro-fibula screws in axial stiffness (p = 0.10), external rotation angle at failure (p = 0.42), failure torque (p = 0.57), energy absorbed before failure (p = 0.47), and motion at the fracture site with cyclic axial loading (p = 0.15). There were no significant differences between augmented and non-augmented locking plates with the tibia-pro-fibula screws in the external rotation angle at failure (p = 0.83), failure torque (p = 0.58), and failure energy (p = 0.4). However, the overall strength of the fixation tended to increase with tibia-pro-fibula screws and augmentation. Internal fixation of an osteoporotic lateral malleolar fracture using a locking plate and screws provided a construct comparable in strength to that augmented with calcium sulfate-calcium phosphate graft and/or tibia-pro-fibula screws. Strategies to augment internal fixation of osteoporotic ankle fractures may minimize risk for failure of fixation and may enable early weight bearing mobilization and return to function in elderly patients.

Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: A report on four cases

Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: A report on four cases

Combination of Hook Plate and Tibial Pro-Fibular Screw Fixation of Osteoporotic Fractures: A Clinical Evaluation of Operative Strategy

Internal fixation of osteoporotic ankle fractures is technically difficult and may fail because of unreliable purchase. This study was undertaken to determine if a combination of a hook plate and tibial pro-fibular screws can provide secure fixation until fracture union. Thirty-one patients between the ages of 55 and 90 years had open reduction and internal fixation of ankle fractures between April, 2001, and April, 2003. Sixteen patients with an average age of 71.4 years had ankle fracture fixation with a combination of hook plate and tibial pro-fibular screws for the distal fibular fracture, and 15 patients with an average age of 71.9 years had fixation of their ankle fractures with standard fixation technique using AO/ASIF principles but no tibial pro-fibular screws. All patients were followed with clinical and radiologic assessment at 2 weeks, 6 weeks, and 12 weeks postoperatively. At an average of 15.8 months after injury, patients also completed a mailed questionnaire with the Olerud-Molander ankle score and the AOFAS ankle-hindfoot score for preoperative and postoperative status. All patients who had tibial pro-fibular screw fixation had fracture union without hardware failure or complications. In the standard fixation group two patients had wound breakdown and one had a valgus malunion with screw pull out. The AOFAS and Olerud-Molander scores for the standard open reduction and internal fixation were 57.3 and 82.8 before injury and 37 and 43.8 postoperatively, respectively. The AOFAS and Olerud-Molander scores for the hook plate and tibial pro-fibular fixation group were 55.9 and 81.3 before injury and 42.4 and 50.3 postoperatively, respectively. The combination of hook plate and tibial pro-fibular screws in osteoporotic ankle fractures in a series of patients has not been reported before. This novel technique provides stable fixation for osteoporotic ankle fractures in elderly patients until union is achieved with good clinical scores.

Treatment of Osteoporotic Ankle Fractures in the Elderly: Surgical Strategies

The goal of displaced ankle fracture treatment is to restore congruity and stability to the ankle mortise. However, adequate fixation in patients with osteoporosis is difficult due to poorly mineralized bone. This article presents alternative fixation strategies that can helpachieve ankle stability in this patient population.

Epidemiology of osteoporotic ankle fractures in elderly persons in Finland.

Although osteoporotic or minimal trauma fractures among elderly persons are a major public health problem worldwide, epidemiologic information on these fractures is limited. To determine the current trend in the number and incidence of osteoporotic ankle fractures in the elderly. A fracture was defined as osteoporotic only if it occurred as a result of minimal trauma in a person 60 years of age or older. National hospital discharge register. Finland, a country with approximately 5 million inhabitants. All patients 60 years of age or older who were admitted to hospitals in Finland for primary treatment of first osteoporotic ankle fracture in 1970 to 1972, 1974, 1975, 1978 to 1980, 1983 to 1985, 1988 to 1989, and 1991 to 1994. The number and the age-specific and age-adjusted incidence of osteoporotic ankle fractures in each year of the study. For the study period, the number and incidence (per 100,000 persons) of osteoporosis-related ankle fractures in Finnish persons 60 years of age or older increased considerably (370 and 57, respectively, in 1970 compared with 1243 and 130, respectively, in 1994). The age-adjusted incidence of these fractures also increased in women, from 66 in 1970 to 162 in 1994, and in men, from 38 in 1970 to 82 in 1994. The number of osteoporotic ankle fractures in Finland is increasing at a rate that cannot be explained simply by demographic changes. Vigorous preventive measures are needed to control the increasing burden of this type of fracture.