The local soft tissue status and the prediction of local complications following fractures of the ankle region

SLR - June 2022 - Matthew Peter, DPM

Reference: S. Halvachizadeh, F.K.L. Klingebiel, R. Pfeifer, M. Gosteli, S. Schuerle, P. Cinellie, B.A. Zelle, H, Pape. The local soft tissue status and the prediction of local complications following fractures of the ankle region. Injury. 2022 Mar 29;S0020-1383(22(00228-5. 

Level of Evidence: Level I

Scientific Literature Review

Reviewed By: Matthew Peter, DPM
Residency Program: Cambridge Health Alliance – Cambridge, MA

Podiatric Relevance: During management of periarticular lower extremity fractures, it is paramount to appreciate the soft tissue status. Despite studies that focus on perioperative and intraoperative complications, a comprehensive risk profile on the development of soft tissue complications following lower extremity fractures has not been compiled. In this study, the authors aim to address this deficit by performing a meta-analysis of the various local and systemic risk factors described throughout the literature. 

Methods: English or German studies published between January 1st, 2000, to December 31st, 2020, were drawn from a literature search of Medline, EMBASE, Cochrane, Web of Science, and Scopus databases that calculated odds ratios of risk factors. Risk factors were separated into three categories including: patient specific systemic risk factors (PSS RF), patient-specific local risk factors (PSL), and non-patient specific risk factors (NPS). Examples of PSS RF included comorbidities, medications, demographics, and lifestyle habits, while PSL and NPS RFs focused on the properties of soft tissue damage and factors related to surgeries, respectively. Included in the analysis were fractures limited to the ankle region, such as pilon, calcaneal, and malleoli fractures. The primary outcome of this study was to assess the incidence of soft tissue complications including but not limited to surgical site infection, wound dehiscence, and additional intervention for wound closure. 

Results: One thousand three hundred fifty-two (1,352) articles were initially analyzed and narrowed down to 34 that met the inclusion criteria for this study.  Most of the included studies met the criteria for a retrospective study design. The number of total patients involved in this review was 57,750 with a mean age of 52.2 and a local complication rate of 10.9 percent. PSS RF was assessed in all 34 studies, PSL RF was assessed in 30 studies, and NPS RF was assessed in 21 studies. Of the PSL RF studies 14 evaluated open fractures (46.7 percent), 13 evaluated fracture classification (43.3 percent), and three evaluated soft tissue status in closed fractures (10.0 percent). Local soft tissue involvement was found in 7.5 percent of all complications. The occurrence of surgical site infection was found to be 8.9 percent and 16.1 percent following closed fractures of the ankle/pilon and calcaneus, respectively. Diabetes and local tissue damage was found to be the largest predictive factor of complications with open fractures. Additional injuries were not found to correlate with complications.

Conclusions: In this article, the authors concluded that the most predictive risk factor in ankle fractures is soft tissue status when compared with additional injuries of non-patient specific risk factors. Local risk factors were found to hold more significance than systemic factors. This study would benefit from standardization of soft tissue assessment in closed fractures. While it is prudent to continue to respect systemic risk factors and local risk factors, soft tissue status play an important role in consideration when planning surgical intervention for a lower extremity periarticular injury.