Scandinavian Journal of Surgery 94: 243–245, 2005
POSTOPERATIVE WOUND COMPLICATIONS AFTER INTERNAL FIXATION OF CLOSED CALCANEAL FRACTURES: A RETROSPECTIVE ANALYSIS OF 126 CONSECUTIVE PATIENTS WITH 148 FRACTURES A. Koski, H. Kuokkanen, E. Tukiainen Helsinki University Central Hospital, Department of Plastic Surgery, Helsinki, Finland
ABSTRACT
Aim: The aim of the study was to analyse the number of soft-tissue complications after internal fixation of calcaneal fractures and to evaluate risk factors leading to these complications. Material: A retrospective analysis of 126 consecutive patients with 148 operatively treated calcaneal fractures was performed. Only primarily closed fractures were included in the study. Results: Wound healing was problematic in 35 cases (24 per cent). The wound was infected in 23 cases (16 per cent) and a wound edge necrosis was observed in 12 cases (8 per cent). The soft tissue complication needed operative treatment in 20 cases (14 per cent). The complications did not lead to amputations in any case. In the end of the follow up all wounds had healed. Conclusions: The statistical analysis identified a longer delay in surgery and longer operation time to be positive risk factors for wound complications. Key words: Calcaneus; fractures; complications; flaps
INTRODUCTION Operative treatment of the calcaneal fracture is challenging due to both the complex shape of the bone and the limited soft tissue available (1). There is evidence that surgically treated patients heel faster and return more quickly to their previous activities than those with a conservatively treated fracture (2, 3). Although the surgical outcome of the operations has improved the rate of post-operative wound healing problems remains quite high (4). The incidence of post-operative wound complication varies from 0 % Correspondence: Antti Koski, M.D. Eira Hospital Laivurinkatu 29 FIN - 00150 Helsinki, Finland Email:
[email protected]
to 32.8 % (3, 4). This can be devastating to the patient. Folk et al reported complications in a series of 190 operatively treated fractures. In this group 48 patients developed wound complications, eleven free flaps were required and four legs had to be amputated as a final result (4). The purpose of this study was to analyse the incidence of wound complications after operative treatment of closed calcaneal fractures in our hospital. We also wanted to identify risk factors leading to these complications and clarify how these complications were treated and what was the end result after wound complications. PATIENTS AND METHODS Between January 1st 1996 and December 31st 1999, a total of 149 patients with a closed calcaneal fracture were admitted to Helsinki University Hospital Trauma Center. The
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A. Koski, H. Kuokkanen, E. Tukiainen
fracture was in the right calcaneus in 69 and in the left in 51 patients. Bilateral fractures were seen in 29 patients. A total of 148 fractures in 126 patients were operated on and were included in this study. Male to female ratio was 101/25. The mean age was 39.8 years (range 14–77 yrs). Bilateral calcaneus fractures were treated on 22 patients. The mechanism of injury was a fall in 84 % from one to 17.5 meters, a traffic accident 10% and miscellaneous in 6% of cases. Four of the patients (3 %) had Diabetes Mellitus and 50 (40 %) were smokers. Additional fractures were observed on 55 patients A standard X-ray and a CT-scan were routinely taken preoperatively. For this study the fractures were classified into three groups according to Regazzoni (7). The classification could not be made in two cases due to lost X-rays. There were two type A (peripheral) fractures, 64 type B (affecting subtalar joint) and 80 type C fractures (affecting subtalar and calcaneocuboidal joint). The primary operations were performed by 33 different surgeons. One surgeon performed on average 4.5 operations (range 1–16 operations). A standard L-shaped lateral approach to the calcaneus was used , with the exception of isolated tuberosity fractures. After reduction the bone was fixed with an AO-plate and screws in 135 cases, screws only in 8, Kirschner wires in 4 and Kirschner wires combined with absorbable rods in one case. The wounds were all closed in two layers. The leg was left without a cast for the first six weeks, during which no weight-bearing was allowed. After six weeks the leg was put in a walkingcast and weight-bearing was prohibited with leg´s own weight for the next four weeks. Routine x-ray controls were taken at six and ten weeks from the operation. All variants were recorded from patient charts. The Mann-Whitney test and the T- tests were used in the statistical analyses of the data. Probability (p) values of 0.05 or less were considered statistically significant.
RESULTS Thirty-five operated fractures (24 %) had post-operative wound complications. In 12 cases the complications was considered as wound edge necrosis (8 %) and in 23 cases as wound infection (16 %). Fifteen of these wounds (10 %) were treated conservatively with local wound care and systemic antibiotic therapy. In the bacterial cultures taken from the wounds the significant results were in all cases normal skin bacteria. Twenty complicated cases (14 %) were treated operatively. On average 1.57 corrective operations were performed (range 1–4). The type of soft tissue reconstruction depended on the size and depth of the skin defect created by the revision. Revision of the wound together with free skin graft on the granulated tissue was performed in cases with a superficial defect. If after revision the hardware was exposed it was removed. The soft-tissue defect was reconstructed with a flap in eight cases (5 %). A bi-pedicle skin flap was used to cover a superficial defect in two cases. The Adductor Longus muscle of the hallux was transposed in one case. A microvascular flap was used for reconstruction in five cases (gracilis muscle 3, rectus abdomis 1, and radial forearm 1). The patients were followed-up in average 10.7 months (range (0.5–56 months). During the follow-
TABLE 1
Diabetes Smoking Delay in surgery Operating time Fracture classification Height of fall Age
Fractures
Complications
4 50
4 9
p
Not estimated 0.41 0.02 0.04 0.07 0.14 0.73
up a late subtalar arthrodesis was performed in six patients (5 %). In the end of the follow-up the softtissues of all patients were healed. The delay from injury to surgery was in average 7.8 days (range 0–24 days). The operation time was in average 101 minutes (range 40–330 minutes). Both of these variables were found to have a statistically significant association with wound complications (Table 1). The patients with complicated wounds had also a higher incidence of spine fractures compared to the non-complicated ones (24 % vs. 14 %). ge, sex, height of fall, fracture classification or smoking habits of the patient were not found to have a statistically significant association with wound complications. Four patients in the study group had Diabetes Mellitus. They all had postoperative wound complications. However, this was statistically non significant due to the small number of patients. DISCUSSION Although the operative treatment of dislocated calcaneal fractures seems to improve the outcome, the evidence reported so far is not strong (2). The complication rate of the wounds after internal fixation remains high. In our study it was 24 %, which is rather high compared to other studies (4, 8, 9). The grade of comminution of fractures seems to have a positive correlation on the post operative wound healing problems (10). This may be due to disruption of the microcirculation in the soft tissue envelope of the calcaneus (11). The more complex fractures also increase the operating time, which was found to have an association with the post-operative wound problems in our study. This may be due to disruption of the microcirculation in the soft tissue envelope of the calcaneus (8). On the other hand the operation time may reflect the experience of the surgeon and thus support the need for centralising the operative treatment of calcaneal fractures. In this material there were six surgeons who under the four-year period operated only one calcaneal fracture. In our material the amount of surgeons was higher than in other studies. However, this had no statistical correlation with wound complications. Previously it has been stated that the operation should be delayed until the skin wrinkles, which usually with the leg elevated usually takes at least one week (11,12). In this study the average time to surgery was 7.8 days (range 0–24 days). We found
Wound complications in calcaneal fractures
that a delay from injury to surgery is in association with wound complications. This can be due to the fact that the patients with multiple fractures and more severe fractures were operated after a longer delay. A prospective, randomised study is needed to clarify this. Our results do not confirm the earlier finding of Sorensen et al. that smoking increases the risk of post-operative wound infections and skin flap necrosis (13). Soft-tissue complications after internal fixation of calcaneal fractures are quite common at least in our clinic. This has to be recognised in selecting patients for internal fixation. We also feel that the operations should be centralised to specially trained surgeons in this field. ACKNOWLEDGEMENTS We thank Mr Timo Pessi for assistance with the statistical analysis. REFERENCES 01. Stromsoe K, Espen M, Hem ES: Open reduction and internal fixation in 46 displaced intrarticular calcaneal fractures. Injury 1998;29:313–316 02. Randle JA, Kreder HJ, Stephen D, Williams J, Jaglal, S, Hu R: Should calcaneal fractures be treated surgically? A metaanalysis. Clin Orthop 2000;377:217–227
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03. Leung KS, Yuen KM, Chan WS: Operative treatment of displaced intra-articular fractures of the calcaneum. J Bone Joint Surg 1993;75–B:197–201 04. Folk JW, Starr AJ, Early JS: Early wound complications of operative treatment of calcaneus fractures: Analysis of 190 fractures; J Orthop Trauma 1999;13:369–372 05. Raymakers JTFJ, Dekkers GHG, Brink PRG: Results after operative treatment of intra-articular calcaneal fractures with a minimum follow-up of 2 years. Injury 1998;29:593–599 06. Abidi NA, Dhawan S, Gruen GS, Vogt MT, Conti SF: Wound healing risk factors after open recution and internal fixation of calcaneal fractures. Foot Ankle Int 1999;19:856–861 07. Regazzoni P, Mosimann P, Calthorpe D: Classification and results of ORIF of calcaneal fractures In: Tscherne H, Schatzker J, Eds. major fractures of the pilon, the talus, and the calcaneus. Springer-Verlag, Berlin Heidelberg 1993:191–194 08. Chan S, Ip FK: Open reduction and internal fixation for displaced intra-articular fractures of the calcaneus. Injury 1995; 26(2):111–1115 09. Bèzes H, Massart P, Delvaux D, Fourquet JP, Tazi F: The operative treatment of intra articular calcaneal fractures. Clinical Orthopedics and Related Research 1993;290:55–59 10. Berry GK, Stevens DG, Kreder HJ, McKee M, Schemitsch E, Stephen DJ: Open fractures of the calcaneus: a review of treatment and outcome. J Orthop Trauma 2004;18(4):202–206 11. Al-Mudhaffar M, Prasad CVR, Mofidi A: Wound complications following operative fixation of calcanel fractures. Injury 2000;31:461–464 12. Zwipp H, Tscherne H, Thermann H, Weber T: Osteosynthesis of displaced intrarticular fractures of the calcaneus. Clin Orthop 1993;(290):76–86 13. Sorensen LT, Horby J, Friis E, Pilsgaard B, Jorgensen T: Smoking as a risk factor for wound healing and infection in breast cancer surgery. Eur J of Surg Oncol 2002;28(8):815–820
Received: February 7, 2005 Accepted: June 3, 2005
