Introduction: The optimal management of ankle fractures in the elderly is controversial, with wide variation in the complication rates reported in the literature. Achieving a satisfactory outcome is essential as reduced mobility exacerbates pre-existing morbidity and diminishes the likelihood of independent living. However, in elderly patients surgery carries increased risks due to osteoporosis, poor skin condition and decreased vascularity.

Methods: We performed a retrospective review of outcome and complications in patients over 70 years of age with ankle fractures. Patients were admitted for manipulation under anaesthetic and application of cast (MUA) or open reduction and internal fixation (ORIF). Data were retrieved from medical and nursing notes relating to pre-operative functioning, type of injury, operative procedure and outcome. All X-rays were also reviewed to confirm fracture grade and union.

Results: A total of 134 patients over the age of 70 were admitted for management of ankle fractures during January 1995 and December 2003 and 117 of these were included in the study. 84 were operatively treated for ankle fractures and a further 27 patients underwent MUA. The mean age in both groups was 76 and there was a female predominance in both groups (89% in MUA, 79% in ORIF). 14.8% of the conservatively managed group were nursing home residents compared to 2.4% of the operatively treated group. The groups were similar with respect to ASA grade and co-morbidities. The median length of stay was shorter for the conservatively managed group (4 vs. 6 days). 7.5% of the MUA group required a second intervention compared to 4.5% of the operatively managed group. There were two below knee amputations in the operatively managed group, both related to open fractures, and one arthrodesis in each group. There were three wound complications in the operatively managed group. The rate of postoperative medical complications was the same in both cohorts. 7.4% of patients treated with MUA and 1.1% of patients treated operatively had reduced mobility at final follow-up.

Conclusion: The decision-making process for treatment of ankle fractures in the geriatric population is challenging. We observed significantly better functional results in the ORIF group than the MUA group. These results indicate that open reduction and internal fixation of ankle fractures in geriatric patients is efficacious and safe in selected patients

It is now well established that operative repair of Tendo Achilles (TA) ruptures reduces re-rupture rate compared with conservative treatment. Operative repair has been reported to be associated with significant morbidity in 11–29% of cases, in particular wound related complications. In 1977 Ma and Griffith described a percutaneous repair of the TA, however initial results showed a disappointingly high re-ruputre rate of approximately 10%. The senior author has modified the technique initially described in attempt to reduce the re-rupture rate.

After marking out the course of the sural nerve, a 2 Ethibond suture is passed into the ruptured tendon end via a stab incision, and passed proximally as in a modified Kessler suture. The suture is then passed first proximally and then back distally in a criss-cross pattern via further stab incisions and brought out at the tendon stump. A second suture is passed into the distal stump in a similar fashion and the sutures tied with the foot in equinus.

We recruited a cohort of patients who had undergone percutaneous repair in the last 5 years, and a cohort of age and sex matched controls who had undergone open repair. Both groups of patients were managed postoperatively in equinus cast for 8 weeks. Subjective outcome was measured using the Foot and Ankle Outcome Score (FAOS). Statistical analysis was performed using the Mann-Whitney U-test for non-parametric data.

Fifteen patients, mean age of 41.3, underwent percutaneous repair. There were 9 men and 6 women. The median time from injury to repair was 2 days in the percutaneous group and 1 day in the open group. Post-operatively there was no statistically significant difference between the two groups in relation to time taken to return to work (12 (percutaneous) versus 10 (open) weeks). However the percutaneous group returned to sport sooner 6 (percutaneous) versus 12 (open) months; p=0.6). There were no re-ruptures in either group. There were two sural nerve injuries in the percutaneous group and none in the open group. There was no significant difference in mean FAOS between the two groups (466 percutaneous versus 468 open).

Percutaneous repair of TA ruptures results in a similar functional outcome as the traditional open repair. The increased incidence of sural nerve injury may be associated with the learning curve of the procedure as both of these cases were early in the series. We propose that percutaneous repair is safe and effective. The avoidance of a large skin incision may reduce wound related complications.