SLR - April 2017 - Sarah Richards

The Impact of Lifestyle Risk Factors on the Rate of Infection After Surgery for a Fracture of the Ankle

Reference: Olsen LL, Moller AM, Brorson S, Hasselager RB, 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 Feb; 99-B:225–230

Scientific Literature Review

Reviewed By: Sarah Richards, DPM
Residency Program: Hoboken University Medical Center

Podiatry Relevance: Risk factors for complications after surgery, such as smoking, alcohol overuse and obesity, are commonly seen in surgical patients. These risk factors have been linked to impaired wound healing and increased risk of infection. The incidence of ankle fractures is not uncommon. Many of these ankle fracture patients require ORIF, and although it is considered to be a low-risk procedure, there is a frequent rate of complications, such as infection. This study was designed to assess the roles smoking, alcohol overuse and obesity have for developing infections after surgery to correct ankle fractures.

Methods: This is a retrospective review of patients who underwent surgery for correction of ankle fracture between 2008 and 2013. Exclusion criteria included fractures not involving the ankle, pilon-type fractures, patients treated with external fixation or arthrodesis and patients with other fractures in the same limb. One thousand forty-three patients were included in the study. The surgical procedure involved ORIF with screw and plate fixation. Staples or wires were occasionally used. The patients were each given standard prophylatic antibiotics, two grams of dicloxacillin preoperatively. In this study, obesity was defined as a BMI greater than or equal to 30 kg/m2. Smoking status and alcohol use were taken from either the anesthesia record or admission record. Alcohol overuse was defined as weekly intake of more than seven units for women or more than 14 units for men. Deep infection was the primary outcome, which was defined if there was need for reoperation. Surgical site infection was the secondary outcome, defined if antibiotic treatment was initiated and there were clinical signs of infection.

Results: Of the 1,043 patients, 17.3 percent were obese, 27.3 percent were smokers and 23.6 percent overused alcohol. Deep infection was recorded in 6.1 percent (64) of patients, and 51 of these patients had positive microbiological cultures. One hundred forty-six patients had a surgical site infection. Seventeen (10.4 percent) of obese patients had deep infections resulting in an odds ratio of 2.21, p=0.017 for sustaining a deep infection when obese. Thirty-three (20.1 percent) of obese patients had an SSI with an odds ratio of 1.68, p=0.014. Twenty-two (9.1 percent) of alcohol overuse patients had deep infections with an OR of 1.77, p=0.037. Forty-seven (19.3 percent) of alcohol overuse patients had an SSI with and OR of 1.7, p=0.006. Smokers did not yield statistical significance associated with infection.

Conclusion: Obesity and alcohol overuse are independent risk factors for infections following ORIF of ankle fractures. Although smoking was not shown to be an independent risk factor in this study, it had been shown to be a risk factor for wound healing after surgery. Also, stopping the consumption of alcohol one month preoperatively has been shown to reduce complications after elective surgery. Obesity is a risk factor to consider when choosing a treatment plan for a patient after s/he has sustained an ankle fracture.

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