Preoperative Ankle Swelling and the Effect on Postoperative Wound Complications Following Ankle Fracture Surgery

Abstract

Category: Trauma Introduction/Purpose: It is widely perceived that swelling in the first 24-48 hours following an ankle fracture precludes fixation, delaying operative treatment by 10-14 days to allow swelling to reduce. Such soft tissue management is assumed to be associated with better immediate soft tissue outcomes (wound closure) and mitigation of medium to long-term soft tissue problems. The aim of this study is to identify whether pre-operative ankle swelling has an independent effect on post-operative wound complications following ankle fracture surgery. The hypothesis of this study is that operative intervention at any point in time after the fracture of the ankle, irrespective of swelling, will show no better or worse soft tissue outcomes than those fixations delayed for swelling. The primary outcome measure will be wound complication. Methods: This is a prospective cohort study of patients presenting to a tertiary referral centre that were operatively managed for malleolar ankle fractures. Skeletally mature patients with closed, isolated ankle fractures were included in the study. Patients who were multiply-injured, had open fractures, and/or had known pre-existing limb oedema were excluded. Time to surgery was determined by the on-call attending orthopaedic surgeon. Ankle swelling of both the operative and non-operative limb was measured using the validated ‘Figure-of-eight’ measurement around the foot and ankle to quantify swelling of the affected ankle. A ratio of the patient’s 2 ankles was used as the measure of swelling to eliminate any bias between operators and standardise measurements between patients. Visual assessment of swelling was also recorded. Follow up was at 2, 6, and 12 weeks. Wound complications, patient co-morbidities, operative time, surgeon experience, and hospital stay duration were recorded Results: A total of 50 patients met inclusion criteria. Demographics were a 69% female predominance, a mean age of 45, and age range of 17- 69 years. A complication rate of 4% (n=2) was identified with both complications being superficial wound infections requiring oral antibiotics and wound episodes for treatment. Time to surgery had a mean of 6 days (range 0- 20). There was no significant difference in ankle swelling or time to surgery between patients with wound complications and those without. There were no significant differences identified between these groups when considering BMI, smoking status, diabetes, or peripheral vascular disease. Level of operating surgeon, operative time, tourniquet time, and closure material were also not significantly different between patients with and without wound complications. Conclusion: Our results show little post-operative soft tissue complications. If anything, our results are consistent with or show fewer soft tissue problems than the reported literature, despite a range of time to intervention. While we acknowledge that there may be a bias between surgeons in their preference in soft tissue management; we perceive that our study was sufficiently pragmatic to level this effect. Pre-operative swelling and time to operative intervention in ankle fracture surgery were not shown to correlate with change in soft tissue outcomes following ankle fracture surgery.