Ankle Fractures: The Bad and the Ugly

Transcription

1 Ankle Fractures: The Bad and the Ugly Florida Podiatric Medical Association Science & Management Symposium January 12, 2018 Alan A. MacGill, DPM, FACFAS, AO Fellow Director, Foot & Ankle Surgery Residency Program Northwest Medical Center, Margate, FL Disclosure BESPA Medical Consultant Integra/Derma Sciences Speaker Bad and Ugly = HIGH RISK Low Risk High Risk Fracture pattern Simple Comminuted Soft tissue envelop Plafond involvement Closed No Open Yes Limb stability Stable Unstable Consider this Factors that negative influence soft tissue and bone healing Factors that increase risk of repair failure Alternative fixation techniques Post op protocol modification 1

2 To Fix...Or NOT Many considerations: Fracture severity/stability Patient age (chronologic vs biologic) Comorbidity Limb perfusion Soft tissue envelop Ambulatory status/needs Operative vs Nonoperative treatment Factors Affecting Tissue Healing Smoking Alcohol Diabetes Advanced age Osteoporosis Renal failure Medications Glucocorticoids, Warfarin, Chemotherapeutic agents Immunosuppressed patients Vascular insufficiency PAD, Venous Insufficiency, Lymphedema Nutritional deficiency Vit B, Vit C, Zinc, Vit D, Calcium Factors Jeopardizing the Repair History of Charcot Obesity Non compliance Peripheral Neuropathy* *Increase period of immobilization by two to three times Marks, Clin Ortho,

3 We need to know our patients!!! The Diabetic Neuropathic Ankle An ankle fracture in a patient with longstanding diabetes and neuropathy can be a calamity for the patient and the physician who treats the fracture as a routine injury Kristiansen, Acta Orthop Scand, 1980 Pinzur et al, FAI, 1996 Connolly, CORR, 2001 A limb threatening injury??? Bad Bone Biology the diabetic state is associated with mechanical deterioration of bone Reddy et al, DiaResClinPrac, 2001 When BG levels were tightly controlled with insulin, fracture healing was similar to non DM controls. Insulin treatment with resultant improved BG control will ameliorate early and late complications of DM fracture healing. Beam et al, JOrthoRes,

4 NEWSFLASH Diabetic patients with ankle fractures have worse results than non diabetic i patients Post op complications Mortality Length of hospital stay Etc Reference: IT S EVERYWHERE JOURNAL OF SURGERY, 2018 Decisions, Decisions Wukich et al, JBJS, 2010 ORIF significantly increases complication rate Infection 5x higher in diabetic patients Schon, Ortho Clin N Am, 1995 Risk of Charcot drastically increases with nonoperative care 100% nonunion rate Should I fix this??? Informed Consent Manage expectations Not just ORIF! Limb Salvage We are going to do our best to save your leg! 4

5 Fibula Pro Tibia Multiple, tetracortical screws Increases construct strength, stiffness, andload to failure The one bone lower leg Wukich. FAI, 2011 Complications in ORIF of diabetic neuropathic ankle fractures ORIF plus = addition of tetracortical syndesmotic screws and/or transarticular pin fixation Lower complication rate compared to ORIF alone, 5.7% versus 20% 5

6 6 neuropathic ankle fractures that failed initial fixation Lateral DCP plate, multiple 4.5 mm syndesmotic screws E f tibi l t Engage far tibial cortex Fibular plate fixation using multiple large fragment syndesmotic screws provides reasonable salvage alternative for neuropathic patients with ankle fractures that failed using traditional hardware techniques. Augmenting Screw Purchase Panchbhavi. FAI, 2008 Paired leg, cadaveric study, bone mineral density quantified with DEXA One leg received injection of composite graft (CaSO4/CaPO4) into screw holes prior to screw placement Augmented screws had SSD: displacement, failure load, and failure energy Koval. JOT, 1997 Retrograde 1.6mm K wire through the fibula, lateral plate screws interdigitate with the wire Greater bending resistance, double the torsional stiffness MIPO Technique Minimally Invasive Plate Osteosynthesis Smaller incisions, minimize periosteal stripping Pires. EurJ Orthop SurgTraumatol, 2013 Prospective cohort study, 20 adult SER fractures tx d with MIPO At 12 mo f/u, all fractures healed, AOFAS avg 88.3 Chiang. Foot Ankle Int, 2016 MIPO vs Open, comparative cohort study, 24 patients MIPO = same radiographic/functional outcomes, less post oppain, fewer woundcomplications 6

7 Fibular Intramedullary Nailing Percutaneous insertion, distal locking screws, syndesmotic screws Asloum. OrthopTraumatol Surg Res, 2013 Prospective, randomized comparative study, plating vs nailing 32 plates, 28 nails, f/u of 1 year Union rate = same, Fewer complications IMN (7% vs 56%) Better functional scores IMN (96 vs 82) Jain. JOT, 2014 Systematic review of IMN fixation of fibular fractures, 17 studies, 1008 pts Excellent union rates (>98%), high patient satisfaction External Fixation Types Circular/Illizarov Multiplane/ Pin to bar Hybrid Indications Open fractures Significant comminution or instability Significant ST edema Temporary fixation for staged approach or definitive fixation? TTC Arthrodesis Jonas. Injury, 2013 Looked at functional outcomes of 31 unstable, osteoporotic ankle fractures treated with TTC fusion via IMN 29/31 patients returned to mobility and all had functional scores comparable to pre injury levels Reserved for Charcot/salvage only? Why not primary? 7

8 Diabetic Protocols Healthy diabetic Grab extra cortices Low threshold for syndesmotic fixation Increased immobilization Neuropathic diabetic Delayed repair/neglected Fibula Pro Tibia Salvage ORIF Locking plate fixation Consider sandwich plating Low threshold for fusion Ex fix has a role Post operative Management 2x 3x immobilization period Long term.crow, AFO, Shoe Modifications Increase padding with casting Monitor contralateral limb Protect the posterior heel!!! Metabolic control Frequent cast changes Bone growth stimulators Early recognition of complications 8

9 Take Home Points Thank You 9