Gross Christopher E, Hamid Kamran S, Green Cynthia, Easley Mark E, DeOrio James K, Nunley James A
1 Department of Orthopaedics, Medical University of South Carolina, Charleston, SC, USA.
2 Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
Foot Ankle Int. 2017 Apr;38(4):360-366. doi: 10.1177/1071100716683341. Epub 2016 Dec 1.
Wound complications following total ankle replacement (TAR) potentially lead to devastating consequences. The aim of this study was to compare the operative and demographic differences in patients with and without major wound problems which required operative management. We hypothesized that increased tourniquet and operative time would negatively influence wound healing.
We identified a consecutive series of 762 primary TARs performed between December 1999 and April 2014 whose data were prospectively collected. We then identified the subset of patients who required a secondary surgery to treat major wound complications (ie, operative debridement, split-thickness skin grafting, and soft tissue reconstruction). All patients requiring a second surgery had operative wound debridement. We then compared the demographics, operative characteristics, and functional scores to see if any differences existed between patients with and without major wound complications. Clinical outcomes including secondary procedures and implant failure rates were recorded.
Twenty-six patients (3.4%) had a total of 49 operative procedures to treat major wound issues. Eighteen patients had flaps and 14 had split-thickness skin grafts. The median time to operatively treating the wound was 1.9 (range: 0.5-12.5) months after the index TAR. The median follow-up time from the wound procedure was 12.7 (range: 1.2-170.8) months. Compared to the control group, patients with major wounds had a significantly longer mean surgery (214.8 vs 189.3 minutes, P = .041) time and trended toward a longer median tourniquet time (151 vs 141 minutes, P = .060). Patients without wound complications were more likely to have posttraumatic arthritis, whereas those with wound complications were more likely to have primary osteoarthritis ( P = .006). The control group trended toward having a higher mean BMI (29.5 vs 27.2, P = .056). There were 6 failures in the major wound complication cohort (23.1%), including 2 below the knee amputations.
Ankle wounds that required operative management had high failure rates and some resulted in devastating outcomes. We did not find any increase in major wound complications in those with various risk factors as identified by other studies. Given our data, we recommend limiting operative time. While correcting hindfoot and midfoot alignment is important for improving patient functionality and survivorship of the implant, thought should be given to staging the TAR if multiple pathologies are to be addressed at the time of surgery to limit operative time.
Level III, retrospective comparative series.
全踝关节置换术（TAR）后的伤口并发症可能导致严重后果。本研究的目的是比较有和没有需要手术处理的重大伤口问题的患者在手术和人口统计学方面的差异。我们假设止血带使用时间和手术时间的增加会对伤口愈合产生负面影响。
我们确定了1999年12月至2014年4月期间连续进行的762例初次TAR病例，其数据为前瞻性收集。然后我们确定了需要二次手术治疗重大伤口并发症（即手术清创、分层皮片移植和软组织重建）的患者亚组。所有需要二次手术的患者均进行了手术伤口清创。然后我们比较了人口统计学、手术特征和功能评分，以观察有和没有重大伤口并发症的患者之间是否存在差异。记录了包括二次手术和植入物失败率在内的临床结果。
26例患者（3.4%）共进行了49次手术以治疗重大伤口问题。18例患者进行了皮瓣手术，14例患者进行了分层皮片移植。初次TAR后手术治疗伤口的中位时间为1.9（范围：0.5 - 12.5）个月。伤口手术后的中位随访时间为12.7（范围：1.2 - 170.8）个月。与对照组相比，有重大伤口的患者平均手术时间显著更长（214.8对189.3分钟，P = 0.041），止血带中位时间有延长趋势（151对141分钟，P = 0.060）。没有伤口并发症的患者更可能患有创伤后关节炎，而有伤口并发症的患者更可能患有原发性骨关节炎（P = 0.006）。对照组的平均BMI有升高趋势（29.5对27.2，P = 0.056）。重大伤口并发症队列中有6例失败（23.1%），包括2例膝下截肢。
需要手术处理的踝关节伤口失败率高，有些导致了严重后果。我们未发现其他研究确定的具有各种风险因素的患者中重大伤口并发症有任何增加。根据我们的数据，我们建议限制手术时间。虽然纠正后足和中足对线对于改善患者功能和植入物存活率很重要，但如果手术时要处理多种病变，应考虑分期进行TAR以限制手术时间。
III级，回顾性比较系列研究。
