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FAS 1037 No. of Pages 6

Foot and Ankle Surgery xxx (2017) xxxxxx

Contents lists available at ScienceDirect

Foot and Ankle Surgery


journal homepage: www.elsevier.com/locate/fas

Tibiotalocalcaneal nail xation and soft tissue coverage of


GustiloAnderson grade 3B open unstable ankle fractures in a frail
population; a case series in a major trauma centre
Lesley Armstrong, BA MBBS MRCS* , John Jackson, MBBCh BSc MRCS1,
Andrew Riddick, MBBCh FRCS Ed
Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol BS10 5NB, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Background: GustiloAnderson grade 3B open ankle fracture-dislocations requiring stable xation and
Received 2 December 2016 soft tissue coverage are increasingly common in frail populations.
Received in revised form 20 March 2017 Methods: We identied all patients with open ankle fracture-dislocations treated with a tibiotalocalca-
Accepted 29 March 2017
neal nail and soft tissue coverage over a ve-year period. We retrospectively recorded pre-morbid status,
Available online xxx
fracture and soft tissue injury pattern, surgical details, post-operative mobility, length of hospital stay,
complication and re-operation rate and survival.
Keywords:
Results: 21 ankles (20 patients) are included, all grade 3B open fractures. All patients were permitted to
Ambulation
Frail elderly
mobilise by one to six weeks post-surgery. One patient required further soft tissue surgery. Six patients
Intramedullary nailing had supercial wound colonization/infection, none developed deep infections. None of the nails have
Open fracture required removal. We observed a 15% three-month mortality rate.
Orthopaedic surgery Conclusion: Tibiotalocalcaneal nail xation and soft tissue coverage of unstable open ankle fractures in
Soft tissue injuries frail patients facilitates early return to ambulation with a low complication and re-operation rate.
Survival rate 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction This can be difcult for frail patients, in whom ambulation is


paramount to managing their activities of daily living [3]. Poor hold
Open fracture-dislocations of the ankle are challenging injuries in osteoporotic bone, and the need for further soft tissue insult in a
to treat in the frail and elderly population. They often occur heavily traumatized area can make plate and screw xation an
following low-energy injuries. Soft tissues around the ankle fail unattractive option in elderly co-morbid patients, and for this
when the fracture-dislocation occurs, resulting in signicant soft reason surgical treatment with a tibiotalocalcaneal nail has
tissue stripping. These injuries pose a challenge to the surgeon in become more popular in the treatment of closed unstable fractures
view of poor quality bone and soft tissues [1]. This group of in frail elderly patients [1]. Emphasis is placed on achieving good
patients frequently have poor pre-operative health [2] in terms of xation that allows the patient to mobilise as quickly as possible,
medical co-morbidities, such as diabetes mellitus and circulatory and less on longer term outcomes in a population with a limited
disease, which further increase the risk of surgical complication. life expectancy. Here we present a case series of patients who have
Their overall pre-morbid state can be compared to the neck of been successfully treated with a primary tibiotalocalcaneal nail in
femur fracture patient population, and the priority as in patients the context of open fracture-dislocation of the ankle, with a low
with neck of femur fractures is to provide a surgical treatment rate of post-operative complication and a timely return to
that minimizes the complication rate and facilitates early ambulation.
ambulation. Traditional open reduction internal xation in
osteoporotic bone can involve a period of non-weight-bearing. 2. Methods

2.1. Participants
* Corresponding author.
E-mail addresses: lesley.armstrong@doctors.org.uk (L. Armstrong), 35 ankles were treated with a tibiotalocalcaneal nail for
john.jackson1@nhs.net (J. Jackson), andrew.riddick@nbt.nhs.uk (A. Riddick). unstable ankle fractures between 1 July 2011 and 30 June 2016.
1
Present address: North Devon District Hospital, Raleigh Park, Barnstaple EX31
22 of these ankle fractures were open fractures requiring soft
4JB, United Kingdom.

http://dx.doi.org/10.1016/j.fas.2017.03.015
1268-7731/ 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: L. Armstrong, et al., Tibiotalocalcaneal nail xation and soft tissue coverage of GustiloAnderson grade 3B
open unstable ankle fractures in a frail population; a case series in a major trauma centre, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.
fas.2017.03.015
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FAS 1037 No. of Pages 6

2 L. Armstrong et al. / Foot and Ankle Surgery xxx (2017) xxxxxx

tissue coverage. All the open fractures were grade 3B as per the Nail (Synthes, West Chester, PA, USA). The diameter of nail ranged
GustiloAnderson classication. One ankle was a revision from 10 to 12 mm and the length 150 to 300 mm. All nails were
procedure following failed open reduction internal xation and locked proximally and distally. None of the ankles had joint surface
was excluded from this study. In the remaining 21 ankles preparation before nailing. All required soft tissue coverage
(in 20 patients), a tibiotalocalcaneal nail was used for primary performed by a Plastic Surgeon, and this was achieved with either
xation. Three patients were male and 17 female. The average age a local ap or free ap and split skin graft (SSG). 12 ankles had a
was 76 (range 4898). Mechanisms of injury were a combination of medial plantar ap, two dorsalis pedis ap, two free gracillis ap,
low- and high-energy. Two patients (three ankles) had concomi- one free anterolateral thigh ap, one free scapula ap, one
tant signicant injuries. 18 patients had isolated injuries. myocutaneous ap, one bilobed transposition ap, and one patient
11 fractures were trimalleolar, four bimalleolar (medial and had SSG alone without a ap. Intravenous antibiotics were started
lateral), two bimalleolar (lateral and posterior), two lateral on admission. Patients having coverage with local aps had the ap
malleolus fractures, one lateral malleolus with anterior tibial raised prior to the tibiotalocalcaneal nailing. After the ap was
Tillaux fractures and one lateral malleolus with ipsilateral talar raised, the nail was inserted by the Trauma & Orthopaedic Surgeon
neck fracture. See Table 1 for a summary of patient demographics using the technique recommended by the implant manufacturer.
and results. Patients having coverage with an anterolateral thigh free ap had
the ap raised from the contralateral thigh at the same time as the
2.2. Data collection nailing. A below-knee backslab was applied to limit movement to
protect the ap. The patients were transferred post-operatively to
We retrospectively identied all patients on our trauma the Plastic Surgery ward, where they were monitored on a strict
database (Bluespier International, Droitwich UK) who had been ap protocol. Please see Figs. 1 and 2.
treated surgically for an ankle fracture within this time frame. We
reviewed the ward-round entries and operation notes for all of 2.5. Ethical approval
these patients to establish which patients had an open ankle
fracture and had been treated with a tibiotalocalcaneal nail and We referred to the NHS Health Research Authority online
soft tissue coverage. We reviewed each patients radiographs pre- information and decision-making tool. We did not require ethical
and post-xation, discharge summaries, Trauma & Orthopaedic approval from the NHS Research and Ethics Committee (NHS REC)
follow-up clinic letters, and letters from the Plastic Surgery for this study.
database. From these sources in combination, we ascertained
patient age and comorbidities, pre-injury residence, mechanism of 3. Results
injury, concomitant injuries, fracture conguration, date of initial
debridement, date of tibiotalocalcaneal nail, details of all surgeries, 3.1. Return to ambulation and discharge destination
grade of open fracture, method of soft tissue coverage, post-op
weight-bearing status, length of hospital stay, discharge destina- 15 patients (16 ankles) lived in their own home prior to their
tion, follow-up details, post-op complications, details of further injury, one in a warden-controlled at, two in a residential home,
surgery, and death rate. We cross-referenced our software sources one in a care home and one in a nursing home. 14 patients
to ensure accuracy of data. (15 ankles) were repatriated to their local hospitals for ongoing
rehabilitation, two were transferred to community hospitals, one
2.3. Staging of surgery to a care home and three discharged home. Only two patients from
home managed to return home directly from our hospital. The
All patients received treatment as per the British Orthopaedic average length of stay in the major trauma centre was 18 days. The
Association Standards for Trauma 4 [4] for open fracture majority of our patients were non-weight-bearing through the
management. The decision on whether to stage the surgery or operative ankle for two weeks to allow ap healing (range one to
carry out debridement, xation and soft tissue coverage in a single six weeks). After this weight-bearing as tolerated was advised. One
sitting was made during the rst visit to theatre. Two ankles were patient had limited mobility at four months post-operatively, but
treated in a single stage, having debridement, tibiotalocalcaneal this was related to frailty rather than to ankle xation complica-
nail and coverage with a medial plantar ap and split skin grafting tions.
in the same session. The remaining 19 open ankle fractures had an
initial washout, debridement and stabilization followed by 3.2. Complications and re-operation
denitive xation and coverage on average 1.5 days later (range
04 days). Three of our patients had the primary debridement One patient required further surgery to their ankle. This was
performed before transfer to our major trauma centre, and one of undertaken during the same admission as their ankle fracture
these had a further debridement (and application of external surgery and was a soft tissue procedure to re-perfuse a
xation) before the denitive surgery. Of the 19 ankles having threatened ap. To date, none of the patients included in this
staged surgery, six were stabilised with temporary external series have required re-operation for implant-related reasons
xation, one with a tibiotalocalcaneal Steinman pin, one with (mean time from surgery 13 months; range 535 months, four
Kirschner wires and a bula nail and 11 with plaster applied in patients died with the implants in situ) and none have undergone
theatre. Nine ankles had vacuum-dressings applied, and ten had amputation. One patient developed cellulitis over the apthis
standard dressings. was successfully treated with antibiotics. Five other patients had
wound swabs taken from the operative leg, which were positive
2.4. Operative technique for various bacteria. This gives an overall supercial post-op
wound colonisation/infection rate of 29%. One patient had a
Three different tibiotalocalcaneal nails were used in total over positive wound swab from the donor site on the contralateral leg.
the ve years; xation was achieved in 10 ankles with the T2 Ankle None of our patients required return to theatre due to deep
Arthrodesis Nail (Stryker Trauma GmbH, Schnkirchen, Germany), infection. One patient had failure of the SSG over donor site of the
nine with the Versanail (DePuy ACE Orthopaedics, Inc., Warsaw, dorsalis pedis ap, but went on to heal following a period of
USA) and two with the Titanium Cannulated Hindfoot Arthodesis observation.

Please cite this article in press as: L. Armstrong, et al., Tibiotalocalcaneal nail xation and soft tissue coverage of GustiloAnderson grade 3B
open unstable ankle fractures in a frail population; a case series in a major trauma centre, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.
fas.2017.03.015
FAS 1037 No. of Pages 6
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Table 1
fas.2017.03.015
open unstable ankle fractures in a frail population; a case series in a major trauma centre, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.
Please cite this article in press as: L. Armstrong, et al., Tibiotalocalcaneal nail xation and soft tissue coverage of GustiloAnderson grade 3B

Overview of patient demographics and results.

Ankle Age Mechanism Wound Other regions injured Co-morbidities Residence Place of Length of Stages Nail Soft tissue Length of Re- Deep Survival
location pre-injury discharge stay in coverage time non- operation infection
major weight
trauma bearing
centre (weeks)
(days)
1 78 Fall Medial & None Diabetes Home Hospital 18 3 DePuy ACE Dorsalis pedis 2 No No Deceased
lateral transfer VersaNail ap & SSG
150  12 mm
2 91 Fall Medial & None Long-term catheter Residential Hospital 18 2 DePuy ACE Myocutaneous 6 No No
lateral home transfer VersaNail ap & SSG
180  10 mm
3 61 Fall Anteromedial None CVA, PE, asthma Home Home 27 2 DePuy ACE Medial plantar 2 No No Deceased
VersaNail ap & SSG
150  10 mm
4 79 Fall Medial None DM2,IHD, CABG, HTN, Home Hospital 7 2 Depuy ACE SSG 2 No No

L. Armstrong et al. / Foot and Ankle Surgery xxx (2017) xxxxxx


asthma transfer VersaNail
150  10 mm
5 91 Fall Medial None Dementia, Residential Hospital 11 2 DePuy ACE Medial plantar 2 No No
hypothyroidism, home transfer VersaNail ap ad SSG
intracerebral tumour 180  10 mm
excision
6 82 Fall Medial None Dementia Home Community 49 1 DePuy ACE Medial plantar 2 No No
hospital VersaNail ap & SSG
150  10 mm
7 84 Fall Medial None CKD 4, vascular Home Community 18 2 DePuy ACE Bilobed 1 No No Deceased
dementia, hospital VersaNail transposition
hypoalbuminaemia, 180  12 mm ao
chronic lymphoedema
8 65 Fall Medial None Partial paraplegia Home Hospital 15 2 Synthes Medial plantar 2 No No
following C1/2 fusion transfer HAN ap & SSG
150  10 mm
9 58 Fall Medial None Psychiatric illness Home Hospital 18 2 DePuy ACE Medial plantar 2 No No
transfer VersaNail ap & SSG
150  10 mm
10 84 Fall Anterolateral None Smoking, moderate Home Home 14 2 DePuy ACE Dorsalis pedis 1 No No
alcohol intake VersaNail ap & SSG
150  10 mm
11 83 RTC Lateral Thorax, pelvis, Hypothyroidism, vulval Nursing Hospital 24 2 Stryker Free scapular 4 No No
contralateral leg lichen sclerosis home transfer T2 ankle ap
(AKA) ipsilateral knee arthrodesis
soft tissue injury and nail
calcaneum fracture 150  12 mm
12 98 Fall Medial None Dementia, CKD 3, IND, Home Care home 31 2 Synthes Medial plantar 4 No No
eczema, THR, cervical HAN ap & SSG
spondylosis, iron- 180  10
deciency anaemia
13 79 Fall Medial None CVA, DM2, HTN, GORD Warden- Hospital 15 2 Stryker T2 Medial plantar 4 No No
controlled transfer ankle ap & SSG
at arthrodesis
nail 150  11
14 59 Absence Medial None Learning difculties, Care home Hospital 16 1 Stryker T2 Medial plantar 2 No No
seizure epilepsy (absence transfer ankle ap & SSG
seizures) arthrodesis
nail
150  11 mm

3
4

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fas.2017.03.015
open unstable ankle fractures in a frail population; a case series in a major trauma centre, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.
Please cite this article in press as: L. Armstrong, et al., Tibiotalocalcaneal nail xation and soft tissue coverage of GustiloAnderson grade 3B

Table 1 (Continued)
Ankle Age Mechanism Wound Other regions injured Co-morbidities Residence Place of Length of Stages Nail Soft tissue Length of Re- Deep Survival
location pre-injury discharge stay in coverage time non- operation infection
major weight
trauma bearing
centre (weeks)
(days)
15 48 Fall Medial None Psoriasis, DM2, Home Home 13 2 Stryker Medial plantar 4 Yes No
hysterectomy, chronic T2 ankle ap & SSG
leg ulcers, unexplained arthrodesis
ts, smoking nail

L. Armstrong et al. / Foot and Ankle Surgery xxx (2017) xxxxxx


300  10 mm
16 93 Fall Medial None AF, COPD, HTN, dementia Home Hospital 10 2 Stryker Medial plantar 4 No No
transfer T2 ankle ap & SSG
arthrodesis
nail 200  12
17 73 Fall Medial/ None HTN, raised BMI, DM2 Home Hospital 11 2 Stryker Free gracilis 4 No No
circumferential transfer T2 ankle ap & SSG
arthrodesis
nail
150  11 mm
18 65 RTC Lateral None Palliative bladder cancer Home Hospital 12 2 Stryker Free ALT ap & 4 No No Deceased
transfer T2 ankle SSG
arthrodesis
nail
200  11 mm
19 77 RTC Posteromedial Spine, thorax Unknown Home Hospital 21 3 Stryker T2 Free gracilis 2 No No
transfer ankle ap
arthrodesis
nail
200  10 mm
20 77 RTC Medial Spine, thorax Unknown Home Hospital 21 2 Stryker T2 Medial plantar 2 No No
transfer ankle ap & SSG
arthrodesis
nail
200  10 mm
21 71 Twisted Anterior None IHD, bromyalgia, PMR, Home Hospital 9 2 Stryker Medial plantar 2 No No
ankle extending bilateral lymphedema, transfer T2 ankle ap & SSG
medial and bilateral TKR, raised BMI, arthrodesis
lateral PE, hiatus hernia, hip & nail
spine OA 150  11 mm
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L. Armstrong et al. / Foot and Ankle Surgery xxx (2017) xxxxxx 5

Fig. 1. Photographs of open unstable ankle fracture on arrival in the emergency department, following debridement and at 8 weeks post-op.

Fig. 2. Pre- and post-op radiographs.

ankle fractures following low-energy injuries. All the patients


3.3. Survival included in our series (irrespective of injury modality) were
functionally low-demand, or in the case of one patient, had a
Four of the 20 patients have died since their open ankle surgery terminal diagnosis and an expected decline in function over the
(20%). Three of these patients died within 3 months of their surgery coming weeks. One of the patients in our study was 48 years old.
(15% three-month mortality). One patient died from metastatic She sustained an open ankle fracture dislocation through a low-
bladder cancer and had already been given a terminal prognosis energy injury (slip in the kitchen) and had signicant comorbid-
before the time of injury. Another patient died of multifocal ities consistent with a biologically older patient. She also had poor
glioblastoma, which was picked up during the open ankle fracture soft tissue integrity and multiple leg ulcers relating to her diabetes
admission while being investigated for post-operative confusion. mellitus, and we therefore felt it appropriate to include her.
We were not able to ascertain information on the cause of death for Al-Nammari et al. [7] published a case series of elderly patients
the other two patients. with a combination of open and closed unstable ankle fractures
undergoing surgical treatment with long tibiotalocalcaneal nails
4. Discussion that bypass the isthmus of the tibia. Their study included 48 low-
demand patients with a mean age of 82. 19 had open fractures and
We present the largest case series to date of patients receiving 10 of these needed soft tissue coverage. They observed an average
treatment with a tibiotalocalcaneal nail and soft tissue coverage for time to mobility of 15 days. Several complications occurred within
open unstable ankle fractures. Georgiannos et al. [5] have the group, including two surgical site infections, two graft/ap-
published a recent prospective randomized-controlled study related infections, two malunions, loosening or breaking of screws
comparing short-term results of ankle fractures in elderly patients in three, one deep infection requiring nail removal, one below knee
treated with open reduction internal xation compared to xation amputation four days following nailing and 14 signicant post-op
with a tibiotalocalcaneal nail. They included 87 patients, and found medical problems. The six-month mortality rate was found to be
a signicant shorter hospital stay, a lower complication rate (which 35% [7].
reached statistical signicance) and a higher rate of return to Our patients were all mobilising by two to six weeks post-
pre-injury mobility in the group treated with tibiotalocalcaneal operatively. The limitation on early mobility was the need for soft
nail. This study supports the use of this technique in frail patients. tissue protection following local or free ap soft tissue coverage,
Ochman et al. [6] published a smaller case series in and all patients were permitted to mobilise weight-bearing as
2012 documenting the use of tibiotalocalcaneal nails as a limb tolerated as soon as their ap protocol had ended. Patients suitable
salvage procedure in three polytraumatised patients aged for xation with a tibiotalocalcanceal nail and soft tissue coverage
1942 with bilateral talus, distal tibia or pilon injuries. These for open ankle fractures are generally frail and functionally low-
three patients had non-reconstructable joints and signicant soft demand.
tissue injury. They demonstrated moderate functional results and We have not, to date, removed any of these nails for any reason
return to former profession within a median follow-up of 5.4 years. including metalwork failure. 20% of the patients have died since
This patient group differs from those included in our series, as our their surgery for reasons unrelated to their ankle injury, three
patients are frail and elderly, and the majority have sustained open within three months resulting in a 15% three-month mortality rate.

Please cite this article in press as: L. Armstrong, et al., Tibiotalocalcaneal nail xation and soft tissue coverage of GustiloAnderson grade 3B
open unstable ankle fractures in a frail population; a case series in a major trauma centre, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.
fas.2017.03.015
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6 L. Armstrong et al. / Foot and Ankle Surgery xxx (2017) xxxxxx

This again reects the frailty of this group of patients. Two of our 5. Conclusion
patients (three ankles) had signicant concomitant injuries, which
limited their mobility. One patient has bilateral open ankle We have demonstrated a reliable technique for xation of open
fractures also with a talar neck fracture on the right (which was unstable ankle fractures in an elderly frail population of patients
treated with open reduction internal xation at the same time as comparable to the neck of femur fracture population. Tibiotalocal-
ankle xation). Their mobility was restricted to heel weight- caneal nail xation with ap coverage allows quick return to
bearing on the right to protect the talar neck xation. The second mobility, limited only by the need for soft tissue protection
patient had an unstable pelvic fracture (requiring stabilization), immediately post-operatively, and an acceptable complication rate.
had a left above-knee amputation for unsalvageable leg injuries,
and a right calcaneum fracture on the same side as the open ankle Funding
fracture. The patient was permitted to mobilise fully-weight-
bearing on the right after the ap protocol ended, but we We did not receive any funding for this work.
appreciate that their mobility may have been limited by these
other injuries. Conict of interest
We have shown an acceptable complication rate in our patients.
All supercial infections and colonisations were successfully The authors of this manuscript have no conicts of interest to
treated medically. None of patients had deep infections and the declare.
only patient to undergo further surgery related to their ankle did so
for ap detachment. Pagliaro et al. [8] carried out a study on the Acknowledgements
outcomes of patients over the age of 65 undergoing traditional
surgical xation. They included 23 ankles; 21 closed and two open We have no further acknowledgements to include.
in patients with an average age of 72. Both open fractures had
complications; the wound dehiscence/deep infection occurred in a References
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Please cite this article in press as: L. Armstrong, et al., Tibiotalocalcaneal nail xation and soft tissue coverage of GustiloAnderson grade 3B
open unstable ankle fractures in a frail population; a case series in a major trauma centre, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.
fas.2017.03.015