Functional outcome of bimalleolar ankle fractures treated with fibular plate for lateral malleolus and C.C. screws for medial malleolus

Category: Ankle, Trauma Introduction/Purpose: Ketorolac has been reported to delay bone healing when administered after spine surgery, and there is hesitancy to use non-steroidal anti-inflammatories (NSAIDs) in the fracture setting despite its reliable ability to relieve surgical pain. The effect of ketorolac administration after foot and ankle surgery has not been well-defined in the literature to date. The purpose of this study is to report clinical and radiographic outcomes for patients treated with a perioperative ketorolac regimen after open reduction and internal fixation (ORIF) of ankle fractures. A secondary purpose is to determine whether there are other patient factors that affect radiographic healing in this population. We hypothesize that the time to radiographic healing with ketorolac use after ORIF of ankle fractures is no different than a historical control. Methods: A retrospective chart review was performed on all patients that received perioperative ketorolac at the time of lateral malleolar, bimalleolar, and trimalleolar ankle ORIF by a single surgeon between 2010 and 2016 with minimum 4 months follow-up. Patients were prescribed 5 days of 10 mg ketorolac every 6 hours. Radiographs were evaluated independently by two blinded fellowship-trained foot and ankle surgeons to assess for radiographic healing of lateral malleolus, medial malleolus, and posterior malleolus fractures at 6, 12, and 16 weeks post-operatively. Two hundred and ninety-four patients were included with an average age of 50 years with 138 males (47%). Literature review was performed to determine an appropriate historical control of time to radiographic healing after ankle ORIF for comparison. Statistical analysis consisted of a linear mixed-effects regression which was performed to estimate the effect of time and covariates, taking into account repeated measurements on the same subject. Results: Radiographic healing was demonstrated by 16 weeks in 221 of 281 (79%) lateral malleolus fractures, 105 of 132 medial malleolus fractures (80%), and 53 of 57 (93%) posterior malleolus fractures (see Figure 1). Median healing times were 12, 11, and 6 weeks for lateral, medial, and posterior malleoli fractures respectively. There was no significant difference in time to radiographic healing of lateral malleolus when compared to a historical control of 16.7 weeks to union. Active tobacco use was an independent risk factor for delayed radiographic healing (p < 0.05). Diabetes mellitus and age greater than 50 years were independent factors associated with faster healing of the lateral malleolus fractures (p < 0.05). Rheumatoid arthritis, oral steroid use, and obesity had no effect on radiographic healing. Conclusion: Perioperative ketorolac use did not affect radiographic healing of ankle fractures after ORIF. As expected, active tobacco use was associated with slower radiographic healing. There is no evidence that ketorolac use further delayed union in smokers, but this may warrant further study. We unexpectedly identified diabetes mellitus and older age as factors associated with faster healing which also warrants further study. This is the first study to date examining the effect of ketorolac on radiographic time to union of ankle fractures. Further study may help determine whether ketorolac helps reduce opioid consumption and improve pain following ORIF of ankle fractures.

Download Full-text

Incidence of Chondral and Osteochondral Lesions in Ankle Fracture Patients Identified with Ankle Arthroscopy Following Rotational Ankle Fracture

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00494 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0049

Author(s):

Emilie Williamson ◽

Kevin Rosas ◽

John Dankert ◽

James P. Toale ◽

Eoghan T. Hurley ◽

...

Keyword(s):

Ankle Fracture ◽

Ankle Arthroscopy ◽

Chondral Lesion ◽

Lateral Malleolus ◽

Ankle Fractures ◽

Medial Malleolus ◽

Fracture Type ◽

Malleolar Fracture ◽

Chondral Lesions ◽

Chondral Injury

Category: Ankle; Trauma Introduction/Purpose: It is controversial whether routine arthroscopy is beneficial at the time of ankle fracture fixation. This may be, in part, due to sparse information regarding the incidence of chondral injury in the setting of ankle fractures.The purpose of this study is to systematically review the incidence of chondral injures in patients with ankle fractures and to further characterize intra-articular chondral injuries of the talus, tibial plafond, medial malleolus, and lateral malleolus in patients who undergo ankle arthroscopy following an ankle fracture. Methods: The literature search was performed based on the PRISMA guidelines. Studies evaluating the incidence of chondral lesions at the time of arthroscopy for ankle fractures were included. The incidence of intraarticular chondral lesions was recorded, as well as location within the ankle, ankle fracture type, time of arthroscopy, characterization of chondral injury, complications, and outcome if available. All statistical analyses were carried out with statistical software package SPSS 24.0 (SPSS, Chicago, IL, USA). Multiple comparisons were used to compare incidence rates of chondral injury based on Weber classification, malleolar fracture type, and Lauge-Hansen classification, using Pearson chi-square test. For all analyses, p < 0.05 was considered statistically significant. Results: Fifteen studies with 1,355 ankle fractures were included. Of those ankles, 738 demonstrated evidence of chondral or osteochondral lesion (54.5%). Overall, 648 ankles had chondral lesions on the talus (47.8%), 207 ankles had lesions on the tibial plafond (15.3%), 165 has lesions of the lateral malleolus (12.2%), and 133 had lesions of the medial malleolus (9.8%). Weber C group had significantly higher incidence than Weber A group (p=0.015). Trimalleolar and isolated lateral malleolar fracture groups had significantly higher incidence of chondral injury than bimalleolar and isolated medial malleolar fracture groups (p<0.001). A significant difference was found in occurrence rate of chondral injury among Lauge-Hansen classification, with supination-adduction having the lowest incidence (p=0.001). Conclusion: Our study found a high incidence of intra-articular chondral lesion in the setting of ankle fractures as demonstrated by arthroscopy, with more than half of all patients having a chondral lesion. Talar lesions were most common. This study may help direct greater attention to the Talus as a source of chondral injury particularly in higher grade fracture patterns.

Download Full-text

Functional outcomes of unstable ankle fractures with and without syndesmotic fixation in the adolescent population

Journal of Children s Orthopaedics ◽

10.1302/1863-2548.15.200250 ◽

2021 ◽

pp. 1-8

Author(s):

Conner J. Paez ◽

Benjamin M. Lurie ◽

Vidyadhar V. Upasani ◽

Andrew T. Pennock

Keyword(s):

Functional Outcome ◽

Functional Outcomes ◽

Weight Bearing ◽

Ankle Fractures ◽

Medial Malleolus ◽

Syndesmotic Injury ◽

Level Of Evidence ◽

Patient Reported ◽

Male Sex

Purpose: The purpose of this study was to compare functional outcomes of adolescents with and without ankle syndesmotic injuries and identify predictors of functional outcome after operative ankle fractures. Methods: A retrospective review was conducted on operative adolescent ankle fractures treated between 2009 and 2019 with a minimum of one-year follow-up (mean 4.35 years). Patients who underwent syndesmotic fixation (SF) (n = 48) were compared with operative ankle fractures without syndesmotic injury (n = 63). Functional outcomes were assessed using standardized questionnaires, specifically the Foot and Ankle Ability Measure (FAAM) and Single Assessment Numerical Evaluation. Results: There were no differences in patient-reported outcomes, rates of return to sport or complications between groups with and without SF. The SF group had a longer tourniquet time (p = 0.04), duration of non-weight-bearing (p = 0.01), more Weber C fibula fractures (p < 0.001), fewer medial malleolus fractures (p = 0.03) and more frequently underwent implant removal (p < 0.0001). Male sex, lower body mass index (BMI) and longer duration of follow-up were significant predictors of a higher FAAM sports score using multivariable linear regression. SF was not a predictor of functional outcome. Conclusion: This study demonstrated that patients that undergo surgical fixation of syndesmotic injuries have equivalent functional outcomes compared to operative ankle fractures without intraoperative evidence of syndesmotic injury. We also identified that male sex, lower BMI and longer duration of follow-up are predictors of a good functional outcome. Level of Evidence: III

Download Full-text

Outcomes of Bridge Plating Versus Standard Fixation in Geriatric Ankle Fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00220 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0022

Author(s):

Russell E Holzgrefe ◽

Amalie Erwood ◽

Samuel Maidman ◽

William Runge ◽

Michael Gottschalk ◽

...

Keyword(s):

Screw Fixation ◽

Lateral Malleolus ◽

Ankle Fractures ◽

Medial Malleolus ◽

Lag Screw ◽

Plate Group ◽

Bridge Plate ◽

Sf 36 ◽

One Year ◽

Bridge Plating

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures represent one of the most common injuries encountered by foot and ankle specialists. Internal fixation of the lateral malleolus can be achieved by several different techniques, most commonly by lag screw and neutralization plating. However, ankle fractures in older patients often present technical challenges as osteoporotic bone is more commonly encountered which may require bridge plating techniques. This study compares outcomes in patients over age 50 years who underwent ORIF of the lateral malleolus with either a bridge plate or lag screw and neutralization plate technique. Methods: This retrospective study evaluated 56 patients with closed ankle fractures, aged over 50 years who underwent open reduction internal fixation of the lateral malleolus. These were divided into two groups: 36 patients had fixation with one or more lag screws and a neutralization plate, and 20 patients had fixation with a bridge plate technique. Fractures were stabilized with lag screw fixation when feasible, while bridge plating was utilized in patients where lag screw fixation was not possible. SF-36 scores were attained at a minimum one-year post-op. Final radiographs and complications were recorded. Results: The lag group had a mean age of 63 years, 17% men, 61% with syndesmotic screw fixation, and 56% with medial malleolus fixation. The bridge group had a mean age of 65 years, 15% men, 60% with syndesmotic screw fixation, and 70% with medial malleolus fixation. At minimum one-year, SF-36 physical component summary score was 74.2 ± 19.4 in the lag group vs 63.2 ± 24.8 in the bridge plate group (p=0.049). The SF-36 mental component summary score was 89.2 ± 12 in the lag group vs 75.5 ± 22.7 in the bridge plate group (p=0.009). One patient in each group required return to the OR for irrigation and debridement for infection. No patients experienced fixation failure and all fractures demonstrated union on final radiograph. Conclusion: In the present study of patients over age 50 years who underwent ORIF of an ankle fracture, as compared with bridge plating, lag screw and neutralization plating is associated with superior one-year SF-36 physical and mental summary scores with similar rates of complications. However, additional research is needed to determine to what degree this difference is causative or correlative with confounding variables as fixation technique was not found to be an independent predictor of SF-36 outcomes in this small cohort.

Download Full-text

The Surgical Outcomes of Unstable Ankle Fractures in Patients Aged >65 Years

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459321997765 ◽

2021 ◽

Vol 12 ◽

pp. 215145932199776

Author(s):

Adem Sahin ◽

Anıl Agar ◽

Deniz Gulabi ◽

Cemil Erturk

Keyword(s):

Surgical Outcomes ◽

External Rotation ◽

High Energy ◽

Ankle Fractures ◽

Medial Malleolus ◽

Aofas Score ◽

Non Union ◽

The Mean ◽

Medial Malleolus Fracture ◽

Mechanism Of Trauma

Aim: To evaluate the surgical outcomes and complications of patients over 65 years of age, with unstable ankle fractures. Material and Method: The study included 111 patients (73F/38 M) operated on between January 2015 and February 2019 and followed up for a mean of 21.2 months (range, 6-62 months).Demographic characteristics, comorbidities, fracture type, and mechanisms of injury were evaluated. Relationships between postoperative complications and comorbidities were examined. In the postoperative functional evaluations, the AOFAS score was used and pre and postoperative mobilization (eg, use of assistive devices) was assessed. Results: The mean age of the patients was 70.5 ± 6.1 years (range, 65-90 years). The mechanism of trauma was low-energy trauma in 90.1% of the fractures and high-energy trauma in 9.9%. The fractures were formed with a SER injury (supination external rotation) in 83.7% of cases and bimalleolar fractures were seen most frequently (85/111, 76%).Complications developed in 16 (14.4%) patients and a second operation was performed in 11 (9.9%) patients with complications. Plate was removed and debridement was performed in 5 of 6 patients due to wound problems. Nonunion was developed in the medial malleolus in 4 patients. Revision surgery was performed because of implant irritation in 2 patients and early fixation loss in the medial malleolus fracture in one patient. Calcaneotibial arthrodesis was performed in 3 patients because of implant failure and ankle luxation associated with non-union. A correlation was determined between ASA score and DM and complications, but not with osteoporosis. The mean follow-up AOFAS score was 86.7 ± 12.5 (range, 36-100).A total of 94 (84.7%) patients could walk without assistance postoperatively and 92 (82.9%) were able to regain the preoperative level of mobilization. Conclusion: Although surgery can be considered an appropriate treatment option for ankle fractures in patients aged >65 years, care must be taken to prevent potential complications and the necessary precautions must be taken against correctable comorbidities.

Download Full-text

The Medial Malleolus in Ankle Fractures

Orthopedic Clinics of North America ◽

10.1016/s0030-5898(20)31464-4 ◽

1980 ◽

Vol 11 (3) ◽

pp. 649-660 ◽

Cited By ~ 3

Author(s):

James Hughes

Keyword(s):

Ankle Fractures ◽

Medial Malleolus

Download Full-text

Functional Outcome and Limitation of Sporting Activities After Bimalleolar and Trimalleolar Ankle Fractures

Foot & Ankle International ◽

10.1177/1071100712472490 ◽

2013 ◽

Vol 34 (6) ◽

pp. 805-810 ◽

Cited By ~ 33

Author(s):

Choon Chiet Hong ◽

Shuvendu Prosad Roy ◽

Nazrul Nashi ◽

Ken Jin Tan

Keyword(s):

Functional Outcome ◽

Ankle Fractures ◽

Sporting Activities

Download Full-text

Functional Outcomes After Fracture-Dislocation of the Ankle

Foot & Ankle Specialist ◽

10.1177/1938640019826701 ◽

2019 ◽

Vol 13 (1) ◽

pp. 18-26 ◽

Cited By ~ 1

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

Download Full-text