SYNOPSIS

Functional outcome following open reduction and internal

fixation of unstable ankle fracture

By
Dr. Zeeshan Siddique
Department of Orthopedics
Combined Military Hospital, Lahore

Supervised
By

Col. SHAHID MUNIR

MBBS, FCPS, FCPS
Department of Orthopedics
Combined Military Hospital, Lahore
INTRODUCTION
Ankle fractures are one of the most common lower extremity injuries, affecting all

age groups. Unstable ankle fractures are usually treated surgically in an effort to prevent

posttraumatic arthritis and thereby maximize functional recovery. However, the optimal

timing of operative treatment for ankle fracture surgery remains uncertain. Early surgery

within 24 to 48 hours after injury may provide some benefit, reducing the risk of wound

complications and the duration of admission if the patient is admitted to the hospital,

although many ankle fracture patients are treated as outpatients in the United States .
(1, 2)

Surgery performed too soon after injury might have an increased risk of wound healing

problems secondary to severe swelling; surgery performed too late may result in some

difficulty obtaining an anatomical reduction. However, some studies have suggested no

increased risk of complications with delayed surgery . Surgical and conservative

(3, 4)

management of displaced or unstable ankle fractures produce comparable short-

term functional outcomes. The higher risk of early treatment failure and malunion/non-union

in the conservative group versus higher rates of further surgery and infection in the surgical

group should be considered. Trials are being conducted to assess short and longer-term

results and functional outcomes of these patients and inform management of select patient

groups (5-7).

Although postsurgical complications and functional assessment are important to study

clinical results, complications of lower-limb injuries are less frequently considered, especially

in the elderly. Several criteria can assess treatment results and the socioeconomic impact,

such as (1) self-sufficient mobilization, (2) time of recovery, (3) duration of physiotherapy,

and (4) duration of pain management (8, 9).

In a previous study, outcome was determined using mean modified ankle score of Olerud and

Molander and it was 47.55 (SD: 17.92) at 3 months follow up.

Ankle fractures in older people are increasing in number as the population ages Although

ankle fractures like all other lower limb fractures pose a serious illness and have high impact

over quality of life of the patients. Still, there is limited evidence on which injury, treatment

and sociodemographic factors predict functional outcomes after ankle fracture and

particularly studies using a structured scale on unstable ankle fractures are scarce. Therefore,

I want to conduct this study to observe functional outcome of open reduction and internal

fixation. Following this study, we will be able to guide and educate our patients regarding

expected outcomes.

OBJECTIVE: To determine the functional outcome (mean modified ankle score of Olerud and

Molander) following open reduction and internal fixation of unstable ankle fracture.

OPERATIONAL DEFINITIONS

Functional outcome: will be determined in terms of mean modified ankle score of Olerud and

Molander. (Annexure)

Each measure of comprised of nine questions. These are all scored together for a total of 100

points. Higher the score better is the outcome. It will be assessed as mean score at 3-months

follow up.

Unstable ankle fractures: Will be considered if any of following is present:

  Bimalleolar fracture (If both medial and lateral malleoli are fractured) (as seen on X-

ray of ankle joint, both Anteroposterior and lateral views)

 Trimalleolar fractures (If both medial and lateral malleoli and distal tibia are

fractured) (as seen on X-ray of ankle joint, both Anteroposterior and lateral views)

 Fracture dislocations (fractures with >5 mm of medial clear-space widening) (as seen

on X-ray of ankle joint, both Anteroposterior and lateral views)

MATERIAL AND METHODS

STUDY DESIGN: Descriptive Case Series

SETTING: Study will be conducted at Orthopedic Department, Ghurki teaching

hospital, Lahore.

DURATION OF STUDY: Six months after the approval of synopsis.

SAMPLE SIZE: Needs to be calculated on stats relevant to outcome variables

SAMPLING TECHNIQUE: Non-probability, consecutive sampling.

SAMPLE SELECTION

Inclusion Criteria:

• All patients aged 18-70 years having unstable ankle fracture as per operational
definitions.

• Patients of both gender

Exclusion Criteria:

 Patients with involvement of both sides (X-rays) (as these patients might have more

disability and poor outcome score)

 Patients having any congenital anomalies of lower limb (Medical records) as these

patients might have more disability and poor outcome score)

  Patients with previous history of fracture to any bone to same lower limb (Medical

records) as these patients might have more disability and poor outcome score)

DATA COLLECTION

Approval from Ethical Review Board of the hospital will be obtained. The patients meeting the

inclusion criteria will be enrolled in the study. Written informed consent for inclusion into

this study will be obtained. Patients presenting in outdoor department with unstable ankle

fractures will be included and demographic details including age, gender, side of injury,

duration since injury, body mass index (BMI) will be noted. They will undergo open

reduction and internal fixation as per standard method by the same surgical team. Following

surgery, they will be provided care as per departmental protocols. At 12 weeks follow up,

they will be assessed for modified ankle score of Olerud and Molander by the same surgical

team. All data will be recorded on the proforma (attached).

DATA ANALYSIS PROCEDURE

The collected data will be entered and analyzed accordingly using SPSS version 24. Mean ±

SD will be calculated for age, duration since injury, BMI and modified ankle score of Olerud

and Molander. Frequency and percentages will be calculated for gender and side of injury.

Final outcome (mean modified ankle score of Olerud and Molander ) will be stratified for age,

gender, side of injury, duration since injury and BMI. Post-stratification student’s t-test will

be done. P-value ≤ 0.05 will be considered as significant.

REFERENCES

1. Johnson JD, Chachula LA, Bickley RJ, Anderson CD, Ryan PM. Return to duty

following open reduction and internal fixation of unstable ankle fractures in the active duty

population. Mil Med. 2019;184(5-6):e381-e4.

2. Keene DJ, Willett K. Implications of the Ankle Injury Management (AIM) trial: close

contact casting or surgery for older adults with an unstable ankle fracture? Bone Joint J.

2019;101-b(12):1472-5.

3. Kashmiri N. Pattern of bimalleolar ankle fractures. J Rawal Med Coll

2017;21(2):148-52.

4. Khan AS, Ullah R, Iqbal J, Inam M. Functional outcome of open reduction and

internal fixation in Danis-Weber type B ankle fracture. Pak J Med Health Sci

2018;12(3):895-7.

5. Loukachov VV, Birnie MFN, Dingemans SA, de Jong VM, Schepers T. Percutaneous

intramedullary screw fixation of distal fibula fractures: A case series and systematic review. J

Foot Ankle Surg. 2017;56(5):1081-6.

6. Lurie BM, Bomar JD, Edmonds EW, Pennock AT, Upasani VV. Functional outcomes

of unstable ankle fractures in adolescents. J Pediatr Orthop. 2019.

7. Rbia N, van der Vlies CH, Cleffken BI, Selles RW, Hovius SER, Nijhuis THJ. High

prevalence of chronic pain with neuropathic characteristics after open reduction and internal

fixation of ankle fractures. Foot Ankle Int. 2017;38(9):987-96.

8. D’Almeida V, Thomas A, Devasia T, Mathew N, Kamath A, Adiga R. Functional

outcome following operative treatment of ankle fractures. J of Evolution of Med and Dent

Sci 2015;4 (63):10937-10955

9. Tantigate D, Ho G, Kirschenbaum J, Backer H, Asherman B, Freibott C, et al. Timing

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8.
 PROFORMA

Functional outcome following open reduction and internal

fixation of unstable ankle fracture
Patient’s Name: ____________________ Date: ____________________

Hosp. Reg. # _______________

Address: ______________________________________________________________

Age: _____________

Gender:

Male

Female

Side of injury:

Right

Left

Duration since injury, _____________

BMI: ________________

 Modified ankle score of Olerud and Molander: _________________________

 Modified ankle score of Olerud and Molander

 Pain will be assessed using Visual Analog scale. Patients will be asked to report their pain as
per VAS scale and it will be recorded. It will be considered “Yes”, if VAS is <5.
 Functional scale questions will be asked from all patients by the investigator and their
responses will be recorded