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Objective: The purpose of this study was to assess the impact of current and remote tobacco smoking on clinical and functional outcomes after torsional ankle fracture., Methods: Nine hundred thirty-five patients treated surgically for torsional ankle fracture over 9 years were reviewed. Tobacco smoking status at the time of injury was defined as current (48.3%), former (11.7%), and nonsmoker (40.0%). Complications, unplanned secondary procedures, pain medication use, and functional outcome scores, as measured by Foot Function Index and Short Musculoskeletal Function Assessment (SMFA) surveys., Results: Mean age was 44.8 years, with 50.3% male. More than 6 months following injury current smokers were more likely than former smokers and nonsmokers to report ankle pain (67.8% vs 45.8% vs 47.5%) and to use prescription pain medicines (23.0% vs 10.4% vs 6.3%), all P  < .05. Multiple logistic regression found current tobacco use to be an independent predictor for prescription pain medication use, and worse scores for the Foot Function Index, SMFA Dysfunction, and SMFA Bothersome scores, all P  < .05. Complications occurred in 15.5% of all patients, and 10.7% underwent unplanned secondary operations. Tobacco smoking was not associated with more complications or secondary procedures., Conclusion: Current smokers are more likely to use prescription pain medications several months after injury and have worse patient-reported functional outcome scores after surgical treatment of torsional ankle fractures than former smokers and nonsmokers., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Objectives: To assess the patient and injury characteristics that impact functional outcomes after ankle fracture., Design: Retrospective study., Setting: Urban level I trauma center., Patients/participants: One thousand patients underwent fixation of ankle fracture (AO/OTA 44) between 2006 and 2015. Four hundred sixteen completed functional outcome surveys by telephone or mail at a mean of 5.9 years after injury., Intervention: Open reduction internal fixation., Main Outcome Measure: Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA)., Results: Mean age was 46.7 years, with 46.2% male. Higher (worse) FFI scores were seen in tobacco users (38.9 vs 30.1), recreational drug users (45.9 vs 32.7), and the morbidly obese (52.0 vs 30.6), all P  < .005. Higher (worse) SMFA dysfunction and bothersome scores were also seen in these groups, and in females and alcohol users. Multiple regression analysis identified female gender, obesity, tobacco and alcohol use, complications, secondary procedures, and multiple additional injuries as independent predictors of higher scores (all P  < .04). Fracture patterns, open fracture, and development of arthritis had no impact on FFI or SMFA scores., Conclusion: Patient characteristics, not under surgeon-control, such as female sex, obesity, and substance use, appear to contribute to patient-reported functional outcome scores more than injury characteristics., Level of Evidence: Level 3, prognostic., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Introduction: It is well known that patients with diabetes mellitus experience higher complication rates after torsional ankle fracture; however, the functional consequences remain less clear. The goal of this study was to determine the effects of diabetes on complications, secondary operations, and functional outcomes after torsional ankle fracture., Methods: Nine hundred seventy-nine adult patients treated surgically for a torsional ankle injury (Orthopaedic Trauma Association 44B, 44C) over 13 years were retrospectively reviewed. Demographic information, comorbidities, injury characteristics, complications, and secondary procedures were recorded. Patient-reported outcome surveys: Foot Function Index (FFI) and Short Musculoskeletal Function Assessment were obtained after minimum of 12 months. Multivariable analysis was done to account for confounding variables., Results: One hundred thirty-one patients (13.4%) had diabetes. Diabetic patients were older (56.4 versus 43.0 years, P < 0.001), with no difference in sex or race. Body mass index was higher among diabetics (36.0 versus 30.4, P < 0.001) as were most medical comorbidities, including stroke, neuropathy, pulmonary disease, and renal disease (all P < 0.03). There were no differences in rates of dislocations or open injuries. Diabetics experienced more complications (26.0% versus 14.6%, P = 0.001), specifically deep infections (6.9% versus 1.3%, P = 0.001), and had more secondary procedures (18.3% versus 9.1%, P = 0.001), including débridement, arthrodesis, and amputation (all P < 0.02). Diabetes was a significant independent predictor of worse FFI activity limitation scores (P = 0.032), but was not predictive of worse outcomes on any other subscore of the FFI or Short Musculoskeletal Function Assessment., Conclusions: Diabetes was associated with more complications and secondary operations. However, functional outcomes including pain and dysfunction were not markedly affected by these clinical outcomes, potentially due to diminished sensory function and less baseline physical activity among diabetic patients., Level of Evidence: Prognostic level III.

Background: Obesity is a growing public health concern. While diabetes mellitus is associated with obesity and is a risk for infection and other complications, effects of obesity on outcomes remains less clear. The purpose was to determine effect of obesity on complications, secondary operations, and functional outcomes after surgical treatment of ankle fracture., Methods: 955 adult patients treated surgically for torsional ankle injury were reviewed. Obese patients (body mass index (BMI) ≥30), and patients without obesity were matched for age, sex, race, diabetes, and fracture pattern. Patient reported outcomes, measured by Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA), were obtained after 12 months., Results: 632 patients (316 obese [mean BMI 36.7] and 316 non-obese [mean BMI 25.5]) with mean age 44.6 years were analyzed. Each group was 52.5% female, and 6.6% had diabetes mellitus. 75.6% of fractures in each group were AO/OTA type 44B and 24.4% were 44C. Non-obese patients were more likely tobacco users (63.3% vs 40.2%, p<0.001). Obese patients trended toward more dislocations (41.8% vs 35.4%, p=0.10), with similar rate of open fracture. Obese patients trended toward more complications (28.5% vs 22.5%. p=0.08) and wound healing problems (4.7% vs 2.2%, p=0.08) with similar rates of secondary procedures. Total FFI scores were higher (worse) for obese patients (35.4 vs 28.5, p=0.03); subcategory scores for disability and activity limitation were worse (p=0.03 and p=0.04, respectively), and obesity was associated with worse SMFA bothersome (31.0 vs 23.6, p=0.02) and mobility scores (41.8 vs 32.5, p=0.008), with a trend towards worse SMFA dysfunction scores in obese patients (29.7 vs 24.7, p=0.06)., Conclusions: Obesity is associated with worse functional outcomes by FFI and SMFA surveys. Contributions of baseline limitations to these poor scores in obese patients remain unclear. Injury characteristics were similar between obese and non-obese patients, though obese patients may be more prone to dislocations. A trend was noted for obese patients to experience more complications and wound healing issues, although rates of secondary operations were no different., Level of Evidence: III., Competing Interests: Declaration of Competing Interest The authors have no disclosures related to the content of this work., (Copyright © 2020. Published by Elsevier Ltd.)

Objectives: To identify predictors of functional outcomes following treatment of ankle fracture in patients 55 years or older., Setting: Level 1 Trauma Center., Patients/participants: Four hundred twenty-nine patients with torsional ankle fractures (44A-C): 233 patients (54%) were ages 55 to 64, 25% were between the ages 65 and 74; 21% were 75 years or older., Intervention: Operative or nonoperative management of ankle fracture., Main Outcome Measure: Early complications were assessed for all patients after minimum of 6 months, and functional outcome scores as assessed by the Foot Function Index (FFI; n = 166, 39%) and Short Musculoskeletal Function Assessment (SMFA; n = 168, 39%) after median 57 months follow-up., Results: Surgical management was elected in 67% of patients. Nonoperative management became more common with advancing age and was associated with fewer unplanned operations (12% vs 3%, P  < .01) and complications (21% vs 13%, P  = .07). African American race was associated with worse pain on the FFI ( P  = .002) and BMI was associated with worse (higher) scores on all categories of the FFI and SMFA (all P  < .05). Diabetes, neuropathy, and mental illness were also predictive of worse scores on various categories of both surveys. Assistive device use or nonambulatory status at the time of injury was associated with worse disability/dysfunction, activity, and mobility scores on both the FFI and SMFA (all P  > 15, P  < .05). Sex, Hispanic ethnicity, tobacco use, open fracture, dislocation, fracture pattern, and operative management were not independent predictors in this regression model., Conclusions: Baseline health and ambulatory capacity at injury were more predictive of outcomes following ankle fracture than were fracture characteristics or type of treatment., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Objectives: To identify comorbidities and injury characteristics associated with surgical site infection (SSI) following internal fixation of malleolar fractures in an urban level 1 trauma setting., Design: Retrospective., Setting: Level 1 trauma center., Patients/participants: Seven-hundred seventy-six consecutive patients with operatively managed malleolar fractures from 2006 to 2016., Intervention: Open reduction internal fixation., Main Outcome Measurements: Superficial SSI (erythema and drainage treated with oral antibiotics and wound care) or deep SSI (treated with surgical debridement and antibiotics)., Results: Fifty-six (7.2%) patients developed SSI, with 17 (30%) of these being deep infections. An a-priori power analysis of n = 325 (α=0.05, β=0.2) was tabulated for differences in univariate analysis. Univariate analysis identified categorical associations ( P  < .05) between SSI and diabetes mellitus, drug abuse, open fracture, and renal disease but not tobacco abuse, body mass index, or neuropathy. Multivariate logistic regression identified categorical associations between diabetes (OR = 2.2, 95% CI: 1.1-4.3), drug abuse (OR = 3.9, 95% CI: 1.2-12.7), open fracture (OR = 4.1, 95% CI: 1.3-12.8), and renal disease (OR = 2.7, 95% CI: 1.4-5.0) and any (superficial or deep) SSI. A separate multivariate logistic regression analysis found categorical associations between deep SSI requiring reoperation and diabetes (OR = 4.4, 95% CI: 1.6-12.2) and open fracture (OR = 4.1, 95% CI: 1.3-12.8). Furthermore, American society of anesthesiologists classification (ASA) Class 4 patients were (OR = 9.2, 95% CI: 2.0-41.79) more likely to experience an SSI than ASA Class 1 patients., Conclusions: Factors associated with SSI following malleolar fracture surgery in a single urban level 1 trauma center included diabetes, drug abuse, renal disease, and open fracture. The presence of diabetes or open type fractures were associated with deep SSI requiring reoperation., Level of Evidence: Level 3 prognostic: retrospective cohort study., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Objectives: To assess clinical and functional outcomes after open versus closed ankle fracture., Design: Retrospective comparative study., Location: Level 1 Trauma Center., Patients/participants: 1303 patients treated for ankle fractures (Weber B and C) between 2003 and 2015. One hundred sixty-five patients (12.7%) presented with open fracture and 1138 (87.3%) with closed fracture., Intervention: Surgical or conservative management of ankle fracture., Main Outcome Measure: Rates of complications and reoperations. Patient-reported functional outcomes were assessed with the Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA), after a minimum of 12 months., Results: Mean age was 46 years and 49% of patients were male. Higher mean age was associated with open injuries (51 vs 45 years, P  < 0.001), and fractures were increasingly open with aging. Open fractures were associated with high-energy mechanisms: 44% following motor vehicle or motorcycle collisions, although the majority of open fractures in patients >65 years occurred after ground-level fall. Complications occurred more often after open fracture (33% vs 11%) and necessitated more secondary procedures (19% vs. 7%), both P  < 0.001. Multivariate regression analysis identified open fracture as a predictor of complications and of worse scores on the activity categories of both the FFI and SMFA., Conclusion: Open fractures occurred more often after high energy mechanisms, and were generally more complex than closed fractures. Advanced age was common among open fracture patients, likely contributing to higher complication and secondary procedure rates. Greater morbidity after open ankle fractures was associated with minor differences on activity functions of the FFI and SMFA. Level of Evidence : Level 3, prognostic., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Objectives: To assess clinical and functional outcomes after ankle fracture in patients with preexisting mental illness., Design: Retrospective study., Setting: Level 1 trauma center., Patients/participants: One thousand three hundred seventy-eight adult patients treated for ankle fractures; 228 (17%) had preexisting mental illness., Intervention: Open reduction internal fixation., Main Outcome Measure: Rates of complications and reoperations. Functional outcomes were assessed via Foot Function Index (n = 530) and Short Musculoskeletal Function Assessment (n = 530)., Results: Depression was the most common mental illness (63%), followed by anxiety (23%). Mental illness was associated with older age, female sex, and preexisting medical comorbidities, including diabetes and obesity. Mental illness was not associated with specific fracture patterns or open injury. Complications occurred no more often in patients with mental illness, but secondary operations (13% vs 7%) were more likely, particularly implant removals (8% vs 4%), both P  < .05. Functional outcomes were worse in mentally ill patients as measured by the Foot Function Index (39 vs 30, P  = .006) and Short Musculoskeletal Function Assessment Mobility: 45 vs 35, Bothersome: 35 vs 26 and Dysfunction: 35 vs 26, all P  < .01., Conclusion: Secondary operations were nearly 50% more frequent in patients with mental illness, and functional outcome scores were significantly worse, suggesting that mental illness, unrelated to injury and treatment parameters, has major influence on outcomes. In the future, strategies to identify and treat mental illness prior to and after treatment could improve functional outcomes following ankle fracture., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

The regional and laminar distribution of the noradrenaline (NA) innervation in the adult rat cerebral cortex was quantified in radioautographs of semithin sections from whole hemisphere slices incubated with tritiated catecholamines and a monoamine oxidase inhibitor. Uptake-labeled axonal varicosities (aggregates of silver grains) were counted with the help of a computerized image analyzer in seven cytoarchitectonic areas of the rostral half of the cortex: Cg3, rostral AID, Cg2, Fr1, Par1, caudal AID, and Pir (prepiriform) according to Zilles's nomenclature. Both dopamine (DA) and NA terminals were detected after incubation with [3H]DA and citalopram or with [3H]NA alone. In the presence of desipramine (DMI), DA terminals alone were demonstrated; the number of NA terminals was then obtained by subtraction from counts in adjacent slices incubated with or without DMI. These counts suggested that DA and NA varicosities were fully visualized only after labeling with their respective tritiated amine. Similar numbers of labeled NA varicosities as inferred after [3H]NA incubation with or without DMI were observed after [3H]NA incubation in the presence of benztropine (BZ). This indicated that NA terminals were then maximally detected to the exclusion of the DA ones, and the latter approach was adopted for the acquisition of normative data. Since the average diameter of the labeled NA varicosities was known from earlier measurements in electron microscope radioautographs, the initial counts of labeled sites/mm2 of histological section could be expressed as numbers of varicosities/mm3 of tissue following a double correction for incomplete detection at the chosen duration of radioautographic exposure and section thickness. The overall density of NA innervation was thus estimated at 1.2 million varicosities/mm3 of tissue, with no statistically significant differences between the seven cortical areas examined. In every region, the number of NA terminals was the greatest in the molecular layer (1.5-2 times the density in the rest of cortex) and then progressively decreased in the underlying cortex, with a two- to threefold difference between upper and lower layers. These numerical data allowed an estimation to be made of the possible number of cortical NA varicosities per locus coeruleus nerve cell body of origin (at least 300,000), of their average number per cortical neuron (30-50), their actual incidence among all terminals in the cortex (1/1,000), their mean endogenous amine content per varicosity (0.22 fg), and the mean number of recognition sites for the uptake blocker DMI (4,500/varicosity).(ABSTRACT TRUNCATED AT 400 WORDS)

Conditions leading to selective and complete labeling of the noradrenaline (NA) and serotonin (5-HT) innervations in rat cerebral cortex were sought by incubating 200-micron-thick whole hemisphere slices with various combinations of tritiated monoamines and uptake blockers at different concentrations in the presence of a monoamine oxidase inhibitor. After fixation with glutaraldehyde, post-fixation with osmium tetroxide and flat-embedding in Epon, 4-micron-thick sections of the entire slices were radioautographed by dipping in nuclear emulsion. As previously reported, dopamine (DA) terminals could be specifically visualized and counted following incubation with 1 micron [3H]DA and 5 microM desipramine (DMI) with or without 5 microM citalopram (CITAL). The number of NA terminals could thus be obtained by subtracting DA varicosities from the total number of sites labeled in adjacent slices incubated without DMI but in presence of CITAL to eliminate some interspecific labeling of 5-HT terminals. NA terminals could also be identified exclusively and counted after labeling with 1 microM [3H]NA in the presence of 10 microM benztropine. 5-HT terminals were specifically detected after incubation with 1 microM [3H]5-HT in the presence of 10 microM non-radioactive NA. The labeled varicosities were counted in areas FR1 and PAR1 of the frontal and the parietal neocortex, respectively, with the aid of a microcomputer-based image analysis system. DA varicosities were concentrated mainly in layer VI of these regions and were more numerous in the frontal than the parietal area. NA terminals were equally distributed in the two regions but approximately twice as numerous in layer I than subjacent layers. The 5-HT innervation also showed a comparable overall density in the two cortical regions but with a differing intracortical distribution. In the frontal area, 5-HT terminals were slightly more concentrated in layer I (1.3-fold) than underlying layers where they were rather uniformly distributed. In the parietal area, layer I was again the most densely innervated (1.8 times the average), but a second zone of higher density (1.5 times average) was present in the outer part of layer V. The remaining layers showed lower numbers of 5-HT terminals than in the frontal region. To obtain absolute estimates of these innervation densities, the number of detected varicosities was assessed experimentally as a function of radioautographic exposure time and of histological section thickness, and their 'equivalent circle diameter' was measured in electron microscope radioautographs.(ABSTRACT TRUNCATED AT 400 WORDS)

The regional and laminar distribution of the serotonin (5-HT) innervation in adult rat cerebral cortex was quantified in radioautographs of semi-thin sections from whole hemisphere slices incubated with tritiated 5-HT and a monoamine oxidase inhibitor. Uptake-labelled axonal varicosities (aggregates of silver grains) were counted with the help of a computerized image analyser, in seven cytoarchitectonic areas of the anterior half of the cortex: Cg3, rostral AID, Cg2, Fr1, Par1, caudal AID and Pir (prepiriform). Since the average diameter of cortical 5-HT varicosities had been previously measured in electron microscope radioautographs, the counts of labelled sites per mm2 of radioautograph could be transformed to numbers of varicosities per mm3 of tissue after a double correction for incomplete detection at the chosen duration of radioautographic exposure and from the thickness of section examined. The mean regional density of cortical 5-HT innervation was thus evaluated at 5.8 million varicosities per mm3 of tissue, ranging from 4.4 (Cg2) to 7.1 million (AIDr). Cg2, Par1 and Fr1 showed significantly lower regional densities than Cg3, AIDc, Pir and AIDr. The highest laminar density was that of layer I in all regions except Pir, but each region had a distinct pattern of 5-HT innervation. In Par1, for example, there was a second band of predilection amounting to 5.3 million varicosities per mm3 at the height of layer Va. On the basis of these figures, it was possible to extrapolate the average number of cortical 5-HT varicosities per midbrain raphe nerve cell body of origin (500,000 at least), their average number per cortical target neuron (145-230), their incidence among all axon terminals in cortex (1/200), their mean endogenous amine content (0.045 fg), and their mean number per varicosity of recognition sites for reuptake blockers such as paroxetine, citalopram or cyanoimipramine (5000-6200). Such quantitative data and further correlations between 5-HT innervation density and other measurable aspects of cortical structure and function should help to elucidate the role(s) of 5-HT in this part of the brain.