SLR - September 2020 - Dong Yu

Poor Prognosis for Infectious Complications of Surgery for Ankle and Hindfoot Fracture and Dislocation. A 34-Case Series

Reference: Krissian S, Samargandi R, Druon J, Rosset P, Le Nail LR. Poor Prognosis for Infectious Complications of Surgery for Ankle and Hindfoot Fracture and Dislocation. A 34-Case Series. Orthop Traumatol Surg Res. 2019;105(6):1119-1124.

Scientific Literature Review

Reviewed By: Dong Yu, DPM
Residency Program: Hoboken University Medical Center - Hoboken, NJ

Podiatric Relevance: Ankle and/or hindfoot fractures are common pathology in podiatric field and are associated with high rates of complications. Infection is one of the most common complications after surgical management of these fractures which is also one of the key factors that affect the successful rate of fracture treatments. The purpose of this study was to exam the outcome of treatment of bone and joint infection following surgical intervention of ankle and/or hindfoot fractures. The hypothesis of this study was the treatment of BJI secondary to surgery for ankle or hindfoot fracture is at high risk of failure.

Methods: This article was based on a single-center retrospective study of patients who was treated for bone and joint infection following surgery for ankle or hindfoot fractures from 2010 to 2015. Thirty-three patients (34 cases) were included. BJI was diagnosed for scar non-healing, purulent effusion, biological signs and results for intra-operative bacteriological samples. Success was defined by absence of fistula and of local or general inflammatory signs, normalization of CRP level and radiologic consolidation. Joint fusion without recurrence of infection was also counted as success. Failure was defined by recurrence of infection, non-union or amputation. Treatment of BJI adhered to the institution’s protocol, which included revision surgery with wound care, bacteriological sampling and lavage, hardware removal if bone healing allowed (>45 days postoperative interval), flap coverage if necessary, initial intravenous antibiotic therapy after sampling. 

Results: Failure rate was 14.7 percent with all of which were all amputations without infection. The mean procedure number was 4.5. Success rate by fusion was 20 percent with mean procedure number of four. The rest 65.3 percent were also defined as success with cleared of infection without fusion. There was no significant difference between the success and failure groups according to open versus closed fracture, skin opening grades, histories or hardware removal rate. However, the failure rate of BJI treatment after surgery of multiple fractures was significantly higher than the failure rate of single fracture. This study also showed 25 percent failure rate in case of initial flap cover versus 55 percent when flap coverage was at the time of BJI treatment. They considered skin coverage to be an integral part of the initial treatment, however, they did not discuss about the flap coverage quality and indications of negative pressure therapy.

Conclusions: The present study confirmed that infection following ankle and/or hindfoot fracture surgery had poor prognosis, especially when the initial injury involved with multiple fractures. Even the patient has been treated as successful infection free, there is still a high chance that patient might end with joint fusion which might lead to stiffness and risk of decompensatory osteoarthritis in adjacent joints. Since patients usually expect good outcome for surgical intervention in general, according to the result in this study, all patients with ankle and/or hindfoot fractures who might need surgery should be informed of this poor prognosis, starting from the initial emergency treatment.

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