scholarly journals Principles and guidelines in the management of ankle fractures in adults

2021 ◽  
pp. 175045892096902
Author(s):  
Harry Kyriacou ◽  
Ahmed MHAM Mostafa ◽  
Benjamin M Davies ◽  
Wasim S Khan
Keyword(s):  
Clinical Guidelines ◽  
Ankle Fracture ◽  
Ankle Fractures ◽  
Recent Developments ◽  
Psychosocial Complications ◽  
British Orthopaedic Association

Ankle fractures are common injuries that have many physical and psychosocial complications. As a result, it is important to be aware of how these patients present and are managed perioperatively. Detailed guidelines from NICE and the British Orthopaedic Association have been produced on this topic, including recent developments such as the decision to weight-bear early after surgery and the use of virtual fracture clinics. This article provides an overview of the key perioperative factors that need to be considered in cases of ankle fracture and the relevant clinical guidelines.

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

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0040
Author(s):  
Ryan G. Rogero ◽  
Emmanuel M. Illical ◽  
Daniel Corr ◽  
Steven M. Raikin ◽  
James Krieg ◽  
...  
Keyword(s):  
Gold Standard ◽  
Ankle Fracture ◽  
Management Strategies ◽  
Ankle Fractures ◽  
Multinomial Regression ◽  
Orthopaedic Surgeons ◽  
Suture Button ◽  
Standard Management ◽  
Management Protocol ◽  
Usage Patterns

Category: Ankle; Trauma Introduction/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.

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

Trials ◽  
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.

The Foot and Ankle Outcome Score (FAOS) During Early Recovery After Ankle Fracture

2021 ◽  
pp. 107110072110028
Author(s):  
Peter Larsen ◽  
Mohammed Al-Bayati ◽  
Rasmus Elsøe
Keyword(s):  
Cohort Study ◽  
Prospective Cohort Study ◽  
Prospective Cohort ◽  
Ankle Fracture ◽  
Minimal Clinically Important Difference ◽  
Ankle Fractures ◽  
Foot And Ankle ◽  
Early Recovery ◽  
Clinically Important Difference ◽  
Test Retest Reliability

Background: Several patient-reported outcome measures (PROMs) are available for assessing the outcomes following ankle fractures. This study aimed to evaluate validity, reliability, and responsiveness and detect the minimal clinically important difference of the Foot and Ankle Outcome Score (FAOS) in patients with ankle fractures. Methods: The study design is a prospective cohort study, including all patients treated both conservatively and surgically following an ankle fracture (AO-43A/B/C). Content validity, test-retest reliability, responsiveness, and minimal clinically important difference were evaluated from 14 days to 3 months following the fracture. Results: The study population consisted of 52 females and 24 males. The mean age was 52.0 years (range, 15-75 years). The percentage of patients at 12 weeks reporting the 5 subscales at least somewhat relevant were pain, 77%; symptoms, 75%; activities of daily living (ADL), 64%; sport, 81%; and quality of life (QOL), 88%. High test-retest reliability of the FAOS questionnaire was observed. The interclass coefficients were 0.78, 0.77, 0.71, 0.73, and 0.74 for the pain, symptoms, ADL, sport, and QOL subscales, respectively. Responsiveness was evaluated with high effect size for the symptoms (0.83), ADL (1.19), sport (4.36), and QOL (2.12) subscales. The minimal clinically important difference of the FAOS was 14 (95% CI, 12-17). Conclusion: The FAOS during early recovery after ankle fracture has high reliability and validity. Level of Evidence: Level II, prospective cohort study

Functional Outcomes After Fracture-Dislocation of the Ankle

2019 ◽  
Vol 13 (1) ◽  
pp. 18-26 ◽  
Author(s):  
Direk Tantigate ◽  
Gavin Ho ◽  
Joshua Kirschenbaum ◽  
Henrik C. Bäcker ◽  
Benjamin Asherman ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Functional Outcomes ◽  
Ankle Fracture ◽  
Statistical Significance ◽  
Ankle Fractures ◽  
Fracture Dislocation ◽  
Wound Complications ◽  
Pain Subscale ◽  
Fracture Dislocations

Background. Fracture dislocation of the ankle represents a substantial injury to the bony and soft tissue structures of the ankle. There has been only limited reporting of functional outcome of ankle fracture-dislocations. This study aimed to compare functional outcome after open reduction internal fixation in ankle fractures with and without dislocation. Methods. A retrospective chart review of surgically treated ankle fractures over a 3- year period was performed. Demographic data, type of fracture, operative time and complications were recorded. Of 118 patients eligible for analysis, 33 (28%) sustained a fracture-dislocation. Mean patient age was 46.6 years; 62 patients, who had follow-up of at least 12 months, were analyzed for functional outcome assessed by the Foot and Ankle Outcome Score (FAOS). The median follow-up time was 37 months. Demographic variables and FAOS were compared between ankle fractures with and without dislocation. Results. The average age of patients sustaining fracture-dislocation was greater (53 vs 44 years, P = .017); a greater percentage were female (72.7% vs 51.8%, P = .039) and diabetic (24.2% vs 7.1%, P = .010). Wound complications were similar between both groups. FAOS was generally poorer in the fracture-dislocation group, although only the pain subscale demonstrated statistical significance (76 vs 92, P = .012). Conclusion. Ankle fracture-dislocation occurred more frequently in patients who were older, female, and diabetic. At a median of just > 3-year follow-up, functional outcomes in fracture-dislocations were generally poorer; the pain subscale of FAOS was worse in a statistically significant fashion. Levels of Evidence: Therapeutic, Level III

Ankle Fracture Classification: A Comparison of Reliability of Three X-ray Views Versus Two

1998 ◽  
Vol 19 (8) ◽  
pp. 555-562 ◽  
Author(s):  
Michael E. Brage ◽  
Matthew Rockett ◽  
Robert Vraney ◽  
Robert Anderson ◽  
Alicia Toledano
Keyword(s):  
Ankle Fracture ◽  
Ankle Injury ◽  
Ankle Fractures ◽  
Kappa Statistics ◽  
Fracture Classification ◽  
X Ray ◽  
Good Accord ◽  
Interexaminer Reliability ◽  
Intraexaminer Reliability ◽  
Good Agreement

Our hypothesis was that malleolar ankle fractures could be classified with two radiographic views as reliably as with three views. Four different observers independently evaluated 99 sets of ankle radiographs. The examiners classified the ankle fractures by using both the Lauge-Hansen and Danis-Weber systems. The interobserver and intraobserver variations were analyzed by kappa statistics. With regard to intraexaminer reliability, the examiners demonstrated excellent accord in classifying the fractures in the Danis-Weber system with either three views or two views. The kappa values were comparable. In the Lauge-Hansen system, three examiners demonstrated excellent accord and one examiner demonstrated good accord in classifying the fractures. Similar kappa values were generated when examiners classified fractures with either three views or two views. With regard to interexaminer reliability, good to excellent accord was demonstrated overall among the four examiners when they used the Danis-Weber system with either three views or two views. The examiners were in good agreement when they used the Lauge-Hansen system. Similar kappa values were generated whether the examiners used three views or two views. Three radiographic views are usually ordered for evaluation of an acute ankle injury. Previous studies have shown that only two views are needed for diagnosis of a malleolar ankle fracture. This study demonstrates that malleolar ankle fractures can be classified with two views, lateral or mortise, with a reliability as good as that achieved with three views. The best agreement is achieved with lateral and mortise views.

scholarly journals Postoperative Pain and Opioid Use Following Surgical Treatment of Ankle Fractures

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0033
Author(s):  
Matthew Pate ◽  
Jacob Hall ◽  
John Anderson ◽  
Donald Bohay ◽  
John Maskill ◽  
...  
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Ankle Fracture ◽  
Management Practices ◽  
Opioid Analgesic ◽  
The United States ◽  
Ankle Fractures ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Opioid Medication

Category: Ankle, Bunion, Trauma Introduction/Purpose: Chronic opioid abuse is one of the greatest public health challenges in the United States. The most common first exposure to opioids comes from acute care prescriptions, such as those after surgery. Moreover, opioids are often prescribed excessively, with current estimates suggesting ˜75% of the pills prescribed are unused. Ankle fractures are the most common operatively treated fracture in orthopaedic surgery, and management of acute pain following surgery is challenging. The optimal perioperative pain regimen is still a point of controversy, as there is limited data available regarding appropriate amount of opioid to prescribe. This study evaluates opioid prescribing techniques of multiple foot and ankle surgeons, and associated patient outcomes. We aim to help surgeons improve their pain management practices and to limit opioid overprescription. Methods: Chart review and phone survey were performed on forty two adult patients within three to six months of ankle fracture fixation at our institution. These patients were offered to voluntarily participate in a standardized questionnaire regarding pain scores, opioid use, non-opioid analgesic use, pain management satisfaction, and patient prescription education. Results: 57% of patients reported that they were given “more” or ”much more” opioid medication than needed, 38% stated that they were given the “right amount”, and 5% reported that they were given ”less” or “much less” than needed. 40.0% were on opioids prior to operation. 53.5% did not require refill of discharge opioid prescriptions, 30.2% of patients did not fill any posteroperative opioid prescription. 16.3% of patients filled their discharge prescription and at least one additionall refill (mean refill = 2.22). Mean number of reported opioid pills taken after surgery was 17.4. Mean satisfaction with overall pain management at phone follow up was 8.6/10. Conclusion: While postoperative pain and management vary substantially, a majority of patients feel that they are given more opioid medication than necessary following ankle fracture repair, and a majority of opioid prescriptions are not completely used. Going forward, it is likely that a majority of patients could experience the same beneficial results with less prescription opioid pain medication, which would reduce overpresciption and potential misuse.

scholarly journals The Development of Heterotopic Ossification Following Ankle Fracture Syndesmotic Screw Fixation

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0044
Author(s):  
Benjamin R. Williams ◽  
Paul M. Lafferty
Keyword(s):  
Risk Factors ◽  
Heterotopic Ossification ◽  
Ankle Fracture ◽  
Screw Fixation ◽  
Low Energy ◽  
Ankle Fractures ◽  
Factors Associated ◽  
Syndesmotic Screw ◽  
The Mean

Category: Ankle, Trauma Introduction/Purpose: Syndesmotic fixation with screws is commonly used for ankle fractures with syndesmotic disruption. Few studies have reported the development of heterotopic ossification (HO) within the syndesmosis following ankle injuries, which may lead to abnormal joint kinematics and even joint synostosis. However, there is little data on the prevalence and on the risk factors associated with the development of HO. The purpose of this study is to determine the (1) prevalence and (2) risk factors associated with the development of HO within the distal tibiofibular syndesmosis following ankle fractures requiring syndesmotic fixation. We hypothesized that screws within the syndesmosis articulation and broken screws would be associated with a higher incidence of HO than extraarticular and intact screws, respectively. Methods: A retrospective review was conducted for patients who sustained an ankle fracture with syndesmotic disruption. Inclusion criteria: age between 18 and 65 years old, a closed ankle fracture treated operatively with syndesmotic screw fixation. Exclusion criteria: additional lower extremity injury, history of prior ankle fracture, lack of radiographic follow-up and fixation other than 1 or 2 syndesmosis screws. Medical records were reviewed for: age, sex, high or low energy injury mechanism, smoking status, diabetes, BMI, perioperative complications, and further procedures. Fractures were classified by Lauge-Hansen and Weber systems. Immediate postoperative radiographs were reviewed for the number of syndesmotic screws, whether screws were intraarticular or extraarticular and the number of cortices each screw crossed. Final postoperative radiographs were reviewed for retention or screw removal and the presence of HO. The presence of HO was defined as new or increased bone formation within the syndesmosis compared to immediate postoperative radiographs. Results: Included were 264 patients, mean radiographic follow-up of 10.5+/-10.2 months. The mean age was 39.2+/-12.6 years (38.7% female) with a mean BMI of 32.1+/-7.8. Current smokers made up 39.4% of patients and 10.6% were diabetic. The mean time to fracture fixation was 12.6+/-3.2 days and 198 patients (75%) had a low energy injury. There was no significant difference in HO formation for demographics, injury mechanism or time to fixation. Overall, HO developed in 160 patients (60.6%). There was no difference, additionally for fracture pattern, number screws or fixation construct (Table 1). HO developed in 92% of broken, 75% of loose and 44% of intact screws (P<0.001). Screws were removed in 107 patients (40.5%) with no difference in HO formation compared to patients with intact screws. Conclusion: Heterotopic ossification is commonplace following screw fixation for syndesmotic injuries with a prevalence of 60.6%. Broken screws and loosened screws are a significant risk factor for the development of HO. However, no other risk factors in this study were found to be associated with the development of HO, including intraarticular syndesmotic screw placement. Patients should be counseled on the prevalence although further research is needed to determine the effect on ankle motion and progression of post-traumatic osteoarthritis.

scholarly journals Screw Fixation of the Posterior Malleolus Fragment in Ankle Fracture: Cadaveric and Clinical Studies

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0026
Author(s):  
Gisoo Lee ◽  
Chan Kang ◽  
Yougun Won ◽  
Jae Hwang Song ◽  
Byungki Cho
Keyword(s):  
Clinical Outcomes ◽  
Ankle Fracture ◽  
Screw Fixation ◽  
Articular Surface ◽  
Cannulated Screw ◽  
Ankle Fractures ◽  
Neutral Position ◽  
Early Recovery ◽  
Malleolar Fracture ◽  
Posterior Malleolus

Category: Ankle, Trauma Introduction/Purpose: Previously, a posterior malleolus fragment (PMF) covering 25–30% of the articular surface was a known indication for surgical fixation for ankle fractures. This study aimed to compare the outcomes of screw fixation for PMF comprising <25% of the articular surface and to evaluate the results of cadaver experiments. Methods: The clinical study enrolled ankle fracture patients with PMFs who planned to undergo surgery between March 2014 and February 2017. Among them, 62 with type 1 PMF comprising <25% of the articular surface were included: 32 patients underwent cannulated screw fixation for PMF after fixation for lateral and/or medial malleolar fracture (A group), whereas the other 30 patients underwent internal fixation for lateral and/or medial malleolar fracture but no screw fixation (B group). Clinical outcomes were determined at the 3-, 6-, 12-, and 18-month visits. Additionally, cadaver studies were conducted to evaluate cannulated screw fixation or no fixation in cases of PMFs comprising <25% of the articular surface and >1 mm displacement. Ankle joint stability was measured under external torque on the ankle in the neutral position. The level of significance was set at P < .05. Results: Clinical outcomes at 6 and 12 months after surgery were significantly higher in group A than in group B. However, there was no significant intergroup difference in clinical outcomes at 18 months of follow-up. In the cadaver study, PMF screw fixations were significantly more stable under external rotation force. Conclusion: Screw fixation was significantly useful during early recovery and in short-term clinical outcomes owing to stabilization of ankle fractures with PMF involving <25% of the articular surface.

Prospective Patient Reported Outcomes (PRO) Study Assessing Outcomes of Surgically Managed Ankle Fractures

2019 ◽  
Vol 41 (2) ◽  
pp. 206-210
Author(s):  
Jasen Gilley ◽  
Raheem Bell ◽  
Mateus Lima ◽  
Bennet Butler ◽  
Joshua E. Barrett ◽  
...  
Keyword(s):  
Ankle Fracture ◽  
Outcome Measurement ◽  
Patient Reported Outcome ◽  
Ankle Fractures ◽  
Measurement Information ◽  
Level Of Evidence ◽  
Mean Values ◽  
Population Mean ◽  
Patient Reported ◽  
Nonnormal Distribution

Background: Ankle fractures are a common cause of morbidity that have increased in incidence over the past decade. The purpose of this study was to compare the outcomes and prognosis of various fracture subtypes by using 2 validated patient-reported outcome measures: the Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) Computer Adaptive Tests (CATs). Methods: Twelve-month postoperative PF and PI CATs were collected for 126 ankle fracture patients presenting between 2014 and 2017. Patients were stratified by ankle fracture subtype and refined by the presence/absence of concomitant deltoid injury or posterior malleolar fracture. Patients defined as members of vulnerable populations and patients presenting more than 2 weeks from time of injury or with prior acute ipsilateral fracture were excluded. The distribution of PF and PI T scores were assessed via a Shapiro-Wilk test and a 1-way analysis of variance. If significant differences were found between groups, pairwise comparisons were tested via Dwass, Steel, and Critchlow-Fligner multiple comparison analysis. Results: Mean values for the PROMIS PF and PI for each fracture subtype were calculated and compared to reference population mean (SD) T scores of 50 (10): isolated lateral malleolar (PF: 50/PI: 51), isolated medial malleolar (PF: 52/PI: 49), bimalleolar (PF: 48/PI: 50), trimalleoar (PF: 47/PI: 51), isolated posterior malleolar (PF: 53/PI: 44), and isolated syndesmotic injury (PF: 60/PI: 46). Shapiro-Wilk test indicated a nonnormal distribution for the postoperative PROMIS PF T scores across all fracture patients ( P = .0421). Conclusion: Operative fixation of an ankle fracture was able to return most patients to the population mean with regard to PROMIS function and pain regardless of fracture type. Level of Evidence: Level II, prospective comparative study.

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