Ankle Fracture Surgery Research Articles

Risk Factors for Prolonged Opioid Use After Ankle Fracture Surgery.

The incidence of ankle fractures is increasing, and risk factors for prolonged opioid use after ankle fracture fixation are unknown. Accordingly, the purpose of this study was to investigate risk factors that lead to prolonged opioid use after surgery. The Truven MarketScan database was used to identify patients who underwent ankle fracture surgery from January 2009 to December 2018 based on CPT codes. Patient characteristics were collected, and patients separated into 3 cohorts based on postoperative opioid use (no refills, refills within 6 months postoperative, and refills within 1 year postoperatively). The χ2 test and multivariate analysis were performed to assess the association between risk factors and prolonged use. In total, 34 691 patients were analyzed. Comorbidities most highly associated with prolonged opioid use include 2+ preoperative opioid prescriptions (odds ratio [OR] = 11.92; P < .001), tobacco use (OR = 2.03; P < .001), low back pain (OR = 1.81; P < .001), depression (OR = 1.48; P < .001), diabetes (OR = 1.34; P < .001), and alcohol abuse (OR = 1.32; P < .001). Opioid use after ankle fracture surgery is common and may be necessary; however, prolonged opioid use and development of dependence carries significant risk. Identifying those patients at an increased risk for prolonged opioid use can aid providers in tailoring their postoperative pain regimen. Prognostic, Level III.

Effects of hospital funding reform on wait times for hip fracture surgery: a population-based interrupted time-series analysis

BackgroundHealth care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences. We assessed the effects of introducing a targeted hospital funding model, based on fixed price and volume, for hip fractures. We hypothesized the policy change was associated with reduction in wait times for hip fracture surgery, increase in wait times for non-hip fracture surgery, and increase in the incidence of after-hours hip fracture surgery.MethodsThis was a population-based, interrupted time series analysis of 49,097 surgeries for hip fractures, 10,474 for ankle fractures, 1,594 for tibial plateau fractures, and 40,898 for appendectomy at all hospitals in Ontario, Canada between April 2012 and March 2017. We used segmented regression analysis of interrupted monthly time series data to evaluate the impact of funding reform enacted April 1, 2014 on wait time for hip fracture repair (from hospital presentation to surgery) and after-hours provision of surgery (occurring between 1700 and 0700 h). To assess potential adverse consequences of the reform, we also evaluated two control procedures, ankle and tibial plateau fracture surgery. Appendectomy served as a non-orthopedic tracer for assessment of secular trends.ResultsThe difference (95 % confidence interval) between the actual mean wait time and the predicted rate had the policy change not occurred was − 0.46 h (-3.94 h, 3.03 h) for hip fractures, 1.46 h (-3.58 h, 6.50 h) for ankle fractures, -3.22 h (-39.39 h, 32.95 h) for tibial plateau fractures, and 0.33 h (-0.57 h, 1.24 h) for appendectomy (Figure 1; Table 3). The difference (95 % confidence interval) between the actual and predicted percentage of surgeries performed after-hours − 0.90 % (-3.91 %, 2.11 %) for hip fractures, -3.54 % (-11.25 %, 4.16 %) for ankle fractures, 7.09 % (-7.97 %, 22.14 %) for tibial plateau fractures, and 1.07 % (-2.45 %, 4.59 %) for appendectomy.ConclusionsWe found no significant effects of a targeted hospital funding model based on fixed price and volume on wait times or the provision of after-hours surgery. Other approaches for improving hip fracture wait times may be worth pursuing instead of funding reform.

Difference in postoperative opioid consumption after spinal versus general anaesthesia for ankle fracture surgery-A retrospective cohort study.

Surgical treatment of ankle fracture is associated with significant pain and high postoperative opioid consumption. The anaesthesia method may affect early postoperative pain. The main objective of the study was to compare postoperative opioid consumption after ankle-fracture surgery between patients treated with spinal anaesthesia and general anaesthesia. We reviewed retrospectively the files of 586 adult patients with surgically treated ankle fracture in the years 2014 through 2016. The primary outcome was opioid consumption during the first 48 postoperative hours. Secondary outcomes were maximal pain scores, postoperative nausea and vomiting, the length of stay in the post-anaesthesia care unit, and opioid use in different time periods up to 48h postoperatively. Propensity score matching was used to mitigate confounding variables. Total opioid consumption 48h postoperatively was significantly lower after spinal anaesthesia (propensity score-matched population: effect size -13.7 milligrams; 95% CI -18.8 to -8.5; P<.001). The highest pain score on the numerical rating scale in the post-anaesthesia care unit was significantly higher after general anaesthesia (propensity score-matched population: effect size 3.7 points; 95% CI 3.2-4.2; P<.001). A total of 60 patients had postoperative nausea and vomiting in the post-anaesthesia care unit, 53 (88.3%) of whom had general anaesthesia (P=.001). Patients with surgically treated ankle fracture whose operation was performed under general anaesthesia used significantly more opioids in the first 48h postoperatively, predominantly in the post-anaesthesia care unit, compared with patients given spinal anaesthesia.

The impact of preoperative opioid use on complications, readmission, and cost following ankle fracture surgery

BackgroundThe incidence of ankle fractures requiring surgical fixation is increasing. Although there has been increasing evidence to suggest that preoperative opioid use negatively impacts surgical outcomes, literature focusing primarily on ankle fractures is scarce. The purpose of this study was to investigate the relationship between preoperative opioid use and outcomes following ankle fracture open reduction and surgical fixation (ORIF). We hypothesized that patients prescribed higher preoperative oral morphine equivalents (OMEs) would have poorer postoperative outcomes. MethodsThe Truven Marketscan claims database was used to identify patients who underwent ankle fracture surgery from 2009 to 2018 based on CPT codes. We used preoperative opioid use status to divide patients into groups based on the average daily OMEs consumed in the 6 months before surgery: opioid-naive,<1, 1-<5, 5-<10, and ≥10 OMEs per day. We retrieved 90-day complication, ER visit, and readmission rates. Opioid use groups were then compared with binomial logistic regression and generalized linear models. ResultsWe identified 61,424 patients. Of those patients, 80.9% did not receive any preoperative opioids, while 6.6%, 6.9%, 1.7%, and 3.9% received <1, 1-<5, 5-<10, and ≥10 OMEs per day over a 6-month time period, respectively. Complications increased with increasing preoperative OMEs. Multivariate analysis revealed that patients using 1-<5 OME per day had increased rates of VTE and infections, while patients using >5 OME per day had higher rates of ED visits, and patients using >10 OMEs had higher rates of pain related ED visits and readmissions. Adjusted differences in 6-month preoperative and 3-month postoperative health care costs were seen in the opioid use groups compared with opioid-naive patients, ranging from US$2052 to US$8,592 (P<.001). ConclusionOpioids use prior to ankle fracture surgery is a common scenario. Unfortunately preoperative opioid use is a risk factor for postoperative complications, ER visits, and readmissions. Furthermore this risk is greater with higher dose opioid use. The results of this study suggests that surgeons should encourage decreased opioid use prior to ankle fracture surgery.

Insulin Dependence Increases the Risk of 30-Day Postoperative Complications Following Ankle Fracture Surgery in Patients With Diabetes Mellitus

Patients with diabetes mellitus that undergo ankle fracture surgery have higher rates of postoperative complications compared to patients without diabetes mellitus. We evaluated the rate of complications in insulin-dependent diabetes mellitus patients, non-insulin-dependent diabetes mellitus patients, and patients without diabetes in the 30-day postoperative period following ankle fracture surgery. We also analyzed hospital length of stay, unplanned readmission, unplanned reoperation, and death. Patients who underwent operative management for ankle fractures between 2012 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program® database using Current Procedural Terminology codes. Multiple logistic regression was implemented. Adjusted odds ratios were calculated along with the 95% confidence interval. A total of 19,547 patients undergoing ankle surgery were identified from 2012 to 2016. Of these patients, 989 (5.06%) had insulin-dependent diabetes mellitus, 1256 (6.43%) had noninsulin-dependent diabetes mellitus, and 17,302 (88.51%) did not have diabetes mellitus. Compared to patients without diabetes, patients with insulin-dependent diabetes mellitus had significantly greater adjusted odds of superficial surgical site infections, deep surgical site infections, osteomyelitis, wound dehiscence, pneumonia, unplanned intubation, mechanical ventilation, urinary tract infection, cardiac arrest, bleeding requiring transfusion, sepsis, hospital length of stay, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery. We demonstrate that insulin-dependent diabetes mellitus is a strong predictor of 30-day postoperative complications, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery.

What is the effect of smoking on postoperative outcomes after ankle-fracture surgery? A retrospective cohort study

Background: Smoking is a primary modifiable factor associated with postoperative complications after ankle-fracture fixation. Although most literature concludes that smoking is detrimental to wound healing and tissue oxygenation, there remains disparity in studies reporting on outcomes after ankle-fracture surgery. Therefore, our purpose was to evaluate the differences in (1) infection; (2) malunion and nonunion rates; (3) return to the operating room; and (4) overall complication rates between smokers and nonsmokers who underwent ankle-fracture fixation. Methods: Patients who had ankle-fracture surgery at our institution between July 2012 and April 2014 were retrospectively identified. Information was collected on demographics, injury data, and smoking status. The incidences of infection, malunion or nonunion, and postoperative complications and revision surgery were determined. A P value of 0.05 was used to determine statistical significance. There were 263 patients included in this study, 112 smokers and 151 nonsmokers. Results: The overall infection rate in the smoker cohort was 29.4% compared with 9.9% in the nonsmoker cohort, and there was a four-fold higher rate of malunions and nonunions in the smoker compared with the nonsmoker cohort (8.7% vs. 2%). The overall rate of return to the operating room was higher in the smoker compared to nonsmoker group (67.8 vs. 43.7%), as well as complication rates (8.9% vs. 2.6%; odds ratio [OR] 3.6, 95% confidence interval [CI] 1.1 to 11.8). Conclusions: This study showed that tobacco smoking had a direct adverse effect on infection rates, union, and return to the operating room in patients who underwent ankle-fracture fixation. These findings reiterated the importance of advocating for smoking cessation to improve postoperative clinical outcomes. Level of Evidence: Level III.

Peri-incisional perfusion does not differ between running versus interrupted Allgöwer-Donati suture technique in ankle fracture surgery: a pilot randomized controlled trial of wound perfusion

Objectives:To compare peri-incisional perfusion, perfusion impairment and wound closure time between the conventional interrupted Allgöwer-Donati (IAD) technique and a modified running Allgöwer-Donati (RAD) technique in ankle fracture surgery.Design:Prospective, randomized controlled clinical trial.Setting:Level I and II trauma centers.Patients:Twenty-five healthy adults with ankle fractures (AO/OTA 44-A, 44-B, or 44-C) between November 2017 and December 2018. (Of 26 patients enrolled in this study, 1 was lost to follow-up.)Intervention:Participants were randomized into the IAD or the RAD group (13 patients each). All participants were followed for at least 3 months after surgery to assess for wound complications.Main Outcome Measurements:Skin perfusion was assessed immediately after wound closure with laser-assisted indocyanine green angiography. Wound closure time, mean incision perfusion, and mean perfusion impairment were measured and compared with analysis of variance. Alpha = 0.05.Results:The RAD technique was significantly faster in terms of mean (± standard deviation) wound closure time (6.2 ± 1.4 minutes) compared with the IAD technique (7.3 ± 1.4 minutes) (P = 0.047). We found no differences in mean incision perfusion and mean perfusion impairment (all, P > 0.05).Conclusion:The IAD and RAD techniques resulted in similar peri-incisional perfusion and perfusion impairment. Closure time was significantly shorter for the RAD technique compared with the IAD technique.Level of Evidence:I

Opioid Consumption Patterns and Prolonged Opioid Use Among Opioid-Naïve Ankle Fracture Patients.

Previous literature has demonstrated an association between acute opioid exposure and the risk of long-term opioid use. Here, the investigators assess immediate postoperative opioid consumption patterns as well as the incidence of prolonged opioid use among opioid-naïve patients following ankle fracture surgery. Included patients underwent outpatient open reduction and internal fixation of an ankle or tibial plafond fracture over a 1-year period. At patients' first postoperative visit, opioid pills were counted and standardized to the equivalent number of 5-mg oxycodone pills. Prolonged use was defined as filling a prescription for a controlled substance more than 90 days after the index procedure, tracked by the New Jersey Prescription Drug Monitoring Program up to 1 year postoperatively. At the first postoperative visit, 173 patients consumed a median of 24 out of 40 pills prescribed. The initial utilization rate was 60%, and 2736 pills were left unused. In all, 32 (18.7%) patients required a narcotic prescription 90 days after the index procedure. Patients with a self-reported history of depression (P = .11) or diabetes (P = .07) demonstrated marginal correlation with prolonged narcotic use. Our study demonstrated that, on average, patients utilize significantly fewer opioid pills than prescribed and that many patient demographics are not significant predictors of continued long-term use following outpatient ankle fracture surgery. Large variations in consumption rates make it difficult for physicians to accurately prescribe and predict prolonged narcotic use. Level III.

Peripheral nerve block anaesthesia and postoperative pain in acute ankle fracture surgery: the AnAnkle randomised trial

BackgroundPeripheral nerve blocks (PNBs) are increasingly popular in acute ankle fracture surgery but rebound pain may outweigh the benefits. The AnAnkle Trial was designed to assess the postoperative pain profile of PNB anaesthesia compared with spinal anaesthesia (SA). MethodsThe AnAnkle Trial was a randomised, two-centre, blinded outcome analysis trial. Eligible adults booked for primary ankle fracture surgery were randomised to PNB or SA. The PNBs were ultrasound-guided popliteal sciatic and saphenous blocks with ropivacaine and SAs were with hyperbaric bupivacaine. Postoperatively, all subjects received paracetamol, ibuprofen, and patient-controlled i.v. morphine for pain. The primary endpoint was 27 h Pain Intensity and Opioid Consumption (PIOC) score. Secondary endpoints included longitudinal pain scores and morphine consumption separately, and questionnaires on quality of recovery. ResultsThis study enrolled 150 subjects, and the PNB success rate was >94%. PIOC was lower with PNB anaesthesia (median, –26.5% vs +54.3%; P<0.001) and the probability of a better PIOC score with PNB than with SA was 74.8% (95% confidence interval, 67.0–82.6). Pain scores and morphine consumption analysed separately also yielded a clear benefit with PNB, despite substantial rebound pain when PNBs subsided. Quality of recovery scores were similar between groups, but 99% having PNB vs 90% having SA would choose the same anaesthesia form again (P=0.03). ConclusionsPNB anaesthesia was efficient and provided a superior postoperative pain profile compared with SA for acute ankle fracture surgery, despite potentially intense rebound pain after PNB. Clinical trial registrationClinicaltrialsregister.eu, EudraCT number: 2015-001108-76.

Second-look arthroscopic findings and clinical outcomes after management of intra-articular lesions in acute ankle fractures with arthroscopy

BackgroundAnatomically surgical reduction of ankle fractures does not always result in a clinically favorable outcome. Arthroscopic examination combined with treatment of intra-articular lesion may related to clinical outcomes ObjectivesThe purpose of the present study was to review initial and second look arthroscopic finding of acute ankle fracture and to evaluate clinical outcomes. ResultsLauge-Hansen classification system of ankle fractures included supination-external rotation type (n = 24), supination-adduction type (n = 3), pronation-external rotation type (n = 7), and pronation-abduction type (n = 6), total 40 ankles. Osteochondral lesions were found in 25 ankles (62%) with an initial arthroscopic finding of acute ankle fracture. Newly discovered chondral lesions in secondary arthroscopy were found in 17 cases. According to the Ferkel and Cheng staging at secondary arthroscopy, 4 of 25 ankles with osteochondral lesions of the talus were deteriorating (more than stage D). In terms of ICRS overall repair grades, 5 ankles (20%) were abnormal (grade III). Diffuse synovitis and arthrofibrosis were found in 12 and 7 ankles, respectively, in secondary arthroscopy, and correlations were found between AOFAS scores, VAS and intra-articular lesions. ConclusionSecond-look arthroscopic examination combined with treatment of intra-articular lesion such as arthrofibrosis and osteochondral lesion arising from ankle fracture surgery may consider to improve clinical outcomes.

Morphology of the incisura fibularis in the Turkish population

Aim: Morphology of the distal tibiofibular syndesmosis plays an important role in the pattern of ankle fracture and reduction strategy. This study aimed to describe the normal morphology of the distal tibiofibular syndesmosis in a Turkish population. Materials and Methods: All analyzes were based on 349 computed tomography images, contributed by 265 male and 84 female patients. The following features were measured on axial images: the depth of the incisura fibularis, anterior tibiofibular depth, posterior tibiofibular depth, anterior-posterior length of the fibula, mediolateral width of the fibula, version of the incisura fibularis, anterior tubercle length, posterior tubercle length, and tibiofibular engagement. All measure ts were performed by an orthopedic surgeon and an experienced musculoskeletal radiologist, repeated at a 2-week interval. Results: The most common morphology of the incisura fibularis was concave (C-shape, depth >4 mm, 66.5%), followed by a shallow morphology (I-shape, depth 4 mm, 18.3%), and r-shape (15.2%). Significant between-sex differences were identified for depth of the incisura fibularis, posterior tibiofibular depth, anterior-posterior length of fibula, mediolateral width of the fibula, anterior tubercle length, posterior tubercle length, tibiofibular engagement, and incisura fibularis height. Across the three morphologies (C-, I- and r-shape), there was a significant difference in the anterior tibiofibular depth, anterior-posterior length of the fibula, degree of retroversion of the incisura fibularis, and extent of tibiofibular engagement (p0.001). Conclusions: Knowledge of the variability in the morphology and measurements of the features of the incisura fibularis can be useful in the diagnosis of syndesmosis injury and lowering the risk of malreduction during surgery of ankle fractures among Turkish individuals.

Retrospective chart review of perioperative pain management of patients having surgery for closed ankle fractures using peripheral nerve blocks at a level one trauma center.

The objective of this investigation was to evaluate the effect of preoperative peripheral nerve blockade on pain outcomes after ankle fracture surgery. After approval from our institutional review board, a Current Procedural Terminology code search was performed of all patients within our institution over a 3-year data collection period (August 2016-June 2019). This resulted in 177 subjects who underwent isolated closed ankle fracture open reduction internal fixation (ORIF), of which 71 subjects met inclusion criteria. Results of the primary outcome measures found no difference in the mean postoperative care unit (PACU) pain scores between the groups (2.39 ± 2.91 vs 3.52 ± 3.09; P = 0.1724) nor the frequency of those who reported only mild pain (63.0% vs 47.10%; P = 0.2704). Subjects who received a peripheral nerve block spent more time in the PACU before discharge (2.06 ± 1.05 vs 0.94 ± 1.21 hours; P = 0.0004). Subjects receiving a peripheral nerve block were more likely to be given no analgesics in the PACU (38.9% vs 11.8%; P = 0.042) and less likely to receive a narcotic analgesic in the PACU (53.7% vs 82.4%; P = 0.047). Although the results of this investigation demonstrate no significant difference in the mean PACU pain scores, they do demonstrate a significant difference in the amount of pain medication given in the PACU setting. This information will be used for future investigations of this discrepancy between pain perception and need for immediate postoperative pain medications as it relates to multimodal pain control in the setting of ankle fracture surgery.

Effects of microsurgical repair treatment on the clinical efficacy, complications, and flap follow-up scores of patients with exposed steel plates after surgery for foot and ankle fractures.

Treatment of exposed steel plates after surgery for foot and ankle fractures is complicated. This study aims to analyze the effects of microsurgical repair treatment on the clinical efficacy, complications, and flap follow-up scores of patients with exposed steel plates following foot and ankle fracture surgery. Eighty-two patients with exposure of steel plates after surgical treatment for foot and ankle fractures in our hospital from March 2017 to March 2018 were included in this study. The patients were divided into a study group (43 patients who received microsurgical repair) and a control group (39 patients who received conventional repair surgery). We compared the clinical efficacy, complication rate, flap followup score, recovery of ankle-hindfoot function and ankle function before treatment and at 3 and 6 months after treatment, and patient satisfaction between the two groups. The clinical effectiveness rate in the study group was 95.35%, which was higher than the control group (76.92%) (P<0.05). The flap appearance, texture, and elasticity scores in the study group were higher than those in the control group (P<0.05). After treatment, the American Orthopedic Foot and Ankle Society (AOFAS) score and Baird ankle score increased significantly in both groups, and reached a peak at 6 months after treatment. The peak scores of the study group were considerably higher than those of the control group at each period after treatment (P<0.05). The incidence of complications in the study group (6.98%) was lower than the control group (25.64%) (P<0.05). Patient satisfaction was higher in the study group (97.67%) than the control group (79.49%) (P<0.05). Microsurgical repair of exposed steel plates after surgery for foot and ankle fractures has a significant clinical effect. It can improve the flap follow-up scores, accelerate healing of the ankle, improve aesthetics, and reduce the incidence of complications. It is therefore worthy of widespread use in clinics.

Factors Affecting Emergency Department Visits, Readmissions, and Reoperations within 30 Days of Ankle Fracture Surgery: An Institutional Retrospective Study

Category:Ankle; TraumaIntroduction/Purpose:With the U.S. healthcare system focused on value of care, providers and hospitals are increasingly measured by factors that increase patient care and decrease healthcare cost. Early postoperative adverse events not only increase healthcare cost, but also illuminate areas of potential improvement in patient care. This study aims to delineate factors that may influence emergency department visits, admissions, and reoperations within 30 days of ankle fracture surgery.Methods:This retrospective review of patients at a Level 1 trauma center evaluated 30-day outcomes after ankle fracture surgery over a 4-year period (2015-2018). The outcome measures assessed were emergency department visits within 30 days, unplanned readmissions within 30 days and unplanned return to the operating room (OR) within 30 days. Patient and injury characteristics were investigated as potential factors related to these 30-day outcomes. Multiple linear regression was used for outcomes. P-values less than 0.05 were considered significant.Results:A total of 619 patients were identified. After exclusion of concurrent pilon fractures, 596 patients were eligible for final analysis. Forty-three (7.2%) patients visited the emergency department within thirty days, 30 (5.0%) patients were readmitted within thirty days, and 10 (1.7%) patients requiring unplanned return to the OR within thirty days. Sex, insurance status, comorbidities such as pulmonary disease, diabetes mellitus, psychiatric disease, and chronic kidney disease, smoking status, and fracture type/location were not found to be significantly related to 30-day events. Age less than 45 was a significant risk factor for returning to the ED within 30 days (RR 2.1, p=0.02). Open fractures were more likely to require unplanned reoperation than closed fractures (RR 5.7, p<0.01).Conclusion:Age less than 45 years old was a risk factor for early ED visits. Open fractures were found to be at increased risk of needing unplanned reoperation. While further investigation into these risk factors is necessary to fully delineate a causal relationship, these findings can help physicians identify ‘at-risk’ populations after ankle fracture surgery and provide the necessary care to minimize early postoperative events.

Hypoalbuminemia is an Independent Predictor of 30-Day Postoperative Complications Following Surgical Fixation of Ankle Fractures

Category:Basic Sciences/Biologics; Trauma; OtherIntroduction/Purpose:Malnutrition is known to be negatively associated with outcomes after multiple orthopedic procedures. We hypothesized that admission albumin levels, as a maker for malnutrition, would correlate with postoperative outcomes. The purpose of this study is to investigate this relationship following surgery for ankle fracture.Methods:This is a retrospective cohort study of the ACS-NSQIP database. Patients undergoing operative fixation of an ankle fracture were identified. 6,138 patients with albumin available for analysis were identified. Baseline patient information, preoperative serum albumin levels, 30-day postoperative complications, readmission, reoperation, and length of stay data were then collected. Poisson regression with robust error variance was performed to assess the effect of preoperative serum albumin level on postoperative outcomes.Results:6,138 patients with albumin available for analysis were identified in the database. The mean albumin level was 3.86 g/dl and 20.3% of patients with available albumin levels were hypoalbuminemic. Multivariate analysis revealed that albumin level <3.5 g/dl is an independent risk factor for complication (RR 1.42, 95% CI 1.13-1.78, p=0.002) and readmission (RR 1.54, 95% CI 1.13- 2.08, p =0.006). Additionally, when analyzed as a continuous variable, albumin level was negatively correlated with risk of mortality (RR 0.37, 95% CI 0.19-0.72, p=0.003). Patients with hypoalbuminemia also had significantly longer length of stays (4.5 v. 2.1 days, p<0.001).Conclusion:While complication rates after fixation of ankle fractures remain low, hypoalbuminemia is a predictor of postoperative course. Malnutrition, therefore, may help inform the decision between surgical and conservative management of patients with ankle fractures potentially amenable to non-operative management. Additionally, hypoalbuminemia should trigger heightened awareness and prophylactic therapy where appropriate.

Impact of Skin Suture Pattern on Incision Perfusion Using Intraoperative Laser Angiography: A Randomized Clinical Trial of Patients With Ankle Fractures.

To assess which skin suture pattern-simple, vertical mattress, horizontal mattress, Allgöwer-Donati (AD), or running subcuticular-enables the greatest degree of perfusion as measured by indocyanine green laser angiography after ankle fracture surgery. Prospective, randomized. Level 1 Academic Trauma Center. Seventy-five patients undergoing ankle fracture surgery were prospectively randomized to 1 of 5 skin suture patterns (n = 15 per cohort). Patient demographics and operative parameters were similar between groups. Skin perfusion was assessed intraoperatively after skin closure using indocyanine green laser angiography and quantified in fluorescence units. Two perfusion values were collected: (1) mean incision perfusion was the mean of 10 points along the incision and (2) mean perfusion impairment was the perfusion difference between the incision and the skin adjacent to it. We also collected a postoperative patient scar assessment score. Running subcuticular closure had significantly better mean incision perfusion than all other closure patterns. Mean perfusion impairment also favored running subcuticular closure, which was significantly lower than all other suture patterns except AD. We found no patient perceived cosmetic differences between the 5 suture pattern types. Running subcuticular suture pattern resulted in the greatest incision perfusion than simple, horizontal mattress, vertical mattress, and AD techniques after ankle fracture fixation. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Management of Ankle Fractures with Syndesmotic Disruption: A Survey of Orthopaedic Surgeons

Category:Ankle; TraumaIntroduction/Purpose:With an increasing frequency of syndesmotic fixation during ankle fracture ORIF and no current gold standard management protocol, it is important for surgeons to understand the frequency and usage patterns of the various techniques among other orthopaedic surgeons. The purposes of this study are to determine how orthopaedic surgeons currently manage ankle fractures with concomitant syndesmotic disruption and to identify surgeon demographics predictive of syndesmotic management.Methods:An 18-question survey, including 10 specific syndesmotic management questions was sent to the Orthopaedic Trauma Association (OTA) and Canadian Orthopaedic Association (COA), as well as sent to email addresses of foot and ankle-fellowship trained surgeons. Surgeon demographic questions included years, country, and type of practice, fellowship(s) completed, setting of ankle fracture surgery, and number of ankle fractures operated on per year. Multinomial regression analysis was performed to determine if surgeon demographics were predictive of syndesmotic management.Results:One-hundred ten orthopaedic surgeons completed our survey. Selected predictors of syndesmotic management included: private practice with academic appointments (0.077 [0.007, 0.834]; p=0.035) being predictive of not using screws through an ORIF plate; foot & ankle fellowship (9.981 [1.787, 55.764]; p=0.009) and trauma fellowship (6.644 [1.302, 33.916]; p=0.023) predictive of utilizing screws through a plate; no fellowship (14.886 [1.226, 180.695]; p=0.034) predictive of only using 1 screw; and surgeons practicing in the U.S. were more likely to not use screws across just 3 cortices (0.031 [0.810, 3.660]; p=0.009). Additionally, among those utilizing suture-button devices, foot & ankle fellowship-trained surgeons were more likely to implement suture-button through plate (7.676 [1.286, 45.806]; p=0.025).Conclusion:Several surgeon factors influence decision making in the management of ankle fractures with syndesmotic disruption. This study raises awareness of differences in management strategies that should be used for further discussion when determining a potential gold standard for management of these complex injuries.

Reliability of Postoperative Radiographies in Ankle Fractures.

The accuracy of reduction of ankle fractures using postoperative plain radiographies (x-ray) remains widely controversial. Some authors have demonstrated that postoperative computed tomography (CT) scan can be useful for these patients. In current study, the efficacy of x-rays after fixation of ankle fractures was investigated based on the CT scan findings. A total of 73 patients with ankle fractures who were subjected to open reduction internal fixation (ORIF) were enrolled. After surgery, if the reduction was acceptable based on the x-rays according to standard measurements, the patient was referred for CT scanning. Forty four patients were included in the study. Undesirable CT scan findings including malreduction of fragments or articular surfaces, device malpositioning, missed fractures, and undetected intra-articular fragments were documented. Undesirable CT findings were seen in 25 patients (56.8%). CT scan showed acceptable reduction without device malpositioning in 19 patients. The most prevalent findings in CT images were malreduction and device malpositioning in 17 and 16 patients, respectively. There was no abnormal finding in CT imaging of lateral malleolar fractures. In two thirds of the injured syndesmosis, device malpositioning, and malreduction were detected in CT scan. Despite acceptable postoperative x-rays, a considerable number of patients with ankle fractures had inappropriate reduction or undesirable findings in their postoperative CT scan. It seems necessary to use CT scan after ORIF of ankle fractures in order to examine the accuracy of reduction. Further validation of postoperative CT scan in ankle fracture surgery should be investigated.

Is supplemental regional anesthesia associated with more complications and readmissions after ankle fracture surgery in the inpatient and outpatient setting?

BackgroundThere is concern that regional anesthesia is associated with increased risk of complications, including return to the hospital for uncontrolled pain once the regional anesthetic wears off. MethodsRetrospective database review of patients who underwent open reduction and internal fixation of a closed ankle fracture from 2014–16 who received general anesthesia alone (GA) or general anesthesia plus regional anesthesia (RA). Results9459 patients met inclusion criteria. Patients in the RA group had significantly longer operative duration in both inpatient (GAI=71min vs RAI=79min, p=0.002) and outpatient setting (GAO=66min vs RAI=72min, p<0.001), lower overall LOS (GA=1.7 days vs RA=1.1 days, p<0.001), and higher readmission rate for pain (RAO=4 [0.3%] vs GAO=1 [0.0%], p=0.007). ConclusionsPatients who received supplemental regional anesthesia had shorter hospital LOS, increased operative time, and increased readmission rates for rebound pain. However, the small number of patients needing readmission are not clinically significant demonstrating that regional anesthesia is safe, effective and readmission for rebound pain should not be a concern. Level of EvidenceIII.

Overlapping Surgery for Ankle Fractures: Is It Safe?

To determine whether the practice of overlapping surgery influenced patient safety after open reduction internal fixation (ORIF) for ankle fractures. Retrospective case-control. Level 1 Academic Midwest trauma center. All patients who underwent ankle fracture ORIF by a single surgeon were eligible for our study, with 478 total patients. Cases that were overlapping were compared against cases that were not overlapping. Cases were defined as overlapping if there was greater than 30 minutes of overlap between procedural times. Patient complications were recorded up to a year from the index surgery. Unexpected return to surgery. There were 478 ankle fracture ORIF patients, 238 with at least 3 months follow-up; 124 (52%) in the overlapping group and 114 (48%) in the nonoverlapping group. There was no difference in the rate of unexpected return to surgery (P = 0.76), infection (P = 0.52), readmission (P = 0.96), painful implant (P = 0.62), malunion (P = 0.27), nonunion (P = 0.52), or arthritis (P = 0.39) between the overlapping and nonoverlapping groups. There were 467 isolated ankle fractures used for time analysis. Average procedure time was 26 minutes longer for the overlapping group than the nonoverlapping group (P < 0.01). Overlapping surgery causes increased operative time for ankle ORIF, but there was no apparent increased risk to the patients for short-term complications. The need for graduated resident responsibility required by ACGME guidelines need to be weighed against the decreased efficiency of operating room time. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.