1 Harvard Medical School, Harvard Combined Orthopaedic Residency Program, Boston, MA, USA.
2 Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Foot Ankle Int. 2019 May;40(5):526-536. doi: 10.1177/1071100718820352. Epub 2019 Jan 28.
Considerable debate exists regarding how soft-tissue edema should influence timing of surgery for ankle and other lower extremity fractures. Assessment of swelling is subjective, and timing varies among surgeons. However, timing of surgery is one of the few modifiable factors in fracture care. Ultrasonography can objectively measure swelling and help determine optimal timing. The purposes of this study were to determine whether objective measures of swelling, timing to surgery, and patient-specific risk factors correlated with wound complications and to try to create a prediction model for postoperative wound complications based on identified modifiable and nonmodifiable risk factors.
Patients with closed ankle and other lower extremity fractures requiring surgery with an uninjured, contralateral extremity were included. Demographic information and sonographic measurements on both lower extremities were obtained pre-operatively. Subjects were followed for 3 months and wound complications were documented. A predictive algorithm of independent risk factors was constructed, determining wound complication risk. Given that patients with ankle fractures made up the majority of the study cohort (75/93 or 80%), a separate statistical analysis was performed on this group. A total of 93 subjects completed the study, with 75/93 sustaining ankle fractures.
Overall wound complication rate was 18.3%. Timing to surgery showed no correlation with wound complications. A heel-pad edema index >1.4 was independently associated with wound complications. Subgroup analysis of ankle fractures demonstrated a 3.4× increase in wound complications with a heel-pad edema index >1.4. Tobacco history and BMI >25 were independent predictors of wound complications. An algorithm was established based on heel-pad edema index, BMI >25, and tobacco history. Patients with none of the 3 factors had a 3% probability of a wound complication. Patients with 1/3, 2/3 and 3/3 factors had a 12-36%, 60-86% and 96% probability of a wound complication, respectively.
Timing to surgery had no correlation with wound complications. Heel-pad edema index >1.4, BMI >25, and tobacco-use correlated with wound complications. When separately analyzing the cohort that sustained ankle fractures, the heel-pad edema index of >1.4 was still demonstrated to be predictive of wound complications corresponding to a 3.4× increase in wound complication rates (11.1% vs 37.5%). Risk of wound complications significantly increased with each factor. In patients with increased BMI and/or tobacco use, resolution of heel edema may significantly reduce wound complications in lower extremity trauma.
Level II, prognostic, prospective cohort study.
对于踝关节和其他下肢骨折的手术时机，软组织肿胀应如何影响存在大量争议。肿胀的评估是主观的，不同外科医生的手术时机也不同。然而，手术时机是骨折治疗中少数几个可改变的因素之一。超声检查可以客观地测量肿胀，并有助于确定最佳的手术时机。本研究的目的是确定肿胀的客观测量值、手术时机和患者特定的危险因素是否与伤口并发症相关，并尝试根据可改变和不可改变的危险因素建立预测术后伤口并发症的模型。
纳入需要手术治疗的闭合性踝关节和其他下肢骨折且对侧未受伤的患者。术前获取双侧下肢的人口统计学信息和超声测量值。对患者进行 3 个月的随访，并记录伤口并发症。构建独立危险因素的预测算法，确定伤口并发症风险。由于踝关节骨折患者占研究队列的大多数（75/93 或 80%），因此对该组进行了单独的统计分析。共有 93 名患者完成了研究，其中 75/93 名患者发生踝关节骨折。
总体伤口并发症发生率为 18.3%。手术时机与伤口并发症无相关性。足跟垫水肿指数>1.4 与伤口并发症独立相关。踝关节骨折的亚组分析显示，足跟垫水肿指数>1.4 时，伤口并发症增加 3.4 倍。吸烟史和 BMI>25 是伤口并发症的独立预测因素。根据足跟垫水肿指数、BMI>25 和吸烟史建立了一个算法。没有这 3 个因素的患者伤口并发症的概率为 3%。有 1/3、2/3 和 3/3 个因素的患者伤口并发症的概率分别为 12-36%、60-86%和 96%。
手术时机与伤口并发症无相关性。足跟垫水肿指数>1.4、BMI>25 和吸烟与伤口并发症相关。当单独分析发生踝关节骨折的队列时，足跟垫水肿指数>1.4 仍可预测伤口并发症，伤口并发症发生率增加 3.4 倍（11.1% 比 37.5%）。伤口并发症的风险随着每个因素的增加而显著增加。在 BMI 增加和/或吸烟的患者中，足跟水肿的消退可能会显著降低下肢创伤的伤口并发症。
II 级，预后，前瞻性队列研究。
