不稳定性踝部骨折的手术治疗分析

目的 分析100 例不稳定性踝部骨折的手术治疗方法和疗效.方法 选取2010年8月至2012年11月,对100 例成人不稳定性踝关节骨折切开复位内固定手术组患者进行随访分析.本组入选病例中排除踝部开放性骨折和Pilon骨折.其中男49 例,女51 例;年龄18～81 岁,平均50 岁.按Danis-Weber分型,A型7 例,B型58 例,C型35 例.按Lauge-Hansen分型,旋前-外旋型21 例（Ⅲ度7 例,Ⅳ度14 例）,旋前-外展型Ⅲ度8 例,旋后-外旋型64 例（Ⅲ度9 例,Ⅳ度55 例）,旋后-内收型Ⅱ度7 例.根据美国矫形足踝协会踝与后足评分标准进行功能和疗效评估.结果 随访时间4～26个月,平均14个月,骨折愈合时间12～16周,平均为12.6周.本组评分68～100分,平均88.6分;优（90～100分）37 例,良（80～89分）49 例,一般（70～79分）13 例,小于等于69分为差1 例,优良率为86%.结论 正确手术方案制定和操作是不稳定性踝关节骨折外科手术治疗成功的关键.     

Early Protected Weightbearing After Open Reduction Internal Fixation of Ankle Fractures With Trans-syndesmotic Screws

Traditional postoperative care after open reduction internal fixation (ORIF) of unstable ankle fractures with syndesmotic instability includes non-weightbearing for 6 to 8 weeks. However, prolonged non-weightbearing may be detrimental. The goal of this case series was to assess the outcomes of early protected weightbearing after operative treatment of acute ankle fractures with syndesmotic instability requiring screw stabilization. Fifty-eight consecutive patients, treated from January 2006 to January 2013, met the inclusion criteria with a minimum follow up of 1 year. Electronic medical records and radiographs were reviewed for patient and surgical characteristics, postoperative complications, and maintenance of reduction. Patients initiated walking at an average of 10 days (range 1 to 15) postoperatively. Surgical treatment consisted of operative reduction with standard fixation devices and 1 or 2 trans-syndesmotic screws that purchased 4 cortices. All 58 patients maintained correction after surgery when allowed to weightbear early in the postoperative recovery. Five complications (8.6%) occurred in the 58 patients, which included 3 superficial infections (5.2%) and 2 cases (3.4%) of neuritis. The maintenance of reduction and low complication rate in this study support the option of early protected weightbearing after ankle fracture ORIF with trans-syndesmotic fixation.     

Morbidity and Readmission After Open Reduction and Internal Fixation of Ankle Fractures Are Associated With Preoperative Patient Characteristics

Background

Ankle fractures are common and can be associated with severe morbidity. Risk factors for short-term adverse events and readmission after open reduction and internal fixation (ORIF) of ankle fractures have not been fully characterized.

Questions/purposes

The purpose of our study was to determine patient rates and risk factors for (1) any adverse event; (2) severe adverse events; (3) infectious complications; and (4) readmission after ORIF of ankle fractures.

Methods

Patients who underwent ORIF for ankle fracture from 2005 to 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP^®) database using International Classification of Diseases, 9^th Revision and Current Procedural Terminology codes. Patients with missing perioperative data were excluded from this study. Patient characteristics were tested for association with any adverse event, severe adverse events, infectious complications, and readmission using bivariate and multivariate logistic regression analyses.

Results

Of the 4412 patients identified, 5% had an adverse event. Any adverse event was associated with insulin-dependent diabetes mellitus (IDDM; odds ratio [OR], 2.05; 95% confidence interval [CI], 1.35–3.1; p = 0.001), age ≥ 60 years (OR, 1.97; 95% CI, 1.22–3.2; p = 0.006), American Society of Anesthesiologists classification ≥ 3 (OR, 1.69; 95% CI, 1.2–2.37; p = 0.002), bimalleolar fracture (OR, 1.6; 95% CI, 1.08–2.37; p = 0.020), hypertension (OR, 1.47; 95% CI, 1.04–2.09; p = 0.031), and dependent functional status (OR, 1.47; 95% CI, 1.02–2.14; p = 0.040) on multivariate analysis. Severe adverse events occurred in 3.56% and were associated with ASA classification ≥ 3 (OR, 2.01; p = 0.001), pulmonary disease (OR, 1.9; p = 0.004), dependent functional status (OR, 1.8; p = 0.005), and hypertension (OR, 1.65; p = 0.021). Infectious complications occurred in 1.75% and were associated with IDDM (OR, 3.51; p < 0.001), dependent functional status (OR, 2.4; p = 0.002), age ≥ 60 years (OR, 2.28; p = 0.028), and bimalleolar fracture (OR, 2.19; p = 0.030). Readmission occurred in 3.17% and was associated with ASA classification ≥ 3 (OR, 2.01; p = 0.017).

Conclusions

IDDM was associated with an increased rate of adverse events after ankle fracture ORIF, whereas noninsulin-dependent diabetes mellitus was not. IDDM management deserves future study, particularly with respect to glycemic control, a potential confounder that could not be assessed with the ACS-NSQIP registry. Increased ASA class was associated with readmission, and future prospective investigations should evaluate the effectiveness of increasing the discharge threshold, discharging to extended-care facilities, and/or home nursing evaluations in this at-risk population.

Level of Evidence

Level III, prognostic study.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-014-4005-z) contains supplementary material, which is available to authorized users.     

Risk Factors for Short-Term Complication After Open Reduction and Internal Fixation of Ankle Fractures: Analysis of a Large Insurance Claims Database

Although fractures of the ankle are common injuries treated by surgical podiatrists and orthopaedic surgeons specializing in foot and ankle surgery, postoperative complications can occur, often imposing an economic burden on the patient. As health care in the United States moves toward value-based care, cost reduction has primarily focused on reducing complications and unplanned episodes of care. We used a large modern database of insurance claims to examine patterns of complications after open reduction internal fixation of ankle fractures, identifying diabetes mellitus and history of myocardial infarction as risk factors for postoperative infection within 30 days of surgery. Lateral malleolar repair was less likely to lead to infection, or need for repeated surgery, than was medial malleolar fracture repair. Diabetes mellitus, neuropathy, and chronic obstructive pulmonary disease were associated with development of postoperative cellulitis. Patients with a history of cerebrovascular accident were more likely to return to the emergency department or to have a pulmonary embolism. Male sex, presence of lupus, and increased age were associated with repeat surgery.     

Effect of Obesity on Total Ankle Arthroplasty: A Systematic Review of Postoperative Complications Requiring Surgical Revision

Total ankle arthroplasty has become an increasingly used alternative to ankle arthrodesis for the treatment of end-stage ankle arthritis. However, despite progressive technological advances and the advent of multiple commercial implant systems, some concern remains for the relatively high complication and failure rates. The objective of the present investigation was to perform a systematic review of the incidence of complications in obese patients undergoing total ankle arthroplasty. We performed a review of electronic databases with the inclusion criteria of retrospective case series, retrospective clinical cohort analyses, and prospective clinical trials with ≥15 total participants, a mean follow-up period of ≥12 months, ≥1 defined cohort with a body mass index of ≥30?kg/m², and a reported incidence rate of complications requiring revisional surgery at the final follow-up point. Four studies met our inclusion criteria, with a total of 400 implants analyzed. Of these, ≥71 (17.8%) developed a complication requiring a revisional surgical procedure. The most commonly reported surgeries were revision of the metallic components and ankle gutter debridement. It is our hope that our investigation will allow foot and ankle surgeons to more effectively communicate the perioperative risk to their patients during the education and consent process.     

2种内固定方法治疗98例踝关节骨折的疗效比较

目的比较闭合复位经皮空心螺钉内固定与传统切开复位内固定治疗踝关节骨折的疗效。方法 2004年3月～2009年8月收治的98例非粉碎型内外踝双骨折根据内固定方法不同分为闭合复位经皮空心螺钉内固定(闭合复位组)和传统切开复位内固定(切开复位组),比较2组患者的手术时间、术中出血量、骨折愈合时间、骨折愈合后外踝有无疼痛及术后1年AOFAS足踝评分。结果闭合复位组术中出血量、术后切口感染发生率及骨折愈合后外踝出现疼痛发生率明显优于切开复位组(P<0.05)。闭合复位组51例术后随访16～81个月,平均29.7月,骨折全部愈合;切开复位组42例随访17～80个月,平均28.3月,4例出现切口红肿、皮缘坏死,经换药后切口愈合,无深部感染发生,1例出现骨折不愈合。结论与传统切开复位内固定比较,闭合复位经皮空心螺钉内固定治疗踝关节骨折具有出血少、术后切口并发症发生率低、骨折愈合后外踝疼痛发生率低的优点,并能获得与切开复位内固定等同的踝关节功能。     

跟骨骨折切开复位内固定术后疗效及切口并发症分析

目的探讨跟骨关节内骨折切开复位钢板内固定手术治疗的疗效及早期手术切口的并发症。方法采用跟骨外侧延长"L"形切口入路对50例57足跟骨关节内骨折进行切开复位钢板内固定治疗。按Essex-Lopresti进行骨折分类,舌型骨折30足,关节压缩型骨折27足。根据手术前后X线片对跟骨高度、宽度、长度及跟骨B hler角和Gissane角进行评估,并观察术后切口愈合情况。采用Maryland足评分系统评价临床功能疗效。结果所有患者术后获得5～36个月(平均18个月)随访,X线片显示术后跟骨高度、宽度、长度及跟骨B hler角和Gissane角均获得满意恢复,Maryland足部评分系统显示优31足,良20足,可6足,优良率89.5%。术后早期出现切口裂开、坏死及感染共10例,占总病例数17.5%。结论采用跟骨外侧延长"L"形入路切开复位钢板内固定是治疗跟骨关节内骨折的有效方法,但术后早期切口并发症仍难以完全避免。     

Resident Involvement Does Not Influence Complication After Total Hip Arthroplasty: An Analysis of 13,109 Cases

Our study aimed to determine the impact of resident involvement on the 30-day postoperative complication rates following primary total hip arthroplasty (THA). Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, 13,109 primary THAs were identified, of which 3462 (26.4%) had resident involvement. Neither univariate (4.45% vs 4.52%, P = 0.86) nor multivariate (OR 1.04, P = 0.75) analyses demonstrated an increased complication rate with resident involvement following THA. We did find, however, that increased operative time, comorbidities, age, obesity, prior history of stroke and/or cardiac surgery were all independent risk factors for short-term complication. Our findings suggest that resident involvement does not increase 30-day complication rates following primary THA.     

Comparative Analysis of Short-Term Postoperative Complications in Outpatient Versus Inpatient Total Ankle Arthroplasty: A Database Study

Ankle arthritis is a potentially debilitating disease, with approximately 50,000 cases diagnosed annually. One treatment option for these patients is total ankle arthroplasty (TAA). This procedure has historically been performed in the inpatient setting with a 1–2-night postoperative hospital stay. Outpatient surgeries are gaining popularity due to their cost effectiveness, decreased length of hospital stay, and convenience. Therefore it is important to evaluate the safety of specific procedures in the outpatient setting compared with the inpatient setting. This study evaluated the complication rates in inpatient versus outpatient TAA. It analyzed data from the National Surgical Quality Improvement Program for 591 patients who received TAA. Postoperative complication rates were compared between 66 outpatients and 535 inpatients. Frequencies of the following complications were analyzed: wound complications, pneumonia, hematologic complications (pulmonary embolism and deep vein thrombosis), renal failure, stroke, and return to the operating room within 30 days. Unadjusted direct comparisons of the cohorts revealed higher complication rates in the inpatient cohort. Inpatients had higher rates of superficial surgical site infections, deep surgical site infections, number of organ/space surgical site infections, pneumonia occurrences, and return to the operating room, but these differences were not significant. These results showed no significant increase in complication rates in outpatients compared to inpatients. Our results suggest that inpatient and outpatient TAA show similar complication rates. This suggests that outpatient TAA is safe and may be a superior option for certain populations. Further investigation is warranted to verify these conclusions.     

Patient-Related Risk Factors for Periprosthetic Ankle Joint Infection: An Analysis of 6977 Total Ankle Arthroplasties

Periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a devastating complication that often results in explantation to resolve the infection. The purpose of the present investigation was to determine the patient-related risk factors for PJI after TAA. A national insurance database was queried for patients undergoing TAA using the Current Procedural Terminology and International Classification of Diseases, ninth revision, procedure codes from 2005 to 2012. Patients undergoing TAA with concomitant fusion procedures or more complex forefoot procedures were excluded. PJI within 6 months was then assessed using the International Classification of Diseases, ninth revision, codes for diagnosis or treatment of postoperative PJI. Multivariate binomial logistic regression analysis was performed to evaluate the patient-related risk factors for PJI. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each risk factor, with p?<?.05 considered statistically significant. A total of 6977 patients were included in the present study. Of these 6977 patients, 294 (4%) had a diagnosis of, or had undergone a procedure for, PJI. The independent risk factors for PJI included age <65 years (OR 1.44; p?=?.036), body mass index <19?kg/m² (OR 3.35; p?=?.013), body mass index >30?kg/m² (OR 1.49; p?=?.034), tobacco use (OR 1.59; p?=?.002), diabetes mellitus (OR 1.36; p?=?.017), inflammatory arthritis (OR 2.38; p?<?.0001), peripheral vascular disease (OR 1.64; p?<?.0001), chronic lung disease (OR 1.37; p?=?.022), and hypothyroidism (OR 1.32; p?=?.022). The independent patient-related risk factors identified in the present study should help guide physicians and patients considering elective TAA and develop risk stratification algorithms that could decrease the risk of deep, postoperative infection.     

Complications,Reoperations, and Long-Term Outcomes after Open Reduction Internal Fixation of Mason Classification Type II and Type III Radial Head Fractures

Introduction  The objectives of this study were to assess long-term outcomes, complications, and reoperations after open reduction internal fixation (ORIF) of radial head fractures. Materials and Methods  35 adult patients, who underwent ORIF of an isolated, displaced radial head fracture without elbow instability (Mason classification type II or III) at two tertiary care referral centers from 2000 to 2017, were identified. Patient satisfaction, pain, and QuickDASH scores were assessed by telephone follow-up at median 12.9 years. Results  The mean age of the 35 patients in our study was 39 years, and 54% were women. The median length of clinical follow-up was 175 days. Postoperative complications occurred in 54% of patients, and reoperations in 23% of patients. Multivariable logistic regression identified fixation with plate and screws versus screws alone as a risk factor for complications and reoperations. The long-term telephone follow-up response rate was 54%. At 13-year median follow-up, the average patient satisfaction was 9.6/10, the average patient-reported pain was 0.7/10, and the average QuickDASH score was 10.5. Conclusion  The long-term outcomes of ORIF of Mason classification type II and III radial head fractures are favorable; however, rates of complication and reoperation are notable and may be higher with plate-and-screw fixation.     

Measuring Recovery After Ankle Fractures: A Systematic Review of the Psychometric Properties of Scoring Systems

Recovery after ankle fractures places a considerable burden on patients both short and long term. Numerous tools called patient-reported outcome measures (PROMs) have been developed to measure the outcome of ankle fractures. They can assist clinicians to measure the effect, guide intervention, and assess the rate of recovery. We identified and evaluated the psychometric properties of PROMs used in the assessment of ankle fractures. In a systematic search, we examined 4 databases from inception to December 4, 2016. Search terms included ankle fracture, ankle pain, disability, gait, questionnaire, and PROMs. Reference lists were also examined. The inclusion criteria were English studies and adult populations. The psychometric properties of the identified PROMs were examined, including internal consistency, test–retest reliability, validity, floor–ceiling effects, and minimally important clinical differences. We identified 22 PROMs relating to ankle pain and disability. Only 5 were specifically used for ankle fractures. The 36-item short-form health survey and short musculoskeletal functional assessment reported floor–ceiling effects, and the lower extremity functional scale reported good responsiveness and content validity, although these are not tools specifically related to ankle fractures. The ankle-fracture outcome of rehabilitation measure (A-FORM) and the Olerud and Molander questionnaire were ankle fracture specific and assessed for internal consistency and validity. Clinicians should use the most appropriate PROM to evaluate patients' recovery from ankle fractures. The A-FORM currently has the most appropriate evidence supporting its use as a PROM for ankle fracture management and rehabilitation.     

切复内固定治疗跟骨关节内骨折疗效观察及分析

目的：观察和分析跟骨关节内骨折早期进行切复内固定的治疗效果。方法：对36例42侧跟骨关节内骨折,经跟骨外侧入路在C形臂X线机监控下行切复内固定术。结果：34例40侧平均随访24个月,按Maryland足部评分系统评估术后功能,优20例,良14侧,可6侧,优良率85％。结论：跟骨关节内骨折经早期手术切复内固定可以取得满意的疗效。     

Cost-Effectiveness Analysis of Primary Arthrodesis Versus Open Reduction Internal Fixation for Primarily Ligamentous Lisfranc Injuries

The purpose of the present study was to determine whether surgical intervention with open reduction internal fixation (ORIF) or primary arthrodesis (PA) for Lisfranc injuries is more cost effective. We conducted a formal cost-effectiveness analysis using a Markov model and decision tree to explore the healthcare costs and health outcomes associated with a scenario of ORIF versus PA for 45 years postoperatively. The outcomes assessed included long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. The costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2017 price base. ORIF was always associated with greater costs compared with PA and was less effective in the long term. When calculating the cost required to gain 1 additional QALY, the PA group cost $1429/QALY and the ORIF group cost $3958/QALY. The group undergoing PA overall spent, on average, $43,192 less than the ORIF group, and PA was overall a more effective technique. Strong dominance compared with ORIF was demonstrated in multiple scenarios, and the model's conclusions were unchanged in the sensitivity analysis even after varying the key assumptions. ORIF failed to show functional or financial benefits. In conclusion, from a healthcare system's standpoint, PA would clearly be the preferred treatment strategy for predominantly ligamentous Lisfranc injuries and dislocations.     

Effect on Hospital Length of Stay of Tourniquet Use During Internal Fixation of Ankle Fractures: Randomized Controlled Trial

Approximately 50% of ankle fractures require internal fixation. A tourniquet is often used to create a bloodless operative field, but its effect on hospital length of stay (LOS) is unclear. This article reports a parallel-group observer-blinded randomized trial of the effect of tourniquet use on LOS. One hundred eighty-eight adult patients requiring internal fixation of ankle fracture were randomized to surgery with or without a tourniquet. LOS was analyzed on intention-to-treat principles using Poisson regression. As a secondary outcome, duration of operation was analyzed by analysis of covariance. Mean LOS was 1.79 ± 1.50 days in the tourniquet group and 1.65 ± 1.11 days in the no-tourniquet group. The covariate-adjusted rate ratio for LOS (reference group: no tourniquet) was 1.084 (95% confidence interval 0.871, 1.348; p?=?.470). Sensitivity analyses (unadjusted intention-to-treat analysis and as-treated analysis) gave similar nonsignificant results. The covariate-adjusted mean difference in duration of operation was 3.03 minutes (95% confidence interval –4.96, 11.02; p?=?.455), favoring the tourniquet group; sensitivity analyses again gave similar results. Adverse events did not differ significantly between groups. In conclusion, the use of a tourniquet during internal fixation does not significantly influence hospital LOS, of which preinjury medical condition of the patient appears to be the most important determinant.