Guryel Enis, McEwan Jo, Qureshi Amir A, Robertson Alastair, Ahluwalia Raju, Baxter Mark, Mason Lyndon, Eardley Will, McFadyen Iain, Trompeter Alex, Giblin Anna V, Handley Bob, Lahoti Om
University Hospitals Sussex, Brighton, UK.
University Hospital Southampton, Southampton, UK.
Bone Jt Open. 2024 Mar 22;5(3):236-242. doi: 10.1302/2633-1462.53.BJO-2023-0155.R1.
Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.
A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS).
In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures.
A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing.
踝关节骨折是常见损伤，也是第三大常见的脆性骨折。总体而言，体弱患者中40%的踝关节骨折为开放性骨折，这代表了一种复杂的临床情况，其发病率和死亡率与髋部骨折患者相似。它们发生并发症的风险更高，如伤口感染、畸形愈合、医院获得性感染、压疮、静脉血栓栓塞事件，以及因长期卧床导致的严重肌肉减少症。
采用改良的德尔菲法，邀请了来自英国足踝协会（BOFAS）、英国骨科协会（BOA）、骨科创伤协会（OTS）、英国整形与重建外科医生协会（BAPRAS）、英国老年医学协会（BGS）和英国肢体重建协会（BLRS）的一群对最佳实践有既得利益的专家。
在第一阶段，有36名受访者参与调查，超过70%的人表示其所在科室每年治疗超过20例此类病例。对于手术时机应按照髋部骨折指南在36小时内进行，还是按照开放性骨折指南在72小时内进行，存在50:50的分歧。总体而言，75%的人会尝试一期伤口闭合，25%的人会采用局部皮瓣。在固定方面没有骨科方面的一致意见，75%的人会允许立即负重。在第二阶段，于英国肢体重建协会会议上进行，专家们讨论了调查结果，并就开放性老年踝关节骨折的管理达成了共识。
专家小组达成了一项共同认可的共识，以实现对体弱开放性踝关节骨折患者的最佳管理：1）所有管理下肢脆性骨折的科室都应通过多学科联合途径进行。该途径应遵循英国骨科协会创伤与骨科标准（BOAST）指南中“老年或体弱骨科创伤患者的护理”所规定的标准。这些患者骨密度低，我们应建议进行全面的跌倒和骨骼健康评估；2）所有开放性下肢脆性骨折应尽可能在受伤后24小时内进行一期治疗；3）所有下肢脆性骨折患者应在术后当天考虑活动；4）所有下肢开放性脆性骨折患者应考虑保留组织，默认进行明智的清创；5）所有下肢开放性脆性骨折患者应由整形外科顾问医生管理，尽可能进行一期闭合；6）固定方法必须允许立即无限制负重。
