Early weight bearing in elderly patients with ankle fractures reduces care needs and maintains independence

Abstract

Background

Ankle fractures in the elderly are increasingly prevalent and are associated with significant morbidity and loss of independence.

Method

Patients over the age of 70 suffering ankle fracture were identified using ICD-9-CM patient coding. Fracture stability was assessed using patient records and radiographic evidence. Management strategy, length of inpatient stay, time non-weight bearing, pre-admission residence, discharge destination and discharge care needs were studied.

Results

169 patients with a mean age 80.3 years were studied. Management strategy was shown to have a significant effect on a patient’s care requirements (p = 0.012) and ability to return to their primary residence (p = 0.014). Management via an intramedullary rod was associated with the lowest rates of increased care needs (29.7%) and the highest rate of returning home on discharge (88.9%).

Conclusions

Early weight bearing had a significant effect on a patient’s ability to maintain independent living and were more likely to return to their own home.

Introduction

Ankle fractures amongst elderly patients carry with them significant morbidity and loss of independent living but lack modern care pathways [1], [2]. The prevalence of ankle fractures in the elderly is predicted to increase further [3]. Optimal surgical management of elderly ankle fractures is debatable and carries certain risks [1], [4]. Local and systemic operating factors complicate their treatment and can make conservative treatment more attractive. Ankle fractures in the elderly carry with them a significant loss in independent living, up to 60% in one study [5]. Further to this, it demonstrated an increased one year mortality in these patients after this change in social circumstances of 15.4% [5]. Weight bearing status has been identified as a key area of focus that may benefit patients by allowing early discharge and return home [6].

Close Contact Casting has been suggested as an alternative to operative fixation with equivalent functional outcomes but runs the risk of loss of reduction [4], [7]. Traditional operative management of an unstable ankle fracture by Open Reduction and Internal Fixation (ORIF) or casting could entail 6 weeks of non-weight bearing. Elderly patients sustaining hip fractures show that restricted weight bearing decrease the likelihood of home discharge [8] and increase a patients’ length of stay in a rehabilitation facility [9]. Immobility in the elderly can lead to adverse health effects such as sarcopenia, pressure injuries and urinary tract infections amongst others [10], [11]. Hospitalisation is also associated with a high incidence of functional decline in the elderly [12]. Protracted hospital stays are both damaging to the patient and the healthcare system. Unnecessarily long stays not only cost the healthcare system financially, but can impair the ability of others to access it (e.g. cancellation of elective surgery).

The goal of surgical fixation of ankle fractures in elderly patients needs to be to return patients to activities of daily living and this can be achieved by early weight bearing [2]. Intramedullary fibular nailing has been suggested as an effective alternative to ORIF and with comparable biomechanical properties [13], [14], [15], [16], [17]. It has been shown to be particularly useful in patients at high risk of wound complications [13], [18]. With the advantages of minimal soft tissue insult from fibular nails, it is possible to begin to early weight bear patients to avoid associated morbidity from loss of mobility.

The objective of this study was to assess the effect of management strategy upon length of inpatient stay, subsequent discharge destination and care needs. It was felt that the ability to immediately weight bear post-operatively would be associated with shorter inpatient stays and a higher rate of patients retuning home with no increased care requirements.