Rockwood Adults CH64

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SECTION FOUR • Lower Extremity

Empirically most authors recommend that patients with dia- betic complications should be managed with prolonged periods of immobilization nonweightbearing, of up to 8 weeks. 72 Aug- mentation of fixation with Steinmann pins across the subtalar and ankle joints has also been suggested. 167,172 There are how- ever no comparative studies of fixation options and postopera- tive protocols. Obesity The impact of obesity on outcome after ankle fracture is contro- versial. Some have found no difference in complication rates or patient-reported outcomes in obese patients in comparison to controls, 362 while others have reported significant differences. Böstman 42 reported that 5.6% of obese patients experienced failure of fixation in comparison to 1.8% of nonobese patients and recommended a prolonged period of time nonweightbear- ing to reduce these risks. Elderly Elderly patients, in particular elderly women, make up a large proportion of patients presenting with ankle fractures. The opti- mum management of ankle fractures in elderly patients has been extensively debated in the literature and there remains a large variation in rates of operative fixation of ankle fractures in elderly patients across the United States 196 with increasing age associated with significantly lower rates of operative intervention. Early reports of poor outcomes of operative treatment in elderly patients 29,327 with high rates of complications particularly in postmenopausal women due to poor bone quality, may have discouraged operative intervention in elderly patients. However a number of studies since have shown that elderly patients with unstable fractures can be successfully treated with operative fixa- tion 10,13,419 with reports of comparable outcomes 14,83 and rates of complications 55,288 to younger patients. Indeed an RCT of patients over 55 with unstable ankle fractures found better subjective and objective outcomes in operatively managed patients. 230 A number of authors have investigated the optimum man- agement of ankle fractures in the super elderly. Fong et al. 115 experienced significant complications in their cohort of 17 patients over the age of 80, leading them to conclude that com- pliance with postoperative instructions may be the most chal- lenging factor when dealing with this group of patients, while Shivarathre et al. 344 reported good outcomes in their cohort. No prospective comparative studies have been undertaken. In frail patients with compromised soft tissues percutaneous methods may be more appropriate. Good clinical outcomes have been reported with use of fibular 411 and calcaneotalotibial nails. 214 Smoking and Alcohol Patients who smoke have a significantly higher rate of compli- cations, particularly deep wound infections, 271 and significantly worse long-term outcomes. 38 However, smoking cessation after fracture is beneficial in reducing complication rates. 270 Those who drink alcohol to excess also appear to be at higher risk of complications. Tønnesen et al. 382 compared 90 patients who drank to excess with 90 controls all presenting with unsta- ble ankle fractures. Following fixation the alcoholic patients had

a far higher rate of complications (33% to 9%) including wound infection (15% to 4%) and a significantly longer hospital stay. Kankare et al. attempted to compare biodegradable internal fixation with metallic fixation in an RCT in alcoholic patients, however, significantly higher rates of failure of fixation in the biodegradable group resulted in early cessation of the study. They report that noncompliance and loss to follow up were a major problem in studying this group of patients. 178

OUTCOMES OF ANKLE FRACTURES

A number of factors have been shown to affect outcome following ankle fracture, many of which have been already discussed. Poorer outcomes and increased rates of complications have been reported in patients presenting with fracture dislocations in comparison to those without 23,55,60,84,182 ; in those with fractures involving the medial malleolus in comparison to those with medial ligamen- tous injuries 60,365,371 ; and in older, female and diabetic patients. 104 A small study looking to correlate patient-related outcomes with surgeon’s perceptions of positive results found good correlation. 110 Sport is the third most common cause of ankle fractures 76 and hence return to sport is a frequent concern of patients. Porter et al. assessed the outcomes in 27 operatively treated patients who sustained their fracture while playing sport. At a mean of 2.4 years after injury, all athletes except one had returned to their previous level of competition. 307 In contrast, Shah et al. 340 found that only 62% of their patients had returned to their prior level of sport- ing activity 5 years after injury. Moreover, Colvin et al. 68 reviewed patients who reported that they had participated in sport prior to their injury (but who were not necessarily playing sport at the time of injury) and found that by 1 year only 24.5% of patients had returned to full sporting activity. These different results may relate to the different demographics of the cohorts: 70% of Porter’s patients were male and had a mean age of 18 years, whereas Col- vin’s group were 55% male and had a mean age of 43 years. In summary, most patients do well following an ankle frac- ture. Eighty-eight percent are pain free or have only mild pain at 1 year, and 90% have no restrictions or only mild recre- ational limitations. A substantial improvement is generally seen between 6 months and 1 year after injury. 104

MANAGEMENT OF ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS IN ANKLE FRACTURES

Common Adverse Outcomes and Complications

• Wound infection/dehiscence • Loss of reduction • Thromboembolism • Symptomatic hardware • Osteoarthritis • Nonunion • Compartment syndrome • Neuroma