ORIF tops casting in restoring function in geriatric patients with ankle fractures

Nearly 18% of conservatively treated patients required additional manipulation and casting.

Issue: December 2006

The best treatment for ankle fractures in older patients has always remained elusive. However, current research indicates there is improved function with open reduction and internal fixation compared to manipulation with casting.

Mihai Vioreanu, MD, and colleagues retrospectively studied 112 patients older than 70 who underwent fracture treatment using open reduction and internal fixation (ORIF) or manipulation with anesthesia and casting (MUA).

The researchers discovered that 72% of patients who received ORIF maintained their previous levels of functioning compared to 42% in the cast group (P<.005). They also found a 27.5% failure rate with MUA and noted that 17.2% of patients who received the conservative treatment required a second manipulation.

"We recommend a balanced, individualized approach in managing these difficult fractures," Vioreanu told Orthopedics Today. "We conclude that open reduction and internal fixation of ankle fractures in geriatric patients is efficacious and safe in selected patients, and age alone should not dictate the treatment of the ankle fractures in [the] geriatric population."

Vioreanu presented the results at the American Orthopaedic Foot and Ankle Society's annual summer meeting.

Finding complications

During follow-up, the researchers found two cases of deep vein thrombosis in the MUA group and four instances in the ORIF cohort. They discovered that 4.1% of the operated group had superficial infections or delayed healing, which resolved with antibiotics.

They also reported a distinct entity of geriatric patients with open fractures. Of these patients, Vioreanu told Orthopedics Today, "We noted a very high incidence of postoperative deep wound infections, associated with serious complications: one mortality, due to generalized sepsis and exacerbation of pre-existent cardiovascular disease, and two below-knee amputations."

Patient demographics

The MUA group consisted of 40 patients and the ORIF group had 72 patients. The average age for the groups was 78.6 and 76.4 years, respectively, and both groups had more women. The cohorts also had comparable rates of Weber type B fractures, 85% for the MUA group and 86.1% of the control.

"Patients treated conservatively had more associated medical conditions at the time of their ankle fracture, [a] fact indicated by the patients' ASA score," Vioreanu said. "In this group, 20% of patients had an ASA [score of] 3 and only 10% had a similar ASA score in the ORIF group. There was, therefore, the likelihood that more ill patients were treated by a MUA rather than ORIF." They followed the MUA-treated patients for an average of 22 weeks and studied the ORIF group for 16 weeks.

The investigators discovered that nine patients in the conservatively treated group lost reduction 2 weeks after casting. Of these patients, eight underwent ORIF and one patient received external fixation. Another two patients later experienced painful nonunions. One underwent ORIF and the other had an arthrodesis, Vioreanu said.

X-rays of both groups revealed that more of the cast patients had reductions with more than 2 mm of medial space. The researchers found that 55.1% of the MUA patients who did not undergo additional surgery had imperfect reductions vs. 20% of the ORIF group.

For more information:
Vioreanu M, Dudeney S, Kelly E, et al. Ankle fractures in the geriatric population: Operative or nonoperative treatment. Presented at the American Orthopaedic Foot and Ankle Society 22nd Annual Summer Meeting. July 14-16, 2006. La Jolla, Calif.
Mihai Vioreanu, MD, is a surgeon at St. Vincent's University Hospital, in Dublin, Ireland. He can be contacted at mihaiv@eircom.net.