Mikko T. Ovaska

Risk factors for deep surgical site infection following operative treatment of ankle fractures.

BACKGROUND Surgical site infection is one of the most common complications following ankle fracture surgery. These infections are associated with substantial morbidity and lead to increased resource utilization. Identification of risk factors is crucial for developing strategies to prevent these complications. METHODS We performed an age and sex-matched case-control study to identify patient and surgery-related risk factors for deep surgical site infection following operative ankle fracture treatment. We identified 1923 ankle fracture operations performed in 1915 patients from 2006 through 2009. A total of 131 patients with deep infection were identified and compared with an equal number of uninfected control patients. Risk factors for infection were determined with use of conditional logistic regression analysis. RESULTS The incidence of deep infection was 6.8%. Univariate analysis showed diabetes (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.0, 4.9), alcohol abuse (OR = 3.8, 95% CI = 1.6, 9.4), fracture-dislocation (OR = 2.0, 95% CI = 1.2, 3.5), and soft-tissue injury (a Tscherne grade of ≥1) (OR = 2.6, 95% CI = 1.3, 5.3) to be significant patient-related risk factors for infection. Surgery-related risk factors were suboptimal timing of prophylactic antibiotics (OR = 1.9, 95% CI = 1.0, 3.4), difficulties encountered during surgery, (OR = 2.1, 95% CI = 1.1, 4.0), wound complications (OR = 4.8, 95% CI = 1.6, 14.0), and fracture malreduction (OR = 3.4, 95% CI = 1.3, 9.2). Independent risk factors for infection identified by multivariable analyses were tobacco use (OR = 3.7, 95% CI = 1.6, 8.5) and a duration of surgery of more than ninety minutes (OR = 2.5, 95% CI = 1.1, 5.7). Cast application in the operating room was independently associated with a decreased infection rate (OR = 0.4, 95% CI = 0.2, 0.8). CONCLUSIONS We identified several modifiable risk factors for deep surgical site infection following operative treatment of ankle fractures.

Predictors of poor outcomes following deep infection after internal fixation of ankle fractures.

The development of deep infection following operative treatment of ankle fractures can have catastrophic consequences. The aim of this study was to identify factors predisposing to treatment failure of an infected ankle fracture. Out of 1923 consecutive ankle fracture operations we identified 97 patients with deep infection necessitating at least one surgical debridement. The outcome measure was a clinical failure or success of the treatment. Various parameters considered to predict clinical outcome were evaluated. Treatment failure occurred in 27% of patients with deep infection necessitating surgical debridement. The mean age of these patients was 54 years and the mean follow-up time was 22 months. The variables that were independently associated with an increased risk of treatment failure included smoking, postoperative malreduction, hardware removal from an ununited fracture and the need for two or more additional debridements. Other significant risk factors included diabetes, alcohol abuse, high-energy injury, Danis-Weber type C fracture, multibacterial infection and ununited fracture at debridement. Our study showed that smoking, postoperative malreduction and hardware removal prior to fracture union were the most important factors predisposing to a permanent complication following an ankle fracture infection. We recommend that hardware be removed only after fracture union has been confirmed.

Contemporary demographics and complications of patients treated for open ankle fractures

Open ankle fractures are rare injuries with a high likelihood of wound complications and subsequent infections. There is limited information about the complications and outcomes of these injuries in different age groups. The aim of this study was to assess the contemporary demographics and complications related to this injury. We performed a chart review of all the 3030 patients treated for ankle fractures at a Level 1 trauma centre from 2006 to 2011. 137 (4.5%) patients had an open ankle fracture. The demographic data, injury mechanism, comorbidities, and fracture type were collected. Treatment, complications, length of stay and number of outpatient visits were also recorded. The mean age of the patients was 60 years and 56% were women. Most fractures were Weber type B with a medial sided wound (93%). Only 20% of the fractures were the result of high-energy trauma, and 31% were Gustilo grade III injuries. Immediate internal fixation was performed in 82% of patients, and the wound was primarily closed in most cases (80%). The incidence of postoperative wound necrosis and deep infection was 18% and 17%, respectively. There were more deep infections if pulsatile lavage was used during the wound debridement (p=0.029). About 14 (10%) patients required a flap reconstruction to cover the soft-tissue defect. Every other patient (54%) had a complication, and 21 patients (15%) suffered a long-term disability related to the injury. The number complications did not differ for nighttime and daytime operations (p=0.083). High-energy injuries were more common in younger patients (p<0.001) and these patients also had more lateral sided open wounds than older patients (p=0.002). Interestingly, younger patients also had significantly more complications (p=0.024), suffered more often from chronic pain (p=0.003), and required more flap reconstructions (p=0.026), reoperations (p=0.026), and outpatient clinic visits (p=0.006). Open ankle fractures have a high complication rate and often require multiple surgical procedures. In young patients these injuries are more likely to be the consequence of high-energy trauma leading to more complications and subsequently increased healthcare resource utilisation.

Dislocation of hip hemiarthroplasty following posterolateral surgical approach: a nested case–control study

PurposeHip hemiarthroplasty dislocation is a serious complication in treatment of displaced intracapsular hip fractures. We investigated factors associated with an increased risk of dislocation after cemented hip hemiarthroplasty following the posterolateral approach.MethodsBetween January 2002 and December 2008, 602 hip fractures were treated with cemented unipolar hip hemiarthroplasty. A registry-based analysis was carried out to determine the total number of hemiarthroplasty dislocations in these patients. A control group of 96 patients without dislocation was randomly selected. Logistic regression analysis was performed to evaluate clinical and operative factors associated with dislocation.ResultsThirty-four patients (5.6%) experienced at least one dislocation. Most were the result of a fall and occurred within two months after surgery. There was a trend for increased dislocation in patients who had been operated on more than 48 hours after admission and in patients who had a longer operative time. Smaller centre-edge angle and hip offset were observed in patients with dislocation. Recurrent dislocation was a significant problem, as 18 patients (62%) experienced multiple dislocations.ConclusionsThe risk of hemiarthroplasty dislocation following the posterolateral surgical approach may be reduced by prompt surgical treatment and fall prevention in the early postoperative period. Patients with smaller acetabular coverage seem more predisposed to dislocation after the posterolateral approach and may be more suitable for other surgical approaches.

Predictors of Postoperative Wound Necrosis Following Primary Wound Closure of Open Ankle Fractures

Background: Most open malleolar ankle fracture wounds can be closed primarily after meticulous debridement. However, the development of wound necrosis following operative treatment of open malleolar ankle fractures can have catastrophic consequences. The aim of this study was to identify risk factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. Methods: A total of 137 patients with open malleolar ankle fractures were identified. The open fracture wound was primarily closed in 110 of 137 (80%) patients, and postoperative wound necrosis occurred in 18 (16%) of these patients. These patients were compared to the open fracture patients without wound necrosis. Twenty possible risk factors for the development of wound necrosis were studied with logistic regression analysis. Results: The variables that were independently associated with an increased risk for postoperative wound necrosis included ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery. Conclusions: Our study showed that ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery were the most important factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. The findings warrant a further study specifically comparing primary and delayed wound closure in patients with Gustilo grade III open malleolar ankle fractures and different ASA classes. Also, the role of pulsatile lavage should be re-evaluated. Level of Evidence: Level III, retrospective comparative series.

The role of outpatient visit after operative treatment of ankle fractures

It is a common practice that patients have a scheduled follow-up visit with radiographs following ankle fracture surgery. The aim of this study was to evaluate whether an early outpatient visit (<3 weeks) after ankle fracture surgery resulted in a change in patient management. For this study, 878 consecutive operatively treated ankle fracture patients with an early outpatient clinical-radiological visit were reviewed. The outcome measure was a change in treatment plan defined as any procedure, medication, or surgical intervention that is not typically implemented during the uncomplicated healing process of an acute fracture. A change in treatment plan was observed in 9.8% of operatively treated ankle fracture patients. The mean age of the patients was 48 years and the mean follow-up time was 64 months. Of the changes in treatment plan, 91% were exclusively due to clinical findings such as infection. Only three of 878 patients required a change in their treatment plan based merely on the findings of the radiographs taken at the outpatient visit. Only 37% of the patients requiring a change in their postoperative management had solicited an unanticipated visit before the scheduled outpatient visit due to clinical problems such as infection or a cast-related issue. Our study showed that every tenth operatively treated ankle fracture patient requires a change in their treatment plan due to a clinical problem such as infection or a cast-related issue. Although at hospital discharge all patients are provided with written instructions on where to contact if problems related to the operated ankle emerge, only one third of the patients are aware of the clinically alarming symptoms and seek care when problems present. Our findings do not support obtaining routine radiographs at the early outpatient visit in an ankle fracture patient without clinical signs of a complication.

Simultaneous bilateral subtrochanteric fractures following risedronate therapy.

Abstract Bisphosphonates are the most commonly prescribed drugs for the treatment of osteoporosis, and have been shown to be highly effective in reducing the risk of vertebral and hip fractures [1]. The mechanism of action of bisphosphonates is based on the inhibition of osteoclast function and induction of osteoclast apoptosis. In experimental studies, prolonged suppression of bone turnover has been shown to result in accumulation of microdamage and increased bone fragility [2, 3].

Amputation following internal fixation of an ankle fracture via the posterolateral approach – a case report

© 2016 The Author(s). Published by Taylor & Francis on behalf of the Nordic Orthopedic Federation. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non-Commercial License (https://creativecommons.org/licenses/by-nc/3.0) DOI 10.1080/17453674.2016.1262679 A 39-year-old previously healthy woman sustained a dislocated trimalleolar ankle fracture as a result of a low-energy twisting injury. The fracture was reduced and stabilized at the emergency department (Figure 1). After reduction, the foot was vital and sensation and motor function were normal. Because of the tendency of the ankle joint to dislocate posteriorly, we decided to fi x the posterior malleolar fracture with an anatomic locking plate through a posterolateral approach. The surgery went according to plan and postoperative radiographs were considered acceptable (Figure 1). However, during the fi rst postoperative day the patient developed severe pain in her foot that was unresponsive to pain medication. Sensation was impaired at the dorsal and plantar aspects of the foot. Active fl exion of toes was intact, but passive extension of the foot caused pain at the level of the ankle. The foot was warm, but neither the dorsalis pedis artery nor the posterior tibial artery was palpable or could be detected with Doppler ultrasound. Because of the absent distal pulses, a computed tomography angiography (CTA) was performed 24 h after surgery. The CTA revealed a bilateral dominant peroneal artery as the only artery supplying vascularity to the foot (Figure 2). However, vascular occlusion was not evident on CTA. Because of the intense pain, urgent revision surgery was done 36 h after primary surgery. During the surgery, a sural nerve entrapment in the subcutaneous sutures was observed. The nerve was liberated, the peroneal muscles were found to be vital, and there were no signs of compartment syndrome.