Evaluation and quantification of geographical differences in wound complication rates following the extended lateral approach in displaced intra-articular calcaneal fractures - A systematic review of the literature

Geographical Differences in Wound Complication Rates Following the Sinus Tarsi Approach in Displaced Intra-articular Calcaneal Fractures: A Systematic Review of the Literature

Background

The sinus tarsi approach (STA) has gained popularity for the treatment of displaced intra-articular calcaneal fractures. No large studies comparing wound complications worldwide after STA surgery are available. The aim of this systematic review was to compare postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following STA surgery between continents and countries and their differences in climate.

Methods

A literature search was performed using the databases of PubMed, Embase, and the Cochrane Library. Studies published before January 1, 2000, including < 10 patients and written in a language other than English were excluded.

Results

In total, 86 studies containing 4,392 surgeries via STA from 20 different countries were included. The mean POWC was 5.9% and the mean POWI was 4.4%. The highest median POWC rate was in North America (8.5%) and the lowest in South America (2.0%). No significant differences were found in the POWC and POWI rates between countries (p = 0.178 and p = 0.570, respectively), but significant differences were found between the POWC and POWI rates between continents (p = 0.011 and p = 0.036, respectively). The number of surgeries per year and climate differences, as represented by mean local temperature, were not correlated with both the POWC/POWI rates and functional outcome scores.

Conclusions

Significant differences between the POWC and POWI rates were found between continents but not between individual countries. With a mean POWC of 5.9% and a mean POWI rate of 4.4%, STA has an intrinsic low risk for complications given the minimally invasive nature of the approach and is inevitably becoming the gold standard for calcaneal surgery.

Are the non-weight bearing guidelines for the after treatment of calcaneal fractures still decisive? A Dutch survey among orthopaedic and trauma surgeons

PURPOSE

The current rehabilitation for patients with surgically treated displaced intra-articular calcaneal fractures (DIACFs) consists of non-weightbearing for 8-12 weeks. The purpose of the present survey was to investigate the current pre-, peri- and post-operative practices among Dutch foot and ankle surgeons. Moreover, it aims to analyze whether surgeons comply to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) guidelines and which decision criteria were used in the determination of the start of weightbearing.

METHODS

A survey was distributed among Dutch trauma and orthopaedic surgeons to determine the most common practices in postoperative weightbearing in patients with DIACFs.

RESULTS

75 surgeons responded to the survey. 33% of the respondents adhered to the AO guidelines. 4% of the respondents strictly followed non-weightbearing guidelines, while 96% interpret the AO guidelines or their local protocol freely, in any frequency. When respondents tended to deviate from the AO guidelines or local protocol, a good patients' compliance to therapy was expected. 83% of the respondents started weightbearing on the fracture, based on reported patient complaints. 87% of the respondents did not see any relation between early weightbearing and the occurrence of complications, including loosening of osteosynthesis materials.

CONCLUSION

This study demonstrates that there is limited consensus on the rehabilitation for DIACFs. Moreover, it shows that most surgeons are inclined to interpret the current (AO) guideline or their own local protocol freely. New guidelines, supported with well-founded literature, could help surgeons in a more appropriate daily practice in weightbearing for the rehabilitation of calcaneal fractures.

Risk factor of postoperative incision infection after plate internal fixation of calcaneal fractures: a retrospective study

BACKGROUND

This study aimed to investigate the risk factors for incision infection after plate internal fixation for calcaneal fractures by a traditional lateral L-shaped approach.

METHODS

The clinical data of 302 patients with calcaneal fractures who underwent surgical treatment in our hospital from January 2012 to June 2018 were retrospectively analysed, consisting of 177 males and 125 females. The enrolled patients were aged 21 to 75 years, with a mean age of 47.72 years. According to the Sanders classification, 108 patients were type II, 138 patients were type III, and 56 cases were type IV. A univariate analysis was conducted with sex, age, smoking history, history of diabetes, cause of injury, Sanders type, tension blisters, time from injury to surgery, preoperative haemoglobin, preoperative albumin, operation time, and bone grafting as possible risk factors. The factors with statistically significant differences were selected for multivariate binary logistic regression analysis. The clinical cut-off values of these risk factors were calculated using characteristic curves.

RESULTS

The follow-up lasted for at least 1 year for all patients, with a mean follow-up time of 15.8 months. The results demonstrated 7.9% (24/302) infection rate after plate internal fixation of calcaneal fractures by the traditional lateral L-shaped approach. Univariate analysis showed that a history of diabetes, preoperative albumin, preoperative haemoglobin, time from injury to surgery, and operation time were correlated with incision infection (p < 0.05). Additionally, multivariate regression analysis indicated that a shorter time from injury to surgery (OR = 1.475, 95% CI: 1.024-2.125, p = 0.037), lower preoperative albumin (OR = 1.559, 95% CI: 1.191-2.041, p = 0.001), and longer operation time (OR = 1.511, 95% CI: 1.219-1.874, p < 0.001) were risk factors for postoperative incision infection, and their cut-off values were 10.5 days, 38.5 g/L, and 84.5 minutes, respectively.

CONCLUSION

Longer preoperative stay and operation time were two risk factors for postoperative incision infection. However, lower preoperative albumin level is the highest risk factor in this study.

TRIAL REGISTRATION

The trial was registered in the China Clinical Trial Registry (ChiCTR2100047038).

Relationship between surgeon volume and the risk of deep surgical site infection (DSSI) following open reduction and internal fixation of displaced intra-articular calcaneal fracture

It is well established that the postoperative results were affected by the surgeon volume in a variety of elective and emergent orthopaedic surgeries; however, by far, no evidences have been available as for surgically treated displaced intra-articular calcaneal fractures (DIACFs). We aimed at investigating the relationship between surgeon volume and deep surgical site infection (DSSI) following open reduction and internal fixation (ORIF) of DIACFs. This was a further analysis of prospectively collected data from a validated database. Patients with DIACFs stabilised by ORIF between 2016 and 2019 were identified. Surgeon volume was defined as the number of surgically treated calcaneal fractures within one calendar year and was dichotomised based on the optimal cut-off value. The outcome measure was DSSI within 1 year postoperatively. Multivariate logistics regression analyses were performed to examine the relationship, adjusting for confounders. Among 883 patients, 19 (2.2%) were found to have a DSSI. The DSSI incidence was 6.5% in surgeons with a low volume (<6/year), 5.5 times as that in those with a high volume (≥6/year) (incidence rate, 1.2%; P < 0.001). The multivariate analyses showed a low volume <6/year was associated with a 5.8-fold increased risk of DSSI (95% confidence interval, 2.2-16.5, P < 0.001). This value slightly increased after multiple sensitivity analyses, with statistical significances still unchanged (OR range, 6.6-6.9; P ≤ 0.001). The inverse relationship indicates a need for at least six cases/year for a surgeon to substantially reduce the DSSIs following the ORIF of DIACFs.

Surgical experience as a decisive factor for the outcome of calcaneal fractures using locking compression plate: results of 3 years

INTRODUCTION

Calcaneal fractures account for 60-75% of all tarsal fractures and represent surgical challenges because of their frequency and complexity. Despite standardized procedures and new implants, literature reports high revision rates and unsatisfactory results. The study aims to describe the role of the surgeon with respect to the clinical outcome.

METHODS

Between 2014 and 2017, 94 calcaneal fractures (all type AO C1-3) were re-examined in 86 patients (67 male and 19 female; mean age: 51 years). The treatment was always carried out by means of locking compression plate via the extensile lateral approach. A comparison was made between treatment by an experienced (ES) and less experienced surgeon (LES). Annually, the ES performed at least 30 procedures for calcaneus fracture treatment as compared to < 10 operations performed by the LES.

RESULTS

The mean AOFAS, VAS FA, and Kiel Score in the ES group were 77.0 (SD 15.9), 69.0 (SD 18.8), and 65.0 (SD 20.6), respectively. The corresponding values in the LES group were 68.1 (SD 21.0), 60.3 (SD 22.4), and 53.0 (SD 21.9) (p < 0.05). The operation time was on average 14 min shorter in the ES group than the LES group (p < 0.05).

CONCLUSION

The significantly better scores, along with shorter operation time, shorter duration of incapacity to work, and lower complication rate prove the importance of having an experienced surgeon perform complex intra-articular calcaneal fracture repairs. The extensile lateral approach is still considered the standard method.

LEVEL OF EVIDENCE

Level III, comparative series.

Risk prediction model for deep surgical site infection (DSSI) following open reduction and internal fixation of displaced intra-articular calcaneal fracture

Deep surgical site infection (DSSI) is a serious complication affecting the surgical outcome of displaced intra‐articular calcaneal fracture, and a risk prediction model based on the identifiable risk factors will provide great clinical value in prevention and prompt interventions. This study retrospectively identified patients operated for calcaneal fracture between January 2014 and December 2019, with a follow‐up ≥1 year. The data were extracted from electronic medical records, with regard to demographics, comorbidities, injury, surgery and laboratory biomarkers at admission. Univariate and multivariate logistics regression analyses were used to identify the independent factors for DSSI, thereby the risk prediction model was developed. Among 900 patients included, 2.7% developed a DSSI. The multivariate analyses identified five factors independently associated with DSSI, including current smoking (OR, 2.8; 95% confidence interval [CI], 1.3‐6.4; P = .021), BMI ≥ 26.4 kg/m² (OR, 3.1; 95% CI, 1.6‐8.4; P = .003), ASA ≥II (OR, 1.3; 95% CI, 1.0‐5.1; P = .043), incision level of II (OR, 3.8; 95% CI, 1.3‐12.6; P = .018) and NLR ≥6.4 (OR, 3.2; 95% CI, 1.3‐7.5; P = .008). A score of 14 as the optimal cut‐off value was corresponding to sensitivity of 0.542 and specificity of 0.872 (area, 0.766; P < .001); ≥14 was associated with 8.1‐times increased risk of DSSI; a score of 7 was corresponding sensitivity of 100% and 10 corresponding to sensitivity of 0.875. The risk prediction model exhibited excellent performance in distinguishing the risk of DSSI and could be considered in practice for improvement of wound management, but its validity requires to be verified by better‐design studies.

Fixation by Open Reduction and Internal Fixation or Primary Arthrodesis of Calcaneus Fractures: Indications and Technique

The quest for the best treatment of displaced intraarticular calcaneal fractures continues. The open reduction and internal fixation of displaced intraarticular calcaneal fractures yields the best results if anatomic reduction is obtained and complications are avoided. The sinus tarsi approach is becoming the new gold standard. In cases with severe comminution or when anatomic reduction cannot be obtained, a primary subtalar arthrodesis is a valuable option, if the overall anatomy of the calcaneus is corrected first. This review discusses the open reduction and internal fixation of displaced intraarticular calcaneal fractures and the indications and technique of the primary arthrodesis.

Biomechanical analysis of minimally invasive crossing screw fixation for calcaneal fractures: Implications to early weight-bearing rehabilitation

BACKGROUND

Minimally invasive fixation using crossing screws was believed to produce satisfactory clinical outcome whereas its stability in early weight-bearing remained controversial. This study aimed to analyze the biomechanical stability of minimally invasive fixation during balanced standing and walking stance, and provide evidence for early rehabilitation.

METHODS

A finite element model of foot-ankle-shank complex was reconstructed based on computed tomography and magnetic resonance images, and validated by plantar pressure of the model participant. A Sanders III calcaneal fracture was created on the model, and then fixed using crossing screws. The predicted stress distribution, fracture displacement, Bohler's angle and Gissane's angle were compared between the intact calcaneus and fracture model with the fixation.

FINDINGS

Postoperatively, the concentrated stress appeared at the junction of the calcaneus and its surrounding tissues (especially Achilles tendon, plantar fascia and ligaments) during standing and walking stances, and the stress exceeded the yield strength of trabecular bone. The longitudinal screws sustained the highest stresses and concentrated at the tips and the calcaneal tuberosity junction. The displacement of posterior joint facet, Bohler's angle, and Gissane's angle were within the acceptable range either standing or walking after the fixation.

INTERPRETATION

Early weight-bearing standing and walking after minimally invasive fixation may cause high stress concentration thereby induce calcaneus stress fractures and other complications like plantar fasciitis and heel pain, so it should not be supported. The peri-calcaneus tendons, i.e., Achilles tendon and plantar fascia, play key roles in the stabilization of the calcaneal fracture after operation.

Risk factors for surgical site infections with the Sinus Tarsi Approach in displaced intra-articular calcaneal fractures; a prospective cohort study with a minimum of one year follow-up

BACKGROUND

In the last decade, the sinus tarsi approach (STA) has gained interest over the extensile lateral approach (ELA) in the operative treatment of displaced intra-articular calcaneal fractures (DIACF's), mainly because of the lower rate of surgical site infections (SSIs). However, most studies are small and retrospective. The aim of this study was to evaluate the rate of SSIs of the STA in a large, prospective series of patients and to identify predictors for SSIs.

METHODS

In this prospective cohort study, all consecutive patients who were operatively treated for a DIACF in our Level 1 trauma center between August 2012 and January 2019 were included and followed for at least one year. All operative procedures were performed by two specialized foot and ankle trauma surgeons using the STA. Using multinomial logistic regression, risk factors for SSIs were identified.

RESULTS

A total of 237 calcaneal fractures in 214 patients were included, of which 179 underwent open reduction and internal fixation and 58 a primary arthrodesis. Most patients were male (73.6%) and the mean age was 45.9 years. There were 16 patients that developed a SSI (6.8%), of which 9 (3.8%) were deep and 7 (3%) were superficial infections. The multivariate analysis pointed out that surgery within one week after injury increased the chance of a SSI, as well as an ASA of 2 or higher and more than 150 cc of blood loss during the procedure.

CONCLUSION

This study confirms the low risk of SSI in DIACFs treated via STA. Significant predictors for SSIs were surgery within one week after injury, ASA of 2 or higher and blood loss > 150cc.

Seasonal effect on the incidence of post-operative wound complications after trauma-related surgery of the foot, ankle and lower leg

INTRODUCTION

Post-operative wound complications remain among the most common complications of orthopedic (trauma) surgery. Recently, studies have suggested environmental factors such as season to be of influence on wound complications. Patients operated in summer are reported to have more wound complications, compared to other seasons. The aim of this study was to identify if "seasonality" was a significant predictor for wound complications in this cohort of trauma-related foot/ankle procedures.

MATERIALS AND METHODS

This retrospective cohort study included all patients undergoing trauma-related surgery (e.g. fracture fixation, arthrodesis, implant removal) of the foot, ankle or lower leg. Procedures were performed at a Level 1 Trauma Center between September 2015 until March 2019. Potential risk factors/confounders were identified using univariate analysis. Procedures were divided into two groups: (1) performed in summer (June, July or August), (2) other seasons (September-May). The number of surgical wound complications (FRIs, SSIs or wound dehiscence) was compared between the two groups, corrected for confounders, using multivariate regression.

RESULTS

A total of 599 procedures were included, mostly performed in the hindfoot (47.6%). Patients were on average 46 years old, and mostly male (60.8%). The total number of wound complications was 43 (7.2%). Age, alcohol abuse, open fracture and no tourniquet use were independent predicting factors. No difference in wound complications was found between summer and other seasons, neither in univariate analysis [4 (3.2%) vs 39 (8.2%), p = 0.086] nor when corrected for predicting factors as confounders (p = 0.096).

CONCLUSIONS

No seasonality could be identified in the rate of wound complications after trauma surgery of the lower leg, ankle and foot in this cohort. This lack of effect might result from the temperate climate of this cohort. Larger temperature and precipitation differences may influence wound complications to a larger extent. However, previous studies suggesting seasonality in wound complications might also be based on coincidence.

Managing the open calcaneal fracture: A systematic review

INTRODUCTION

Open fractures of the calcaneus are rare. They are mostly caused by high-energy trauma. There are several treatment options for calcaneal fractures. However, treatment of open calcaneal fractures might need a different approach, as open calcaneal fractures are associated with high rates of complications. The purpose of this study was to provide a literature overview on the management of open calcaneal fractures, and deduct a more standardized treatment algorithm.

MATERIAL AND METHODS

A literature review was conducted in the databases of PubMed, EMBASE and the Cochrane Library for articles describing the management of open calcaneal fractures. Excluded were studies with less than 10 patients, studies describing combat injuries and reviews. Only articles published from 1998 to 2017 were included and there were no language restrictions.

RESULTS

A total of 18 articles were included with 616 open calcaneal fractures in 598 patients. Most wounds were Gustilo grade III and most fractures were Sanders type III. Definitive surgery was performed after a mean of 9.8days and in most cases in the form of ORIF via ELA. The complication rate was 21% and the mean AOFAS score was 73.7 points.

CONCLUSION

The complication rates of open calcaneal fractures are high and increase with the severity of the wound. A treatment algorithm is suggested. However, to produce a more evidence-based protocol and achieve consensus for treatment, additional research should be done, preferably in the form of a prospective multicenter database.

Correlation of Soft Tissue Swelling and Timing to Surgery With Acute Wound Complications for Operatively Treated Ankle and Other Lower Extremity Fractures

BACKGROUND

Considerable debate exists regarding how soft-tissue edema should influence timing of surgery for ankle and other lower extremity fractures. Assessment of swelling is subjective, and timing varies among surgeons. However, timing of surgery is one of the few modifiable factors in fracture care. Ultrasonography can objectively measure swelling and help determine optimal timing. The purposes of this study were to determine whether objective measures of swelling, timing to surgery, and patient-specific risk factors correlated with wound complications and to try to create a prediction model for postoperative wound complications based on identified modifiable and nonmodifiable risk factors.

METHODS

Patients with closed ankle and other lower extremity fractures requiring surgery with an uninjured, contralateral extremity were included. Demographic information and sonographic measurements on both lower extremities were obtained pre-operatively. Subjects were followed for 3 months and wound complications were documented. A predictive algorithm of independent risk factors was constructed, determining wound complication risk. Given that patients with ankle fractures made up the majority of the study cohort (75/93 or 80%), a separate statistical analysis was performed on this group. A total of 93 subjects completed the study, with 75/93 sustaining ankle fractures.

RESULTS

Overall wound complication rate was 18.3%. Timing to surgery showed no correlation with wound complications. A heel-pad edema index >1.4 was independently associated with wound complications. Subgroup analysis of ankle fractures demonstrated a 3.4× increase in wound complications with a heel-pad edema index >1.4. Tobacco history and BMI >25 were independent predictors of wound complications. An algorithm was established based on heel-pad edema index, BMI >25, and tobacco history. Patients with none of the 3 factors had a 3% probability of a wound complication. Patients with 1/3, 2/3 and 3/3 factors had a 12-36%, 60-86% and 96% probability of a wound complication, respectively.

CONCLUSIONS

Timing to surgery had no correlation with wound complications. Heel-pad edema index >1.4, BMI >25, and tobacco-use correlated with wound complications. When separately analyzing the cohort that sustained ankle fractures, the heel-pad edema index of >1.4 was still demonstrated to be predictive of wound complications corresponding to a 3.4× increase in wound complication rates (11.1% vs 37.5%). Risk of wound complications significantly increased with each factor. In patients with increased BMI and/or tobacco use, resolution of heel edema may significantly reduce wound complications in lower extremity trauma.

LEVEL OF EVIDENCE

Level II, prognostic, prospective cohort study.

Should the Extended Lateral Approach Remain Part of Standard Treatment in Displaced Intra-articular Calcaneal Fractures?

The aim of this study was to evaluate the results of open reduction and internal fixation through the extended lateral approach (ELA) in displaced intra-articular calcaneal fractures and to determine whether this approach should remain part of standard therapy. This retrospective cohort study included 60 patients with 64 displaced intra-articular calcaneal fractures who underwent surgical treatment through the ELA. Outcome measures were the visual analog scale foot and ankle (VAS FA), the American Orthopedic Foot and Ankle Society (AOFAS) score, surgical site infections (SSIs), and reoperations. We determined the AOFAS score for 40 patients with 42 fractures, and 42 patients with 44 fractures completed the VAS FA questionnaire. The mean VAS FA score was 61.0 ± 23.4 and the median AOFAS score was 83 (range 33 to 100), with 55% good to excellent scores. We found 10.9% superficial SSIs successfully treated with antibiotics. In 4.7% of patients a deep SSI was diagnosed, wherefore premature implant removal was necessary. Patients with an SSI did not have significantly lower VAS FA or AOFAS scores than did patients without an SSI (p = .318 and p = .766, respectively). Implant removal in absence of SSIs was necessary in 17 patients because of pain, and 3 patients needed secondary arthrodesis because of persistent pain. We concluded that the ELA proved to be a safe procedure, and moreover the most common complications did not influence the long-term outcomes of patients. However, recent literature demonstrates that less invasive techniques seem to exceed the ELA with respect to wound complications.

Preoperative disinfection of foot and ankle: microbiological evaluation of two disinfection methods

BACKGROUND

The aim of the current study was to investigate the effect of a footbath in alcohol prior to preoperative disinfection on bacterial flora of the foot and ankle.

METHODS

Twenty-two volunteers underwent skin preparation mimicking pre-surgical disinfection. One foot was submerged in a bag filled with 70% ethanol containing 10% IPA for 5 min after which it was painted with regular 0.5% chlorhexidine in 70% alcohol. The other foot was only painted with 0.5% chlorhexidine in 70% alcohol. Swabs were taken at four locations: (1) under the nailfold of the first toe, (2) first webspace, (3) sinus tarsi and (4) pre-tibial. A quantitative and qualitative analysis of the cultures was performed.

RESULTS

No statistically significant difference between the number of positive cultures between the two methods was observed. The number of colony forming units was statistically significantly lower on two locations in the footbath group (i.e., subungual and the first webspace) (median 1 versus median 92 p =0.03 and median 0 versus median 1 p =0.03, respectively). The number of cultures with heavy growth was lower in the footbath group under the nailfold of the first toe (5 versus 13 p =0.008). Thirty-eight different microorganisms were cultured.

CONCLUSION

A footbath in alcohol prior to regular preoperative skin antisepsis significantly reduces the amount of bacteria under the nailfold and in the first webspace. The number of cultures with heavy growth is lower after a footbath in alcohol.

LEVEL OF EVIDENCE

IV.