Predictors for Wound Healing Complications and Prolonged Hospital Stay in Patients with Isolated Calcaneal Fractures

SLR - March 2023 - James Diep, DPM 

Title: Predictors for Wound Healing Complications and Prolonged Hospital Stay in Patients with Isolated Calcaneal Fractures 

Reference: Bläsius, F.M., Stockem, L.E., Knobe, M. et al. Predictors for Wound Healing Complications and Prolonged Hospital Stay in Patients with Isolated Calcaneal Fractures. Eur J Trauma Emerg Surg. Jan 2022; (48:3157–3163) 

Level of Evidence: Retrospective Cohort Study, Level III 

Scientific Literature Review 

Reviewed By: James Diep, DPM 

Residency Program: Kaiser San Francisco Bay Area Foot & Ankle Residency Program – Oakland, CA 

Podiatric Relevance: Calcaneal fractures are the most common fractured tarsal bone, often occurring from high impact injuries secondary to traumatic axial loading. Surgical treatments of calcaneal fractures have a high risk of postoperative healing complications and longer hospital stays. As such, it is important to understand the variables that can promote faster recovery of foot functions. The purpose of this study was to identify the predictor variables associated with complications leading to prolonged hospital stays in patients with isolated calcaneal fractures.  

Methods: This is a retrospective cohort study that analyzed patients   with isolated calcaneal fractures who were admitted to a level I trauma center in Germany between 2008 and 2018. Patients were treated either with open reduction internal fixation (ORIF) using low profile locking plate osteosynthesis or were treated surgically using a minimally invasive approach (MIA) using percutaneous screws/K-wires or low-profile locking plates via a sinus tarsi approach. The decision to perform ORIF vs MIA was determined by a specialist. Exclusion criteria included polytraumas, bilateral fractures, patients treated with conservative therapy, early transfers out of hospital, and multiple fractures of lower extremity. The aim of the study was to analyze variables that affected impaired wound healing (IWH) and prolonged hospital length of stay (LOS). Independent variables for LOS included age, sex, time-to surgery (TTS), open fracture, MIA, IWH, Bohler’s angle, ASA physical status, and overweight. Independent variables for IWH included age, sex, TTS, open fracture, MIA, active smoker, alcohol abuse, drug addiction, arterial hypertonia, anticoagulation, and overweight. A multivariable linear regression model was used to analyze 2 dependent variables: hospital length of stay (Model A) and impaired wound healing (Model B) with their corresponding independent variables  

Results: In total, 89 patients aged 18 or older (mean age 45.5 years; SD: 15.1) with isolated calcaneal fractures were included in this study. Sixty-eight patients were treated with ORIF and twenty-one patients were treated with MIA. In Model A, a higher pre-operative Bohler’s angle and minimally invasive approach were independent variables that reduced length of stay whereas a longer time to surgery and impaired wound healing increased length of stay. In Model B, open fractures and overweight (BMI >24  kg/m2) were independent variables that increased risk of impaired wound healing. Predictive validities were moderate in Model A for the length of stay whereas Model B showed high predictive validity for impaired wound healing. 

Conclusions: Overall, this study identified that a higher preoperative Bohler’s angle and using a minimally invasive approach was positively associated with shortened hospital lengths of stay while overweight and open fractures were the major risk factors associated with impaired wound healing. Surprisingly, ORIF did not increase wound healing complication rates when compared to MIA. Finally, the authors concluded that monitoring soft tissue is an effective practice and does not prolong post-operative hospital stays as they found that time to surgery only extended the total hospital stay by the corresponding time. This highlights the importance of monitoring soft tissue swelling in the setting of high energy trauma when considering patients for surgery.