SLR - April 2017 - Kyler Thomas

Allgower-Donati vs. Vertical Mattress Suture Technique Impact of Perfusion in Ankle Fracture Surgery: A Randomized Clinical Trial Using Intraoperative Angiography

Reference: Shannon SF, Houdek MT, Wyles CC, Yuan BJ, Cross WW 3rd, Cass JR, Sems SA. Allgower-Donati vs. Vertical Mattress Suture Technique Impact of Perfusion in Ankle Fracture Surgery: A Randomized Clinical Trial Using Intraoperative Angiography. J Orthop Trauma. 2017 Feb; 31(2): 97–102.

Scientific Literature Review

Reviewed By: Kyler Thomas, DPM
Residency Program: KentuckyOne Health, Louisville, KY

Podiatric Relevance: The podiatric surgeon is exposed to a wide variety of lower-extremity trauma. Ankle fractures are one such fracture that a podiatrist will commonly encounter. These fractures encompass 10 percent of all fractures and are second only to hip fractures in lower-extremity fracture occurrence. Wound dehiscence and surgical site infections are relatively common following operative intervention for these injuries due to the significant edema that often accompanies these injuries as well as the relatively tenuous blood supply around the ankle. Rates of surgical site infection in the general population range from 1.25 percent to 1.44 percent; however, in the population of people living with diabetes, these rates can be up to 32 percent. Maintaining perfusion about the surgical wound is a vital factor in wound healing. This paper aimed to see which closure technique, Allgower-Donati or vertical mattress, maintained greatest incision perfusion following ankle fracture surgery as measured using laser-assisted indocyanine green angiography.

Methods: This study was a randomized clinical trial at a single center and involved four surgeons. Thirty patients were enrolled and were randomly allocated into either Allgower-Donati or vertical mattress groups via computer-generated randomization. Only lateral or posterolateral ankle incisions were evaluated. Patient exclusion criteria included allergy to iodine, peripheral arterial disease, HIV, diabetes mellitus, systemic corticosteroid use, long-term anticoagulant use, hepatitis C or syphilis. Demographics were comparable throughout groups. Fracture pattern, time to surgery, mechanism of injury or surgical time between groups were similar. Following closure, a Spy Elite fluorescent imaging system was used to assess perfusion at the 70-second mark following injection of the indocyanine green dye. Ten data points were then collected at evenly based intervals about the incision to measure perfusion. An additional 10 data points were also collected 1 cm anterior and also posterior to the incision to act as theoretically undisturbed skin flaps. Primary outcome was defined as mean incision perfusion and quantified absolute perfusion to the incision with high values indicating stronger perfusion. Secondary outcome was mean perfusion impairment and was based on the difference in the undisturbed data points collected anterior and posterior to the incision compared to directly along the incision. In this case, smaller values indicate perfusion closer to baseline.

Results: Allgower-Donati closure demonstrated higher mean incision perfusion at 51 fluorescence units compared to 28 for vertical mattress technique. Mean perfusion impairment was higher for vertical mattress technique at 23.4 compared to 12.8 for Allgower-Donati. No difference in wound complications were appreciated with one in each group.

Conclusions: The Allgower-Donati technique was found to provide less tissue strangulation and better incision perfusion compared to the vertical mattress closure after ankle fracture ORIF. Overall, the hypothesis was confirmed though clinical implications cannot be elucidated on this study alone. Still, surgeons can consider the increased incision perfusion afforded with the Allgower-Donati technique when deciding on closure technique for ankle fractures.

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