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Journal of Foot and Ankle Research Jun 2024This systematic review aimed to analyse the effect of early weight bearing versus late weight bearing on rehabilitation outcomes after ankle fractures, which primarily... (Meta-Analysis)
Meta-Analysis Review
The effect of early weight-bearing and later weight-bearing rehabilitation interventions on outcomes after ankle fracture surgery: A systematic review and meta-analysis of randomised controlled trials.
OBJECTIVE
This systematic review aimed to analyse the effect of early weight bearing versus late weight bearing on rehabilitation outcomes after ankle fractures, which primarily include ankle function scores, time to return to work/daily life and complication rates.
METHODS
The China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, China Science and Technology Journal, Web of Science, PubMed, Embase and Cochrane Library databases were searched. The focus was on identifying randomised controlled trials centred on early weight-bearing interventions for post-operative ankle fracture rehabilitation. All databases were searched for eligible studies published within the period from database inception to 20 June 2023. The eligible studies were screened according to the inclusion criteria. Study quality was evaluated using the methodology recommended by the Cochrane Handbook for the Systematic Evaluation of Interventions. Two authors independently performed the literature search and data extraction. Eligible studies were subjected to meta-analyses using Review Manager 5.3. Based on the time points at which post-operative ankle function was reported in the studies included in this paper, we decided to perform a meta-analysis of ankle function scores at 6 weeks post-operatively, 12 weeks post-operatively, 24-26 weeks post-operatively and 1 year post-operatively.
RESULTS
A total of 11 papers, comprising 862 patients, were included. Meta-analysis indicated that patients receiving early weight-bearing interventions, which referred to weight-bearing for 6 weeks post-operatively, experienced enhancements in ankle function scores (Olerud-Molander score, AOFAS score or Baird-Jackson score) at various post-operative milestones: 6 weeks (SMD = 0.69, 95% CI: 0.49-0.88 and p < 0.01), 12 weeks (SMD = 0.57, 95% CI: 0.22-0.92 and p < 0.01) and the 24-26 weeks range (SMD = 0.52, 95% CI: 0.20-0.85 and p < 0.01). The results of subgroup analyses revealed that the effects of early weight-bearing interventions were influenced by ankle range-of-motion exercises. Additionally, early weight bearing allows patients to return to daily life and work earlier, which was evaluated by time when they resumed their preinjury activities (MD = -2.74, 95% CI: -3.46 to -2.02 and p < 0.01), with no distinct elevation in the incidence of complications (RR = 1.49, 95% CI: 0.85-2.61 and p > 0.05).
CONCLUSION
The results showed that early weight bearing is effective in improving ankle function among post-operative ankle fracture patients and allows patients to return to daily life earlier. Significantly, the safety profile of early weight bearing remains favourable, with no higher risk of complications than late weight bearing.
Topics: Humans; Ankle Fractures; Treatment Outcome; China; Weight-Bearing; Randomized Controlled Trials as Topic
PubMed: 38635458
DOI: 10.1002/jfa2.12011 -
The Journal of Foot and Ankle Surgery :... 2023The goal of this study is to evaluate the effect of time-to-surgery following closed ankle fractures on long-term patient reported outcomes, fracture healing, and wound...
The goal of this study is to evaluate the effect of time-to-surgery following closed ankle fractures on long-term patient reported outcomes, fracture healing, and wound complications. To date, little research has been done focusing on the impact "time to definitive fixation" has on patient reported outcomes. We performed a retrospective analysis of 215 patient records who underwent open reduction and internal fixation (ORIF) for an ankle fracture from July 2011 to July 2018. A total of 86 patients completed the patient reported outcome measurement information systems (PROMIS) survey at long-term follow-up. Primary outcomes were the rate of delayed union, postoperative wound complications, patient reported outcome measurement information system (PROMIS) pain interference (PI), and physical function (PF) scores. No differences were found when comparing time to surgery on a continuous scale with rates of delayed union, nonunion, or wound complications (p = .84, .47, and .63, respectively). PROMIS scores were collected at a median of 4.5 years (2.0 interquartile range (IQR), range 2.5-12.3) postoperatively. The time from ankle fracture to surgery was independently associated with worse PROMIS PI scores (unstandardized β 0.38, 95% CI 0.07-0.68) but not PROMIS PF scores. Severe Lauge-Hansen injuries were independently associated with decreased PROMIS PF scores (unstandardized β -7.02, 95% CI -12.0 to -2.04). Increased time to surgical intervention and severe Lauge-Hansen injuries were independently associated with worse long-term patient reported outcomes. Surgical timing did not impact union rates or wound complications. Surgeons should be aware that delaying ankle fracture repair beyond 12 days after injury may negatively affect long-term patient reported pain scores.
Topics: Humans; Ankle; Ankle Fractures; Fracture Fixation, Internal; Pain; Patient Reported Outcome Measures; Postoperative Complications; Retrospective Studies; Treatment Outcome
PubMed: 37003858
DOI: 10.1053/j.jfas.2023.02.011 -
Archives of Orthopaedic and Trauma... Oct 2023Trimalleolar fractures are difficult to treat and malreduction can lead to functional impairment. Involvement of the posterior malleolus has a poor predictive value....
INTRODUCTION
Trimalleolar fractures are difficult to treat and malreduction can lead to functional impairment. Involvement of the posterior malleolus has a poor predictive value. Current computed-tomography (CT)-based fracture classifications led to an increase in fixation of the posterior malleolus. The aim of this study was to describe the functional outcome after a two-stage stabilisation with direct fixation of the posterior fragment in trimalleolar dislocation fractures.
MATERIALS AND METHODS
In a retrospective study, all patients presenting with a trimalleolar dislocation fracture, an available CT scan, and a two-stage operative stabilisation including the posterior malleolus by a posterior approach were included. All fractures were treated with initial external fixator and delayed definitive stabilisation including fixation of the posterior malleolus. Next to clinical and radiological follow-up, outcome measures (Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS), Activity of Daily Living (ADL), Hulsmans implant removal score) and complications were analysed.
RESULTS
Between 2008 and 2019, of 320 trimalleolar dislocation fractures, 39 patients were included. Mean follow-up was 49 months (standard deviation (SD) 29.7, range 16-148). Mean age was 60 years (SD 15.3, 17-84) with 69% female patients. The mean FAOS was 93/100 (SD 9.7, 57-100), NRS 2 (interquartile range (IQR) 0-3) and ADL 2 (IQR 1-2). Four patients showed a postoperative infection, three re-operations had to be performed and implants were removed in 24 individuals.
CONCLUSION
A two-stage procedure of trimalleolar dislocation fractures with in-direct reduction and fixation of the posterior tibial fragment through a posterior approach leads to good functional outcome scores with a low rate of complications.
Topics: Humans; Female; Middle Aged; Male; Ankle Fractures; Ankle; Retrospective Studies; Treatment Outcome; Fracture Fixation, Internal; Ankle Joint; Fracture Dislocation; Joint Dislocations; Tomography, X-Ray Computed
PubMed: 37335355
DOI: 10.1007/s00402-023-04949-0 -
British Journal of Anaesthesia Apr 2021Peripheral nerve blocks (PNBs) are increasingly popular in acute ankle fracture surgery but rebound pain may outweigh the benefits. The AnAnkle Trial was designed to... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Peripheral nerve blocks (PNBs) are increasingly popular in acute ankle fracture surgery but rebound pain may outweigh the benefits. The AnAnkle Trial was designed to assess the postoperative pain profile of PNB anaesthesia compared with spinal anaesthesia (SA).
METHODS
The AnAnkle Trial was a randomised, two-centre, blinded outcome analysis trial. Eligible adults booked for primary ankle fracture surgery were randomised to PNB or SA. The PNBs were ultrasound-guided popliteal sciatic and saphenous blocks with ropivacaine and SAs were with hyperbaric bupivacaine. Postoperatively, all subjects received paracetamol, ibuprofen, and patient-controlled i.v. morphine for pain. The primary endpoint was 27 h Pain Intensity and Opioid Consumption (PIOC) score. Secondary endpoints included longitudinal pain scores and morphine consumption separately, and questionnaires on quality of recovery.
RESULTS
This study enrolled 150 subjects, and the PNB success rate was >94%. PIOC was lower with PNB anaesthesia (median, -26.5% vs +54.3%; P<0.001) and the probability of a better PIOC score with PNB than with SA was 74.8% (95% confidence interval, 67.0-82.6). Pain scores and morphine consumption analysed separately also yielded a clear benefit with PNB, despite substantial rebound pain when PNBs subsided. Quality of recovery scores were similar between groups, but 99% having PNB vs 90% having SA would choose the same anaesthesia form again (P=0.03).
CONCLUSIONS
PNB anaesthesia was efficient and provided a superior postoperative pain profile compared with SA for acute ankle fracture surgery, despite potentially intense rebound pain after PNB.
CLINICAL TRIAL REGISTRATION
Clinicaltrialsregister.eu, EudraCT number: 2015-001108-76.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Ankle Fractures; Autonomic Nerve Block; Female; Humans; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Single-Blind Method; Young Adult
PubMed: 33546844
DOI: 10.1016/j.bja.2020.12.037 -
The Journal of Foot and Ankle Surgery :... 2023The standard surgical treatment for unstable ankle fractures involves open reduction and internal fixation (ORIF) with plates. However, ORIF has been associated with... (Meta-Analysis)
Meta-Analysis Review
The standard surgical treatment for unstable ankle fractures involves open reduction and internal fixation (ORIF) with plates. However, ORIF has been associated with several complications, such as soft tissue irritation, wound infection, and nerve injury. Previous studies have shown that closed reduction and internal fixation with locked intramedullary nails (LIMNs) yields satisfactory efficacy in the treatment of ankle fractures and is associated with low complication rates. Therefore, a systematic review and meta-analysis of randomized controlled trials is imperative to provide evidence on whether or not LIMN fixation is comparable to or superior than traditional ORIF. We conducted a comprehensive literature search in the PubMed, Cochrane Library and EMBASE databases. A total of 4 randomized controlled trials involving 359 participants who suffered ankle fractures were included in this systematic review and meta-analysis. The results showed that the LIMN fixation group was statistically significant in terms of functional outcomes at the 3-month follow-up and wound-related complications. There was no statistical advantage for patients in the LIMN fixation group in terms of nonwound-related complications, total complications, or mid-term follow-up functional outcomes. There was no statistical difference between the LIMN and ORIF groups regarding operation time and quality of reduction. We believe LIMN fixation is a viable option for the treatment of unstable ankle fractures in both young and elderly individuals.
Topics: Humans; Aged; Ankle Fractures; Fibula; Treatment Outcome; Fracture Fixation, Internal; Fracture Fixation, Intramedullary; Bone Plates
PubMed: 36333182
DOI: 10.1053/j.jfas.2022.10.003 -
Foot & Ankle Specialist Aug 2021We assessed the quality, accuracy, and readability of websites for ankle fractures. Ankle Fracture, Broken Ankle, and Fibular Fracture were entered into 3 search...
We assessed the quality, accuracy, and readability of websites for ankle fractures. Ankle Fracture, Broken Ankle, and Fibular Fracture were entered into 3 search engines. The first 25 results from each search were collected. Quality, accuracy, and readability were assessed by a custom rubric, 3 surgeons, and Fleisch-Kincaid grade level (FKGL), respectively. A total of 57 websites were included: 24 were assigned to Ankle Fracture, 26 to Broken Ankle, and 7 to Fibular Fracture. The average quality score out of 36, accuracy score out of 12, and FKGL for all websites were 13.1 ± 6.8, 10.8 ± 1.2, and 9.6 ± 1.7, respectively. Websites assigned to the term Broken Ankle had a significantly lower New Dale-Chall score. Websites of lower FKGL and appearing earlier in results had significantly higher quality scores. Physician specialty societies (PSSs) had a significantly lower FKGL than websites of other types. The readability of patient materials is above the recommended level for ankle fractures. Encouragingly, a trade-off between readability and quality was not found. Patients should use search terms they are familiar with and prioritize websites that appear earlier in search results, are easier to read, and produced by PSSs.: Level 3.
Topics: Ankle Fractures; Comprehension; Humans; Internet; Reading; Search Engine
PubMed: 32674596
DOI: 10.1177/1938640020916286 -
Orthopedics 2024The purpose of this review was to determine whether there is a benefit to early weight bearing or mobilization in surgically treated ankle fractures. All randomized... (Meta-Analysis)
Meta-Analysis Review
The purpose of this review was to determine whether there is a benefit to early weight bearing or mobilization in surgically treated ankle fractures. All randomized controlled trials that analyzed early vs delayed weight bearing and/or mobilization after an ankle surgery were included. The primary outcome measure was the pooled Olerud Molander Ankle Score 1 year postoperatively. No significant differences in ankle function were found at 1 year postoperatively between early and delayed weight bearing and mobilization. The 12-week results demonstrated superior early ankle function scores for patients who had early weight bearing. Patients who had early mobilization were at increased risk for postoperative complications. In surgically treated ankle fractures, early weight bearing resulted in improved short-term ankle function scores. [. 2024;47(2):71-78.].
Topics: Humans; Ankle Fractures; Ankle; Randomized Controlled Trials as Topic; Fracture Fixation, Internal; Weight-Bearing; Treatment Outcome; Fracture Fixation
PubMed: 37561102
DOI: 10.3928/01477447-20230804-08 -
European Journal of Orthopaedic Surgery... Feb 2022To evaluate the variability in ankle syndesmotic morphology on contralateral ankle fluoroscopic images and the reductions obtained utilizing these images.
PURPOSE
To evaluate the variability in ankle syndesmotic morphology on contralateral ankle fluoroscopic images and the reductions obtained utilizing these images.
METHODS
A retrospective cohort study was performed at a level one trauma center including 46 adult patients undergoing operative fixation of malleolar ankle fractures that also had anteroposterior (AP) and lateral fluoroscopic images of the uninjured contralateral ankle intraoperatively. Contralateral and post-fixation fluoroscopic images were used to measure the tibiofibular clear space (TFCS) as a proportion of the superior clear space (SCS) on mortise images and the posterior tibiofibular distance (PTFD) as a proportion of the lateral superior clear space (LSCS) on lateral images. Differences between contralateral and post-fixation ankle measurements were compared between those patients with syndesmotic injuries and those without (control group).
RESULTS
The mean TFCS/SCS and PTFD/LSCS ratios measured on contralateral ankle images were 1.2 (95% confidence interval (CI) 1.1 to 1.3; range 0.7 to 1.8) and 1.8 (95% CI 1.5 to 2; range 0.5 to 3.4). The mean difference between the contralateral and post-fixation TFCS/SCS and PTFD/LSCS in patients with and without syndesmotic fixation was 0.07 vs. 0.13 (F-ratio 0.3, p = 0.5) and -0.2 vs 0.5 (F ratio 5.2, p= 0.02).
CONCLUSIONS
Contralateral syndesmotic measurements varied widely and the utilization of these images allowed for syndesmotic reductions with similar measurements. Intraoperative contralateral ankle images should be considered to assess syndesmotic reduction.
Topics: Adult; Ankle; Ankle Fractures; Ankle Injuries; Ankle Joint; Fracture Fixation, Internal; Fractures, Bone; Humans; Retrospective Studies; Treatment Outcome
PubMed: 33890171
DOI: 10.1007/s00590-021-02984-4 -
BMC Musculoskeletal Disorders Aug 2021Studies exploring risk factors for ankle fractures in adults are scarce, and with diverging conclusions. This study aims to investigate whether overweight, obesity and...
BACKGROUND
Studies exploring risk factors for ankle fractures in adults are scarce, and with diverging conclusions. This study aims to investigate whether overweight, obesity and osteoporosis may be identified as risk factors for ankle fractures and ankle fracture subgroups according to the Danis-Weber (D-W) classification.
METHODS
108 patients ≥40 years with fracture of the lateral malleolus were included. Controls were 199 persons without a previous fracture history. Bone mineral density of the hips and spine was measured by dual-energy x-ray absorptiometry, and history of previous fracture, comorbidities, medication, physical activity, smoking habits, body mass index and nutritional factors were registered.
RESULTS
Higher body mass index with increments of 5 gave an adjusted odds ratio (OR) of 1.30 (95% confidence interval (CI) 1.03-1.64) for ankle fracture, and an adjusted OR of 1.96 (CI 0.99-4.41) for sustaining a D-W type B or C fracture compared to type A. Compared to patients with normal bone mineral density, the odds of ankle fracture in patients with osteoporosis was 1.53, but the 95% CI was wide (0.79-2.98). Patients with osteoporosis had reduced odds of sustaining a D-W fracture type B or C compared to type A (OR 0.18, CI 0.03-0.83).
CONCLUSIONS
Overweight increased the odds of ankle fractures and the odds of sustaining an ankle fracture with possible syndesmosis disruption and instability (D-W fracture type B or C) compared to the stable and more distal fibula fracture (D-W type A). Osteoporosis did not significantly increase the odds of ankle fractures, thus suffering an ankle fracture does not automatically warrant further osteoporosis assessment.
Topics: Absorptiometry, Photon; Adult; Ankle Fractures; Bone Density; Humans; Obesity; Osteoporosis
PubMed: 34425796
DOI: 10.1186/s12891-021-04607-9 -
The Surgeon : Journal of the Royal... Oct 2021Preoperative home care for suitable patients with ankle fractures is becoming an increasingly common practice. It allows adequate time for reduction of ankle swelling...
OBJECTIVES
Preoperative home care for suitable patients with ankle fractures is becoming an increasingly common practice. It allows adequate time for reduction of ankle swelling following a decision to undertake operative fixation has been made. We aim to assess the safety, efficiency, cost-effectiveness and differences in clinical & patient outcomes of day surgery unit (DSU) care for ankle fracture treatment in selected patients. Our study combined home therapy treatment with DSU care for suitable ankle fractures.
DESIGN
Prospective cohort study.
SETTING
Trauma Centre.
PATIENTS
Fifty-three patients requiring operative fixation for an ankle fracture were divided into 2 groups. Patients in group 1 entered the home care combined with DSU treatment pathway whilst in group 2 were treated as in patient in the main trauma theatre in our standard pathway.
INTERVENTION
Comparison of Home Care & Day Case Surgery vs. in patient admission for patients requiring operative ankle fractures fixation.
MAIN OUTCOME MEASURES
Prospective data collection was undertaken over a 2-year period, on fracture type, logistical outcomes including time to surgery and total length of stay in the hospital and clinical outcomes including the rate of post-operative complications, incidence of unplanned surgical revisions and objective patient satisfaction. Economic analysis was performed to compare the marginal cost saving per case for group 1 vs. group 2.
RESULTS
There were 21 patients in group 1. They waited for on average 5.8 days at home for their operation and none were admitted pre or post operatively. There were no associated complications and the majority of patients were discharged from follow-up at 6 weeks post-surgery. In-group 2, there were 32 patients. They waited on average 2.4 days for their operation in the hospital and had an average length of stay of 4.9 days. One patient in group 2 suffered from a deep vein thrombosis. The benefit from our chargeable tariff for group 1 patients was £2295 per case while the margin for group 2 patients was £277 per case. The financial benefit to the health care provider was £2018 in favour of home care and DSU treatment, with high service satisfaction and low complication rates.
DISCUSSION
This study provides focused evidence supporting the use of home care for the management of ankle fractures. The DSU pathway improves the value in healthcare delivery with high patient satisfaction scores when compared to the traditional pathway. Our model demonstrates predictably good clinical outcomes with a financial cost benefit over in-patient admission care model for selected patients.
LEVEL OF EVIDENCE
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Topics: Ambulatory Surgical Procedures; Ankle; Ankle Fractures; Fracture Fixation, Internal; Home Care Services; Humans; Patient Satisfaction; Prospective Studies; Treatment Outcome
PubMed: 33158745
DOI: 10.1016/j.surge.2020.08.004