Early Protected Weightbearing After Ankle Fractures in Patients With Diabetes Mellitus.

The traditional protocol for treatment after ankle fracture in the diabetic patient involves a period of prolonged non-weightbearing to reduce the incidence of complications. The goal of the present study was to identify the risk factors and complications associated with early protected weightbearing after closed ankle fractures in patients with diabetes. The data from 73 diabetic patients with operatively and nonoperatively treated ankle fractures were retrospectively reviewed. All patients were allowed to begin protected weightbearing in a cast or removable boot at 2 weeks after the index injury or surgery. The mean follow-up period was 51 (range of 26 to 480) weeks. Complications occurred in 25% of the operative cases and 8% of the nonoperative cases. In both categories, the complication rate was less than that from existing reports using prolonged non-weightbearing. Wound dehiscence was the most common complication in the operatively treated patients (18.8%). A statistically significant difference was found in the complications rates for the patients aged >60 years (p = .0403). No statistically significant differences were identified according to hemoglobin A1c, the presence of peripheral neuropathy, smoking status, fracture type, or the presence of end-stage renal disease. The results of the present study suggest that early protected weightbearing after closed ankle fractures in diabetic patients is fairly safe, with an acceptable complication rate. However, the patients selected for early weightbearing had low comorbidity profiles, which might have accounted, in part, for the low complication rate.

A Biomechanical Comparison of Locking Versus Conventional Plate Fixation for Distal Fibula Fractures in Trimalleolar Ankle Injuries.

Previous biomechanical studies have advocated the use of locking plates for isolated distal fibula fractures in osteoporotic bone. Complex rotational ankle injuries involve an increased number of fractures, which can result in instability, potentially requiring the same fixed angle properties afforded by locking plates. However, the mechanical indication for locking plate technology has not been tested in this fracture model. The purpose of the present study was to compare the biomechanical properties of locking and conventional plate fixation for distal fibula fractures in trimalleolar ankle injuries. Fourteen (7 matched pairs) fresh-frozen cadaver leg specimens were used. The bone mineral density of each was obtained using dual x-ray absorptiometry scans. The fracture model simulated an OTA 44-B3.3 fracture. The syndesmosis was not disrupted. Each fracture was fixated in the same fashion, except for the distal fibula plate construct: locking (n = 7) and one-third tubular (n = 7). The specimens underwent axial and torsional cyclic loading, followed by torsional loading to failure. No statistically significant differences were found between the locking and conventional plate constructs during both fatigue and torque to failure testing (p > .05). Our specimen bone mineral density averages did not represent poor bone quality. The clinical implication of the present study is that distal fibular locking plates do not provide a mechanical advantage for trimalleolar ankle injuries in individuals with normal bone density and in the absence of fracture comminution.

Fixation orientation in ankle fractures with syndesmosis injury.

Accurate reduction of the syndesmosis has been shown to be an important prognostic factor for functional outcome in ankle injuries that disrupt the syndesmosis. The purpose of the present case series was to assess the fixation orientation and the position of the fibula within the tibial incisura after open reduction and internal fixation of ankle fractures with syndesmosis injury. Computed tomography was used to assess the accuracy of the reduction. Twelve patients were included in the present case series. A ratio representing the relationship between the tibia and fibula and the orientation of the syndesmotic fixation was measured preoperatively and postoperatively and compared with the uninjured contralateral ankle, representing the patient's normal anatomy. The measurements were accomplished electronically to one tenth of 1 mm using Stentor Intelligent Informatics, I-site, version 3.3.1 (Phillips Electronics; Andover, MA). Posteriorly oriented syndesmotic fixation caused posterior translation of the fibula with respect to the tibia and anteriorly oriented syndesmotic fixation caused anterior translation.

Bicortical fixation of medial malleolar fractures: a review of 23 cases at risk for complicated bone healing.

Several methods have been described for fixation of unstable medial malleolar fractures. Certain patient populations, including the elderly, those with osteoporosis and osteopenia, and patients with diabetes mellitus, are generally known to be susceptible to complications associated with ankle fracture healing. The goal of the present retrospective investigation was to review the outcomes of a series of patients who had undergone medial malleolar fracture repair using fully threaded bicortical interfragmental compression screw fixation. Patients were included in the present series if they had undergone bicortical fixation of an unstable ankle fracture with a medial malleolar fracture component, in addition to having at least 1 of the following comorbidities: age 55 years or older, osteoporosis or osteopenia, diabetes mellitus, peripheral arterial disease, end-stage renal disease, chronic kidney disease, previous kidney transplantation, peripheral neuropathy, or current tobacco use. A total of 23 ankle fractures in 22 consecutive patients met the inclusion criteria. The mean age of the patients was 69.52 (range 45 to 89) years; 17 were female (77.27%) and 5 were male (22.73%). Of the 23 medial malleolar fractures, 21 (91.3%) achieved complete, uncomplicated healing. The mean interval to union was 62.6 (range 42 to 156) days. A total of 4 complications (17.39%) were noted, including 1 nonunion (4.35%), 1 malunion (4.35%), and 2 cases of painful retained hardware (8.7%). From our experience with this series of patients, bicortical screw fixation for medial malleolus fractures appears to be an acceptable alternative for fixation that provides a stable construct for patients at greater risk of bone healing complications.

Analysis of ankle range of motion and functional outcome following total ankle arthoplasty.

The success of ankle joint replacement has primarily been reviewed with respect to patient morbidity and survivorship rather than patient satisfaction. A retrospective review was performed of 95 patients who had undergone a total ankle replacement and who had completed both postoperative range of motion fluoroscopy and a subjective patient score sheet. Collected data included age, body mass index, length of follow-up, presence of complications, performance of adjunctive procedures, range of motion, and the etiology of the end-stage arthritis. These variables were then compared with patient satisfaction to see if there were any predictive conditions of successful outcomes. Patients older than 60 years and those with a body mass index (BMI) less than 30 demonstrated a significant positive association with subjective satisfaction scores (P = .0023 and .0008, respectively). The amount of postoperative range of motion did not appear to correlate with patient satisfaction. Furthermore, there were no significant associations of patient satisfaction with a patient age younger than 60 years, a BMI greater than 30, additional procedures, perioperative complications, the length of time after surgery, and the presenting etiology.

Rates of revision surgery using Chevron-Austin osteotomy, Lapidus arthrodesis, and closing base wedge osteotomy for correction of hallux valgus deformity.

To identify complications that necessitated revision surgery after the primary operation, a multicenter retrospective chart review was conducted for 646 patients who received either a modified chevron-Austin osteotomy (270 patients), modified Lapidus arthrodesis (342 patients), or closing base wedge osteotomy (34 patients) to correct hallux valgus deformity. Revision surgery for complications was calculated and compared. All surgery was performed by 1 of 5 staff foot and ankle surgeons at Kaiser Permanente medical centers. Complications included recurrent hallux valgus, iatrogenic hallux varus, painful retained hardware, nonunion, postoperative infection, and capital fragment dislocation. The rates of revision surgery after Lapidus arthrodesis, closing base wedge osteotomy and chevron-Austin osteotomy were similar with no statistical difference between them. The total rate for re-operation was 5.56% among patients who received chevron-Austin osteotomy, 8.82% among those who had a closing base wedge osteotomy, and 8.19% for patients who received modified Lapidus arthrodesis. Among patients who had the chevron-Austin osteotomy procedure, rates of re-operation were 1.85% for recurrent hallux valgus and 1.48% for hallux varus. Among patients who had the modified Lapidus arthrodesis, rates of re-operation were 2.92% for recurrent hallux valgus and 0.29% for hallux varus. Among patients who had the closing base wedge osteotomy, rates of reoperation were 2.94% for recurrent hallux valgus and 2.94% for hallux varus. The collected comparative complication rates should serve to provide adjunctive information for foot and ankle surgeons and patients regarding hallux valgus surgery.

Arthroscopic assisted fixation of juvenile intra-articular epiphyseal ankle fractures.

The purpose of this study was to present the long-term follow-up of a case series of arthroscopically assisted fixation of juvenile intraarticular epiphyseal ankle fractures. The functional and radiographic outcomes of 6 patients with a range of follow-up of 1 to 5 years were evaluated. Five of the 6 patients had triplane injuries, whereas the remaining patient sustained a juvenile Tillaux fracture. All of the patients returned to full activity within 14 weeks of surgery, and none of the patients had any restriction in the ankle range of motion at the time of last follow-up. The results of this small series of patients suggest that arthroscopic-assisted, percutaneous fixation of intraarticular juvenile epiphyseal ankle fractures is an effective, less invasive surgical technique. Several surgical maneuvers that are helpful in the consistent execution of this technique are also mentioned.