Predictors of Poor Outcome Following Deep Infection After Internal Fixation of Ankle Fractures

SLR - October 2013 - Danielle DiStefano

Reference: Mikko, T. Ovaska, Tatu J. Makinen, Rami Madanat, Tero Vahlberg, Eero Hirvensalo, Jan Lindahl.  Predictors of Poor Outcomes Following Deep Infection After Internal Fixation of Ankle Fractures. Injury, Int. J. Care Injured 44 (2013) 1002-1006.

 

Scientific Literature Review

Reviewed by: Danielle DiStefano, DPM 
Residency Program: University Hospital - Newark, NJ

Podiatric Relevance: Deep infection following ankle ORIF is a complication that can have severe consequences. Identifying risk factors of poor outcomes after surgical debridement of deep ankle infections following ORIF can help us more appropriately anticipate prognosis and adequately treat our patients. Having an appreciation for at-risk patients allows for an increased index of suspicion and hopefully a more timely diagnosis and treatment.  
 

Methods: The authors conducted a retrospective review of all ankle fractures undergoing ORIF over a 4-year period. Ultimately 97 patients were included that needed at least one surgical debridement due to deep infection after ankle ORIF. All of these patients had their hardware present at the time of surgical debridement. The authors evaluated patient co-morbidities including diabetes and smoking history, high verse low energy injuries, mal-reduction of the fracture post operatively as well as fracture type and when the hardware was removed. Wound cultures were also taken at the surgeon’s discretion. Data was assessed via the Fisher’s exact test as well as the Mann-Whitney U-test.

Results: Twenty-seven percent of patients included failed treatment of surgical debridement of deep infection following ankle ORIF. Factors that significantly increased treatment failure included diabetes, smokers, alcohol abuse, mal-reduction of the fracture post operatively as well as hardware removal from an un-united fracture at time of debridement. The most commonly grown organisms included Staphylococcus Epidermidis followed by Staphylococcus Aureus.
 

Conclusion: Smokers and patients with mal-reduction of fracture postoperatively had higher likelihood of treatment failure after surgical debridement. Furthermore, hardware removal prior to fracture union was also associated with poor clinical outcome and treatment failure. Based on these results, the authors recommend to postpone hardware removal until fracture union is present.