Does the quality of preoperative closed reduction of displaced ankle fractures affect wound complications after surgical fixation?

      Abstract

      Background

      Displaced ankle fractures are initially closed reduced and splinted with the goal of restoring gross ankle alignment. The benefits of an exact closed reduction are unclear and possibly detrimental and unnecessary if multiple attempts are made. The purpose of this study was to determine whether the quality of preoperative closed reduction in patients with operative ankle fractures affects post-operative wound complications.

      Methods

      A retrospective analysis was performed of patients with isolated, closed, operative ankle fractures treated at two level 1 trauma centers who had an initial closed reduction performed on presentation. Patient demographics, fracture characteristics, data pertinent to the reduction, and post-operative wound complications were collected. A novel grading system to assess reduction quality was developed, applied, and evaluated for inter- and intra-observer agreement.

      Results

      161 patients met inclusion criteria for analysis. 17% (27/161) sustained a post-operative wound complication. There was no statistically significant association between wound complications and quality of preoperative closed reduction (p = 0.17) nor with multiple reduction attempts (p = 0.887). However, patients with poor initial reductions had a decreased mean time to surgery (1.4 ± 2.9 versus 4.7 ± 6.3 days, p = 0.03), which may have been protective. Interclass correlation coefficients for inter- and intra-rater reliability of the classification schema was 0.942 and 0.922, respectively, demonstrating excellent agreement.

      Conclusion

      There was no association between preoperative closed reduction quality and incidence of post-surgical wound complications in patients with operative ankle fractures when analyzing the variables assessed in this investigation. While initial ankle reduction is still recommended, multiple attempts to achieve a perfect reduction are likely unnecessary.

      Keywords

      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Basques B.A.
        • Miller C.P.
        • Golinvaux N.S.
        • Bohl D.D.
        • Grauer J.N.
        Morbidity and readmission after open reduction and internal fixation of ankle fractures are associated with preoperative patient characteristics.
        Clin Orthop Relat Res. 2015; 473: 1133-1139https://doi.org/10.1007/s11999-014-4005-z
        • Beerekamp M.S.
        • Haverlag R.
        • Ubbink D.T.
        • Luitse J.S.
        • Ponsen K.J.
        • Goslings J.C.
        How to evaluate the quality of fracture reduction and fixation of the wrist and ankle in clinical practice: a Delphi consensus.
        Arch Orthop Trauma Surg. 2011; 131: 739-746https://doi.org/10.1007/s00402-010-1198-9
        • Belmont Jr., P.J.
        • Davey S.
        • Rensing N.
        • Bader J.O.
        • Waterman B.R.
        • Orr J.D.
        Patient-based and surgical risk factors for 30-day postoperative complications and mortality after ankle fracture fixation.
        J Orthop Trauma. 2015; 29: e476-82https://doi.org/10.1097/BOT.0000000000000328
        • Carragee E.J.
        • Csongradi J.J.
        Increased rates of complications in patients with severe ankle fractures following interinstitutional transfers.
        J Trauma. 1993; 35: 767-771
        • Carragee E.J.
        • Csongradi J.J.
        • Bleck E.E.
        Early complications in the operative treatment of ankle fractures. Influence of delay before operation.
        J Bone Joint Surg Br. 1991; 73: 79-82
        • Dean D.B.
        Field management of displaced ankle fractures: techniques for successful reduction.
        Wilderness Environ Med. 2009; 20: 57-60https://doi.org/10.1580/08-WEME-CON-240.1
        • Drijfhout van Hooff C.C.
        • Verhage S.M.
        • Hoogendoorn J.M.
        Influence of fragment size and postoperative joint congruency on long-term outcome of posterior malleolar fractures.
        Foot Ankle Int. 2015; 36: 673-678https://doi.org/10.1177/1071100715570895
        • Federici A.
        • Sanguineti F.
        • Santolini F.
        The closed treatment of severe malleolar fractures.
        Acta Orthop Belg. 1993; 59: 189-196
        • Fleiss J.L.
        Statistical methods for rates and proportions.
        2nd ed. Wiley, New York, NY1982
        • Hinds R.M.
        • Lazaro L.E.
        • Burket J.C.
        • Lorich D.G.
        Risk factors for posttraumatic synostosis and outcomes following operative treatment of ankle fractures.
        Foot Ankle Int. 2014; 35: 141-147https://doi.org/10.1177/1071100713510913
        • Hoiness P.
        • Stromsoe K.
        The influence of the timing of surgery on soft tissue complications and hospital stay. A review of 84 closed ankle fractures.
        Ann Chir Gynaecol. 2000; 89: 6-9
        • Horisberger M.
        • Valderrabano V.
        • Hintermann B.
        Posttraumatic ankle osteoarthritis after ankle-related fractures.
        J Orthop Trauma. 2009; 23: 60-67https://doi.org/10.1097/BOT.0b013e31818915d9
        • Kannus P.
        • Palvanen M.
        • Niemi S.
        • Parkkari J.
        • Jarvinen M.
        Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970–2000 and projections for the future.
        Bone. 2002; 31 (S8756328202008323 [pii]): 430-433
        • Lanzetti R.M.
        • Lupariello D.
        • Venditto T.
        • Guzzini M.
        • Ponzo A.
        • De Carli A.
        • et al.
        The role of diabetes mellitus and BMI in the surgical treatment of ankle fractures.
        Diabetes Metab Res Rev. 2018; 34 (Epub 2017 Nov 7)https://doi.org/10.1002/dmrr.2954
        • Lubbeke A.
        • Salvo D.
        • Stern R.
        • Hoffmeyer P.
        • Holzer N.
        • Assal M.
        Risk factors for post-traumatic osteoarthritis of the ankle: an eighteen year follow-up study.
        Int Orthop. 2012; 36: 1403-1410https://doi.org/10.1007/s00264-011-1472-7
        • Miller A.G.
        • Margules A.
        • Raikin S.M.
        Risk factors for wound complications after ankle fracture surgery.
        J Bone Joint Surg Am. 2012; 94: 2047-2052https://doi.org/10.2106/JBJS.K.01088
        • Murphy J.M.
        • Kadakia A.R.
        • Irwin T.A.
        Variability in radiographic medial clear space measurement of the normal weight-bearing ankle.
        Foot Ankle Int. 2012; 33: 956-963https://doi.org/10.3113/FAI.2012.0956
        • Murphy J.M.
        • Kadakia A.R.
        • Schilling P.L.
        • Irwin T.A.
        Relationship among radiographic ankle medial clear space, sex, and height.
        Orthopedics. 2014; 37: e449-54https://doi.org/10.3928/01477447-20140430-55
        • Musgrave D.J.
        • Fankhauser R.A.
        Intraoperative radiographic assessment of ankle fractures.
        Clin Orthop Relat Res. 1998; 351: 186-190
        • Olsen L.L.
        • Moller A.M.
        • Brorson S.
        • Hasselager R.B.
        • Sort R.
        The impact of lifestyle risk factors on the rate of infection after surgery for a fracture of the ankle.
        Bone Joint J. 2017; 99-B: 225-230https://doi.org/10.1302/0301-620X.99B2.BJJ-2016-0344.R1
        • Ovaska M.T.
        • Mäkinen T.J.
        • Madanat R.
        • Huotari K.
        • Vahlberg T.
        • Hirvensalo E.
        • et al.
        Risk factors for deep surgical site infection following operative treatment of ankle fractures.
        J Bone Joint Surg Am. 2013; 95: 348-353https://doi.org/10.2106/JBJS.K.01672
        • Pasco J.A.
        • Lane S.E.
        • Brennan-Olsen S.L.
        • Holloway K.L.
        • Timney E.N.
        • Bucki-Smith G.
        • et al.
        The epidemiology of incident fracture from cradle to senescence.
        Calcif Tissue Int. 2015; 97: 568-576https://doi.org/10.1007/s00223-015-0053-y
        • Payne R.
        • Kinmont J.C.
        • Moalypour S.M.
        Initial management of closed fracture-dislocations of the ankle.
        Ann R Coll Surg Engl. 2004; 86: 177-181https://doi.org/10.1308/003588404323043300
        • Schepers T.
        • De Vries M.R.
        • Van Lieshout E.M.
        • Van der Elst M.
        The timing of ankle fracture surgery and the effect on infectious complications; a case series and systematic review of the literature.
        Int Orthop. 2013; 37: 489-494https://doi.org/10.1007/s00264-012-1753-9
        • Shibuya N.
        • Davis M.L.
        • Jupiter D.C.
        Epidemiology of foot and ankle fractures in the United States: an analysis of the National Trauma Data Bank (2007 to 2011).
        J Foot Ankle Surg. 2014; 53: 606-608https://doi.org/10.1053/j.jfas.2014.03.011
        • SooHoo N.F.
        • Krenek L.
        • Eagan M.J.
        • Gurbani B.
        • Ko C.Y.
        • Zingmond D.S.
        Complication rates following open reduction and internal fixation of ankle fractures.
        J Bone Joint Surg Am. 2009; 91: 1042-1049https://doi.org/10.2106/JBJS.H.00653
        • Stufkens S.A.
        • Knupp M.
        • Horisberger M.
        • Lampert C.
        • Hintermann B.
        Cartilage lesions and the development of osteoarthritis after internal fixation of ankle fractures: a prospective study.
        J Bone Joint Surg Am. 2010; 92: 279-286https://doi.org/10.2106/JBJS.H.01635
        • Sun Y.
        • Wang H.
        • Tang Y.
        • et al.
        Incidence and risk factors for surgical site infection after open reduction and internal fixation of ankle fracture: a retrospective multicenter study.
        Medicine (Baltimore). 2018; 97: e9901https://doi.org/10.1097/MD.0000000000009901
        • Tejwani N.C.
        • McLaurin T.M.
        • Walsh M.
        • Bhadsavle S.
        • Koval K.J.
        • Egol K.A.
        Are outcomes of bimalleolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injury?.
        J Bone Joint Surg Am. 2007; 89 (89/7/1438 [pii]): 1438-1441
        • Tunturi T.
        • Kemppainen K.
        • Patiala H.
        • Suokas M.
        • Tamminen O.
        • Rokkanen P.
        Importance of anatomical reduction for subjective recovery after ankle fracture.
        Acta Orthop Scand. 1983; 54: 641-647
        • Verhage S.M.
        • Schipper I.B.
        • Hoogendoorn J.M.
        Long-term functional and radiographic outcomes in 243 operated ankle fractures.
        J Foot Ankle Res. 2015; 8 (45-015-0098-1. eCollection 2015)https://doi.org/10.1186/s13047-015-0098-1
        • Willett K.
        • Keene D.J.
        • Mistry D.
        • et al.
        Close contact casting vs surgery for initial treatment of unstable ankle fractures in older adults: a randomized clinical trial.
        JAMA. 2016; 316: 1455-1463https://doi.org/10.1001/jama.2016.14719
        • Wynkoop A.
        • Ndubaku O.
        • Walter N.
        • Atkinson T.
        Temporal variation in ankle fractures and orthopedic resident program planning in an urban level 1 trauma center.
        J Foot Ankle Surg. 2017; 56 (S1067-2516(17)30089-3 [pii]): 724-729