Early complications of surgery in operative treatment of ankle fractures in those over 60: A review of 186 cases

Zaghloul, Ahmed; Haddad, Behrooz; Barksfield, R; Davis, Benjamin J.

doi:10.1016/j.injury.2013.11.008

Cited by 128 publications

(81 citation statements)

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“…The benefits of surgery are less clear because of the substantially increased risk of complications such as infection, wound breakdown and fixation failure. 24 It is more difficult to achieve successful surgical outcomes in older people because of a higher prevalence of comorbidities resulting in lower bone density (osteoporosis), frail skin and impaired wound healing. Poor bone quality directly affects the efficacy of implant stabilisation treatment methods for the bone fracture fragments.…”

Section: Issues With Surgery In Older Adults After Ankle Fracturementioning

confidence: 99%

“…The complications included superficial surgical site infection and delayed wound healing (17/186, 9%), deep surgical site infection (13/186, 7%), failure of fixation (6/186, 3%), non-union or malunion (20/186, 11%) and additional surgery for wound debridement, removal of metalwork or revision of the fixation (20/186, 11%). 24 Operative versus casting treatment of unstable and/or displaced ankle fractures…”

Section: Introductionmentioning

confidence: 99%

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The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years

Keene

Mistry

Nam

et al. 2016

Health Technol Assess

126

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BackgroundClose contact casting (CCC) may offer an alternative to open reduction and internal fixation (ORIF) surgery for unstable ankle fractures in older adults.ObjectivesWe aimed to (1) determine if CCC for unstable ankle fractures in adults aged over 60 years resulted in equivalent clinical outcome compared with ORIF, (2) estimate cost-effectiveness to the NHS and society and (3) explore participant experiences.DesignA pragmatic, multicentre, equivalence randomised controlled trial incorporating health economic evaluation and qualitative study.SettingTrauma and orthopaedic departments of 24 NHS hospitals.ParticipantsAdults aged over 60 years with unstable ankle fracture. Those with serious limb or concomitant disease or substantial cognitive impairment were excluded.InterventionsCCC was conducted under anaesthetic in theatre by surgeons who attended training. ORIF was as per local practice. Participants were randomised in 1 : 1 allocation via remote telephone randomisation. Sequence generation was by random block size, with stratification by centre and fracture pattern.Main outcome measuresFollow-up was conducted at 6 weeks and, by blinded outcome assessors, at 6 months after randomisation. The primary outcome was the Olerud–Molander Ankle Score (OMAS), a patient-reported assessment of ankle function, at 6 months. Secondary outcomes were quality of life (as measured by the European Quality of Life 5-Dimensions, Short Form questionnaire-12 items), pain, ankle range of motion and mobility (as measured by the timed up and go test), patient satisfaction and radiological measures. In accordance with equivalence trial US Food and Drug Administration guidance, primary analysis was per protocol.ResultsWe recruited 620 participants, 95 from the pilot and 525 from the multicentre phase, between June 2010 and November 2013. The majority of participants, 579 out of 620 (93%), received the allocated treatment; 52 out of 275 (19%) who received CCC later converted to ORIF because of loss of fracture reduction. CCC resulted in equivalent ankle function compared with ORIF at 6 months {OMAS 64.5 points [standard deviation (SD) 22.4 points] vs. OMAS 66.0 points (SD 21.1 points); mean difference –0.65 points, 95% confidence interval (CI) –3.98 to 2.68 points; standardised effect size –0.04, 95% CI –0.23 to 0.15}. There were no differences in quality of life, ankle motion, pain, mobility and patient satisfaction. Infection and/or wound problems were more common with ORIF [29/298 (10%) vs. 4/275 (1%)], as were additional operating theatre procedures [17/298 (6%) vs. 3/275 (1%)]. Malunion was more common with CCC [38/249 (15%) vs. 8/274 (3%);p < 0.001]. Malleolar non-union was lower in the ORIF group [lateral: 0/274 (0%) vs. 8/248 (3%);p = 0.002; medial: 3/274 (1%) vs. 18/248 (7%);p < 0.001]. During the trial, CCC showed modest mean cost savings [NHS mean difference –£644 (95% CI –£1390 to £76); society mean difference –£683 (95% CI –£1851 to £536)]. Estimates showed some imprecision. Incremental quality-adjusted life-years following CCC were no different from ORIF. Over common willingness-to-pay thresholds, the probability that CCC was cost-effective was very high (> 95% from NHS perspective and 85% from societal perspective). Experiences of treatments were similar; both groups endured the impact of fracture, uncertainty regarding future function and the need for further interventions.LimitationsAssessors at 6 weeks were necessarily not blinded. The learning-effect analysis was inconclusive because of limited CCC applications per surgeon.ConclusionsCCC provides a clinically equivalent outcome to ORIF at reduced cost to the NHS and to society at 6 months.Future workLonger-term follow-up of trial participants is under way to address concerns over potential later complications or additional procedures and their potential to impact on ankle function. Further study of the patient factors, radiological fracture patterns and outcomes, treatment responses and prognosis would also contribute to understanding the treatment pathway.Trial registrationCurrent Controlled Trials ISRCTN04180738.FundingThe National Institute for Health Research Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 75. See the NIHR Journals Library website for further project information. This report was developed in association with the National Institute for Health Research Oxford Biomedical Research Unit funding scheme. The pilot phase was funded by the AO Research Foundation.

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Section: Issues With Surgery In Older Adults After Ankle Fracturementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years

Keene

Mistry

Nam

et al. 2016

Health Technol Assess

126

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“…SSI is a strong predictor of mortality in elderly patients (Lee et al 2006), and controversies remain regarding the risks and benefits of operative treatment in geriatric patients (Koval et al 2007, Strauss and Egol 2007, Hak et al 2011, Shivarathre et al 2011, Lynde et al 2012, McKean et al 2013, Olsen et al 2013, Zaghloul et al 2014. The risks of surgical treatment should be carefully evaluated in all elderly patients (Kettunen and Kröger 2005).…”

Section: Elderly Patientsmentioning

confidence: 99%

Complications in ankle fracture surgery

Ovaska¹

2015

Acta Orthop

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“…Zaghoul et al found an overall rate of complications in surgically treated ankle fractures in patients over the age of 60 years to be 21.5% with 10.8% of them being major complications prompting surgical intervention for wound washout, removal of implants, and revision of fixation. Smoking, age, diabetes, and local factors (osteopenia, peripheral neuropathy, peripheral vascular disease, lymphedema, and venous insufficiency) were significantly associated with occurrence of complications [13•]. An audit performed by Kurar showed considerably improved anatomical reduction rates following internal fixation but did not report on functional outcomes and patient satisfaction [14].…”

Section: Introductionmentioning

confidence: 99%

Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly

2017

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Purpose of ReviewTreatment of osteoporotic and neuropathic ankle fractures in the elderly is challenging. The purpose of this paper is to review recent publications on this topic and to identify the optimal treatment for these fractures.Recent FindingsTreatment consists of a variety of conservative or operative options all with advantages and disadvantages as described in this review. Little research has been published that specifically focuses on elderly patients with ankle fractures. Operative treatment has a high complication rate. Multiple comorbidities are predictors for complications.SummaryAn optimal treatment could not be distilled but based on the available literature, a general treatment algorithm is proposed. Since the elderly typically are accompanied by multiple comorbidities as well as impaired mobility, the physician should focus not only on treating the fractured ankle but also on the patient as a whole. Further research on this specific topic is needed.

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Early complications of surgery in operative treatment of ankle fractures in those over 60: A review of 186 cases

Cited by 128 publications

References 24 publications

The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years

The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years

Complications in ankle fracture surgery

Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly

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