Abstract
Background
Swelling following an ankle fracture is commonly believed to preclude surgical fixation; swelling is thought to be associated with increased wound complications. Delaying surgery until swelling subsides is thought to secure better outcomes, although no guidelines exist to direct surgeons when an appropriate time to intervention is or whether a visual inspection of the swelling is correlated to quantitative measurement. This study aimed to identify whether preoperative ankle swelling influences postoperative wound complications following ankle fracture surgery.
Methods
This prospective cohort study recruited patients undergoing operative management of closed rotational ankle fractures on a single side (unilateral injury). Individual surgeons determined the time to surgery based on their usual practice. Ankle swelling was measured on a subjective visual scale and then quantitatively using the validated figure-of-8 technique. Follow-up was standardized at 2, 6, and 12 weeks postoperatively. Between-group participant, surgical, and wound characteristics were recorded and analyzed, in addition to the agreement between qualitative and quantitative ankle-swelling measures.
Results
Eighty participants were recruited. The wound complication rate was 8.75% (n = 7), with only 1 deep infection requiring operative intervention and antibiotic therapy. Wound complication rates were not associated with quantitative ankle swelling (P = .76), visual assessment of ankle swelling (P = .65), or time to operative intervention (P = .27). Increasing age (P = .006) and female gender (P = .034) were associated with wound complications. Between-group body mass index, experience level of the operating surgeon, and tourniquet time were not statistically significant. Visual assessment of ankle swelling had a poor to moderate correlation to “figure-of-8’ ankle swelling measurements (intraclass correlation = 0.507, 95% CI = 0.325-0.653).
Conclusion
In this prospective and underpowered study, we did not find that time to surgical intervention or residual swelling at the time of surgery was associated with increased wound complications following fixation of closed unilateral malleolar ankle fractures, including those involving multiple malleoli. Although surgeon discretion was used in determining readiness for surgery, all cases had some delay, which may have influenced results. Visual assessment of swelling showed only moderate correlation with objective measurement, questioning its reliability as a surgical readiness tool.
These findings suggest that in carefully selected cases, delaying surgery beyond initial clinical readiness for reasons of residual swelling may not be necessary.
Level of Evidence:
Level II, prospective cohort study.
Introduction
Ankle fractures are common, with an incidence of 184 per 100 000 people per year, 21 representing 10% of all fractures. 25 Between 20% and 30% of these fractures are displaced bi- or trimalleolar fracture patterns requiring operative intervention.5,21 Surgical fixation of unstable ankle fractures has been associated with good clinical outcomes,7,11,18 but preoperative ankle swelling is a frequent feature, and surgeons often delay time to surgery for fear of wound dehiscence and associated complications. 22 This practice is particularly common for high-energy fractures, such as pilon and tibial plateau fractures. However, there are fewer standardized guidelines for ankle fractures.
Complication rates in malleolar ankle fractures have been reported at levels up to 40% in specific populations.13,16 Reported wound complication rates vary widely in the existing literature, from 1.4 % to 18.8%.10,14,16 The literature reports swelling, elderly patient age, gender, high body mass index (BMI), smoking, diabetes mellitus, and peripheral vascular disease as factors associated with wound complications.6,7,16,17,26 Surgical site infections are a recognized wound complication of ankle fracture surgical fixation. In severe cases, devastating sequelae such as sepsis, amputation, and death can result. 26 Unsurprisingly, surgeons seek to avoid wound complications, and if preoperative swelling is a risk factor, it should be mitigated. The delay to surgery, although well-reasoned, is not based on sound empirical data.
Traditional orthopaedic thinking has been that swelling following ankle fracture precludes surgical fixation. Therefore, operative treatment is commonly delayed, allowing swelling to subside in an attempt to avoid excessive wound tension and subsequent breakdown. This is most commonly assessed by evaluating for the presence of skin wrinkling on pinching the skin at the proposed incision site, although this approach has not been scientifically validated. 19 However, the delay in operating is not without incident. Delaying operative treatment can lead to several unwanted outcomes, including increased costs to the health care system and increased patient length of stay in hospital.1,19 Delay in treatment also importantly delays the patient’s recovery and rehabilitation from their injury. Furthermore, prolonged immobilization may lead to muscle atrophy, joint stiffness, and increased risk of deep vein thrombosis. 10
It is not well documented nor researched precisely how much swelling would or should preclude surgery, the time required to diminish such swelling to an acceptable level prior to an operation, or the effect residual minor subluxation has on ongoing soft tissue concerns. Surgeons commonly assess ankle swelling visually to determine suitability to proceed with surgical fixation. Objective measures, such as volume displacement or direct measurements of the ankle, are only commonly encountered in the research setting. To the authors’ knowledge, visual assessment of ankle swelling has not been validated to correlate with any objective measure of ankle swelling.
The primary aim of this study was to determine whether time to surgery or ankle swelling affects wound complications in closed malleolar ankle fractures. The secondary aim was to assess whether visual assessment of ankle swelling correlates with objective swelling measurements. The hypothesis was that operative intervention at any time, irrespective of swelling, would not be associated with increased rates of wound complications.
Methods
A nonconsecutive cohort of patients presenting to a level 1 trauma center with closed malleolar ankle fractures was prospectively enrolled in this study after obtaining institutional ethics board approval. Data were collected from November 18, 2016, to October 8, 2018.
Eligibility Criteria
Patients were included if they were skeletally mature and had a closed, ankle fracture (unimalleolar, bimalleolar, or trimalleolar) on a single side (right or left) requiring surgical management. Exclusion criteria included skeletal immaturity, patients with bilateral or concomitant ipsilateral lower limb injuries, open injuries, skin blistering overlying the operative site, or preexisting unilateral limb edema.
Participant Data
Demographic information was collected, including patient age, gender, BMI, smoking status, diabetic status, and preexisting peripheral vascular disease. Fracture characteristics were also recorded at the time of patient enrollment, including the Weber classification, number of malleoli involved, and the laterality.
Timing of Operation
A pragmatic approach was undertaken for this study, where the decision on time to surgery was determined by the treating orthopaedic surgeon based on his or her clinical judgment. Because of widely varying preferences at this institution, the study design allowed for a range of swelling levels and time to surgery, representing the current practice at a level 1 trauma center in Australia. The decision was made prior to enrolment.
Ankle Swelling Assessment
Swelling was assessed at the time of surgery, following anaesthesia provision. First, a qualitative visual assessment was performed by the primary surgeon, and a numerical score was assigned on a scale of 0 (no swelling) to 10 (severe swelling). The primary surgeon used the contralateral limb as the control to make the determination of swelling. Swelling was quantitatively assessed quantitatively using the “Figure-of-8” tape measure technique, which has been validated to be equivalent to volume displacement measurement, the gold standard in assessing lower limb edema.8,9,15,20 This measurement technique has been reported to have a high intrarater reliability with an intraclass correlation coefficient (ICC) of 0.99 (P < .001). 9 To mitigate between-participant differences due to varying ankle sizes, both the injured and noninjured ankles were measured, and a ratio of the 2 ankles was calculated.
Surgical-Related Variables
Time to surgery from injury, experience level of the operating surgeon, and tourniquet time were recorded. Surgical technique, time to surgery, and wound closure technique and material were based on the consultant surgeons’ usual practice.
Participant Follow-up
Follow-up occurred at 2, 6, and 12 weeks postoperatively. Suture removal, when required, occurred at 2 weeks. All patients were evaluated at each time point with a comprehensive wound assessment. A clinical review of patients was performed by an investigator who was not the operating surgeon to minimize potential bias.
Wound Classification Criteria
Wound complications were recorded and classified as superficial or deep using criteria standardized in the literature.12,23,27 Superficial complications were defined as those requiring additional wound care and/or oral antibiotic therapy. Deep wound complications were defined as those requiring surgical debridement and/or intravenous (IV) antibiotic therapy. Review of all postoperative clinic notes was performed to ensure accurate identification of all wound complications.
Data Analysis
Data analysis was performed using SPSS version 25 (IBM SPSS Statistics, Armonk, NY, USA). Missing data were handled via pairwise deletion, and no sensitivity analyses were performed. Continuous data were analyzed with independent samples t test or Mann-Whitney U test, as reported, whereas categorical data were analyzed with the χ2 test unless otherwise indicated. To analyze the agreement between the quantitative and qualitative assessment of ankle swelling, ICC estimates and their 95% CIs were calculated based on a mean rating (κ = 2), consistency agreement, 2-way mixed effects model. A post hoc power analysis was performed to determine the statistical power achieved with the sample size of 80 participants, given an alpha level of .05 and the observed effect size for ankle swelling differences between groups. Statistical significance was set at a P value of less than .05.
Results
Eighty participants were prospectively recruited for this study. Participant demographics and fracture characteristics are reported in Table 1. Seven (8.75%) wound complications were recorded from 0 to 12 weeks. Of those, 6 were superficial wound complications and 1 was classified as a deep infection requiring both IV antibiotic therapy and surgical debridement with removal of implants at 8 weeks postoperatively. Postoperative wound complications were found at week 2 (four), week 6 (2), and week 12 (one). Superficial wound complications occurred on patients operated on postinjury day 1 (1), day 8 (2), day 11 (1), day 14 (1), and day 20 (1). The patient with the deep wound complication was operated on day 2 postinjury.
Participant Characteristics. a
Abbreviation: IQ, interquartile range.
Continuous data are presented as mean (SD) and analyzed with independent samples t test; categorical data are presented as n and analyzed with χ2 test, unless otherwise indicated. The no wound complication group had missing data for height (6), weight (1), and body mass index (7).
Analyzed with the Mann-Whitney U test.
Ankle swelling, quantitatively measured by the figure-of-8 technique, was not associated with wound complications (P = .76). Visual assessment of swelling (P = .65) and time to surgery (P = .270) were also not associated with wound complications. Other surgical factors, including the experience level of the surgeon (P = .73), tourniquet time (P = .66), and postoperative inpatient stay duration (P = .11), were also not associated with wound complications (Table 2).
Surgical Characteristics. a
Continuous data are presented as median (interquartile range) and analyzed with Mann-Whitney U test; categorical data are presented as n and analyzed with χ2 test, unless otherwise indicated.
Analyzed with independent samples t test.
Increased patient age and female gender were significantly associated with wound complications (P = .006) and (P = .034), respectively. BMI (P = .55; max = 40, min = 18), fracture laterality (P = .33), Weber classification (P = .11), and number of malleoli fractured (P = .16) were not significantly associated with wound complications (Table 1). Smoking status, diabetes, and preexisting peripheral vascular disease were all low in this cohort and not significantly associated with wound complications.
The ICC for reliability of visual assessment with the figure-of-8 measurement was 0.507 (95% CI = 0.325-0.653). This ICC indicates only a poor-to-moderate correlation between qualitative visual assessment of swelling and a true quantitative swelling measurement.
Discussion
Conventional teaching holds that significant swelling about the ankle should delay surgery to prevent wound complications. However, this belief has limited empirical support. In this prospective relatively small cohort study, we found no association between quantitatively or visually assessed preoperative swelling and postoperative wound complications. Similarly, time to surgery was not predictive of wound complications. These findings challenge current assumptions and suggest that surgeon judgment based on overall clinical readiness may suffice in guiding surgical timing.
Prior studies, in an attempt to associate ankle swelling with wound complication, have used indirect surrogates for ankle swelling, including time to surgery. Riedel et al 19 used an ultrasonographic assessment of plantar heel-pad edema as their measure of ankle swelling. In a subgroup analysis of lower-limb fractures, the authors concluded that an increased heel-pad edema index was associated with an increased wound complication rate. 19 Although ultrasonography has been validated for edema measurement in general, plantar heel-pad edema measured using ultrasonography has not been proven or validated as a surrogate measure of ankle swelling. It is not a common technique used by orthopaedic surgeons.
Orthopaedic surgeons will typically determine the timing of surgery using a visual assessment of swelling, a technique that may have questionable repeatability and limited validity. To our knowledge, visual swelling assessment has not been previously compared to validated quantitative ankle swelling measurement techniques reported in the literature. In addition, the reported finding that residual swelling at time of surgery was not associated with increased wound complication rates demonstrates only a poor to moderate correlation between visual swelling assessment and quantitative swelling measurement taken in the same encounter. This study suggests that the traditional assessment of ankle swelling has questionable concurrent validity, but more importantly, preoperative ankle swelling is unlikely to impact wound complications once the surgical team has determined that swelling has subsided sufficiently for surgery.
Although the figure-of-8 measurement technique objectively quantifies total ankle volume changes, it is important to recognize that visual assessment and volumetric measurements may be evaluating different aspects of swelling that impact surgical risk. 9 Volumetric measurements capture the total increase in ankle size, but do not distinguish between different types of fluid collections, such as subcutaneous edema or hematoma, or assess the compliance and tension of overlying skin. 22 As Riedel et al 19 noted in a study of lower extremity fractures, the distribution of swelling may be more important than total volume, with certain anatomical areas potentially indicating higher surgical risk. This suggests that visual assessment, although subjective, may incorporate factors such as skin compliance and local tension that volumetric measurements may not capture. The poor to moderate correlation between visual and quantitative assessments reported in this study (ICC = 0.507) might reflect the different but complementary aspects of swelling evaluation rather than simply indicating the inadequacy of visual assessment.
Additionally, time to surgery was not associated with wound complications in this study. Although there is variation in the literature on recommendations for early vs delayed surgical intervention,3,4,22 the reported results are consistent with several recent studies that have concluded that timing to surgery is not associated with wound complication.16,19 However, it is important to note that in the reported results, all patients had some delay to surgery (range: 1-20 days). The median time to surgery was 6 days in patients without complications and 8 days in those with complications, suggesting that surgeons were already exercising clinical judgment in delaying surgery for some period in all cases.
Nonmodifiable risk factors such as increasing age have been shown to be risk factors for wound complications following lower limb fracture surgery.18,26 The results of this study support this conclusion, demonstrating a significantly higher wound complication rate with increasing age. This may be due to age-related changes in skin quality, decreased vascular supply, and impaired healing mechanisms. 11 The association between gender and wound complications is unclear. Previous studies have found discordance, with both male and female gender being found to have increased rates of wound complication.2,11,16,24,26 This study had a nearly even distribution of males and females, and the association of female gender with wound complication only marginally reached statistical significance. The clinical significance of this is unclear and needs to be further investigated.
Interestingly, 5 of 7 wound complications occurred in trimalleolar fractures (71%), despite this fracture pattern representing 35% of the overall cohort. Although this association did not reach statistical significance (P = .16), it suggests that fracture complexity may contribute to wound complications. 26 Trimalleolar fractures typically involve greater traumatic force, more soft tissue disruption, and potentially longer surgical time, which may influence wound healing. Future studies with larger cohorts may further elucidate this relationship.
Modifiable risk factors such as BMI have been associated with increased rates of wound complications in ankle fracture surgery and other surgeries.16,17,19,24 However, our study did not demonstrate an association between BMI and wound complications. The direct relationship between BMI and wound complication is confounded by the association of high BMI with other comorbidities such as diabetes mellitus and nutritional deficits, which have been shown to be independent risk factors for wound complication.16,17,19,24 Despite a wide range of BMIs (18-40), our population only encompassed 2 people with diagnosed diabetes, which may account for this result.
A strength of this study is its pragmatic design. By allowing operating surgeons to decide on surgical timing per their usual practice, and operate per their usual technique, it eliminates error from unfamiliar practices and techniques. It also accurately represents actual contemporary practice in a tertiary referral and trauma center. Although the visual assessment score used in this study is not validated, the validated quantitative figure-of-8 technique to assess ankle swelling provides a direct comparison between subjective clinical assessment and objective measurement.
There are several limitations to consider. First, the participants were nonconsecutive and not randomized to treatment arms, as this study was designed as an observational cohort study to reflect practice rather than a randomized control trial. Because of the wide variety of practice, variables including surgical technique, closure type, and suture material were not controlled for. These are potential confounding factors, although no association was found in a secondary analysis of the data. Second, the 12-week follow-up period may have missed later presentations of infection. Third, although this study did not find a relationship between residual swelling or time to surgery and wound complications, no surgeon operated immediately after a fracture on severely swollen ankles, and there was a range of time between injury and surgery. Therefore, results should be interpreted with this knowledge, and a future randomized clinical trial could quantify the balance of swelling and timing for surgical intervention. Fourth, surgeon experience levels were unevenly distributed, which may limit the generalizability of findings related to surgeon experience and wound complications. Moreover, the relatively small sample size may limit the ability to detect associations between wound complications and certain variables. A post hoc power analysis revealed that with the observed effect size (Cohen d = 0.13), for the difference in ankle swelling between groups with and without wound complications, this study was underpowered to detect differences and no significant difference could be detected. To achieve adequate power, approximately 750 participants would be required. There was inadequate data to report the total number of patients screened for eligibility and the number of patients excluded for various reasons. Finally, there is heterogeneity of ankle fracture patterns included (unimalleolar, bimalleolar, and trimalleolar fractures). This introduces potential confounding factors, as patients may have multiple incisions and soft tissue disruption that may influence wound healing independent of swelling or timing to surgery. Further studies may consider stratifying analysis by fracture pattern or controlling for the number of incisions to better isolate the effects of swelling on wound complications.
In conclusion, this prospective observational study did not demonstrate a significant relationship between preoperative ankle swelling or surgical timing and the risk of wound complications following surgical treatment of closed malleolar ankle fractures.
Given the small sample size and heterogeneity in fracture patterns and surgical technique, these results should be interpreted cautiously. However, they support the view that delaying surgery solely based on residual swelling, once the treating surgeon deems the soft tissues acceptable, may not be necessary for closed rotational ankle fractures.
Supplemental Material
sj-pdf-1-fao-10.1177_24730114251342252 – Supplemental material for Preoperative Ankle Swelling and the Effect On Postoperative Wound Complications Following Ankle Fracture Surgery
Supplemental material, sj-pdf-1-fao-10.1177_24730114251342252 for Preoperative Ankle Swelling and the Effect On Postoperative Wound Complications Following Ankle Fracture Surgery by Anthony M. Silva, Helena Franco, Tom P. Walsh, Albert Hohuynh and Simon Platt in Foot & Ankle Orthopaedics
Footnotes
Ethical Approval
Ethical approval for this study was obtained from the Gold Coast Hospital and Health Service Human Research and Ethics Committee (HREC Reference: HREC/18/QGC/96; Project ID: 40102).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Data Availability Statement
The data in this study can be found on scanned electronic records accessed through the Integrated Electronic Medical Record (ieMR), a Queensland Health–developed electronic medical record system.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
