SLR - February 2021 - Sean R. Lyons

Impact of Surgical Procedures on Soft Tissue Microcirculation in Calcaneal Fractures: A Prospective Longitudinal Cohort Study

Reference: Bläsius FM, Link BC, Beeres FJP, Iselin LD, Leu BM, Gueorguiev B, Klos K, Ganse B, Nebelung S, Modabber A, Eschbach D, Weber CD, Horst K, Knobe M. Impact of Surgical Procedures on Soft Tissue Microcirculation in Calcaneal Fractures: A Prospective Longitudinal Cohort Study. Injury. 2019 Dec;50(12):2332-2338.

Level of Evidence: II

Scientific Literature Review

Reviewed By: Sean R. Lyons, DPM
Residency Program: Inova Fairfax Medical Campus – Falls Church, VA

Podiatric Relevance: Open reduction and internal fixation (ORIF) via low-profile locking plate for calcaneal fractures via lateral extensile or sinus approach is the current standard of care for these fractures. These fractures are associated with high incidence of wound healing complications approaching 30 percent. As a result, surgical techniques have been developed to decrease the impact on soft tissue microcirculation by minimally invasive approaches (MIA) by screw or K-wire fixation. This prospective study aims to characterize and contrast the dynamics of changes in microcirculation comparing ORIF and minimally invasive approach.

Methods: This prospective study performed on 19 patients with 24 calcaneal fractures (5 bilateral) who met the inclusion criteria of > 18 years and intra-articular calcaneal fractures (Sanders type = 2). Exclusion criteria were uncontrolled medical conditions, such as PAD, polytrauma patients, open fractures, COPD, generalized infections, diabetes mellitus and Raynaud’s disease. The ORIF group was treated with a low-profile locking plate through lateral extensile approach. The MIA group with a short 2 centimeter skin incision over the posterior facet for reduction and percutaneous K wire fixation. Patients with distinct soft tissue swelling and obesity were enrolled in the MIA group. A spectrophotometer was then used to measure oxygen saturation (sO₂), blood flow (BF) and relative amount of hemoglobin (rHb). These were performed at 2 millimeter and 8 millimeter depths before surgery and every 24 hours for total of six days after surgery.

Results: Postoperative sO₂ at both depths showed significantly higher values in the ORIF group than the MIA group. Overall, the sO₂ increased at the 2 millimeter depth and decreased at the 8 millimeter depth in both groups. A correlation in post-operative sO₂ between surgical technique was found at the 2 mm depth but not the 8 mm depth. Blood flow was higher at both depths in the ORIF group and increased after surgery in both groups. There was no correlation between surgical technique and blood flow. The relative amount of hemoglobin did not differ between groups at both depths.

Conclusions: The ORIF technique was associated with greater changes in microcirculation compared to MIA group and pre-operatively. Intact microcirculation has been shown to be a key factor for reducing risk of soft tissue complications represented by the 2 millimeter depth at the dermis/subcutaneous tissue and proper fracture healing represented by the 8 millimeter depth. The microcirculation changes at each depth as shown by spectrophotometer stresses the importance of future studies to monitor wound healing and fracture healing after surgery as it relates to minimally invasive procedures. 

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