SLR - September 2018 - Nathanael T. Smith

Minimal Invasive Fixation Can Decrease Infection Rates in Diabetic and Obese Patients with Severe Ankle Fracture and Syndesmotic Injury
Reference: Ebraheim, Nabil A., et al. "Minimal Invasive Fixation Can Decrease Infection Rates in Diabetic and Obese Patients with Severe Ankle Fracture and Syndesmotic Injury." Foot & Ankle Specialist (2018): 1938640018766627.

Scientific Literature Review

Reviewed By: Nathanael T. Smith, DPM
Residency Program: Chino Valley Medical Center, Chino, CA

Podiatric Relevance: Ankle injuries are among the most common problems evaluated by foot and ankle specialists, with some references citing up to 25 percent of all joint-related injuries. A subset of those injuries involve breaks in one of the bones in the ankle complex and can involve the syndesmosis. Complications during open reduction internal fixation attempt to be avoided at all costs, but in some populations, this is much more difficult. This research attempts to give an alternative method of fixation to reduce complications in that group of patients who statistically have the most complications during these procedures; the obese and the diabetic population.

Methods: One hundred-ten patients at a level 1 trauma center between 2008 and 2016 were separated into two groups based on the presence of diabetes and/or obesity (BMI>30). Only the presence or absence of diabetes at the time of the fracture was considered. Other distinctions in terms of length, severity or presence of diabetic complications were not included. Neither was the distinction between obese and morbidly obese (BMI >40). Patients were also divided into comorbid and not groups based on the primary care provider’s listed health pathologies present. The operative procedures were either minimally invasive with external fixation and percutaneous pinning through a 1 cm incision or open reduction with internal fixation with plate and screws in the standard way. Information regarding patient pre-, surgical and postoperative details were obtained from the electronic medical record. Standard postoperative protocols were followed, including nonweightbearing for six to eight weeks with only range-of-motion exercises. Infections were defined as purulent drainage from the incision site or constitutional signs accompanied by erythema, with or without drainage from the postoperative area, requiring antibiotic treatment or incision and drainage. The groups were stratified based on age, sex, ASA level and Weber classification. Other parameters evaluated in the study included union rates, rates of revision, reduction grade, pain and time until full weightbearing.  

Results: The mean age and BMI of the comorbid group was significantly higher than the nongroup. Using the chi-squared analysis, the comorbid group was seen to have a higher ASA level than the nongroup. The Weber classification level was stratified and compared and also using chi-squared analysis found a significantly higher number of Weber C fractures in the comorbid group. No significant difference was found when analyzing unimalleolar versus bimalleolar and trimalleolar fractures or mechanism of injury between the comorbid and nongroups. Infections in patients in the comorbid group who underwent minimally invasive surgery were 0, whereas in the ORIF, there were 11. In the noncomorbid group, there were seven infections in the ORIF and one in the percutaneous cohort. There were no other significant differences found in the other categories examined.

This article gives evidence toward the correlation that using a minimally invasive technique when surgically fixating ankle fractures with syndesmotic injury may lead to less postoperative complications in the higher-risk patient population.

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