title: Low energy open ankle fractures in the elderly: Outcome and treatment algorithm.
abstract: BACKGROUND
  With an aging but still active population, open ankle fractures are increasingly presenting as low energy fragility injuries, sharing many characteristics with that of hip fractures. Yet, there is little in the literature on the management and outcome of these fractures. The primary aim of this study was to describe the outcome following open, ankle fragility fracture. Our secondary aim was to identify potential factors that improved outcome.
  
  
  METHODS
  All consecutive, low energy open ankle fractures treated at a Level I Trauma Centre over a five-year period were included. The method of fracture fixation, soft tissue closure, patient demographics, complications and mortality were recorded. Functional outcome was assessed using the Enneking Scoring system.
  
  
  RESULTS
  The cohort comprised 61 patients with a mean age of 73 years (range 27-100); 50 (82%) were females and all patients requiring operative intervention. The overall rate of complication was 24.5% (n=15), with reoperation due to loss of reduction, non-union, infection or amputation required in 7 cases (11.5%). The one-year mortality was 23%. The mean Enneking score, measuring functional outcome, was 36 out of 40 (SD: 6, range: 16-40). It was significantly higher for those treated with internal fixation (37, SD: 5 range: 16-40) than those with external fixation (31, SD: 6 range: 21-38) (p=0.01). Similarly, definitive wound closure - primary closure (37, SD: 5) or flap with split thickness skin graft (SSG) (36, SD: 6) - led to better outcomes than non-definitive closure (31, SD: 8).
  
  
  CONCLUSIONS
  The high morbidity associated with low energy ankle fractures is likely to reflect the hosts' reserves and is comparable to other fractures seen in the elderly. It is evident that definitive fracture fixation providing absolute, rather than relative stability; and definitive wound cover, with either primary closure or flap and SSG, enable early mobilization and shorter hospital stays with improved overall functional outcomes.
authors.affiliation: Trauma Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, United Kingdom. Electronic address: awijendra@doctors.org.uk.
authors.forename: Asanka
authors.initials: A
authors.lastname: Wijendra
authors.affiliation: Trauma Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, United Kingdom.
authors.forename: Rupali
authors.initials: R
authors.lastname: Alwe
authors.affiliation: Trauma Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, United Kingdom.
authors.forename: Michael
authors.initials: M
authors.lastname: Lamyman
authors.affiliation: Trauma Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, United Kingdom.
authors.forename: George A
authors.initials: GA
authors.lastname: Grammatopoulos
authors.affiliation: Trauma Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, United Kingdom.
authors.forename: Gregoris
authors.initials: G
authors.lastname: Kambouroglou
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D064386:Ankle Fractures / Q000453:epidemiology / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005593:Fracture Fixation, Internal; D005597:Fractures, Open / Q000453:epidemiology / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000517:prevention & control; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology; D014945:Wound Healing / Q000502:physiology
keywords: Ankle; Elderly; Fragility fracture; Functional outcome; Low energy; Open fracture