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Use of Cem-Ostetic® Putty for Augmentation of Ankle Fracture Fixation in Osteoporotic Bone
A 78-year-old osteoporotic female presented after a fall complaining of severe right ankle pain. The patient had not sustained a previous ankle injury. Examination of the ankle revealed marked swelling and deformity, intact skin, brisk pulses and an intact neurologic exam. Radiographs demonstrated a closed comminuted bimalleolar right ankle fracture with marked osteopenia (Figure 1).
After medical clearance and a review of treatment options, the decision was made to proceed with open reduction and internal fixation. The lateral fibular fracture was exposed through a direct lateral incision. Dissection revealed marked comminution at the fracture site with poor bone quality. The comminuted fibular fracture was fixed with a 6-hole, one-third tubular locking plate. All 6 holes were filled with screws. The medical malleolar fracture was then exposed with an anteromedial approach. Marked medial comminution was also noted with bone loss. The medial malleolus was fixed with 2 40mm long partially threaded 4mm screws according to standard technique. Appropriate reduction and fixation was confirmed fluoroscopically (Figure 2).
Given the bone loss at the fracture site and the poor bone quality, the decision was made to augment the fixation with the use of Cem-Ostetic® putty. A 10cc volume of putty was mixed, placed into a syringe then injected both medially and laterally. The fibula fracture was injected through comminution anterior to the plate. The medical fracture was augmented with putty injected directly into the fracture site. After the material had set at 5 minutes, the wounds were irrigated with the pulsatile irrigation device then closed in layers. Fluoroscopy confirmed proper placement of graft material (Figure 3).
Postoperative Results and Outcome
The patient had an unremarkable postoperative course. The wounds healed well with no prolonged wound drainage noted. The ankle was placed initially in a splint and later a cast for 6 weeks. The patient was maintained non weightbearing in the cast for the first 6 weeks. Range of motion was then initiated. The ankle was placed in a camwalker orthotic and the patient was allowed to progress to full weightbearing as tolerated. By 9 weeks, the fracture was healing well. The patient was experiencing minimal symptoms at that time walking in athletic shoes with a cane. By 12 weeks, the fracture was fully healed. X-rays demonstrated a well-healed ankle fracture with excellent remodeling of the Cem-Ostetic® putty. No collapse of the fracture was evident (Figure 4).
Use of the Cem-Ostetic® putty in the treatment of an ankle fracture with osteoporotic bone allowed for augmentation of the poor quality bone in the region of the fracture site. By 12 weeks, the fracture had healed without collapse or displacement.
Figure 1. Preoperative: AP view of right ankle demonstrating bimalleloar fracture with marked comminution deplacement and osteopenia.
Figure 2. Intraoperative: Fluoroscopic views of right ankle demonstrating reduction and fixation of the fracture.
Figure 3. Intraoperative: AP Fluoroscopic view of right ankle after placement of graft material in both medial and lateral fracture sites.
Figure 4. 3 months postoperative: AP X-ray demonstrates the well-healed fracture with incorporation and remodeling of graft material.