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Open Fractures of the Ankle: Management Options10.5005/Jp-Journals-10040-1074 and Factors Influencing Outcomes Symposium-Review Article

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Open Fractures of the Ankle: Management Options10.5005/Jp-Journals-10040-1074 and Factors Influencing Outcomes Symposium-Review Article JFASJFAs (AP) Open Fractures of the Ankle: Management Options10.5005/jp-journals-10040-1074 and Factors influencing Outcomes SymPoSium-Review ARticle Open Fractures of the Ankle: Management Options and Factors influencing Outcomes 1Uttam C Saini, 2Mandeep S Dhillon, 3Udai Cheema, 4Rajesh K Rajnish ABSTRACT severe, often seen in young adult males, and frequently Open ankle fractures are rare injuries among all the ankle frac- neglected in polytrauma cases. Injuries of the bones con- tures and commonly occur after high-velocity trauma in road stituting the ankle (30.6%) are most common among the traffic accidents resulting in varying amounts of soft-tissue loss, foot injuries followed closely by metatarsal (27.9%) and periosteal stripping, microbial contamination, bone loss, and calcaneal fractures (21.4%).1,3 Open ankle fractures are vascular injury. Management of open ankle fractures remains a rare (3 to 6%) injuries among all the ankle fractures and daunting task due to the complex osseo-ligamentous complex, relatively thin soft-tissue coverage around the joint, propensity have also been increasingly seen in the elderly population 4 for wound infection and complications, and the risk of impaired besides the young trauma patients. These commonly functional ability. Management in the emergency trauma room occur after high-velocity trauma in road traffic accidents, includes initial stabilization of the patient, focused history, and resulting in varying amount of soft-tissue loss, periosteal detailed clinical evaluation determining the level and type of stripping, microbial contamination, bone loss, and vas- injury, extent of wound contamination, soft-tissue and/or bone cular injury. The classification of open ankle fractures loss, and neurovascular status of the injured limb followed by 5 radiographic evaluation. Early antibiotics administration and based on Gustilo and Anderson and modified by Gustilo wound assessment, irrigation, aseptic dressing, and temporary et al6 helps in injury description, treatment decisions, and splintage form the cornerstone of initial orthopedic stabilization predicting the outcome of injury. of open fractures. There is a general consensus that all open Management of open ankle fractures remains a daunt- ankle fractures need early debridement and fixation to restore ing task for the orthopedic surgeon due to the complex articular congruity and alignment of fracture fragments although the timing of internal/definitive fixation of open ankle fractures osseo-ligamentous complex, a relatively thin soft-tissue is still debatable. Common complications include superficial coverage around the joint, which can be easily damaged, and deep infections, marginal skin necrosis, compartment propensity for wound infection and complications, and syndrome, nonunion/malunion, and secondary osteoarthritis. the risk of impaired functional ability in the patient sec- Timely interventions improve orthopedic outcomes in these ondary to multiple surgeries. Hence, the goals of man- patients. agement include early wound care and either immediate Keywords: Ankle fractures, Debridement, Flap cover, Foot or staged fixation depending on the wound condition to fractures, Open fractures. reduce complications. The purpose of this brief review is How to cite this article: Saini UC, Dhillon MS, Cheema U, to discuss the management options, complications, and Rajnish RK. Open Fractures of the Ankle: Management Options factors influencing outcomes of open ankle fractures. and Factors influencing Outcomes. J Foot Ankle Surg (Asia- Pacific) 2017;4(2):69-76. EPIDEMIOLOGY Source of support: Nil Foot and ankle injuries have been noted to constitute up Conflict of interest: None to 10% of the total orthopedic trauma cases in tertiary care hospitals from developing countries.1 A vast major- INTRODUCTION ity of these injuries are caused by road traffic accidents followed by falls and industrial accidents and are open Foot and ankle injuries are among the most common fractures. A brief review of studies pertaining to open injuries (10%) encountered in orthopedic trauma centers ankle fractures is provided in Table 1. of tertiary hospitals.1,2 The majority of these injuries are MECHANISM OF INJURY AND FACTORS AFFECTING OUTCOMES 1Assistant Professor, 2Professor and Head, 3,4Senior Resident 1-4Department of Orthopaedics, Postgraduate Institute of Medical Mechanism of open ankle fracture is usually direct Education and Research, Chandigarh, India impact or crushing injuries as in high-speed motor Corresponding Author: Mandeep S Dhillon, Professsor and vehicle accidents and run-over injuries. Sometimes, open Head, Department of Orthopaedics, Postgraduate Institute of fracture can be a result of skin penetration by sharp bone Medical Education and Research, Chandigarh, India, Phone: spike leading to the so-called inside-out compounding. +919815951090, e-mail: [email protected] This type of fracture is usually low-energy trauma with The Journal of Foot and Ankle Surgery (Asia-Pacific), July-December 2017;4(2):69-76 69 Uttam C Saini et al 70 Table 1: A review of studies related to open ankle fractures No of Study Study type patients Gustillo classification Treatment protocol Follow-up Results Chummun et al7 Retrospective 68 Divided into three groups: P– Patients from groups “P” and “S” if Mean follow-up; group Mean AO scores of groups patient initially seen and managed reconstruction was possible, flap and definitive P: 55.5 weeks; group P, S, and R were 11.5, 12.3, by orthoplastic center, S–referral fixation if not, external fixator and a negative S: 61.0 weeks; group and 9.7 Mean Enneking group after initial stabilization pressure dressing were applied. Combined R: 57.0 weeks scores for groups P, S, and for fixation and management, orthoplastic approach planned next. Group “R” R were 63.3, 74.8, and 73.5 and R–referral group following orthoplastic plan for the delayed reconstruction (p = 0.16) complication Lee and Chen8 Retrospective 47 I: 26; II: 21; III: excluded Debridement, irrigation, antibiotics, immediate 29 months Loss to Baird and Jackson ankle open reduction and fixation, primary wound follow-up: 4 score: excellent/good: 90% closure Khan et al9 Retrospective 24 Group P–treated primarily by Group P: external fixator, soft-tissue P: 10.5 months; S: Enneking score: P: 74.6 S: orthoplastic team Group S–referral transfer after radical debridement Group S: 11.4 months 70.4 BKA: 2 (one primary group heterogeneous group, external fixation, plaster treatment); time to union: P: application, internal fixation 17 weeks S: 21.6 weeks Joshi et al10 Prospective 30 I:11; II: 12; IIIA: 5; B: 2 Debridement, irrigation, antibiotics, immediate Functional: excellent 22, open reduction and fixation, soft-tissue good 8, fair 2 management according to fracture grade Acello et al11 Retrospective 33 I: 8, II: 7, III: 8 Debridement, irrigation, antibiotics, immediate – – open reduction and fixation/ amputation, delayed closure Tho et al12 Retrospective 15 IIIA: 14 III B: 1 Debridement, irrigation, antibiotics, immediate 1–3 years Range of movement Good: open reduction and fixation, delayed closure/ 7 Satisfactory: 6 Poor: 2 SSG flap by sec. Intention. 6–12 weeks cast NWB Sanders et al13 Retrospective 11 IIIB: 11 Multiple debridement, removal of preexisting 48 months Mazur ankle fusion score implants, antibiotics (intravenous and beads), Good: 3, Poor: 5, Failure:3 temporary external fixator or posterior splint. Delayed wound closure with definitive bony stabilization (ankle fusion/ankylosis) including bone graft, in case of flap 4–6 weeks after flap transfer. NWB 3 months Ngcelwane14 Retrospective 64 Weber A: 7 B: 26 C: 24 Other: 8. Debridement, irrigation, antibiotics, immediate – 23 had no pain, 21 had pain Clean: 42 Contaminated: 22 open reduction and fixation: 27, 26 K-wires and on weight bearing plaster, 11 plaster only Bray et al15 Retrospective 31 I:12, II: 9, III: 10 Group I: debridement, closed reduction, I: 90 months, II: Pain reduction and function immobilization or delayed open reduction and 33 months, 1 lost to in both groups same. fixation, delayed closure. Group II: debridement, follow-up Group II: better range of irrigation, antibiotics, immediate open reduction movement. Both groups one and fixation, delayed primary closure infection each Franklin et al16 Retrospective 38 I:12, II: 14, III: 16 Debridement, irrigation, antibiotics, immediate 39 months Function: excellent in 26, fair open reduction and fixation, delayed primary or poor in 9 closure BKA: Below-knee amputation; SSG: Split skin graft; NWB: Nonweight bearing JFAs (AP) Open Fractures of the Ankle: Management Options and Factors influencing Outcomes minimal soft-tissue damage and has good prognosis. A fracture wounds have been gram-positive followed by number of factors influence the outcome of open ankle gram-negative, anaerobic, and gas-forming organisms.20 fracture, such as the grade, level of contamination, degree Hence, a broader spectrum prophylactic antibiotic, such of comminution, systemic factors, such as age, nutrition, as first-generation cephalosporin is recommended for immunity, systemic diseases, such as diabetes and ath- open fractures. Additional use of one aminoglycoside erosclerosis, drug and alcohol abuse, timing and quality is recommended in type III open fractures.21,22 In the of fracture reduction and fixation, soft-tissue handling, postoperative period, there are no added benefits of and wound coverage. The only variables under surgeon’s continuing antibiotic
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