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