Does the Removal of Implants Improve Function Following Ankle Open Reduction and Internal Fixation?

Transcription

1 Does the Removal of Implants Improve Function Following Ankle Open Reduction and Internal Fixation? Benjamin R. Williams, MD 1 Dylan L. McCreary, BA 1,2 Michael Chau, MD, PhD 1 Fernando Pena, MD 1,3 Brian P. Cunningham, MD 1,2 Marc F. Swiontkowski, MD 1,3 AOFAS Annual Meeting July University of Minnesota, Department of Orthopaedic Surgery, Minneapolis, MN 2 Regions Hospital, Department of Orthopaedic Surgery, St. Paul, MN 3 TRIA Orthopaedic Center, Minneapolis, MN

2 The authors have no financial conflicts to disclose relevant to this presentation

3 Background Removal of orthopaedic implants following fracture healing is one of the most common orthopaedic procedures Rates of implant removal between 5% and 16% Complications reported to be as high a 10% Despite the high rates of removal, there is no consensus or guideline for implant removal following uneventful fracture healing Several retrospective studies have shown improvement in pain and satisfaction following implant removal Prospective outcome studies assessing function following implant removal in the lower extremity are scarce

4 Purpose To evaluate the functional outcomes following the removal of symptomatic ankle implants after open reduction internal fixation of a healed ankle fracture Primary outcome: Short Musculoskeletal Function Assessment (SMFA) dysfunction index change from baseline to 6-month follow-up We hypothesize that removal of implants after a healed ankle fracture will result in improved functional outcomes

5 Methods A prospective implant removal registry between two hospital systems in Minneapolis and St. Paul between May 2013 and August 2016 Patients completed the SMFA at baseline and at 6 month f/u after implant removal Inclusion criteria: skeletal maturity, closed ankle fracture, symptomatic ankle implants Exclusion criteria: nonunion, infection or complex regional pain syndrome from initial surgery, other lower extremity surgery performed during the study period Regression analysis: evaluated the effects of age, sex, BMI, smoking status, number of comorbidities, and Lauge-Hansen and AO/OTA fracture classification on outcomes

6 Patient Demographics 43 patients (31 females, 12 males) Mean age 49.9 years (range, 19 to 83) Mean time from initial surgery to implant removal: 37 ± 46 months (range, 2.2 to 209) Time from baseline to SMFA completed: 5.7 ± 0.5 months (range, 5.1 to 7.4) following removal BMI 26.5 (range, 18.8 to 34.6) Workers Compensation 4/43 (9.3%) Current Smokers 5/43 (11.3%) Diabetes 3/43 (7.0%)

7 Results Lauge-Hansen fracture classification: supination-external rotation: 23 (53%) pronation-external rotation 6 (14%) pronation-abduction 2 (4.7%) supination-adduction 1 (2.3%) AO/OTA 44-A: 3 (6.9%) 44-B: 18 (41.4%) 44-C: 11 (25.3%) Pilons - 11 fractures (26%) 43-B: 6 (13.8%) 43-C: 5 (11.5%)

8 SMFA Results Significant improved in SMFA dysfunction index from baseline to follow-up (p = 0.002) Pre-operative: ± 9.8 (range, 0 to 41.4) Follow-up: 9.0 ± 9.3 (range, 0 to 31.1) Significant improvement was seen in the secondary outcomes of bother index (p = 0.003) Pre-operative: 16.0 ± 12.7 (range, 0 to 47.9) Follow-up: 11.3 ± 12.7 (range, 0 to 45.8) And daily activities domain (p = 0.006) Pre-operative: 12.0 ± 10.8 (range, 0 to 45.0) Follow-up: 8.0 ± 10.7 (range, 0 to 37.5)

9 Results Regression analysis revealed a significant improvement in the bother index, post-implant removal, correlating with: Female gender (p = 0.01) Decreasing number of comorbidities (p = 0.03) Complications: 1 intra-operative stripped screw requiring hollow over reaming

10 Conclusion Patients who have undergone ORIF of an ankle fracture have a significant improvement in function following the removal of symptomatic ankle implants Appears to be value in removing ankle implants in patients who report discomfort during their daily functions Low intra-operative complication rate Further investigation into the specific indications for implant removal and the impact of injury and fracture pattern on outcomes is warranted

11 Literature Williams et al, 2012: assessed a heterogeneous population of 69 foot and ankle implant removals at 6 weeks Short-form McGill Pain Questionnaire Showed a significant improvement in pain following implant removal Reith, et al., 2015: retrospectively surveyed 70 ankle implant removal patients 332 patients upper and lower extremities 53% reported less pain and 55% better function Low complication rate in other studies as well Williams, et al., 2012, 2/69 superficial infections Minkowitz, et al., 2007, 0/60 Boyle, et al., 2014, 0/51 Gyuricza, et al., 2011, 2/28, broken implants

12 Small sample size No long-term follow-up Limitations Did not capture all patients who presented for ankle implant removal Not compared to a control group Those who did not have an implant removed likely did not have similar pain Selection criteria was a painful implant, did not select patients with other reasons for implant removal such as decreased range of motion

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