Nilkkamurtuma – Infektioriskipotilaiden hoito nilkkamurtumissa

25.05.2022

Acumed Fibula Rod System fibula-murtuma levytykseen.
  • Nilkkamurtuman leikkauksenjälkeisistä komplikaatiosta 38 % ovat syviä infektioita.
  • Komplikaatiot nostavat reilusti murtumapotilaiden hoitokustannuksia.
  • Mini-invasiivinen ydinnaulan käyttö vähentää leikkaushaavainfektioita nilkkamurtumaleikkauksissa.

Nilkkamurtuma on yleisin sairaanhoitoa vaativa murtuma työikäisillä. Näitä murtumia hoidetaan Suomessa vuosittain 4500 kappaletta. Leikkauksen jälkeen tekijät kuten pehmytkudosvamma, verenkierto-ongelmat sekä nilkan anatomia, voivat altistaa ongelmille. Kaikista nilkkamurtumaleikkauksen jälkeisistä komplikaatioista syvän infektion osuus on suomalaisen väitöskirjan mukaan 38 %. Komplikaatiot nostavat reilusti hoitokustannuksia murtumien hoidossa. Kustannuksia on pystytty laskemaan oikealla implanttivalinnalla, mikä vähentää komplikaatioita. Nilkan murtuman leikkaushoidossa tulee huomioida monia eri asioista, eikä katsoa pelkästään röntgenkuvia.

Yleisimmät leikkaukseen liittyvät komplikaatiot

Leikkausta edeltävät komplikaatiot

  • Puutteellinen diagnostiikka
  • Väärä hoitomenetelmä
  • Väärä leikkauksen ajoitus

Leikkauksenaikaiset komplikaatiot

  • Suboptimaalinen mikrobilääkeprofylaksia
  • Latrogeeninen hermovaurio
  • Ruuvi nivelessä
  • Puutteellinen murtuman kiinnitys
  • Reduction epäonnistuminen

Varhaiset leikkauksenjälkeiset komplikaatiot

  • Haavan aukeaminen
  • Haavan reunanekroosi
  • Pinnallinen infektio
  • Syvä infektio
  • Asennon pettäminen

Myöhäiset leikkauksenjälkeiset komplikaatiot

  • Trombi
  • Luutumattomuus
  • Jäykkyys
  • Implanttiin liittyvä kipu
  • Virheasentoon luutunut murtuma

Miten komplikaatioilta voidaan välttyä nilkkamurtuman leikkaushoidossa?

Ennen leikkausta

  • Hoitomenetelmän arviointi: stabiili -> ei leikkaushoitoa vs. instabiili -> leikkaushoito
  • Riskitekijöiden arviointi: tupakointi, diabetes, aso-tauti, alkoholi, ylipaino, pehmytkudosvammat, murtumatyyppi
  • Leikkausajankohta

Leikkauksen aikana

  • Mikrobiprofylaksian oikea-aikaisuus
  • Implantin valinta
  • Kudosten oikeaoppinen käsittely
  • Nivelhaarukka kongruentiksi

Leikkauksen jälkeen

  • Mahdollisimman varhainen kipsaus
  • Oikein ajoitettu mobilisaatio

Implanttivaihtoehdot nilkkamurtumien leikkaushoidossa

Nilkkamurtuma voidaan hoitaa erilaisilla implanttivaihtoehdoilla. Oikean implantin valinta onkin tärkeässä osassa nilkkamurtumapotilaan leikkaushoitoa. Yleisimmin käytettävät implantit leikkaushoidossa ovat 1/3-tubulaarilevy tai mini-invasiivisesti asennettava kanyloitu ruuvi. Pirstaleisissa murtumissa ja huonon luunlaadun omaavilla potilailla käytetään yleensä lukkolevyjä, jolloin murtuma-alueelle on mahdollista saada enemmän ruuveja. Lukkolevyissä myös ruuvien pito saadaan levystä eikä luusta, joka helpottaa murtuman korjaamista. Pahoissa nilkkamurtumissa voidaan käyttää myös externifixaattoria tai kantanaulaa, mikäli muilla leikkausmenetelmillä riskit ovat liian suuret.

Ydinnaula nilkkamurtuman hoitoon

Aikaisemmin mainittujen lisäksi pohjeluun ydinnaulaaminen nilkkamurtumien hoidossa on lisääntynyt viime vuosien aikana hyvien tutkimustulosten ja käyttökokemuksien johdosta. Ydinnaulaa käytetään erityisesti korkean infektioriskin potilailla komplikaatioiden välttämiseksi ja hoitokustannusten pienentämiseksi. Ydinnaula asennetaan mini-invasiivisesti eli pienistä viilloista, jolloin yleiset leikkaushaavan infektiot ja ongelmat vähentyvät huomattavasti. Aiheesta on julkaistu sekä kotimaisia, että ulkomaisia tutkimuksia viime vuosina. Tutkimusten mukaan hoitotulokset ovat vastanneet levyttämällä hoidettujen tuloksia, ja samalla infektiot ovat vähentyneet huomattavasti pohjeluun ydinnaulan käytön johdosta. Julkaisuihin pääset tutustumaan sivun lopussa.

Acumedin ratkaisut infektioriskipotilaiden hoitoon

Fibula Rod

Acumedin Fibula Rod järjestelmä tarjoaa vaihtoehtoisen lähestymisen traditionaaliseen fibulan levytykseen. Järjestelmän avulla leikkaus voidaan suorittaa mini-invasiivisesti ja intramedullaarinen titaaninen implantti tukee hyvin murtuma-aluetta ja on biomekaanisesti levyä tukevampi ratkaisu. Mini-invasiivinen tekniikka auttaa minimoimaan ihoavauksen määrän sekä pehmytkudosten ja periosteumin dissekaation. Implantti on suunniteltu erityisesti korkean komplikaatioriskin potilaiden hoitoon.

Fibula Nail 2

Acumed Fibula Nail 2 on toisen sukupolven järjestelmä pohjeluun naulaamiseen. Myös Fibula Nail 2 on samat edut, kun Fibula Rodissa: se on mini-invasiivinen, murtumaa tukeva ja infektioita vähentävä. Naulan muotoilua on kehitetty aiemmasta versiosta ja implanttivalikoimaan on tullut lisää naulan paksuuksia ja pituuksia. Myös instrumentaatiota on kehitetty käyttäjäystävällisempään suuntaan.

Lue myös artikkeli trimalleolaarisen nilkkamurtuman leikkauksesta posterioirisesta avauksesta.

Lähteet:

Pakarinen, Harri; Laine, Heikki-Jussi; Ristiniemi, Jukka. 2012. Milloin nilkkamurtuman voi hoitaa ilman leikkausta? Lääketieteen aikakausikirja Duodecim 2012;128(17):1770-6 (viitattu 19.5.2022). Saatavilla internetissä: https://www.duodecimlehti.fi/duo10477

Ovaska, Mikko; Madanat, Rami; Mäkinen, Tatu; Lindahl, Jan. 2015. Nilkkamurtuman leikkaushoidon komplikaatiot. Lääketieteen Aikakausikirja Duodecim 2015;131(16):1451-9 (viitattu 19.5.2022). Saatavilla internetissä: https://www.duodecimlehti.fi/duo12386


Julkaisuja aiheesta

Fibular nailing for fixation of ankle fractures in patients at high risk of surgical wound infection

Karkkola S, Kortekangas T, Pakarinen H, Flinkkilä T, Niinimäki J, Leskelä HV. Fibular nailing for fixation of ankle fractures in patients at high risk of surgical wound infection. Foot Ankle Surg. 2020 Oct;26(7):784-789. doi: 10.1016/j.fas.2019.10.005. Epub 2019 Oct 25. PMID: 31734044. PubMed

Postoperative infection is a severe complication after operative treatment of ankle fractures, associated with age, comorbidities, and severe soft tissue injuries. We assessed the efficacy of intramedullary fibular nailing for treating ankle fractures in patients at high risk of wound complications.
41 high-risk patients were included in the study. We retrospectively reviewed the medical records to assess the risk profile, the treatment data, and possible infections and re-operations. After a minimum of 2 years eight patients had died, three had advanced-staged dementia and two were lost to follow-up. Remaining 28 patients reported the functional outcome and QoL through patient-reported questionnaires. Radiographs and cone-beam computed tomography were performed, as well as range-of-motion was measured.
No surgical wound infections were found. The mean Olerud-Molander score was 67 points (SD 28 [20-100]). The osteoarthritis stages and the range-of-motion were significantly different between the injured and uninjured ankles, but we detected no significant effect on the QoL.
Intramedullary fibular fixation appeared to be a safe treatment choice for ankle fractures in high-risk patients.
IV.

A prospective randomised controlled trial of the fibular nail versus standard open reduction and internal fixation for fixation of ankle fractures in elderly patient

White TO, Bugler KE, Appleton P, Will E, McQueen MM, Court-Brown CM. A prospective randomised controlled trial of the fibular nail versus standard open reduction and internal fixation for fixation of ankle fractures in elderly patients. Bone Joint J. 2016 Sep;98-B(9):1248-52. doi: 10.1302/0301-620X.98B9.35837. PMID: 27587528. PubMed

The fundamental concept of open reduction and internal fixation (ORIF) of ankle fractures has not changed appreciably since the 1960s and, whilst widely used, is associated with complications including wound dehiscence and infection, prominent hardware and failure. Closed reduction and intramedullary fixation (CRIF) using a fibular nail, wires or screws is biomechanically stronger, requires minimal incisions, and has low-profile hardware. We hypothesised that fibular nailing in the elderly would have similar functional outcomes to standard fixation, with a reduced rate of wound and hardware problems.
A total of 100 patients (25 men, 75 women) over the age of 65 years with unstable ankle fractures were randomised to undergo standard ORIF or fibular nailing (11 men and 39 women in the ORIF group, 14 men and 36 women in the fibular nail group). The mean age was 74 years (65 to 93) and all patients had at least one medical comorbidity. Complications, patient related outcome measures and cost-effectiveness were assessed over 12 months.
Significantly fewer wound infections occurred in the fibular nail group (p = 0.002). At one year, there was no evidence of difference in mean functional scores (Olerud and Molander Scores 63; 30 to 85, versus 61; 10 to 35, p = 0.61) or scar satisfaction. The overall cost of treatment in the fibular nail group was £91 less than in the ORIF group despite the higher initial cost of the implant.
We conclude that the fibular nail allows accurate reduction and secure fixation of ankle fractures, with a significantly lower rate of soft-tissue complications, and is more cost-effective than ORIF.

Optimizing Long-Term Outcomes and Avoiding Failure With the Fibula Intramedullary Nail

Carter TH, Mackenzie SP, Bell KR, Bugler KE, MacDonald D, Duckworth AD, White TO. Optimizing Long-Term Outcomes and Avoiding Failure With the Fibula Intramedullary Nail. J Orthop Trauma. 2019 Apr;33(4):189-195. doi: 10.1097/BOT.0000000000001379. PMID: 30562254. PubMed

To identify risk factors for fixation failure, report patient outcomes, and advise on modifications to the surgical technique for fibula nail stabilization of unstable ankle fractures.
Retrospective review.
Academic orthopaedic trauma unit.
All 342 patients were identified retrospectively from a prospectively collected single-center trauma database over a 9-year period.
Unstable ankle fractures managed surgically with a fibula nail.
The primary short-term outcome was failure, defined as any case that required revision surgery because of an inadequate mechanical construct. The mid-term outcomes included the Olerud-Molander Ankle Score and the Manchester-Oxford Foot Questionnaire.
Twenty failures occurred (6%), of which 7 (2%) were due to device failure and 13 (4%) due to surgeon error. Of the surgeon errors, 8 consisted of inappropriate weight-bearing after syndesmotic diastasis, and 5 were due to inadequate fracture reduction or poor nail placement. Proximal locking screw (PLS) pull-out was the cause of all device failures. Positioning the PLS >20 mm above the plafond significantly increased failure risk (P = 0.003). At a mean follow-up of 5.1 years (range, 8 months-8 years) the median Olerud-Molander Ankle Score and Manchester-Oxford Foot Questionnaire were 80 (interquartile range, 45) and 10.94 (interquartile range, 44.00), respectively. Patient outcome was not negatively affected by the requirement for revision surgery.
The fibula nail offers secure fixation and good patient-reported outcomes for unstable ankle fractures. Appropriate postoperative management and surgical technique, including careful placement of the PLS, is essential to minimize construct failure risk.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fluoroscopy-guided reduction and fibular nail fixation to manage unstable ankle fractures in patients with diabetes: a retrospective cohort study

Ashman BD, Kong C, Wing KJ, Penner MJ, Bugler KE, White TO, Younger AS. Fluoroscopy-guided reduction and fibular nail fixation to manage unstable ankle fractures in patients with diabetes: a retrospective cohort study. Bone Joint J. 2016 Sep;98-B(9):1197-201. doi: 10.1302/0301-620X.98B9.37140. PMID: 27587520. PubMed

Patients with diabetes are at increased risk of wound complications after open reduction and internal fixation of unstable ankle fractures. A fibular nail avoids large surgical incisions and allows anatomical reduction of the mortise.
We retrospectively reviewed the results of fluoroscopy-guided reduction and percutaneous fibular nail fixation for unstable Weber type B or C fractures in 24 adult patients with type 1 or type 2 diabetes. The re-operation rate for wound dehiscence or other indications such as amputation, mortality and functional outcomes was determined.
Two patients developed lateral side wound infection, one of whom underwent wound debridement. Three other patients required re-operation for removal of symptomatic hardware. No patient required a below-knee amputation. Six patients died during the study period for unrelated reasons. At a median follow-up of 12 months (7 to 38) the mean Short Form-36 Mental Component Score and Physical Component Score were 53.2 (95% confidence intervals (CI) 48.1 to 58.4) and 39.3 (95% CI 32.1 to 46.4), respectively. The mean Visual Analogue Score for pain was 3.1 (95% 1.4 to 4.9). The mean Ankle Osteoarthritis Scale total score was 32.9 (95% CI 16.0 to 49.7).
Fluoroscopy-guided reduction and fibular nail fixation of unstable ankle fractures in patients with diabetes was associated with a low incidence of wound and overall complications, while providing effective surgical fixation. Cite this article: Bone Joint J 2016;98-B:1197-1201.

Intramedullary Fixation Versus Plate Fixation of Distal Fibular Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

Tas DB, Smeeing DPJ, Emmink BL, Govaert GAM, Hietbrink F, Leenen LPH, Houwert RM. Intramedullary Fixation Versus Plate Fixation of Distal Fibular Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies. J Foot Ankle Surg. 2019 Jan;58(1):119-126. doi: 10.1053/j.jfas.2018.08.028. PMID: 30583773. PubMed

Intramedullary fixation (IMF) has been described as a minimally invasive alternative to open reduction and internal fixation for operative treatment of distal fibular fractures in case of compromised soft tissue or severe comorbidities. The objective was to compare postoperative complications and functional outcomes of intramedullary versus plate fixation (PF) in distal fibular fractures. A systematic review and meta-analysis was performed. The PubMed/MEDLINE, Embase, Cochrane, and CINAHL databases were searched for both randomized controlled trials and observational studies. A total of 26 studies was included, reporting on 1710 patients with a mean age of 51.6 years. Meta-analysis was performed on 8 comparative studies, including subgroup and sensitivity analyses on all outcomes. IMF was associated with significantly fewer wound related complications (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.04 to 0.25; p < .01), implant removals (OR, 0.54; 95% CI, 0.31 to 0.93; p = .03), and nonunions (OR, 0.31; 95% CI, 0.15 to 0.62; p < .01). No differences were found regarding malunion (OR, 0.45; 95% CI, 0.17 to 1.21; p = .11) and the Olerud Molander Ankle Score for long-term functional outcome (mean difference, 9.56; 95% CI, 1.24 to 20.37; p = .08). Results of this study apply to a select group of patients, in which the advantages of minimal soft tissue damage by IMF are preferable to optimal fracture reduction by PF. IMF of distal fibular fractures resulted in fewer wound-related complications, implant removals, and nonunions compared with PF. Especially in elderly patients, patients with chronic comorbidity, and patients with compromised soft tissue, IMF may be preferred over PF.

Complications in ankle fracture surgery

Ovaska M, Madanat R, Mäkinen T, Lindahl J. Nilkkamurtuman leikkaushoidon komplikaatiot [Complications in ankle fracture surgery]. Duodecim. 2015;131(16):1451-9. Finnish. PMID: 26485938. PubMed

Ankle fractures are among the most frequently encountered surgically treated fractures. The operative treatment can be associated with several complications such as malreduction and infection. Reinforcing the surgical armamentarium with meticulous preoperative planning together with recognition of common surgical errors are valuable adjuncts in reducing these complications. Furthermore, it is crucial to recognize and address modifiable risk factors for infection so as to minimize this potentially devastating complication. When a deep infection does occur, it is best managed by a multidisciplinary musculosceletal infection team.