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Injury, Int. J. Care Injured 44 S3 (2013) S20–S22
Introduction
Ankle fractures represent an exceptionally common injury
within the elderly population. The total incidence of ankle
fractures has been reported to be up to 184 fractures per 100,000
persons per year, of which 20 to 30 percent occur in the elderly.1
Nowadays, ankle fractures have become an “epidemic”, mainly
because of the higher activity levels within the elderly.
Treatment of complex ankle fractures still remains a subject
of great controversy. The majority of authors are in favor of non-
operative management, an argument supported by the good
late functional results, small number of complications and low
cost of treatment as compared to the overall costs of operative
management.2 On the other hand, operative management can
result in high complication rates, with the infection rate being
reported as high as 12%.3,4 Moreover, osteoporosis is often
the cause of poor fixation and can result in an unsatisfactory
outcome (in up to 42% of patients).3,4
On the contrary, the advocates of operative management
argue that the patients achieve better functional outcomes
following open reduction and internal fixation (ORIF). Anand et
al. reported better anatomic congruency and functional results
following operative treatment, as compared to non-operative
management.5 Besides, other authors report that bad bone
quality is not a limiting factor for an operative management.6,7
This study reports on the results of operative management of
ankle fractures in the elderly, with regard to functional outcome
and complication rates.
Patients and methods
Study design
This was a retrospective, non-randomized observational
study. Ethical approval was obtained by the University Hospital
of Zagreb and the study was conducted within the principles
set out in the Declaration of Helsinki. Informed consent was
acquired by each of the participants.
K E Y W O R D S
Ankle Fracture
American Orthopaedic Foot and Ankle Society
(AOFAS)
Elderly
Functional Outcome
Linear analog scale (LAS)
Open reduction and internal fixation (ORIF)
A B S T R A C T
Ankle fractures represent an exceptionally common injury within the elderly population. The total
incidence of ankle fractures has been reported to be up to 184 fractures per 100,000 persons per year,
of which 20 to 30 percent occur in the elderly. This study reports the results of operative management
of ankle fractures in the elderly, with regard to functional outcome and complication rates.
This was a retrospective, non-randomized observational study. Subjects were identified from a trauma
registry kept in our Department and were tested for eligibility. Patients were then categorized into
two groups according to their age: Group A included all patients less than 65 years of age and Group B
included all patients over the age of 65.
The outcome was measured using the AOFAS Ankle-Hindfoot score and a Linear analog scale.
A total of 120 consecutive patients fulfilled the eligibility criteria and were included in our study
(60 patients in each group). We detected statistically significant difference between the LAS score of
the two groups (p=0.02), the alignment between the two groups (p=0.04) and the AOFAS score versus
LAS score in Group B (p=0.03). Two patients from Group B had wound dehiscence, but finally their
wounds healed uneventfully. We didn’t observe any serious complications such as skin necrosis, deep
infection, osteomyelitis and failure of metalwork.
Our study suggests that the operative management of Weber B2 and B
3 injuries can result in a favorable
outcome. It is however of great importance that there are no delays in treatment, that the reduction
is anatomical, that the fracture fixation is satisfactory and that the rehabilitation is commenced early.
© 2013 Elsevier Ltd. All rights reserved.
Operative management of unstable ankle fractures in the elderly: our institutional experience
Tin Ehrenfreund*, Damir Haluzan, Ivan Dobric, Tomislav Zigman, Daniel Rajacic, Tonisav Antoljak, Slavko Davila
Department of Surgery, University Hospital Centar Zagreb, Croatia
* Corresponding author at: Department of Surgery, University Hospital Centar
Zagreb, Kispaticeva 12, 10 000 Zagreb, Croatia
E-mail address: ehrtin@yahoo.com (T. Ehrenfreund).
0020-1383/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
Contents lists available at SciVerse ScienceDirect
Injury
j our na l homepage: www.e lsev ie r.com/ loca te / in ju r y
T. Ehrenfreund et al. / Injury, Int. J. Care Injured 44 S3 (2013) S20–S22 S21
Subjects were identified from a trauma registry kept in our
Department and were tested for eligibility. Patients were then
categorized into two groups according to their age: Group A
included all patients less than 65 years of age and Group B
included all patients over the age of 65. When the number of
60 participants was completed in each of the study groups, the
recruitment was stopped.
Criteria for eligibility
The criteria for eligibility were: 1) isolated ankle fracture,
classified as Weber B2 or Weber B
3; 2) minimum follow-up of two
years; 3) patient ambulatory prior to injury (with or without the
use of walking aids); 4) patient able to adhere to post-operative
instructions; 5) capacity to give informed consent. Exclusion
criteria included: 1) open fractures; 2) background of diabetes;
3) peripheral arterial disease prior to injury and/or leg ulceration;
4) patient not fit for anaesthetic; 5) cognitive impairment.
Operative management
Indications for operative management included: 1) displace-
ment > 1 mm on the antero-posterior (AP) and/or lateral radio-
graphs; 2) any unstable injury patterns.
The anaesthetic and pain protocol was used according to
the anaesthetist’s preference. All operations were performed
by a consultant or their trainee under supervision and
consisted of osteosteosynthesis according to AO principles.
Post-operatively, all patients received Thrombo Embolus
Deterrent stockings (TEDs) and Low Molecular Weight Heparin
(LMWH). Moreover, all patients were immobilised in a cast for
six weeks and were advised not to bear any weight. After that
period of time, they were allowed to bear weight as tolerated
and then progressively returned to full weight bearing. At
the same time, a referral was made to physiotherapy. AOFAS
ankle score8 and linear analog scale9 were calculated and
documented for each patient.
American Orthopaedic Foot and Ankle Society (AOFAS)
Ankle-Hindfoot score
We used the AOFAS Ankle-Hindfoot score, a validated function
score.10 It is composed of scoring the function (50 points); the
pain (40 points); and the alignment (10 points). The total score
is equal to 100; a patient can therefore score maximum points
when he is in no pain, has no activity limitations, no motion
limitations, shows no joint instability, shows good alignment,
can walk the distance of more than 6 blocks without support
requirements (walker, crutches, wheelchair, brace etc.), has no
difficulty on any walking surface, shows no gait abnormality
nor limitations in daily recreational activities. The range
of motion was measured by goniometer and the alignment
was determined by physical examination and radiological
examination.
Linear analog scale (LAS)
Each subject was given a 15 cm long paper strip that was
calibrated from 0 to 100, in five-percent increments. 0 was
considered to be a completely dysfunctional ankle whereas
100 was considered a perfectly functional ankle. Following the
explanation of the assessment procedure, patients were asked to
mark their ankle function.
Results ranging from 0 to 30 were considered as bad, those
ranging from 31 to 60 satisfactory, those from 61 to 90 good, and
those from 91 to 100 excellent.
Statistical analysis
Statistical analysis was made using SAS version 9.0 software.
Non-parametric tests (Mann-Whitney test and Wilcoxon signed
ranks test) were used as appropriate. A p value <0.05 was
considered significant.
Results
A total of 120 consecutive patients fulfilled the eligibility
criteria and were included in our study (60 patients in each group).
84 of these patients were female and all patients completed the
follow-up. The results of our analysis are summarized in Tables 1
to 4.
When we compared the AOFAS score in the two groups, we
found no statistical significance. There was however statistically
significant difference in the LAS score between the two groups
(p=0.02).
No statistical significance was evident when the function
and pain levels were analyzed separately. On the contrary, the
alignment was statistically different between the two groups
(p=0.04).
When we compared AOFAS score and LAS score for Group A
(i.e. patients < 65 years of age), we did not detect any statistical
difference. This was not the case when we repeated the analysis
for Group B (i.e. patients ≥ 65 years of age) (p=0.03).
LAS score of both groups was satisfactory.
Complications
Two patients from Group B had wound dehiscence, but
eventually their wounds healed uneventfully. We didn’t observe
any serious complications such as skin necrosis, deep infection,
osteomyelitis and failure of metalwork.
Discussion
Ankle fractures remain a common type of injury in
Orthopaedics.1 Because of their complexity and high complication
rate, most of them are treated operatively, followed up by a strict
rehabilitation program. In order to obtain a successful outcome,
anatomic reposition, meticulous surgical technique and early
rehabilitation are necessary.11 Certain fracture patterns often do
not respond to treatment and can result in a painful, arthritic
joint. Anderson et al has also reported that operative management
can restore the ankle joint congruity regardless of the patient’s
age.12 Additionally, a recent systematic review reported that a
poor fracture reduction can result in an unfavorable long-term
outcome.13
Our results indicate that the AOFAS score in both groups was
equivalent throughout the rehabilitation period, a finding that
agrees to the reported outcomes by Davidovitch et al.14
LAS score represents a subjective measurement and only
provides limited information with regards to the treatment
outcome. Nevertheless, it takes into account the overall state of
the patient, both physical and psychological. As already reported,
pain and satisfaction rates differ in different cultures, which is
again reflected in the LAS score.15 This finding is also supported
by the good late functional results in AOFAS score calculated for
group B, compared to a lower LAS score.
Osteoporosis, skin problems, peripheral vascular disease,
diabetes and other co-morbidities are all factors that predispose
to poor operative outcomes.16 We did not detect any high
complication rates in our series, where only two minor wound
problems were reported. This is significantly lower than the
complication rates reported in the literature.3,4,17
S22 T. Ehrenfreund et al. / Injury, Int. J. Care Injured 44 S3 (2013) S20–S22
All ankle fractures require post-operative immobilization,
regardless of the type of injury.14 According to Srinivasan
et al., external splintage to support the fixation and a strict
no weightbearing protocol are very important factors for
the elderly population, even though this comes in contrast
to the philosphophy of early mobilisation.18 He also reports
that unprotected weight bearing following an ankle ORIF
contributes to the high incidence of infection and malunion, a
finding previously reported in the literature.3,19 Other authors
recommend an eight-week immobilization regime, regardless of
the type of management.1,20 Recently, Kimmel et al recommended
a period of immobilization of six weeks without any prolonged
post-operative bed rest.21
Conclusion
Our study suggests that the operative management of Weber
B2 and B
3 injuries can result in a favorable outcome. It is however
of great importance that there are no delays in treatment, that the
reduction is anatomical, that the fracture fixation is satisfactory
and that the rehabilitation is commenced early.
Conflict of interest
The authors declare no conflict of interest.
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Table 1AOFAS-score in subjects under 65 years of age
Mean value Confidence interval Median Standard deviation Min. Max.
90.57 88.72 – 92.41 92.41 7.15 80 100
Table 2AOFAS-score in subjects over 65 years of age
Mean value Confidence interval Median Standard deviation Min. Max.
83.7 81.66 – 85.74 84 7.90 59 100
Table 3LAS-score in subjects under 65 years of age
Mean value Confidence interval Median Standard deviation Min. Max.
85.67 83.57 - 87.76 85 8.10 70 95
Table 4LAS-score in subject over 65 years of age
Mean value Confidence interval Mean Standard deviation Min. Max.
79.67 75.82 - 83.51 80 14.90 30 95
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