SLR - April 2019 - Kristopher Jerry
Reference: Andrew Konopitski, MD, Anthony J. Boniello, MD, Mitesh Shah, MD, Anya Katsman, MS, Garrett Cavanaugh, MD, and Susan Harding, MD (2019). Techniques and Considerations for the Operative Treatment of Ankle fractures in the Elderly. JBJS. 2019 Jan 2 - Volume 101 - Issue 1 - 85-94.Scientific Literature Review
Reviewed By: Kristopher Jerry, DPM
Residency Program: Northwest Medical Center, Margate, FL
Podiatric Relevance: The management of ankle fractures in the elderly population often proves difficult as poor bone quality, an increased presence of vascular diseases, and diabetes make surgical intervention less viable. The prevalence of decreased bone mineral density in the elderly creates an inherent challenge when considering surgical techniques, as the bone cannot withstand required compressive forces in certain repair methods. In managing ankle fragility fractures in elderly patients nonoperative treatments and less invasive surgical techniques should be considered especially when minding the preservation of soft-tissue integrity. This study illuminates the healing and repair challenges faced by the elderly population in response to ankle fractures. Noting that the United States has an aging population, this article is quite useful in the advancement of podiatric medicine. This article helps surgeons determine the best treatment and rehabilitation plan when faced with challenging elderly fragility fractures.
Methods: This article reviews the recovery and success rates of different repair methods and recovery techniques used on the elderly to mend fragility ankle fractures. Several factors have to be considered by the physician in each individual case. This study focuses on grading the levels of recommendation for the following treatment plans: nonoperative treatment, tibia-pro formula (TPF), known as the trans-syndesmotic technique screws, intramedullary fibular fixation, bicortical screw fixation of medal malleolar fragments, posterior malleolar anterior-to-posterior screws, lateral locking plates, tibiotalocalcaneal (TTC) nails and external fixation with hydroxyapatite-coated pins.
Results: Soft tissue integrity is of the utmost importance, therefore nonoperative treatment plans should be considered. The article states that nonoperative methods, such as close contact casting, has lead to “more favorable outcomes with a higher return to baseline function in elderly cohorts.” Less invasive surgical techniques such as percutaneously placed anterior-to-posterior screws for posterior malleolar fractures proved to be a successful option. Medical optimization, especially nutritionally, is also very important, as diet supplementations can reduce the risks of complications. Fibular intramedullary fixation has had great success, when it is performed with smaller incisions and less time under anesthesia. Lateral locking plates have also been advantageous for the elderly, as they do not rely on preserved bone mineral density to maintain fixation. Hydroxyapatite-coated pins have also reduced the issues associated with pin loosening and pin-site infection, which is extremely important to avoid.
Conclusions: This article concludes that nonoperative treatments are preferable when treating an ankle fracture in the elderly. If the doctor decides to pursue a surgical solution, less invasive techniques are recommended. The ultimate goal for elderly patients with an ankle fracture is to maintain joint congruity, soft tissue integrity and stability. Every patient presents with different issues, but the fragility of the elderly has to be noted and taken into consideration when deciding the best methods for recovery and repair. The results of this study allow surgeons to better assess their plan of treatment when caring for an elderly patient.