SLR - November 2009 - Shirley M. Catoire
Reference:
Farsetti P., Caterini R., Potenza V., De Luna V., De Maio F., Ippolito E. (2009). Immediate Continuous Passive Motion after Internal Fixation of an Ankle Fracture. Journal of Orthopaedic Traumatology, 10, 63-69.
Scientific Literature Review
Reviewed by: Shirley M. Catoire, DPM
Residency Program: Yale/ VA Podiatric Residency Program
Podiatric Relevance
This study addresses the post operative management of a common injury frequently encountered in the podiatric profession – ankle fractures. Bimalleolar and trimalleolar fractures of the ankle are frequent injuries and are surgically reduced and stabilized with internal fixation if displaced. The objective of this study was to compare two groups of ankle fractures that were surgically reduced via open reduction internal fixation (ORIF). The first group consisted of 22 patients that received a continuous passive motion (CPM) machine immediately after surgery. The second group consisted of 22 patients that were immobilized in a splint or a cast immediately after surgery.
Material and Methods
Inclusion criteria for this study included a unilateral bimalleolar or trimalleolar fracture of the ankle between the years of 1985-1995. Fractures treated surgically between 1985-1990 were placed into group two (immobilization group). Fractures treated surgically between 1990-1995 were placed into group one (CPM group). Twenty-two patients were selected for group one. Of this group, there were 13 females, 9 males, and the age ranged from 20-62 years old. Twenty-two patients were also selected for group two. Of this group, there were 12 females, 10 males, and the age ranged from 18-69 years old. The first group consisted of 8 bimalleolar fractures and 14 trimalleolar fractures. The fractures were further subdivided into 4 Weber A fractures, 6 Weber B fractures, and 12 Weber C fractures. The second group consisted of 10 bimalleolar fractures, 12 trimalleolar fractures. There fractures are also subdivided into 2 Weber A fractures, 8 Weber B fractures, and 12 Weber C fractures.
In all cases, the fibular fracture was fixated first. The CPM machine was applied immediately post-op in group one and started with 5 of dorsiflexion and 10 of plantarflexion. The machine was applied full time for 3 weeks. A splint or cast was applied immediately post-op in group two and patients were immobilized for 3 weeks. Gradual weight bearing was initiated in 8 weeks after surgery in both groups. At follow-up the patients were evaluated clinically and radiographically. The AOFAS ankle hindfoot score was used to rate the final clinical result.
Results
In group one, follow-up ranged from 10 -14 years. The average AOFAS score was 95.7 points. The sagittal motion of the ankle joint measured 30 – 70. Two patients in this group showed mild signs of osteoarthritis radiographically. Complications observed in this group were superficial wound infection in one patient and syndesmotic screw breakage in one patient.
In group two, follow up ranged from 14-20 years. The average AOFAS score was 88 points. The sagittal motion of the ankle joint measured 20-65. Mild signs of osteoarthritis were observed radiographically in 6 patients. One patient showed severe signs of osteoarthritis radiographically. Complications observed in this group included superficial wound infection, deep wound infection, and DVT.
Overall, the differences in the AOFAS scores between the two groups were statistically significant. However the difference in the range of motion of the ankle joint was not statistically significant.
Conclusion
The study reported the CPM group did not have significant restriction of motion of the ankle joint. In the immobilization group, moderate restriction of motion of the ankle joint was observed in 7 patients. The authors of this study believe that early range of motion allows for quick recovery of ankle range of motion as well as better healing of articular cartilage. Continuous passive motion started immediately after surgery allows for good recovery of range of motion and may minimize the risk of osteoarthritis.