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Better is the foe of good: Outcome of operatively treated ankle fractures in the elderly
The Foot 36 (2018) 15–20
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The Foot journal homepage: www.elsevier.com/locate/foot
Original Article
Better is the foe of good: Outcome of operatively treated ankle fractures in the elderly
T
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Markus Ruppa,b, , Stefan Kockmannc, Thaqif El Khassawnab, Michael J. Raschkec, Christian Heissa,b, Sabine Ochmanc a University Hospital Giessen and Marburg, Campus Giessen, Department of Trauma, Hand, and Reconstructive Surgery, Rudolf-Buchheim-Strasse 7, 35385 Giessen, Germany b Justus-Liebig-University of Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany c Westfaelische-Wilhelms-University of Muenster, University Hospital Muenster, Department of Trauma, Hand, and Reconstructive Surgery, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
A R T I C LE I N FO
A B S T R A C T
Keywords: Ankle Fracture Surgical treatment ORIF Elderly
Background: Ankle fractures are the second most common fractures of the lower extremities. Nonetheless, no standardized treatment protocol for unstable ankle fractures of the elderly exists today. Choices to treat ankle fractures are debated controversially, including (1) conservative treatment, (2) open reduction and internal fixation (ORIF), and (3) primary hind-foot arthrodesis. This retrospective study aimed to examine the healing result in patients treated by ORIF after unstable ankle fractures. Methods: The study was designed as a retrospective comparative series. The American Orthopaedic Foot and Ankle Society (AOFAS) score was followed to assess the postsurgical outcome. Data was obtained from 66 patients younger than 65 (median age, 42 years; range, 18–63) and 28 patients aged 65 or older (median age, 71 years; range, 65–81). The mean follow-up period for the younger-than-65 group was 48 months; for patients older than 65, it was 49 months. Results: An AOFAS score of 86.4 in the older and 92.4 in the younger group was determined, p-value < 0.05. Elderly patients suffered from significantly more open-ankle fractures and comorbidities than the younger group did, p-value < 0.05 each. The duration of hospital stay and the time needed to reach sufficient self-mobilization were both significantly different between the two groups, p-value < 0.05. Conclusion: ORIF treatment of ankle fractures resulted in good functional assessment after a mean follow-up of 49 months in the elderly. Pre-fracture health condition positively affected the healing results in younger patients. This study confirms the basic AO Foundation principles for good postsurgical results. Level of evidence: Level III, retrospective comparative series.
1. Introduction The overall incidence of ankle fractures exceeds 10% of all fractures [1]. Since the 1950s, numbers and incidence of ankle fractures have increased because of demographic changes in the Western world. An overall incidence of 126–169 per 100,000 people in the past decade is described. For example, incidence peaked in people older than 60 years in Finland, with 169 per 100,000 in 1997, which then declined to 126 per 100,000 in 2014 [1–3]. Despite the high frequency in the elderly and the socioeconomic impact, a standardized ankle fracture treatment continues to be debated. Healing of ankle fracture is negatively affected by comorbidities, such as peripheral vascular disease, diabetes mellitus,
or osteoporosis, and are more frequent in the elderly than in younger patients [4,5]. Conservative-treatment studies report better clinical results after 37.5 months or equivalent clinical results after 6 months, with fewer wound complications and less intervention cost [6,7]. To the authors’ knowledge, no long-term follow-up of conservative treatment of ankle fractures in the elderly reports the consequences for not following AO foundation principles. However, better results from surgical treatment than from conservative treatment are still debatable [8–10]. Although postsurgical complications and functional assessment are important to study clinical results, complications of lower-limb injuries are less frequently considered, especially in the elderly. Several criteria can assess treatment results and the socioeconomic impact, such as (1)
⁎ Corresponding author at: University Hospital Giessen and Marburg, Campus Giessen, Department of Trauma, Hand, and Reconstructive Surgery, RudolfBuchheim-Strasse 7, 35385 Giessen, Germany. E-mail address: [email protected] (M. Rupp).
https://doi.org/10.1016/j.foot.2018.04.002 Received 7 December 2017; Received in revised form 8 April 2018; Accepted 18 April 2018 0958-2592/ © 2018 Elsevier Ltd. All rights reserved.
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physiotherapist. Patients maintained partial weight bearing of up to 20 kg on the injured lower extremity by using crutches or a walker for 6 weeks. Physical therapists instructed patients on active and passive range-of-motion exercises within their pain tolerance. Thus, the postoperative mobilization protocol followed the guidelines for the treatment of ankle fractures of the German Society of Trauma Surgery in the then-current version. At 6 weeks after surgery, patients were allowed to bear weight within their pain tolerance and offered referral to a physiotherapist. Patients who underwent syndesmotic screw fixation underwent screw removal 6 weeks after surgery as an outpatient procedure. A follow-up period of at least 12 months post-surgery was needed to assess the functional outcome of fully consolidated ankle fractures. Associated injuries were not a reason for exclusion. A cut-off of 65 years between young and elderly was taken as the pensionable age in Germany and other industrial countries in the 2010s. The cut-off did not consider longer life expectancy and increased activity levels. Thus, using the age of 65 as cut-off, two cohorts of patients with surgically treated unstable ankle fractures were compared. Patients were recruited through telephone conversations and written invitation. The enrolled patients were then educated in verbal and written form, and they signed a consent form, after which the American Orthopaedic Foot and Ankle Society (AOFAS) score was determined. Predisposing causes for poor surgical results were assessed. The study focused on comorbidities, which represent impaired vascular, neurological, and skeletal conditions for fracture healing such as arterial hypertension, diabetes mellitus, and osteoporosis. Data was based on a patient survey, which was performed before examination. Further, medical records were consulted to extract information about diagnosed diseases. Besides this, the ankle-brachial index (ABI) was measured in the follow-up examination to determine possible peripheral arterial occlusive disease (PAOD). Assessments of functional status, recovery time, duration of pain
self-sufficient mobilization, (2) time of recovery, (3) duration of physiotherapy (PT), and (4) duration of pain management. This work identifies demographic data, comorbidities, and functional outcome at every follow-up examination. The study highlights clinical results after a long-term follow-up.
2. Patients and methods The present investigation was approved by the responsible ethics committee of the physicians association of Westfalen-Lippe and the Westfälischen-Wilhelms-University under permit number 2012-143-f-S. The study was designed as a retrospective comparative study and included subjects who underwent surgical treatment of ankle fractures between January 2003 and December 2010 at the Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Muenster, Germany. The consenting subjects’ medical records were reviewed for evidence of isolated, unstable ankle fractures. The subjects were asked to undertake a clinical examination of mobility and healing assessment. Patients 18 years old or older were included in this study. Healthy volunteers were accepted, and no random sample was taken. Ankle fracture was considered unstable when a medial widening gap greater than 4 mm was measured on radiographs. Unstable fractures were investigated in bimalleolar and trimalleolar fracture patterns as well as in isolated lateral malleolar fractures. Fracture types were determined according to the AO classification (Fig. 1). Surgical treatment aimed to restore bone morphology (anatomical reduction). Therefore, the included cases encompassed open reduction and internal fixation by using plates, screws, and K-wire fixation. Excluded cases encompassed conservative treatment, closed reduction, and external fixation with primary ankle arthrodesis. After surgery, ankles were cast in plaster to replace orthosis. Mobilization of the patient started under supervision of a
Fig. 1. AO classification of ankle fractures. Weber types A, B, and C fractures are extended, depending on fracture severity. A and B fractures describe unifocal (1), bifocal (2), and circumferential or trifocal fracture patterns. C fractures are divided into simple diaphyseal (1), multi-fragmentary (2), and proximal (3). 16
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infections, which required surgical intervention with removal of implants and debridement necessary; and (2) superficial wound infections, which could be treated conservatively by wound care and antibiotic treatment. Other complications, such as thrombosis, pulmonary embolism, and loss of fixation, could not be determined. Radiological signs of osteoarthritis (OA) were staged in accordance with the Kellgren and Lawrence classification. For a better overview, the classification was simplified to (1) no, (2) doubtful, and (3) confirmed OA. One malunion of the fibula was determined in the younger group, and one synostosis of the medial malleolus was seen among the elderly patients (Table 3). In the younger group, 66.7% (44/66) did not suffer from a secondary diagnosis such as arterial hypertension, diabetes mellitus, and osteoporosis. On the other hand, only 21.4% (6/28) in the older group did not suffer from at least one mentioned secondary diagnosis (Table 4). Duration of pain management after surgery was not statistically different in either group, 11.9 (range, 0–120) days in the younger patients versus 35.6 (range, 0–420) days in the patients older than 65 years. However, a statistically significant difference was determined in self-sufficient mobilization after surgery. Defined as walking on crutches, mobilization was reached on average in 1.6 (range, 1–5) days for patients younger than 65 years; patients aged 65 or older needed 7.5 (range, 1–35) days for self-sufficient mobilization. No difference in duration of physiotherapy after discharge of hospital care was reported by the patients, 10.2 (range, 0–156) weeks for younger patients versus 9.3 (range, 0–52) weeks for older patients (Table 2).
management, time until self-sufficient mobilization, and duration of physiotherapy were conducted during the follow-up, whereas demographic data, time of surgery after trauma, duration of hospital stay, and disturbances of wound healing were obtained from patient files. Statistical analysis was performed using the Student’s t-test to compare continuous and normally distributed variables in two groups. The Mann–Whitney U-test was used to compare continuous, not normally distributed variables. The Chi-square and Fisher’s exact tests were used for nominal variables. A p-value of less than 0.05 indicated significance.
3. Results According to the inclusion and exclusion criteria, 253 patients younger than 65 years [median; minimum–maximum; percentage of male:percentage of female], [42.0; 18–64; 43.9%:56.1%, respectively] and 57 patients older than 65 [73.4; 65–84; 33.3%:66.7%, respectively] were suitable in the set time frame. However, 66 patients younger than 65 years [median; minimum–maximum; percentage of male:percentage of female; recruitment rate], [42; 18–63; 35%:65%; 26.1%, respectively] and 28 patients 65 years or older [71; 65–81; 31%:69%; 49.1%, respectively] participated in the study. The mean follow-up was 49 (range, 12–90) months in the group of elderly patients and 48 (range, 12–108) months in the group of patients aged younger than 65 years (Table 1). Of the patients aged 65 years or older, 89.2% (25/28) suffered an AO 44B type of fracture, 3.6% (1/28) of the elderly patients showed an AO 44A type of fracture, and 7.2% (2/28) showed an AO 44C type of fracture. Patients younger than 65 years showed in 78.8% (52/66) an AO 44B type, in 3.0% (2/66) an AO 44A type, and in 18.2% (12/66) an AO 44C type of fracture (Fig. 2). An AOFAS score of 86.4 was determined in the older group. Compared with the AOFAS score of 92.4 in the younger group, the difference was statistically significant, p < 0.05 (Table 2). No significant difference in fracture type distribution was determined. However, older patients (14.3%, 4/28) showed significantly more open fractures than younger patients did (0/66), p < 0.05 (Table 1). Despite lack of statistical significance, the elderly (17.9%, 5/28) were treated more often with a two-stage surgical approach than younger patients were (7.6%, 5/66). The first surgery used external reduction; the second one included open reduction and internal fixation. Time intervals of the two-stage surgical approach did not differ significantly between the younger (7.5 days) and elderly groups (5 days). The analysis of patient data showed no difference in either associated injuries (10.7%, 3/28 in older vs. 12.1%, 8/66 in younger patients) or in time of surgery after trauma (2.2 days in older vs. 2.6 days in younger patients). The period of hospitalization of older patients was more than twice as long (16.4 days) as in younger patients (8.2 days), p < 0.05. Associated healing disorders were not significantly different between the two groups (7.6% (5/66) of the younger and 10.7% (3/28) of the older patients). Healing disorders included (1) deep surgical-site
4. Discussion The 11.6% rate of proximal femur fracture and 10.2% of ankle fracture makes the latter the second-most frequent lower limb fracture [1,11]. Unlike proximal femur fractures, no standardized treatment protocol for ankle fractures in the elderly is yet established [12,13]. Establishing such a protocol depends on retrospective case series or comparative studies [4,5,8,14]. However, the low number of prospective studies is the main factor in the absence of a standard treatment protocol [6,7]. The variation in reported studies makes drawing a collective conclusion for the best treatment procedure difficult, especially because discrepancies in study design (i.e., retrospective and prospective), and the cut-off in age for elderly, are not defined. Some studies report the cut-off age between young and elderly at 50 years old [15], others at 70 years old [16]. Furthermore, few studies compare conservative and surgical treatment [6,7]; others compare surgical treatment in the elderly with that in younger patients [4,5]. Nonetheless, open reduction and internal fixation of ankle fractures was compared with primary hind-foot arthrodesis by tibiotalocalcaneal nailing [17]. The present study followed the criteria of Davidovitch et al. and Anderson et al. on 94 included patients [4,5]. Nonetheless, Anderson et al. reported a recruitment rate of 27% compared to 30.3% in the present study. However, Davidovitch et al. conducted a patient filebased analysis, whereas in this work, a patient interview and physical examination were carried out in addition to the file-based analysis. The mean duration of follow-up period was 49 months for elderly patients and 48 months for the younger ones, so this study has twice and four times the mean follow-up periods of Anderson et al. and Davidovitch et al., respectively [4,5]. Several previous studies have shorter followup periods, for example, Salai et al. with 37.5 months [7], Georgiannos et al. [17] with 14 months, and Willett et al. with 6 months [6]. Our results showed a significantly lower AOFAS score (86.4) in the group aged 65 years or older than the younger patients (92.4). However, the less successful results in the elderly group compared to the young patients raises the question of its adequacy. In other words, should the better results achieved in young patients be a standard, leading to dropping the AO treatment principles that are achieving good results in elderly patients? Nonetheless, reasons for unsatisfactory
Table 1 Demographic data comparing patients around the cut-off of 65 years of age.
N (recruitment rate) Average age (range) Male/female (%) Follow-up (months) AO fracture type (A/B/C) Bimalleolar fractures Trimalleolar fractures Open fractures Comorbidities
< 65 years Mean (%)
≥65 years Mean (%)
66 (26.1) 42 (18–63) 23/43 (35%/65%) 48 (12–108) 2/52/12 8 (12.1) 10 (15.2) 0 22 (33.3)
28 (49.1) 71 (65–81) 11/17 (39%/61%) 49 (14–90) 1/25/2 6 (21.5) 8 (28.6) 4 (14.3) 22 (78.6)
p Value
p < 0.05 p < 0.05
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Fig. 2. Pattern of fracture type does not correlate to age differences. Patient groups, above or below 65 years of age, show the same pattern of frequency of ankle fracture. However, below 65 years of age, a 100% increase in type AO 44C is seen compared to patients older than 65 years. Table 2 Outcome data of ankle fracture patients around the cut-off of 65 years of age. Time unit = days; PT = physiotherapy; PAOD = peripheral occlusive artery disease; ABI = ankle-brachial index.
AOFAS score PAOD (ABI < 0.9) Time of surgery after trauma Two-staged operation Duration of hospital stay Duration of pain therapy Self-sufficient mobilization Duration of PT Subjective recovery time
< 65 years
≥65 years
p Value
92.4 10.6 2.2 5 (7.6%) 8.2 11.9 1.6 10.2 weeks 13.1 weeks
86.4 14.2 2.6 5 (17.9%) 16.4 35.6 7.5 9.3 weeks 20.7 weeks
p < 0.05
Table 4 Comorbidities: arterial hypertension (AH); osteoporosis (O); diabetes mellitus (DM), representing impaired vascular, skeletal, and neurological conditions; p < 0.05.
Comorbidities AH O DM AH + DM AH + O DM + O AH + O + DM
p < 0.05 p < 0.05
N (recruitment rate) Nonunion Malunion Wound healing disturbance • Deep infectiona • Wound deteriorationb Thrombosis Pulmonary embolism Loss of fixation No OA Doubtful OAc Confirmed OAd No X-rays at follow-up
≥65 years Mean (%)
66 (26.1%) 0 1 (1.5) 5 (7.6) 4 (6.1) 1 (1.5) 0 0 0 41 (62.1) 8 (12.1) 1 (1.5) 16 (24.2)
28 (49.1%) 0 1 (3.6) 3 (10.7) 2 (7.1) 1 (3.6) 0 0 0 7 (25) 6 (21.4) 15 (53.6) 0
≥65 years
22 (33.3%) 17 (25.8%) 3 (4.5%) 0 1 (1.5%) 1 (1.5%)
22 (78.6%) 10 (35.7%) 3 (10.8%) 1 (3.6%) 2 (7.1%) 2 (7.1%) 1 (3.6%) 3 (10.8%)
significant frequency of open fractures and two-staged surgical procedures in the elderly indicate more complicated fractures and severe soft-tissue damage than in the young group. These results accord with the observations regarding more open fractures in elderly patients made by Anderson et al. and Vioreanu et al. [5,18]. Furthermore, Ovaska et al. reported high complication rates from open fractures, with wound necrosis and deep infection of 17% and 18%, respectively [19]. However, according to Zaghloul et al., the fracture type using Weber’s classification does not influence the healing outcome [20]. Nonetheless, the simple Weber’s ankle fracture classification neglects the severity of ankle fractures, whereas, the AO classification system, which expands the Weber classification to describe bimalleolar as well as trimalleolar fractures, is more accurate (Fig. 1). Nevertheless, the simple Weber’s classification is more popular, which masks information and conclusions. Osteoporosis as a reason for severe and complicated fracture pattern, and thus for a poor postsurgical outcome, is discussed. However, ankle fractures themselves are not regarded as typically osteoporotic fractures [11,21]. In elderly patients, our results showed a mean AOFAS score of 78.9 in patients suffering from two or more comorbidities compared with an AOFAS score of 89 in patients suffering from one or no comorbidity. This suggests that a higher rate of comorbidities in the elderly can be a factor of less successful (good) results than those in the younger group. Presence of two or more comorbidities is reported by Gauthé et al. as risk factors for impaired functional recovery [14]. The American Society of Anesthesiologists (ASA) classification system
Table 3 Complications in the course of treatment. < 65 years Mean (%)
< 65 years
a
Premature implant removal with necessary surgical debridement. Conservative treatment without necessary surgical revision. c Equivalent to Kellgren and Lawrence stage 1. d Radiologically confirmed osteoarthritis (OA), Kellgren and Lawrence stage 2–4. b
results must be analyzed, including treatment alternatives. Based on the AO fracture classification, bimalleolar and trimalleolar fractures occurred in 21.5% and 28.6% of the elderly group and in 12.1% and 15.2% in the younger group (Table 1), respectively. Furthermore, the 18
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assesses the fitness of patients before surgery in a scale of six categories, with one standing for a healthy patient and six for a declared brain death. The ASA classification category of two or higher, together with pulsatile lavage and Gustilo grade III open injury, were reported as predictors of postsurgical wound necrosis [22]. Despite the lower AOFAS score in elderly patients, complication rates were not significantly different between the groups. However, comparing our data to literature is difficult due to the variable definition of complication itself. Although this study considered local wound infections and wound healing disturbances, other studies included complications such as thrombosis, pulmonary embolism, and malunion [16,23]. Self-sufficient mobilization in patients aged 65 or older was reached five times later than in the group younger than 65. This significant difference between the groups describes the postsurgical challenge for elderly patients suffering from ankle fractures. Furthermore, a hospital stay that is twice as long as in younger patients underlines the physical impairment caused by an ORIF-treated ankle fracture. However, the overall length of hospital stay was much longer than time to self-sufficient mobilization in both groups, maybe because of the definition of self-sufficient mobilization. At the follow-up investigation, patients were asked when they could stand up and walk with crutches or a walker without assistance. Furthermore, at dismissal, walking stairs was usually intended in patients who were used to it prior to surgery, which could explain the discrepancy between self-sufficient mobilization and length of hospital stay. Moreover, organization of further care for the elderly takes time, especially in cases when homeward discharge is not possible anymore. Compared to other studies, which describe the length of hospital stay between 5 and 26 days, our results show no mismatch, though [16,24]. Another reason for longer hospital stays by both the younger and elderly groups might be that until 2004, general hospital benefits were reimbursed in Germany through hospital-specific care rates payable per day of hospitalization. The use of the old pay-perday system and the change to the presently applied diagnosis-related group (DRG) billing system during the study period might be the reason hospital stays were longer than we would expect today. A significant difference between length of hospital stay by patients walking with a Zimmer frame before injury and independently walking patients was observed [16]. Therefore, taking comorbidities as well as preinjury mobility in elderly patients into account should be standard before making the best therapy decision. Concerning postsurgical treatment protocols, Smeeing et al. showed in a meta-analysis that active exercise as well as early weight-bearing accelerates return to work and daily activities without elevated complication rates [25]. Gul et al. compared postsurgical full weightbearing without plaster cast immobilization with conventional nonweight-bearing in younger patients, mean age 45.24 and 43.44, respectively. No significant differences were observed in the duration of hospital stay, functional recovery, and complications. However, the mean for the time of return to work was significantly shorter in the full weight-bearing group [26]. Besides ORIF, other treatment concepts such as conservative treatment and primary hind-foot arthrodesis were examined. Further criteria were observed after a mean follow-up of 14 months. Immediate postsurgical weight-bearing to prevent immobilization and complications (i.e., wound infection), shorten the hospital stay, and lower the mortality rate in patients treated with arthrodesis by tibiotalocalcaneal nailing was reported by Georgiannos et al. [17]. On the other hand, drawbacks of hind-foot arthrodesis must be taken into account for longterm follow-ups. Despite the noticeably minor procedure compared to tibiotalocalcaneal nailing, patients treated by tibiotalar arthrodesis showed impaired functional results. The functional assessment is present through radiological changes in adjoining joints, which leads to limitations in daily living and poor life quality even after 20 years [27]. Georgiannos et al. observed no difference in postsurgical Olerud Molander Ankle scores (OMAS) in both groups treated by ORIF or hindfoot arthrodesis, with a fair score of 56.9 and 56.6, respectively [17].
However, these scores are comparable to an average AOFAS score of 63 after hind-foot arthrodesis in patients suffering from combined ankle and subtalar arthritis [28]. All three scores indicate an acceptable postsurgical result, using two scoring systems [17,28]. Conservative treatment by closed reduction under anesthesia and plaster cast immobilization is reported to lead to similar or even better results in unstable-ankle fracture treatment [6,7]. However, Willett et al. showed that 19% of patients initially treated by plaster cast had to be treated again using ORIF. Furthermore, radiological examination showed frequent malunions within a short follow-up of 6 months [6]. Moreover, the impact of malunion on long-term outcome is not clear. The latency of end-stage osteoarthritis (OA) is described by Horisberger et al. as 20.9 (range, 1–52) years. A negative correlation of OA latency time with fracture severity and complications during the healing process was observed [29]. However, the prospective trial conducted by Salai et al., which shows better results for conservative treatment, lacks randomization. The study investigated 30 patients subjected to conservative treatment; however, ORIF was conducted after unsuccessful reduction and maintenance in a plaster cast, which leads to a selection bias [7]. Lovy et al. considered that in diabetic patients, conservative treatment with closed reduction and plaster cast fixation leads to an unnecessarily high overall complication rate of 75%. Complications after conservative treatment included reduction loss, deep infection, wound complication, Charcot joint, and the need for reoperation. In contrast, a 25% rate of complications was reported in the surgically treated group [30]. Taken together, treatment of elderly patients suffering from ankle fractures should include attention to comorbidities, fracture patterns, and preinjury mobility as the key to success in ankle fracture care. 5. Conclusion In the elderly, good functional results were achieved by open reduction and internal fixation of ankle fractures after a mean follow-up of 49 months. After the same period, younger patients showed better results than the elderly did. To achieve satisfying results for both patient and surgeon, surgical treatment can be regarded as an appropriate therapy method in the elderly as well as in younger patients. Surgical therapy choices as well as postsurgical treatment protocols should be improved to enable early mobilization, thereby preventing unnecessary bed rest, associated long hospital stay, and delayed or impossible return to daily activities. Despite the limiting retrospective design of this study, the acquired data can provide a criteria set for future prospective studies. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of conflicts of interest None. References [1] Elsoe R, Ostgaard SE, Larsen P. Population-based epidemiology of 9767 ankle fractures. Foot Ankle Surg 2018;24:34–9. [2] Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Stabilizing incidence of low-trauma ankle fractures in elderly people: Finnish statistics in 1970–2006 and prediction for the future. Bone 2008;43:340–2. [3] Kannus P, Niemi S, Parkkari J, Sievänen H. Declining incidence of fall-induced ankle fractures in elderly adults: Finnish statistics between 1970 and 2014. Arch Orthop Trauma Surg 2016;136:1243–6. [4] Davidovitch RI, Walsh M, Spitzer A, Egol KA. Functional outcome after operatively treated ankle fractures in the elderly. Foot Ankle Int 2009;30:728–33. [5] Anderson SA, Li X, Franklin P, Wixted JJ. Ankle fractures in the elderly: initial and long-term outcomes. Foot Ankle Int 2008;29:1184–8.
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The Foot journal homepage: www.elsevier.com/locate/foot
Original Article
Better is the foe of good: Outcome of operatively treated ankle fractures in the elderly
T
⁎
Markus Ruppa,b, , Stefan Kockmannc, Thaqif El Khassawnab, Michael J. Raschkec, Christian Heissa,b, Sabine Ochmanc a University Hospital Giessen and Marburg, Campus Giessen, Department of Trauma, Hand, and Reconstructive Surgery, Rudolf-Buchheim-Strasse 7, 35385 Giessen, Germany b Justus-Liebig-University of Giessen, Experimental Trauma Surgery, Aulweg 128, 35392 Giessen, Germany c Westfaelische-Wilhelms-University of Muenster, University Hospital Muenster, Department of Trauma, Hand, and Reconstructive Surgery, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
A R T I C LE I N FO
A B S T R A C T
Keywords: Ankle Fracture Surgical treatment ORIF Elderly
Background: Ankle fractures are the second most common fractures of the lower extremities. Nonetheless, no standardized treatment protocol for unstable ankle fractures of the elderly exists today. Choices to treat ankle fractures are debated controversially, including (1) conservative treatment, (2) open reduction and internal fixation (ORIF), and (3) primary hind-foot arthrodesis. This retrospective study aimed to examine the healing result in patients treated by ORIF after unstable ankle fractures. Methods: The study was designed as a retrospective comparative series. The American Orthopaedic Foot and Ankle Society (AOFAS) score was followed to assess the postsurgical outcome. Data was obtained from 66 patients younger than 65 (median age, 42 years; range, 18–63) and 28 patients aged 65 or older (median age, 71 years; range, 65–81). The mean follow-up period for the younger-than-65 group was 48 months; for patients older than 65, it was 49 months. Results: An AOFAS score of 86.4 in the older and 92.4 in the younger group was determined, p-value < 0.05. Elderly patients suffered from significantly more open-ankle fractures and comorbidities than the younger group did, p-value < 0.05 each. The duration of hospital stay and the time needed to reach sufficient self-mobilization were both significantly different between the two groups, p-value < 0.05. Conclusion: ORIF treatment of ankle fractures resulted in good functional assessment after a mean follow-up of 49 months in the elderly. Pre-fracture health condition positively affected the healing results in younger patients. This study confirms the basic AO Foundation principles for good postsurgical results. Level of evidence: Level III, retrospective comparative series.
1. Introduction The overall incidence of ankle fractures exceeds 10% of all fractures [1]. Since the 1950s, numbers and incidence of ankle fractures have increased because of demographic changes in the Western world. An overall incidence of 126–169 per 100,000 people in the past decade is described. For example, incidence peaked in people older than 60 years in Finland, with 169 per 100,000 in 1997, which then declined to 126 per 100,000 in 2014 [1–3]. Despite the high frequency in the elderly and the socioeconomic impact, a standardized ankle fracture treatment continues to be debated. Healing of ankle fracture is negatively affected by comorbidities, such as peripheral vascular disease, diabetes mellitus,
or osteoporosis, and are more frequent in the elderly than in younger patients [4,5]. Conservative-treatment studies report better clinical results after 37.5 months or equivalent clinical results after 6 months, with fewer wound complications and less intervention cost [6,7]. To the authors’ knowledge, no long-term follow-up of conservative treatment of ankle fractures in the elderly reports the consequences for not following AO foundation principles. However, better results from surgical treatment than from conservative treatment are still debatable [8–10]. Although postsurgical complications and functional assessment are important to study clinical results, complications of lower-limb injuries are less frequently considered, especially in the elderly. Several criteria can assess treatment results and the socioeconomic impact, such as (1)
⁎ Corresponding author at: University Hospital Giessen and Marburg, Campus Giessen, Department of Trauma, Hand, and Reconstructive Surgery, RudolfBuchheim-Strasse 7, 35385 Giessen, Germany. E-mail address: [email protected] (M. Rupp).
https://doi.org/10.1016/j.foot.2018.04.002 Received 7 December 2017; Received in revised form 8 April 2018; Accepted 18 April 2018 0958-2592/ © 2018 Elsevier Ltd. All rights reserved.
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physiotherapist. Patients maintained partial weight bearing of up to 20 kg on the injured lower extremity by using crutches or a walker for 6 weeks. Physical therapists instructed patients on active and passive range-of-motion exercises within their pain tolerance. Thus, the postoperative mobilization protocol followed the guidelines for the treatment of ankle fractures of the German Society of Trauma Surgery in the then-current version. At 6 weeks after surgery, patients were allowed to bear weight within their pain tolerance and offered referral to a physiotherapist. Patients who underwent syndesmotic screw fixation underwent screw removal 6 weeks after surgery as an outpatient procedure. A follow-up period of at least 12 months post-surgery was needed to assess the functional outcome of fully consolidated ankle fractures. Associated injuries were not a reason for exclusion. A cut-off of 65 years between young and elderly was taken as the pensionable age in Germany and other industrial countries in the 2010s. The cut-off did not consider longer life expectancy and increased activity levels. Thus, using the age of 65 as cut-off, two cohorts of patients with surgically treated unstable ankle fractures were compared. Patients were recruited through telephone conversations and written invitation. The enrolled patients were then educated in verbal and written form, and they signed a consent form, after which the American Orthopaedic Foot and Ankle Society (AOFAS) score was determined. Predisposing causes for poor surgical results were assessed. The study focused on comorbidities, which represent impaired vascular, neurological, and skeletal conditions for fracture healing such as arterial hypertension, diabetes mellitus, and osteoporosis. Data was based on a patient survey, which was performed before examination. Further, medical records were consulted to extract information about diagnosed diseases. Besides this, the ankle-brachial index (ABI) was measured in the follow-up examination to determine possible peripheral arterial occlusive disease (PAOD). Assessments of functional status, recovery time, duration of pain
self-sufficient mobilization, (2) time of recovery, (3) duration of physiotherapy (PT), and (4) duration of pain management. This work identifies demographic data, comorbidities, and functional outcome at every follow-up examination. The study highlights clinical results after a long-term follow-up.
2. Patients and methods The present investigation was approved by the responsible ethics committee of the physicians association of Westfalen-Lippe and the Westfälischen-Wilhelms-University under permit number 2012-143-f-S. The study was designed as a retrospective comparative study and included subjects who underwent surgical treatment of ankle fractures between January 2003 and December 2010 at the Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Muenster, Germany. The consenting subjects’ medical records were reviewed for evidence of isolated, unstable ankle fractures. The subjects were asked to undertake a clinical examination of mobility and healing assessment. Patients 18 years old or older were included in this study. Healthy volunteers were accepted, and no random sample was taken. Ankle fracture was considered unstable when a medial widening gap greater than 4 mm was measured on radiographs. Unstable fractures were investigated in bimalleolar and trimalleolar fracture patterns as well as in isolated lateral malleolar fractures. Fracture types were determined according to the AO classification (Fig. 1). Surgical treatment aimed to restore bone morphology (anatomical reduction). Therefore, the included cases encompassed open reduction and internal fixation by using plates, screws, and K-wire fixation. Excluded cases encompassed conservative treatment, closed reduction, and external fixation with primary ankle arthrodesis. After surgery, ankles were cast in plaster to replace orthosis. Mobilization of the patient started under supervision of a
Fig. 1. AO classification of ankle fractures. Weber types A, B, and C fractures are extended, depending on fracture severity. A and B fractures describe unifocal (1), bifocal (2), and circumferential or trifocal fracture patterns. C fractures are divided into simple diaphyseal (1), multi-fragmentary (2), and proximal (3). 16
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infections, which required surgical intervention with removal of implants and debridement necessary; and (2) superficial wound infections, which could be treated conservatively by wound care and antibiotic treatment. Other complications, such as thrombosis, pulmonary embolism, and loss of fixation, could not be determined. Radiological signs of osteoarthritis (OA) were staged in accordance with the Kellgren and Lawrence classification. For a better overview, the classification was simplified to (1) no, (2) doubtful, and (3) confirmed OA. One malunion of the fibula was determined in the younger group, and one synostosis of the medial malleolus was seen among the elderly patients (Table 3). In the younger group, 66.7% (44/66) did not suffer from a secondary diagnosis such as arterial hypertension, diabetes mellitus, and osteoporosis. On the other hand, only 21.4% (6/28) in the older group did not suffer from at least one mentioned secondary diagnosis (Table 4). Duration of pain management after surgery was not statistically different in either group, 11.9 (range, 0–120) days in the younger patients versus 35.6 (range, 0–420) days in the patients older than 65 years. However, a statistically significant difference was determined in self-sufficient mobilization after surgery. Defined as walking on crutches, mobilization was reached on average in 1.6 (range, 1–5) days for patients younger than 65 years; patients aged 65 or older needed 7.5 (range, 1–35) days for self-sufficient mobilization. No difference in duration of physiotherapy after discharge of hospital care was reported by the patients, 10.2 (range, 0–156) weeks for younger patients versus 9.3 (range, 0–52) weeks for older patients (Table 2).
management, time until self-sufficient mobilization, and duration of physiotherapy were conducted during the follow-up, whereas demographic data, time of surgery after trauma, duration of hospital stay, and disturbances of wound healing were obtained from patient files. Statistical analysis was performed using the Student’s t-test to compare continuous and normally distributed variables in two groups. The Mann–Whitney U-test was used to compare continuous, not normally distributed variables. The Chi-square and Fisher’s exact tests were used for nominal variables. A p-value of less than 0.05 indicated significance.
3. Results According to the inclusion and exclusion criteria, 253 patients younger than 65 years [median; minimum–maximum; percentage of male:percentage of female], [42.0; 18–64; 43.9%:56.1%, respectively] and 57 patients older than 65 [73.4; 65–84; 33.3%:66.7%, respectively] were suitable in the set time frame. However, 66 patients younger than 65 years [median; minimum–maximum; percentage of male:percentage of female; recruitment rate], [42; 18–63; 35%:65%; 26.1%, respectively] and 28 patients 65 years or older [71; 65–81; 31%:69%; 49.1%, respectively] participated in the study. The mean follow-up was 49 (range, 12–90) months in the group of elderly patients and 48 (range, 12–108) months in the group of patients aged younger than 65 years (Table 1). Of the patients aged 65 years or older, 89.2% (25/28) suffered an AO 44B type of fracture, 3.6% (1/28) of the elderly patients showed an AO 44A type of fracture, and 7.2% (2/28) showed an AO 44C type of fracture. Patients younger than 65 years showed in 78.8% (52/66) an AO 44B type, in 3.0% (2/66) an AO 44A type, and in 18.2% (12/66) an AO 44C type of fracture (Fig. 2). An AOFAS score of 86.4 was determined in the older group. Compared with the AOFAS score of 92.4 in the younger group, the difference was statistically significant, p < 0.05 (Table 2). No significant difference in fracture type distribution was determined. However, older patients (14.3%, 4/28) showed significantly more open fractures than younger patients did (0/66), p < 0.05 (Table 1). Despite lack of statistical significance, the elderly (17.9%, 5/28) were treated more often with a two-stage surgical approach than younger patients were (7.6%, 5/66). The first surgery used external reduction; the second one included open reduction and internal fixation. Time intervals of the two-stage surgical approach did not differ significantly between the younger (7.5 days) and elderly groups (5 days). The analysis of patient data showed no difference in either associated injuries (10.7%, 3/28 in older vs. 12.1%, 8/66 in younger patients) or in time of surgery after trauma (2.2 days in older vs. 2.6 days in younger patients). The period of hospitalization of older patients was more than twice as long (16.4 days) as in younger patients (8.2 days), p < 0.05. Associated healing disorders were not significantly different between the two groups (7.6% (5/66) of the younger and 10.7% (3/28) of the older patients). Healing disorders included (1) deep surgical-site
4. Discussion The 11.6% rate of proximal femur fracture and 10.2% of ankle fracture makes the latter the second-most frequent lower limb fracture [1,11]. Unlike proximal femur fractures, no standardized treatment protocol for ankle fractures in the elderly is yet established [12,13]. Establishing such a protocol depends on retrospective case series or comparative studies [4,5,8,14]. However, the low number of prospective studies is the main factor in the absence of a standard treatment protocol [6,7]. The variation in reported studies makes drawing a collective conclusion for the best treatment procedure difficult, especially because discrepancies in study design (i.e., retrospective and prospective), and the cut-off in age for elderly, are not defined. Some studies report the cut-off age between young and elderly at 50 years old [15], others at 70 years old [16]. Furthermore, few studies compare conservative and surgical treatment [6,7]; others compare surgical treatment in the elderly with that in younger patients [4,5]. Nonetheless, open reduction and internal fixation of ankle fractures was compared with primary hind-foot arthrodesis by tibiotalocalcaneal nailing [17]. The present study followed the criteria of Davidovitch et al. and Anderson et al. on 94 included patients [4,5]. Nonetheless, Anderson et al. reported a recruitment rate of 27% compared to 30.3% in the present study. However, Davidovitch et al. conducted a patient filebased analysis, whereas in this work, a patient interview and physical examination were carried out in addition to the file-based analysis. The mean duration of follow-up period was 49 months for elderly patients and 48 months for the younger ones, so this study has twice and four times the mean follow-up periods of Anderson et al. and Davidovitch et al., respectively [4,5]. Several previous studies have shorter followup periods, for example, Salai et al. with 37.5 months [7], Georgiannos et al. [17] with 14 months, and Willett et al. with 6 months [6]. Our results showed a significantly lower AOFAS score (86.4) in the group aged 65 years or older than the younger patients (92.4). However, the less successful results in the elderly group compared to the young patients raises the question of its adequacy. In other words, should the better results achieved in young patients be a standard, leading to dropping the AO treatment principles that are achieving good results in elderly patients? Nonetheless, reasons for unsatisfactory
Table 1 Demographic data comparing patients around the cut-off of 65 years of age.
N (recruitment rate) Average age (range) Male/female (%) Follow-up (months) AO fracture type (A/B/C) Bimalleolar fractures Trimalleolar fractures Open fractures Comorbidities
< 65 years Mean (%)
≥65 years Mean (%)
66 (26.1) 42 (18–63) 23/43 (35%/65%) 48 (12–108) 2/52/12 8 (12.1) 10 (15.2) 0 22 (33.3)
28 (49.1) 71 (65–81) 11/17 (39%/61%) 49 (14–90) 1/25/2 6 (21.5) 8 (28.6) 4 (14.3) 22 (78.6)
p Value
p < 0.05 p < 0.05
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Fig. 2. Pattern of fracture type does not correlate to age differences. Patient groups, above or below 65 years of age, show the same pattern of frequency of ankle fracture. However, below 65 years of age, a 100% increase in type AO 44C is seen compared to patients older than 65 years. Table 2 Outcome data of ankle fracture patients around the cut-off of 65 years of age. Time unit = days; PT = physiotherapy; PAOD = peripheral occlusive artery disease; ABI = ankle-brachial index.
AOFAS score PAOD (ABI < 0.9) Time of surgery after trauma Two-staged operation Duration of hospital stay Duration of pain therapy Self-sufficient mobilization Duration of PT Subjective recovery time
< 65 years
≥65 years
p Value
92.4 10.6 2.2 5 (7.6%) 8.2 11.9 1.6 10.2 weeks 13.1 weeks
86.4 14.2 2.6 5 (17.9%) 16.4 35.6 7.5 9.3 weeks 20.7 weeks
p < 0.05
Table 4 Comorbidities: arterial hypertension (AH); osteoporosis (O); diabetes mellitus (DM), representing impaired vascular, skeletal, and neurological conditions; p < 0.05.
Comorbidities AH O DM AH + DM AH + O DM + O AH + O + DM
p < 0.05 p < 0.05
N (recruitment rate) Nonunion Malunion Wound healing disturbance • Deep infectiona • Wound deteriorationb Thrombosis Pulmonary embolism Loss of fixation No OA Doubtful OAc Confirmed OAd No X-rays at follow-up
≥65 years Mean (%)
66 (26.1%) 0 1 (1.5) 5 (7.6) 4 (6.1) 1 (1.5) 0 0 0 41 (62.1) 8 (12.1) 1 (1.5) 16 (24.2)
28 (49.1%) 0 1 (3.6) 3 (10.7) 2 (7.1) 1 (3.6) 0 0 0 7 (25) 6 (21.4) 15 (53.6) 0
≥65 years
22 (33.3%) 17 (25.8%) 3 (4.5%) 0 1 (1.5%) 1 (1.5%)
22 (78.6%) 10 (35.7%) 3 (10.8%) 1 (3.6%) 2 (7.1%) 2 (7.1%) 1 (3.6%) 3 (10.8%)
significant frequency of open fractures and two-staged surgical procedures in the elderly indicate more complicated fractures and severe soft-tissue damage than in the young group. These results accord with the observations regarding more open fractures in elderly patients made by Anderson et al. and Vioreanu et al. [5,18]. Furthermore, Ovaska et al. reported high complication rates from open fractures, with wound necrosis and deep infection of 17% and 18%, respectively [19]. However, according to Zaghloul et al., the fracture type using Weber’s classification does not influence the healing outcome [20]. Nonetheless, the simple Weber’s ankle fracture classification neglects the severity of ankle fractures, whereas, the AO classification system, which expands the Weber classification to describe bimalleolar as well as trimalleolar fractures, is more accurate (Fig. 1). Nevertheless, the simple Weber’s classification is more popular, which masks information and conclusions. Osteoporosis as a reason for severe and complicated fracture pattern, and thus for a poor postsurgical outcome, is discussed. However, ankle fractures themselves are not regarded as typically osteoporotic fractures [11,21]. In elderly patients, our results showed a mean AOFAS score of 78.9 in patients suffering from two or more comorbidities compared with an AOFAS score of 89 in patients suffering from one or no comorbidity. This suggests that a higher rate of comorbidities in the elderly can be a factor of less successful (good) results than those in the younger group. Presence of two or more comorbidities is reported by Gauthé et al. as risk factors for impaired functional recovery [14]. The American Society of Anesthesiologists (ASA) classification system
Table 3 Complications in the course of treatment. < 65 years Mean (%)
< 65 years
a
Premature implant removal with necessary surgical debridement. Conservative treatment without necessary surgical revision. c Equivalent to Kellgren and Lawrence stage 1. d Radiologically confirmed osteoarthritis (OA), Kellgren and Lawrence stage 2–4. b
results must be analyzed, including treatment alternatives. Based on the AO fracture classification, bimalleolar and trimalleolar fractures occurred in 21.5% and 28.6% of the elderly group and in 12.1% and 15.2% in the younger group (Table 1), respectively. Furthermore, the 18
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assesses the fitness of patients before surgery in a scale of six categories, with one standing for a healthy patient and six for a declared brain death. The ASA classification category of two or higher, together with pulsatile lavage and Gustilo grade III open injury, were reported as predictors of postsurgical wound necrosis [22]. Despite the lower AOFAS score in elderly patients, complication rates were not significantly different between the groups. However, comparing our data to literature is difficult due to the variable definition of complication itself. Although this study considered local wound infections and wound healing disturbances, other studies included complications such as thrombosis, pulmonary embolism, and malunion [16,23]. Self-sufficient mobilization in patients aged 65 or older was reached five times later than in the group younger than 65. This significant difference between the groups describes the postsurgical challenge for elderly patients suffering from ankle fractures. Furthermore, a hospital stay that is twice as long as in younger patients underlines the physical impairment caused by an ORIF-treated ankle fracture. However, the overall length of hospital stay was much longer than time to self-sufficient mobilization in both groups, maybe because of the definition of self-sufficient mobilization. At the follow-up investigation, patients were asked when they could stand up and walk with crutches or a walker without assistance. Furthermore, at dismissal, walking stairs was usually intended in patients who were used to it prior to surgery, which could explain the discrepancy between self-sufficient mobilization and length of hospital stay. Moreover, organization of further care for the elderly takes time, especially in cases when homeward discharge is not possible anymore. Compared to other studies, which describe the length of hospital stay between 5 and 26 days, our results show no mismatch, though [16,24]. Another reason for longer hospital stays by both the younger and elderly groups might be that until 2004, general hospital benefits were reimbursed in Germany through hospital-specific care rates payable per day of hospitalization. The use of the old pay-perday system and the change to the presently applied diagnosis-related group (DRG) billing system during the study period might be the reason hospital stays were longer than we would expect today. A significant difference between length of hospital stay by patients walking with a Zimmer frame before injury and independently walking patients was observed [16]. Therefore, taking comorbidities as well as preinjury mobility in elderly patients into account should be standard before making the best therapy decision. Concerning postsurgical treatment protocols, Smeeing et al. showed in a meta-analysis that active exercise as well as early weight-bearing accelerates return to work and daily activities without elevated complication rates [25]. Gul et al. compared postsurgical full weightbearing without plaster cast immobilization with conventional nonweight-bearing in younger patients, mean age 45.24 and 43.44, respectively. No significant differences were observed in the duration of hospital stay, functional recovery, and complications. However, the mean for the time of return to work was significantly shorter in the full weight-bearing group [26]. Besides ORIF, other treatment concepts such as conservative treatment and primary hind-foot arthrodesis were examined. Further criteria were observed after a mean follow-up of 14 months. Immediate postsurgical weight-bearing to prevent immobilization and complications (i.e., wound infection), shorten the hospital stay, and lower the mortality rate in patients treated with arthrodesis by tibiotalocalcaneal nailing was reported by Georgiannos et al. [17]. On the other hand, drawbacks of hind-foot arthrodesis must be taken into account for longterm follow-ups. Despite the noticeably minor procedure compared to tibiotalocalcaneal nailing, patients treated by tibiotalar arthrodesis showed impaired functional results. The functional assessment is present through radiological changes in adjoining joints, which leads to limitations in daily living and poor life quality even after 20 years [27]. Georgiannos et al. observed no difference in postsurgical Olerud Molander Ankle scores (OMAS) in both groups treated by ORIF or hindfoot arthrodesis, with a fair score of 56.9 and 56.6, respectively [17].
However, these scores are comparable to an average AOFAS score of 63 after hind-foot arthrodesis in patients suffering from combined ankle and subtalar arthritis [28]. All three scores indicate an acceptable postsurgical result, using two scoring systems [17,28]. Conservative treatment by closed reduction under anesthesia and plaster cast immobilization is reported to lead to similar or even better results in unstable-ankle fracture treatment [6,7]. However, Willett et al. showed that 19% of patients initially treated by plaster cast had to be treated again using ORIF. Furthermore, radiological examination showed frequent malunions within a short follow-up of 6 months [6]. Moreover, the impact of malunion on long-term outcome is not clear. The latency of end-stage osteoarthritis (OA) is described by Horisberger et al. as 20.9 (range, 1–52) years. A negative correlation of OA latency time with fracture severity and complications during the healing process was observed [29]. However, the prospective trial conducted by Salai et al., which shows better results for conservative treatment, lacks randomization. The study investigated 30 patients subjected to conservative treatment; however, ORIF was conducted after unsuccessful reduction and maintenance in a plaster cast, which leads to a selection bias [7]. Lovy et al. considered that in diabetic patients, conservative treatment with closed reduction and plaster cast fixation leads to an unnecessarily high overall complication rate of 75%. Complications after conservative treatment included reduction loss, deep infection, wound complication, Charcot joint, and the need for reoperation. In contrast, a 25% rate of complications was reported in the surgically treated group [30]. Taken together, treatment of elderly patients suffering from ankle fractures should include attention to comorbidities, fracture patterns, and preinjury mobility as the key to success in ankle fracture care. 5. Conclusion In the elderly, good functional results were achieved by open reduction and internal fixation of ankle fractures after a mean follow-up of 49 months. After the same period, younger patients showed better results than the elderly did. To achieve satisfying results for both patient and surgeon, surgical treatment can be regarded as an appropriate therapy method in the elderly as well as in younger patients. Surgical therapy choices as well as postsurgical treatment protocols should be improved to enable early mobilization, thereby preventing unnecessary bed rest, associated long hospital stay, and delayed or impossible return to daily activities. Despite the limiting retrospective design of this study, the acquired data can provide a criteria set for future prospective studies. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of conflicts of interest None. References [1] Elsoe R, Ostgaard SE, Larsen P. Population-based epidemiology of 9767 ankle fractures. Foot Ankle Surg 2018;24:34–9. [2] Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Stabilizing incidence of low-trauma ankle fractures in elderly people: Finnish statistics in 1970–2006 and prediction for the future. Bone 2008;43:340–2. [3] Kannus P, Niemi S, Parkkari J, Sievänen H. Declining incidence of fall-induced ankle fractures in elderly adults: Finnish statistics between 1970 and 2014. Arch Orthop Trauma Surg 2016;136:1243–6. [4] Davidovitch RI, Walsh M, Spitzer A, Egol KA. Functional outcome after operatively treated ankle fractures in the elderly. Foot Ankle Int 2009;30:728–33. [5] Anderson SA, Li X, Franklin P, Wixted JJ. Ankle fractures in the elderly: initial and long-term outcomes. Foot Ankle Int 2008;29:1184–8.
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