SLR - March 2020 - Jessica M. Arneson

Does Surgical Approach Influence the Risk of Post-operative Infection Following Surgical Treatment of Tibial Pilon Fractures?

Reference: Esposito JG, Van Der Vilet QMJ, Heng M, Potter J, Cronin PK, Harris MB, Weaver MJ. Does Surgical Approach Influence the Risk of Post-operative Infection Following Surgical Treatment of Tibial Pilon Fractures? J Orthop Trauma. 2019 Sep 30.

Scientific Literature Review

Reviewed By: Jessica M. Arneson, DPM
Residency Program: MedStar Georgetown University Hospital – Washington, DC

Podiatric Relevance: The management of tibial pilon fractures is a challenge to the podiatric and orthopaedic surgeon. High-energy trauma can predispose to wound complications and infections following open reduction and internal fixation (ORIF) of these fractures. A variety of surgical approaches exist for pilon fractures and although it has been described that the major fracture line should dictate surgical approach, it has not been elucidated whether surgical approach itself affects soft tissue complication risk.

Methods: This is a level III retrospective review from Harvard University of two level-one trauma centers where 590 tibial pilon fractures from January 2001 to December 2015 underwent surgical treatment through ORIF. Osteosynthesesfragen/Orthopaedic Trauma Assocation (AO/OTA) 43-B and 43-C fractures of patients in patient 18 years and older were included. The primary outcome measure, deep infection, was defined as any type of infection at the surgical site that required operative treatment. Multiple cox proportional hazard regression analysis was used to identify risk factors for the development of post-operative deep infection on a time-to-event basis.

Results: Of the 590 fractures, 316 (54 percent) were treated with a medial approach, 147 (25 percent) underwent anterolateral, 64 (11 percent) anteromedial, 50 (8 percent) posterolateral, and 13 (2 percent) posteromedial approach. A dual tibial approach was used in 109 of 590 fractures (18 percent). The cumulative prevalence of deep surgical site infection was 18.6 percent (110/590). One hundred thirty-nine of 590 (24 percent) were open fractures of which 36 (26 percent) required some type of soft tissue coverage (i.e free flap) and 39 (28%) developed deep infection. The highest unadjusted infection rate was the anterolateral approach (21.8 percent) followed by medial (19 percent), anteromedial (15.6 percent) posteromedial (15.4 percent), and posterolateral (12.0 percent) approaches. There was no association between primary surgical approach and development of deep infection (p: 0.19 – 0.78). Independent risk factors for infection were smoking (Hazard Ratio (HR) 2.1; p<0.001) and need for soft tissue coverage (HR 6.9; p<0.0001).

Conclusions: The authors conclude that no specific surgical approach or combination of approaches were a risk factor for deep infection, rather that active smoking and need for soft tissue coverage were independent risk factors. To date, this is the largest cohort examining deep infection rate after ORIF of pilon fractures utilizing an established criteria for deep infection. Although open fractures were not found to be an independent risk factor in this study, they were found to be strongly associated with deep infections in the univariate analysis and 26 percent required soft tissue coverage which was found to be a risk factor for deep infection. The retrospective design of this study is a significant limitation. Additionally, although a large number of patients treated by a large number of surgeons across multiple institutions over many years improve the generalizability of the results, surgeon preference, level of expertise and improved hand hygiene over the years could influence the results. The results of this study allow surgeons to confidently choose surgical approaches best for fracture reduction and fixation without worsened concern for deep infection and could be improved in the future with further prospective evaluation.  

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