ArticlePDF Available
ISSN 1745-3674
Supplementum no 358 Volume 86 February 2015
Complications in ankle fracture surgery
Mikko Ovaska
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Complications in ankle fracture surgery
Mikko Ovaska
Doctoral Thesis
From the Department of Orthopaedic Surgery and Traumatology,
Helsinki Bone and Joint Research Group
Helsinki University Central Hospital
University of Helsinki,
Helsinki, Finland
ACTA ORTHOPAEDICA SUPPLEMENTUM NO. 358, VOL. 86, 2015
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Copyright © Informa Healthcare Ltd 2015. ISSN 1745–3674. Printed in England – all rights reserved
DOI 10.3109/17453674.2014.1002273
Printed in England by Henry Ling
2015
Contact address
Mikko Ovaska, MD, PhD
Department of Orthopaedic Surgery and Traumatology
Helsinki University Central Hospital
00260 Helsinki, Finland
E-mail: mikko.ovaska@hus.fi
Supervised by
Tatu Mäkinen, Adjunct Professor, FEBOT
Division of Orthopaedic Surgery
Mount Sinai Hospital and University of Toronto
Toronto, Ontario, Canada
Rami Madanat, MD, PhD, FEBOT
Harris Orthopaedic Laboratory
Department of Orthopaedic Surgery
Massachusetts General Hospital and Harvard Medical School
Boston, Massachusetts, USA
Reviewed by
Jukka Ristiniemi, Adjunct Professor
Department of Orthopaedic Surgery and Traumatology
Oulu University Hospital
Oulu, Finland
Jari Salo, Professor
Department of Orthopaedics, Traumatology and Hand Surgery
Kuopio University Hospital
Kuopio, Finland
Opponent
Heikki Kröger, Professor
Department of Orthopaedics, Traumatology and Hand Surgery
Kuopio University Hospital
Kuopio, Finland
This Supplementum is based on a Doctoral Thesis, which was defended in October 2014.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 1
Contents
ACKNOWLEDGEMENTS, 2
LIST OF ORIGINAL PUBLICATIONS, 2
ABBREVIATIONS, 2
INTRODUCTION, 3
REVIEW OF THE LITERATURE, 4
Epidemiology of ankle fractures, 4
Operative treatment of ankle fractures, 4
Classification of ankle fractures, 4
Fixation methods, 4
Locked plating systems, 4
Syndesmosis, 5
Posterior malleolus, 5
Vertical fracture of the medial malleolus, 5
Postoperative immobilization and weight bearing, 6
Outcome of ankle fracture surgery, 6
Complications in ankle fracture surgery, 6
Wound complications and surgical site infection (SSI), 6
Malreduction, loss of reduction, and post-traumatic
osteoarthritis, 7
Other complications, 8
Patients at higher risk for postoperative complications, 9
Hardware related infection, 9
General principles, 10
Exposed hardware and biofilm, 10
Removal or retention of infected hardware? 10
Salvage of exposed hardware, 10
Flap reconstruction for soft-tissue defects in the ankle, 10
Timing of flap coverage, 11
Negative pressure wound therapy (NPWT), 11
Flap coverage in the salvage of infected hardware, 11
AIMS OF THE STUDY, 12
PATIENTS AND METHODS, 13
Identification of the study population, 13
Treatment protocol during the study period, 13
Identification of deep postoperative infection, 13
Indications for surgical debridement following deep infec-
tion, 13
Study design, 13
Radiological evaluation, 13
Definition of treatment failure and flap-related complica-
tion, 13
Outcome measurements, 13
Statistical analyses, 14
RESULTS, 17
Incidence of early reoperation following ankle fracture sur-
gery, 17
Indications for early reoperation, 17
Results of early reoperation, 18
Incidence of deep SSI following ankle fracture operations, 18
Most common causative pathogens, 18
Risk factors for deep SSI, 18
Flap reconstruction for hardware exposure following deep
ankle infection, 18
The outcome of patients with flap reconstruction, 19
Incidence of treatment failure following deep SSI, 20
Risk factors for treatment failure following deep SSI, 20
DISCUSSION, 21
The most important complications, 21
Recognition of “red flags”, 22
Ankle fracture surgery – where do we go wrong? 22
Soft-tissue reconstruction for infected ankle fractures, 23
Hardware removal, 23
The outcome of patients with an infected ankle fracture, 23
Multidisciplinary musculoskeletal infection team, 24
Limitations and strengths of the study, 24
Future aspects, 24
CONCLUSIONS, 26
REFERENCES, 27
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
2 Acta Orthopaedica (Suppl 358) 2015; 86
This thesis is based on the following original publications,
which are referred to in the text be their respective Roman
numerals I–IV.
I Ovaska M T, Mäkinen T J, Madanat R, Huotari K, Vahl-
berg T, Hirvensalo E, Lindahl J. Risk factors for deep sur-
gical site infection following operative treatment of ankle
fractures. J Bone Joint Surg Am 2013; 95: 348-53.
II Ovaska M T, Mäkinen T J, Madanat R, Vahlberg T,
Hirvensalo E, Lindahl J. Predictors of poor outcomes fol-
lowing deep infection after internal fixation of ankle frac-
tures. Injury 2013; 44: 1002-6.
List of orginal publications
This work was financially supported by The Research Founda-
tion for Orthopaedics and Traumatology in Finland, The Emil
Aaltonen Foundation, The Orion-Farmos Research Founda-
tion, The Duodecim Foundation, and Helsinki University
Central Hospital (EVO-grant).
Acknowledgements
Abbreviations
95% CI 95% confidence interval
ASA American society of anaesthesiology score
ATFL anterior tibiofibular ligament
BMI body mass index (kg/m2)
CI confidence interval
C-RP C-reactive protein
CT computed tomography
HRQoL health related quality of life
ICD international classification of diseases
KL Kellgren-Lawrence
MCS medial clear space
NPWT negative pressure wound therapy
NRS numeric rating scale
OMA Olerud Molander ankle score
OA osteoarthritis
OR odds ratio
ORIF open reduction and internal fixation
PTFL posterior tibiofibular ligament
SPN superficial peroneal nerve
SSI surgical site infection
TFCS tibiofibular clear space
TFO tibiofibular overlap
III Ovaska MT, Mäkinen TJ, Madanat R, Kiljunen V, Lindahl
J. A comprehensive analysis of patients with malreduced
ankle fractures undergoing re-operation. Int Orthop 2014;
38: 83-8.
IV Ovaska MT, Madanat R, Tukiainen E, Pulliainen L, Sin-
tonen H, Mäkinen TJ. Flap reconstruction for soft-tissue
defects with exposed hardware following deep infection
after internal fixation of ankle fractures. Injury 2014;
Accepted for publication.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 3
Introduction
Ankle fractures, varying in severity from stable lateral mal-
leolus fractures to open fracture dislocations with comminu-
tion, are among the most common fractures requiring surgical
treatment. It was recently shown, that the incidence of more
complex fracture patterns is increasing (Thur et al. 2012). The
overall aim of surgical treatment of an ankle fracture is to
restore the anatomical congruity of the ankle mortise. How-
ever, for many reasons, anatomic fracture reduction may not
be achieved (Horisberber et al. 2009, Luebbeke et al. 2012).
Failure to reproduce the anatomic relationship of the distal
tibia and fibula leads to altered loading of the tibiotalar joint
(Ramsay and Hamilton 1976, Thordarson et al. 1997, Harris
and Fallat 2004, Lloyd et al. 2006) and subsequent post-trau-
matic arthritis (Lindsjö 1981, Pettrone et al. 1983, Leeds et al.
1984, Lindsjö 1985, Beris et al. 1997, Rukavina 1998) with
poor functional outcomes (Joy et al. 1974, Pettrone et al. 1983,
Mont et al. 1992, Weening et al. 2005, Wikerøy et al. 2009,
Sagi et al. 2012).
Surgical site infection (SSI) is one of the most common
complications following ankle fracture surgery (Shephers
et al. 2011). These infections are associated with significant
morbidity (Soohoo et al. 2009), and often lead to increased
resource utilization (Whitehouse et al. 2002, de Lissovoy et
al. 2009). The management of an infected ankle fracture with
exposed hardware is one of the great challenges faced by the
orthopaedic surgeon, and identification of risk factors for
SSI is crucial for developing strategies to prevent potentially
disastrous complications.
The primary goals of successful treatment of an infected
ankle fracture are anatomic fracture consolidation, a healed
soft tissue envelope, and prevention of a chronic infection
(Trampuz and Zimmerli 2006). Traditionally, fracture man-
agement has included debridement of all necrotic tissue and
removal of the infected hardware (Thordasson et al. 2000, Ng
and Barnes 2009). However, removal of the infected hardware
prior to fracture union may result in permanent disability (Cal-
vert et al. 2006). Recently, the strategy of wound closure with-
out hardware removal using techniques of soft-tissue recon-
struction has been emphasized (Calvert et al. 2006, Cavadas
and Landin 2007, Cyrochristos et al. 2009, Viol et al. 2009,
Tan et al. 2010, Vaienti et al. 2012a, Vaienti et al. 2012b).
This doctoral thesis was initiated to investigate complica-
tions following ankle fracture surgery. The first two studies
focused on deep postoperative infection, the third study tar-
geted the reasons for early reoperation following ankle frac-
ture surgery, and the fourth study investigated the outcome of
patients requiring flap reconstruction for hardware exposure
following deep ankle fracture infection.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
4 Acta Orthopaedica (Suppl 358) 2015; 86
Epidemiology of ankle fractures
Ankle fractures represent approximately 10% of all frac-
tures and are among the most frequently encountered surgi-
cally treated fractures (Schepers et al. 2013, Somersalo et al.
2014). The incidence of a rotational ankle fracture is 71–187/
100000/ year (Jensen et al. 1998, Pakarinen et al. 2011a, Thur
et al. 2012), and the most common mechanism of injury is a
same level fall (Jensen et al. 1998, Thur et al. 2012). The mean
age of patients obtaining an ankle fracture is 45 years for men
and 58 years for women (Thur et al. 2012).
As the population continues to age, the number of elderly
patients sustaining rotational ankle fractures continues to rise
(Kannus et al. 2002, Kannus et al. 2008, Olsen et al. 2013).
Recent studies have shown an increase in more complicated
bi- and trimalleolar ankle fractures in women over 60 years
of age (Thur et al. 2012). As the incidence of ankle fractures
in elderly people with comorbidities is rapidly increasing,
a cumulative rise in the number of complications related to
ankle fracture surgery may be expected.
Operative treatment of ankle fractures
Prior to the 1960’s, when it became popular, ankle fractures
were operated only when repeated attempts of closed reduc-
tion failed. In the 1960’s, operative treatment of ankle frac-
tures involved only the medial malleolus. However, the results
were far from satisfactory, and starting from the 1970’s, the
greatest emphasis was put on the anatomic reduction and rigid
fixation of the lateral malleolus (DeSouza et al. 1985). Year
2014, operative treatment of ankle fractures is based on the
stability of the ankle joint (Michelson et al. 2007, Gougoulias
et al. 2010, Pakarinen et al. 2011a, Pakarinen 2012).
Classication of ankle fractures
Traditionally, ankle fractures have been classified with AO-
Danis-Weber (Muller et al. 1979) or Lauge-Hansen classifica-
tion systems (Lauge-Hansen 1950). However, neither of these
systems can really aid in decision-making whether to operate
or not (Gardner et al. 2006, Haraguchi and Armiger 2009). It
has been shown that stable ankle fractures can be treated con-
servatively with excellent results (Yde and Kristensen 1980,
Ryd and Bengtsson 1992, Bauer et al. 1985, Kristensen and
Hansen 1985, Bauer et al. 1987, Michelson 1995, Michelson
et al. 2007, van den Bekerom et al. 2009, Pakarinen 2012),
and recently a classification system based on ankle fracture
stability was reported (Michelson et al. 2007). The authors
Review of the literature
noted that a stability based classification system could be
prognostic as well as guide in decision-making (Michelson et
al. 2007). These findings were further emphasized in a recent
doctoral thesis (Pakarinen 2012). Unimalleolar fractures are
usually stable, and can often be treated nonoperatively (Pak-
arinen et al. 2011a, Pakarinen 2012). However, bi- and trimal-
leolar fractures are unstable injuries, and are normally treated
by operative means (Michelson et al. 2007, Pakarinen 2012)
(Figure 1).
Fixation methods
Ankle fracture dislocations need to be reduced immediately. If
they cannot be reduced by closed means, early surgical inter-
vention must be carried out (Schepers et al. 2013). Operative
treatment options for an ankle fracture are open reduction and
internal fixation (ORIF) or external fixation. External fixator
is often used as a temporary fixation, but can exceptionally be
used as a definitive treatment modality or in combination with
ORIF in complicated fractures requiring additional stability.
Operative treatment of ankle fractures is based on AO-prin-
ciples (Ruedi et al. 2007), and the choice of fixation depends
on the size of the fragments, on the comminution present, and
on the stability required for a stable fixation (Hak et al. 2011).
Posterior plating may sometimes provide additional stability
in posterior malleolar fractures (Hak et al. 2011). Syndes-
motic instability must always be evaluated intraoperatively
and treated accordingly (van den Bekerom 2011).
Locked plating systems
Locked plating systems improve fixation in osteoporotic bone,
and can be useful in treating patients with poor bone quality or
Figure 1. The treatment of ankle fractures based on stability criteria.
Modified from the original picture by Michelson et al. Clinical utility of
a stability-based ankle fracture classification system. J Orthop Trauma
2007; 21: 307-15.
Ankle fracture
No fracture
dislocation
Fracture
dislocation
UnimalleolarBi- or trimalleolar
Unstable
ORIF ORIF ORIF Conservative
treatment
Unstable Unstable Stable
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 5
in patients with complex fractures (Hak et al. 2011, Bariteau
et al. 2014). In ankle fracture surgery, angular stable implants
have been emphasized especially in geriatric patients (Strauss
and Egol 2007, Lynde et al. 2012, Olsen et al. 2013), in obese
patients (Chaudhry and Egol 2011), and in patients with dia-
betes (Wukich and Kline 2008). The advantages of locking
plates include preservation of the periosteal blood supply, and
better resistance to bending and torsional forces compared to
conventional plating (Wagner 2003).
Syndesmosis
Syndesmosis is a ligamentous complex that stabilizes the
distal articulation between the fibula and tibia. The four main
ligaments that contribute to the syndesmotic complex are the
anterior tibiofibular ligament (ATFL), the posterior tibiofibu-
lar ligament (PTFL), the transverse ligament, and the interos-
seous ligament (Hermans et al. 2010). The PTFL is the stron-
gest part of the syndesmosis, and together with the associated
transverse ligament it provides 42% of the overall syndes-
motic resistance strength (Ogilvie-Harris et al. 1994).
It has been shown that the level of the fibular fracture does
not necessarily correlate with the presence of syndesmotic
instability (Ebraheim et al. 2003, Nielson et al. 2004). There-
fore, the decision to stabilize the distal tibiofibular syndesmo-
sis should always be based on intraoperative dynamic stress
testing following malleolar fracture fixation (van den Bekerom
et al. 2007, van den Bekerom 2011, Pakarinen et al. 2011b).
The intraoperative testing can be done with the Cotton test
(lateral fibular translation test), external rotation stress test,
or with sagittal plane stress test (Candal-Couto et al. 2004,
Jenkinson et al. 2005, Stoffel et al. 2009, van den Bekerom
2011, Hak et al. 2011, Pakarinen et al. 2011b). The sensitivity
of any of these tests alone is insufficient to adequately detect
instability of the syndesmosis (Pakarinen et al. 2011b), thus a
combination of various tests should probably be used (van den
Bekerom 2011).
The ultimate goal of ankle fracture treatment is to main-
tain the normal relationship between the ankle mortise and the
syndesmosis until healing has occurred (Hak et al. 2011), and
anatomic reduction of the syndesmosis is critical for optimiz-
ing patient outcome (Weening et al. 2005, Wikerøy et al. 2009,
Sagi et al. 2012, Van Heest and Lafferty 2014). However,
recent studies with computed tomography (CT) have revealed,
that the rate of syndesmotic malreduction is higher than pre-
viously thought (Gardner et al. 2006, Vasarhelyi et al. 2006,
Mukhopadhyay et al. 2011, Franke et al. 2012, Davidovitch
et al. 2013). There is substantial anatomic variability in the
tibiofibular incisure (Elgafy et al. 2010, Mukhopadhyay et al.
2011, Lepojärvi et al. 2013), and the risk for syndesmotic mal-
reduction is especially high in patients with flatter tibiofibular
articulations (Elgafy et al. 2010). In these patients, the vector
of the reduction clamp is critical for appropriately positioning
the fibula within the tibiofibular incisure during syndesmotic
reduction (Phisitkul et al. 2012).
Recent studies have shown, that syndesmotic transfixation
may not be necessary in type B ankle fractures with intraop-
eratively confirmed syndesmotic disruption (Pakarinen et al.
2011c, Kortekangas et al. 2014). Since a malpositioned syn-
desmotic screw is an important risk factor leading to syndes-
motic malreduction in the tibiofibular incisure (Vasarhelyi et
al. 2006, Nimick et al. 2013), unnecessary syndesmotic screws
should not be used.
Posterior malleolus
A posterior malleolus fracture is present in 14% to 44% of
patients with an ankle fracture (Hak et al. 2011). It has been
shown that ankle fractures with posterior malleolus involve-
ment have worse clinical outcomes (Hak et al. 2011, Irwin et
al. 2013, Hong et al. 2014). Less than 1% of posterior mal-
leolar fractures occur as isolated injuries, and most of them are
associated with ligamentous injuries or fractures of the other
malleoli (Nugent and Gale 1990, Irwin et al. 2013). Studies
with CT have revealed, that fracture lines in posterior mal-
leolar fragments are highly variable (Haraguchi et al. 2006,
Yao et al. 2013), and greatly underestimated with plain radio-
graphs (Büchler et al. 2009).
In the literature there is no consensus which fragment size
should be internally fixed (van den Bekerom et al. 2009). Crite-
ria based on fracture characteristics include fragments greater
than 25% of the joint surface area, or fractures with greater
than 2mm articular incongruity (Hak et al. 2011). However,
larger posterolateral fragments, transverse-type fractures, and
fragments that do not reduce with fibular reduction, should be
reduced and fixed (Hak et al. 2011). Residual posterior sub-
luxation of the talus after reduction of the medial and lateral
malleoli is an absolute indication for posterior malleolus fixa-
tion (Miller et al. 2010).
Recent studies suggest, that regardless of the size, fixation of
the posterior malleolus reduces persistent fragment displace-
ment, increases syndesmotic stability, and improves clinical
outcome (Gardner et al. 2006, Miller et al. 2010, Irwin et al.
2013). With an increased interest for posterior malleolar fixa-
tion, the use of a posterolateral surgical approach has recently
been emphasized for simultaneous posterior malleolar frag-
ment and fibular fracture fixation (Little et al. 2013).
Vertical fracture of the medial malleolus
The vertical fracture of the medial malleolus occurs in 5%
of all ankle fractures (McConnell and Tornetta III 2001).
The first structure injured is either the tibiofibular ligament
or the fibula. A fibular fracture appears on radiographs as a
low transverse fracture line below the level of syndesmosis.
However, the lateral-sided injury can be purely ligamentous.
As the severity of the adduction moment increases, the talus
displaces towards the medial malleolus, and a vertical fracture
line is created extending from the medial axilla of the joint
into the metaphyseal cortex of the tibia. Usually the medial
tibial plafond will sustain an impaction injury, which is not
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
6 Acta Orthopaedica (Suppl 358) 2015; 86
always recognized on plain radiographs. A failure to ade-
quately assess the articular impaction will lead to inadequate
reduction and poor outcome. Most vertical fractures of the
medial malleolus require surgical fixation with buttress plat-
ing or screws inserted perpendicular to the fracture line (Hak
et al. 2011).
Postoperative immobilization and weight bearing
Long-term functional outcome following cast immobilization
or early postoperative mobilization is similar (Lehtonen et al.
2003, Thomas et al. 2009). However, early mobilization has
been associated with an increased risk for wound complica-
tions (Lehtonen et al. 2003, Vioreanu et al. 2007, Thomas et
al. 2009). Based on the current literature, a patient with higher
risk for postoperative infection should probably be treated
with a cast following ankle fracture surgery (Thomas et al.
2009, Lin et al. 2012, Keene et al. 2014).
Studies on postoperative weight bearing are scarce, but is
has been shown that patients with early weight bearing return
to work earlier than patients with no weight bearing (Simanski
et al. 2006, Kubiak et al. 2013, Black et al. 2014). According to
biomechanical studies, axial loading stabilizes the ankle joint
and prevents translational talar movement as well as external
talar rotation (Sasse et al. 1999). Therefore, early weight bear-
ing should be encouraged following operative stabilization of
ankle fractures (Starkweather et al. 2012, Kubiak et al. 2013,
Black et al. 2014). However, in obese and diabetic patients
a longer period of non- or partial weight bearing is recom-
mended, as premature weight bearing is the greatest contrib-
uting factor to a loss of reduction in this patient population
(Bibbo et al. 2001, Wukich and Kline 2008, Rizvi et al. 2010,
Chaudhry and Egol 2011).
Outcome of ankle fracture surgery
Patients have significant improvement in function from six
months to one year following ankle fracture surgery (Egol
et al. 2006). However, at one year many patients continue to
have symptoms or functional limitations (Ponzer et al. 1999,
Obremskey et al. 2002, Nilsson et al. 2007, Hong et al. 2014),
and only 27% of patients with bi- or trimalleolar fractures are
able to practice sporting activities at pre-injury level without
difficulties (Hong et al. 2013). Older age, female sex, greater
ASA class, diabetes, obesity, presence of an open fracture or
fracture dislocation, a trimalleolar fracture, type C fracture,
syndesmotic injury, and longer cast immobilization are pre-
dictive of worse functional recovery (De Souza et al. 1985,
Ebraheim et al. 1997, Egol et al. 2006, Soohoo et al. 2009,
Egol et al. 2010, Tejwani et al. 2010, Lübbeke et al. 2012, Van
Schie-Van der Weert 2012, Dodson et al. 2013). The develop-
ment of infectious wound complications has a direct negative
effect on the overall functional outcome (Hoiness et al. 2001,
Schepers et al. 2013, Korim et al. 2014).
Complications in ankle fracture surgery
Surgical treatment of ankle fractures may be accompanied by
several complications. The overall complication rate follow-
ing ORIF of ankle fractures varies considerably in the litera-
ture ranging from 1% to 40% (Ebraheim et al. 1997, Leyes et
al. 2003, Soohoo et al. 2009). A large population-based study
noted that open injuries, diabetes, and peripheral vascular dis-
ease were strong risk factors predicting a complicated short-
term postoperative course (Soohoo et al. 2009).
Complications in ankle fracture surgery may be classified
as perioperative, early postoperative, and late postoperative
(Leyes et al. 2003). The most frequently encountered prob-
lems are postoperative wound complications, of which deep
infection may have the most devastating consequences (Schep-
ers et al. 2013). Hirvensalo et al. analyzed 273 compensated
patient injuries resolved in Patient Insurance Centre between
2002 and 2007 due to complications following ankle fracture
treatment in Finland (Hirvensalo et al. 2009). They reported
that 35% of the compensated injuries were due to a technical
error during the surgical procedure. In the rest of the cases,
the reason for a compensation was inadequate diagnostics in
23%, wrong treatment modality in 15%, and deep infection in
13%. The mean additional in-hospital stay was seven days, but
in patients with deep infection it prolonged to an average of
one month. The mean duration of sick leave was two months,
but in patients with deep infection it was more than a year
(Hirvensalo et al. 2009).
Wound complications and surgical site infection (SSI)
Wound complications include wound edge necrosis, wound
dehiscence, superficial infection, and deep infection (Schepers
et al. 2013). In orthopaedic surgery, the key features to sus-
ceptibility to wound complications are the personality of the
injury, patient-related aspects, and surgery-related aspects
(Table I).
SSI is the most common complication following ankle frac-
ture surgery. The incidence of SSI following operative treat-
ment of ankle fractures varies considerably in the literature,
ranging from 1.4% to 5.5% (Soohoo et al. 2009, Wukich et
al. 2010, Schepers et al. 2011), and infection rates as high
as 19% have been reported in diabetic patients (Jones et al.
2005). Additionally, the recurrence of a postoperative ankle
fracture infection is not uncommon (Zalavras et al. 2009).
Postoperative infections extend total hospital stay and may
increase healthcare costs by more than 300% (Whitehouse
et al. 2002, DeLissovoy et al. 2009), and the development of
SSI may lead to potentially devastating consequences such as
permanent disability, amputation, or even death (Soohoo et al.
2009). However, there is only limited data on risk factors for
deep SSI specifically associated with operative treatment of
ankle fractures.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 7
Definition of SSI
The literature has been inconsistent in defining postoperative
infection. Some authors defined postoperative infection as the
presence of purulent fluid (Lesavoy et al. 1989), while others
required positive wound cultures for the diagnosis (Hoch-
berg et al. 1998). One study gave a more strict definition of
deep infection, requiring clinical signs of infection with posi-
tive bacterial cultures together with intraoperative findings of
infection spreading into the hardware (Johnson et al. 1986).
Around the ankle, there is no real fascia on top of the deeper
structures, thus the traditional classification into superficial,
deep, or organ specific infections is not suitable. Conse-
quently, SSIs following ankle fracture operations should be
classified into superficial or deep infections (Schepers et al.
2011). Superficial infections are minor complications treat-
able with local wound care and oral antibiotics. On the con-
trary, deep infections are major complications invading deeper
structures and hardware (Viol et al. 2009).
Diagnosis of SSI
The classical signs and symptoms of an infection are increas-
ing pain, swelling, redness, and bad smelling pus in the
wound. A sudden elevation of C-reactive protein (C-RP) value
can lead to suspect postoperative infection. Bacterial cultures
must always be obtained, and the cultures have to be positive
to set the diagnosis of an infection. In orthopaedic surgery, the
most common causative bacteria for postoperative infection
are Staphylococcus aureus and Staphylococcus epidermidis
(Schoifet and Morrey 1990, Calvert et al. 2006, Cyrochristos
et al. 2009, Zalavras et al. 2009).
Malreduction, loss of reduction and post-traumatic
osteoarthritis
The overall aim of surgical treatment of ankle fractures is to
restore the anatomical congruity of the ankle mortise. Failure
to reproduce the anatomic relationship of the distal tibia and
fibula leads to altered loading of the tibiotalar joint (Ramsay
and Hamilton 1976, Thordarson et al. 1997, Harris and Fallat
2004, Lloyd et al. 2006, Thordarsson 2012) with subsequent
post-traumatic arthritis (Lindsjö 1981, Pettrone et al. 1983,
Leeds et al. 1984, Lindsjö 1985, Beris et al. 1997, Rukavina
1998, Thordasson 2012) and poor functional outcomes (Joy
et al. 1974, Pettrone et al. 1983, Mont et al. 1992, Kennedy
et al. 2000, Weening et al. 2005, Wikerøy et al. 2009, Sagi et
al. 2012). The more structures showing residual displacement,
the poorer the outcome (Pettrone et al. 1983).
Postoperative malreduction
For many reasons, anatomic reduction may not be achieved.
Fracture comminution, poor bone quality, and technical errors
may predispose a patient to residual displacement following
ankle fracture surgery (Horisberger et al. 2009, Lübbeke et al.
2012). Recent studies with CT scan have revealed that proper
reduction of a syndesmotic injury is especially demanding
(Gardner et al. 2006, Vasarhelyi et al. 2006, Miller et al. 2009,
Mukhopadhyay et al. 2011, Franke et al. 2012, Sagi et al.
2012, Davidovitch et al. 2013). In a large population based
study with 57,183 patients, the rate of revision ORIF follow-
ing ankle fracture surgery was 0.8% within the first three post-
operative months (Soohoo et al. 2009). Although there is a
large body of literature about ankle fractures, no studies have
Table I. The key features to susceptibility to wound complications in orthopaedic surgery
Risk factor Reference
Personality of the injury
Severity of the fracture Høiness and Strømsøe 2000, Høiness et al. 2001, Dodson et al. 2013
Soft tissue violation or contamination Carragee et al. 1991, Høiness et al. 2003, Gonzalez and Weinzweig 2005
Open fracture Gustilo et al. 1990, Soohoo et al. 2009, Pollak et al. 2010, Miller et al. 2012
Patient related aspects
Age Koval 2007, Soohoo et al. 2009, Lynde et al. 2012
Diabetes Jones et al. 2005, Costigan et al. 2007, Chaudhary et al. 2008,
Obesity Chaudhary nd Egol 2011
Peripheral vascular disease Soohoo et al. 2009
Peripheral neuropathy Miller et al. 2012, Dodson et al. 2013
Malnutrition Moucha et al. 2011
Alcohol abuse Tønnesen et al. 1991, Høiness et al. 2003
Smoking Nåsell et al. 2011
Non-compliance Miller et al. 2012
Surgery related aspects
Number of previous operations Bachoura et al. 2011, Kessler et al. 2012
Suboptimal control of glucose level Flecher et al. 2007, Richards et al. 2012
Timing of surgery Miller et al. 2012, Schepers et al. 2013
Improper timing of antibiotic prophylaxis Jaeger et al. 2006, Olsen et al. 2008
Type of implant used Richards 2006, Schepers et al. 2011
Use of a drain Bachoura et al. 2011
Use of non-occlusive dressings Bosco III et al. 2010
Postoperative immobilization Lehtonen et al. 2003, Thomas et al. 2009
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
8 Acta Orthopaedica (Suppl 358) 2015; 86
examined the true frequency of the most common types of
postoperative malreduction necessitating early reoperation.
Loss of reduction and malunion
The complexity of the fracture, unsatisfactory reduction, or loss
of the achieved reduction may lead to ankle fracture malunion
(Giannini et al. 2010). The alteration in articular congruency
leads to chronic pain, functional impairment, deterioration of
the articular cartilage, and finally post-traumatic osteoarthritis
(Giannini et al. 2010). Most patients with a malunited fracture
complain about pain, swelling or stiffness of the ankle joint,
as well as difficulty in walking or in physical activities (van
Wensen et al. 2011). Fibular shortening and fibular malrota-
tion are the most common types of malunion following ankle
fracture surgery (van Wensen et al. 2011, Thordarson 2012).
Unfortunately, they are also the most difficult to reconstruct
(Henderson and Lau 2006).
Plain radiographic findings on ankle fracture malunion
include asymmetry of the medial and lateral clear space, talar
tilt or talar shift, talar subluxation anteriorly or posteriorly,
and shortening of the fibula. In fibular malunions, the radio-
graphic diagnosis of fibular shortening can be achieved with a
mortise view. The criteria for normal fibular length are shown
in Figure 2.
Fibular malrotation is difficult to visualize on plain radio-
graphs, and when rotational malalignment is suspected, a
CT scan with 3D–reconstruction should be considered (van
Wensen et al. 2011).
Post-traumatic osteoarthritis
Primary or idiopathic osteoarthritis (OA) is the most common
joint disease. However, primary OA occurs much less fre-
quently in the ankle (Salzman et al. 2005). Whereas primary
OA is the most common indication for total hip and total knee
replacement, post-traumatic OA is the most common indi-
cation for ankle arthrodesis (Salzman et al. 2005); 78% of
patients with end-stage ankle OA are post-traumatic (Valder-
rabano et al. 2009). The severity of the initial fracture, articu-
lar cartilage damage, talocrural joint instability, and fracture
malunion are the determinants of post-traumatic OA (Lindsjö
1981, DeSouza et al. 1985, Wyss and Zollinger 1991, Valder-
rabano et al. 2009, Soohoo et al. 2009, Stufkens et al. 2010).
Traumatic ankle injuries that may result in OA include frac-
tures of the malleoli, tibial plafond, talus, as well as ligamen-
tous injuries of the ankle (Valderrabano et al. 2009). However,
37% of post-traumatic ankle OA patients present with a past
rotational ankle fracture (Salzman et al. 2005). A prospective
study showed that the true prevalence of post-traumatic OA
following malleolar ankle fractures is 14% (Lindsjö 1985),
and tibiotalar varus is the predominant malalignment (Valder-
rabano et al. 2009).
In a large database study with 57,183 patients following
ankle fracture surgery, the rate of ankle fusion or replacement
for end-stage OA was 1% (Soohoo et al. 2009). Significant
predictors for fusion or replacement were the presence of a
trimalleolar fracture or an associated open injury. Another
study reported that the most important factor predicting ankle
arthrodesis is fibular malunion (Wyss and Zollinger 1991).
Other complications
Nonunion
The true incidence of nonunion following operative treatment
of malleolar ankle fractures is not known. However, in conser-
vatively treated stable lateral malleolar fractures the reported
incidence of nonunion is 2% (Donken et al. 2011). Excess
motion at the fracture site due to poor reduction or fixation,
and loss of blood supply due to periosteal stripping contribute
to the formation of nonunion. Other factors such as infection,
obesity, tobacco use, diabetes, alcohol abuse, and advanced
age also contribute to the development of this complication
(Rodriguez-Merchan and Forriol 2004, Khurana et al. 2013).
Nonunion should be considered and treated accordingly in all
ankle fracture patients with persistent pain six months after
the initial fracture (Walsh and DiGiovanni 2004, McGonagle
et al. 2010).
Neurologic complications
Neurologic complications of ankle fracture surgery are infre-
quently described, but account for significant morbidity.
Most commonly, neuroma due to transection of the superfi-
cial peroneal nerve (SPN) has been reported (Redfern et al.
2003, Halm and Schepers 2012). SPN is at risk during the
lateral approach to the fibula, and injury to this nerve can fre-
quently be identified as a cause of chronic ankle pain (Red-
fern et al. 2003). The risk of nerve injury is increased for the
Blair and Botta type B pattern of the intermediate cutaneuos
dorsal nerve branch, crossing the distal fibula from posterior
to anterior at 5 to 7cm proximal from the malleolar tip (Halm
and Schepers 2012). Symptomatic injuries to SPN have been
Figure 2. The criteria for normal fibular length as seen on the mor-
tise view: 1) Equal joint space; 2) Intact Shenton line of the ankle; 3)
Unbroken curve between the lateral part of the talus and the peroneal
groove of the fibular. Modified from the original picture by Thordarson
DB. Patients with a crooked radiograph after ankle fracture: what to
do? Foot Ankle Int 2012; 33: 355-8.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 9
reported in 15% of patients following lateral approach to the
fibula (Redfern et al. 2003). With a posterolateral approach,
the sural nerve can potentially be damaged, causing a painful
neuroma or numbness along the lateral border of foot (Talbot
et al. 2005, Jowett et al. 2010). Chronic pain overlying hard-
ware in another possible complication, and 23% of patients
desire hardware removal due to persistent lateral pain (Brown
et al. 2001). However, many patients continue to have some
degree of pain despite hardware removal (Brown et al. 2001,
Kim et al. 2013).
Thromboembolic complications
Clinically detectable thromboembolic events following opera-
tive treatment of ankle fractures are uncommon, and do not
appear to be influenced by the use of thromboprophylaxis
(Pelet et al. 2012, Selby et al. 2014). The reported incidence of
thromboembolic events in patients with ankle fracture is 3%,
involving pulmonary embolism in 0.3% (Soohoo et al. 2011,
Pelet et al. 2012). Patients with certain risk factors (older age,
obesity, history of smoking, prolonged use of a tourniquet,
non-weight bearing, immobilization, history of a previous
thromboembolic event, pregnancy, hormonal replacement
therapy, paralysis, neoplasia) appear to be at higher risk for
thromboembolic events (Soohoo et al. 2011, Kadous et al.
2012, Pelet et al. 2012), and prophylaxis should be considered
for these patients (Testroote et al. 2008, Kadous et al. 2012,
Yi et al. 2014).
Patients at higher risk for postoperative complica-
tions
Diabetic patients
A recent report projected that between 2009 and 2034, in the
US the number of people with diabetes will increase from 24
to 44 million (Huang et al. 2009). The rise in prevalence has
been characterized as a worldwide epidemic, particularly in
the developing nations (Chan et al. 2009). Patients with dia-
betes have higher complication rates for both open and closed
management of ankle fractures (McCormack and Leith 1998,
Wukich and Kline 2008, Hak et al. 2011). Wound complica-
tion rates as high as 32% and 64% have been reported in dia-
betic patients following ORIF of closed (Flynn et al. 2000,
Jones et al 2005, Wukich et al. 2011) and open (Blotter et al.
1999, White et al. 2003) ankle fractures, respectively. How-
ever, there is good evidence that operative management of an
unstable ankle fracture in a diabetic patient is more likely to
result in a stable and functional lower extremity compared to
nonoperative treatment (Bibbo et al 2001, Wukich and Kline
2008). Conservative treatment with a cast in patients with dia-
betic neuropathy and impaired sensation may be disastrous
(Connolly and Csencsitz 1998).
A study of 57,183 surgically treated ankle fracture patients
reported, that diabetes is a strong predictor of short-term com-
plications (Soohoo et al. 2009). Another study showed, that
diabetic patients have an increased mortality rate, more post-
operative complications, longer in-hospital stay, and elevated
costs compared to non-diabetic patients (Ganesh et al. 2005).
Additionally, diabetic patients with neuro- or vasculopathy
have a 6-fold risk of overall complications following ankle
fracture surgery compared to patients with uncomplicated dia-
betes (Jones et al. 2005, Wukich and Kline 2008, Wukich et al.
2010, Wukich et al. 2011).
Obese patients
Given the high prevalence of type II diabetes in obese patients,
one must pay particular attention to the risks and benefits of
surgery in this patient population (Chaudhry and Egol 2011).
Nonoperative management may seem like an attractive option
in the light of the morbidity associated with surgery, but with
higher rates of loss of reduction, great difficulty in tolerating
casting, and inability to comply with weight bearing restric-
tions, operative treatment plays a major role (Guss and Bhat-
tacharyya 2006, Chaudhry and Egol 2011). Supplemental
fixation in form of stronger locking plates, additional plates
or external fixation, and longer periods of non-weight bearing
can counteract the tendency towards a failure, as premature
weight bearing is most likely the greatest contributing factor
to the higher rates of loss of reduction (Chaudhry and Egol
2011). There is a strong association between obesity and loss
of reduction after operative treatment of the syndesmotic inju-
ries (Mendelsohn et al. 2013).
Elderly patients
Geriatric patients provide unique challenges in fracture man-
agement due to their bone quality and medical comorbidities
(Little et al. 2013). SSI is a strong predictor of mortality in
elderly patients (Lee et al. 2006), and controversies remain
regarding the risks and benefits of operative treatment in geri-
atric patients (Koval et al. 2007, Strauss and Egol 2007, Hak
et al. 2011, Shivarathre et al. 2011, Lynde et al. 2012, Little
et al. 2013, McKean et al. 2013, Olsen et al. 2013, Zaghloul
et al. 2014). The risks of surgical treatment should be care-
fully evaluated in all elderly patients (Kettunen and Kröger
2005). Smoking and polypharmacy have shown to be inde-
pendent risk factors for ankle fractures in elderly women
(Valtola et al. 2002). Interestingly, osteoporosis is not a risk
factor, nor does prior ankle fracture predict subsequent major
osteoporotic fractures (Hasselman et al. 2003, Hak et al. 2011,
Pritchard et al. 2012, Olsen et al. 2013). However, osteo-
porosis is a risk factor for loss of reduction (Kettunen and
Kröger 2005, Strauss et al. 2007, McKean et al. 2013, Olsen
et al. 2013), thus locking plates may be necessary in elderly
patients to enhance angular stability (Kettunen and Kröger
2005, McKean et al. 2013). Taken together, in elderly patients
osteopenia and osteoporosis pose a challenge to achieve stable
fixation. However, if stable fixation is achieved, these patients
are likely to experience results similar to those without poor
bone quality (Strauss et al. 2007, Lynde et al. 2012, Little et al.
2013, Olsen et al. 2013).
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
10 Acta Orthopaedica (Suppl 358) 2015; 86
Hardware related infection
Infection is an omnipresent risk of every surgical procedure.
Fractured bones have a diminished capacity to resist infection
due to endosteal and periosteal blood vessel damage (Liu et al.
2012). The presence of hardware near the wound poses an addi-
tional risk for infection, because implants are avascular and not
protected by the host’s immune system (Calvert et al. 2006). Due
to the diminished circulation of the overlying skin and subcuta-
neous location of the distal tibia and fibula, wound dehiscence
around the ankle generally results in immediate contamination
of the underlying bone and hardware (Thordarson et al. 2000).
General principles
The treatment of a patient with infected hardware is one of
the great challenges faced by the orthopaedic and reconstruc-
tive surgeon. These infections are best managed with a team
approach, and standard of care mandates that a plastic, vascu-
lar, and orthopaedic trauma surgeon together with an infec-
tious diseases specialist be an integral part of the multidis-
ciplinary team (Thordarson et al. 2000, Naique et al. 2006,
Culliford et al. 2007, Liu et al. 2012).
The management of hardware related infection is based on
the type of fracture fixation, the degree of bony healing, and
the physiological status as well as comorbidities of the patient
(Darouiche 2004). The primary goals of successful treatment
are anatomic fracture consolidation, a healed soft tissue enve-
lope, and prevention of a chronic infection (Trampuz and
Zimmerli 2006). Traditionally, the management has included
debridement of all necrotic tissue, a prolonged course of intra-
venous antibiotics, and likely removal of all infected hardware
(Thordarson et al. 2000, Calvert et al. 2006, Viol et al. 2009,
Ng and Barnes 2009, Tan et al. 2010).
Exposed hardware and biolm
Various studies have reported a correlation between the dura-
tion of infection and the rate of successful hardware salvage
(Viol et al. 2009). Gristina et al. showed that bacteria adhere
to the implant, and by forming a biofilm acquire additional
pathogenic potential (Gristina et al. 1991). In the biofilm the
bacteria enter into a slow or stationary phase, which make the
bacteria more resistant to most antimicrobial agents. Once
the biofilm has established, the immune system and antibi-
otics cannot eradicate bacteria until the implant is removed
(Darouiche 2004, Trampuz and Zimmerli 2006). Because of
biofilm production, prompt treatment of early infections is
preferable to treating late infections, where biofilm already
exists protecting the bacteria within it (Darouiche 2004).
Removal or retention of infected hardware?
Fractures pose a dilemma when infection occurs in the acute
postoperative period as a vast majority of fractures will not
have achieved osseous union at this point. Studies have shown
that removal of hardware prior to fracture union may result in
loss of reduction or even permanent disability (Thordarson et
al. 2000, Calvert et al. 2006, Cyrochristos et al. 2009). In these
complex cases one must consider, whether the stability and
fracture consolidation are optimized through hardware reten-
tion, or whether the infected hardware should be removed to
give the patient the best chance to clear the infectious process
(Calvert et al. 2006, Berkes et al. 2010).
There is surprisingly scant literature to help to guide the deci-
sion regarding retention or removal of infected hardware in the
early postoperative period following internal fracture fixation
(Trebse et al. 2005, Rightmire et al. 2008, Zalavras et al. 2009,
Berkes et al. 2010). The few published studies have reported
fracture consolidation rates of 70% with retention of infected
hardware (Rightmire et al. 2008, Berkes et al. 2010). However,
the recurrence of infection is not uncommon (Ueng and Shih
1992, Cavadas and Landin 2006, Zalavras et al. 2009).
Studies have shown that if infection is treated early, implant
could probably be retained provided that that the skeletal
reconstruction is anatomically correct, there is no necrotic
bone, and hardware continues to provide good fixation
(Schoifet et al. 1990, Thordarson et al. 2000, DeFranzo et al.
2001, Cavadas and Landin 2006, Hultman et al. 2006, Viol et
al. 2009). In this setting, the infection is probably not eradi-
cated but rather controlled, yet permitting the fracture to con-
solidate (Zalavras et al. 2009). However, the optimal treatment
of an infected ankle fracture remains a subject for debate.
Salvage of exposed hardware
The presence of a soft-tissue defect or signs of infection at
areas of exposed hardware necessitates early aggressive ther-
apy (Viol et al. 2009). Since removal of infected hardware
prior to fracture union may result in disastrous complications
(Calvert et al. 2006), wound closure without hardware removal
using techniques of soft-tissue reconstruction has been pro-
posed. (Calvert et al. 2006, Cavadas and Landin 2006, Cyro-
christos et al. 2009, Viol et al. 2009, Tan et al. 2010, Vaienti
2012a, Viaenti 2012b).
The presence of hardware exposure ultimately necessitates
soft-tissue reconstruction, because inconsistent results have
been achieved with secondary wound closure or skin grafting
(Viol et al. 2009). Soft-tissue management of lower extrem-
ity wounds includes local fasciocutaneus flaps, local muscle
flaps, and microvascular free flap transfers (Thordarson et al.
2000, Culliford et al. 2007, Vaienti 2012b). The location of
the defect plays a role in the choice between a local or a free
muscle flap (Viol et al. 2009). Free muscle flaps are especially
appropriate because they provide well-vascularized tissue to
the injured zone increasing the rate of salvage (Gopal et al.
2000, Pollak et al. 2000, Thordasson et al. 2000, Calvert et al.
2006, Viol et al. 2009, Zahorka 2009).
The following parameters have been identified as impor-
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 11
tant for the potential salvage of the exposed hardware with
soft-tissue coverage: 1) a proper patient selection; 2) hardware
location; 3) duration of exposure; 4) presence and duration
of infection; and; 5) presence of hardware loosening (Gonza-
lez et al. 2002, Gonzalez and Weinzweig 2005, Cavadas and
Landin 2007, Cyrochristos et al. 2009, Viol et al. 2009, Liu et
al. 2012, Vaienti et al. 2012a).
Flap reconstruction for soft-tissue defects in the ankle
Soft-tissue defects around ankle are demanding to treat due
to a fragile subcutaneous vascular network, thin soft-tissue
coverage, and limited elasticity of the local skin (Kneser et
al. 2011, Vaienti et al. 2012a). When planning a flap recon-
struction for wounds around ankle, the patient’s vascular
status must be carefully determined with palpation of pulses,
doppler ultrasound, and sometimes even with angiography
(Levin 2001). Partial-thickness wound defects can sometimes
be managed with conservative measures or with skin graft-
ing. However, when hardware exposure already exists, early
aggressive soft-tissue reconstruction should be carried out.
The classic reconstructive armamentarium suggests the
use of well-vascularized microvascular free flap transfers
for the coverage of wounds in the distal leg (Hallock 2000,
Thordason et al. 2000, Cyrochristos et al. 2009, Viol et al.
2009). However, free flap transfers are technically demand-
ing procedures, and the actual contour of the ankle allowing
normal shoe wear, is difficult to normalize with bulky free
flaps (Levin 2001). Reintroduction of local fasciocutaneus
and muscle flaps has added a simpler option for the coverage
of defects around ankle (Hallock 2000, Culliford et al. 2007,
Vaienti et al. 2012b). The decision between a local or a distal
flap depends on the presence of infection, depth of the defect,
vascular supply, and damage to other areas of the ankle pre-
cluding the use of local flaps.
After Masquelet’s detailed description of the surgical tech-
nique on a distally based sural flap, it became the workhorse
in the reconstruction of the distal lower leg (Masquelet et al.
1992, Vaienti et al. 2012b). The use of a distally based per-
oneus brevis flap was reported a decade later by Eren et al.
(Eren et al. 2001). Elevation of the distally based peroneus
flap does not require elaborate microsurgical skills (Yang et
al. 2005, Bach et al. 2007, Kneser et al. 2011), and successful
results for soft-tissue reconstruction of the ankle have been
reported with this flap (Koski et al. 2005, Yang et al. 2005,
Bach et al. 2007, Lorenzetti et al. 2010, Kneser et al. 2011).
Distally based peroneus brevis flap has been recommended as
a first-line procedure for small- to medium-sized defects in
malleolar region, since patients managed with sural flaps have
higher complication rates (Kneser et al. 2011). A distally based
sural flap could be used for extended skin defects, especially
when a larger arc of rotation is required (Akhtar and Hameed
2006, Rios-Luna et al. 2007, Xu and Lai-Jin 2008, Kneser et
al. 2011). Recently, local propeller flaps have been introduced
as another possible tool for soft-tissue reconstruction around
the ankle (Jakubietz et al. 2007, Jakubietz et al. 2012).
Timing of ap coverage
In his landmark paper presented in 1986, Godina concluded
that microsurgical reconstruction of lower extremity injuries
should be performed within the first 72 hours after injury,
since flap reconstruction undertaken after three days led to
higher failure rates (Godina 1986). Thereafter, several stud-
ies have reported superior outcomes with definitive early soft-
tissue coverage (Hertel et al. 1999, Gopal et al. 2000, Hal-
lock 2000, Bhattacharyya et al. 2008, Liu et al. 2012). With
hardware exposure, the most important prognostic factors
for successful outcome seem to be the duration the exposure
and the presence of a pre-flap infection; Presence of hardware
exposure predisposes to higher rates of wound infection, and
patients with negative cultures have better outcome after flap
reconstruction (Viol et al. 2009, Liu et al. 2012).
Negative pressure wound therapy (NPWT)
The concept of immediate fixation and early soft-tissue cover-
age for open fractures has been referred to as “Fix and flap”
(Gopal et al. 2000), and negative pressure wound therapy
(NPWT) has a major impact in this area. NPWT is a recent
development in the treatment of complex wounds, which
employs a subaltmospheric pressure of 125mmHg in either
continuous or intermittent mode (Stannard et al. 2009). NPWT
acts by promoting angiogenesis to the injured tissue (Argenta
et al. 2006, Mouës et al. 2011). It also reduces the extent and
complexity of the wound, allowing simpler soft tissue proce-
dures for wound closure in the “reconstructive ladder” (Kana-
karis et al. 2007, Stannard et al. 2009, Stannard et al. 2010).
Additionally, NPWT increases the take rate of skin grafts,
and allows quicker graft incorporation, especially in patients
with wound healing problems (Kanakaris et al. 2007, Stan-
nard et al. 2010, Mouës et al. 2011). Although bacterial clear-
ance has been advocated with NPWT (Stannard et al. 2009),
this mechanism of action has not been proven in basic science
(Birke-Sorensen et al. 2011, Mouës et al. 2011). Therefore,
NPWT provides effective temporary wound coverage, but it
does not allow delay in soft-tissue coverage without a con-
comitant increase in the infection rate (Bhattacharyya et al.
2008, Hou et al. 2011, Liu et al. 2012). NPWT does not work
without a thorough debridement of all non-viable bone and
soft-tissue, and should not be applied onto secreting infected
wounds (DeFranzo et al. 2001).
Flap coverage in the salvage of infected hardware
Lower extremity flap reconstruction is associated with high
complication rates (Benacquista et al. 1996, Culliford et al.
2007). One of the key factors to reconstructive success with
infected soft-tissue defects is the adherence to rigid crite-
ria to define wound readiness for the coverage (Gonzalez et
al. 2002). Important factors are the duration exposure, the
duration of infection, and eradication of the infective patho-
gen (Gonzalez et al. 2002, Gonzalez and Winzweig 2005,
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
12 Acta Orthopaedica (Suppl 358) 2015; 86
Cavadas and Landin 2007, Viol et al. 2009, Liu etal. 2012,
Vaienti et al. 2012a). There is a strong correlation between
the pre-flap bacterial cultures and the outcome (Vaienti et al.
2012a, Liu et al. 2012), and flap failure rates as high as 23%
have been reported in patients with pre-flap infection (Gon-
zalez et al. 2002, Gonzalez and Winzweig 2005). Microvas-
cular free flaps have been recommended for the coverage of
infected hardware exposure of the distal leg, since the use of
a well-vascularized tissue has shown to increase the rate of
The present study had the following aims:
1. To identify the most important patient- and surgery-related
risk factors for deep SSI following operative treatment of
ankle fractures.
2. To recognize the main factors predisposing to a treatment
failure of an infected ankle fracture.
3. To determine the most common technical errors resulting in
early reoperation following ankle fracture surgery.
4. To assess the outcome of patients treated with flap recon-
struction following deep infection with exposed hardware
after internal fixation of an ankle fracture.
Aims of the study
salvage (Hallock 2000, Thordason et al. 2000, Calvert et al.
2006, Cyrochristos et al. 2009, Viol et al. 2009, Zahorka et al.
2009). Although lower extremity flap reconstruction is asso-
ciated with higher complication and failure rates than those
to any other part of the body, the alternative to flap recon-
struction may sometimes be much worse, a primary lower-leg
amputation (Benacquista et al. 1996, Culliford et al. 2007).
In the literature, there are no studies specifically examining
patients requiring flap reconstruction following deep postop-
erative ankle fracture infection.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 13
Identication of the study population
Approval from our institutional review board (I-IV) and local
ethics committee (IV) was obtained prior to the beginning
of the study. All patients who had undergone an ankle frac-
ture operation at a level-I trauma center from January 2002
through December 2011 were identified by querying the hos-
pital surgical procedure database for diagnoses coded with
ICD-10 for fibular fracture (S82.4), medial malleolar fracture
(S82.5), lateral malleolar fracture (S82.6), bi- or trimalleolar
fracture (S82.8), and procedure codes for internal or external
fixation of ankle fractures. Eligible operations were restricted
to those performed primarily at our institution in patients 18
years of age or older, and all patients had to be definitively
treated with open reduction and internal fixation (ORIF). We
identified 5,123 consecutive ankle fracture operations in 5,071
patients. The number of treating surgeons was 151, including
residents and specialists.
Treatment protocol during the study period
A standardized operative and postoperative protocol was
used at our institution during the study period. ORIF was per-
formed based on AO-principles and a tourniquet was applied
depending on personal preferences of the treating surgeon.
The wound was closed in three layers (peroneal fascia, subcu-
taneous layer, skin). Fluoroscopic images were obtained in the
operating room before wound closure. Postoperatively, a cast
was applied to all patients. Radiographs (AP, mortise, and lat-
eral view) were obtained before weight bearing was allowed.
Sutures or staples were removed at two weeks, after which the
patients were allowed to begin active ankle range of motion
exercises. Full weight bearing was allowed at four weeks, and
the cast was removed at six weeks.
Identication of deep postoperative infection
Postoperative infections were classified as deep when all
three of the following criteria were met at the same time:
clinical signs of a SSI (redness, swelling, drainage, or dehis-
cence), positive bacterial cultures taken from the wound, and
osteosynthesis material visible or palpable in the wound.
Local wound irrigation was performed, and empiric antibiotic
treatment was initiated in all patients. If needed, antibiotic
treatment was later modified according to the antimicrobial
sensitivity tests.
Patients and methods
Indications for surgical debridement following
deep infection
The indications for performing surgical debridement following
deep infection were necrotic tissue in the wound, continuous
wound drainage, sepsis, widely exposed osteosynthesis mate-
rial, or wounds requiring soft-tissue coverage. Local wound
care or NPWT was applied in cases where wound bed con-
ditioning was required. In Study IV, decisions regarding the
required flap or the timing of flap reconstruction were based
on local conditions of the infected wound. Doppler ultrasound
examination was routinely used for planning of reconstructive
surgical procedures.
Study design
The summary of the included studies is presented in Table 2.
Study I was an age-and sex-matched case-control study.
For this study, we identified 1,923 consecutive ankle fracture
operations in 1915 patients between January 2006 through
December 2009. The number of treating surgeons was 93. The
medical and microbiological records of all 1915 patients were
reviewed for recorded signs and symptoms for SSI, and 131
of 1,915 patients (6.8%) fulfilled the aforementioned criteria
for deep infection. For these 131 patients, an age- and sex-
matched control group was randomly selected from the same
cohort of patients without a subsequent SSI. Potential patient-
and surgery-related risk factors for deep SSI were reviewed
for all included patients. There were no differences between
the groups regarding the basic fracture characteristics (Table
3).
A total number of 345 complications were observed in
these 1915 patients (Unpublished data). The 131 deep infec-
tions constituted 38% of the observed complications, but other
important factors were a technical error during the surgical
Table 2. Summary of the included studies
Study Design Cohort of Included
patients patients
I Age- and sex-matched case-control study 1,915 131 + 131a
II Case-control study 1,915 97
III Chart review 5,071 79 + 79 a
IV Prospective cohort study 3,030 56
a age-and sex-matched control patients
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
14 Acta Orthopaedica (Suppl 358) 2015; 86
procedure (19%) and a loss of reduction (16%) (Unpublished
data).
Study II was a retrospective case-control study including all
patients from January 2006 through December 2009 with a
deep postoperative ankle fracture infection requiring at least
one surgical debridement in the operating theatre. Superficial
infections, deep infections that could be managed with local
wound care and antibiotics alone, and infections that occurred
after scheduled hardware removal were excluded from the
study. 97 patients constituted the study population (Figure
3). The end point of the study was the failure or success of
the treatment, and potential factors for treatment failure were
reviewed for all included patients. The mean follow-up time
was 22 months (range 2–57 months). One patient died due to
a cardiac arrest at two months shortly after a second debride-
ment. In the remaining 96 patients, the minimum follow-up
time was six months.
Study III was a chart review of all ankle fractures that
were surgically treated from January 2002 through Decem-
ber 2011. From a total of 5,123 ankle fracture operations in
5,071 patients, we identified 79 patients (1.6%) who were
reoperated due to a fracture malreduction observed in post-
operative radiographs. As controls, from the same cohort we
randomly selected 79 age- and sex-matched patients who did
not undergo reoperation (Table 4).
Study IV was a prospective cohort study including all
patients from January 2006 through December 2011 with a
deep postoperative ankle fracture infection requiring flap
reconstruction for hardware exposure. Out of 3041 consecu-
tive ankle fracture operations performed in 3030 patients, we
identified 56 (1.8%) patients requiring flap reconstruction for
infected hardware exposure (Figure 4): 32 of the 56 included
patients could be examined at a follow-up visit. The mean fol-
low-up time was 52 months (range 1–97 months). One patient
died due to pneumonia one month postoperatively, and in the
remaining 55 patients the minimum follow-up time was 12
months.
Table 3. Fracture characteristics of the age- and sex-matched
groups (I)
Characteristic Patients with Control p-value
infection (%) patients (%)
High-energy injury 17 (13) 13 (10) 0.4
Fracture type 0.2
unimalleolar 25 (19) 35 (27)
bimalleolar 45 (34) 46 (35)
trimalleolar 61 (47) 50 (38)
Weber-classsification a 0.6
B 104 (79) 99 (79)
C 27 (21) 27 (21)
a 5 patients with an isolated medial malleolus fracture in the control
group
Figure 3. Flow diagram of the patients (II).
Table 4. Fracture characteristics of the reoperated patients and
controls (III)
Patients with Control
reoperation patients
Characteristic n (%) n (%) p-value
Fracture dislocation 42 (53) 27 (34) 0.01
Open fracture 6 (8) 1 (1) 0.06
Fracture type 0.001
unimalleolar 12 (15) 32 (41)
bimalleolar 22 (28) 18 (23)
trimalleolar 45 (57) 29 (37)
Weber-classsification 0.2
A 2 (3) 2 (3)
B 42 (55) 52 (69)
C 32 (42) 21 (28)
Posterior malleolar fracture 58 (73) 41 (52) 0.005
Associated medial malleolar
fracture 55 (70) 35 (44) 0.001
Chaput-Tillaux fragment 4 (5) 1 (1) 0.2
Use of syndesmotic screw 41 (52) 32 (41) 0.2
Syndesmotic reduction technique 1
clamp 33/41 (80) 26/32 (81)
direct visualization 8/41 (20) 6/32 (19)
Figure 4. Flow diagram of the patients (IV).
1,923 ankle fracture operations
97 patients required at least
one debridement in the OR
TREATMENT FAILURE
26 patients
TREATMENT SUCCESS
71 patients
131 patients (6.8%)
with deep infection
– Persistent infection
– Severe talocrural osteoarthritis
– Non-union requiring fusion
– Amputation
– Death
Fracture union without infection
– No signs of osteoarthritis
or malunion
Ankle fracture with ORIF (n = 3,030)
Deep infection (n = 226)
Flap reconstruction for
hardware exposure (n = 56)
Follow-up visit (n = 32)
Death prior
to follow-up
(n = 11)
Could not
be enrolled
(n = 13)
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 15
Medical, operative, microbiological, and radiological
records were reviewed for all included patients (I–IV). The
demographic data and possible co-morbidities of the patients,
primary injury mechanism (low- or high-energy injury), frac-
ture type, as well as the presence of an open fracture or frac-
ture dislocation at the time of the injury was collected. The
causative pathogens for deep infection were recorded, and
infections were classified as mono- or multibacterial based on
the initial bacterial cultures. The levels of C-RP (mg/L) and
blood leukocyte count (E9/L) prior to debridement were evalu-
ated at infection onset (I), prior to debridement (II), and at the
time of flap reconstruction (IV). Fracture consolidation and
hardware removal or retention were assessed from the radio-
graphs and operative records at the time of the debridement
(II), and at the time of flap reconstruction (IV).
In addition to the previously mentioned characteristics, in
Study I, delay from fracture to admission, soft tissue condition
(Tscherne grade 0–4 in closed fractures, and Gustilo grade I–
III in open fractures), delay from admission to surgery, dura-
tion of surgery, use of a tourniquet, surgeon experience, sub-
optimal timing of antibiotic prophylaxis (administered >60
minutes before the incision or after the incision, or < 5 minutes
before inflation or after inflation of the tourniquet), wound
closure method (staples or interrupted monofilament sutures),
application of a cast in the operating room, and postopera-
tive wound necrosis or blistering as well as non-compliance
(defined as not adhering to the postoperative weight bearing
regimen) were recorded. In Study II, delay from index surgery
to infection onset was analyzed, and infections were divided
into early (≤ 42 days after surgery) or late (> 42 days after
surgery). The number of additional surgical procedures was
collected. In Study III, the number of patients with a posterior
malleolar fracture, an associated medial malleolar fracture,
or a Chaput-Tillaux fragment was recorded. The time of day
of surgery, duration of surgery, and surgeon experience were
collected, and the fixation method of each malleolus and syn-
desmotic screw application was noted. In Study IV, the time
from infection onset to flap reconstruction was determined.
The location of the soft-tissue defect (lateral, medial, or bilat-
eral) and the type of flap used for soft-tissue coverage was
recorded. The number of surgical debridements prior to flap
coverage, and the number of subsequent operations following
flap reconstruction was collected. The need for local wound
care or NPWT for wound bed conditioning was analysed.
Postoperative complications were recorded.
Radiological evaluation
Postoperative radiographs were assessed for ankle joint con-
gruency (talar shift or talar tilt) and possible fracture malre-
duction of each malleolus (mm) (I-IV). Additionally, fibular
shortening (Thordarson 2012), medial clear space widening (>
4 mm in mortise view) (Nielson et al. 2005), tibiofibular clear
space (TFCS; the distance between the medial border of the
fibula and the floor of the tibiofibular incisura on the AP view
at 10 mm above the ankle joint level) (Beumer and Swierstra
2003), and syndesmotic screw positioning were analyzed (III).
Attention was paid to the fibular positioning in the tibiofibular
incisure at 10 mm above the joint line in the axial CT scan (III).
In Study III, the surgical errors were classified according
to the anatomic site of malreduction: fibula, medial malleo-
lus, posterior malleolus, Chaput-Tillaux fragment, and syn-
desmosis. Problems related to syndesmotic reduction or fixa-
tion were further divided into four categories: malpositioning
of the fibula in the tibiofibular incisure with a syndesmotic
screw, tibiofibular widening (TFCS > 6 mm) (Pneumaticos et
al. 2002), positioning of a syndesmotic screw posterior to the
posterior margin of the tibia (missed), and syndesmotic trans-
fixation in the presence of a stable syndesmosis. A syndes-
motic screw was considered unnecessary if lateral and exter-
nal rotation stress tests were negative after proper reduction
and fixation of the fracture at the time of reoperation (van den
Bekerom 2011).
The presence of external callus bridging the fracture site or
absence of fracture lines was regarded as radiological union,
and severe talocrural osteoarthritis was defined as KL grade
III–IV (Kellgren and Lawrence 1957) (II–IV).
Denition of treatment failure and ap-related
complication
In Study II, treatment failure following ankle fracture infec-
tion was defined as persistent infection requiring suppressive
antibiotic treatment, severe talocrural osteoarthritis, nonunion
requiring fusion, amputation, or death related to treatment of
an infected ankle fracture. In Study IV, flap take-back was
defined as any flap complication requiring a return to the oper-
ating theatre. Partial flap loss was considered when debride-
ment occurred for partial flap necrosis. Total flap loss required
a complete removal of the necrotic flap with a subsequent re-
reconstruction. A patient was considered to have a persistent
infection if hardware removal was required following flap
reconstruction to eradicate the causative pathogen.
Outcome measurements
In Study IV, Olerud Molander ankle score (OMA) was used
for functional outcome measurement (Olerud and Molander
1984). This score is a self-administered patient questionnaire
with a result ranging from 0 (totally impaired) to 100 (com-
pletely unimpaired), and is based on nine different items: pain,
stiffness, swelling, stair climbing, running, jumping, squat-
ting, supports, and work/ activities of daily living.
The 15D was used to measure patients’ health-related qual-
ity of life (Sintonen 2001). This standardized self-administered
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
16 Acta Orthopaedica (Suppl 358) 2015; 86
instrument can be used both as a profile and as a single index
score measure. It is a health state descriptive questionnaire
that consists of the following 15 dimensions: mobility, vision,
hearing, breathing, sleeping, eating, speech, excretion, usual
activities, mental function, discomfort and symptoms, depres-
sion, distress, vitality, and sexual activity. The 15D scores on
a 0–1 scale (0 = being death, 1 = full health) are shown to be
highly reliable, sensitive and responsive to change (Sintonen
2001).
Subjective pain and general satisfaction were assessed with
two single questions using numeric rating scale (NRS) (range
0–10) (Hjermstad et al. 2011). Additionally, the patients
were asked whether they had recovered to their pre-injury
level of activity or if they needed any walking aids. It was
also recorded, if the patients were able to wear all the shoes
they used to wear before the injury. Total range of motion of
the ankle joint was recorded with a goniometer. Calf muscle
strength was assessed with rising-on-toes test (Kaikkonen et
al. 1994). In the test, the patient is asked to rise on the toes
with one leg as many times as possible at a pace of 60 times
per minute to measure the fatigue of the plantar flexors. The
pace (1/sec) was given with a metronome. Calf muscle and
ankle circumference were measured at the widest part of the
muscle and 5 cm proximal to the tip of the lateral malleolus,
respectively. The uninjured leg was used for comparison. The
flap was photographed, and the plastic reconstructive surgeon
evaluated the consistency of the flap.
Statistical analyses
An independent biostatistician performed the statistical analy-
sis of the data (I–III). Results of logistic regression analyses
are expressed using odds ratios (OR) with their 95% confi-
dence intervals (CI). P values of < 0.05 were considered sig-
nificant. The differences between the case and control groups
were tested with McNemar’s test (dichotomous variables), the
test of marginal homogeneity (polytomous variables), and the
Wilcoxon signed-rank test (continuous variables) (I,III). In
Study I, McNemar’s test was also used to analyze differences
between the two groups in postoperative non-compliance. In
Study II, differences in categorical variables between the two
groups were analysed using the chi-squared test or Fisher’s
exact test, and differences in continuous variables were tested
with two-sample t-test or Mann-Whitney U-test. In Study IV,
independent samples t-test was used to compare the mean 15D
scores of the study patients and a representative sample of the
age-standardized general population. Logistic regression anal-
ysis was used to determine significant risk factors for deep
SSI (I) and significant risk factors for treatment failure (II).
Multivariable conditional logistic regression analysis using a
stepwise procedure was applied to identify the independent
risk factors (I, II). Factors with p value < 0.2 in the univariate
analyses were included in the multivariable model (I, II). In
the final model, multicollinearity between the risk factors was
not detected (I).
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 17
Incidence of early reoperation following ankle
fracture surgery
Study III showed, that 79 of 5,071 (1.6%) operatively treated
ankle fracture patients were reoperated on within the first post-
operative week due to malreduction observed in postoperative
radiographs. The incidence of early reoperation was 1.5% and
1.6% during the time period of 2002–2006 and 2007–2011,
respectively (Figure 5). The mean age of these patients was 44
years (range 18–80), and 49% of them were women.
Indications for early reoperation
The indications for early reoperation following ankle fracture
surgery were classified according to the anatomic sites of mal-
reduction (Table 5 and Figure 6).
Of the 79 (46%) reoperated patients, 36 had a combination
of at least two different malreductions, most commonly of
both the fibula and syndesmosis (16 of 79 patients, 20%).
Four main types of errors were identified related to syn-
desmotic reduction or fixation, with malpositioning of the
Results
Figure 5. The incidence of early reoperation during the study period
(III).
Figure 6. Three of the most common errors in reoperated patients: Left)
posterior positioning of the fibula in the tibiofibular incisure, Middle)
fibular shortening associated with syndesmotic malreduction, Right)
malreduction of medial malleolus (III).
Table 5. Indications for reoperation (n = 79) (III)
Anatomic site of malreduction a n (%)
Syndesmosis 47 (59)
Fibula 30 (38)
Medial malleolus 30 (38)
Posterior malleolus 12 (15)
Chaput-Tillaux fragment 4 (5)
a one patient may have more than one malreduction
Reoperation rate (%)
2002 2003 2002 2005 2006 2007 2008 2009 2010 2011
2.5
2.0
1.5
1.0
0.5
0.0
Table 6. Errors related to syndesmotic reduction or xation (n = 47)
in relation to the fracture type (III)
Characteristic Fracture type (Weber) Total
A B C
n (%) n (%)
Number of patients 2 42 32 76 a
Syndesmotic screw 0 15 (36) 26 (81) 41
Error related to syndesmotic reduction
or fixation 0 (48) 27 (84) 47
Malpositioning of the fibula in the
tibiofibular incisura 9 15 24
Tibiofibular widening 8 5 13
Posterior positioning of screw (missed) 2 4 6
Syndesmotic transfixation in the
presence of a stable syndesmosis 1 3 4
a 3 patients had no fibular fracture thus could not be classified with
Weber classification
fibula in the tibiofibular incisure being the most common error
(Table 6).
Of the 24 patients with fibular malpositioning in the tibio-
fibular incisure, a CT scan was available for further analysis
in 14 patients (six patients with a type B fracture and eight
patients with a type C fracture). A posterior malposition-
ing was observed in nine (64%) of these patients. Of the 30
patients with fibular malreduction, 20 (67%) presented short-
ening, and in 17 of these 20 (85%) patients, fibular shortening
was associated with malreduction at another anatomic site.
Conversely, malreduction of the medial malleolus often pre-
sented as an isolated indication for reoperation (16 of all 30
patients with medial malleous malreduction, 53%). In all four
patients with a Chaput-Tillaux fragment, reoperation was due
to a primarily missed fracture.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
18 Acta Orthopaedica (Suppl 358) 2015; 86
Results of early reoperation
Correction of the malreduction was achieved in the majority
of reoperated cases (84%). In 13 of the 79 patients, for whom
malreduction could not be corrected, a trimalleolar fracture
was the most common type (69%). None of these patients had
a unimalleolar fracture. The most common persistent mal-
reduction was related to the medial malleolus (seven of 13
patients). In 10 of the 13 patients with unsuccessful correc-
tion, post-traumatic talocrural osteoarthritis was seen in the
last available follow-up radiographs.
Incidence of deep SSI following ankle fracture
operations
Study I showed, that the incidence of deep SSI following ankle
fracture operations is 6.8%. The mean age of the patients with
deep infection was 56 years (range 20–90), and 44% of them
were men. Infection was diagnosed on average at 53 days after
internal fixation of the fracture. The mean operative time for
patients with deep infection was 88 minutes (range 17–382)
and for controls 69 minutes (range 14–240) (p < 0.001). Only
4% of patients with deep postoperative infection had multiple
concomitant risk factors (diabetic smoker with compromised
soft tissue). Patients with deep infection needed on average
two additional surgical interventions (range 0–10). Altogether,
103 of 131 (79%) patients had at least one subsequent opera-
tion due to the infection. In Study III, the rate of deep infec-
tion did not significantly differ between reoperated patients
and controls (6% versus 3%; p = 0.3).
Most common causative pathogens
In Study I, 88 of 131 (67%) deep infections were monobacte-
rial, and the three most prevalent causative pathogens were
Staphylococcus aureus (n = 43), Staphylococcus epidermidis
(n = 34) and Pseudomonas aeruginosa (n = 3). The remain-
ing 43 infections (33%) were multibacterial, and the most
frequent pathogens in these infections were Staphylococcus
epidermidis (n = 23), Staphylococcus aureus (n = 16), and
Enterococcus faecalis (n = 8). At the time of infection onset,
60% of the patients with deep infection presented with ele-
vated C-RP values (> 10 mg/L). Similarly, 52% of the patients
had elevated blood leucocyte count (> 8.2 E9/L).
In Study II, Staphylococcus epidermidis was the most
common causative pathogen (54%) in patients with treatment
failure. Infections caused by Staphylococcus aureus were
observed in 42% of the patients, and Pseudomonas aeruginosa
was the causative agent in 8% of the patients. The mean levels
of C-RP prior to debridement were 59 mg/L (range 5–297)
and 35 mg/L (range 3–235) in patients with treatment failure
and treatment success, respectively (p = 0.1). The correspond-
ing mean levels of blood leukocyte count were 8.6 E9/L (range
3–14) and 7.7 E9/L (range 3–19) (p = 0.1).
In Study IV, Staphylococcus aureus was the most common
causative pathogen (53%) for deep monocaterial infection,
and infections caused by Staphylococcus epidermidis were
observed in 32% of the patients. A multibacterial infection
was observed in 18 of 56 (32%) patients. The mean time
from infection onset to flap reconstruction was 28 days (range
1–150). At the time of the flap reconstruction, bacterial cul-
tures were still positive in 24 of 56 (43%) patients, and Staph-
ylococcus epidermidis was observed in 58% of these cultures.
The mean levels of C-RP prior to flap reconstruction were 13
mg/L (range 3–75), and the mean levels of blood leukocyte
count were 7.4 E9/L (range 3–16).
Risk factors for deep SSI
Patient-related factors, which were associated with a signifi-
cantly increased risk of deep SSI following ankle fracture
operations are shown in Table 7 (I).
In addition to these factors, postoperative non-compliance
significantly increased the risk for deep SSI (13 patients
with deep infection, 0 patients in control group, p < 0.001).
Surgery-related factors for deep SSI following ankle fracture
operations are shown in Table 8 (I).
No significant associations were found with regard to obe-
sity (BMI > 30 kg/m2) (p = 0.4), ASA score of 3 or 4 (p =
0.051), neuropathy (p = 0.08), schizophrenia (p = 0.054),
injury mechanism (p = 0.4), Weber-classification (p = 0.6),
presence of an open fracture (p = 0.3), delay from admission
to surgery (p = 0.2), tourniquet use (p = 0.5), wound closure
method (p = 0.6), surgeon experience (p = 0.3), nor for use of a
syndesmotic screw (p = 0.4) (I). In the multivariable analysis,
the variables that remained independently associated with an
increased risk of deep SSI are presented in Table 9 (I).
Flap reconstruction for hardware exposure
following deep ankle infection
Study IV showed, that the most commonly used flap recon-
Table 7. Univariate conditional logistic regression analyses for
patient-related risk factors for deep SSI (I)
Patients with Control
infection patients
Factor n (%) n (%) OR (95% CI) p-value
Smoking 47 (36) 17 (13) 4.8 (2.2–10) <0.001
Alcohol abuse 29 (22) 12 (9) 3.8 (1.6–9.4) 0.003
Diabetes 20 (15) 9 (7) 2.2 (1.0–4.9) 0.047
Fracture dislocation 71 (54) 49 (37) 2.0 (1.2–3.5) 0.007
Tscherne grade 1 38 (32) 19 (15) 2.6 (1.3–5.3) 0.006
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 19
Table 8. Univariate conditional logistic regression analyses for surgery-related risk
factors for deep SSI (I)
Patients with Control
infection patients
Factor n (%) n (%) OR (95% CI) p-value
Suboptimal timing of prophylactic
antibiotic therapy 42 (32) 27 (21) 1.9 (1.0–3.4) 0.035
Duration of surgery > 90 min 46 (35) 22 (17) 2.7 (1.5–5.0) 0.001
Postoperative skin necrosis
or blistering 19 (15) 4 (3) 4.8 (1.6–14) 0.005
Malreduction in postoperative
radiographs 19 (15) 6 (5) 3.4 (1.3–9.2) 0.016
Application of a cast in the
operating room 31 (24) 59 (45) 0.4 (0.2–0.7) <0.001
Table 9. Multivariable conditional logistic regression analyses for
independent risk factors for deep SSI following ankle fracture oper-
ations (I)
Factor Adjusted OR (95% CI) p-value
Smoking 3.7 (1.6–8.5) 0.04
Duration of surgery > 90 min 2.5 (1.1–5.7) 0.001
Application of a cast in the
operating room 0.4 (0.2–0.8) <0.001
struction for hardware exposure following deep ankle fracture
infection is a distally based peroneus brevis muscle flap with
a split-thickness skin graft (STSG) (71%) (Figure 7). The 58
flap reconstructions for infected hardware exposure follow-
ing ankle fracture operations are presented in Table 10. A
microvascular free flap was required only in one patient. Flap
reconstruction was performed over lateral malleolus in 91%
of patients. The mean age of the patients was 57 years (range
25–93), and nearly half (48%) of the patients were smokers.
The most common fracture type (45%) was a trimalleolar
ankle fracture.
Figure 7. A distally based peroneus brevis flap with a split-thickness skin graft: A) during surgery; B) 9 days after surgery; C) 22 months after
surgery at follow-up visit.
The outcome of patients with ap reconstruction
Of the 56 patients, 32 (57%) had a complication (Table 11)
(IV), and 22 of 56 (39%) patients required subsequent surgi-
cal interventions in the operating theatre due to a flap-related
complication. Five patients required hardware removal due to
B C A
Table 10. The 58 ap reconstructions performed in
56 patients (IV)
Type of flap reconstruction n (%)
Distally based peroneus brevis flap 41 (71)
Direct cutaneous flap 8 (14)
Bipedicular (n = 5)
Transposition (n = 3)
Propeller flap 6 (10)
Tibialis posterior (n = 3)
Fibularis (n = 2)
Tibialis anterior (n = 1)
Suralis flap 2 (3)
Microvascular free flap (Latissimus dorsi) 1 (2)
Table 11. Patients with a complication following
ap reconstruction for exposed hardware after
deep ankle fracture infection (n = 56) (IV)
Complication Number of patients a
Flap related complications requiring surgery
Partial flap loss 14
Total flap loss 4
Incomplete take of skin graft 4
Hematoma 3
Other complications
Severe osteoarthritis (KL III-IV) 12
Persistent infection 5
Fracture nonunion requiring fusion 1
Death related to treatment 1
a 8 patients had more than one complication
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
20 Acta Orthopaedica (Suppl 358) 2015; 86
a persistent infection. Of the soft-tissue defects, 93% evean-
tually healed, but four (7%) patients suffered a total flap loss
and required a flap re-reconstuction. Patients needed an aver-
age of 2.9 surgical interventions (range 1–10) following deep
infection. With flap reconstruction, hardware could eventu-
ally by salvaged in 53% of patients with a non-consolidated
fracture.
The mean OMA score was fair or poor in 53% of the 32
clinically examined patients, and only 56% of the patients
had recovered their pre-injury level of function. Half of the
patients had shoe wear limitations. The mean 15D score of
the patients was significantly lower than that of a represen-
tative sample of age-standardized general population. The
patients had poorer scores than the general population on the
dimensions of mobility, vision, breathing, usual activities,
distress and vitality (Figure 8). The mean pain NRS was 2.1
and the mean satisfaction NRS was 6.6. The mean ROM of
the ankle joint was 15 degrees less than in the contralateral
ankle (IV).
Incidence of treatment failure following deep SSI
In Study II, treatment failure occurred in 26 of 97 (27%)
patients with deep postoperative ankle fracture infection
(Figure 4). The mean age of these patients was 54 years (range
20–72). The most common fracture type (58%) was a trimal-
leolar ankle fracture, and 73% of the patients had a fracture
dislocation. Most infections (69%) manifested ≤ 42 days after
the index surgery (Table 12).
Risk factors for treatment failure following deep
SSI
Factors, which significantly increased the risk of a treatment
failure, are presented in Table 13 (II).
Figure 8. The 15D profile of the patients and those of a representative
sample of an age-standardized general population (IV). a p < 0.05.
0.55
0.60
0.65
0.70
0.75
0.80
0.85
0.90
0.95
1.00
Mobility a
Vision a
Hearing
Sleeping
Eating
Speech
Excretion
Usual activities a
Mental function
Discomfort
Depression
Distress a
Vitality a
Sexual activity
Population
Patients
a
p < 0.05
15D score
Table 12. Characteristics of patients with treatment failure and suc-
cess (II)
Treatment Treatment
failure success
Characteristics (n = 26) (n = 71) p-value
Age (years) a 54 (20–72) 58 (24–84) 0.1
Male 14 (54%) 27 (38%) 0.2
Body mass index (kg/m2) a 28 (18–39) 28 (18–46) 0.6
ASA class 3 or 4 10 (38%) 28 (39%) 0.9
Fracture type 0.5
unimalleolar 5 (19%) 13 (18%)
bimalleolar 6 (23%) 25 (35%)
trimalleolar 15 (58%) 33 (47%)
Fracture dislocation 19 (73%) 37 (52%) 0.06
Open fracture 6 (23%) 6 (8%) 0.08
Early infection onset 18 (69%) 46 (65%) 0.7
a mean (range)
In the multivariable analysis, the variables that remained
independently associated with an increased risk for treatment
failure are presented in Table 14 (II).
Table 13. Univariate logistic regression analysis of the risk factors
predicting treatment failure following deep ankle fracture infection
(n = 97) (II)
Treatment Treatment
failure success
(n=26) (n=71)
Factor n (%) n (%) OR (95% CI) p-value
Smoking 15 (58) 18 (25) 4.0 (1.6–10) 0.004
Alcohol abuse 10 (38) 11 (15) 3.4 (1.2–9.4) 0.02
Diabetes 9 (35) 7 (10) 3.4 (1.1–11) 0.04
Weber type C fracture 11 (42) 12 (17) 3.6 (1.3–9.8) 0.01
Multibacterial infection 13 (50) 18 (26) 2.9 (1.1–7.4) 0.03
Hardware removal from
nonunited fracture 15 (58) 14 (20) 5.6 (2.1–15) <0.001
Nonunited fracture at
debridement 20 (77) 33 (47) 3.8 (1.4–11) 0.01
Malreduction in
postop. radiographs 7 (27) 6 (8) 4.0 (1.2–13) 0.02
2 additional surgical
procedures 19 (73) 21 (30) 6.5 (2.4–18) <0.001
Table 14. Multivariable logistic regression analysis of the risk fac-
tors predicting treatment failure following deep ankle fracture infec-
tion (n = 97) (II)
Factor OR (95% CI) p-value
Smoking 4.1 (1.3–13.0) 0.02
Malreduction in postoperative radiographs 4.6 (1.0–20.3) 0.04
Hardware removal from nonunited
fracture at debridement 3.3 (1.0–10.7) 0.04
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 21
The most important complications
The number of geriatric patients sustaining rotational ankle
fractures is rising (Kannus et al. 2002, Olsen et al. 2013).
Recent studies have a shown an increase in more compli-
cated bi-and trimalleolar fractures in these patients (Thur et
al. 2012). As the number of ankle fractures in elderly patients
with comorbidities is increasing, a concomitant rise in the
absolute amount of complications related to ankle fracture
surgery may be expected in the near future.
Surgical treatment of ankle fractures may be accompanied
by several complications. They could be classified as preoper-
ative, perioperative, early postoperative and late postoperative
complications (Figure 9).
The most frequently encountered complications are wound
complications, of which deep infection may have the most
devastating consequences (Soohoo et al. 2009, Schepers et al.
2013). For this reason, the current study focused on deep SSI
following ankle fracture operations. Study I identified signifi-
cant patient- and surgery-related risk factors for deep SSI, and
Study IV determined the outcome of patients treated with flap
reconstruction following deep infection with hardware expo-
sure. Study II recognized the main factors predisposing to a
treatment failure following deep infection. In contrast to the
other studies, the focus of Study III was not on postoperative
infection. Instead, the purpose of that study was to evaluate
the most common surgical errors resulting in early reoperation
following ankle fracture surgery.
The rate of deep SSI was 6.8% (I), which is slightly higher
than in previous reports (Soohoo et al. 2009, Wukich et al.
Discussion
Figure 9. Complications and factors related to the formation of a complication
following operative treatment of ankle fractures.
2010, Schepers et al. 2011). The relatively high infection rate
may partly be due to over-representation of complex frac-
tures and patients with multiple comorbidities referred from
other community hospitals. Including the 131 cases of deep
SSI, a total amount of 345 complications were observed in the
1,915 operatively treated ankle fracture patients (Unpublished
data). Deep infections constituted the majority (38%) of the
observed complications. Other important reasons for postop-
erative complication were a technical error during the surgi-
cal procedure and a loss of reduction (Unpublished data). The
data from the Patient Insurance Center reveal that 35% of the
compensated ankle injuries in Finland are due to a technical
error during the surgical procedure (Hirvensalo et al. 2009).
Additionally, inadequate diagnostics, wrong treatment modal-
ity, and deep SSI were common reasons for a compensation
(Hirvensalo et al. 2009).
Taken together, the most important reasons for a complica-
tion following ankle fracture surgery seem to be inadequate
diagnostics, wrong treatment modality, technical error during
the surgical procedure, deep infection, and loss of reduction
(Figure 10).
Deep infection is the most important complication following
ankle fracture surgery. Although successful treatment of the
soft-tissue defect with exposed hardware can be achieved with
reconstructive procedures (IV), a treatment failure is common
(II). In the absence of a panacea for postoperative infections,
we rely primarily on preventive measures. Therefore, identi-
fication of risk factors is crucial for developing strategies to
prevent potentially disastrous complications.
Figure 10. The most important reasons for a complica-
tion following ankle fracture surgery.
Wrong treatment modality
Deep infection
Loss of reduction
Surgical error
Inadequate diagnostics
Inadequate
diagnostics
Wrong
treatment
modality
Inappropriate
timing of
surgery
Suboptimal
antibiotic
prophylaxis
Iatrogenic
nerve injury
Screw
penetration
Insucient
fixation
method
Malreduction
Wound
dehiscence
Wound edge
necrosis
Superficial
infection
Deep
infection
Loss of
reduction
Thromboembolic
event
Delayed union /
nonunion
Stiness
Hardware
related pain
Malunion
Osteoarthritis
Preop. Intraop. Early postop. Late postop.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
22 Acta Orthopaedica (Suppl 358) 2015; 86
Recognition of “red ags”
The goal of ankle fracture surgery should be the achievement
and maintenance of an anatomic reduction with minimal dura-
tion of surgical wound exposure to surrounding pathogens.
In Study I, a prolonged operative time was an independent
risk factor for deep infection. However, tourniquet use did not
increase the risk of infection (I). Study III showed that prob-
lems related to syndesmotic reduction were the most important
indications for early reoperation, and that more severe fracture
patterns were associated with postoperative malreduction.
Furthermore, we found that fibular shortening can initiate an
insidious cascade of events leading to a combination of surgi-
cal errors (III). The above findings together support the use of
a tourniquet as a measure to facilitate accurate fracture reduc-
tion with a shorter duration of surgery.
A significantly lower number of infections was observed,
when a cast was applied in the operating room following ankle
fracture operations (I). This is not a surprising finding, since
immobilization may have a beneficial effect on soft tissue
recovery (Lehtonen et al. 2003). Furthermore, cast applica-
tion in the operating room probably protects the surgical
wound from bacterial contamination, since the dressings are
less likely to be opened during the following few days (Bosco
III et al. 2010). The above conclusion seems rational, but soft
tissue condition may be a confounding factor, since patients
with more severe swelling are more likely to have delayed cast
application. Although we do not believe that immediate cast
application itself prevents deep infection, our findings suggest
that a cast should be applied as early as possible, provided that
soft tissue injury is minimal.
We noted, that suboptimal timing of antibiotic prophylaxis
increases the risk for deep SSI following ankle fracture sur-
gery (I). This is not a surprising finding, since the efficacy of
a single-dose prophylactic antibiotic therapy has already been
described (Gillespie et al. 2001, Jaeger et al. 2006, Flecher et
al. 2007, Slobogean et al. 2010). However, to have the desired
effect, antibiotic prophylaxis has to be administered within
60 minutes before the incision (Flecher et al. 2007). In addi-
tion, it has to be fully administered before the tourniquet is
inflated (Bosco III et al. 2010). We observed that antibiotic
prophylaxis was administered suboptimally in many patients
even without postoperative infection (I). This is a cause for
concern since similar results have recently been reported in
another study, reflecting the possible magnitude of this prob-
lem (Olsen et al. 2008). Suboptimal timing of antibiotic pro-
phylaxis is an important risk factor for infection, and easily
modifiable since it is due to a human error. The routine use
of a surgical check-list is one solution to improve timely and
effectively administered antibiotic prophylaxis.
Smoking is a major risk factor for poor fracture healing
(Rightmire et al. 2008), and it has been shown to increase the
risk of postoperative infection up to 5-fold following ankle
fracture surgery (Nåsell et al. 2011). Our results support these
findings, since tobacco use was the strongest predictor of
deep infection even after adjusting for all other variables (I).
The current study also revealed that most patients requiring
flap reconstruction for an infected ankle fracture were smok-
ers (IV). Additionally, smoking was one of the most impor-
tant factors predisposing to treatment failure following ankle
fracture infection (II). Based on these findings, every smoker
undergoing ankle fracture surgery should be encouraged to
quit. Even a reduction in smoking may have beneficial effects
(Kean 2010), especially in patients with a compromised soft
tissue envelope (I,IV).
A delay from admission to surgery did not increase the risk
of deep infection following ankle fracture surgery (I). How-
ever, previous studies have shown that in patients with frac-
ture dislocation, a delay in surgery increases the risk of post-
operative infection (Carragee et al. 1991, Höiness et al. 2000).
Similarly, we noted that a fracture dislocation or even minor
superficial skin abrasion results in an increased risk of postop-
erative infection (I). This is line with a previous study report-
ing that major perioperative soft-tissue injury has a negative
effect on long-term functional outcome following ankle frac-
ture operations (Höiness et al. 2001). Based on these findings,
judicious timing of surgery allowing for soft tissue recovery
is warranted in patients without an associated ankle fracture
dislocation.
Ankle fracture surgery – where do we go wrong?
Data on failed fracture surgery is limited and often under-
reported. To our knowledge, Study III was the first to focus
on determining the most common surgical errors resulting in
early reoperation after ankle fracture surgery.
It has recently been demonstrated that proper reduction
of syndesmosis is technically more demanding than previ-
ously thought (Miller et al. 2009, Mukhopadhyay et al. 2011,
Franke et al. 2012, Sagi et al. 2012). Direct visualization and
open reduction of the syndesmosis has been recommended
(Miller et al. 2009), since lateral translation and rotational
malalignment of the fibula at the level of the syndesmosis
may go underdetected (Marmor et al. 2011). This is reflected
in our findings, since the majority of reoperated cases were
due to syndesmotic malreduction (III). Studies have revealed
a large variation in syndesmosis anatomy regarding the degree
of incisura concavity and the position of the fibula within it
(Elgafy et al. 2010, Mukhopadhyay et al. 2011, Franke et
al. 2012, Sagi et al. 2012). Additionally, recent studies have
shown that syndesmotic transfixation may not be necessary
in type B ankle fractures despite intraoperatively confirmed
syndesmotic disruption (Pakarinen et al. 2011c, Kortekan-
gas et al. 2014). In our study, the most common error was
a posterior fibular malpositioning in the tibiofibular incisura
(III). Our findings are in line with a previous study caution-
ing, that the syndesmotic screw may be a factor leading to
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 23
syndesmotic malpositioning (Vasarhelyi et al. 2006, Nimick
et al. 2013) (III).
Studies have shown that anatomic syndesmosis reduction
cannot be achieved if the fibula is malreduced (Leeds and
Ehrlich 1984). In the current study, the most commonly com-
bined surgical errors were malreductions of the fibula and syn-
desmosis (III). Typically, the fibula was shortened, resulting
in erroneous syndesmotic transfixation. Since malunion of the
fibula is the most common and the most difficult malunion to
reconstruct (van Wensen et al. 2011), particular attention must
be paid to fibular length assessment in the operative treatment
of this common fracture.
Soft-tissue reconstruction for infected ankle
fractures
Soft-tissue defects around the ankle are demanding to manage
(Levin 2001), and lower extremity flap reconstruction is asso-
ciated with higher complication rates than those to any other
part of the body (Benacquista et al. 1996, Culliford et al.
2007). Free flap transfers have been considered as the ideal
coverage method for infected defects of the distal leg (Thor-
dason et al. 2000, Cyrochristos et al. 2009, Viol et al. 2009).
In the current study, most soft-tissue defects following ankle
fracture infection occurred over the lateral malleolus (IV).
This is not surprising since most ankle fractures occur over the
lateral malleolus (Zalavras et al. 2009). Although the number
of flap-related complications was high, the majority of the
infected soft-tissue defects around the ankle eventually healed
with local fasciocutaneus and muscle flaps (IV).
Pre-flap infection has shown to be an independent predic-
tor of adverse flap outcomes (Liu et al. 2012). Of note, even
though all patients in Study IV had a deep infection prior to
flap reconstruction, the number of complications was less than
in a previous study assessing post-flap complications in non-
united fractures of the distal leg (Vaienti et al. 2012a). Flap
failure rates as high as 23% have been reported in patients
with pre-flap infection (Gonzalez et al. 2002). Interestingly, in
the current study only 7% of the patients suffered a total flap
loss (IV).
Hardware removal
Hardware removal prior to fracture union led to a perma-
nent complication in the majority of patients with an infected
ankle fracture, and it was the most important factor predis-
posing to a treatment failure (II). The presence of hardware
exposure ultimately necessitates soft-tissue reconstruction,
because inconsistent results have been achieved with second-
ary wound or split-thickness skin grafting (Viol et al. 2009).
Hardware stability, duration of hardware exposure, and pres-
ence of an infection have been identified as important factors
for the potential salvage of the exposed hardware with soft-tis-
sue coverage (Gonzalez et al. 2002, Gonzalez and Winzweig
2005, Cavadas and Landin 2007, Viol et al. 2009, Liu et al.
2012, Vaienti et al. 2012a). We showed that infected hardware
could be salvaged with flap reconstruction in more than half of
the patients with a non-consolidated and infected ankle frac-
ture (IV). Based on the findings of the current study, we do not
recommend hardware removal from a nonconsolidated ankle
fracture infection (II, IV).
The outcome of patients with an infected ankle
fracture
Postoperative malreduction predisposes to poor clinical out-
come and subsequent osteoarthritis. We showed that fracture
type, associated medial malleolar fracture, posterior malleolar
fracture, fracture dislocation, duration of index surgery, and
medial malleolar fixation with other than two screws were all
associated with postoperative malreduction (III). Additionally,
Study II showed that malreduction in postoperative radio-
graphs was an independent risk factor for treatment failure
following ankle fracture infection (II). Fortunately enough, in
the majority of reoperations postoperative malreduction could
be corrected without an increased risk for postoperative infec-
tion (III). According to our findings, more complex fractures
and fracture dislocations are more prone to postoperative mal-
reduction, and the treatment of these fractures should prob-
ably be left to surgeons with greater expertise.
In patients requiring flap reconstruction for ankle fracture
infection (IV), the average functional outcome assessed with
the OMA score was similar to those previously reported fol-
lowing lower leg soft-tissue reconstruction with a distally
based peroneus brevis flap (Lorenzetti et al. 2010). However,
the OMA score was fair or poor in 53% of the examined
patients, and only half of the patients recovered their pre-
injury level of function (IV). Additionally, 25% of the patients
were unable to ambulate without walking aids at the time of
the follow-up visit, and half of them had shoe wear limita-
tions (IV). The 15D showed that the HRQoL of the patients
was poorer than that of a sample of age-standardized general
population (IV).
Although successful treatment of a soft-tissue defect with
exposed hardware can be achieved with reconstructive pro-
cedures (IV), a treatment failure following ankle fracture
infection is common (II). Surgical site infections are known
to prolong total hospital stay and increase total costs by more
than 300% (Whitehouse et al. 2002, de Lissovoy et al. 2009).
Since patients with flap reconstruction needed an average of
2.9 surgical interventions following deep infection (IV), and
patients with treatment failure required 1.5 times more surgi-
cal procedures than patients with treatment success (II), we
expect the total costs of treating patients with deep infection
to be substantially higher than previously thought.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
24 Acta Orthopaedica (Suppl 358) 2015; 86
Multidisciplinary musculoskeletal infection team
Deep ankle fracture infections are best managed by a multi-
disciplinary musculoskeletal infection team consisting of an
orthopaedic trauma surgeon, a plastic reconstructive surgeon,
a vascular surgeon, and a specialist in infectious diseases.
Fracture union is the most important aspect when deciding the
proper treatment path, and radiographs as well as CT scans
should be carefully evaluated prior to debridement (Figure
11). Unstable implants should always be removed, and stable
implants should be removed from all patients with a consoli-
dated fracture. If hardware has to be removed from a noncon-
solidated fracture, temporary stabilization with external fix-
ator should be considered, since ankle fracture infection with
an incongruent joint is doomed to failure. Removal of retained
implants should be considered after fracture consolidation,
since the recurrence of infection is common.
After debridement, wounds may be left open and local
wound care or NPWT is used for wound bed conditioning.
NPWT provides effective temporary wound coverage and
reduces the complexity of the wound allowing simpler soft
tissue procedures for definitive wound closure; however, it
does not allow delay in soft-tissue coverage without a con-
comitant increase in the infection rate (Stannard et al. 2010,
Hou et al. 2011, Liu et al. 2012).
Before planning of any reconstructive procedures, the vas-
cular status of the patient must be carefully evaluated with
palpation of the pulses, Doppler ultrasound examination, and
with angiography in patients with absent pulses. In compli-
cated cases, vascular intervention should be considered before
reconstructive soft-tissue procedures. The type of the required
soft-tissue procedure depends on many patient- and wound-
related aspects, and should be evaluated by the plastic recon-
structive surgeon.
Limitations and strengths of the study
An inherent limitation of the current study is the reliance on
data provided by the medical and surgical charts. To con-
trol for these unavoidable reporting deficiencies, the charts
of each patient were scrutinized, and records from all other
medical specialties were assessed as well. In Study I, some
occult infections may not have been identified. However, had
occult or superficial infections progressed to a deep infection,
they would probably be included in the study population. An
important limitation of the Studies II and IV is that there was
no standardized protocol for infected hardware removal prior
to osseous union, and implant stability at debridement could
not be categorically assessed. One of the limitations of Study
III is that postoperative CT scans were not available for all
reoperated patients, thus some minor syndesmotic malreduc-
tions may have been missed. Another limitation is that that the
design did not enable standardised outcome measurements.
Additionally, it is possible that some older patients with mal-
reduced fractures were not reoperated due to their general
Figure 11. Proposed treatment algo-
rithm for deep ankle fracture infection.
Deep infection
Fracture not united
Hardware unstable
Fracture not united
Hardware stable
Fracture united
Hardware stable or unstable
Debridement
Hardware removal
Temporary stabilization
Definitive stabilization
Debridement
Hardware retention
Wound assessment:
1) Closure; 2) NPWT; 3) Local care for secreting wounds left open
Debridement
Hardware removal
Fracture union?
Hardware stability?
Significant soft-tissue defect?
Ye
sN
o
Flap:
Peroneus brevis
Fasciocutaneous
Propeller
Microvascular
Wound closure
NPWT with STSG
Local wound care with STSG
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 25
health condition. However, there were no differences in the
prevalence of multiple comorbidities between the reoperated
and control patients. In Study IV, all included patients could
be not examined at the follow-up visit.
The strengths of the current study include a large number of
consecutive ankle fracture patients treated at a single institution.
Furthermore, the great number of treating surgeons increases
the generalizability of the results. One of the strengths of Study
I is an extensive array of evaluated potential risk factors for
ankle fracture infection. Another strength is the inclusion of
only deep infections, because they can be diagnosed with high
specificity, and have the greatest impact on clinical outcome.
In Study II, in contrast to previous studies, the outcome criteria
were chosen to be relevant in the clinical setting. One of the
strengths of Study III is that radiographs were evaluated using
well-defined criteria. Study IV included the biggest published
series of patients requiring flap reconstruction to cover a soft-
tissue defect following ankle fracture infection, and evaluated
both subjective and objective outcome of the patients using
validated questionnaires and clinical tests.
Future aspects
As the number of geriatric patients sustaining ankle fractures
increases, a growing number of complications following oper-
ative treatment of this common fracture may be expected. In
the future, unnecessary surgery should be avoided, and the cri-
teria for operative treatment of ankle fractures must be clearly
defined. Unstable isolated lateral malleolar fractures with a
congruent ankle joint should probably be treated by conserva-
tive means (Sanders et al. 2012, Slobogean et al. 2012). Addi-
tionally, in patients with multiple comorbidities, conservative
treatment should probably be considered sometimes even in
bi- and trimalleolar fractures.
The devastating nature of deep infection following operative
treatment of an ankle fracture emphasizes the crucial role of
preventive measures. Therefore, recognition of red flags such
as diabetes, smoking, alcohol abuse, and compromised soft
tissue condition is of paramount importance. The number of
postoperative complications could be reduced with simple
methods; every smoker undergoing ankle fracture surgery
should be encouraged to quit; blood glucose levels should be
evaluated and optimized in all patients because elevated blood
glucose levels predispose to postoperative infection even in
patients without a history of diabetes mellitus (Richards et al.
2012); and, surgery should be postponed in patients with a
compromised soft-tissue envelope provided that the ankle joint
remains congruent. A meticulous preoperative planning and
implementation of a check-list seem to be valuable adjuncts in
reducing human error as a source of postoperative infection.
Additionally, a proper understanding and recognition of the
most common surgical errors is of paramount importance to
avoid the need for reoperation.
Studies have shown that fixation of even a small posterior
malleolar fragment increases syndesmotic stability (Gardner
et al. 2006, Miller et al. 2010, Irwin et al. 2013). A postero-
lateral approach to the fibula should probably be used more
often, since it allows a more posterior positioning of the fib-
ular plate with a simultaneous option for a posterior plating
or fixation of a posterior malleolar fragment. Locking plates
should be considered in patients with poor bone quality, as
well as in obese, diabetic or noncompliant patients.
In most cases, deep infection occurs over the lateral malleo-
lus; thus, in patients with multiple comorbidities bulky plates
or syndesmotic screws with prominent screw heads positioned
directly over the lateral malleolus should be avoided. In these
patients, fibular nails, syndesmotic screws with smaller size
heads, or rope-type fixation method of syndesmosis may
play an important role (Rajeev et al. 2011, Bugler et al. 2012,
Schepers 2012, Asloum et al. 2014). Syndesmotic instability
shoud be carefully evaluated and unnecessary screws avoided
(Kortekangas et al. 2014). Intraoperative CT scan may be
required to provide an accurate reduction of syndesmosis with
good functional outcome (Van Heest and Lafferty 2014).
Postoperatively, surgical incisions should not be manipulated
during the first 48 hours. A cast should probably be applied
to all patients already in the operating room, since it protects
the wound from contamination, and prevents postoperative
swelling. NPWT applied to the surgical incision directly after
wound closure, as well as newer generation wound healing
composite dressings with therapeutic agents may be valu-
able tools in treating compromised wounds in patients with
a higher risk for postoperative infection (Boateng et al. 2008,
Stannard et al. 2012).
In the future, deep ankle fracture infections are best man-
aged by a multidisciplinary musculoskeletal infection team. A
meticulous treatment plan is warranted to provide the patient
the best possibilities for a successful outcome. PCR-based
methods as well as sonication may be valuable tools in the
proper diagnostics of an implant-related infection (Borens et
al. 2013). Fracture union should be the most important aspect
when deciding the proper treatment path. In comorbid patients
with open wounds and retained implants, NPWT devices with
antibiotic releasing sponges could be one solution provid-
ing valuable time for the fracture to consolidate. If hardware
has to be removed from a non-consolidated fracture, antibi-
otic-releasing implants should be considered since infected
ankle with an incongruent joint is doomed to failure. Care-
ful vigilance after flap reconstruction should be carried out
since flap-related complications occur frequently. All patients
with deep SSI following ankle fracture operation need to be
informed about the potential functional impairment that may
result despite eventual reconstructive success of the soft-tissue
defect.
The findings of the current thesis could serve as a basis for
optimizing treatment algorithms for patients undergoing oper-
ative treatment of ankle fractures.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
26 Acta Orthopaedica (Suppl 358) 2015; 86
On the basis of the present clinical studies, the following con-
clusions can be drawn:
1. Smoking, prolonged operative time, and delayed cast appli-
cation are independent risk factors for deep SSI following
ankle fracture operations.
2. Smoking, malreduction in postoperative radiographs, and
hardware removal prior to fracture union are the most
important factors predisposing to treatment failure follow-
ing deep ankle fracture infection.
3. Problems related to syndesmotic reduction together with
fibular shortening are the most important indications for
early reoperation following ankle fracture surgery.
4. Soft-tissue defects following ankle fracture infections can
be reconstructed with local flaps. Despite reconstuctive
success, patients perceive a poorer health-related quality
of life, many have shoe wear limitations, and only half of
them achieve their pre-injury level of function.
Conclusions
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 27
References
Akhtar S, Hameed A. Versatility of the sural fasciocutaneous flap in the cover-
age of lower third leg and hind foot defects. J Plast Reconstr Aesthet Surg
2006; 59: 839-45.
Argenta L C, Morykwas M J, Marks M W, DeFranzo A J, Molnar J A, David
L R. Vacuum-assisted closure: state of clinic art. Plast Reconstr Surg 2006;
117 Suppl 7: S127-42.
Asloum Y, Bedin B, Roger T, Charissoux J L, Arnaud J P, Mabit C. Inter-
nal fixation of the fibula in ankle fractures. A prospective, randomized and
comparative study: plating versus nailing. Orthop Traumatol Surg Res
2014; 100 Suppl 4: S255-9.
Bach A D, Leffler M, Kneser U, Kopp J, Horch R E. The versatility of the
distally based peroneus brevis muscle flap in reconstructive surgery of the
foot and lower leg. Ann Plast Surg 2007; 58: 397-404.
Bachoura A, Guitton T G, Smith R M, Vrahas M S, Zurakowski D, Ring D.
Infirmity and injury complexity are risk factors for surgical-site infection
after operative fracture care. Clin Orthop Relat Res 2011; 469: 2621-30.
Bariteau J T, Fantry A, Blankenhorn B, Lareau C, Paller D, Digiovanni C W. A
biomechanical evaluation of locked plating for distal fibula fractures in an
osteoporotic sawbone model. Foot Ankle Surg 2014; 20: 44-7.
Bauer M, Johnell O, Redlund-Johnell I, Johnsson K. Ankle fractures. Foot
Ankle 1987; 8: 23-5.
Bauer M, Jonsson K, Nilsson B. Thirty-year follow-up of ankle fractures.
Acta Orthop Scand 1985; 56: 103-6.
van den Bekerom M P. Diagnosing syndesmotic instability in ankle fractures.
World J Orthop 2011; 2: 51-6.
van den Bekerom M P, Haverkamp D, Kloen P. Biomechanical and clinical
evaluation of posterior malleolar fractures. A systematic review of the lit-
erature. J Trauma 2009; 66: 279-84.
van den Bekerom M P, Mutsaerts E L, van Dijk C N. Evaluation of the integ-
rity of the deltoid ligament in supination external rotation ankle fractures:
a systematic review of the literature. Arch Orthop Trauma Surg 2009; 129:
227-35.
van den Bekerom M P, Lamme B, Hogervorst M, Bolhuis H W. Which ankle
fractures require syndesmotic stabilization? J Foot Ankle Surg 2007; 46:
456-63.
Beris A E, Kabbani K T, Xenakis T A, Mitsionis G, Soucacos P K, Soucacos P
N. Surgical treatment of malleolar fractures. A review of 144 patients. Clin
Orthop Relat Res 1997; 341: 90-8.
Benacquista T, Kasabian A K, Karp N S. The fate of lower extremities with
failed free flaps. Plast Reconstr Surg 1996; 98: 834-40.
Beris A E, Kabbani K T, Xenakis T A, Mitsionis G, Soucacos P K, Soucacos P
N. Surgical treatment of malleolar fractures. A review of 144 patients. Clin
Orthop Relat Res 1997; 341: 90-8.
Berkes M, Obremskey W T, Scannell B, Ellington J K, Hymes R A, Bosse
M. Maintenance of hardware after early postoperative infection following
fracture internal fixation. J Bone Joint Surg Am 2010; 92: 823-8.
Beumer A, Swierstra B A. The influence of ankle positioning on the radiogra-
phy of the distal tibial tubercles. Surg Radiol Anat 2003.25: 446-50.
Bhattacharyya T, Mehta P, Smith M, Pomahac B. Routine use of wound
vacuum-assisted closure does not allow coverage delay for open tibia frac-
tures. Plast Reconstr Surg 2008; 121: 1263-6.
Bibbo C, Lin S S, Beam H A, Behrens FF. Complications of ankle fractures in
diabetic patients. Orthop Clin North Am 2001; 32: 113-33.
Birke-Sorensen H, Malmsjo M, Rome P, et al.; International Expert Panel
on Negative Pressure Wound Therapy [NPWT-EP], Martin R, Smith J.
Evidence-based recommendations for negative pressure wound therapy:
treatment variables (pressure levels, wound filler and contact layer)--steps
towards an international consensus. J Plast Reconstr Aesthet Surg 2011;
64: S1-16.
Black J D, Bhavikatti M, Al-Hadithy N, Hakmi A, Kitson J. Early weight-
bearing in operatively fixed ankle fractures: a systematic review. Foot
(Edinb) 2013; 23: 78-85.
Blotter R H, Connolly E, Wasan A, Chapman M W. Acute complications in
the operative treatment of isolated ankle fractures in patients with diabetes
mellitus. Foot Ankle Int 1999; 20: 687-94.
Boateng J S, Matthews K H, Stevens H N, Eccleston G M. Wound healing
dressings and drug delivery systems: a review. J Pharm Sci 2008; 97: 2892-
923.
Borens O, Yusuf E, Steinrücken J, Trampuz A. Accurate and early diagnosis
of orthopedic device-related infection by microbial heat production and
sonication. J Orthop Res 2013; 31: 1700-3.
Bosco III J A, Slovar J D, Haas J P. Perioperative strategies for decreasing
infection. A comprehensive evidence-based approach. J Bone Joint Surg
Am 2010; 92: 232-9.
Brown O L, Dirschl D R, Obremskey W T. Incidence of hardware-related pain
and its effect on functional outcomes after open reduction and internal fixa-
tion of ankle fractures. J Orthop Trauma 2001; 15: 271-4.
Bugler K E, Watson C D, Hardie A R, Appleton P, McQueen M M, Court-
Brown C M, White T O. The treatment of unstable fractures of the ankle
using the Acumed fibular nail: development of a technique. J Bone Joint
Surg Br 2012; 94: 1107-12.
Büchler L, Tannast M, Bonel H M, Weber M. Reliability of radiologic assess-
ment of the fracture anatomy at the posterior tibial plafond in malleolar
fractures. J Orthop Trauma 2009; 23: 208-12.
Calvert J W, Kohanzadeh S, Tynan M, Evans G R. Free flap reconstruction for
infection of ankle fracture hardware: case report and review of the litera-
ture. Surg Infect 2006; 7: 315-22.
Candal-Couto J J, Burrow D, Bromage S, Briggs P J. Instability of the tibio-
fibular syndesmosis: have we been pulling in the wrong direction? Injury
2004; 35: 814-8.
Carragee E J, Csongradi J J, Bleck E E. Early complications in the operative
treatment of ankle fractures. Influence of delay before operation. J Bone
Joint Surg Br 1991; 73: 79-82.
Cavadas P C, Landin L. Management of soft-tissue complications of the lat-
eral approach for calcaneal fractures. Plast Reconstr Surg 2007; 120: 459-
66.
Chan J C, Malik V, Jia W, Kadowaki T, Yajnik C S, Yoon K H, Hu F B. Diabe-
tes in Asia: epidemiology, risk factors, and pathophysiology. JAMA 2009;
301: 2129-40.
Chaudhary SB, Liporace FA, Gandhi A, Donley BG, Pinzur MS, Lin SS.
Complications of ankle fracture in patients with diabetes. J Am Acad
Orthop Surg 2008; 16: 159-70.
Chaudhry S, Egol KA. Ankle injuries and fractures in the obese patient.
Orthop Clin North Am 2011; 42: 45-53.
Connolly JF, Csencsitz TA. Limb threatening neuropathic complications from
ankle fractures in patients with diabetes. Clin Orthop Relat Res 1998; 348:
212-9.
Costigan W, Thordarson D B, Debnath U K. Operative management of ankle
fractures in patients with diabetes mellitus. Foot Ankle Int 2007; 28: 32-7.
Culliford AT 4th, Spector J, Blank A, Karp NS, Kasabian A, Levine J P. The
fate of lower extremities with failed free flaps: a single institution’s experi-
ence over 25 years. Ann Plast Surg 2007; 59: 18-21.
Cyrochristos D J, Papadopoulos O, Liapis C, Felekouras E L, Giannopoulos A
M, Bastounis E. Coverage strategies in exposed implants. Am Surg 2009;
75: 1132-8.
Darouiche R O. Treatment of infections associated with surgical implants. N
Engl J Med 2004; 350: 1422-9.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
28 Acta Orthopaedica (Suppl 358) 2015; 86
Davidovitch R I, Weil Y, Karia R, Forman J, Looze C, Liebergall M, Egol K.
Intraoperative syndesmotic reduction: three-dimensional versus standard
fluoroscopic imaging. J Bone Surg Am 2013; 95: 1838-43.
DeFranzo A J, Argenta L C, Marks M W, Molnar J A, David L R, Webb L X,
Ward W G, Teasdall R G. The use of vacuum-assisted closure therapy for
the treatment of lower-extremity wounds with exposed bone. Plast Recon-
str Surg 2001; 108: 1184-91.
Dodson N B, Ross A J, Mendicino R W, Catanzariti AR. Factors affecting
healing of ankle fractures. J Foot Ankle Surg 2013; 52: 2-5.
Donken C C, van Laarhoven C J, Edwards M J, Verhofstad M H. Misdiagnosis
of OTA type B (Weber B) ankle fractures leading to nonunion. J Foot Ankle
Surg 2011; 50: 430-3.
Ebraheim N A, Elgafy H, Padanilam T. Syndesmotic disruption in low fibular
fractures associated with deltoid ligament injury. Clin Orthop Relat Res
2003; 409: 260-7.
Ebraheim N A, Mekhail A O, Gargasz S S. Ankle fractures involving the
fibula proximal to the distal tibiofibular syndesmosis. Foot Ankle Int 1997;
18: 513-21.
Egol K A, Pahk B, Walsh M, Tejwani N C, Davidovitch R I, Koval K J. Out-
come after unstable ankle fracture: effect of syndesmotic stabilization. J
Orthop Trauma 2010; 24: 7-11.
Egol K A, Tejwani N C, Walsh M G, Capla E L, Koval K J. Predictors of
short-term functional outcome following ankle fracture surgery. J Bone
Joint Surg Am 2006; 88: 974-9.
Elgafy H, Semaan HB, Blessinger B, Wassef A, Ebraheim NA. Computed
tomography of normal distal tibiofibular syndesmosis. Skeletal Radiol
2010; 39: 559-64.
Eren S, Ghofrani A, Reifenrath M. The distally pedicled peroneus brevis
muscle flap: a new flap for the lower leg. Plast Reconstr Surg 2001; 107:
1443-8.
Fletcher NF, Sofianos DM, Berkes MB, Obremskey W. Current concepts
review. Prevention of perioperative infection. J Bone Joint Surg Am 2007;
89: 1605-18.
Flynn J M, Rodriguez-del Rio F, Pizá P A. Closed ankle fractures in the dia-
betic patient. Foot Ankle Int 2000; 21: 311-9.
Franke J, von Recum J, Suda A J, Grützner P A, Wendl K. Intraoperative
three-dimensional imaging in the treatment of acute unstable syndesmotic
injuries. J Bone Joint Surg Am 2012; 94: 1386-90.
Ganesh S P, Pietrobon R, Cecílio WA, Pan D, Lightdale N, Nunley J A. The
impact of diabetes on patient outcomes after ankle fracture. J Bone Joint
Surg Am 2005; 87: 1712-8.
Gardner M J, Brodsky A, Briggs S M, Nielson J H, Lorich D G. Fixation of
posterior malleolar fractures provides greater syndesmotic stability. Clin
Orthop Relat Res 2006; 447: 165-71.
Gardner M J, Demetrakopoulos D, Briggs S M, Helfet D L, Lorich D G. The
ability of the Lauge-Hansen classification to predict ligament injury and
mechanism in ankle fractures: an MRI study. J Orthop Trauma 2006; 20:
267-72.
Gardner M J, Demetrakopoulos D, Briggs S M, Helfet D L, Lorich D G.
Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle
Int 2006; 27: 788-92.
Giannini S, Faldini C, Acri F, Leonetti D, Luciani D, Nanni M. Surgical treat-
ment of post-traumatic malalignment of the ankle. Injury 2010; 41: 1208-
11.
Gillespie W J. Antibiotic prophylaxis for surgery for proximal femur and
other closed long bone fractures. Cochrane Database Syst Rev 2001; 1:
CD000244.
Godina M. Early microsurgical reconstruction of complex trauma of the
extremities. Plast Reconstr Surg 1986; 78: 285-92.
Gonzalez M H, Weinzweig N. Muscle flaps in the treatment of osteomyelitis
of the lower extremity. J Trauma 2005; 58: 1019-23.
Gonzalez M H, Tarandy D I, Troy D, Phillips D, Weinzweig N. Free tissue
coverage of chronic traumatic wounds of the lower leg. Plast Reconstr Surg
2002; 109: 592-600.
Gopal S, Majumder S, Batchelor A G, Knight S L, De Boer P, Smith R M.
Fix and flap: the radical orthopaedic and plastic treatment of severe open
fractures of the tibia. J Bone Joint Surg Br 2000; 82: 959-66.
Gougoulias N, Khanna A, Sakellariou A, Maffulli N. Supination-external
rotation ankle fractures: stability a key issue. Clin Orthop Relat Res 2010;
468: 243-51.
Gristina A G, Naylor P T, Myrvik Q N. Mechanisms of musculoskeletal
sepsis. Orthop Clin North Am 1991; 22: 363-71.
Guss D, Bhattacharyya T. Perioperative management of the obese orthopaedic
patient. J Am Acad Orthop Surg 2006; 14: 425-32.
Gustilo R B, Merkow R L, Templeman D. The management of open fractures.
J Bone Joint Surg Am 1990; 72: 299-304.
Hak D J, Egol K A, Gardner M J, Haskell A. The “not so simple” ankle frac-
ture: avoiding problems and pitfalls to improve patient outcomes. Instr
Course Lect 2011; 60: 73-88.
Hallock G G. Utility of both muscle and fascia flaps in severe lower extremity
trauma. J Trauma 2000; 48: 913-7.
Halm J A, Schepers T. Damage to the superficial peroneal nerve in operative
treatment of fibula fractures: straight to the bone? Case report and review
of the literature. J Foot Ankle Surg 2012; 51: 684-6.
Haraguchi N, Armiger R S. A new interpretation of the mechanism of ankle
fracture. J Bone Joint Surg Am 2009; 91: 821-9.
Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior mal-
leolar fractures of the ankle. J Bone Joint Surg Am 2006; 88: 1085-92.
Harris J, Fallat L. Effects of isolated Weber B fibular fractures on the tibiotalar
contact area. J Foot Ankle Surg 2004; 43: 3-9.
Hasselman C T, Vogt M T, Stone K L, Cauley J A, Conti S F. Foot and ankle
fractures in elderly white women. Incidence and risk factors. J Bone Joint
Surg Am 2003; 85: 820-4.
Henderson W B, Lau J T. Reconstruction of failed ankle fractures. Foot Ankle
Clin 2006; 11: 51-60.
Hermans J J, Beumer A, de Jong T A, Kleinrensink G J. Anatomy of the distal
tibiofibular syndesmosis in adults: a pictorial essay with a multimodality
approach. J Anat 2010; 217: 633-45.
Hertel R, Lambert S M, Müller S, Ballmer F T, Ganz R. On the timing of
soft-tissue reconstruction for open fractures of the lower leg. Arch Orthop
Trauma Surg 1999; 119: 7-12.
Hirvensalo E, Pajarinen J, Majola A, Salo J, Palonen R, Böstman O. Nilk-
kamurtumien diagnostiikkaan ja hoitoon liittyvät potilasvahingot: Poti-
lasvakuutuskeskuksen korvaamat tapaukset vuosilta 2002-2007. Suomen
Lääkärilehti 2009; 38: 3101-6.
Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH,
Fainsinger R, Aass N, Kaasa S; European Palliative Care Research Col-
laborative (EPCRC). Studies comparing Numerical Rating Scales, Verbal
Rating Scales, and Visual Analogue Scales for assessment of pain intensity
in adults: a systematic literature review. J Pain Symptom Manage 2011;
41: 1073-93.
Hochberg J, Ardenghy M, Yuen J, Gonzalez-Cruz R, Miura Y, Conrado R M,
Pait T G. Muscle and musculocutaneous flap coverage of exposed spinal
fusion devices. Plast Reconstr Surg 1998; 102: 385-9.
Hong C C, Nashi N, Prosad Roy S, Tan K J. Impact of trimalleolar ankle
fractures: How do patients fare post-operatively? Foot Ankle Surg 2014;
20: 48-51.
Hong C C, Roy S P, Nashi N, Tan K J. Functional outcome and limitation of
sporting activities after bimalleolar and trimalleolar ankle fractures. Foot
Ankle Int 2013; 34: 805-10.
Horisberger M, Valderrabano V, Hintermann B. Posttraumatic ankle osteo-
arthritis after ankle-related fractures. J Orthop Trauma 2009; 23: 60-7.
Hou Z, Irgit K, Strohecker K A, Matzko M E, Wingert N C, DeSantis J G,
Smith W R. Delayed flap reconstruction with vacuum-assisted closure
management of the open IIIB tibial fracture. J Trauma 2011; 71: 1705-8.
Huang E S, Basu A, O’Grady M, Capretta J C. Projecting the future diabe-
tes population size and related costs for the U.S. Diabetes Care 2009; 32:
2225-9.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 29
Hultman C S, Jones G E, Losken A, Seify H, Schaefer T G, Zapiach L A,
Carlson G W. Salvage of infected spinal hardware with paraspinous muscle
flaps: anatomic considerations with clinical correlation. Ann Plast Surg
2006; 57: 521-8.
Höiness P, Engebretsen L, Strömsöe K. Soft tissue problems in ankle fractures
treated surgically. A prospective study of 154 consecutive closed ankle
fractures. Injury 2003; 34: 928-31.
Höiness P, Engebretsen L, Strömsöe K. The influence of perioperative soft
tissue complications on the clinical outcome in surgically treated ankle
fractures. Foot Ankle Int 2001; 22: 642-8.
Höiness P, Strømsøe K. The influence of the timing of surgery on soft tissue
complications and hospital stay. A review of 84 closed ankle fractures. Ann
Chir Gynaecol 2000; 89: 6-9.
Irwin T A, Lien J, Kadakia A R. Posterior malleolus fracture. J Am Acad
Orthop Surg 2013; 21: 32-40.
Jaeger M, Maier D, Kern W V, Suedkamp N P. Antibiotics in trauma and
orthopaedic surgery – a primer of evidence-based recommendations. Injury
2006; 37 Suppl 2: S74-80.
Jakubietz R G, Schmidt K, Holzapfel B M, Meffert R H, Rudert M, Jakubi-
etz M G. Soft tissue reconstruction of the distal lower extremity using the
180-degree perforator-based propeller flap. Oper Orthop Traumatol 2012;
24: 43-9.
Jakubietz R G, Jakubietz M G, Gruenert J G, Kloss D F. The 180-degree
perforator-based propeller flap for soft tissue coverage of the distal, lower
extremity: a new method to achieve reliable coverage of the distal lower
extremity with a local, fasciocutaneous perforator flap. Ann Plast Surg
2007; 59: 667-71.
Jensen S L, Andresen B K, Mencke S, Nielsen P T. Epidemiology of ankle
fractures. A prospective population-based study of 212 cases in Aalborg,
Denmark. Acta Orthop Scand 1998; 69: 48-50.
Johnson D P, Bannister G C. The outcome of infected arthroplasty of the knee.
J Bone Joint Surg Br 1986; 68: 289-91.
Jones K B, Maiers-Yelden K A, Marsh J L, Zimmerman M B, Estin M,
Saltzman C L. Ankle fractures in patients with diabetes mellitus. J Bone
Joint Surg Br 2005; 87: 489-95.
Joy G, Patzakis M J, Harvey J P Jr. Precise evaluation of the reduction of
severe ankle fractures. J Bone Joint Surg Am 1974; 56: 979-93.
Jowett A J, Sheikh F T, Carare R O, Goodwin M I. Location of the sural
nerve during posterolateral approach to the ankle. Foot Ankle Int 2010;
31: 880-3.
Kadous A, Abdelgawad A A, Kanlic E. Deep venous thrombosis and pulmo-
nary embolism after surgical treatment of ankle fractures: a case report and
review of literature. J Foot Ankle Surg 2012; 51: 457-63.
Kaikkonen A, Kannus P, Järvinen M. A performance test protocol and scoring
scale for the evaluation of ankle injuries. Am J Sports Med 1994; 22: 462-9.
Kanakaris N K, Thanasas C, Keramaris N, Kontakis G, Granick M S,
Giannoudis P V. The efficacy of negative pressure wound therapy in the
management of lower extremity trauma: review of clinical evidence. Injury
2007; 38 Suppl 5: S9-18.
Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Increasing number
and incidence of low-trauma ankle fractures in elderly people: Finnish sta-
tistics during 1970-2000 and projections for the future. Bone 2002; 31:
430-3.
Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Stabilizing incidence
of low-trauma ankle fractures in elderly people Finnish statistics in 1970-
2006 and prediction for the future. Bone 2008; 43: 340-2.
Karanas Y L, Nigriny J, Chang J. The timing of microsurgical reconstruction
in lower extremity trauma. Microsurgery 2008; 28: 632-4.
Kean J. The effects of smoking in the wound healing process. J Wound Care
2010; 19: 5-8.
Keene D J, Williamson E, Bruce J, Willett K, Lamb S E. Early ankle move-
ment versus immobilization in the postoperative management of ankle
fracture in adults: a systematic review and meta-analysis. J Orthop Sports
Phys Ther 2014; 44: 690-701.
Kellgren J H, Lawrence J S. Radiological assessment of osteo-arthrosis. Ann
Rheum Dis 1957; 16: 494-502.
Kennedy J G, Soffe K E, Dalla Vedova P, Stephens M M, O’Brien T, Walsh M
G, McManus F. Evaluation of the syndesmotic screw in low Weber C ankle
fractures. J Orthop Trauma 2000; 14: 359-66.
Kessler B, Sendi P, Graber P, Knupp M, Zwicky L, Hintermann B, Zimmerli
W. Risk factors for periprosthetic ankle joint infection: a case-control
study. J Bone Joint Surg Am 2012; 94: 1871-6.
Kettunen J, Kröger H. Surgical treatment of ankle and foot fractures in the
elderly. Osteoporos Int 2005; 16 Suppl 2: S103-6.
Khurana S, Karia R, Egol K A. Operative treatment of nonunion following
distal fibula and medial malleolar ankle fractures. Foot Ankle Int 2013;
34: 365-71.
Kim H N, Park Y J, Kim G L, Park Y W. Arthroscopy combined with hard-
ware removal for chronic pain after ankle fracture. Knee Surg Sports Trau-
matol Arthrosc 2013; 21: 1427-33.
Kneser U, Brockmann S, Leffler M, Haeberle L, Beier J P, Dragu A, Unglaub
F, Bach A, Horch R E. Comparison between distally based peroneus brevis
and sural flaps for reconstruction of foot, ankle and distal lower leg: an
analysis of donor-site morbidity and clinical outcome. J Plast Reconstr
Aesthet Surg 2011; 64: 656-62
Korim M T, Payne R, Bhatia M. A case-control stydy of surgical site infection
following opertive fixation of fracture of the ankle in a large U.K. trauma
unit. Bone Joint J 2014; 96: 636-40.
Kortekangas T H, Pakarinen H J, Savola O, Niinimäki J, Lepojärvi S, Ohtonen
P, Flinkkilä T, Ristiniemi J. Syndesmotic fixation in supination-external
rotation ankle frctures: a prospective randomized study. Foot Ankle Int
2014: 35; 988-95.
Koski E A, Kuokkanen H O, Tukiainen E J. Distally-based peroneus brevis
muscle flap: a successful way of reconstructing lateral soft tissue defects
of the ankle. Scand J Plast Reconstr Surg Hand Surg 2005; 39: 299-301.
Koval K J, Zhou W, Sparks M J, Cantu R V, Hecht P, Lurie J. Complications
after ankle fracture in elderly patients. Foot Ankle Int 2007; 28: 1249-55.
Kristensen K D, Hansen T. Closed treatment of ankle fractures. Stage II supi-
nation-eversion fractures followed for 20 years. Acta Orthop Scand 1985;
56: 107-9.
Kubiak E N, Beebe M J, North K, Hitchcock R, Potter M Q. Early weight
bearing after lower extremity fractures in adults. J Am Acad Orthop Surg
2013; 21: 727-38.
Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical
and experimental-roentgenologic investigations. Arch Surg 1950; 60: 957-
85.
Lee J, Singletary R, Schmader K, Anderson D J, Bolognesi M, Kaye K S.
Surgical site infection in the elderly following orthopaedic surgery. Risk
factors and outcomes. J Bone Joint Surg Am 2006; 88: 1705-12.
Leeds H C, Ehrlich M G. Instability of the distal tibiofibular syndesmosis
after bimalleolar and trimalleolar ankle fractures. J Bone Joint Surg Am
1984; 66: 490-503.
Lehtonen H, Järvinen T L, Honkonen S, Nyman M, Vihtonen K, Järvinen M.
Use of a cast compared with a functional ankle brace after operative treat-
ment of an ankle fracture. A prospective, randomized study. J Bone Joint
Surg Am 2003; 85: 205-11.
Lepojärvi S, Pakarinen H, Savola O, Haapea M, Blanco R, Niinimäki J. Poste-
rior translation of the fibula may indicate malreduction: CT study of normal
variation in uninjured ankles. J Orthop Trauma 2014: 28; 205-9.
Lesavoy M A, Dubrow T J, Wackym P A, Eckardt J J. Muscle-flap coverage of
exposed endoprostheses. Plast Reconstr Surg 1989; 83: 90-9.
Levin LS. Soft tissue coverage options for ankle wounds. Foot Ankle Clin
2001; 6: 853-66.
Leyes M, Torres R, Guillén P. Complications of open reduction and internal
fixation of ankle fractures. Foot Ankle Clin 2003; 8: 131-47.
Lin C W, Donkers N A, Refshauge K M, Beckenkamp P R, Khera K, Moseley
A M. Rehabilitation for ankle fractures in adults. Cochrane Database Syst
Rev 2012; 11: CD005595.doi: 10.1002/14651858.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
30 Acta Orthopaedica (Suppl 358) 2015; 86
Lindsjö U. Operative treatment of ankle fractures. Acta Orthop Scand Suppl
1981; 189: 1-131.
Lindsjö U. Operative treatment of ankle fracture-dislocations. A follow-up
study of 306/321 consecutive cases. Clin Orthop Relat Res 1985; 199:
28-38.
de Lissovoy G, Fraeman K, Hutchis V, Murphy D, Song D, Vaughn B B.
Surgical site infection: Incidence and impact on hospital utilization and
treatment costs. Am J Infect Control 2009; 37: 387-97.
Little M T, Berkes M B, Lazaro L E, Sculco P K, Cymerman R M, Pardee N,
Helfet D L, Lorich D G. Comparison of supination external rotation type
IV ankle fractures in geriatric versus nongeriatric populations. Foot Ankle
Int 2013; 34: 512-7.
Little M T, Berkes M B, Lazaro L E, Sculco P K, Helfet D L, Lorich D G.
Complications following treatment of supination external rotation ankle
fractures through the posterolateral approach. Foot Ankle Int 2013; 34:
523-9.
Liu D S, Sofiadellis F, Ashton M, MacGill K, Webb A. Early soft tissue cov-
erage and negative pressure wound therapy optimises patient outcomes in
lower limb trauma. Injury 2012; 43: 772-8.
Lloyd J, Elsayed S, Hariharan K, Tanaka H. Revisiting the concept of talar
shift in ankle fractures. Foot Ankle Int 2006; 27: 793-796.
Lorenzetti F, Lazzeri D, Bonini L, Giannotti G, Piolanti N, Lisanti M, Panta-
loni M. Distally based peroneus brevis muscle flap in reconstructive sur-
gery of the lower leg: Postoperative ankle function and stability evaluation.
J Plast Reconstr Aesthet Surg 2010; 63: 1523-33.
Lübbeke A, Salvo D, Stern R, Hoffmeyer P, Holzer N, Assal M. Risk factors
for post-traumatic osteoarthritis of the ankle: an eighteen year follow-up
study. Int Orthop 2012; 36: 1403-10.
Lynde M J, Sautter T, Hamilton G A, Schuberth J M. Complications after
open reduction and internal fixation of ankle fractures in the elderly. Foot
Ankle Surg 2012; 18: 103-7.
Marmor M, Hansen E, Han H K, Buckley J, Matityahu A. Limitations of stan-
dard fluoroscopy in detecting rotational malreduction of the syndesmosis in
an ankle fracture model. Foot Ankle Int 2011; 32: 616-22.
Masquelet A C, Romana M C, Wolf G. Skin island flaps supplied by the vas-
cular axis of the sensitive superficial nerves: anatomic study and clinical
experience in the leg. Plast Reconstr Surg 1992; 89: 1115-21.
McConnell T, Tornetta P 3rd. Marginal plafond impaction in association with
supination-adduction ankle fractures: a report of eight cases. J Orthop
Trauma 2001; 15: 447-9.
McCormack R G, Leith J M. Ankle fractures in diabetics. Complications of
surgical management. J Bone Joint Surg Br 1998; 80: 689-92.
McGonagle L, Ralte P, Kershaw S. Non-union of Weber B distal fibula frac-
tures: a case series. Foot Ankle Surg 2010; 16: 63-7.
McKean J, Cuellar D O, Hak D, Mauffrey C. Osteoporotic ankle fractures: an
approach to operative management. Orthopedics 2013; 36: 936-40.
Mendelsohn E S, Hoshino C M, Harris T G, Zinar D M. The effect of obe-
sity on early failure after operative syndesmosis injuries. J Orthop Trauma
2013; 27: 201-6.
Michelson J D, Magid D, McHale K. Clinical utility of a stability-based ankle
fracture classification system. J Orthop Trauma 2007; 21: 307-15.
Michelson J D. Fractures about the ankle. J Bone Joint Surg Am 1995; 77:
142-52.
Miller AG, Margules A, Raikin SM. Risk factors for wound complications
after ankle fracture surgery. J Bone Joint Surg Am 2012; 94: 2047-52.
Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Posterior malleolar
stabilization of syndesmotic injuries is equivalent to screw fixation. Clin
Orthop Relat Res 2010; 468: 1129-35.
Miller A N, Carroll E A, Parker R J, Boraiah S, Helfet D L, Lorich D G. Direct
visualization for syndesmotic stabilization of ankle fractures. Foot Ankle
Int 2009; 30: 419-26.
Mont M A, Sedlin E D, Weiner L S, Miller A R. Postoperative radiographs as
predictors of clinical outcome in unstable ankle fractures. J Orthop Trauma
1992; 6: 352-7.
Moucha C S, Clyburn T, Evans R P, Prokuski L. Modifiable risk factors for
surgical site infection. J Bone Joint Surg Am 2011; 93: 398-404.
Mouës C M, Heule F, Hovius S E. A review of topical negative pressure ther-
apy in wound healing: sufficient evidence? Am J Surg 2011; 201: 544-56.
Mukhopadhyay S, Metcalfe A, Guha AR, Mohanty K, Hemmadi S, Lyons K,
O’Doherty D. Malreduction of syndesmosis--are we considering the ana-
tomical variation? Injury 2011; 42: 1073-6.
Muller M, Allgowre M, Schneider R, Willenegger H. Manual of internal
fixation. Techniques recommended by the AO Group. Springer, New York
1979.
Naique S B, Pearse M, Nanchahal J. Management of severe open tibial frac-
tures: the need for combined orthopaedic and plastic surgical treatment in
specialist centres. J Bone Joint Surg Br 2006; 88: 351-7.
Ng A, Barnes E S. Management of complications of open reduction and inter-
nal fixation of ankle fractures. Clin Podiatr Med Surg 2009; 26: 105-25.
Nielson J H, Gardner M J, Peterson M G, Sallis J G, Potter H G, Helfet D L,
Lorich DG. Radiographic measurements do not predict syndesmotic injury
in ankle fractures: an MRI study. Clin Orthop Relat Res 2005; 436: 216-21.
Nielson J H, Sallis J G, Potter H G, Helfet D L, Lorich D G. Correlation of
interosseous membrane tears to the level of the fibular fracture. J Orthop
Trauma 2004; 18: 68-74.
Nilsson G, Jonsson K, Ekdahl C, Eneroth M. Outcome and quality of life
after surgically treated ankle fractures in patients 65 years or older. BMC
Musculoskelet Disord 2007; 20; 8: 127.
Nimick C J, Collman D R, Lagaay P. Fixation orientarion in ankle fractures
with syndesmosis injury. J Foot Ankle Surg 2013; 52: 315-8.
Nugent J F, Gale B D. Isolated posterior malleolar ankle fractures. J Foot Surg
1990; 29: 80-3.
Nåsell H, Ottoson C, Törnqvist H, Linde J, Ponzer S. The impact of smok-
ing on complications after operatively treated ankle fractures – a follow-up
study of 906 patients. J Orthop Trauma 2011; 25: 748-55.
Obremskey W T, Dirschl D R, Crowther J D, Craig W L 3rd, Driver R E,
LeCroy C M. Change over time of SF-36 functional outcomes for opera-
tively treated unstable ankle fractures. J Orthop Trauma 2002; 16: 30-3.
Ogilvie-Harris D J, Reed S C, Hedman T P. Disruption of the ankle syndes-
mosis: biomechanical study of the ligamentous restraints. Arthroscopy
1994; 10: 558-60.
Olerud C, Molander H. A scoring scale for symptom evaluation after ankle
fracture. Arch Orthop Trauma Surg 1984; 103: 190-4.
Olsen J R, Hunter J, Baumhauer J F. Osteoporotic ankle fractures. Orthop Clin
North Am 2013; 44: 225-41.
Olsen MA, Nepple JJ, Riew KD, Lenke LG, Bridwell KH, Mayfield J, Fraser
VJ. Risk factors for surgical site infection following orthopaedic spinal
operations. J Bone Joint Surg Am 2008; 90: 62-9.
Pakarinen H. Stability-based classification for ankle fracture management and
the syndesmosis injury in ankle fractures due to a supination external rota-
tion mechanism of injury. Acta Orthop Suppl 2012; 83: 1-26.
Pakarinen H J, Flinkkilä T E, Ohtonen P P, Ristiniemi J Y. Stability criteria for
nonoperative ankle fracture management. Foot Ankle Int 2011a; 32: 141-7.
Pakarinen H, Flinkkilä T, Ohtonen P, Hyvönen P, Lakovaara M, Leppilahti J,
Ristiniemi J. Intraoperative assessment of the stability of the distal tibio-
fibular joint in supination-external rotation injuries of the ankle: sensitiv-
ity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am
2011b; 93: 2057-61.
Pakarinen H J, Flinkkilä T E, Ohtonen P P, Hyvänen P H, Lakovaara M T,
Leppilahti JI, Ristiniemi JY. Syndesmotic fixation in supination-external
rotation ankle fractures: a prospective randomized study. Foot Ankle Int
2011c: 32; 1103-9.
Pelet S, Roger M E, Belzile E L, Bouchard M. The incidence of thrombo-
embolic events in surgically treated ankle fracture. J Bone Joint Surg Am
2012; 94: 502-6.
Pettrone F A, Gail M, Pee D, Fitzpatrick T, Van Herpe L B. Quantitative crite-
ria for prediction of the results after displaced fracture of the ankle. J Bone
Joint Surg Am 1983; 65: 667-77.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Acta Orthopaedica (Suppl 358) 2015; 86 31
Phisitkul P, Ebinger T, Goetz J, Vaseenon T, Marsh J L. Forceps reduction
of the syndesmosis in rotational ankle fractures: a cadaveric study. J Bone
Joint Surg Am 2012; 94: 2256-61.
Pneumaticos S G, Noble P C, Chatziioannou S N, Trevino S G. The effects
of rotation on radiographic evaluation of the tibiofibular syndesmosis. Foot
Ankle Int 2002; 23: 107-11.
Pollak A N, Jones A L, Castillo R C, Bosse M J, MacKenzie E J, The LEAP
Study Group. The relationship between time to surgical debridement and
incidence of infection after open high-energy lower extremity trauma. J
Bone Joint Surg Am 2010; 92: 7-15.
Pollak A N, McCarthy M L, Burgess A R. Short-term wound complications
after application of flaps for coverage of traumatic soft-tissue defects about
the tibia. The Lower Extremity Assessment Project (LEAP) Study Group. J
Bone Joint Surg Am 2000; 82: 1681-91.
Ponzer S, Nåsell H, Bergman B, Törnkvist H. Functional outcome and quality
of life in patients with Type B ankle fractures: a two-year follow-up study.
J Orthop Trauma 1999; 13: 363-8.
Pritchard J M, Giangregorio L M, Ioannidis G, Papaioannou A, Adachi J D,
Leslie W D. Ankle fractures do not predict osteoporotic fractures in women
with or without diabetes. Osteoporos Int 2012; 23: 957-62.
Ramsey P L, Hamilton W. Changes in tibiotalar area of contact caused by
lateral talar shift. J Bone Joint Surg Am 1976; 58: 356-7.
Rajeev A, Senevirathna S, Radha S, Kashayap N S. Functional outcomes
afterfibula locking nail for fragility fractures of the ankle. J Foot Ankle
Surg 2011; 50: 547-50.
Redfern D J, Sauvé P S, Sakellariou A. Investigation of incidence of superfi-
cial peroneal nerve injury following ankle fracture. Foot Ankle Int 2003;
24: 771-4.
Richards J E, Kauffmann R M, Zuckerman S L, Obremskey W T, May A K.
Relationship of hyperglycemia and surgical-site infection in orthopaedic
surgery. J Bone Joint Surg Am 2012; 94: 1181-6.
Richards R. Introduction: Implants and infection in fracture fixation “ten
years on”. Injury 2006; 37: S1-2.
Rightmire E, Zurakowski D, Vrahas M. Acute infections after fracture repair:
management with hardware in place. Clin Orthop Relat Res 2008; 466:
466-72.
Ríos-Luna A, Villanueva-Martínez M, Fahandezh-Saddi H, Villanueva-Lopez
F, del Cerro-Gutiérrez M. Versatility of the sural fasciocutaneous flap in
coverage defects of the lower limb. Injury 2007; 38: 824-31.
Rizvi A A, Chillag S A, Chillag K J. Perioperative management of diabetes
and hyperglycemia in patients undergoing orthopaedic surgery. J Am Acad
Orthop Surg 2010; 18: 426-35.
Rodriguez-Merchan E C, Forriol F. Nonunion: general principles and experi-
mental data. Clin Orthop Relat Res 2004; 419: 4-12.
Ruedi T, Buckley R, Moran C. AO Principles of fracture management. Vol
2 – Specific fractures. Malleoli. Pages 871-899. Second expanded edition.
Hahn D, Colton C. Pages 871-899. Thieme. New York 2007.
Rukavina A. The role of fibular length and the width of the ankle mortise in
post-traumatic osteoarthrosis after malleolar fracture. Int Orthop 1998; 22:
357-60.
Ryd L, Bengtsson S. Isolated fracture of the lateral malleolus requires no
treatment. 49 prospective cases of supination-eversion type II ankle frac-
tures. Acta Orthop Scand 1992; 63: 443-6.
Sagi H C, Shah A R, Sanders R W. The functional consequence of syndes-
motic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma
2012; 26: 439-43.
Saltzman C L, Salamon M L, Blanchard G M, Huff T, Hayes A, Buckwalter
J A, Amendola A. Epidemiology of ankle arthritis: report of a consecutive
series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J
2005; 25: 44-6.
Sanders D W, Tieszer C, Corbett B; Canadian Orthopedic Trauma Society.
Operative versus nonoperative treatment of unstable lateral malleolar frac-
tures: a randomized multicenter trial. J Orthop Trauma 2012; 26: 129-34.
Schepers T, De Vries M R, Van Lieshout E M, Van der Elst M. The timing of
ankle fracture surgery and the effect on infectious complications; a case
series and systematic review of the literature. Int Orthop 2013; 37: 489-94.
Schepers T, Van Lieshout E M, De Vries M R, Van der Elst M. Increased
rates of wound complications with locking plates in distal fibular fractures.
Injury 2011; 42: 1125-9.
Schepers T. Acute distal tibiofibular syndesmosis injury: a systematic review
of suture-button versus syndesmotic screw repair. Int Orthop 2012; 36:
1199-206.
van Schie-Van der Weert E M, Van Lieshout E M, De Vries M R, Van der
Elst M, Schepers T. Determinants of outcome in operatively and non-oper-
atively treated Weber-B ankle fractures. Arch Orthop Trauma Surg 2012;
132: 257-63.
Schoifet S D, Morrey B F. Treatment of infection after total knee arthroplasty
by débridement with retention of the components. J Bone Joint Surg Am
1990; 72: 1383-90.
Selby R, Geerts W H, Kreder H J, Crowther M A, Kaus L, Sealey F. Symp-
tomatic venous thromboembolism uncommon without thromboprophy-
laxis after isolated lower-limb fracture: the knee-to-ankle fracture (KAF)
cohort study. J Bone Joint Surg Am 2014; 96: e83
Shivarathre DG, Chandran P, Platt SR. Operative fixation of unstable ankle
fractures in patients aged over 80 years. Foot Ankle Int 2011; 32: 599-602.
Simanski C J, Maegele M G, Lefering R, Lehnen D M, Kawel N, Riess P,
Yücel N, Tiling T, Bouillon B. Functional treatment and early weightbear-
ing after an ankle fracture: a prospective study. J Orthop Trauma 2006; 20:
108-14.
Sintonen H. The 15D instrument of health-related quality of life: properties
and applications. Ann Med 2001; 33: 328-36.
Slobogean G P, Marra C A, Sadatsafavi M, Sanders D W; Canadian Orthope-
dic Trauma Society. Is surgical fixation for stress-positive unstable ankle
fractures cost effective? Results of a multicenter randomized control trial. J
Orthop Trauma 2012; 26: 652-8.
Slobogean G P, O’Brien P J, Brauer C A. Single-dose vs multiple-dose anti-
biotic prophylaxis for the surgical treatment of closed fractures. A cost-
effectiveness analysis. Acta Orthop 2010; 81: 258-64.
Somersalo A, Paloneva J, Kautiainen H, Lönnroos E, Heinänen M, Kiviranta
I. Incidence of fractures requiring inpatient care. Acta Orthop 2014; 85:
525-30.
SooHoo N F, Eagan M, Krenek L, Zingmond D S. Incidence and factors pre-
dicting pulmonary embolism and deep venous thrombosis following surgi-
cal treatment of ankle fractures. Foot Ankle Surg 2011; 17: 259-62.
SooHoo N F, Krenek L, Eagan M J, Gurbani B, Ko C Y, Zingmond D S.
Complication rates following open reduction and internal fixation of ankle
fractures. J Bone Joint Surg Am 2009; 91: 1042-9.
de Souza L J, Gustilo R B, Meyer T J. Results of operative treatment of dis-
placed external rotation-abduction fractures of the ankle. J Bone Joint Surg
Am 1985; 67: 1066-74.
Stannard J P, Volgas D A, McGwin G 3rd, Stewart R L, Obremskey W, Moore
T, Anglen J O. Incisional negative pressure wound therapy after high-risk
lower extremity fractures. J Orthop Trauma 2012; 26: 37-42.
Stannard J P, Singanamala N, Volgas D A. Fix and flap in the era of vacuum
suction devices: What do we know in terms of evidence based medicine?
Injury 2010; 41: 780-6.
Stannard J P, Volgas D A, Stewart R, McGwin G Jr, Alonso J E. Negative pres-
sure wound therapy after severe open fractures: a prospective randomized
study. J Orthop Trauma 2009; 23: 552-7.
Starkweather M P, Collman D R, Schuberth J M. Early protected weightbear-
ing after open reduction internal fixation of ankle fractures. J Foot Ankle
Surg 2012; 51: 575-8.
Stoffel K, Wysocki D, Baddour E, Nicholls R, Yates P. Comparison of two
intraoperative assessment methods for injuries to the ankle syndesmosis. A
cadaveric study. J Bone Joint Surg Am 2009; 91: 2646-52.
Strauss E J, Egol K A. The management of ankle fractures in the elderly.
Injury 2007; 38 Suppl 3: S2-9.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
32 Acta Orthopaedica (Suppl 358) 2015; 86
Stufkens S A, Knupp M, Horisberger M, Lampert C, Hintermann B. Cartilage
lesions and the development of osteoarthritis after internal fixation of ankle
fractures: a prospective study. J Bone Joint Surg Am 2010; 92: 279-86.
Talbot M, Steenblock T R, Cole P A. Posterolateral approach for open reduc-
tion and internal fixation of trimalleolar ankle fractures. Can J Surg 2005;
48: 487-90.
Tan K J, Lim C T, Lim A Y. The use of muscle flaps in the salvage of infected
exposed implants for internal fixation. J Bone Joint Surg Br 2010; 92:
401-5.
Tejwani N C, Pahk B, Egol K A. Effect of posterior malleolus fracture on
outcome after unstable ankle fracture. J Trauma 2010; 69: 666-9.
Testroote M, Stigter W, de Visser DC, Janzing H. Low molecular weight
heparin for prevention of venous thromboembolism in patients with lower-
leg immobilization. Cochrane Database Syst Rev 2008; 4: CD006681.doi:
10.1002/14651858.
Thomas G, Whalley H, Modi C. Early mobilization of operatively fixed ankle
fractures: a systematic review. Foot Ankle Int 2009; 30: 666-74.
Thordarson D B. Patients with a crooked radiograph after ankle fracture: what
to do? Foot Ankle Int 2012; 33: 355-8.
Thordarson D B, Ahlmann E, Shepherd L E, Patzakis M J. Sepsis and osteo-
myelitis about the ankle joint. Foot Ankle Clin 2000; 5: 913-28.
Thordarson D B, Motamed S, Hedman T, Ebramzadeh E, Bakshian S. The
effect of fibular malreduction on contact pressures in an ankle fracture mal-
union model. J Bone Joint Surg Am, 1997; 79: 1809-15.
Thur C K, Edgren G, Jansson K Å, Wretenberg P. Epidemiology of adult
ankle fractures in Sweden between 1987 and 2004: a population-based
study of 91,410 Swedish inpatients. Acta Orthop 2012; 83: 276-81.
Trampuz A, Zimmerli W. Diagnosis and treatment of infections associated
with fracture-fixation devices. Injury 2006; 37 Suppl 2: S59-66.
Trebse R, Pisot V, Trampuz A. Treatment of infected retained implants. J Bone
Joint Surg Br 2005; 87: 249-56.
Tønnesen H, Pedersen A, Jensen M R, Møller A, Madsen J C. Ankle fractures
and alcoholism. The influence of alcoholism on morbidity after malleolar
fractures. J Bone Joint Surg Br 1991; 73: 511-3.
Ueng W N, Shih C H. Management of infected tibial plate osteosynthesis
using a staging system for infected fractures. J Formos Med Assoc 1992;
91: 531-7.
Vaienti L, Di Matteo A, Gazzola R, Pierannunzii L, Palitta G, Marchesi A.
First results with the immediate reconstructive strategy for internal hard-
ware exposure in non-united fractures of the distal third of the leg: case
series and literature review. J Orthop Surg Res 2012a; 7: 30.
Vaienti L, Di Matteo A, Gazzola R, Randelli P, Lonigro J. Distally based sural
fasciomusculocutaneous flap for treatment of wounds of the distal third
of the leg and ankle with exposed internal hardware. J Orthop Traumatol
2012b; 13: 35-9.
Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B. Etiol-
ogy of ankle osteoarthritis. Clin Orthop Relat Res 2009; 467: 1800-6.
Valtola A, Honkanen R, Kröger H, Tuppurainen M, Saarikoski S, Alhava
E. Lifestyle and other factors predict ankle fractures in perimenopausal
women: a population-based prospective cohort study. Bone 2002; 30: 238-
42.
Van Heest T J, Lafferty PM. Injuries to ankle syndesmosis. J Bone Joint Surg
Am 2014; 96: 603-13.
Vasarhelyi A, Lubitz J, Gierer P, Gradl G, Rösler K, Hopfenmüller W, Klaue
K, Mittlmeier T W. Detection of fibular torsional deformities after surgery
for ankle fractures with a novel CT method. Foot Ankle Int 2006; 27: 1115-
21.
Viol A, Pradka S P, Baumeister S P, Wang D, Moyer K E, Zura R D, Olson S
A, Zenn M R, Levin S L, Erdmann D. Soft-tissue defects and exposed hard-
ware: a review of indications for soft-tissue reconstruction and hardware
preservation. Plast Reconstr Surg 2009; 123: 1256-63.
Vioreanu M, Dudeney S, Hurson B, Kelly E, O’Rourke K, Quinlan W. Early
mobilization in a removable cast compared with immobilization in a cast
after operative treatment of ankle fractures: a prospective randomized
study. Foot Ankle Int 2007; 28: 13-9.
Wagner M. General principles for the clinical use of the LCP. Injury 2003; 34
Suppl 2: B31-42.
Walsh E F, DiGiovanni C. Fibular nonunion after closed rotational ankle frac-
ture. Foot Ankle Int 2004; 25: 488-95.
Webb L X, Bosse M J, Castillo R C, MacKenzie E J; LEAP Study Group.
Analysis of surgeon-controlled variables in the treatment of limb-threaten-
ing type-III open tibial diaphyseal fractures. J Bone Joint Surg Am 2007;
89: 923-8.
Weening B, Bhandari M. Predictors of functional outcome following trans-
syndesmotic screw fixation of ankle fractures. J Orthop Trauma 2005; 19:
102-8.
van Wensen R J, van den Bekerom M P, Marti R K, van Heerwaarden R J.
Reconstructive osteotomy of fibular malunion: review of the literature.
Strategies Trauma Limb Reconstr 2011; 6: 51-7.
White C B, Turner N S, Lee G C, Haidukewych G J. Open ankle fractures in
patients with diabetes mellitus. Clin Orthop Relat Res 2003; 414: 37-44.
Whitehouse J D, Friedman N D, Kirkland K B, Richardson W J, Sexton D
J. The impact of surgical-site infection following orthopaedic surgery at
a community hospital and a university hospital: adverse quality of life,
excess length of stay, and extra cost. Infect Control Hosp Epidemiol 2002;
23: 183-9.
Wikerøy A K, Høiness P R, Andreassen G S, Hellund J C, Madsen J E. No dif-
ference in functional and radiographic results 8.4 years after quadricortical
compared with tricortical syndesmosis fixation in ankle fractures. J Orthop
Trauma 2010; 24: 17-23.
Wukich D K, Joseph A, Ryan M, Ramirez C, Irrgang J J. Outcomes of ankle
fractures in patients with uncomplicated versus complicated diabetes. Foot
Ankle Int 2011; 32: 120-30.
Wukich D K, Lowery N J, McMillen R L, Frykberg R G. Postoperative infec-
tion rates in foot and ankle surgery: a comparison of patients with and
without diabetes mellitus. J Bone Joint Surg Am 2010; 92: 287-95.
Wukich D K, Kline A J. The management of ankle fractures in patients with
diabetes. J Bone Joint Surg Am 2008; 90: 1570-8.
Wyss C, Zollinger H. The causes of subsequent arthrodesis of the ankle joint.
Acta Orthop Belg 1991; 57 Suppl 1: 22-7.
Xu G, Lai-Jin L. The coverage of skin defects over the foot and ankle using
the distally based sural neurocutaneous flaps: experience of 21 cases. J
Plast Reconstr Aesthet Surg 2008; 61: 575-7.
Yang Y L, Lin T M, Lee S S, Chang KP , Lai C S. The distally pedicled pero-
neus brevis muscle flap anatomic studies and clinical applications. J Foot
Ankle Surg 2005; 44: 259-64
Yao L, Zhang W, Yang G, Zhu Y, Zhai Q, Luo C. Morphologic characteristics
of the posterior malleolus fragment: a 3-D computer tomography based
study. Arch Orthop Trauma Surg 2014; 134: 389-94.
Yde J, Kristensen K D. Ankle fractures. Supination-eversion fractures stage
II. Primary and late results of operative and non-operative treatment. Acta
Orthop Scand 1980; 51: 695-702.
Yi X, Zhu J, Wei M, Li J, Chen J, Wang Y, Shen E, Hu B. Risk factors of
venous thrombosis in patients with ankle fractures. Int Angiol 2014; 33:
324-8.
Zaghloul A, Haddad B, Barksfield R, Davis B. Early complications of surgery
in operative treatment of ankle fractures in those over 60: A review of 186
cases. Injury 2014; 45: 780-3.
Záhorka J, Nejedlý A, Tvrdek M, Dzupa V. Management of infected tibial
fractures and chronic tibial osteomyelitis by muscle flap transfer: a com-
parison of two series of patients. Acta Chir Plast 2009; 51: 3-9.
Zalavras C G, Christensen T, Rigopoulos N, Holtom P, Patzakis M J. Infection
following operative treatment of ankle fractures. Clin Orthop Relat Res
2009; 467: 1715-20.
Acta Orthop Downloaded from informahealthcare.com by University of Helsinki (Main) on 02/09/15
For personal use only.
Article
Background While open reduction and internal fixation is currently considered the optimum treatment option for displaced ankle fractures, the most optimal post-operative rehabilitation strategy in this setting remains unclear. The objective of this investigation was to compare the effect of early vs. late weight bearing and ankle mobilization in the post-operative management of ankle fractures. Methods Medline, Embase, CENTRAL, Scopus, CINHAL, and Web of Science were searched to identify randomized controlled trials (RCTs) and quasi-RCTs. Two review authors screened articles, abstracted data, and evaluated risk of bias in duplicate. Outcomes of interest included post-operative ankle function and overall time to return to work. Studies on weight bearing and ankle mobilization were analysed separately and all data were pooled using random-effects models. Results Eighteen trials were included in the review of which 14 were included in the meta-analysis of at least one outcome of interest. Majority of the studies presented a high overall risk of bias. Early weight bearing demonstrated significantly better short-term postoperative functional scores at 6-9 weeks postoperatively (SMD: 0.39, 95% CI: 0.19, 0.58; p < 0.0001; I² = 0%). However, the functional effect of early weight bearing compared to late weight bearing gradually became equivalent by the 6 month postoperative time-period. Early weight bearing also demonstrated a significant reduction in the time to return to work/daily activities (MD: -12.29, 95% CI: -17.39, -7.19; p < 0.0001; I² = 0%). In comparison, no significant differences were found between early ankle mobilization/exercises and immobilization. Conclusion Our findings suggest a potential role of EWB in improving post-operative ankle-function in the short-term and reducing the overall time to return to work/daily activities, but no clinical benefit associated with early ankle mobilization post-surgery.
Chapter
The goal of ankle surgery is to provide pain relief and functional improvement. Any slight imperfection in the ankle will create much alteration in both gait and biomechanics of the foot and ankle.
Article
Peripheral nerve blocks (PNB) have become an important modality for pain management in ankle fracture surgery. Previous studies have reported their efficacy, but concerns with rebound pain and readmissions have been cited as possible deterrents. The purpose of this study was to evaluate the effects of PNB on hospital length of stay (LOS), narcotic intake, visual analog scale (VAS) for pain, and associated complications in patients undergoing outpatient ankle open reduction internal fixation (ORIF). Adult patients undergoing ankle ORIF were matched 2:1 (no block:block) using propensity-score matching. Preoperative patient characteristics and postoperative outcomes were compared between cohorts. VAS and total narcotic intake were evaluated for each of the first three postoperative 8-hour shifts. Narcotic medication was converted to morphine milligram equivalents (MME). Thirty-two patients who received PNB were matched to 64 patients who did not. The PNB group had lower VAS and MME during each of the 8-hour shifts after surgery: 0 to 8 hrs (VAS 1.8 vs 6.3; MME 10.6 vs 77.9; p<0.001), 8 to 16 hrs (VAS 1.2 vs 5.9; MME 9.2 vs 28.2; p<0.001), 16 to 24 hrs (VAS 3.7 vs 6.2; MME 13.2 vs 24.2; p=0.006 and 0.019). PNB had a shorter LOS (average 16.7 hrs vs 26.8 hrs; p<0.001). There were no differences in rates of ED presentations after discharge, hospital readmissions, or complications between cohorts. Peripheral nerve blocks after ankle ORIF are associated with shorter hospital LOS, lower VAS, and reduced narcotic intake without increasing rates of ED visits, hospital readmissions, or complications.
Article
Full-text available
Ankle fractures are common injuries that can result in substantial morbidity in the population. This review discusses the management of closed ankle fractures and outlines the recent evidence and guidelines on perioperative management. In general, a detailed history should be undertaken, followed by examination and imaging of the affected limb. Fixation is based on the AO principles of fracture management that aims towards restoring stability of the joint and reducing the risk of long-term complications. A multidisciplinary approach towards perioperative management is recommended in view of the increasing proportion of aging patients with significant comorbidities.
Article
Full-text available
Introduction Ankle fractures are commonly treated by open reduction and internal fixation with plate and screws. Unplanned return to theatre is common, in many cases to extract prominent osteosynthesis material from the lateral malleolus as swelling subsides. We hypothesised that patients operated with a posterolateral plate placement on the lateral malleolus would have fewer reoperations, and fewer complications, compared to patients with a lateral plate placement. Materials and Methods From a prospectively collected database of all orthopaedic surgery performed at our institution, we identified 664 ankle fractures undergoing plate fixation between 2008-01-01 and 2012-04-30. Radiographs were analysed to only include AO/OTA 44-B-fractures (n=453), and to define study groups based on plate positioning. Hospital files were assessed to identify possible confounding factors, and any unplanned reoperation or complication. Complications were classified according to Dindo-Clavien. Results The risk of reoperation was 13% after posterolateral plating, compared with 24% after lateral plating; absolute risk reduction 10% (95% CI: 2.5–18), p = 0.02. After adjusting for possible confounders, the odds ratio of undergoing reoperation after lateral plating was 2.2 (95% CI: 1.17–4.1), p = 0.01. The two surgical methods did not differ with regard to complication frequency: 31% vs 34%, p = 0.6, but complications following lateral plate fixation were more serious, p=0.03. Plate positioning depended on surgeon preference. Discussion The two studied methods are both considered standard treatment of ankle fractures, and relatively simple surgical procedures. High rates of sec ondary surgery after plate fixation have been reported, but no study comparing plate positioning has been previously published to our knowledge. AO Sweden has recently switched to teaching posterolateral plating in group exercises during the AO Basic Fracture Surgery course, based on the belief that it may be safer than lateral plating. Our findings support this change in practice. Conclusions Posterolateral plate positioning on the lateral malleolus in AO/OTA 44-B-fractures may be preferential to lateral plate positioning, due to a large difference in unplanned secondary surgery.
Article
Full-text available
Background: Osteoarthritis (OA) is a growing health concern that affects approximately 27 million people in the USA and is associated with a $185 billion annual cost burden. Choosing between open surgery and arthroscopic arthrodesis for ankle arthritis is still controversial. This study compared arthroscopic arthrodesis and open surgery by performing a systematic review and meta-analysis. Methods: For the systematic review, a literature search was conducted in 4 English databases (PubMed, Embase, Medline and the Cochrane Library) from inception to February 2020. Three prospective cohort studies and 7 retrospective cohort studies, enrolling a total of 507 patients with ankle arthritis, were included. Results: For fusion rate, the pooled data showed a significantly higher rate of fusion during arthroscopic arthrodesis compared with open surgery (odds ratio 0.25, 95% CI 0.11 to 0.57, p = 0.0010). Regarding estimated blood loss, the pooled data showed significantly less blood loss during arthroscopic arthrodesis compared with open surgery (WMD 52.04, 95% CI 14.14 to 89.94, p = 0.007). For tourniquet time, the pooled data showed a shorter tourniquet time during arthroscopic arthrodesis compared with open surgery (WMD 22.68, 95% CI 1.92 to 43.43, p = 0.03). For length of hospital stay, the pooled data showed less hospitalisation time for patients undergoing arthroscopic arthrodesis compared with open surgery (WMD 1.62, 95% CI 0.97 to 2.26, p < 0.00001). The pooled data showed better recovery for the patients who underwent arthroscopic arthrodesis compared with open surgery at 1 year (WMD 14.73, 95% CI 6.66 to 22.80, p = 0.0003). Conclusion: In conclusion, arthroscopic arthrodesis was associated with a higher fusion rate, smaller estimated blood loss, shorter tourniquet time, and shorter length of hospitalisation than open surgery.
Article
Current nationwide epidemiological data regarding ankle fractures are scarce. Such information is important towards better quantifying the mortality associated with such injuries, financial impact, as well as the implementation of preventative measures. This study evaluated the epidemiology of ankle fractures that occurred during a 5-year period. Specifically, we evaluated demographics, mechanism of injury, and disposition. The National Electronic Injury Surveillance System was queried to identify all patients with ankle fractures that presented to US hospital emergency departments between 2012 and 2016. Census data were used to determine the incidence rates of ankle fractures in terms of age, sex, and race. There was an estimated total of 673,214 ankle fractures that occurred during this period, with an incidence rate of 4.22/10,000 person-years. The mean age of patients with an ankle fracture was 37 ± 22.86 (SD) years; 23.5% of ankle fractures occurred in patients aged 10 to 19 years (7.56/10,000 person-years). In addition, 44% of ankle fractures occurred in men (3.81/10,000 person-years), whereas 56% occurred in women (4.63/10,000 person-years). Data on race/ethnicity were available for 71% of the subjects, with incidence rates of 2.85/10,000 person-years for whites, 3.01/10,000 person-years for blacks, and 4.08/10,000 person-years for others. The most common mechanism of injury was falls (54.83%), followed by sports (20.76%), exercise (16.84%), jumping (4.42%), trauma (2.84%), and other (0.30%). For disposition, 81.84% of patients were treated and released, 1.43% were transferred, 16.01% were admitted, 0.59% were held for observation, and 0.13% left against medical advice. The highest incidence of ankle fractures in men occurred in the 10-to-19-years age group, but women were more commonly affected in all other age groups.
Article
Full-text available
Introduction: The "logsplitter injury" is a special type of ankle fractures that results from high energy violence with combined rotational forces and axial loads. So far, the diagnose and treatment of "logsplitter injury" remain largely unsettled and related literature is rare. Patient concerns: An 18-year-old male fell from a fence and got his left ankle injured with severe malformation and swollen condition. No open wound was observed. Diagnosis: Logsplitter injury, ankle fracture (AO/OTA classification 44C1.1, Lauge-Hansen classification: pronation-external rotation). Interventions and outcomes: The patient was initially treated by internal fixation of fibular, repair of deltoid ligaments, and 1 syndesmotic screw fixation. When the X-ray applied after surgery, another 2 syndesmotic screws were performed to enhance stability. The syndesmotic screws were removed at 12-week and 16-week respectively. The patient was allowed for full weight-bearing immediately. However, the syndesmotic space was slightly increased compared to the contralateral side in CT views at 1-year follow-up, the function outcome was satisfied. Conclusion: The logsplitter injury is a high-energy ankle fracture that requires both axial and rotational load. It is categorized as 44B or 44C by the AO/OTA classification. In the classification scheme of Lauge-Hansen, our case is in line with the pronation-external rotation classification. Anatomic reduction and fixation of ankle syndesmotic injuries are required to restore the biomechanics of the ankle joint so that long-term complications can be prevented. How to fixation the syndesmosis, whether to reconstruct the deltoid ligament remains in debate in the treatment of logsplitter injury, whether and when to remove the syndesmotic screws were still debated. Correct surgical intervention is successful in the treatment of "logsplitter injury", however, the optimal fixation of syndesmosis and repair of deltoid ligaments need further investigate.
Article
Ankle fractures are among the most common orthopaedic surgical procedures. Skin‐related complications of these surgeries are difficult to reconstruct due to the inadequacy of soft tissue in the region. Although free flaps are generally considered as the first choice in reconstruction of this area, free flaps may not be a suitable option especially in patients with advanced age and comorbidities. Perforator flaps offer a fast and safe alternative in lower extremity reconstruction. In the literature, there are a limited number of studies using perforator flaps in managing the postoperative complications of the lower extremity trauma surgeries. In our study, we report our experience with reconstruction of soft‐tissue defects of medial malleolar region using posterior tibial artery perforator flap for postoperative complications of ankle fracture‐related surgeries.
Article
Introduction Ankle fractures account for up to 10% of total fractures. Most of them require surgical fixation, which involves an important risk of wound complications. The aim of this study was to determine whether a silver-impregnated occlusive surgical dressing (Aquacel Ag Extra®) was effective in reducing the rates of wound complications after ankle fracture open reduction and internal fixation compared to standard sterile dressing. Methods We prospectively reviewed 233 patients who underwent ankle fracture open reduction and internal fixation. Surgeons switched from using a standard dressing to an Aquacel Ag Extra® from July 2017 to February 2018, without other major changes in perioperative management. We compared skin complications between both groups after 3 months’ follow-up. Results The statistical analysis showed that there is no difference in the prevalence of skin complications between both groups. Conclusions The theoretical advantages of silver impregnated dressings need further prospective randomised controlled studies to assess the appropriate indications for their use in orthopaedic surgery.
Article
Full-text available
We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year. After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection. The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (> 72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure.
Article
In order to define the predisposing factors and outcome of infected arthroplasty of the knee, a retrospective analysis of a consecutive series of 471 knee arthroplasties was performed. There were 23 cases of superficial wound infection and 25 of deep infection. Superficial wound infection alone resulted in a painfree gait, with little limitation of movement. Rheumatoid arthritis, the use of constrained prostheses and the presence of a superficial wound infection, all predisposed to deep infection. Deep infection was eradicated by long-term antibiotics in only two patients in whom skin cover was successfully provided by a gastrocnemius musculocutaneous flap. Excision of a sinus track, wound debridement and exchange arthroplasty were universally unsuccessful. Arthrodesis, however, in 11 out of 12 cases, provided the painfree gait these patients desire.
Article
A method for the assessment of the accuracy of reduction in postreduction roentgenograms was developed. The final clinical results, one to 7.5 years after injury, were studied in 117 patients with 118 displaced bimalleolar or trimalleolar fractures at the ankle treated at the Los Angeles County-University of Southern California Medical Center between January 1966 and December 1970. Three variables were found to significantly affect the final clinical results: (1) the amount of talar displacement prior to reduction; (2) the type of fracture; and (3) the presence of rupture of the deltoid ligament.
Article
John Gray Seiler III, editor. Philadelphia: Lippincott Williams and Wilkins; 2001. 304 pages. $49.95. This book, a collaborative effort of eleven experienced hand surgeons, is a compact and portable overview of hand surgery that seeks to provide easy access to basic information concerning the diagnosis and treatment of hand problems. The text is neatly laid …
Article
Background: The purpose of the present study was to compare the rate of short-term wound complications associated with rotational flaps and that associated with free flaps for coverage of traumatic soft-tissue defects about the tibia. Methods: Of 601 patients prospectively enrolled in a multicenter study of high-energy trauma of the lower extremity, 190 patients (195 limbs) required nap coverage and had six months of follow-up. The injury data included the ASIF/OTA classification of the tibial fracture and the soft-tissue injury and the functional status of the neurovascular and muscular structures of the soft-tissue compartments at the time of soft-tissue coverage. The treatment data consisted of the type of flap, the timing of the flap coverage, and the type of fixation, The patient characteristics that were recorded included the age, gender, presence of comorbidities, and smoking status at the time of the injury, Short-term complications included wound infection, wound necrosis, and loss of the nap within the first six months after the injury. Results: Eighty-eight limbs were treated with a rotational nap, and 107 limbs were treated with a free nap. Overall, complications occurred after fifty-three (27 percent) of the 195 nap procedures; forty-six (87 percent) of the fifty-three required operative treatment. The two treatment groups were similar with respect to age, gender, comorbidities, preinjury smoking status, ASIF/OTA classification of the fracture, and prevalence of vascular injury requiring repair (p > 0.05). There were two important differences between the two groups. First, three of the four leg compartments - that is, the anterior, lateral, and deep posterior compartments - were more likely to be functionally compromised in the free-flap group than in the rotational flap group (p < 0.05), suggesting that patients in the free-flap group had sustained more severe soft-tissue injuries. Second, the Injury Severity Score was significantly higher (p = 0.001) in the rotational flap group (mean, 14 points) than in the free-nap group (mean, 11 points), suggesting that patients in the former group had sustained more substantial total body trauma. Overall, there were no significant differences between the two groups with respect to the complication rates. However, among those with the most severe grade of underlying osseous injury (an ASIF/OTA type-C injury), 44 percent of the limbs that were treated with a rotational nap had a wound complication compared with 23 percent of the limbs that were treated with a free flap (p = 0.10). To control for any differences between the two groups with respect to the severity of the injury, the treatment methods, or the patient characteristics, multivariate regression modeling was performed. An interaction effect between the type of nap and the severity of the underlying osseous injury demonstrated significance (p < 0.05) after controlling for other factors. Of the limbs that sustained an ASIF/OTA type-C osseous injury, those that were treated nifh a rotational Bap were 4.3 times more likely to have a wound complication requiring operative intervention than were those treated with a free nap. No significant difference in the rate of complications was detected with respect to the type of flap used for the limbs that had lower-grade osseous injuries. Conclusions: We found that use of a free flap to treat limbs with a severe underlying osseous injury was significantly less likely to lead to a wound complication requiring operative intervention than was use of a rotational nap.