Abstract
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.
Keywords:
ankle instability
early mobilization
fracture disease
syndesmosis
Ankle fractures are a common injury, with >2 million new cases per year in North America(1). Trauma of the distal tibiofibular syndesmosis is present in »23% of all ankle fractures(1,2). Indications for surgical intervention for unstable ankle fractures are well defined(2). Those fractures with syndesmotic disruption usually require trans-syndesmotic fixation. Historically, the postoperative protocol includes cast immobilization and non-weightbearing for ≥6 weeks. This postoperative protocol is intended to reduce the risk of fracture displacement, loss of syndesmotic reduction, hardware failure, and wound complications(3−6).
An increasing number of reports have heralded the benefits of early weightbearing and early range of motion after ORIF in acute rotational ankle fractures without syndesmotic fixation(3−12). The reported complications in these studies are similar to those in patients treated with immobilization and non-weightbearing. There is sparse literature examining early protected weightbearing after ORIF of acute ankle fractures requiring trans-syndesmotic stabilization. Recently, 2 papers concluded that early weightbearing in ankle fractures with syndesmotic fixation is not detrimental(13,14). The purpose of this study was to contribute to the body of literature and assess the maintenance of reduction and complication rates associated with early protected weightbearing in patients after ORIF of ankle fractures with trans-syndesmotic screw stabilization.
Results
Fifty-eight patients met inclusion criteria. Each surgeon performed 29 surgeries. Patient demographics are shown in Table 1. There were 30 male (51.7%) and 28 female (48.3%) patients. Thirty-one occurred on the left side (53.4%), and 27 on the right side (46.6%). The mean age was 46 years (range 15 to 85). Nineteen patients (32.8%) were age 60 and older. Mean BMI was 30.4 (range 17.6 to 45.2).
The injury characteristics are shown in Table 2. Ankle fracture patterns included supination external rotation and pronation external rotation. There were 8 (13.8%) ankle dislocations. The posterior malleolus was fractured in 30 (51.7%) of the cases.
Postoperative complications are depicted in Table 3. There were 5 total complications, which included 3 superficial infections (5.2%) and 2 reports of neuritis (3.4%). Four of the complications (80%) occurred in patients age ≥60 years. For the patients who experienced complications, the average time to weightbearing was 10 days. There were no deep vein thromboses or deep infections. There were no cases of medial clear space or syndesmotic widening. At 12 months postsurgery, all 58 patients had maintenance of reduction and returned to their preoperative level of walking.
Discussion
Traditionally, patients with these fracture patterns were not allowed to bear weight, primarily for fear of loss of reduction of the syndesmosis. The results of this study demonstrate that patients with unstable ankle fractures and syndesmotic disruption can be fully weightbearing within 15 days after ORIF without loss of reduction, hardware failure, or increase in complications. There was a low complication rate and no loss of reduction in our case series. These results are comparable to previous studies that involve early weightbearing in cases without syndesmotic involvement(5,6,10−13). They also reinforce the findings of the previously published works, demonstrating that loss of syndesmotic integrity is not potentiated by early weightbearing(13,14,20).
Prolonged non-weightbearing can be detrimental, particularly in the elderly and patients with comorbidities(4,20). In some cases, nonweightbearing is not realistic because of body habitus, frailty, and lack of coordination and upper extremity weakness. Moreover, early ambulation after ankle fracture surgery helps minimize deconditioning and is inherently appealing to patients.
Although we would not expect loss of reduction or hardware failure after 12 months of follow-up, we were not able to determine whether this protocol had any potentiation of the development of posttraumatic arthritis. Intuitively, patients with fractures requiring syndesmotic stabilization have more severe fractures that are more likely to culminate in posttraumatic arthritis(21). The damage to the tibial plafond at the time of injury often goes undetected, and the effect of early weightbearing may be detrimental in the early postoperative period. However, we believe that by eliminating motion and rotational forces at the ankle by virtue of the cast, all the load from weightbearing is transmitted to the central portion of the distal tibia, which is unlikely to be compromised.
We also did not analyze the fate of the syndesmotic fixation at 1 year, because we were primarily concerned with the integrity of the mortise. Had we observed cases of lost reduction, we would have analyzed whether the screws had broken or loosened to allow widening of the tibiofibular space.
Limitations of the study include that it was a retrospective analysis with a relatively small cohort that was not randomized. The medical comorbidities that were documented in this study were not evaluated independently as risk factors for complications. In addition, there was no functional outcome scoring system. We were not able to verify the extent of weightbearing activity after the walking cast was applied. It is possible that some patients did not assume weightbearing for an extended period of time after they were allowed. Lastly, we were not able to determine if less robust methods of trans-syndesmotic fixation would withstand the weightbearing protocol. All of our cases had 4-cortex purchase, and in many instances, >1 screw was used.
In conclusion, the results of the present study support early protected weightbearing in patients undergoing ankle fracture ORIF with syndesmotic screw stabilization. However, further randomized controlled studies with extended follow-up and multivariate analysis are needed to determine whether there are any long-term negative consequences of this protocol.
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