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SICOT e-Newsletter

Issue No. 58 - July 2013

Worldwide News

Open reduction and internal fixation of acute intra-articular displaced calcaneal fractures: A retrospective analysis of surgical timing and infection rates
Authors: Cheng-Jung Ho, Hsuan-Ti Huang, Chung-Hwan Chen, Jian-Chih Chen, Yuh-Min Cheng, Peng-Ju Huang.
Journal Injury; 2013 Jul;44(7):1007-10.

Comment by Ahmed M. Khedr - Cairo, Egypt (revised by Ahmed H. Abdel-Azeem)
Abstract

The choice of surgical timing in open reduction for calcaneal fractures has been proposed to be associated with soft-tissue complications and infection. This study analysed the correlation between surgical timing and postoperative infection rates. We performed a retrospective single-surgeon single-facility study (Kaohsiung Medical University Hospital, KMUH) between January 2006 and January 2010. Fifty patients with 53 close intra-articular calcaneal fractures were included. They received open reduction and internal fixation via the extensile lateral L-shaped approach. We assessed the duration between heel trauma and operation from the medical records and sorted our patients into early (within 3 days), intermediate (from 3 to 10 days) and delayed (over 10 days) surgical groups. The mean follow-up period was 13 months. Only one of the 50 patients, a 74-year-old female with diabetes mellitus, developed deep infection requiring hardware removal and serial debridement. Overall, we did not find a statistical difference in postoperative infection rates in the different timing groups. Our conclusion is that in experienced hands, surgical timing may not affect postoperative infection rates in calcaneal fracture among strictly selected patients who do not have potential risk factors for wound complication. Therefore, early operation may be helpful to these patients.


Comment

Wound-healing problems and infection continue to plague the surgical treatment of calcaneus fractures. With a reported incidence between 10 and 30%, wound edge necrosis is the most common complication of open treatment of calcaneus fractures1. The incidence of wound edge necrosis has declined with the popularization of the extensile lateral approach, an approach that respects the lateral angiosomes about the foot and ankle. In 2003, Howard et al reported 20.8% infections among 226 patients treated by lateral approach2. In 2004, Zwipp and colleagues reported a 6.7% prevalence of wound edge necrosis in 553 operatively treated calcaneus fractures via a lateral extensile exposure3. In 2005, Koski reported 8% rate of wound edge necrosis4. Despite the development of new approaches and surgical techniques, wound infection is still a concern. In 2011, Tomesen et al reported 13% infection rate among 39 patients treated by closed reduction and percutaneous fixation5. Although there is a consensus that soft tissue swelling and edema negatively affects the outcome of surgery, the decision of “when to operate?” is still controversial.

This retrospective study shows that selected patients could probably benefit from early surgery without wound related complications. The study strengths include that all patient were operated upon by the same surgeon in the same institute and in the five-year interval. This minimises the bias from different operation teams, hardware, treatment protocols and the institutional antibiotic-sensitivity spectrum. The limitation of the study is the small sample size which the author confessed to be “insufficient to provide significant statistical power between the three surgical-timing groups”. However, this study can provide a clue to determine the optimum timing for operating upon this fracture. It also highlights the importance of tailoring this decision according to the patients’ individual factors and co-morbidities.



References

  1. Benirschke SK, Sangeorzan BJ Extensive intraarticular fractures of the foot. Surgical management of calcaneal fractures. Clin Orthop Relat Res 1993:128-34.
  2. Howard JL, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, Galpin R Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 2003;17:241-9.
  3. Zwipp H, Rammelt S, Barthel S Calcaneal fractures--open reduction and internal fixation (ORIF). Injury 2004;35 Suppl 2:SB46-SB54.
  4. Koski A, Kuokkanen H, Tukiainen E Postoperative wound complications after internal fixation of closed calcaneal fractures: a retrospective analysis of 126 consecutive patients with 148 fractures. Scand J Surg 2005;94:243-5.
  5. Tomesen T, Biert J, Frolke JP Treatment of displaced intra-articular calcaneal fractures with closed reduction and percutaneous screw fixation. J Bone Joint Surg Am 2011;93:920-8.