Introduction

Open fragility ankle fractures involve complex decision making. There is no consensus on the method of surgical management. Our aim in this study was to analyse current management of these patients in a major trauma centre (MTC).

Diabetes mellitus is a risk factor for complications after operative management of ankle fractures. Generally, diabetic sequelae such as neuropathy and nephropathy portend greater risk; however, the degree of risk resulting from these patient factors is poorly defined. We sought to evaluate the effects of the diabetic sequelae of neuropathy, chronic kidney disease (CKD), and peripheral vascular disease (PVD) on the risk of complications following operative management of ankle fractures.

Using a national claims-based database we analyzed patients who had undergone operative management of an ankle fracture and who remained active in the database for at least two years thereafter. Patients were divided into two cohorts, those with a diagnosis of diabetes and those without. Each cohort was further stratified into five groups: neuropathy, CKD, PVD, multiple sequelae, and no sequelae. The multiple sequelae group included patients with more than one of the three sequelae of interest: CKD, PVD and neuropathy. Postoperative complications were queried for two years following surgery. The main complications of interested were: deep vein thrombosis (DVT), surgical site infection, hospital readmission within 90 days, revision internal fixation, conversion to ankle fusion, and below knee amputation (BKA).

We identified 210,069 patients who underwent operative ankle fracture treatment; 174,803 had no history of diabetes, and 35,266 were diabetic. The diabetic cohort was subdivided as follows: 7,506 without identified sequelae, 8,994 neuropathy, 4,961 CKD, 1,498 PVD, and 12,307 with multiple sequelae.

Compared to non-diabetics, diabetics without sequelae had significantly higher odds of DVT, infection, readmission, revision internal fixation and conversion to ankle fusion (OR range 1.21 – 1.58, p values range Compared to uncomplicated diabetics, diabetics with neuropathy alone and diabetics with multiple sequelae were found to have significantly higher odds of all complications (OR range 1.18 – 31.94, p values range < 0.001 - 0.034). Diabetics with CKD were found to have significantly higher odds of DVT, readmission, and BKA (OR range 1.34 – 4.28, p values range < 0.001 - 0.002). Finally, diabetics with PVD were found to have significantly higher odds of DVT, readmission, conversion to ankle fusion, and BKA (OR range 1.62 - 9.69, p values range < 0.001 - 0.039).

Diabetic patients with sequelae of neuropathy, CKD or PVD generally had higher complication rates than diabetic patients without these diagnoses. Unsurprisingly, diabetic patients with multiple sequalae are at the highest risk of complications and had the highest odds ratios of all complications. While neuropathy is known to be associated with postoperative complications, our analysis demonstrates that CKD represents a significant risk factor for multiple complications following the operative management of ankle fractures and has rarely been discussed in prior studies.

Patients awaiting resolution of swelling and oedema prior to ankle surgery can represent a significant burden on hospital beds. Our study assessed whether external pneumatic intermittent compression (EPIC) can reduce delays to surgery.

Our prospective randomised controlled trial (n= 20) compared outcomes of patients treated with EPIC vs control group managed with ice and elevation. Included were patients aged <18 years with isolated closed ankle fractures admitted for management of swelling prior to surgery. Excluded were open fractures, injuries to contralateral leg, diabetes, absent pulses, peripheral vascular disease, inability to consent, no requirement for admission. Eligible patients were randomised to active or control arms. All patients were managed initially with reduction and back slab application. Patients in active arm fitted with EPIC (Hydroven 3000) device over the back slab. Assessment by treating team determined the time at which patient is assessed ready for surgery.

Patients in the treatment arm were assessed as ready for surgery sooner, (123 hrs vs 168hrs, T score = 1.925, P 0.035) and had a shorter time to surgery (167 hrs vs 216 hrs, T score = 1.748, P 0.047) Length of stay was reduced bud did not reach statistical significance. (259 hrs vs 269 hrs, T score 0.229, P 0.41)

Our results showed a statistically and clinically significant reduction in time that patients were assessed ready for surgery and time to surgery in the treatment cohort. We conclude that although further data is needed to achieve an adequately powered study and assess the safety profile of the EPIC, incorporation of EPIC into routine clinical practice has the potential for significant cost savings.

Aim

Surgical treatment of ankle fractures comes with a substantial risk of complications, including infection. An unambiguously definition of fracture-related infections (FRI) has been missing. Recently, FRI has been defined by a consensus group with a diagnostic algorithm containing suggestive and confirmatory criteria. The aim of the current study was to report the prevalence of FRI in patients operated for ankle fractures and to assess the applicability of the diagnostic algorithm from the consensus group.

Introduction

Ankle fractures in the elderly have been increasing with an ageing but active population and bring with them specific challenges. Medical co-morbidities, a poor soft tissue envelope and a requirement for early mobilisation to prevent morbidity and mortality, all create potential pitfalls to successful treatment. As a result, different techniques have been employed to try and improve outcomes. Total contact casting, both standard and enhanced open reduction internal fixation, external fixation and most recently tibiotalocalcaneal (TTC) nailing have all been proposed as suitable treatment modalities. Over the past five years popular literature has begun to herald TTC nailing as an appropriate and contemporary solution to the complex problem of high-risk ankle fragility fractures. We sought to assess whether, within our patient cohort, the outcomes seen supported the statement that TTC has equal outcomes to more traditional open reduction internal fixation (ORIF) when used to treat the high-risk ankle fragility fracture.

Introduction

With an aging population, the prevalence of fragility ankle fractures is rising. The surgical management of these injuries is challenging and associated with high rates of complications. The incidence of fragility ankle fractures is currently estimated to be around 150 per 100,000 people annually and is anticipated to rise to around 269 per 100,000 by 2030. The aim of surgery is to restore mobility, preserve function and to prevent complications related to non-weight-bearing and the application of hind foot nail (HFN) seems to provide these advantages. This systematic review aims to investigate the role of HFN in the treatment of fragility ankle fractures. We aim to review the available evidence published on the functional recovery observed in patients following treatment with HFN and the observed complications in the literature.

Fractures of the ankle are common, and they mostly affect young adults. Wound complications are not uncommon following the fixation of these fractures. This study evaluated the impact of HIV on wound healing after plate osteosynthesis in patients with closed ankle fractures.

This is an observational retrospective study of patients operated on at a tertiary level hospital. We reviewed hospital records for patients above 18 years of age who presented with wound breakdown following ankle open reduction and internal fixation. The patients’ hospital records were retrieved to identify all the patients treated for closed ankle fractures and those who developed wound breakdown. Patients with Pilon fractures were excluded. The National Health Laboratory System (NHLS) database was accessed to retrieve the CD4 count, viral load, haematology study results, and biochemistry results of these patients at the time of surgery and subsequent follow-up. The x-rays were retrieved from the electronic picture archiving system (PACS) and were assessed for fracture union at a minimum of 3 months follow-up.

We reviewed the medical records of 172 patients with closed ankle fractures treated from 2018 to 2022. Thirty-one (18.0%) developed wound breakdown after surgery, and they were all tested for HIV. Most of the patients were male (58.0%), and the average age of the cohort was 43.7 years (range: 21 years to 84 years). Ten of these patients (32.2%) were confirmed HIV positive, with CD4 counts ranging from 155 to 781. Viral load levels were lower than detectable in 40% of these patients. All patients progressed to fracture union at a minimum of 3 months follow-up.

We observed no difference between HIV-positive and HIV-negative patients in terms of wound breakdown and bone healing post-plate osteosynthesis for closed ankle fractures.

Aim

The purpose of this study is to analyze the demographic and microbiological variables of acute ankle infections posterior to ankle osteosynthesis and to determine the different characteristics of patients withE. cloacae infection.

Introduction

A subset of patients in cast awaiting fixation of ankle fractures require conversion to delayed external fixation (dEF). We aimed to evaluate the effect of delayed versus planned external fixation (pEF), then identify objective characteristics contributing to need for conversion.

The purpose of this study was to investigate the effectiveness of casting in achieving acceptable radiological parameters for unstable ankle injuries.

This retrospective observational cohort study was conducted involving the retrieval of X-rays of all ankles taken over a 2 year period in an urban setting to investigate the radiological outcomes of cast management for unstable ankle fractures using four acceptable parameters measured on a single X- ray at union. The Picture Archiving and Communication System (PACS) was used, the X-rays were measured by a single observer.

From the 1st of January 2020 to the 31st of December 2021, a total of 1043 ankle fractures were treated at the three hospitals with a male to female ratio of 1:1.7. Of the 628 unstable ankle injuries, 19% of patients were lost to follow up. 190 were managed conservatively with casts, requiring an average of 4 manipulations, with a malunion rate of 23.2%. Unstable ankle injuries that were treated surgically from the outset and those who failed conservative management and subsequently converted to surgery had a malunion rate of 8.1% and 11.0% respectively.

Unstable ankle fractures pose a challenge with a high rate of radiological malunion, regardless of the treatment Casting surgery from the outset or converted to surgery, with rates of 23% and 8% and 11% respectively. In this multivariate analysis we found that conservative management was the only factor influencing the incidence of malunion, age, sex and type of fracture did not have a scientific significant influence.

The optimal management of rotationally-unstable ankle fractures involving the posterior malleolus remains controversial. Standard practice involves trans-syndesmotic fixation (TSF), however, recent attention has been paid to the indirect reduction of the syndesmosis by repairing small posterior malleolar fracture avulsion fragments, if present, using open reduction internal fixation. Posterior malleolus fixation (PMF) may obviate the need for TSF. Given the limited evidence and diversity in surgical treatment options for rotationally-unstable ankle fractures with ankle syndesmosis and posterior malleolar involvement, we sought to assess the research landscape and identify knowledge gaps to address with future clinical trials.

We performed a scoping review to investigate rotational ankle fractures with posterior malleolar involvement, utilizing the framework originally described by Arksey and O'Malley. We searched the English language literature using the Ovid Medline and Embase databases. All study types investigating rotationally-unstable ankle fractures with posterior malleolus involvement were categorized into defined themes and descriptive statistics were used to summarize methods and results of each study.

A total of 279 articles published from 1988 to 2018 were reviewed, and 70 articles were included in the final analysis. The literature consists of studies examining the surgical treatment strategies for PMF (n=21 studies, 30%), prognosis of rotational ankle fractures with posterior malleolar involvement (n=16 studies, 23%), biomechanics and fracture pattern of these injuries (n=13 studies, 19%), surgical approach and pertinent anatomy for fixation of posterior malleolus fractures (n=12 studies, 17%), and lastly surgical treatment of syndesmotic injuries with PMF compared to TSF (n=4 studies, 6%). Uncontrolled case series of single treatment made up the majority of all clinical studies (n=44 studies, 63%), whereas controlled study designs were the next most common (n=16 studies, 23%). Majority of research in this field has been conducted in the past eight years (n=52 studies, 74%).

Despite increasing concern and debate among the global orthopaedic community regarding rotationally-unstable ankle fractures with syndesmosis and posterior malleolar involvement, and an increasing trend towards PMF, optimal treatment remains unclear when comparing TSF to PMF. Current research priorities are to (1) define the specific injury pattern for which PMF adequately stabilizes the syndesmosis, and (2) conduct a randomized clinical trial comparing PMF to TSF with the assistance of the orthopaedic community at large with well-defined clinical outcomes.

Diabetes is a poor prognostic indicator after an acute ankle fracture. Many surgeons avoid essential surgery due to their concerns regarding complications.

We performed a retrospective analysis of complication rates for acute ankle fractures in diabetics with a control non-diabetic patient treated by all surgeons in our unit and assessed factors for success including long-segment fixation methodologies.

Patient records were cross-referenced with departmental databases and a retrospective review of all ankle fractures managed in our department was conducted from 2014. All patients subjected to a retrospective review of their notes and assessment of their follow up for at least 6 months. Radiographs were assessed of the ankle before and at completion of treatment were reviewed independently (RA and FR).

We identified all patients with a diabetic ankle fracture their HB1Ac (for diabetic control) and systematic co-morbidities. Fractures were classified into unimalleolar, bi malleolar and trimalleolar and surgery grouped into standard or long-segment-rigid fixation. Statistical analysis was conducted using absolute/relative risk (RR); numbers needed to treat (NNT) were calculated. We compared a control-group, a diabetic group managed conservatively, and undergoing surgery; comparing the concept of rigid fixation. Further sub-analysis conducted to assess differences between diabetic neuropathy, retinopathy and nephropathy. Ethics approval was granted as per our institutional policy by our governance lead.

We identified 64 patients with a diabetic ankle fractures, their fracture pattern and a control group. Thirty-one had conservative treatment; 33 had operative fixation of which 13 had rigid fixation. Compared to the control (n=32) both diabetic groups had a higher risk of possible complication. The relative risk was between 3.1–3.4 (P<0.002) and linked to systematic complications of diabetes e.g. neuropathy 5.9 (P<0.003); HBA1c 4.6 P<0.004); and neuropathy and retinopathy 6.2 P<0.0003). We observed RR is reduced for a complication occurring following surgery with prolonged immobilization (0.86) and rigid fixation (0.65) and NNT required to see a benefit from rigid fixation was 7. The overall RR for a complication was similar between conservative and surgical management (4.6 vs.5.1).

We agree diabetics have a higher risk for complications than non-diabetics, however the risk is not as great as previously reported. There is little difference in surgical or conservative treatment but strong evidence indicating rigid long-segment-fixation with prolonged-immobilization could improve the risk benefit ratio when compared to non- operative management alone but further evaluation is required.

The purpose of this study was to define the risk and incidence of eventual ankle arthroplasty or fusion after documented ankle fracture in a large cohort, and compare that rate to matched healthy patients from the general population.

The Ontario health insurance plan (OHIP) physician billing database, Institute for Clinical Evaluative Sciences (ICES) Physician Database, the Canadian Institute for Health Information (CIHI) databases, Discharge Abstract Database (DAD) and Same Day Surgery (SDS) were used to identify patients treated surgically and non-surgically for ankle fractures. Each patient was matched to four individuals from the general population (13.5 million) with no documented prior treatment for ankle fracture, according to age, sex, income, and urban/rural residence. Fusion and replacement incidence was compared using time-to-event analysis (Kaplan-Meier). A Cox Proportional Hazards model was used to explore the influence of patient, provider and surgical factors on time to surgery.

We identified 45,444 (58.8% female, mean age 48.7 years) and 140, 629 (53.9% female, mean age 47.1 years) patients who had undergone open reduction internal fixation (ORIF) or non-operative management of an ankle fracture (NOA), respectively. Among ORIF patients, n=237 (0.5%) and n=69 (0.15%) patients underwent fusion or arthroplasty after a median 2.8 and 6.9 years, respectively. Among non-operatively treated ankle fractures, n=198 (0.14%) and n=36 (0.03%) patients underwent fusion or arthroplasty after a median of 3.2 and 5.6 years, respectively. Surgical treatment (vs. non-operatively treated fracture), older age, greater co-morbidity and a history of infection post fracture significantly increased the risk of eventual fusion or arthroplasty (HR 3.6 (3.1–4.3), p < 0 .001, HR 1.01 (1.01–1.02), p=0.009, HR 1.2 (1.1–1.3), p < 0 .001, HR 11.3 (6.8–18.7), p < 0 .001, respectively). Compared to matched controls, the risk of fusion/arthroplasty was not independent of time, following an exponential decay pattern. ORIF patient risk was 20 times greater than the general population in the first three years post-ORIF, and approached the risk of non-operatively treated patients (HR 4.5 (95CI: 3.5–5.8), p < 0 .0001) by approximately 14 years out from injury on time and comorbidity adjusted KM curves.

Rates of fusion/arthroplasty are very low after ORIF and non-operative treatment of an ankle fracture in the general population of a public healthcare system. Utilization patterns suggest fusion is more common earlier, and arthroplasty remote, which may be a factor of patient age, injury severity, and complications from initial injury/surgery. Patients who underwent ORIF have >20 times the risk of fusion/arthroplasty in the short-term, however, the risk decreases over time eventually approaching that of non-operatively treated patients (∼4.5x the general population) when compared to non-fractured controls.

Introduction

The incidence of osteochondral lesions following ankle fractures varies in the literature between 17-70%. They are commonly associated with chronic pain and swelling in patients diagnosed with such pathology. There is less evidence about the relationship between OCL and the development of post-traumatic osteoarthritis, the most common type of ankle arthritis.

Stable ankle fractures can be successfully treated non-operatively with a below knee plaster cast. In some European centres it is standard practice to administer thromboprophylaxis, in the form of low molecular weight heparin, to these patients in order to reduce the risk of deep venous thrombosis (DVT).

The aim of our study was to assess the incidence of DVT in such patients in the absence of any thromboprophylaxis. We designed a prospective study, which was approved by the local ethics committee. We included 100 consecutive patients with ankle fractures treated in a below knee plaster cast. At the time of plaster removal (6 weeks), patients were examined for signs of DVT. A colour doppler duplex ultrasound scan was then performed by one of the two experienced musculoskeletal ultrasound technicians.

We found that 5 patients developed a DVT. Two of these were above knee, involving the superficial femoral vein and popliteal vein respectively. The other three were below knee. None of the patients had any clinical symptoms or signs of DVT. None of the patients developed pulmonary embolism. Of these five patients, four had some predisposing factors for DVT.

The annual incidence of DVT in the normal population is about 0.1%. This can increase to about 4.5% by the age of 75. DVT following hip and knee replacement can occur in 40-80% of cases. Routine thromboprophylaxis may be justified in these patients. However, with a low incidence of 5% following ankle fractures treated in a cast, we believe that routine thromboprophylaxis is not justified.

Tunning fork lines (TFL) were drawn on ankle anterior-posterior radiographs to assess the talar shift in ankle fractures.

A 3-D ankle joint reconstruction was prepared by mapping normal ankle joint using auto CAD in 1997. TFL were drawn using normal anatomical landmarks on saggital, coronal and transverse planes. The ankle joint anatomical relationship with talus was studied in various rotation simulating radiographic anterior-posterior views and talar shift was studied. Between 2006 and 2012 on antero-posterior view of ankle radiographs and PACS, TFL were drawn. The premise is that in a normal radiograph the superior-lateral dome of the talus lies medial to the handle of TFL, and in ankle with talar shift the dome of the talus would cross this line laterally. In two district hospitals 100 radiographs were observed by 4 observers in 67 males and 33 females with mean age of 49 (15–82) years. The TFL confirmed talar shift with sensitivity of 99.2 % showing talarshift and inferior tibio-fibular ankle diastasis.

We conclude that in ankle anterio-posterior view it is possible to comment on the talar shift and diastasis of the ankle joint, even if proper ankle mortise views were not available.

Introduction

Fixation of the distal fibula in conjunction with ankle fractures has not changed over the last 50 years. The complication rate of these fixation techniques is as high as 30%. The fibula nail is an alternative method of fixation and uses a minimal invasive technique. This technique preserves soft tissue compared to previous techniques used, and fewer soft tissue complications.

AIM

To evaluate patient outcomes in surgically managed ankle fractures with respect to fracture pattern, timing of surgery and length of stay.

Note: No previous similar study to this has been carried out in the Republic of Ireland, to our knowledge. Ankle fractures are the most common lower limb fracture in all age groups in Ireland. Approximately 43% of all ankle fractures will require operative fixation.¹ 82% of all operative ankle procedures in Ireland are carried out on patients between 18–65 years old.

We felt it was imperative to study the incidence within various age groups, the associated length of hospital stay and to offer suggestions in reducing this length-of-stay.

The National Hospital Inpatient Enquiry system (data collection accuracy 95.9%–98.2%), ICD-coding and data from the Central Statistics Office were analysed.²

14,903 ankle fractures underwent ORIF between 2002–09 (average 1,928/year). While there was a statistical increase in ORIF's in the over 65 group, there was no overall increase in the incidence of surgical procedures.

The average length-of-stay in 2002 was 4.8 days, but had significantly dropped to 4.0 days by 2009. This was most marked in the over 65's where it decreased from 10.5 to 7.7 days.

The annual incidence of ankle fractures requiring operative intervention in Ireland was 44.43 per 100,000 persons.

This study highlights many issues, namely: a)

While there is a significant decrease in length-of-stay to 4 days, we feel this figure could be significantly reduced further.

Purpose

A recent multicentre randomized control trial (RCT) failed to demonstrate superior quality of life at one year following open reduction and internal fixation (ORIF) compared to nonoperative treatment for unstable isolated fibular fractures. We sought to determine the cost-effectiveness of ORIF compared to non-operative management of unstable fibular fractures.