Surgical Fixation Of Ankle Fractures Research Articles

Risk Stratification for Ankle Fracture Complications in Diabetic Patients

Category: Diabetes Introduction/Purpose: While diabetes is a well-known risk factor for morbidity following surgical fixation of ankle fractures, it is likely that increased risk is related to specific diabetes-associated comorbidities. Compared to patients with uncomplicated diabetes, patients with complicated diabetes have higher risks of infection, overall complications, and a higher likelihood of needing revision surgery/arthrodesis. This suggests that the presence and severity of specific risk factors may help predict post-operative risks for diabetic ankle fracture patients and help guide treatment decisions. To date, no study has identified specific diabetes-associated factors and comorbidities which can pose an increased risk of complications for diabetic ankle fracture patients. We hypothesized that patients with diabetes-related comorbidities will suffer significantly more major complications following surgery for unstable ankle fractures compared to uncomplicated diabetics. Methods: We retrospectively reviewed all patients with diabetes treated surgically for ankle fracture at a University medical center over a 12-year period, examining patient and fracture characteristics, treatment method, and clinical and laboratory factors associated with complications. Outcome variables include time to union, wound complication, infection, hardware failure, and need for additional surgery following injury. The primary outcome was major complication, defined as the presence of one or more of the following: deep infection (as evidenced by hardware removal or I&D), amputation, malunion or non-union, skin graft, or wound complication (as evidenced by infection or dehiscence). Bivariate analyses and logistic regression were used to examine the relationships between specific complications and various clinical and demographic factors. A p-value of < 0.05 denotes statistical significance. Results: A total of 61 patients met inclusion criteria. Patient characteristics are depicted in Table 1. Bivariate analyses showed that when compared to diabetic patients without complications, patients who experienced major complications had a significantly higher rate of renal disease (p = 0.032) and retinopathy (p = 0.020), and significantly more hospital readmissions (p < 0.001). Factors associated with complications were determined by a logistic regression model. Age, sex, race, tobacco use and HgbA1C were not associated with increased risk of major complications. However, for each 1-unit increase in the Charlson Comorbidity Index (CCI) Score, there was a 40.6% increase in the likelihood of major complication among diabetic patients with ankle fractures (p = 0.025). Conclusion: Patients with diabetes-related comorbidities have a significantly higher risk of experiencing major complications following treatment of unstable ankle fractures. In this cohort, renal disease, retinopathy and higher CCI were found to be significantly associated with major complications. Interestingly, neuropathy, smoking, and HgA1C were not independent predictors of major complications in this cohort. These data will inform a multi-center prospective registry of patients with diabetes and ankle fractures, and ultimately the development of a risk tool to help guide clinical decision-making and post-operative care for diabetic patients at risk of major complication, re-admission, or re-operation following treatment for ankle fractures.

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.

Early motion and directed exercise (EMADE) versus usual care post ankle fracture fixation: study protocol for a pragmatic randomised controlled trial

BackgroundFollowing surgical fixation of ankle fractures, the traditional management has included immobilisation for 6 weeks in a below-knee cast. However, this can lead to disuse atrophy of the affected leg and joint stiffness. While early rehabilitation from 2 weeks post surgery is viewed as safe, controversy remains regarding its benefits. We will compare the effectiveness of early motion and directed exercise (EMADE) ankle rehabilitation, against usual care, i.e. 6 weeks’ immobilisation in a below-knee cast.Method/designWe have designed a pragmatic randomised controlled trial (p-RCT) to compare the EMADE intervention against usual care. We will recruit 144 independently living adult participants, absent of tissue-healing comorbidities, who have undergone surgical stabilisation of isolated Weber B ankle fractures. The EMADE intervention consists of a non-weight-bearing progressive home exercise programme, complemented with manual therapy and education. Usual care consists of immobilisation in a non-weight-bearing below-knee cast. The intervention period is between week 2 and week 6 post surgery. The primary outcome is the Olerud and Molander Ankle Score (OMAS) patient-reported outcome measure (PROM) at 12 weeks post surgery. Secondary PROMs include the EQ-5D-5 L questionnaire, return to work and return to driving, with objective outcomes including ankle range of motion. Analysis will be on an intention-to-treat basis. An economic evaluation will be included.DiscussionThe EMADE intervention is a package of care designed to address the detrimental effects of disuse atrophy and joint stiffness. An advantage of the OMAS is the potential of meta-analysis with other designs. Within the economic evaluation, the cost-utility analysis, may be used by commissioners, while the use of patient-relevant outcomes, such as return to work and driving, will ensure that the study remains pertinent to patients and their families. As it is being conducted in the clinical environment, this p-RCT has high external validity. Accordingly, if significant clinical benefits and cost-effectiveness are demonstrated, EMADE should become a worthwhile treatment option. A larger-scale, multicentre trial may be required to influence national guidelines.Trial registrationISRCTN, ID: ISRCTN11212729. Registered retrospectively on 20 March 2017.

Effect of Hypoalbuminemia on Perioperative Complications and Hospital Outcomes in Ankle Fracture Fixation

Category: Trauma Introduction/Purpose: Pre-operative serum albumin levels have routinely been utilized to assess nutritional status. Malnutrition, as defined by serum albumin levels < 3.5 g/dL, has been associated with worse post-operative outcomes in multiple surgical settings. The effect of hypo-albuminemia on 30-day post-operative outcomes after operative fixation of ankle fractures has not been well delineated. Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, 1,526 patients who had undergone surgical fixation of ankle fractures were identified using Current Procedural Terminology (CPT) codes. Perioperative complications and length of hospital stay were compared between patients with and without hypoalbuminemia (serum albumin concentration <3.5 g/dL) with adjustment for patient and procedural factors. Complications were divided into major and minor. Major complications included death, myocardial infarction, sepsis, and return to operating room. Results: Preoperative diagnosis of hypoalbuminemia was present in 324 patients (21%). Multivariate analysis confirmed hypoalbuminemia as an independent risk factor for major complications following surgical fixation of ankle fractures (2.3% vs 7.7%; odds ratio [OR], 2.35; 95% confidence interval [CI], 1.29 to 4.27; p=0.05). Patients with a preoperative diagnosis of hypoalbuminemia had an increased length of stay (p<0.001) and increased risk of rehospitalization (1.9% vs 7.1%; OR 4.072; 2.03 to 8.19, p<0.001) compared to those with normal albumin levels. Conclusion: The presence of hypoalbuminemia upon admission for ankle fracture fixation increases risk of major perioperative complications as well as hospital length of stay. Nutritional optimization of malnourished patients is important in patients undergoing operative fixation of ankle fractures.

Audit changes practice; simple education intervention can lead to better outcome for ankle fractures undergoing surgery

Category: Ankle, Trauma Introduction/Purpose: Unstable ankle fractures are common orthopaedic injuries and majority requires open reduction and internal fixation (ORIF). The goal of surgery is to achieve anatomical reduction and stable fixation of fracture. Recent literature reports malreduction rate as high as 25% to 33%. There is emerging evidence that malreduction leads to poor patient reported outcome (PROMs) and may render additional surgery. The aim of this study was to evaluate the quality of anatomical reduction and surgical fixation of ankle fractures and the effect of a simple education intervention on the adequacy of reduction of these fractures. Methods: An audit cycle was completed starting with retrospective review (phase 1) of 114 consecutive cases of ankle fracture that underwent ORIF between October 2006 and December 2007. Data was retrieved from theatre log and PACS. Age, fracture morphology, time to surgery, time to revision surgery and the quality of anatomical reduction were assessed by three surgeons using three radiological parameters (Pettrone’s criteria + Weber’s dime test). Paediatrics, pathological fractures, open fractures were excluded. The results were conveyed and interventions in the form of regional teaching and introduction of radiological criteria were implemented. Phase 2 (re-audit) was conducted with prospective review of 72 cases between December 2015 and June 2016. Inter-rater reliability was determined using kappa value. Chi- square test was used to compare malreduction rates between 2 phases. Logistic regression was performed for age, gender, time to ORIF with regards to revision surgery. P value < 0.05 was considered significant Results: Results of initial cohort showed significant rate of malreduced fixation in 25% of cases (29 out of 114). After implementation of interventions, malreduction rate reduced to 12.6% (9 out of 72). Of these nine malreduced cases, 3 cases underwent early revision surgery within the first 6 weeks of surgery. There was no significant correlation between age, gender and time to surgery, and time to revision surgery within 3 months of surgical fixation (p = 0.4). Using three radiological parameters (Weber’s dime test, tibiofibular overlap and medial clear space) the mean kappa values for inter-rater reliability was 0.786 (0.727- 0.861), representing a substantial agreement using three radiological parameters in order to avoid failure and or further surgery. Conclusion: This study demonstrates that simple education intervention locally can lead to better understanding of fixation and reduce the rate of malreduction of these fractures. We suggest using three radiological parameters in correction of corresponding anatomy of ankle mortise is a reliable tool to avoid malreduction. Malreductions were more likely to occur in complex fractures with syndesmotic injuries.

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

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

Cost description of inpatient treatment for ankle fracture

Background The study estimated the hospital costs associated with the surgical fixation of ankle fractures by either open reduction internal fixation (ORIF) or external fixation. Method A retrospective review of the clinical records of all 264 patients admitted with an ankle fracture requiring surgical stabilisation between 1 March 2007 and 29 February 2008. Patient records were examined for a minimum of 6 months after primary admission. A mean cost per patient was calculated based on patient-level hospital resource use. This included all procedures received during both their primary hospitalisation and subsequent re-admissions. Results Approximately equal numbers of males and females (mean age 46.2 years) were admitted, and males were significantly younger than females. The mean length of stay was 10.8 days (SD 9.1); however, ORIF (which was performed in the vast majority of cases, 94.7%) was associated with a much shorter mean length of stay compared with external fixation (10.4 days; SD 8.9 vs. 17.4 days; SD 10.2). The mean total hospital cost per patient including was £4730.28 (SD £2340.73) with a higher mean cost for those who received external fixation as the primary procedure (£9453.92; SD £3391.84) compared with ORIF (£4465.76; SD £1965.10). Patients with severe health problems had significantly higher costs than fit and healthy patients (£5982.65; SD £28 77.74 vs. £4375.00; SD £1957.65). Conclusions The results highlight the considerable hospital costs associated with the surgical fixation of an ankle fracture, thus providing valuable information for resource planners. Future research should broaden the perspective of the economic analysis to include rehabilitation costs and assess the cost-effectiveness of potential cost-saving strategies.