SLR - December 2018 - Kevin J. Huntsman

Does the Quality of Preoperative Closed Reduction of Displaced Ankle Fractures Affect Wound Complications After Surgical Fixation?

Reference: Chien BY, Stupay KL, Miller CP, Smith JT, Briceno J, Kwon JY. Does the Quality of Preoperative Closed Reduction of Displaced Ankle Fractures Affect Wound Complications After Surgical Fixation? Injury. 2018 Oct;49(10):1931–1935.

Scientific Literature Review

Reviewed By: Kevin J. Huntsman, DPM
Residency Program: Hunt Regional Medical Center, Greenville, TX

Podiatric Relevance: Ankle fractures are one of the most common fractures in adults and one of the most common fractures treated by orthopaedic surgeons and podiatric surgeons today. Displaced ankle fractures are typically closed, reduced and splinted with the aim to achieve anatomical alignment between the tibia and talus; however, multiple attempts at closed reduction may in fact be more detrimental to cartilage and soft tissue even if it is eventually relocated, anatomically. The purpose of this study was to determine whether the quality of preoperative closed reduction in patients with operative ankle fractures affects postoperative wound complications. Secondly, due to no accepted method in evaluating closed reductions, a classification system was proposed to determine the quality of reduction for unstable ankle fractures.

Methods: A retrospective analysis at two level 1 trauma centers had been performed with patients presenting and treated with isolated, closed and operative ankle fractures that had an initial closed reduction performed on presentation. The time period for these fractures was from July 2012–September 2015. A minimum of three months' follow-up was required to be included in the study, which was to assess postoperative wound complications. Included in the study was fracture type, patient demographics, data that was considered pertinent to the reduction and postop wound complications. All statistical analysis was performed using IBM SPSS software, ANOVA with post-hoc Bonferroni adjusted comparisons and an apriori power analysis was performed. A new classification system to assess reduction quality was developed, applied and evaluated for inter- and intra-observer agreement. It assessed AP and lateral radiographs to observe amount of talar shift under the tibia in relation to a central tibia axis line.

Results: One hundred and sixty-one patients met inclusion criteria for analysis. Of those, 17 percent (27/161) sustained a postoperative wound complication. The study found that there was no statistically significant association between the patient presenting with wound complications based on the quality of the preoperative closed reduction of the injury (p = 0.17) or with attempting to close reduce more than one time (p = 0.887). One factor to consider, which may have been protective, is that patients with poor initial closed reductions were taken to surgery sooner than those who were reduced to anatomical alignment (1.4 ± 2.9 versus 4.7 ± 6.3 days, p = 0.03). This may have been a factor in decreasing the possibility of post-op wound complications. Interclass correlation coefficients for inter- and intra-rater reliability of the classification schema was 0.942 and 0.922, respectively, demonstrating excellent agreement.

Conclusions: Overall, this study demonstrates there was no statistically significant relationship between the quality of ankle closed reduction and subsequent postoperative surgical wound complications in patients with closed, displaced ankle fractures that would eventually require operative treatment. Continued attempts to achieve a perfect reduction are most likely unnecessary when operative intervention is ultimately decided. However, earlier surgical intervention or rereduction may be appropriate in cases of poor reduction, based on the classification system that was introduced in this study. Future studies to assess functional outcomes with multiple reductions may be warranted to further guide management of this common injury.

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