SLR - July 2016 - Michelle Allen Morse
Reference: Wang CL, Huang SF, Sun XS, Zhu T, Lin C, Li Q. Abductor Digiti Minimi Muscle Flap Transfer to Prevent Wound Healing Complications after ORIF of Calcaneal Fractures. Int J Clin Exp Med. 2015 Aug 15,8(8):13001–13006.Scientific Literature Review
Reviewed By: Michelle Allen Morse, DPM
Residency Program: Beth Israel Deaconess Medical Center
Podiatric Relevance: Calcaneal fractures represent about 2 percent of all fractures. If left untreated, displaced intra-articular calcaneal fractures would likely develop posttraumatic arthritis. Wound complications are a known risk after ORIF of calcaneal fractures, especially when the lateral extensile incision is used. Complications include wound edge necrosis, hematoma, dehiscence, full-thickness sloughing, deep purulence infections and osteomyelitis. Many previous studies have shown complication rates of 10–20 percent for superficial skin infection or wound dehiscence and 5 percent for deep infection after calcaneal fracture ORIF. Most complications occur within 1 month after surgery and may require a soft-tissue flap or below-the-knee amputations in rare cases. In this study, the authors hypothesized that muscle flaps would eliminate the dead space to prevent hematoma and add coverage of hardware to help reduce the risk of wound edge necrosis or dehiscence avoiding further complications.
Methods: This study is a retrospective review of 26 cases of acute closed calcaneal fractures treated with an ORIF and abductor digit minimi (ADM) muscle flap between February 2007 and January 2013. Patients were chosen according to a higher than normal risk for postoperative wound healing due to diabetes, high BMI, smoking or serious fracture. In all cases, the extensile L-shaped incisional approach was used with subperiosteal dissection and the “no-touch” technique to protect the flap. A plate and screws were used to achieve reduction. After the ORIF of the calcaneal fracture, a portion of the ADM muscle was transected at its insertion to permit arc of rotation for the flap. Average muscle flap size was 1.5cmx1.5cm.5.5cm. During dissection, care was taken to preserve the nerve to minimize muscle atrophy. The flap was rotated into the corner of the incision while kinking or stretching of the dominant pedicle was avoided. All wounds were closed without tension using interrupted absorbable subcutaneous sutures to eliminate dead space in the plantar dermo-fat tissues and then with nonabsorbable sutures. A few capillary drains were placed at the ADM donor site. Postoperatively, the patients remained non-weightbearing for 10–12 weeks, initially in a short-leg cast or postoperative splint for three weeks. Follow-up of the patients ranged between 6–72 months. Wound healing rates, postoperative complications and time to heal were measured. Telephone surveys assessed patient satisfaction and ambulatory status.
Results: All wounds healed uneventfully, except for one case of minor superficial epithelial necrosis during the early postoperative period, which was treated conservatively. All patients regained ambulatory status with regular foot apparel. At last follow-up, the patients presented no clinical, laboratory or radiological signs of complications. In addition, there was no effect on the functionality of toe abduction in all cases.
Conclusions: For displaced intra-articular calcaneal fractures, the lateral extensile approach is most widely utilized for ORIF and provides excellent visualization. However, with this approach, there is a high rate of wound healing complications, especially in patients with increased risk factors. This retrospective case study serves to illustrate that the ADM muscle flap transfer technique is a viable adjunctive procedure in these high-risk patients who require a lateral extensile calcaneal fracture ORIF. However, future studies with greater numbers of cases in addition to control groups are required to further investigate its success in preventing major wound healing complications.