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The overall complication rate after open reduction and internal fixation (ORIF) of ankle fractures varies widely in the literature. In a retrospective study [
] reported much higher complication rates of surgically-treated closed ankle fractures, of 30% and 40%, respectively. These different figures can be explained by the different type of fractures and patient populations.
Complications after ORIF of ankle fractures can be attributed to patient factors (eg, age, obesity, lowered immunity, diabetes, alcohol abuse, and noncompliance), fracture factors (eg, open fractures, comminution), and iatrogenic factors (eg, poor reduction, penetration of the joint with screws, early removal of syndesmotic screws) [
Ankle fractures in the elderly are common. The incidence of ankle fractures is estimated to be 184 per 100,000 persons per year; of those, approximately 20% to 30% occur in the elderly [
]. It is widely accepted that operative fixation of unstable ankle fractures yields predictably good outcomes in the general population. The current literature [
Togninalli D., Delmi M., Regusci M., et al. Complications after ankle fractures-comparison between “older” and “young” patients. Presented at the American Orthopaedic Foot & Ankle Society (AOFAS) 2001 Annual Summer Meeting. July 19–21, 2001, San Diego , CA.
], however, reports less acceptable results in the geriatric population aged 65 years and older. Poor bone quality presents technical difficulties, there is a significant risk of wound edge necrosis with delayed wound healing, and the inability of the patients to weight-bear early leads to lengthy hospital stays and difficult socioeconomic problems.
] reviewed the early results and complications of ORIF in 74 patients over the age of 70. They detected 1% deep infection, 9% delayed wound healing, 5% malunion, and 3% mortality. In 12% of patients, soft bone and comminution precluded fixation of one malleolus. Despite the high complication rate, 85% of patients regained their preinjury mobility and residential status.
] analyzed the outcome of surgical treatment of unstable ankle fractures in 23 patients who were at least 65 years old and found a complication rate of 25%. There were three significant complications that included a lateral wound dehiscence with delayed fibular union in an open fracture dislocation, and two below-the-knee amputations. Complications were associated with open fractures and pre-existing systemic disease.
] reviewed the results of ankle fracture fixation in 76 patients who were older than 50. Their series showed a 1.8% incidence of infection and a 5.2% incidence of delayed healing and wound necrosis. Malunion occurred in 7.9% of patients and was caused, in all cases, by either imperfect perioperative reduction or inadequate fixation. In no case did fixation fail because of poor bone quality. They concluded that internal fixation of ankle fractures in the elderly carries acceptable risks if careful attention is paid to surgical technique and fixation is in accordance with Arbeitsgeimeinschaft für Osteosynthesefrgen–Association for the Study of Internal Fixation (AO/ASIF) principles.
A nonoperative approach should be considered in the treatment of well-reduced ankle fractures in the elderly. Salai et al [
] performed a prospective, randomized study of 84 patients with displaced ankle fractures who were over the age of 65; they were assigned to operative or conservative treatment after closed reduction. The results of treatment, assessed according to the American Orthopedic Foot and Ankle Society Score, showed a mean of 91.4 in the group who had conservative treatment compared with a mean of 75.2 (P = 0.001) in the group that underwent surgery. The costs of surgical treatment were higher than conservative treatment.
In the old patient, the risk of serious complications has to be weighed against the advantages that are expected for each patient. Togninalli et al [
Togninalli D., Delmi M., Regusci M., et al. Complications after ankle fractures-comparison between “older” and “young” patients. Presented at the American Orthopaedic Foot & Ankle Society (AOFAS) 2001 Annual Summer Meeting. July 19–21, 2001, San Diego , CA.
] analyzed the early follow-up after treatment of ankle fractures in 39 patients who were older than 80 years of age; they compared the results with a matched group of patients who were younger than 50 years of age. The older patients had a 50% overall (local or general) complication rate, 20% had a loss of social independence, and there was a 5% mortality rate. ORIF had a 30% complication rate and led to a prolonged hospital stay (66% increase in patients older than 80 years who underwent ORIF compared to those who were treated conservatively). The investigators concluded that the treatment of ankle fractures in old patients must be adapted to the real needs of the patients.
Pediatric ankle fractures account for approximately 5% of pediatric fractures and 15% of physical injuries [
]. Most ankle fractures that are seen in the pediatric population do not require operative management. Salter-Harris types III and IV ankle fractures with greater than 2 mm of displacement require open reduction and internal fixation, however. A thorough knowledge of functional growth plate anatomy is essential to proper surgical management of those fractures. The potential complications associated with pediatric ankle fractures include those seen with adult fractures, as well as those that result from physeal damage including leg-length discrepancy, angular deformity, or a combination thereof [
]. Every effort should be made to avoid penetration of the physis during ORIF. Children under the age of 10 have a better prognosis for spontaneous correction of nongrowth, arrest-induced deformities but a much poorer prognosis with growth arrest injuries than older children [
Systemic and local manifestations of diabetes mellitus may complicate the treatment of ankle fractures in the diabetic population. The diabetic patients who are poorly compliant with evidence of neuropathic disease, peripherovascular disease, and severe swelling and ecchymosis is the most difficult group to manage [
], using a case-controlled study, compared the results of the management of displaced malleolar fractures in 26 patients with diabetes with those of a matched group of nondiabetic patients. Diabetic patients had a 42.3% incidence of significant complications. By contrast, there were no complications in the matched group of nondiabetic patients. Of 19 diabetic patients who were treated surgically, six developed major complications including one case of malunion, one case of necrosis of the wound edge that required a flap, and two cases of deep sepsis. Two patients required amputation but both died. In their series, diabetic patients with displaced ankle fractures that were treated nonoperatively had a high incidence of loss of reduction and malunion, but these caused few symptoms.
] reviewed 21 patients with diabetes mellitus and isolated ankle fractures that were treated operatively; the complication rate was 43%. Complications in the diabetic group included seven infections (five deep, two superficial) and three losses of fixation. The complications were severe and required seven additional procedures, including two below-the-knee amputations; a third patient refused an amputation. The relative risk for postoperative complications in patients with diabetes who sustained ankle fractures that were treated operatively was 2.76 times greater than the control group's . Flynn et al [
] found that the risk of infection in the diabetic population (32%) was four times higher than in the nondiabetic population (8%). The infection rate in the diabetic group that was treated surgically was more than double that of the nondiabetic group. Diabetic patients who were treated conservatively also had a tendency to infection. In their series, four out of six diabetic patients who were treated with a cast became infected. In diabetic patients a tight, postoperative glucose control is essential to improve the fracture milieu and to ameliorate the potential complications.
Wound dehiscence and other soft tissue complications are more common in patients with rheumatoid arthritis and peripheral vascular disease. Rheumatic patients have osteoporotic bone and fragile soft tissues and skin. Those with severe osteoporosis, and high-load corticosteroid or methotrexate therapy are at a higher risk of developing complications.
Psychological traits
The patient's psychological traits may predispose to reflex sympathetic dystrophy (RSD) after foot and ankle surgery. De Vilder [
] studied 35 cases of severe RSD in the foot or ankle and found that most patients were anxious, depressive, emotional, nervous, and irritable with neurovegetative instability. Hypochondria and hysteria, whether accompanied by depression or not, increased anxiety, emotional lability, and lowered self-esteem were also encountered regularly. The best therapy for RSD is prophylaxis. The two most important triggers, instability and pain, should be avoided. Early functional mobilization after surgery is another major factor in the avoidance of sympathetic reflex dystrophy.
Alcohol abuse
There is a well recognized association between the ingestion of alcohol and trauma. Alcohol is significantly involved in the epidemiology of ankle fractures [
]. Ethanol inhibits osteoblast function; chronic ethanol consumption induces systemic bone loss and increases the risk of fracture in humans and compromises the healing of injured bone in animal experimental models [
] investigated the postoperative morbidity after osteosynthesis of malleolar fractures by comparing 90 alcohol abusers with 90 controls. The alcohol abusers developed significantly more early complications, especially infections, after surgery. Kankare et al [
] reviewed 16 alcohol abusers with displaced malleolar fractures who were treated with biodegradable, self-reinforced, polyglycolide screws. During an average follow-up of 7 months, eight patients had postoperative redisplacement of the fracture and 6 underwent reoperation.
Fracture factors
High energy fractures with comminution are associated with higher rates of complications after surgery [
], fracture-dislocations had three times as many major complications as simple fractures; fractures with skin blisters or abrasions had more than double the overall complication rate. With regards to the type of fracture, as classified by Lauge-Hansen, the pronation–eversion injury has the poorest results [
] because of the complete ligamentous disruption of the syndesmosis, which, unlike intraosseous diastasis, fails to heal solidly in a high percentage of patients.
Early complications of surgically managed ankle fractures related to the AO classification. A review of 118 ankle fractures treated with open reduction and internal fixation.
] found perioperative problems, such as wound margin necrosis and infections, were significantly related to fracture types B2 and B3. The period of hospitalization was significantly longer in patients with B2 and B3 fractures and major perioperative soft tissue complications had a negative effect on the long-term functional outcome. In the series of Hoiness and Stromsoe, all wound infections were found in grossly displaced fractures despite adequate closed reduction immediately after arrival in the hospital [
Superficial infection and osteomyelitis are more common after open ankle fractures. In the literature, the infection rate after ORIF of open ankle fractures ranges between 6% [
]. In grade I and clean grade II open injuries, immediate aggressive debridement, irrigation, open reduction and internal fixation speeds recovery with no greater incidence of infection than encountered with a more conservative treatment [
]. In type III B Gustilo's open fractures with severe wound contamination, an external fixator may be necessary. Posttraumatic arthritis is more common in Danis Weber type C fractures, or in stage 4 of supination–external rotation and pronation–external rotation, and in stage 3 of pronation–abduction injuries in the Lauge-Hansen Classification [
Complications can occur intraoperatively or in the early or late postoperative period. Perioperative complications include malreduction, inadequate fixation, and intra-articular penetration of hardware, all of which may be minimized by preoperative planning and meticulous operative technique. We will focus on early postoperative and late complications.
Early complications
Early complications after ORIF of ankle fractures include wound edge dehiscence, necrosis, infection, and compartment syndrome. Internal fixation should be accomplished either before or after the period of critical soft tissue swelling. Open reduction and internal fixation of an extensively swollen ankle may lead to wound closure problems, blistering, wound edge necrosis, and infection. The incidence of wound complications may be lessened by delaying surgery until the posttraumatic swelling, fracture blisters, or abrasions have subsided [
] and incisions through blood-filled blisters should be avoided whenever possible. The pneumatic pedal compression serves as a useful adjunct in preoperative edema resolution after ankle fracture [
] reported a patient who sustained an iatrogenic hypothermic injury after continuous preoperative cryocompression therapy of an ankle fracture. The patient developed skin epidermolysis, partial nerve damage, muscle atrophy, and clawing of the toes.
Immediate surgery is indicated in the severely displaced ankle fracture. Hoiness and Stromsoe [
] investigated whether the timing of surgery had any influence upon soft tissue complications and hospital stay. They reviewed the clinical course of the first six postoperative weeks of 84 closed ankle fractures that were treated by ORIF. Seventeen patients were operated on after 5 days or more. These patients were compared with the patients who were operated on within 8 hours (n = 67). Despite a higher incidence of primary soft tissue injuries in the group who had early surgery, the patients who had delayed surgery had a higher incidence of wound infections (17.6% vs. 3.0%) and their hospital stay was prolonged. The investigators concluded that delayed surgery of closed ankle fractures increased the risk of soft tissue complications and prolonged hospital stay. To minimize soft tissue compromise and devascularization of the fracture fragments in distal tibial fractures, some authors [
] assessed venous pump function and femoral and popliteal venous patency in 26 patients with ankle fractures that required ORIF and immobilization in plaster. They concluded that there was a significant and prolonged (12 weeks) impairment in venous pump function following ankle fracture.
Wound complications can lead to deep infection, with potentially catastrophic consequences.. The incidence of infection after open reduction and internal fixation of closed ankle fractures ranges between 1.8% [
] in the general population. Superficial infections are more frequent than deep ones. As discussed earlier, elderly patients have a higher infection rate (12% in patients older than 65 years) [
], patients who were transferred from another medical facility also had a higher rate of deep infections (11% vs. 1.7%), especially if they had fracture-dislocation.
As discusses earlier, the risk of infection in the diabetic population is four times higher than in the nondiabetic population [
] reported a 33% infection rate in diabetics with isolated ankle fractures that were treated operatively. Peripherovascular disease, peripheral neuropathy, swelling, or ecchymosis contribute to an increased risk of infection in the diabetic population.
Infection rates do not increase with the use of absorbable implants. Sinisaari et al [
] compared the infection rates of metallic (2073 patients) and absorbable fracture fixation devices (1012 patients) in displaced ankle fractures. The infection rate associated with metallic fixation was 4.1%, compared with 3.2% with absorbable fixation (P = 0.3). Infections were caused mostly by micro-organisms of Staphylococcus. Deep infections were equally common with both fixation methods (0.4%).
Compartment syndrome in association with ankle fracture is extremely rare (Fig. 2) [
] reported a case in which a patient had a Bosworth fracture-dislocation of the ankle, underwent open reduction internal fixation, and subsequently had an anterior compartment syndrome of the leg. Early recognition and prompt decompression of the affected compartments is essential to avoid the late sequelae of compartment syndrome.
Fig. 2Severe wound dehiscence and soft tissue necrosis in a 18-year-old patient who developed a compartment syndrome after ORIF of a high energy ankle fracture.
Many orthopedic surgeons fail to appreciate the potential complications of thromboembolic events because of their rare and delayed occurrence in foot and ankle operations. The necessity of prophylaxis for deep vein thrombosis (DVT) in those patients who undergo foot and ankle surgery remains poorly defined [
] performed a prospective study to establish the incidence of DVT in patients who had undergone surgery of the foot and ankle. Two hundred and one consecutive patients who underwent foot and ankle surgery had duplex ultrasound performed of the bilateral calves at their first postoperative visit. Deep calf clots were found in seven patients (3.5%), but none of these showed progression on follow-up ultrasound or extension proximal to the calf. The investigators concluded that the rate and progression of DVT after foot and ankle surgery is low and does not require routine prophylaxis. Although uncommon, pulmonary embolism may occur after ORIF of ankle fractures. Wang et al [
] presented three cases in which patients who underwent operative treatment of ankle fractures subsequently developed pulmonary embolism. Postoperative immobilization, tourniquet time, and advancing age are factors that are associated with risk of DVT and pulmonary embolism (PE) [
Loss of ankle motion is a frequent complication that can be minimized by early range-of-motion exercise after stable fixation has been achieved. Recent studies [
] performed a comparative study of early motion and immediate plaster splintage after internal fixation of unstable fractures of the ankle. No significant difference was apparent between the two groups, although the group that had early movement contained more patients who were completely pain free, had a normal gait, and no radiologic signs of arthrosis (P<0.05).
] performed a prospective study, in which 30 patients were randomized to either postoperative immobilization in a plaster cast for 6 weeks or early mobilization (1–2 weeks after surgery) in an ankle brace. At 10 weeks, impaired muscle torque and restricted range of motion was found on the affected side. This impairment was significantly less in the group who had an ankle brace. At 12 months, range of motion of the ankle and subtalar joints was restored, but dorsiflexion was still better in the group with an ankle brace.
] reported excellent results in patients who underwent early mobilization of ankle fractures after ORIF. Seventy-two percent of 32 patients who were treated in an ankle–foot orthosis (AFO) had ankle dorsiflexion greater than 15° compared with 37% of the 19 patients who were treated with a cast (P = 0.014). No complications were directly related to the AFO and no loss of reduction occurred in any patient. The investigators concluded that early motion was not associated with increased morbidity or loss of reduction.
Early mobilization also allows an earlier return to work. In Egol et al's series [
], the mean time from surgery to return-to-work in patients who underwent internal fixation of ankle fractures, followed by a functional brace and early movement, was 53.3 days compared with 106.5 days for those who were immobilized in a below-the-knee cast (P = 0.01).
Syndesmotic screw fixation is recommended when there is a tibiofibular diastasis, a Maisonneuve fracture, or syndesmotic instability after fixation of distal tibia–fibula fractures [
]. Posttraumatic distal tibiofibular synostosis is an uncommon, late complication of severe ankle fractures with tibiofibular diastasis requiring transsyndesmotic fixation [
] this complication is more frequent when absorbable polyglycolide rods are used because of the osteogenic potential of the absorbable polymeric material.
Most adults with tibiofibular synostosis after ankle fracture have no symptoms and require no treatment [
] described iatrogenic tibiofibular synostosis after internal fixation of distal tibial and fibular metaphyseal fractures through a single incision. Following tibiofibular synostosis, the normal growth pattern of distal migration of the fibula relative to the tibia was reversed; this resulted in a shortening of the lateral malleolus and ankle valgus, as well as prominence of the fibular head at the knee.
Degenerative changes of the ankle joint may result in disabling pain with a significant decrease in function and mobility. Primary osteoarthritis of the ankle joint is uncommon, and posttraumatic conditions with significant changes in joint mechanics are usually the primary source of joint degeneration [
] studied the results from a consecutive series of 144 surgically-treated malleolar fractures during a 10-year period. Posttraumatic osteoarthritis was associated with poor clinical results, bimalleolar fractures, and unsatisfactory surgical reduction. Lindsjo et al [
] reviewed 327 surgically-treated ankle fractures and followed them for 1 to 6 years postoperatively. Posttraumatic arthritis developed in 14% of the patients with dislocation fractures and 50% of the patients with impact fractures. There was a significantly higher degree of arthritis among the patients with a posterior articular surface-bearing fragment. Posttraumatic arthritis was significantly more common among middle-aged women. The most decisive factors that influenced the clinical results were the type of fracture, the accuracy of the reduction, and the sex of the patient. There was also a strong correlation between the severity of arthritis and the clinical result.
], there is a trend of increasing radiologic evidence of posttraumatic arthritis with longer follow-ups and the long-term outcome (10 to 14 years) of patients with bimalleolar fractures of the ankle who had undergone open reduction and internal fixation. Rukavina [
] assessed the role of fibular length and the width of the ankle mortise as risk factors in the occurrence of posttraumatic osteoarthritis of the ankle joint by comparison of radiographs of the affected and unaffected sides. A shortened fibular malleolus (P<0.01), a wide ankle mortise (P<0.01) and Weber type B fracture (P<0.01) were associated with the development of osteoarthrosis.
] evaluated peak contact stresses in a human cadaver ankle model of ankle fracture malunion. They found no increase in peak stresses with lateral displacements of the talus or with removal of posterior malleolar fragments. Because peak stresses with simulated ankle malunions were not elevated, factors other than the magnitude of normal contact stresses are of greater importance in the pathogenesis of posttraumatic arthritis.
Restoration of the anatomy and joint alignment in malleolar fractures, as well as ligament reconstruction in chronic instability, are factors that can prevent development or progression of osteoarthritis (Fig. 3) [
] reported a series of 32 ankle fractures that were treated by internal fixation and followed for at least 15 years. They noted degenerative changes in 37% of the ankles despite an anatomic reconstruction that had been perfect in 28 patients. This is probably the result of unrecognized injuries to the cartilaginous surfaces of the tibio–talar joint at the time of injury. These associated chondral injuries occur frequently. Thordason et al [
] performed plate fixation plus ankle arthroscopy in nine patients who had a supination external rotation (SER) or pronation external rotation (PER) fracture with an intact medial malleolus without evidence of intra-articular debris preoperatively. The arthroscopic examination revealed that eight of the nine patients had articular damage to the dome of the talus. Lantz et al [
] reviewed 63 patients with isolated closed malleolar fractures who underwent open reduction and internal fixation using standard AO techniques. Thirty-one patients (49%) had injuries to the talar dome cartilage, ranging from mild scuffing to free osteochondral fragments. The overall results, including functional status and ankle range of motion, were significantly poorer in patients with talar dome chondral injuries.
Fig. 3(A) A 32-year-old male sustained a high energy fracture dislocation of his ankle. (B) Despite anatomic reduction of the fracture, radiological evidence of posttraumatic arthritis is observed 2 years after surgery.
Fig. 3(A) A 32-year-old male sustained a high energy fracture dislocation of his ankle. (B) Despite anatomic reduction of the fracture, radiological evidence of posttraumatic arthritis is observed 2 years after surgery.
Fig. 4Complication derived from poor surgical technique. (A) The distal tibiofibular syndesmosis was not adequately reduced. The syndesmotic screw was too short, cancellous, and placed too high. (B) Despite subsequent reduction of the syndesmosis (C) the patient developed degenerative osteoarthritis.
Fig. 4Complication derived from poor surgical technique. (A) The distal tibiofibular syndesmosis was not adequately reduced. The syndesmotic screw was too short, cancellous, and placed too high. (B) Despite subsequent reduction of the syndesmosis (C) the patient developed degenerative osteoarthritis.
Fig. 4Complication derived from poor surgical technique. (A) The distal tibiofibular syndesmosis was not adequately reduced. The syndesmotic screw was too short, cancellous, and placed too high. (B) Despite subsequent reduction of the syndesmosis (C) the patient developed degenerative osteoarthritis.
] documented a 31% incidence of late pain and 23% incidence of hardware removal after open reduction and internal fixation of 126 unstable, malleolar fractures. Although pain was generally decreased after hardware removal, nearly one half of the patients continued to have pain. Functional outcome scores were poorer for patients with pain overlying lateral ankle hardware than for those with no pain at this location. Hardware-related pain and soft tissue complications may be decreased by performing lag screw-only fixation in noncomminuted oblique fractures of the lateral malleolus [
] compared radiographic and clinical outcome parameters of 47 patients who were younger than 50 years of age and who were treated with lag screw-only fixation of lateral malleolus fractures with those of patients who were previously treated at the same institutions using different techniques. The incision for lag screw placement was 30% shorter. No patient lost reduction and no soft tissue complications were observed in the group treated only with lag screws. Only one patient (2%) in the group who had lag screws had complaints of lateral pain compared with 17% in the group who had plates. No patient that was fixed with lag screws had palable hardware compared with 56% in the group who had plates. None of the patients in the group who had lag screws had any restrictions in shoe wear compared with 15% in the group who had plates. No patient in the group who had lag screws required removal of the hardware compared with 31% in the group who had plates. There was no difference in radiographic outcome between the two groups.
Bioabsorbable implants have restricted indications because of their unique biochemical properties and their inferior biomechanical properties when compared with conventional metallic implants [
]. Since absorbable, internal fracture fixation devices that are made of polyglycolide have been used clinically, a peculiar type of complication has emerged. After an initially uneventful course, a local, nonbacterial, inflammatory reaction appears 2 to 4 months postoperatively which results in a discharging sinus on the skin [
]. The microscopic examination of biopsy specimens showed a nonspecific foreign-body reaction that was composed mainly of neutrophilic polymorphonuclear leukocytes and foreign-body giant cells that were phagocytizing the polymer debris. On roentgenograms, an osteolytic increase of the diameter of the implant channels was observed, but the bony union of the fracture did not seem to be disturbed.
] reviewed 1223 patients with malleolar fractures of the ankle who were treated by ORIF with absorbable pins and screws. Seventy-four (6.1%) had an obvious inflammatory foreign-body reaction to the implants. Of these 74, 10 later developed moderate to severe osteoarthritis of the ankle despite no evidence of incongruity of the articular surface. The joint damage seemed to be caused by polymeric debris that entered the articular cavity through an osteolytic extension of an implant track. The incidence of these changes in the whole series was 0.8%, which is not high, but we should be aware of this possible late complication.
] found no evidence of osteolysis or sterile effusion in 17 patients with pronation-lateral rotation ankle fractures who were treated with polylactic acid bioabsorbable screw fixation of the syndesmosis. Thus, with newer bioabsorbable material, these sterile effusions may be minimized.
References
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Begrow B.
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[Early complications and fatalities following surgical treatment of fractures of the upper ankle joint].
Togninalli D., Delmi M., Regusci M., et al. Complications after ankle fractures-comparison between “older” and “young” patients. Presented at the American Orthopaedic Foot & Ankle Society (AOFAS) 2001 Annual Summer Meeting. July 19–21, 2001, San Diego , CA.
Early complications of surgically managed ankle fractures related to the AO classification. A review of 118 ankle fractures treated with open reduction and internal fixation.
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