Management of severe open ankle injuries

Functional outcome after reconstruction of open ankle injuries has not been well presented in the literature. The authors present the functional results of 24 patients who sustained complex ankle injuries.

Patients were assessed using three scoring systems (a modified A/O score, the Enneking score, and the AOFAS) and subdivided into two groups: those primarily treated at Charing Cross Hospital according to strict protocols combining orthopedic and plastic surgical techniques (group P) and those secondarily treated who were transferred to Charing Cross Hospital after initial management at a remote unit (group S).

There were nine patients (37.5 percent) in group P and 15 (62.5 percent) in group S. Eighteen patients (75 percent) underwent free-tissue transfer. Sixteen patients (67 percent) were assessed (group P, n = 7; group S, n = 9) for return of function using the Enneking score. Mean time to assessment was 10.5 months for group P and 11.4 months for group S. Mean Enneking percentage score was 75 for group P and 72.2 for group S. There were no significant differences (p > 0.05) between these scores. The mean time to union was 19 weeks (n = 5) for group P and 24 weeks (n = 7) for group S. The mean AOFAS Ankle-Hindfoot Scores were comparable to the Enneking scores when independent observers undertook this assessment. Most patients in both groups reported difficulty with descent of stairs.

Although the authors were able to achieve a similar return of function for both groups, group S patients needed at least one more operation. In cases of ankle fracture where there is significant soft-tissue injury (either closed or open), representing a complex injury, the authors recommend making no attempt to internally fix the fracture and instead referring the patient to a specialist center for combined orthoplastic attention. If this is not immediately at hand, screw fixation of the medial malleolus should be undertaken after open reduction. The lateral malleolus should not be internally fixed, but should it require control, external fixation is the preferred method of skeletal stabilization.