SLR - October 2021 - Katie J. Backstrand

A Novel Fixation Method for Unstable Ankle Fractures in the Elderly Using Dual Percutaneous Tibiotalar Cannulated Screws

Reference: Hancock DW, Hainsworth L, Pentlow AK. A Novel Fixation Method for Unstable Ankle Fractures in the Elderly Using Dual Percutaneous Tibiotalar Cannulated Screws. J Surg Case Rep. 2021 Jul 24;2021(7):rjab311.

Level of Evidence: Level IV 

Scientific Literature Review 

Reviewed By: Katie J. Backstrand, DPM 
Residency Program: Northwest Medical Center – Margate, FL 

Podiatric Relevance: With a prevalence as high as 184 per 100,000 patients per year, ankle fractures comprise of approximately 25 percent of all lower limb fractures. Nearly 30 percent of these fractures occur in the elderly, making these injuries a common occurrence in this population. However, co-morbidities frequently exist in the elderly, making management of these injuries challenging both surgically and conservatively. The Ankle Injury Management trial concluded that in this patient population  close contact casting yields favorable results by providing reduction until union in the most conservative manner while avoiding surgery. Casting, however, requires a lengthy non-weightbearing period, therefore, hindfoot nails have been more frequently utilized in order to allow immediate weight bearing but have their own associated risk. The goal of this study was to describe and report the authors’ experience for managing the unstable ankle fracture in the co-morbid, elderly population with an innovative minimally invasive surgical option. 

Methods: A level IV retrospective review was performed of six patients with unstable ankle fractures who underwent dual percutaneous tibiotalar cannulated screw fixation for acute management. The study took place via the trauma database between from January 2018 to 2020. Co-morbidities were evaluated in the demographic data which included age, gender, American Society of Anesthesiology (ASA) grade, and smoking status. Additionally, the ankle fractures were analyzed according to their Danis-Weber classification on preoperative radiographs. Following closed manipulation, percutaneous fixation of the tibiotalar joint with two large, cannulated screws was performed. Patients were placed in a plaster cast and allowed full weight bearing immediately postoperatively. During the postoperative period between six and 20 weeks, patients were evaluated for any suggestion of talar shift, syndesmotic widening, mal or non-union, screw loosening or periprosthetic fracture.

Results: All six patients had significant co-morbidities and were classified with an average ASA score of three. Radiographically, four of the six patients had no evidence of talar shift, mal or non-union, syndesmotic widening or screw loosening and overall satisfactory outcomes. One of the patients at five months had minor talar shift not associated with pain or limited mobility. In one patient, complete closed reduction of the talus was unable to be obtained and as such screw loosening, syndesmotic widening and talar shift developed at six weeks. However, the patient experienced minimal pain and adequate mobility levels. Clinically, all patients were ambulatory at follow-up, with five out of the six patients reporting 0 out of 10 pain and the remaining patient reporting 1 out of 10 pain. 

Conclusions: Clinical data from this study reveals that the technique described is a viable option in management of the unstable ankle fracture in the elderly, at risk population, through a less invasive surgical approach while sparing the subtalar joint. Additionally, this technique allows for immediate full weight bearing and minimal to no pain postoperatively while keeping patients mobile. Through this study’s findings, a move toward a treatment strategy that will avoid unnecessary surgical risks appears to be appropriate but further, larger scale studies are required before this technique can be considered standard of care. 

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