Dhillon Mandeep S, Rajnish Rajesh Kumar, Patel Sandeep, Chouhan Devendra K, Bansal Tungish
Department of Orthopaedics, PGIMER, Chandigarh, 160012, India.
Department of Orthopaedics, AIIMS, New Delhi, India.
J Clin Orthop Trauma. 2020 May-Jun;11(3):380-387. doi: 10.1016/j.jcot.2019.10.010. Epub 2019 Nov 4.
The management of Osteoporotic ankle fractures is still considered to be a challenge by many surgeons. One of the issues seems to be a lack of data focused on this special subgroup, with very little evidence of good quality. We did a narrative review of the literature in an attempt to identify the magnitude of the problem and to evaluate the evidence in support of management options.The current review of the literature has brought to light some interesting facts. Despite limited data there seems to be an in increase in the incidence of these fractures. Although we could not demonstrate any clear distinction between geriatric and osteoporotic ankle fractures from the available literature; it is clear that all geriatric fractures are not necessarily osteoporotic and neither is the reverse true. The evidence to associate osteoporotic ankle fractures with poor outcomes is weak, and factors other than osteoporosis may have a stronger influence. From this analysis, we could not establish a higher incidence of implant failure for this specific fracture group, although many modifications in technique have been proposed due to the fear of fixation failure. Hook plating and Tibia-pro fibula fixation have weak evidence in support, but posterior fibular plating is preferred due to soft tissue protection. There is weak evidence in support of Locking plates for these fractures, as publications focused on this are limited; nevertheless some advantages have been documented. Augmentation by calcium based bone graft substitutes has been reported to improve pull out strengths of screws, but again the evidence of its role in Osteoportic fractures is limited. Fibular nailing has been proposed with specific advantages in osteoporotic fibular fractures, but the concept is new and it is indicated only in a select a subgroup of cases. Some evidence exists for the use of trans-articular nails in geriatric subgroups with limited pre-injury mobility, but the technique has to be used with caution to prevent other complications.
More data needs to be accumulated before clear guidelines for management of osteoporotic ankle factures are defined; however the current literature supports the need for modifications in standard ankle facture fixation methods to improve outcomes.
许多外科医生仍认为骨质疏松性踝关节骨折的治疗是一项挑战。其中一个问题似乎是缺乏针对这一特殊亚组的数据，高质量的证据非常少。我们对文献进行了叙述性综述，试图确定该问题的严重程度，并评估支持治疗方案的证据。当前对文献的综述揭示了一些有趣的事实。尽管数据有限，但这些骨折的发生率似乎在上升。虽然从现有文献中我们无法明确区分老年踝关节骨折和骨质疏松性踝关节骨折；但很明显，并非所有老年骨折都是骨质疏松性的，反之亦然。将骨质疏松性踝关节骨折与不良预后相关联的证据很薄弱，骨质疏松以外的因素可能有更强的影响。通过此次分析，我们无法确定这一特定骨折组植入物失败的发生率更高，尽管由于担心固定失败已提出了许多技术改进建议。钩钢板和胫腓联合固定的支持证据薄弱，但由于对软组织的保护，后外侧腓骨钢板更受青睐。对于这些骨折，锁定钢板的支持证据薄弱，因为专注于此的出版物有限；然而，已记录了一些优点。据报道，使用钙基骨移植替代物进行增强可提高螺钉的拔出强度，但同样，其在骨质疏松性骨折中作用的证据有限。有人提出腓骨髓内钉在骨质疏松性腓骨骨折中有特定优势，但这一概念尚新，仅适用于特定的一小部分病例。对于在伤前活动受限的老年亚组中使用经关节髓内钉有一些证据支持，但使用该技术时必须谨慎以防止其他并发症。
在确定骨质疏松性踝关节骨折的明确治疗指南之前，需要积累更多数据；然而，当前文献支持对标准踝关节骨折固定方法进行改进以改善预后。
