Novel Technique for Reduction of Ankle Valgus Malunion and Chronic Talus Subluxation during Hindfoot Nailing

In recent years, there has been a significant increase in the incidence and severity of ankle fractures in the elderly. We present a case of an elderly patient with significant medical comorbidities and social issues who sustained an unstable ankle fracture that led to a severe malunion secondary to refusal for surgery and noncompliance with weight-bearing precautions. By choosing an intramedullary fixation method that can be inserted through a biologically advantageous surgical exposure, we can permit early mobilization, create a stable plantigrade foot for ambulation, and alleviate the expected noncompliance with weight-bearing precautions in this patient. Despite debridement of callus, fibular osteotomy, and plate-assisted reduction, a displaced valgus angulation of the ankle joint remained. The nail was removed then reinserted backwards with the bend directed medially instead of its normal lateral position in order to use the bend in the nail as a reduction aid to finalize the reduction. We feel this technique may be of assistance to future surgeons encountering a similar situation.

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Primary bipolar replacement arthroplasty versus internal fixation in the management of unstable intertrochanteric fractures in the elderly

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20195803 ◽

2019 ◽

Vol 6 (1) ◽

pp. 111

Author(s):

Abhishek Bansal ◽

Rajendra Kumar Beniwal ◽

Saumya Agarwal

Keyword(s):

Internal Fixation ◽

Intertrochanteric Fracture ◽

Weight Bearing ◽

Early Mobilization ◽

The Elderly ◽

Medical Illness ◽

Sliding Hip Screw ◽

Replacement Arthroplasty ◽

Hip Screw ◽

Intertrochanteric Femur Fracture

Background: Management of unstable intertrochanteric femur fracture in the elderly has been always a matter of debate. There has been always a dilemma between osteosynthesis and prosthesis.Methods: We retrospectively evaluated, 108 osteoporotic elderly patients with unstable intertrochanteric for internal fixation versus primary bipolar replacement arthroplasty in a span of 4 years.Results: Bipolar replacement arthroplasty gives better outcome as compared to internal fixation with sliding hip screw.Conclusions: It was found that cemented bipolar arthroplasty is the choice in freely mobile elderly osteoporotic comminuted displaced intertrochanteric fracture, though is a surgically demanding technique, it spares the postoperative complication of non-weight bearing after internal fixation of these fracture. The internal fixation is also compounded by osteoporosis, medical illness, difficulty to achieve and maintain reduction of comminuted and widely displaced unstable fractures, which restricts the mobilization and weight bearing and further increase the risk of morbidity and mortality in elderly in comparison to cemented bipolar replacement arthroplasty which allows early mobilization and weight bearing.

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345 A Novel Fixation Method for Unstable Ankle Fractures in The Elderly with Poor Quality Skin, Via Dual Percutaneous Tibiotalar Cannulated Screws

British Journal of Surgery ◽

10.1093/bjs/znab259.984 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

D Hancock ◽

L Hainsworth ◽

A Pentlow

Keyword(s):

Elderly Patient ◽

Functional Outcomes ◽

Screw Fixation ◽

Soft Tissue Injury ◽

The Elderly ◽

Cannulated Screw ◽

Ankle Fractures ◽

Fixation Method ◽

Cannulated Screws ◽

Post Operative Pain

Abstract Introduction The incidence of ankle fractures is highest in the elderly population due to poor bone quality. Osteoporosis and poor overlying skin increase risk of infection, wound breakdown, and fixation failure. This ultimately results in worse functional outcomes. This retrospective case-series describes a novel dual percutaneous tibiotalar cannulated screw fixation method, for managing unstable ankle fractures, in high-risk elderly patient with low functional demand. Method Six elderly patients were identified between January 2019-2020 who underwent dual tibiotalar cannulated screw fixation for unstable ankle fractures. Pre-operative and post-operative pain and mobility scores were obtained via telephone consultation and case-note review. Radiographs were analysed pre-operatively for fracture type and post-operatively for complications such as, talar shift. Wound Infection post-operatively was monitored. Results The mean age was 86.8 with an average ASA grade of three. Functional outcomes were excellent with 83.3% of patients remaining ambulatory with no post-operative pain at an average follow-up of 10.25 months. Three patients (50%) had excellent post-operative radiographs with evidence of union and no talar shift. Two patients (33.3%) had either non-union or minor talar shift, and one patient (16.7%) had multiple radiological complications likely due to delayed fixation. All three patients remained ambulatory and had minimal post-operative pain. There were no reports of soft tissue injury or infection due to the surgery. Conclusions Dual percutaneous tibiotalar cannulated screws can be used to manage unstable ankle fractures in the low demand elderly patient, with poor skin quality. Function outcomes were good with satisfactory post-operative mobility and minimal pain in the majority of cases.

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Creating a Safer Patient Room Environment: The Contribution of Patient Bed Height

Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care ◽

10.1177/2327857921101163 ◽

2021 ◽

Vol 10 (1) ◽

pp. 180-184

Author(s):

Dorothy Taylor ◽

Janice Morse ◽

Andrew Merryweather

Keyword(s):

Elderly Patient ◽

Fall Risk ◽

The Elderly ◽

Lower Leg ◽

Patient Specific ◽

Leg Length ◽

Patient Room ◽

Patient Falls ◽

Sit To Stand ◽

Bed Height

Elderly patient falls are expensive and may cause serious harm. Studies have identified the sit-to-stand-and-walk (STSW) task as the task where the greatest number of elderly patient falls occur. There is a great need to identify the particular movement and environmental conditions that lead to these elderly patient falls. This study begins to address this gap by evaluating the elderly patient during self-selected hospital bed egress. Using an observed fall risk episode (FRE) as a fall proxy, statistically significant parameters were identified which include bed height, pausing prior to initiating gait, level of fall risk, and Stand phase. Low bed height was identified as the least safe bed height. Patient-specific bed height (PSBH) using the patient’s lower leg length (LLL) is recommended. In addition, suggested guidelines are presented for clinical application in setting PSBH without measuring the patient’s LLL.

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Is postoperative non-weight-bearing necessary? INWN Study protocol for a pragmatic randomised multicentre trial of operatively treated ankle fracture

Trials ◽

10.1186/s13063-021-05319-0 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Ramy Khojaly ◽

Ruairí Mac Niocaill ◽

Muhammad Shahab ◽

Matthew Nagle ◽

Colm Taylor ◽

...

Keyword(s):

Ankle Fracture ◽

Multicentre Trial ◽

Short Form ◽

Plantar Flexion ◽

Weight Bearing ◽

Ankle Fractures ◽

Hospital Length Of Stay ◽

Complication Rates ◽

Fracture Patterns ◽

Randomised Controlled

Abstract Background Postoperative management regimes vary following open reduction and internal fixation (ORIF) of unstable ankle fractures. There is an evolving understanding that extended periods of immobilisation and weight-bearing limitation may lead to poorer clinical outcomes. Traditional non-weight-bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates. Methods A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 h versus non-weight-bearing (NWB) and immobilisation in a cast for 6 weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury) is proposed. All patients presenting to three trauma units will be included. The exclusion criteria will be skeletal immaturity and tibial plafond fractures. The three institutional review boards have granted ethical approval. The primary outcome measure will be the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection (deep and superficial), displacement of osteosynthesis, the full arc of ankle motion (plantar flexion and dorsal flection), RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. The trial will be reported in accordance with the CONSORT statement for reporting a pragmatic trial, and this protocol will follow the SPIRIT guidance. Discussion Traditional management of operatively treated ankle fractures includes an extended period of non-weight-bearing. There is emerging evidence that earlier weight-bearing may have equivocal outcomes and favourable patient satisfaction but higher wound-related complications. These studies often preclude more complicated fracture patterns or patient-related factors. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner in recent decades. This pragmatic randomised-controlled multicentre trial will investigate immediate weight-bearing following ORIF of all ankle fracture patterns in the usual care condition. It is hoped that these results will contribute to the modern management of ankle fractures. Trial registration ISRCTN Registry ISRCTN76410775. Retrospectively registered on 30 June 2019.

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Decreasing Emergency Room Utilization in High Risk Geriatric Patients

Innovation in Aging ◽

10.1093/geroni/igaa057.443 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 135-135

Author(s):

Shamsi Fani ◽

Lizette Munoz ◽

Susana Lavayen ◽

Blair McKenzie ◽

Audrey Chun ◽

...

Keyword(s):

New York ◽

High Risk ◽

Emergency Room ◽

Geriatric Patients ◽

Social Issues ◽

The Elderly ◽

Mount Sinai Hospital ◽

Status Change ◽

Community Paramedicine ◽

Ed Visits

Abstract Background: The Acute Life Interventions Goals & Needs Program (ALIGN) at the Mount Sinai Hospital in New York City aims to work closely with high risk geriatric patients for short term intensive management of acute medical and social issues. Quantitative measures for determining success of the program is comparing emergency room visits and hospitalizations prior to and after enrollment with ALIGN. The Community Paramedicine service allows a paramedic, the ALIGN provider, and an emergency room physician to assess and triage patients in their home via video conference thereby avoiding ED visits for non-urgent services. Method: We reviewed the utilization of the Community Paramedicine service (from July 2017-February 2020) and its impact on ALIGN’s efforts to reduce unnecessary ED visits and hospitalizations. Results: 36 patients were evaluated with the Community Paramedicine service (from July 2017-February 2020). 19 or 52.8% avoided an ED visit and 17 or 47.2% were transported to the ED. 12 or 70.6% were admitted to the hospital of those that were transported to the ED initially. Top reasons for transport to ED included generalized weakness, acute mental status change (AMS), and shortness of breath (SOB). Conclusions: A Community Paramedicine program utilized by a high risk geriatrics team like ALIGN is effective in reducing ED visits and hospitalizations for the elderly population who incur greater expenses to the health care system and traditionally have poorer health outcomes.

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