3.17 Ankle
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1 Introduction
Ankle fractures (AFs) in older adults are among the most common injuries and present trauma surgeons with multiple unique problems:
Ankle fractures in older adults are a predictor of osteoporotic fractures [1] but can also be the result of osteoporosis treatment with bisphosphonates [2].
Geriatric patients more often present with unstable fractures, predominantly pronation-abduction stage III, supination-external rotation stage IV, and pronation-external rotation stage IV [3]. These severe injuries are often accompanied by articular cartilage damage, influencing functional outcome [4].
Ankle fractures have an increased risk of complications after surgery [5–7]. Patients with diabetes, peripheral vascular disease, type C fractures, tobacco use, and those who reside in nursing homes have increased risk for wound infections (up to 4%), resulting in reduced functional recovery [8, 9]. Poor soft-tissue conditions require delicate handling.
Obesity is common in older adults. Although it has been suggested that a larger soft-tissue envelope might protect against wound-healing complications in obese patients with open AFs, it has never been shown, and instead a trend towards increased complications exists. There is no literature support for a unique treatment approach in obese patients with AFs [10].
Osteoporosis is commonly present in the aged population. Bone mass, quality, and bone mineral density of the cortical layer are the main factors, which affect the purchase of screws in bone [11]. Poor bone quality is vulnerable during fracture reduction, drilling, and screw insertion.
2 Epidemiology and etiology
The incidence of AF is anticipated to increase over the next 20 years, especially in women. The incidence of AFs in patients older than 60 years in 2000 was 1,545 per 100,000 people per year and is expected to increase by 319% in 2030 [12, 13]. The majority of patients continue to have symptoms and functional limitations one year after the injury [14, 15]. Octogenarians are at a high risk for poor functional recovery and loss of autonomy. Additional risk factors for poor functional outcomes include inadequate surgical reduction, two or more comorbidities, and female gender [16].
3 Open ankle fractures
Open AFs in geriatric patients are associated with high morbidity and increased mortality [17]. These injuries usually result from low-energy trauma, whereas in young patients open fractures are often the result of high-energy trauma. This difference might explain why older patients have surprisingly fewer wound complications in open fractures than young patients [18]. Although the medial and lateral malleoli lie subcutaneously, most wound problems are seen at the medial side of the ankle because the foot almost invariably dislocates laterally. This holds true for open as well as closed AFs ( Case 1: Fig 3.17-1 ).
CASE 1
Patient
A 71-year-old man fell from his bike and sustained a Gustilo grade 2 medial open bimalleolar type C left ankle fracture dislocation ( Fig 3.17-1a–b ). A few centimeters proximal to the obvious fibular fracture, a second fracture (fissure) was present.
Comorbidities
Morbid obesity (body mass index 45)
Type 2 diabetes mellitus
Peripheral polyneuropathy
Obstructive sleep apnea syndrome
Hypertension
Pulmonary embolism
Ischemic heart disease treated with coronary artery bypass grafting and percutaneous transluminal coronary angioplasty
Treatment and outcome
After reduction, surgery was performed the same day. The medial wound was cleaned and fixed with a tension band technique. The fibula was fixed with two lag screws and a locking compression plate with locking screws ( Fig 3.17-1c–d ). The postoperative x-rays show some angulation of the proximal fibular fissure at the most proximal screw. During surgery, the second fissure was observed with image intensification. No longer plate was inserted, because the patient was planned for nonweight-bearing plaster postoperatively due to the open wound and obesity. The syndesmosis was unstable and fixed with a tricortical screw approximately 6 cm above the joint space. Literature supports a screw lower than 4 cm above the joint; single tricortical screws above 4 cm are associated with poorer results [19]. Two weeks after surgery, the medial wound had healed and 50% weight bearing in a plaster was allowed for another 6 weeks. Complete union was achieved. X-rays show a broken syndesmotic screw ( Fig 3.17-1e ). The medial tension band was removed 9 months after the initial operation, because of pain in that area.
Discussion
Despite severe comorbidities and a severe injury, good functional outcome can be achieved if immediate and aggressive surgery is performed to clean and close the joint and to support the soft tissues. Fibular length is restored using a solid plate, but congruency of the ankle joint is secured with a positioning screw.
4 Emergency treatment
In case of severe medial skin problems in a closed dislocated fracture, prompt reduction of the ankle joint is required to improve perfusion of the medial skin. In such cases, operative fixation of the fibula alone with or without delayed fixation of the medial malleolus must be considered. However, in open fractures, a proper wash out and debridement of the (medial) wound with fracture reduction and fixation to reduce the amount of dead space is indicated, regardless of age ( Case 2: Fig 3.17-2 ).
CASE 2
Patient
A 70-year-old woman sustained a Gustilo grade 2 open ankle fracture with a medial transverse fracture and a lateral multifragmentary injury ( Fig 3.17-2a–b ). The fracture could not be classified according to Lauge-Hansen.
Comorbidities
Severe osteoporosis
Treatment and outcome
Patient was treated with immediate washout of the joint, debridement, and immediate internal fixation. Due to the specific fracture pattern, the medial and posterior malleolus were repaired first with a tension band and lag screw respectively. Finally, the lateral malleolus was fixed. First, anatomical reconstruction of the malleolar/articular piece using 1.8/2.4 mm compression screws, followed by bridging the fibular fracture using a locking distal radial plate (1.8/2.4 mm screws). Despite the posterior malleolar screw, an additional positioning screw was inserted to support the bridging plate ( Fig 3.17-2c–f ). A plaster of Paris cast was placed for 1 week to facilitate soft-tissue healing. Partial weight bearing began after soft-tissue healing was uneventful. X-rays were made after 5 weeks ( Fig 3.17-2g–h ) and 5 months ( Fig 3.17-2i–l ).
Discussion
Uneventful healing and functional recovery. The patient has full range of motion and walks without pain. Implant removal after 6 months was necessary due to local plate irritation.
5 Diagnostics
5.1 Clinical evaluation
History and physical examination are the first diagnostic steps in clinical evaluation. However, the reliability of typical clinical signs and symptoms in older adults can be reduced due to physical and cognitive comorbidities, polypharmacy, or other factors. Hematoma formation can be more extensive due to anticoagulant use, but on the other hand, the discriminative power of pain can be reduced due to peripheral neuropathy (eg, in diabetes), use of analgesics, or cognitive impairment. Especially in older adults, one must realize that tenderness at the medial malleolus might be absent despite injury of the (deep) deltoid ligament fibers. Health status and preinjury functional performance may influence the type of operative treatment but cannot serve as an excuse for suboptimal operative treatment. The goal of treatment should be to restore the patient back to the same level of mobility and independence. Treatment of older frail patients with AFs is often challenging and time-consuming but important work ( Case 3: Fig 3.17-3 ).
CASE 3
Patient
An 88-year-old woman fell while standing up from her chair. She sustained a fracture dislocation pronation-abduction stage III injury, which was treated immediately with surgery ( Fig 3.17-3a–b ). Both ankles were significantly swollen due to peripheral edema.
Comorbidities
Hypertension
Polyneuropathy
Atrial fibrillation
Benign paroxysmal positional vertigo
Slowly growing meningioma
Treatment and outcome
The lateral malleolus was fixed with an 8-hole locking compression plate. Due to the multifragmentary zone, adequate fibular length could only be estimated. The medial malleolus was fixed with two K-wires ( Fig 3.17-3c–d ). The treating surgeon reported very poor bone quality during surgery. A plaster cast was applied to facilitate wound healing. Within 1 month, all hardware was removed because of an infection, and an external fixator was placed ( Fig 3.17-3e ). One week later, vascular reconstruction was unsuccessful. Plastic surgery was consulted. Despite intensive wound care and antibiotics, union could not be achieved. Both medial ( Fig 3.17-3f ) and lateral ( Fig 3.17-3g ) fractures were visible through open infected wounds with pus, and a below-knee amputation was performed 6 weeks after injury. The patient died 6 months later.
Discussion
In these multimorbid patients, perfect anatomical bony reconstruction is not the treatment goal. Complications often result in a horrible scenario. The treatment goal is to prevent complications like these above. Initial definitive external fixation, even with a ring fixator, and better diagnostics of the vascular status could have avoided the catastrophic outcome.
5.2 Imaging
Clinical signs that justify radiographic investigations are summarized in the Ottawa ankle rules [20]: if the patient has pain or tenderness over the posterior 6 cm or tip of the medial or lateral malleolus, pain or tenderness over the navicular bone or base of the fifth metatarsal, or is unable to take four steps, an x-ray of the painful area is indicated. Because of the reduced reliability of physician exam findings, plain x-rays should be performed liberally and consist of AP, lateral, and mortise views. Mortise views with the ankle in 15–20° internal rotation are important to judge tibiotalar congruity [21, 22].
5.3 Stress views
Stress x-rays are often considered in light of the difficulty in identifying instability in nonstress x-rays [23]. Cadaver studies have shown that dorsiflexion combined with external rotation are the best stress position to detect medial ligament rupture [24]. A medial clear space of more than 5 mm probably reflects a rupture of the deep deltoid ligament fibers best. It must be noted that medial tenderness is not always accompanied with a deltoid ligament rupture leading to medial clear space widening in ankle stress x-rays [25]. Alternatively, gravity stress views can be used [26].
5.4 Computed tomography and magnetic resonance imaging
The deep fibers of the deltoid ligament are the key structures that prevent lateral dislocation and external rotation of the talus [27, 28]. The problem with ankle injuries is the “invisible medial injury” of the deltoid ligament. The short and less elastic fibers can be ruptured, resulting in external rotation or lateral dislocation of the talus, whereas the longer, superficial ligaments are not. There is no literature that justifies the acceptance of more (medial) joint space widening in osteoporotic AFs than in the highly active young patient.
Several diagnostic findings and tools to investigate the integrity of the deltoid ligament have been studied (eg, presence of a hematoma, external rotation, or gravity stress x-rays, medial clear space widening, ultrasound examination, arthroscopic examination, and magnetic resonance imaging [MRI]). None of these tools has been proven reliable enough to be adopted as an accepted best practice [29].
Magnetic resonance imaging seems to be the best diagnostic test to diagnose rupture of the deep [30] and anterior [31] deltoid ligament fibers. Its sensitivity is estimated 80% and specificity 100% compared to operative exploration. Magnetic resonance imaging can diagnose syndesmotic injury as predicted with the Lauge-Hansen classification [32, 33]. Radiographic images can be used for a rough estimate of the size of the posterior fragment, but a computed tomographic (CT) scan is superior in evaluating the type of fracture, extension to the medial malleolus, the degree of impaction, and osteochondral lesions [34, 35]. Preoperative CT scans influence the operative plan in up to 24% [36] and are often helpful prior to posterior malleolar fixation [3]. More frequent use of CT scans may be appropriate in older adults, as osteoporosis results in more atypical fracture patterns.
5.5 Instability and displacement
As noted above, the integrity of both the medial and posterior pillars is important. Bi- and trimalleolar fractures are clearly unstable injuries, visible on plain x-rays. But in isolated lateral malleolar fractures, stability is much more difficult to assess. A lateral shift of the talus of more than 2 mm is considered to reflect an unstable joint and is a widely accepted indication for operative reduction and fixation of the fibular fracture [37]. However, such a cut-off point is a simplification of reality. A lateral talar dislocation of only 1 mm is believed to lead to a substantial reduction of the contact area between talus and tibia [38], which results in excessive peak loads to the joint. Moreover, one must realize that the dislocation as seen on a plain x-ray might not be the maximum dislocation that can occur during weight bearing. Any displacement leads to a certain instability of the ankle joint. The same holds true for associated posterior malleolar fractures. Peak contact stress and instability may lead to secondary loss of cartilage, which in turn increases the risk of posttraumatic arthritis. Scientific proof supporting a statement that “the patient is too old to develop osteoarthritis” does not exist. On the contrary, older adults might be more susceptible to posttraumatic arthritis due to a thinner layer of cartilage. Malalignment and slight joint instability can result in symptomatic osteoarthritis in a relatively short period of time.
Joint stability results from bony joint configuration and ligamentous support. Energy creating a fracture can compromise both joint configuration and ligamentous stability. In theory, more energy leads to more damage, which results in more instability. On the other hand, young and healthy bone is able to absorb more energy than osteoporotic bone without the occurrence of a fracture. The energy that remains after fracturing of the bone determines the extent of soft-tissue injury.
6 Classification
6.1 Lauge-Hansen classification
With experimental studies, Lauge-Hansen classified malleolar fractures according to their injury pattern [33]. Using experimental cadaver studies, Lauge-Hansen offered more insight into the various fracture mechanisms and developed a classification system that is still broadly used today.
The Lauge-Hansen classification has been a matter of debate in the past. Some authors claim a poor correlation between trauma mechanism and MRI or other radiographic findings [39, 40]. Nevertheless, the 17 different stages within the Lauge-Hansen classification describe almost all AFs. The Lauge-Hansen classification describes the trauma mechanism via the position of the ankle and the direction of the injury force. Five categories are described: supination-adduction, supination-external rotation, pronation-abduction, pronation-external rotation, and pronation-dorsiflexion (axial loading). The axial loading injury, better known as the pilon fracture, will not be covered in this chapter. Each mechanism category is further subdivided based on severity ( Table 3.17-1 ). The cla ssification is useful for a grounded and balanced treatment protocol. For instance, the theoretical distinction between the supination-external rotation stages II–III and supination-external rotation stage IV AFs can provide the basis for choosing operative or nonoperative treatment.
6.2 Weber classification
The Weber classification is an anatomical classification that considers the level of the fracture of the fibula ( Table 3.17-2 ) [41]. Unlike the Lauge-Hansen classification, it does not take medial and posterior injury into account, nor does it describe the trauma mechanism. This makes the Weber classification easier to use than the Lauge-Hansen classification, but less descriptive and specific.
7 Decision making
The ultimate goal is to restore pretraumatic functional status. Functional independence for older adults depends strongly on mobility and AFs are a serious threat to long-term mobility and independence. Whereas treatment in a mobile octogenarian living an independent life should almost certainly involve surgery, a similar fracture in a wheelchair- or bed-bound patient can be treated with a plaster cast. Decision making in older adults requires more patient-specific treatments than in younger patients.
7.1 Operative versus nonoperative treatment
In current practice, most Weber A fractures are treated nonoperatively and most Weber C fractures are treated by open anatomical reduction and internal fixation. The remainder (roughly 50%) of all AFs consists of Weber B fractures, which are treated with or without surgery. The Lauge-Hansen and Weber classification systems cannot assess the intrinsic stability of all AFs, which is considered an additional determinant for the type of treatment.
There is some variation in practice over the use of nonoperative measures in AFs; some consider precise anatomical reconstruction essential to prevent posttraumatic osteoarthritis, while others believe nonoperative measures are sufficient. The tendency for operative intervention increases with the number of malleoli fractures, but depending on location, a wide range (14–72%) in the frequency of operative repair has been reported in the US [44].
There is controversy regarding the treatment of frail adults with osteoporosis and comorbidities that increase the risk of operative complications [5]. In 2012, the authors of this chapter published a Cochrane review about operative versus nonoperative treatment for AFs in adults [45], suggesting that there is insufficient high-quality evidence to conclude that operative or nonoperative treatment results in superior long-term outcomes. Only one of the four included studies specifically considered older patients [37]. This study included 36 patients with a mean age of 66 years, randomized to closed reduction or operative treatment. Operatively treated patients had a higher functional outcome score and range of motion after 2 years and a better anatomical reduction. The nonoperative group showed more loss of reduction. However, there was no intention-to-treat analysis where 11 patients did not participate.
Since this Cochrane review, there have been no new randomized controlled trials (RCTs) to inform the management of AFs in geriatric patients. Currently, anatomical reduction and stable internal fixation is recommended, if the soft tissues around the ankle and the patient′s health are not surgical contraindications.
7.2 Stable versus unstable injury
There is no “true” definition for an unstable AF, but we know medial joint space widening is indicative of mortise displacement. Understanding the trauma mechanism according to Lauge-Hansen is essential for adequate treatment [33]. Ankle mortise incongruity is poorly tolerated and leads to abnormal loads on the articular cartilage [38]. The apparent long-term advantage of anatomical restoration relevant for younger patients may not be realized for older adults due to shorter life expectancy. The development of end-stage osteoarthritis can take up to 20 years [46], although some disabling changes can develop within 1 year [47]. There is a tendency towards nonoperative treatment in geriatric patients, even with fracture patterns that would demand operative treatment in younger patients. It is not clear if the time course and outcomes of nonoperative treatment are clearly understood; it is possible that osteoarthritis may develop more quickly in older adults, making exact reduction even more important than in young patients. This dilemma stresses the need for personalized decision making.
Historically, a prolonged period of immobilization and nonweight bearing was advised for osteoporotic fractures. However, deficits in coordination, baseline impaired mobility and reduced arm strength required for the use of crutches increase the risk of falling and often limit nonweight-bearing rehabilitation. Such functional immobilization in older adults can lead to catastrophic complications including pressure sores, sarcopenia, joint stiffness, and permanent loss of function (see chapter 1.8 Postoperative surgical management).
Long-term outcomes may be irrelevant to patients in the last months to years of life, but even poor short-term outcomes may have a significant negative impact on the lives of older adults. Direct operative stabilization can facilitate enhanced postoperative mobilization and recovery. Most authors agree that standard internal fixation techniques are recommended in patients younger than 80 years [48] and open reduction and internal fixation (ORIF) is superior to closed reduction [49–54], as claimed by Makwena et al [37]. However, chronological age alone should not dictate treatment selection in geriatric patients but should be based on preinjury functional status and comorbidity. From a mechanical point of view, operative fixation of fractures in osteoporotic bone requires a larger contact area between bone and implant. This implies that at least an equal amount of implant contact is needed as in young patients to maintain reduction and fixation. Generally, in operative treatment of AFs in geriatric patients, there is little room for error and a meticulous operative technique is important [55, 56].
8 Therapeutic options
The authors of this chapter performed a systematic search for relevant articles in the Medline and Embase databases from the year 2000, identifying 394 potentially relevant articles that were all screened for possible use in this chapter. This yielded 55 relevant articles, which are referenced throughout this chapter.
8.1 Nonoperative treatment
If the ankle mortise is stable and congruent, unimalleolar fibular fractures in mobile older patients can be best treated nonoperatively. Operatively treated patients show better radiographic alignment but no better functional outcome [57]. The outcomes of a nonoperative approach cannot be determined from a simple x-ray or protocol only. Pain, pretraumatic physical and mental health, local soft-tissue injury, and socioeconomic status of the patient are important additional determinants. The goal of nonoperative treatment is to make life as comfortable as possible during the period of fracture healing. Early weight bearing during this period is preferred. For severe pain, a plaster cast can be an excellent analgesic, but unfortunately can be highly problematic in older adults.
A simple lower leg cast can lead to catastrophic complications related to immobility. Once fracture-related pain and swelling have subsided, a plaster cast should be removed and replaced by a device that provides more comfort and allows weight-bearing mobilization. A high shoe or removable boot can be appropriate [58, 59]. Such a tailored therapy requires intensive follow-up, especially in the early phase. Immobilization should not exceed 4–5 weeks in healthy older adults, although there have been recommendations for longer nonweight bearing for patients with diabetes [60]. However, a recent paper suggested that the number of complications of nonoperative treatment exceeds those after surgery [61].
Nonoperative treatment is also indicated in wheelchair-bound or bedridden patients for both stable and unstable fractures simply because anatomical reduction of the ankle joint and internal fixation will not produce improvement in mobility or function. Although a plaster cast will reduce pain in the group of immobile patients, attention should be paid to local soft-tissue problems in this group, as these patients are often at exceptional risk for the development of pressure sores related to the cast. These patients not only develop outside-in skin problems due to the cast, but also dislocation of the fracture can result in inside-out skin problems, especially at the medial aspect of the ankle. A plaster cast immobilizing both ankle and knee might reduce this risk, but in this particular group minimally invasive surgical stabilization may be a better alternative ( Case 4: Fig 3.17-4 ).
CASE 4
Patient
An 89-year-old woman fell while going to bed in her nursing home after consuming alcohol. Before this fall, she was able to walk with a walker inside the house. The patient used an orthopedic shoe because of preexisting drop foot.
X-rays after reduction ( Fig 3.17-4a–b ) show an atypical fracture configuration. The oblique lateral malleolar fracture fits a supination-external rotation injury (type B fracture), but they usually start anterior at the level of the joint space. This fracture is situated more proximally, suggesting a type C ankle fracture. But a typical type C fracture is horizontal or multifragmentary. The medial malleolar fracture in type B fractures is horizontal, whereas in type C fractures it is vertical. Medially, a small skin abrasion with severe edema was present ( Fig 3.17-4c–d ); sensation was absent due to known neuropathy.
Comorbidities
Multiple myocardial infarctions with cardiac failure and atrial fibrillation
Chronic obstructive pulmonary disease Gold 1
Type 2 diabetes mellitus with peripheral polyneuropathy
Hypertension
Cerebrovascular accident
Left total knee replacement complicated by pulmonary embolism
Right total hip replacement
Cataract surgery of both eyes
Frequent falling
Urinary incontinence
Treatment and outcome
She was scheduled for delayed surgery but developed blisters on the heel, first and second toes, and medial malleolus. Wound healing was delayed because of occlusion of the superficial femoral artery requiring revascularization. Osteosynthesis was therefore cancelled. She left the hospital after 12 days. The fibular fracture healed in malunion before the wounds healed. Seven months after the accident the medial malleolus had developed a nonunion with tibiotalar incongruity ( Fig 3.17-4e–f ). Calcaneotalotibial arthrodesis with a hindfoot nail was considered, but not done because the patient had little pain when mobilizing in orthopedic shoes.
Discussion
An acceptable functional result can be achieved in older patients with severe comorbidities because of reduced functional requirements. In young patients, this fracture configuration would be a clear indication for surgery.
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