January 2015

Breaking bad: Ankle fracture study highlights mortality

1ITM-iStock23033942-copyBy P.K. Daniel

Is ankle fracture in the elderly the new hip fracture? Hip fractures in older adults have often been linked to high mortality rates, and a recent study suggests the same may be true of ankle fractures, given that some of the same variables are at play.

Preexisting health issues, complications related to surgery, immobility, and rehabilitation limitations are contributing factors in mortality rates among older adults after hip or ankle surgery. For example, elderly patients with ankle fractures and multiple medical problems are vulnerable to deep vein thrombosis and pulmonary embolism following prolonged periods of non-weightbearing.

Of 11 patients older than 60 years who had experienced low-energy, open-ankle fractures and had been treated at the University of Florida in the College of Medicine’s Department of Orthopaedic Surgery and Rehabilitation in Jacksonville, more than a quarter (27.2%) died in less than three months.

But the study, epublished in December 2014 by the Journal of Foot and Ankle Surgery (JFAS), also found that 81.81 % of the 11 patients had three or more medical comorbidities, including hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, or a combination of these conditions.

AnkleRoll-Guard-Ad-1“Overall, these patients are indeed sicker at the time of presentation,” said lead study author William Peyton Toole, MD, an orthopedic surgeon at the University of Florida.

In addition to comorbidities jeopardizing patients, the loss of mobility and conditioning from being non-weightbearing impedes the healing process, said Christy M. King, DPM, an attending foot and ankle surgeon with Kaiser Permanente in the San Francisco Bay Area.

“It may be that keeping them non-weightbearing causes a rapid decline in their conditioning and makes it a much harder battle to fight when reconditioning,” King said. “This may contribute as much to the risk of mortality as the comorbidities.”

Orthopedic surgeons and physical therapists realize the risks associated with hip fractures and therefore try to get patients out of bed and moving as soon as possible after surgery, King noted.

“It may be time for foot and ankle surgeons to consider earlier weightbearing in our high-risk populations,” she said.

While surgery-related complications contribute to mortality risk, there currently isn’t another treatment option, particularly with an open ankle fracture, which typically requires open reduction and internal fixation (ORIF) to realign the fractured bone.

In this study, all of the ankle fractures were the result of low-energy falls, ie, those from a standing or sitting position. One patient, Toole noted, sustained an open ankle fracture while getting up after using the toilet. The study findings offer more evidence of the need for fall prevention in older adults.

“These patients sustain devastating and potentially catastrophic injuries from low-energy falls,” said Toole. “I think this study provides further credence for fall prevention in the elderly population, such as smart homes.” A smart home allows its occupants to control lighting, heating and electronic devices remotely by phone or computer.

King agreed fall prevention and safety should be paramount to help patients avoid these low-energy injuries.

DJO Global Bone Healing - CMF“Gait training is important, and making sure patients are protected when weightbearing with a walker or assistive device,” she said.

King also stressed that, since it’s more challenging to prevent falls in patients with dementia, these patients need more attention.

“It is important to have assistants around who can help watch these patients so they don’t get up confused and injure themselves,” she said.

Reducing obesity in older adults can also help prevent falls, King said. Bone mineral density is thought to be higher in obese individuals than in their normal-weight counterparts, but the percentage of lean body mass is lower in obese patients, so the relative bone mineral density is also lower—which may increase the risk of ankle fragility fractures in the elderly, she said. In the JFAS study, the average BMI was 35.93, which is considered severely obese.

Toole plans to undertake expanded research using data pooled from multiple medical centers across the US.

“We hope to better be able to study associations with particular medical problems, risks, etc,” he said.


Toole WP, Elliott M, Hankins D, et al. Are low-energy open ankle fractures in the elderly the new geriatric hip fracture? J Foot Ankle Res 2014 Dec 5. [Epub ahead of print]

Lynde MJ, Sautter T, Hamilton GA, Schuberth JM. Complications after open reduction and internal fixation of ankle fractures in the elderly. Foot Ankle Surg 2012;18(2):103-107.

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