The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Are Low-Energy Open Ankle Fractures in the Elderly the New Geriatric Hip Fracture? William P. Toole, MD, Mark Elliott, MD, David Hankins, MD, Corey Rosenbaum, DO, Anthony Harris, MD, Christopher Perkins, MD Department of Orthopaedic Surgery and Rehabilitation, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
As the geriatric population in the United States continues to increase, ankle fractures in the elderly are predicted to exponentially increase in the future. As such, these injuries will become a common injury seen by physicians in various fields. Currently, no studies discussing low-energy open ankle fractures in the elderly and/or the mortality rate associated with these devastating injuries have been published. The purpose of the present study was to retrospectively review the morality rate associated with low-energy open ankle fractures in the elderly. We retrospectively identified 11 patients >60 years old who had sustained low-energy open ankle fractures and been treated at our institution. The patient demographics, mechanism of injury, wound size, medical comorbidities, treatment, follow-up data, and outcomes were recorded. Low-energy falls were defined as ground level falls from sitting or standing. The mean age of the patients was 70.72 years, with a mean body mass index of 35.93 10.24. Of the 11 patients, 9 (81.81%) had 3 comorbidities (ie, hypertension, diabetes, coronary artery disease, congestive heart failure, and/or chronic obstructive pulmonary disease). The mean size of the medially based ankle wound was 14.18 4.12 cm; 10 (90.90%) were Gustilo and Anderson grade IIIA open ankle fractures. In our study, low-energy open ankle fractures in the elderly, very similar to hip fractures, were associated with a high mortality incidence (27.27%) at a mean of 2.67 2.02 months, and 81.81% of our patients had 3 medical comorbidities. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: geriatric insufficiency fracture morbidity and mortality open fracture
Ankle fractures are a common injury within the elderly population. Low-energy ankle fractures in the elderly have been increasing in incidence, with nearly 3 times more low-energy ankle fractures estimated to occur in 2030 (1). As the US elderly population continues to increase, low-energy ankle fractures are becoming an “epidemic” (2). Currently, a paucity of published data is available on the mortality associated with low-energy open ankle fractures in the elderly population. The purpose of the present study was to review the low-energy open ankle fractures that occurred in patients >60 years old at our level 1 trauma center. Several studies have shown that geriatric hip fractures are associated with overall poor health status and increased mortality rates. We believe that elderly patients with overall poor health status can sustain low-energy open ankle fractures and, as a result, experience high morbidity and mortality.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: William P. Toole, MD, Department of Orthopaedic Surgery and Rehabilitation, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, ACC Building, 2nd Floor, Jacksonville, FL 32209. E-mail address: [email protected]fl.edu (W.P. Toole).
Patients and Methods After obtaining institutional review board approval, we retrospectively identified 11 patients >60 years old who had sustained low-energy open ankle fractures treated at our level 1 trauma center from January 2004 to March 2014. A search of our trauma database using the ankle fracture “International Classification of Disease, 9th revision” codes (824.0, 824.2, 824.4, 824.6, and 824.8) yielded 685 consecutive ankle fractures. Furthermore, using the codes 824.1, 824.3, 824.5, 824.7, and 824.9, 102 open ankle fractures (14.89%) were identified. Of these 102 open ankle fractures, 11 (10.78%) had occurred in patients >60 years old and were secondary to a low-energy mechanism. Low-energy falls were defined as ground level falls from sitting or standing. Open ankle fractures resulting from high-energy mechanisms such as motor vehicle accidents, motorcycle accidents, or falls from heights were excluded. All 11 patients (100%) were treated by 2 orthopedic traumatologists (A.H. and C.P.) at our institution. The data were obtained from the electronic medical records for all 11 open ankle fractures using a defined protocol that included the history and physical examination, radiographic studies, operative notes, and clinic followup visits. The patient demographics, AO/Orthopaedic Trauma
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.10.015
Yes No 23.85 10, Medial ankle wound IIIA 44-B2.2 Male 63 11
Bimalleolar
No Yes No No No Yes Yes Yes Yes Yes 50.02 22.48 NA NA NA IIIA IIIA II IIIA IIIA 15, Medial ankle wound 14, Medial ankle wound 8, Medial ankle wound 15, Medial ankle wound 12, Medial ankle wound 44-C2.3 44-A2.3 44-B3.1 44-B3.2 44-B3.1 Female Male Female Female Female 82 63 65 84 85 6 7 8 9 10
Trimalleolar Bimalleolar Bimalleolar Trimalleolar Bimalleolar
No No 34.3 10, Medial ankle wound IIIA 44-B2.3 61 5
Male
61 4
Bimalleolar
No Yes 45.3 18, Medial ankle wound IIIA
Yes Yes 39.63 22, Medial ankle wound IIIA 78 3
Female Trimalleolar 44-B3.2
No Yes 35.94 18, Medial ankle wound IIIA 44-B2.2 Female Bimalleolar 73 2
Female Lateral 63 1
Abbreviations: BMI, body mass index; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; GERD, gastroesophageal reflux disease; HTN, hypertension; NA, not applicable; OTA, Orthopaedic Trauma Association; PCI, percutaneous coronary intervention; RA, rheumatoid arthritis.
3 mo
3 mo 8 mo 6 mo Lost to follow-up 9 mo
None
6 mo
4 mo
Pin site infection, calcaneus pin Yes (4.5 mo Hepatitis C, CABG, CAD, loosening, loss of reduction after injury) hypothyroidism, esophageal varices Asthma, CAD, GERD, HTN, COPD Placement in skilled No nursing facility Atrial fibrillation, COPD, HTN None Yes (18 d after injury) Ankle stiffness, equinus Yes (3 mo after CABG, CAD, HTN, COPD, hypothyroidism contracture injury) Hepatitis C, HTN, GERD Pin site infection, wound No complications, osteomyelitis COPD, CHF, CAD, PCI, RA None No HTN, COPD, Parkinson’s disease Wound complications No HTN, peripheral neuropathy Symptomatic hardware No CABG, CAD, HTN, CHF Unknown Unknown No CHF, chronic kidney disease Pin site infection, calcaneus pin loosening, wound complications COPD Wound complications (required No pedicled fasciocutaneous flap for coverage) No Yes NA 14, Medial ankle wound IIIA
Complications BMI Diabetes Smoking Medical Comorbidities (kg/m2) Gustilo Class OTA Wound Size (cm), Classification Description Age Gender Fracture (y)
According to the Centers for Disease Control, the US elderly population will nearly double to approximately 72 million by 2030. As such, nearly 1 in 5 Americans will be aged 65 years. The “graying” of the US population has been predicted to increase Medicare spending from $555 billion in 2011 to $905 billion in 2020 (3). Ankle fractures are a relatively common injury within the elderly population. In Finland, the total number of closed low-energy ankle fractures in patients >60 years old increased 319% from 1970 to 2000 (from 369 to 1545). If this trend continues, the incidence of closed low-energy ankle fractures in 2030 will be about 3 times greater (1). In the United States, ankle fractures have been reported to occur in as many as 8.3 per 1000 Medicare recipients (4). An abundance of published studies have discussed open fractures resulting from high-energy trauma. In 2012, a retrospective review of open fractures performed by Court-Brown et al (5) highlighted the importance and overall high incidence of open fractures in the elderly
Patient No.
Discussion
Table Patient demographics, injury description, fracture classification, complications, and mortality
A total of 11 open ankle fractures in 11 patients >60 years old as a result of a low-energy fall during the 10-year study period met the inclusion criteria. Of the 11 patients, 3 (27.27%) were male and 8 (72.72%) were female. The mean patient age was 70.72 9.83 years. The mean body mass index was 35.93 10.24 kg/m2. One of the ankle fractures (9.09%) was an isolated lateral malleolus fracture (AO-OTA 44-B1.2). Six (54.54%) were bimalleolar (AO-OTA 44-A2.3 in 1, 44-B2.2 in 2, 44-B2.3 in 1, and 44-B3.1 in 2). Four (36.36%) were trimalleolar (AO-OTA 44-B3.2 in 2 and 44-C2.3 in 2; Fig. 1). The mean size of the medially based ankle wound (Fig. 2) was 14.18 4.12 cm. Ten patients (90.90%) had Gustilo and Anderson grade IIIA wounds, and one (9.09%) had a Gustilo and Anderson grade II wound. All patients received prophylactic intravenous antibiotics and were initially treated with thorough debridement and irrigation, followed by application of a uniplanar external fixator (Fig. 3). Of the 11 patients, 2 (18.18%) were treated definitively with external fixation and 9 (81.81%) underwent open reduction internal fixation when the soft tissues allowed (Fig. 4). Three patients (27.27%) were smokers. Eight patients (72.72%) had diabetes. Nine patients (81.81%) had hypertension requiring 1 antihypertensive medications. Five patients (45.45%) had coronary artery disease, four (80%) of whom had undergone coronary artery bypass grafting or stent placement. Six patients (54.54%) had chronic obstructive pulmonary disease requiring maintenance medications or home oxygen therapy. Three patients (27.27%) had congestive heart failure. Finally, 9 patients (81.81%) had 3 of these comorbidities (ie, diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, obesity, and/or congestive heart failure). Three patients (27.27%) included in the present study died. The mean interval from injury to death was 2.67 2.02 months. The mean follow-up duration for the remaining 8 living patients was 10.14 11.63 months. One patient (9.09%) was lost to follow-up after the index procedure (debridement and irrigation, uniplanar external fixator). Of these 8 patients, 6 (75%) continued to require an assistive device with ambulation at the last follow-up visit, and all patients reported significant pain and a lack of ankle range of motion.
Mortality
Results
44-B1.2
Follow-Up Duration
Association (OTA) fracture classification, wound description, body mass index, medical comorbidities, follow-up data, and outcomes were recorded (Table).
1 mo (died at outside hospital) 3y
W.P. Toole et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Female Trimalleolar 44-C2.3
2
W.P. Toole et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
3
Fig. 1. (A) Anteroposterior and (B) lateral radiographs demonstrating AO 44-B3.2 ankle fracture dislocation with medial soft tissue injury.
Fig. 2. Clinical photograph demonstrating medially based ankle wound.
population. In that study, patients aged 65 years accounted for 20.3% of all open fractures and females aged 80 years accounted for 20.8% of all open ankle fractures (5). Although that study highlighted the overall high incidence, the paucity of published data addressing the epidemiology of low-energy open ankle fractures in the elderly population has continued. White et al (6) in 2003 performed a retrospective review of 14 open ankle fractures in 13 patients with diabetes. The mean age of their patient population was 54 years (range, 29 to 80). Most of these fractures were secondary to high-energy trauma. Of the 14 open ankle fractures, 64% developed wound complications, 36% developed deep infection, 42% ultimately required a below-the-knee amputation, and only 21% achieved bony union without complications. They concluded that open ankle fractures in patients with diabetes are limb-threatening injuries with high amputation and infection rates (6). In our study, the mean patient age was 70.72 9.83 years, 100% of the fractures were due to low-energy trauma, and 72% of the patients had diabetes. Of these 11 patients, 3 (27.27%) had died within 2.67 months, further highlighting the potentially devastating complications associated with low-energy open ankle fractures in the elderly. The main limitation of our study was the small series size, which limited our analysis. Thus, our investigation was solely observational. Our findings suggest that elderly patients who sustain low-energy open ankle fractures will have multiple medical comorbidities and that these fractures result in high mortality. Future studies are needed to better understand these potentially devastating injuries. Ankle fractures are the third most common fracture, after fractures of the hip and wrist, in patients aged >65 years (7). The projected aging of the population should lead to concern regarding a much greater incidence of ankle fractures in the elderly. Several studies have shown the high mortality associated with hip fractures in the elderly
4
W.P. Toole et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Fig. 3. (A) Lateral and (B) anteroposterior radiographs demonstrating alignment after debridement and irrigation and placement of a uniplanar external fixator.
Fig. 4. (A) Anteroposterior and (B) lateral radiographs after staged open treatment.
compared with age-matched controls (9% at 30 days, 19% at 90 days, and 30% at 12 months) (7). In our study, low-energy open ankle fractures were associated with a 27.27% incidence of death at a mean of 2.67 2.02 months. Thus, physicians encountering this injury should view it in much the same light as a hip fracture in the elderly and counsel patients appropriately about the potentially devastating complications and high mortality incidence. References 1. Kannus P, Palvanen M, Niemi S, Parkkari J, Jarvinen M. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future. Bone 31:430–433, 2002.
2. Ehrenfreund T, Haluzan D, Dobric I, Zigman T, Rajacic D, Antoljak T, Davila S. Operative management of unstable ankle fractures in the elderly: our institutional experience. Injury 44(suppl S3):S20–S22, 2013. 3. Centers for Disease Control and Prevention. The State of Aging and Health in America 2013, Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta, GA, 2013. 4. Koval KJ, Lurie J, Zhou W, Sparks MB, Cantu RV, Sporer SM, Weinstein J. Ankle fractures in the elderly what you get depends on where you live and who you see. J Orthop Trauma 19:635–639, 2005. 5. Court-Brown CM, Bugler KE, Clement ND, Duckworth AD, McQueen MM. The epidemiology of open fractures in adults: a 15-year review. Injury 43:891–897, 2012. 6. White CB, Turner NS, Lee GC, Haidukewych GJ. Open ankle fractures in patients with diabetes mellitus. Clin Orthop Relat Res 414:37–44, 2003. 7. Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture, is delay before surgery important? J Bone Joint Surg Am 87:483–489, 2005.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Are Low-Energy Open Ankle Fractures in the Elderly the New Geriatric Hip Fracture? William P. Toole, MD, Mark Elliott, MD, David Hankins, MD, Corey Rosenbaum, DO, Anthony Harris, MD, Christopher Perkins, MD Department of Orthopaedic Surgery and Rehabilitation, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
As the geriatric population in the United States continues to increase, ankle fractures in the elderly are predicted to exponentially increase in the future. As such, these injuries will become a common injury seen by physicians in various fields. Currently, no studies discussing low-energy open ankle fractures in the elderly and/or the mortality rate associated with these devastating injuries have been published. The purpose of the present study was to retrospectively review the morality rate associated with low-energy open ankle fractures in the elderly. We retrospectively identified 11 patients >60 years old who had sustained low-energy open ankle fractures and been treated at our institution. The patient demographics, mechanism of injury, wound size, medical comorbidities, treatment, follow-up data, and outcomes were recorded. Low-energy falls were defined as ground level falls from sitting or standing. The mean age of the patients was 70.72 years, with a mean body mass index of 35.93 10.24. Of the 11 patients, 9 (81.81%) had 3 comorbidities (ie, hypertension, diabetes, coronary artery disease, congestive heart failure, and/or chronic obstructive pulmonary disease). The mean size of the medially based ankle wound was 14.18 4.12 cm; 10 (90.90%) were Gustilo and Anderson grade IIIA open ankle fractures. In our study, low-energy open ankle fractures in the elderly, very similar to hip fractures, were associated with a high mortality incidence (27.27%) at a mean of 2.67 2.02 months, and 81.81% of our patients had 3 medical comorbidities. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: geriatric insufficiency fracture morbidity and mortality open fracture
Ankle fractures are a common injury within the elderly population. Low-energy ankle fractures in the elderly have been increasing in incidence, with nearly 3 times more low-energy ankle fractures estimated to occur in 2030 (1). As the US elderly population continues to increase, low-energy ankle fractures are becoming an “epidemic” (2). Currently, a paucity of published data is available on the mortality associated with low-energy open ankle fractures in the elderly population. The purpose of the present study was to review the low-energy open ankle fractures that occurred in patients >60 years old at our level 1 trauma center. Several studies have shown that geriatric hip fractures are associated with overall poor health status and increased mortality rates. We believe that elderly patients with overall poor health status can sustain low-energy open ankle fractures and, as a result, experience high morbidity and mortality.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: William P. Toole, MD, Department of Orthopaedic Surgery and Rehabilitation, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, ACC Building, 2nd Floor, Jacksonville, FL 32209. E-mail address: [email protected]fl.edu (W.P. Toole).
Patients and Methods After obtaining institutional review board approval, we retrospectively identified 11 patients >60 years old who had sustained low-energy open ankle fractures treated at our level 1 trauma center from January 2004 to March 2014. A search of our trauma database using the ankle fracture “International Classification of Disease, 9th revision” codes (824.0, 824.2, 824.4, 824.6, and 824.8) yielded 685 consecutive ankle fractures. Furthermore, using the codes 824.1, 824.3, 824.5, 824.7, and 824.9, 102 open ankle fractures (14.89%) were identified. Of these 102 open ankle fractures, 11 (10.78%) had occurred in patients >60 years old and were secondary to a low-energy mechanism. Low-energy falls were defined as ground level falls from sitting or standing. Open ankle fractures resulting from high-energy mechanisms such as motor vehicle accidents, motorcycle accidents, or falls from heights were excluded. All 11 patients (100%) were treated by 2 orthopedic traumatologists (A.H. and C.P.) at our institution. The data were obtained from the electronic medical records for all 11 open ankle fractures using a defined protocol that included the history and physical examination, radiographic studies, operative notes, and clinic followup visits. The patient demographics, AO/Orthopaedic Trauma
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.10.015
Yes No 23.85 10, Medial ankle wound IIIA 44-B2.2 Male 63 11
Bimalleolar
No Yes No No No Yes Yes Yes Yes Yes 50.02 22.48 NA NA NA IIIA IIIA II IIIA IIIA 15, Medial ankle wound 14, Medial ankle wound 8, Medial ankle wound 15, Medial ankle wound 12, Medial ankle wound 44-C2.3 44-A2.3 44-B3.1 44-B3.2 44-B3.1 Female Male Female Female Female 82 63 65 84 85 6 7 8 9 10
Trimalleolar Bimalleolar Bimalleolar Trimalleolar Bimalleolar
No No 34.3 10, Medial ankle wound IIIA 44-B2.3 61 5
Male
61 4
Bimalleolar
No Yes 45.3 18, Medial ankle wound IIIA
Yes Yes 39.63 22, Medial ankle wound IIIA 78 3
Female Trimalleolar 44-B3.2
No Yes 35.94 18, Medial ankle wound IIIA 44-B2.2 Female Bimalleolar 73 2
Female Lateral 63 1
Abbreviations: BMI, body mass index; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; GERD, gastroesophageal reflux disease; HTN, hypertension; NA, not applicable; OTA, Orthopaedic Trauma Association; PCI, percutaneous coronary intervention; RA, rheumatoid arthritis.
3 mo
3 mo 8 mo 6 mo Lost to follow-up 9 mo
None
6 mo
4 mo
Pin site infection, calcaneus pin Yes (4.5 mo Hepatitis C, CABG, CAD, loosening, loss of reduction after injury) hypothyroidism, esophageal varices Asthma, CAD, GERD, HTN, COPD Placement in skilled No nursing facility Atrial fibrillation, COPD, HTN None Yes (18 d after injury) Ankle stiffness, equinus Yes (3 mo after CABG, CAD, HTN, COPD, hypothyroidism contracture injury) Hepatitis C, HTN, GERD Pin site infection, wound No complications, osteomyelitis COPD, CHF, CAD, PCI, RA None No HTN, COPD, Parkinson’s disease Wound complications No HTN, peripheral neuropathy Symptomatic hardware No CABG, CAD, HTN, CHF Unknown Unknown No CHF, chronic kidney disease Pin site infection, calcaneus pin loosening, wound complications COPD Wound complications (required No pedicled fasciocutaneous flap for coverage) No Yes NA 14, Medial ankle wound IIIA
Complications BMI Diabetes Smoking Medical Comorbidities (kg/m2) Gustilo Class OTA Wound Size (cm), Classification Description Age Gender Fracture (y)
According to the Centers for Disease Control, the US elderly population will nearly double to approximately 72 million by 2030. As such, nearly 1 in 5 Americans will be aged 65 years. The “graying” of the US population has been predicted to increase Medicare spending from $555 billion in 2011 to $905 billion in 2020 (3). Ankle fractures are a relatively common injury within the elderly population. In Finland, the total number of closed low-energy ankle fractures in patients >60 years old increased 319% from 1970 to 2000 (from 369 to 1545). If this trend continues, the incidence of closed low-energy ankle fractures in 2030 will be about 3 times greater (1). In the United States, ankle fractures have been reported to occur in as many as 8.3 per 1000 Medicare recipients (4). An abundance of published studies have discussed open fractures resulting from high-energy trauma. In 2012, a retrospective review of open fractures performed by Court-Brown et al (5) highlighted the importance and overall high incidence of open fractures in the elderly
Patient No.
Discussion
Table Patient demographics, injury description, fracture classification, complications, and mortality
A total of 11 open ankle fractures in 11 patients >60 years old as a result of a low-energy fall during the 10-year study period met the inclusion criteria. Of the 11 patients, 3 (27.27%) were male and 8 (72.72%) were female. The mean patient age was 70.72 9.83 years. The mean body mass index was 35.93 10.24 kg/m2. One of the ankle fractures (9.09%) was an isolated lateral malleolus fracture (AO-OTA 44-B1.2). Six (54.54%) were bimalleolar (AO-OTA 44-A2.3 in 1, 44-B2.2 in 2, 44-B2.3 in 1, and 44-B3.1 in 2). Four (36.36%) were trimalleolar (AO-OTA 44-B3.2 in 2 and 44-C2.3 in 2; Fig. 1). The mean size of the medially based ankle wound (Fig. 2) was 14.18 4.12 cm. Ten patients (90.90%) had Gustilo and Anderson grade IIIA wounds, and one (9.09%) had a Gustilo and Anderson grade II wound. All patients received prophylactic intravenous antibiotics and were initially treated with thorough debridement and irrigation, followed by application of a uniplanar external fixator (Fig. 3). Of the 11 patients, 2 (18.18%) were treated definitively with external fixation and 9 (81.81%) underwent open reduction internal fixation when the soft tissues allowed (Fig. 4). Three patients (27.27%) were smokers. Eight patients (72.72%) had diabetes. Nine patients (81.81%) had hypertension requiring 1 antihypertensive medications. Five patients (45.45%) had coronary artery disease, four (80%) of whom had undergone coronary artery bypass grafting or stent placement. Six patients (54.54%) had chronic obstructive pulmonary disease requiring maintenance medications or home oxygen therapy. Three patients (27.27%) had congestive heart failure. Finally, 9 patients (81.81%) had 3 of these comorbidities (ie, diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, obesity, and/or congestive heart failure). Three patients (27.27%) included in the present study died. The mean interval from injury to death was 2.67 2.02 months. The mean follow-up duration for the remaining 8 living patients was 10.14 11.63 months. One patient (9.09%) was lost to follow-up after the index procedure (debridement and irrigation, uniplanar external fixator). Of these 8 patients, 6 (75%) continued to require an assistive device with ambulation at the last follow-up visit, and all patients reported significant pain and a lack of ankle range of motion.
Mortality
Results
44-B1.2
Follow-Up Duration
Association (OTA) fracture classification, wound description, body mass index, medical comorbidities, follow-up data, and outcomes were recorded (Table).
1 mo (died at outside hospital) 3y
W.P. Toole et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Female Trimalleolar 44-C2.3
2
W.P. Toole et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
3
Fig. 1. (A) Anteroposterior and (B) lateral radiographs demonstrating AO 44-B3.2 ankle fracture dislocation with medial soft tissue injury.
Fig. 2. Clinical photograph demonstrating medially based ankle wound.
population. In that study, patients aged 65 years accounted for 20.3% of all open fractures and females aged 80 years accounted for 20.8% of all open ankle fractures (5). Although that study highlighted the overall high incidence, the paucity of published data addressing the epidemiology of low-energy open ankle fractures in the elderly population has continued. White et al (6) in 2003 performed a retrospective review of 14 open ankle fractures in 13 patients with diabetes. The mean age of their patient population was 54 years (range, 29 to 80). Most of these fractures were secondary to high-energy trauma. Of the 14 open ankle fractures, 64% developed wound complications, 36% developed deep infection, 42% ultimately required a below-the-knee amputation, and only 21% achieved bony union without complications. They concluded that open ankle fractures in patients with diabetes are limb-threatening injuries with high amputation and infection rates (6). In our study, the mean patient age was 70.72 9.83 years, 100% of the fractures were due to low-energy trauma, and 72% of the patients had diabetes. Of these 11 patients, 3 (27.27%) had died within 2.67 months, further highlighting the potentially devastating complications associated with low-energy open ankle fractures in the elderly. The main limitation of our study was the small series size, which limited our analysis. Thus, our investigation was solely observational. Our findings suggest that elderly patients who sustain low-energy open ankle fractures will have multiple medical comorbidities and that these fractures result in high mortality. Future studies are needed to better understand these potentially devastating injuries. Ankle fractures are the third most common fracture, after fractures of the hip and wrist, in patients aged >65 years (7). The projected aging of the population should lead to concern regarding a much greater incidence of ankle fractures in the elderly. Several studies have shown the high mortality associated with hip fractures in the elderly
4
W.P. Toole et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Fig. 3. (A) Lateral and (B) anteroposterior radiographs demonstrating alignment after debridement and irrigation and placement of a uniplanar external fixator.
Fig. 4. (A) Anteroposterior and (B) lateral radiographs after staged open treatment.
compared with age-matched controls (9% at 30 days, 19% at 90 days, and 30% at 12 months) (7). In our study, low-energy open ankle fractures were associated with a 27.27% incidence of death at a mean of 2.67 2.02 months. Thus, physicians encountering this injury should view it in much the same light as a hip fracture in the elderly and counsel patients appropriately about the potentially devastating complications and high mortality incidence. References 1. Kannus P, Palvanen M, Niemi S, Parkkari J, Jarvinen M. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future. Bone 31:430–433, 2002.
2. Ehrenfreund T, Haluzan D, Dobric I, Zigman T, Rajacic D, Antoljak T, Davila S. Operative management of unstable ankle fractures in the elderly: our institutional experience. Injury 44(suppl S3):S20–S22, 2013. 3. Centers for Disease Control and Prevention. The State of Aging and Health in America 2013, Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta, GA, 2013. 4. Koval KJ, Lurie J, Zhou W, Sparks MB, Cantu RV, Sporer SM, Weinstein J. Ankle fractures in the elderly what you get depends on where you live and who you see. J Orthop Trauma 19:635–639, 2005. 5. Court-Brown CM, Bugler KE, Clement ND, Duckworth AD, McQueen MM. The epidemiology of open fractures in adults: a 15-year review. Injury 43:891–897, 2012. 6. White CB, Turner NS, Lee GC, Haidukewych GJ. Open ankle fractures in patients with diabetes mellitus. Clin Orthop Relat Res 414:37–44, 2003. 7. Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture, is delay before surgery important? J Bone Joint Surg Am 87:483–489, 2005.
