SLR - December 2022 - Marisa Mosier, DPM
Title: High-risk ankle fractures in high-risk older patients: to fix or nail?Reference: Large TM, Kaufman AM, Frisch HM, Bankieris KR. High-risk ankle fractures in high-risk older
patients: to fix or nail? Arch Orthop Trauma Surg. 2022 Aug 10.
Level of Evidence: Level III
Scientific Literature Review
Reviewed by: Marisa Mosier, DPM
Residency Program: Eastern Virginia Medical School, Norfolk VA
Podiatric Relevance: As our population continues to age, the incidence of acute ankle injuries in the high risk elderly population rises. These are often difficult and challenging to approach and therefore the most optimal surgical treatment within this population cohort remains unknown. This retrospective analysis looked to compare open reduction internal fixation (ORIF) versus tibio-talocalcaneal (TTC) fusions in high risk ankle injuries involving the high-risk elderly population looking specifically at reoperation, union and complication rates.
Methods: This retrospective case-control cohort study evaluated 60 patients with traumatic ankle fractures over the age of 50 treated by 4 orthopedic surgeons between January 2012 and December 2017. Included were patients with an open ankle fracture or >50% talar subluxation. Additionally, patients had at least 1 high risk comorbidity including either diabetes mellitus, peripheral vascular disease, immunosuppression, tobacco abuse or a BMI > 35. Fourteen TTC fusion nails and 47 ORIF cases were included with an average follow up of 17.9 months. The primary outcome evaluated was rate of reoperation within 1 year. Secondary outcomes included infection, peri-implant fracture, malunion/nonunion, mortality, length of stay, disposition and hospital acquired complications. Time to weight bearing, nonunion/malunion, deep and superficial infection/re-fracture rates and mortality were also measured.
Results: No statistically significant differences between ORIF and TTC re-operation rates were observed (17% vs 21.4%), infection rates (12.8% vs 14.3%), discharge disposition (61.7% vs 85.7% SNF), weeks until weight bearing (8 vs 9.5 weeks) or union rates (76% vs 85.7%). Twenty-one out of 47 ORIF’s included tibia-pro-fibula screws, 16/47 utilized at least 1 locking screw in the fibula construct and 6/47 utilized additional external fixation in addition to internal fixation. A single TTC patient sustained peri-implant fracture which was treated non-operatively. Three patients in the ORIF group converted to TTC and 1 TTC patient required revision to longer nail due to arthrodesis nonunion and hardware failure. One patient in the ORIF group also underwent conversion to total ankle arthroplasty 9 months post operatively. One patient required amputation. No statistically significant differences in medical risk factors between groups was observed aside from a higher rate of DM in the TTC group (42.6% vs 78.6%).
Conclusions: Unstable ankle fractures in the younger patient population are often more straightforward and treated primarily with ORIF with fairly low complication rates and return to function. The elderly patient population represents a complicated population cohort with no established optimal treatment. Common surgical approaches include tibia-pro-fibula screws, transarticular pinning, intramedullary fibular fixation, fibular lateral locking plates and TTC fusions, each with their own advantages and disadvantages. Both ORIF and TTC nails in the elderly after high risk ankle fractures yielded acceptable outcomes with a reoperation rate of 17% for ORIF and 21.4% for TTC fusions. This study emphasizes that optimal treatment for this specific patient population remains unknown. As surgeons, we must take into account several aspects of the patient’s clinical picture including co-morbidities, lifestyle, age, and fracture type.