- Email: [email protected]
Functional outcome following tibio-talar-calcaneal nailing for unstable osteoporotic ankle fractures
Injury, Int. J. Care Injured 44 (2013) 994–997
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Functional outcome following tibio-talar-calcaneal nailing for unstable osteoporotic ankle fractures S.C. Jonas *, A.F. Young, C.H. Curwen, P.A. McCann Gloucester Royal Hospital, Gloucester, Gloucestershire, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 8 November 2012
Introduction: Fragility fractures of the ankle are increasing in incidence. Such fractures typically occur from low-energy injuries but lead to disproportionately high levels of morbidity. Ankle fractures in this age group are managed conservatively in plaster or by open reduction and internal fixation. Both modalities have shown high rates of failure in terms of delayed union or mal-union together with perioperative complications such as implant failure and wound breakdown. The optimal treatment of these patients remains controversial. Objectives: We aimed to review the functional outcome of patients with ankle fragility fractures primarily managed using a tibio-talar-calcaneal nail (TTC). Methods: We retrospectively reviewed 31 consecutive patients primarily managed with a TCC nail for osteoporotic fragility fractures about the ankle. Data were collected via case notes, radiographic reviews and by clinical reviews at the outpatient clinic or a telephone follow-up. Information regarding patient characteristics, indication for operation, Arbeitsgemeinschaft fu¨r Osteosynthesefragen (AO) fracture classification, operative and postoperative complications, time to radiographic union and current clinical state including Olerud and Molander scores were recorded (as a measure of ankle function). Results: Nine of 31 patients had died by the time of follow-up. Mean preoperative and postoperative Olerud and Molander scores were 56 and 45, respectively. There were no postoperative wound complications. Twenty-nine of 31 patients returned to the same level of mobility as pre-injury. There were three peri-prosthetic fractures managed successfully with nail removal and replacement or plaster cast. There were two nail failures, both in patients who mobilised using only a stick, which were managed by nail removal. Ten of 31 patients were not followed up radiographically due to either infirmity or death. Thirteen of 21 followed up radiographically had evidence of union and 8/21 had none. None, however, had clinical evidence of fracture nonunion. Conclusion: The TTC nail can successfully be used to manage fragility fractures about the ankle in the elderly. Much like fractured neck of femur patients, who also have a high rate of mortality, this allows immediate mobilisation with minimal risk of wound complications. However, careful assessment must be made of each patient’s mobility, as there is a significant incidence of device failure in the more active patient. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Fragility fractures Ankle fractures Elderly Hind foot nail
Fragility fractures of the ankle are increasing in incidence. With an ageing population, they are becoming proportionally more common in the elderly age group1 and, in particular, females.2 Such fractures typically occur from low-energy injuries but lead to disproportionately high levels of morbidity.2,3 Increasing age is associated with systemic disorders such as osteoporosis, diabetes and peripheral vascular disease. These influence both rates of bone union and wound healing and are associated with higher rates of intra-operative complications, wound infection and dehiscence.4
* Corresponding author. Tel.: +44 08454 222222. E-mail address: [email protected] (S.C. Jonas). 0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.11.008
Ankle fractures in this age group are managed by conservative means in plaster or by open reduction and internal fixation (ORIF). Both modalities have shown high rates of failure in terms of delayed union or mal-union or perioperative complications such as implant failure and wound breakdown.5–10 The optimal treatment of these patients remains controversial. Indirect stabilisation of the ankle has been well documented in the form of augmented intra-medullary Steinmann pins.5,6 Retrograde tibio-talar-calcaneal (TTC) nails have previously been described in the treatment of complex ankle pathology such as pantalar osteoarthritis, Charcot arthropathy and post-traumatic pseudarthrosis and as a salvage procedure in the failed ankle replacement.11–16 With regard to fragility fractures about the ankle, TTC nails were originally described for failure of other forms
S.C. Jonas et al. / Injury, Int. J. Care Injured 44 (2013) 994–997
995
of management17; however, more recently they have been successfully used as a primary treatment.18,19 Prior reports in the literature have described the use of such implants in small numbers of patients. This article discusses the use of the TCC nailing as a primary treatment for unstable osteoporotic fractures about the ankle in a cohort of 31 patients treated at a single institution, representing the largest series to date. Patients and methods A retrospective review was conducted of 31 consecutive patients treated with a Smith and Nephew TTC implant (Trigen) for fragility fractures of the ankle or distal tibia between September 2008 and November 2011. There were 10 males and 21 females with a mean age of 77 years (range 42–98 years). None of the fractures was open. Fracture patterns were categorised according to the Arbeitsgemeinschaft fu¨r Osteosynthesefragen (AO) classification. There were four distal tibia fractures (AO 43-A1), 21 bimalleolar ankle fractures (one AO 44-A2, 17 AO 44-B2 and three AO 44-C1) and six tri-malleolar patterns (five AO 44-B3 and one AO 44-C1) (Table 1). Time to union and complications such as infection, thromboembolism and implant failure were also recorded. Functional outcome was evaluated via the Olerud and Molander score25 (lower scores denoting poorer functional outcome) in all surviving patients. For all deceased patients, an assessment of their mobility was made from the last outpatient or inpatient documentation. The decision to proceed with TTC nailing as a primary treatment was made following assessment of the patient’s preoperative mobility, medical co-morbidity, soft-tissue condition, fracture pattern stability and patient compliance with the non-weight bearing status frequently required in other forms of management. These characteristics were recorded. Eight were diabetic, 12 had poor soft tissue and 11 were unable to comply with a non-weight bearing status. Postoperatively, the patients were mobilised fully weight bearing as their pain allowed. They were followed up at 2 weeks for a wound check and then at 6 week- and 3-month intervals until fracture union, unless the patient was too frail to attend for review. If so, radiographic evaluation was not possible; however, clinical evaluation using the Olerud and Molander score was possible via telephone calls. Results The results are summarised in Table 1. There were no intraoperative complications. All patients were allowed to mobilise fully weight bearing from day 1 postoperatively. The majority were discharged from hospital within 2 weeks of surgery and had their wound checked at a 2-week follow-up appointment. No complications of wound or deep vein thromboses (DVTs) were reported. There were three peri-prosthetic fractures, two at 1 month, which were managed either conservatively as an un-displaced fracture or revised to a PHOENIX nail (Biomet, Warsaw, IN, USA) and one at 7 months, which was revised to a tibial nail as union had been achieved in the original fracture. There were two incidences of a broken nail at 4 and 24 months, respectively, which were managed by nail removal as union had been achieved. Two patients had distal locking screws removed due to chronic pain that resolved after removal. If unable to attend the outpatient clinic and not deceased, patients were contacted by telephone for clinical evaluation with a mean follow-up time of 18 months. Ten of 31 patients had no X-ray follow-up, as they were either deceased or too infirm to attend the outpatient clinic. For the 21 patients who had radiographic
Graph 1. Survivorship of patients following treatment.
follow-up, there was an average follow-up time of 8 months, 13/31 had formed radiographic union (3–36 months X-ray follow-up, average 12 months) and 8/31 had no evidence of radiographic union (1–3 months X-ray follow-up, average 2 months). Nine patients had died by the time of follow-up interview from causes unrelated to surgery (Graph 1). The mean Olerud and Molander functional assessment score was 45 compared to a pre-injury score of 56 (this was used as a preinjury assessment of function, similar to Lemon et al.9). All patients returned to a functional level comparable to their preoperative state. Twenty-nine of the 31 patients retained the same level of mobility and the remaining had their mobility reduced by one level. Discussion The management challenge of fragility fractures about the ankle is growing. Traditional management of these patients (ORIF or conservative) has been shown to give suboptimal results in a significant proportion of patients.8,20 In this patient group, there are high rates of complication in terms of DVT, pressure sores and pneumonia, particularly in the non-weight bearing group. We are also presented with particular operative challenges such as complex fracture patterns, poor softtissue coverage, poor bone stock and poor compliance with nonweight bearing. These operative factors lead to higher rates of wound complications, loss of reduction and nonunion.3,4,8,20 Several different choices are currently available in terms of device. Lemon et al.9 report success using an expandable nailing system; the use of a straight locking nail was commented on by Amirfeyz et al.19 These studies, although prospective, were small and do not reveal the potential complication rate in terms of device failure and peri-prosthetic fracture that may be more evident in larger series. These studies did not include any functional data on the medium-term outcome after treatment with the TTC nail. Previous studies have highlighted that the decision to perform an ORIF should not be related solely to age.21–23 However, it is apparent that the preoperative level of mobility should be taken into account. The majority of our series mobilised only with a frame, making them ideal candidates. We experienced two nail failures in patients who used a stick and no walking aid, respectively. These patients were treated with nails as a result of poor soft tissues but in retrospect they may have been too active to warrant this intervention. Peri-implant fracture is a recognised complication of TTC nailing. We experienced three such fractures proximal to the tip of the implant in our patient population, most likely due to a modulus mismatch between the tip of the nail and the bone. Lemon et al.9
996
Table 1 Clinical and radiological follow up of patients.
Olerud & Molander Score
Walking aids Radiographic Follow up (months) 3 12 24 No follow up
Union at Latest Radiographic Assessment No Yes Yes -
Deceased No No No No
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
24 29 1 22 7 11 12 21 37 14 7 8 25 22 36 26 12
21 No follow up No follow up 18 4 2 4 2 No follow up 7 7 No follow up 10 3 36 No follow up 6
Yes Yes Yes No Yes No Yes Yes Yes No Yes Yes
No No No No No No No No No No No No No No No No No
22 23 24 25 26 27 28
36 31 39 6 21 24 5
2 1 2 No follow up 1 4 3
No No No No Yes Yes
No Yes Yes Yes Yes Yes Yes
29 30 31
19 24 13
No follow up No follow up No follow up
-
Yes Yes Yes
Grey shaded area indicates deceased group.
Complications None None Pain (broken screw removed 24 months) Peri-prosthetic fracture (revised to phoenix nail 1 month) Broken nail (nail removed 21 months) None None Pain (broken screw removed 13 months) None None Broken nail (nail removed 4 months) None None None None None None None None None Peri-prosthetic fracture (revised to tibial nail 7 months) None None None None None None Peri-prosthetic fracture (nail removed 1 month, managed in pop) None None None
Preoperative Frame Frame Frame Frame
Postoperative Frame Frame Frame Frame
Pre-operative 45 40 40 35
Post-operative 35 25 25 25
None Frame Stick Stick Stick Frame Stick Frame Stick Stick Stick Stick Stick Stick Frame Frame Frame
Stick Frame Stick Stick Stick Frame Stick Frame Stick Stick Stick Stick Frame Stick Frame Frame Frame
65 40 45 50 55 50 50 55 65 60 60 65 65 65 70 75 70
25 30 30 35 40 40 40 45 50 50 50 55 60 60 60 65 65
Stick Frame Frame Frame Frame Wheelchair Frame
Stick Frame Frame Frame Frame Wheelchair Frame
80 -
75 -
Frame Frame Wheelchair
Frame Frame Wheelchair
-
-
S.C. Jonas et al. / Injury, Int. J. Care Injured 44 (2013) 994–997
Case 1 2 3 4
Clinical Follow up (months) 6 24 25 2
S.C. Jonas et al. / Injury, Int. J. Care Injured 44 (2013) 994–997
suggest that removal should be standard practice to prevent such complications. However, given the general poor health of this patient group further operative intervention may not be advisable. At the time of follow-up postoperatively 9/31 (29%) patients had died (Graph 1). This reflects the high associated rate of mortality experienced by this group.18,19 As this study suggests, our treatment goals differ from that of a young patient population with direction towards early mobilisation to prevent loss of function and social independence. Thirteen of our patients had achieved union radiographically, eight had not achieved union but only had a mean follow-up time of less than 3 months and 10 were not followed up radiographically. On clinical review (mean follow-up 19 months), none of the patients who were still alive and had evidence of radiographic nonunion had any pain implying that they had clinically formed union by this follow-up. This study was limited by its retrospective design in that no specific criteria were used for the selection of patients treated with this implant. This does however represent the clinical decisions that have to be made in everyday practice in the management of this difficult patient group. The TTC nail can be successfully used to manage fragility fractures about the ankle in the elderly. Much like fractured neck of femur patients, who also have a high rate of mortality, this allows immediate mobilisation with minimal risk of wound complications. However, careful assessment must be made of each patient’s mobility, as there is a significant incidence of device failure in the more active patient. Conflict of interest statement No conflicts of interest or sources of funding to any of the authors. References 1. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures—an increasing problem? Acta Orthopaedica Scandinavica 1998;69:43–7. 2. Kannus P, Palvanen M, Niemi S, Parkkari J, Ja¨rvinen M. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970–2000 and projections for the future. Bone 2002;31:430–3. 3. Bauer M, Bengner U, Johnell O, Redlund-Johnell I. Supination–eversion fractures of the ankle joint: changes in incidence over 30 years. Foot and Ankle 1987;8:26–8. 4. Wukich DK, Lowery NJ, McMillen RL, Frykberg RG. Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus. Journal of Bone and Joint Surgery 2010;92(February (2)):287–95.
997
5. Childress HM. Vertical transarticular pin fixation for unstable ankle fractures: impressions after 16 years of experience. Clinical Orthopaedics and Related Research 1976;120:164–71. 6. Duke RFN. Severe fracture-dislocation of ankle treated by transarticular Steinmann pin. Lancet 1963;2:1251–3. 7. Hammett R, Hepple S, Forster B, Winson I. Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail. The results of 52 procedures. Foot and Ankle International 2005;26: 810–5. 8. Litchfield JC. The treatment of unstable fractures of the ankle in the elderly. Injury 1987;18:128–32. 9. Rockwood CA, Green DP, Bucholz RW, Heckman JD. Fractures in adults. 4th ed. Philadelphia: Lippincott-Raven; 1996. 10. Scioscia TN, Ziran BH. Use of a vertical transarticular pin for stabilisation of severe ankle fractures. American Journal of Orthopedics 2003;32:46–8. 11. Caravaggi C, Cimmino M, Caruso S, Dalla Noce S. Intramedullary compressive nail Wxation for the treatment of severe Charcot deformity of the ankle and rear foot. Journal of Foot and Ankle Surgery 2006;45:20–4. 12. Culpan P, Le Strat V, Piriou P, Judet T. Arthrodesis after failed total ankle replacement. Journal of Bone and Joint Surgery British Volume 2007;89: 1178–83. 13. Gagneux E, Gerard F, Garbuio P, Vichard P. Treatment of complex fractures of the ankle and their sequelae using transplantar intramedullary nailing. Acta Orthopaedica Belgica 1997;63:294–304. 14. De Smet K, De Brauwer V, Burssens P, Van Ovost E, Verdonk R. Tibiocalcaneal Marchetti–Vicenzi nailing in revision arthrodesis for posttraumatic pseudarthrosis of the ankle. Acta Orthopaedica Belgica 2003;69:42–8. 15. Mendicino RW, Catanzariti AR, Saltrick KR, Dombek MF, TullisBL. Statler TK, et al. Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing. Journal of Foot and Ankle Surgery 2004;43:82–6. 16. Paola LD, Volpe A, Varotto D, Postorino A, Brocco E, Senesi A, et al. Use of a retrograde nail for ankle arthrodesis in Charcot neuroarthropathy: a limb salvage procedure. Foot and Ankle International 2007;28:967–70; Pelton K, Hofer JK, Thordarson DB. Tibiotalocalcaneal arthrodesis using a dynamically locked retrograde intramedullary nail. Foot and Ankle International 2006;27:759–63. 17. Houshian S, Bajaj SK, Mohammed AM. Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: a report on four cases. Injury 2006;37(8):791–4. Epub 2005 Oct 25. 18. Lemon M, Somayaji HS, Khaleel A, Elliot DS. Fragility fractures of the ankle stabilisation with an expandable calcaneotalotibial nail. Journal of Bone and Joint Surgery British Volume 2005;87:809–13. 19. Amirfeyz R, Bacon A, Ling J, Blom A, Hepple S, Winson I, et al. Fixation of ankle fragility fractures by tibiotalocalcaneal nail. Archives of Orthopaedic and Trauma Surgery 2008;128(April (4)):423–8. [Epub 2008 February 13]. 20. Buckingham RA, Hepple S, Winson IG. Outcome of ankle fractures in the elderly. Foot and Ankle Surgery 2000;6:175–8. 21. Michelson JD. Fractures about the ankle. Journal of Bone and Joint SurgeryAmerican Volume 1995;77-A:142–52. 22. Ali MS, McLaren CAN, Rouholamin E, O’Connor BT. Ankle fractures in the elderly: nonoperative or operative treatment. Journal of Orthopaedic Trauma 1988;1:275–80. 23. Anand N, Klenerman L. Ankle fractures in the elderly: MUA versus ORIF. Injury 1993;24:116–20. 25. Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. Archives of Orthopaedic and Trauma Surgery 1984;103(3): 190–4.
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Functional outcome following tibio-talar-calcaneal nailing for unstable osteoporotic ankle fractures S.C. Jonas *, A.F. Young, C.H. Curwen, P.A. McCann Gloucester Royal Hospital, Gloucester, Gloucestershire, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 8 November 2012
Introduction: Fragility fractures of the ankle are increasing in incidence. Such fractures typically occur from low-energy injuries but lead to disproportionately high levels of morbidity. Ankle fractures in this age group are managed conservatively in plaster or by open reduction and internal fixation. Both modalities have shown high rates of failure in terms of delayed union or mal-union together with perioperative complications such as implant failure and wound breakdown. The optimal treatment of these patients remains controversial. Objectives: We aimed to review the functional outcome of patients with ankle fragility fractures primarily managed using a tibio-talar-calcaneal nail (TTC). Methods: We retrospectively reviewed 31 consecutive patients primarily managed with a TCC nail for osteoporotic fragility fractures about the ankle. Data were collected via case notes, radiographic reviews and by clinical reviews at the outpatient clinic or a telephone follow-up. Information regarding patient characteristics, indication for operation, Arbeitsgemeinschaft fu¨r Osteosynthesefragen (AO) fracture classification, operative and postoperative complications, time to radiographic union and current clinical state including Olerud and Molander scores were recorded (as a measure of ankle function). Results: Nine of 31 patients had died by the time of follow-up. Mean preoperative and postoperative Olerud and Molander scores were 56 and 45, respectively. There were no postoperative wound complications. Twenty-nine of 31 patients returned to the same level of mobility as pre-injury. There were three peri-prosthetic fractures managed successfully with nail removal and replacement or plaster cast. There were two nail failures, both in patients who mobilised using only a stick, which were managed by nail removal. Ten of 31 patients were not followed up radiographically due to either infirmity or death. Thirteen of 21 followed up radiographically had evidence of union and 8/21 had none. None, however, had clinical evidence of fracture nonunion. Conclusion: The TTC nail can successfully be used to manage fragility fractures about the ankle in the elderly. Much like fractured neck of femur patients, who also have a high rate of mortality, this allows immediate mobilisation with minimal risk of wound complications. However, careful assessment must be made of each patient’s mobility, as there is a significant incidence of device failure in the more active patient. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Fragility fractures Ankle fractures Elderly Hind foot nail
Fragility fractures of the ankle are increasing in incidence. With an ageing population, they are becoming proportionally more common in the elderly age group1 and, in particular, females.2 Such fractures typically occur from low-energy injuries but lead to disproportionately high levels of morbidity.2,3 Increasing age is associated with systemic disorders such as osteoporosis, diabetes and peripheral vascular disease. These influence both rates of bone union and wound healing and are associated with higher rates of intra-operative complications, wound infection and dehiscence.4
* Corresponding author. Tel.: +44 08454 222222. E-mail address: [email protected] (S.C. Jonas). 0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.11.008
Ankle fractures in this age group are managed by conservative means in plaster or by open reduction and internal fixation (ORIF). Both modalities have shown high rates of failure in terms of delayed union or mal-union or perioperative complications such as implant failure and wound breakdown.5–10 The optimal treatment of these patients remains controversial. Indirect stabilisation of the ankle has been well documented in the form of augmented intra-medullary Steinmann pins.5,6 Retrograde tibio-talar-calcaneal (TTC) nails have previously been described in the treatment of complex ankle pathology such as pantalar osteoarthritis, Charcot arthropathy and post-traumatic pseudarthrosis and as a salvage procedure in the failed ankle replacement.11–16 With regard to fragility fractures about the ankle, TTC nails were originally described for failure of other forms
S.C. Jonas et al. / Injury, Int. J. Care Injured 44 (2013) 994–997
995
of management17; however, more recently they have been successfully used as a primary treatment.18,19 Prior reports in the literature have described the use of such implants in small numbers of patients. This article discusses the use of the TCC nailing as a primary treatment for unstable osteoporotic fractures about the ankle in a cohort of 31 patients treated at a single institution, representing the largest series to date. Patients and methods A retrospective review was conducted of 31 consecutive patients treated with a Smith and Nephew TTC implant (Trigen) for fragility fractures of the ankle or distal tibia between September 2008 and November 2011. There were 10 males and 21 females with a mean age of 77 years (range 42–98 years). None of the fractures was open. Fracture patterns were categorised according to the Arbeitsgemeinschaft fu¨r Osteosynthesefragen (AO) classification. There were four distal tibia fractures (AO 43-A1), 21 bimalleolar ankle fractures (one AO 44-A2, 17 AO 44-B2 and three AO 44-C1) and six tri-malleolar patterns (five AO 44-B3 and one AO 44-C1) (Table 1). Time to union and complications such as infection, thromboembolism and implant failure were also recorded. Functional outcome was evaluated via the Olerud and Molander score25 (lower scores denoting poorer functional outcome) in all surviving patients. For all deceased patients, an assessment of their mobility was made from the last outpatient or inpatient documentation. The decision to proceed with TTC nailing as a primary treatment was made following assessment of the patient’s preoperative mobility, medical co-morbidity, soft-tissue condition, fracture pattern stability and patient compliance with the non-weight bearing status frequently required in other forms of management. These characteristics were recorded. Eight were diabetic, 12 had poor soft tissue and 11 were unable to comply with a non-weight bearing status. Postoperatively, the patients were mobilised fully weight bearing as their pain allowed. They were followed up at 2 weeks for a wound check and then at 6 week- and 3-month intervals until fracture union, unless the patient was too frail to attend for review. If so, radiographic evaluation was not possible; however, clinical evaluation using the Olerud and Molander score was possible via telephone calls. Results The results are summarised in Table 1. There were no intraoperative complications. All patients were allowed to mobilise fully weight bearing from day 1 postoperatively. The majority were discharged from hospital within 2 weeks of surgery and had their wound checked at a 2-week follow-up appointment. No complications of wound or deep vein thromboses (DVTs) were reported. There were three peri-prosthetic fractures, two at 1 month, which were managed either conservatively as an un-displaced fracture or revised to a PHOENIX nail (Biomet, Warsaw, IN, USA) and one at 7 months, which was revised to a tibial nail as union had been achieved in the original fracture. There were two incidences of a broken nail at 4 and 24 months, respectively, which were managed by nail removal as union had been achieved. Two patients had distal locking screws removed due to chronic pain that resolved after removal. If unable to attend the outpatient clinic and not deceased, patients were contacted by telephone for clinical evaluation with a mean follow-up time of 18 months. Ten of 31 patients had no X-ray follow-up, as they were either deceased or too infirm to attend the outpatient clinic. For the 21 patients who had radiographic
Graph 1. Survivorship of patients following treatment.
follow-up, there was an average follow-up time of 8 months, 13/31 had formed radiographic union (3–36 months X-ray follow-up, average 12 months) and 8/31 had no evidence of radiographic union (1–3 months X-ray follow-up, average 2 months). Nine patients had died by the time of follow-up interview from causes unrelated to surgery (Graph 1). The mean Olerud and Molander functional assessment score was 45 compared to a pre-injury score of 56 (this was used as a preinjury assessment of function, similar to Lemon et al.9). All patients returned to a functional level comparable to their preoperative state. Twenty-nine of the 31 patients retained the same level of mobility and the remaining had their mobility reduced by one level. Discussion The management challenge of fragility fractures about the ankle is growing. Traditional management of these patients (ORIF or conservative) has been shown to give suboptimal results in a significant proportion of patients.8,20 In this patient group, there are high rates of complication in terms of DVT, pressure sores and pneumonia, particularly in the non-weight bearing group. We are also presented with particular operative challenges such as complex fracture patterns, poor softtissue coverage, poor bone stock and poor compliance with nonweight bearing. These operative factors lead to higher rates of wound complications, loss of reduction and nonunion.3,4,8,20 Several different choices are currently available in terms of device. Lemon et al.9 report success using an expandable nailing system; the use of a straight locking nail was commented on by Amirfeyz et al.19 These studies, although prospective, were small and do not reveal the potential complication rate in terms of device failure and peri-prosthetic fracture that may be more evident in larger series. These studies did not include any functional data on the medium-term outcome after treatment with the TTC nail. Previous studies have highlighted that the decision to perform an ORIF should not be related solely to age.21–23 However, it is apparent that the preoperative level of mobility should be taken into account. The majority of our series mobilised only with a frame, making them ideal candidates. We experienced two nail failures in patients who used a stick and no walking aid, respectively. These patients were treated with nails as a result of poor soft tissues but in retrospect they may have been too active to warrant this intervention. Peri-implant fracture is a recognised complication of TTC nailing. We experienced three such fractures proximal to the tip of the implant in our patient population, most likely due to a modulus mismatch between the tip of the nail and the bone. Lemon et al.9
996
Table 1 Clinical and radiological follow up of patients.
Olerud & Molander Score
Walking aids Radiographic Follow up (months) 3 12 24 No follow up
Union at Latest Radiographic Assessment No Yes Yes -
Deceased No No No No
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
24 29 1 22 7 11 12 21 37 14 7 8 25 22 36 26 12
21 No follow up No follow up 18 4 2 4 2 No follow up 7 7 No follow up 10 3 36 No follow up 6
Yes Yes Yes No Yes No Yes Yes Yes No Yes Yes
No No No No No No No No No No No No No No No No No
22 23 24 25 26 27 28
36 31 39 6 21 24 5
2 1 2 No follow up 1 4 3
No No No No Yes Yes
No Yes Yes Yes Yes Yes Yes
29 30 31
19 24 13
No follow up No follow up No follow up
-
Yes Yes Yes
Grey shaded area indicates deceased group.
Complications None None Pain (broken screw removed 24 months) Peri-prosthetic fracture (revised to phoenix nail 1 month) Broken nail (nail removed 21 months) None None Pain (broken screw removed 13 months) None None Broken nail (nail removed 4 months) None None None None None None None None None Peri-prosthetic fracture (revised to tibial nail 7 months) None None None None None None Peri-prosthetic fracture (nail removed 1 month, managed in pop) None None None
Preoperative Frame Frame Frame Frame
Postoperative Frame Frame Frame Frame
Pre-operative 45 40 40 35
Post-operative 35 25 25 25
None Frame Stick Stick Stick Frame Stick Frame Stick Stick Stick Stick Stick Stick Frame Frame Frame
Stick Frame Stick Stick Stick Frame Stick Frame Stick Stick Stick Stick Frame Stick Frame Frame Frame
65 40 45 50 55 50 50 55 65 60 60 65 65 65 70 75 70
25 30 30 35 40 40 40 45 50 50 50 55 60 60 60 65 65
Stick Frame Frame Frame Frame Wheelchair Frame
Stick Frame Frame Frame Frame Wheelchair Frame
80 -
75 -
Frame Frame Wheelchair
Frame Frame Wheelchair
-
-
S.C. Jonas et al. / Injury, Int. J. Care Injured 44 (2013) 994–997
Case 1 2 3 4
Clinical Follow up (months) 6 24 25 2
S.C. Jonas et al. / Injury, Int. J. Care Injured 44 (2013) 994–997
suggest that removal should be standard practice to prevent such complications. However, given the general poor health of this patient group further operative intervention may not be advisable. At the time of follow-up postoperatively 9/31 (29%) patients had died (Graph 1). This reflects the high associated rate of mortality experienced by this group.18,19 As this study suggests, our treatment goals differ from that of a young patient population with direction towards early mobilisation to prevent loss of function and social independence. Thirteen of our patients had achieved union radiographically, eight had not achieved union but only had a mean follow-up time of less than 3 months and 10 were not followed up radiographically. On clinical review (mean follow-up 19 months), none of the patients who were still alive and had evidence of radiographic nonunion had any pain implying that they had clinically formed union by this follow-up. This study was limited by its retrospective design in that no specific criteria were used for the selection of patients treated with this implant. This does however represent the clinical decisions that have to be made in everyday practice in the management of this difficult patient group. The TTC nail can be successfully used to manage fragility fractures about the ankle in the elderly. Much like fractured neck of femur patients, who also have a high rate of mortality, this allows immediate mobilisation with minimal risk of wound complications. However, careful assessment must be made of each patient’s mobility, as there is a significant incidence of device failure in the more active patient. Conflict of interest statement No conflicts of interest or sources of funding to any of the authors. References 1. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures—an increasing problem? Acta Orthopaedica Scandinavica 1998;69:43–7. 2. Kannus P, Palvanen M, Niemi S, Parkkari J, Ja¨rvinen M. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970–2000 and projections for the future. Bone 2002;31:430–3. 3. Bauer M, Bengner U, Johnell O, Redlund-Johnell I. Supination–eversion fractures of the ankle joint: changes in incidence over 30 years. Foot and Ankle 1987;8:26–8. 4. Wukich DK, Lowery NJ, McMillen RL, Frykberg RG. Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus. Journal of Bone and Joint Surgery 2010;92(February (2)):287–95.
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