Kwon John Y, Guss Daniel, Lin Darius E, Abousayed Mostafa, Jeng Clifford, Kang Steve, Ellington J Kent
Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
Massachusetts General Hospital, Boston, Massachusetts, USA
Foot Ankle Int. 2015 May;36(5):508-17. doi: 10.1177/1071100714565178. Epub 2015 Jan 14.
There are conflicting data regarding the benefits of delaying operative fixation of calcaneus fractures to decrease wound complication rates. The purpose of this study was to examine the effect of delaying fixation on wound complication rates as well as to identify other risk factors.
A retrospective review at 4 institutions, including 24 surgeons, identified 405 closed, operatively treated, intra-articular calcaneus fractures. We compared fractures with and without wound complications with regards to patient demographics, medical risk factors, fracture severity, time to fixation, operative approach, primary subtalar arthrodesis, and surgeon experience.
Wound complications were observed in 21% (87/405) of fractures, of which 33% (29/87) required operative intervention. Male sex (P = .032), smoking (P = .028), and the extensile lateral approach (P < .001) were associated with higher complication rates. Fractures treated with an extensile lateral approach had an overall wound complication rate of 32.1%, while those treated with a sinus tarsi or percutaneous approach had an overall wound complication rate of 8.3% (odds ratio [OR], 5.3; 95% confidence interval [CI], 2.9-9.5; P < .001). Among patients treated with an extensile lateral approach, delayed operative fixation did not decrease wound complication rates despite comparable fracture severity across time points. In contrast, among fractures treated with less invasive approaches, delayed fixation beyond 2 weeks resulted in a significantly increased wound complication rate of 15.2% as compared to a wound complication rate of only 2.1% among fractures treated within a week of injury (OR, 3.2; 95% CI, 1.3-9.5; P = .01). This was observed despite similar fracture severity across time points. Primary subtalar arthrodesis did not impact complication rates. A higher wound complication rate among senior surgeons was likely secondary to their predilection for the extensile lateral approach.
Delaying definitive fixation of closed, intra-articular calcaneus fractures did not decrease wound complication rates when using the extensile lateral approach, and we found an increased wound complication rate when using less invasive approaches.
Level III, observational study.
关于延迟跟骨骨折手术固定以降低伤口并发症发生率的益处，存在相互矛盾的数据。本研究的目的是探讨延迟固定对伤口并发症发生率的影响，并确定其他风险因素。
对4家机构（包括24名外科医生）进行回顾性研究，确定了405例闭合性、接受手术治疗的关节内跟骨骨折。我们比较了有无伤口并发症的骨折患者在人口统计学、医疗风险因素、骨折严重程度、固定时间、手术入路、一期距下关节融合术以及外科医生经验等方面的情况。
21%（87/405）的骨折出现伤口并发症，其中33%（29/87）需要手术干预。男性（P = 0.032）、吸烟（P = 0.028）和外侧扩大入路（P < 0.001）与较高的并发症发生率相关。采用外侧扩大入路治疗的骨折总体伤口并发症发生率为32.1%，而采用跗骨窦或经皮入路治疗的骨折总体伤口并发症发生率为8.3%（优势比[OR]，5.3；95%置信区间[CI]，2.9 - 9.5；P < 0.001）。在采用外侧扩大入路治疗的患者中，尽管各时间点骨折严重程度相当，但延迟手术固定并未降低伤口并发症发生率。相比之下，在采用创伤较小入路治疗的骨折中，延迟固定超过2周导致伤口并发症发生率显著增加，为15.2%，而受伤后1周内治疗的骨折伤口并发症发生率仅为2.1%（OR，3.2；95% CI，1.3 - 9.5；P = 0.01）。尽管各时间点骨折严重程度相似，但仍观察到这一情况。一期距下关节融合术对并发症发生率无影响。资深外科医生中较高的伤口并发症发生率可能与其偏好外侧扩大入路有关。
采用外侧扩大入路时，延迟闭合性关节内跟骨骨折的确定性固定并不能降低伤口并发症发生率，并且我们发现采用创伤较小入路时伤口并发症发生率会增加。
三级，观察性研究。
