Medical Device Daily Associate

CHICAGO – Some of the best new approaches for treating ankle fractures in the elderly and the newest surgical options for ankle arthritis in both younger and older patients were outlined in a media briefing here at the McCormick Place Convention Center during the American Academy of Orthopaedic Surgeons (AAOS; Rosemont, Illinois) annual meeting.

A new study may bolster the utility of ankle surgery in patients over the age of 60 with severe fractures, a group that has traditionally had a cast put on and told just to “Hope for the best.“

The study was presented by Kenneth Egol, MD, chief of orthopedic trauma service at the New York University – Hospital for Joint Disease (New York), who said that these older patients do not have worse functional outcomes than younger patients, contrary to the indications of previous research.

“Our data show that those over age 60 do just as well clinically as younger people one year after surgery, with few complications,“ said Egol. “However,“ he cautioned, “self-reported functional results fall below those of patients younger than 60.“

Even despite the underreporting by older patients, Egol said he believes elderly ankle fracture patients need to be treated the same way as younger patients.

“This study gives support to the current aggressive treatment for unstable ankle fractures so patients can return to their pre-injury function,“ he said.

Egol noted that unstable fractures – those with injury to both sides of the ankle – require surgery to fix the joint so it will heal properly. Unlike surgical treatment of hip fractures, considered standard therapy, surgical repair of ankle fractures in older patients is “still debated,“ he said, noting that many doctors believe that some age-related diseases like osteoporosis, diabetes and skin problems predispose older patients to poor surgical outcomes.

Even so, Egol pointed out that casting may have complications of its own, including joint stiffness, decreased range of motion and improper healing.

The study followed 369 patients (313 patients younger than 60 and 56 patients 60 or older) who received surgical treatment of unstable ankle fractures, followed by six weeks of wearing a brace and not putting weight on their ankle. Total scores for functional outcome – the ability to perform activities of daily living – did not significantly differ between the two groups when measured at three, six and 12 months.

While function steadily improved in both groups, Egol said it did so to a lesser degree in the 60 and over patients. He said this finding indicates that elderly patients may need a more intensive rehabilitation program early on to improve functional ability.

In another presentation, Charles Saltzman, MD, professor and chairman of orthopedics at the University of Utah (Salt Lake City), provided an overview of current treatments for ankle arthritis, including new surgical techniques that may improve the results of ankle fusion, considered by many to be the current gold standard for the end stage of the condition.

Saltzman said that while fusion in the ankle can result in nearly 90% of patients experiencing initial pain relief, many will inevitably develop complications in adjacent joints to the fusion site.

“Long-term results of ankle fusion are not always satisfactory in terms of function and pain relief,“ he said.

One alternative method to fusion he described is total ankle replacement (TAR), which includes the popular and most commonly performed Agility ankle replacement, sold by DePuy (Warsaw, Indiana).

He reported that one 126-patient study, with an average follow-up time of nine years, revealed that 92% of patients were still satisfied with their implants and that 94% of the would have the surgery, again even though 27% of them said they still experienced pain on a daily basis.

Saltzman said, however, that it is difficult to find good TAR candidates since patients for this procedure must be low demand, have good skin and vascularity and good ankle alignment.

“When I started looking for these patients,“ he said, “I find they are relatively rare.“

An emerging treatment he described involves the use of osteochondral allograft from a donor. This requires resurfacing a damaged area of ankle bone and cartilage – which is the covering on the ends of the bone – and transplanting bone and cartilage from a donor.

He said that while the procedure can be successful and produce excellent patients, there are concerns with the potential viability of the cartilage, the possibility for host vs. graft disease, and a slim chance of disease transmission, though this has been greatly reduced due to more rigorous screening procedures for donor tissue.

Saltzman told Medical Device Daily that since the procedure is reversible, patients are not put on anti-rejection drugs even with the graft vs. host disease concerns. “Due to their negative side effects,“ he said, “those types of drugs are reserved for organ transplant patients who have to have them to survive.“

A new surgery being investigated for treatment of severe ankle arthritis is distraction – the surgical separation of two parts of bone – and leaving a supportive frame on the ankle for three months.

“The concept is to pull the joint apart, allowing it to rest and repopulate the surface with cells that are able to help the joint repair itself,“ Saltzman said.

He said one 50-patient Dutch study reported a 75% improvement of patients who underwent the procedure, with 13 patients ultimately having to undergo a fusion.

Distraction in particular, he noted, is a good alternative to fusion for younger patients.