Session II 11:30 11:45 am Wound Complications and How to Prevent Them Mark J. Berkowitz, MD Cleveland, Ohio Disclosure: (n) Wound Complications after ORIF of Calcaneus Fractures and How to Prevent Them I. Scope of the problem The most common complication of surgical treatment of calcaneus fractures involves the surgical wound and surrounding soft-tissues Text books cite an incidence of wound complications in up to 30% of cases for closed fractures However, the numbers at the high end of this range frequently come from smaller, less prominent studies Al-Mudhaffar, et al. Injury, 2000 o 18.1% of 33 fractures Abidi, et al. FAI, 1998 o 33% of 63 fractures with wound complications Larger studies from prominent authors document a much lower incidence Benirshke, et al. JOT, 2004 341 closed fractures o 1.6% serious infection closed fractures Harvey, et al. FAI, 2001 218 fractures o 3.2% infection o 8.2% wound complications Zwipp, et al. Injury, 2004 453 fractures o 6.7% wound necrosis o 4.7% hematoma o 4.3% soft tissue infection o 2.2% bone infection Canadian study, JOT, 2003 226 fractures o 16% superficial wound slough o 4.4% deep infection Sanders, et al. CORR, 1993 120 fractures o 5 wound dehiscence/infection in 89 Type II fractures o 2/30 Type III fractures o 2/11 Type IV with deep infections Incidence of wound complication in open fractures definitively higher, 19-31% Mehta, et al. JOT, 2010 14 open fractures o 7% osteomyelitis o 7% superficial infection Heier, et al. JBJS, 2003 43 open fractures o 37% infection o 19% osteomyelitis Must accurately characterize the nature of the wound complication Dehiscence vs. infection 65
Partial-thickness dehiscence vs. full-thickness Superficial infection vs. deep infection Osteitis vs. osteomyelitis II. III. Definition and types of soft-tissue complications Pre-operative Skin necrosis o Tongue-type fractures Blisters o Clear (partial thickness) o Hemorrhagic (full thickness) Wounds from open fractures Post-operative Surgical wound dehiscence o Superficial/partial-thickness dehiscence o Apical wound necrosis Full-thickness dehiscence Exposed bone and/or hardware Infection o Non-Serious (Benirshke, et al. JOT, 2004) Managed with oral antibiotics Risk factors Smoking Noncompliance Diabetes Obesity Change in Bohler s angle Open fractures Timing of surgery Prolonged surgical time Prolonged tourniquet time Single layer closure o Serious Requiring intravenous antibiotics, surgery, admission, etc. Superficial infection (osteitis) Deep infection (osteomyelitis) V. Prevention Patient selection (non-operative treatment) Non-surgical treatment eliminates wound complications but creates other complications o Canadian study, JOT, 2003 25% major complications in surgical group 18% major complications in non-surgical group o Radnay, et al. JBJS, 2006 11% wound complication for ST fusion with prior ORIF 28% wound complication for ST fusion without ORIF Delay in surgical treatment 10-21 days 66
Wrinkle test Optimization of risk factors Smoking cessation Glucose control Staged surgical treatment Initial external fixation (Attinger, Cooper. OCNA, 2001) Initial I and D and K-wires for open fractures (Mehta, et al. JOT, 2010) Prevents contraction of soft-tissue envelope Edema resolution Cryotherapy Pulsed-intermittent compression Elevation Blister treatment Observation vs. unroofing with Silvadene (Strauss, et al. JOT, 2006) Surgical technique Extensile lateral incision o Incision should be between angiosomes of flap (lateral calcaneal artery) and heel pad (medial calcaneal artery) o No-touch technique o Double-layered closure o Suture material (absorbable vs. nonabsorbable) o Suturing technique Allgower-Donati least strangulating (Sagi, et al. JOT, 2008) o Immediate local flaps (EDM) Alternative incisions / approaches o Sinus tarsi o Modified Palmer o Percutaneous / minimially invasive osteosynthesis o External fixation Post-surgical Immobilization vs. early mobilization Suture retention Drain VAC Incisional VAC (Stannard, et al. Injury, 2006) VI. Treatment Most cases of wound complication are non-serious Basic wound care Cessation of motion Dressing changes Whirlpool therapy Oral antibiotics VAC for more extensive dehiscence Serious infections usually require surgical treatment Osteitis o Irrigation/debridement o IV antibiotics o Hardware retention o DPC, VAC, or free flap for closure 67
Osteomyelitis o Radical debridement o Hardware removal o Antibiotic cement o Free flap o Possible staged fusion o Amputation REFERENCES: Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Abidi NA. Dhawan S. Gruen GS. Vogt MT. Conti SF. Foot & Ankle International. 19(12):856-61, 1998 Dec. Soft tissue reconstruction for calcaneal fractures or osteomyelitis. Attinger C. Cooper P. Orthopedic Clinics of North America. 32(1):135-70, 2001 Jan. Wound healing complications in closed and open calcaneal fractures. Benirschke SK. Kramer PA. Journal of Orthopaedic Trauma. 18(1):1-6, 2004 Jan. Vascularity of the lateral calcaneal flap: a cadaveric injection study. Borrelli J Jr. Lashgari C. Journal of Orthopaedic Trauma. 13(2):73-7, 1999 Feb. Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. Folk JW. Starr AJ. Early JS. Journal of Orthopaedic Trauma. 13(5):369-72, 1999 Jun-Jul. Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach. Harvey EJ. Grujic L. Early JS. Benirschke SK. Sangeorzan BJ. Foot & Ankle International. 22(11):868-73, 2001 Nov. Open fractures of the calcaneus: soft-tissue injury determines outcome. Heier KA. Infante AF. Walling AK. Sanders RW. Journal of Bone & Joint Surgery - American Volume. 85-A(12):2276-82, 2003 Dec 68
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