Immediate versus Delayed Surgical Intervention Following Ankle Fractures: A Retrospective Review Andrew Bernhard DPM PGY3 1 , Jorge Matuk DPM 2 1 Chief Resident, Kingwood Medical Center, Kingwood, TX 2 Residency Director, Kingwood Medical Center, Kingwood, TX BACKGROUND The most common fractures affecting the foot and ankle are ankle fractures. A 2014 epidemiology article by Shibuya et. al. identified that 56% of fractures within the podiatric scope of practice occur through the ankle. While many of these fractures will be referred to orthopedic physicians, within our institution the podiatric residents are generally the first line of treatment. Owing to a unique relationship with the emergency department, it has become standard for the residents to be the paged first for attempts at closed reduction and for surgical evaluation. Because of the nature of the timing, residents and attending physicians are often able to schedule immediate open reduction and internal fixation of these ankle fractures before significant edema presents. While immediate ORIF is often contraindicated due to severe trauma, it has been our experience that, due to the low energy involved in ankle fractures, there may anecdotally be fewer wound complications than expected with immediate surgical intervention for these fractures. Utilizing a modification of Sanders’ wrinkle test, post-traumatic edema is identified by pinching the skin over the surgical site and noting skin wrinkles. Should wrinkles be present, surgery would be performed prior to discharge from the hospital and emergency department. Those patients with edema already present were thought to benefit from traditional timing of surgery, due to increased risk of wound complications. METHODS A retrospective chart review was performed at our institution from July 2011 until July 2014 in order to identify all patients who were treated by the senior author (JAM) for ankle fractures. All fractures managed with definitive conservative treatment (n=4) were excluded from the study, as were those with under one year of follow up. No exclusion criteria regarding type of fracture, open or closed, number of malleoli involved, or comorbidities were instituted. A total of 39 consecutive ankle fractures were identified utilizing these search criteria. All ankle fractures were closed reduced in the emergency department, with 28 of those reductions being performed by the on-call podiatric resident emergently. Appropriateness of operative timing was verified utilizing the skin wrinkle test, adapted from Sanders description associated with calcaneal fractures. If skin wrinkles were noted where the operative incisions would be located, i.e. laterally for fibular fractures and medially if deltoid or medial malleolar fixation was required, surgery was performed. The patients were operated on immediately, defined as within the first 24 hours, delayed but before edema formation, from 24 to 48 hours, or traditionally after resolution of edema. All sutures were removed at two weeks post-operatively. The patients were maintained in the splint, non-weightbearing, until clinical signs of healing were noted, including absence of pain on palpation of the fracture site and lack of motion at the fracture site. Patients began weightbearing as tolerated in a CAM boot until radiographic union, where they could transition to normal shoe gear as tolerated. OBJECTIVES • To identify any problems associated with immediate open reduction and internal fixation of displaced ankle fractures • To determine the efficacy of a modified Wrinkle Test in pre-operative planning and timing of surgical intervention for these fractures • To explore any benefit of podiatric involvement in the early management of ankle fractures in the emergency department setting RESULTS Table 1: Breakdown of Surgical Techniques Number Percent Wound Dehiscence Immediate ORIF 25 64.1 1 (3%) Delayed ORIF 4 10.3 0 Traditional ORIF 10 25.6 0 Total 39 100 1 (3%) Figure 4 Figure 5 Figure 6 Figure 7 Preoperative and postoperative radiographs for patient in Figure 2 below • Of 39 ankle fractures fixed operatively, 64% were treated within one day of injury. An additional 10% were fixated prior to edema formation. • All patients who underwent open reduction and internal fixation went onto radiographic union, with no delayed unions, mal-unions, or non-unions noted, regardless of time to operative fixation. • Only one patient in the immediate fixation group (3%) had wound dehiscence, medially and laterally, with exposure of the lateral hardware noted. The wounds never developed deep infection and healed with local wound care only, requiring no further surgical intervention. No patients in the intermediate or delayed internal fixation groups developed wound healing problems. There was no significant difference noted in wound complication or infection rates between the immediate and the delayed or traditional groups (P=1.00). RADIOGRAPHS CONCLUSIONS • Performing immediate open reduction and internal fixation of rotational ankle fractures appears to be safe an effective without any increased risk of complications. • The wrinkle test, originally described by Sanders and modified here for ankle fractures by Matuk, is a reliable indicator of the soft tissue envelope in these common injuries. • With early involvement of the podiatric residency with closed reductions of ankle fractures, the majority of these injuries were able to be treated prior to formation of edema and with no significant adverse results. Figure 8 Figure 9 Figure 10 Figure 11 Preoperative and postoperative mortise and lateral views of a typical trimalleolar fracture Table 2: Patient Demographics Number Age < 50 years old 50 – 75 years old > 75 years old Avg 49.3 yrs 20 (51%) 16 (41%) 3 (8%) Sex Male Female 16 (41%) 23 (59%) Comorbid Conditions 21 (54%) Diabetes Mellitus Tobacco Use Obesity Hypothyroidism Worker’s Compensation 5 (13%) 8 (21%) 9 (23%) 2 (5%) 1 (3%) Fracture Type Lateral Malleolar Medial Malleolar Bimalleolar Equivalent Trimalleolar Equivalent 8 (21%) 1 (3%) 17 (43%) 13 (33%) DISCUSSION Timing of surgical intervention for fractures has been researched in the past, with the general consensus being to wait until after edema is managed, approximately 7-14 days after the initial trauma. Schepers et. al. showed a significant reduction of wound and infection complications when ORIF was performed as early as reasonably possible. Our research supports early to immediate surgical intervention as well. The current poster presents evidence that the wrinkle test is useful in predicting a viable soft tissue envelope. Saithna et. al. found report similar findings, going a step further to suggest that generally “delaying surgery until swelling has subsided completely is unnecessary.” Finally, Westacottet. al. showed a significant increase in hospital stay when surgical intervention was delayed longer than 24 hours. Early involvement with the podiatric residency, as demonstrated, generally allows for immediate ORIF. MODIFIED WRINKLE TEST Figure 2 Acceptable Skin Wrinkles Figure 1 Acceptable Skin Wrinkles Figure 3 Negative Wrinkle Sign with fracture blister formation References: SchepersT, De Vries MR, Van Lieshout EMM, Van der Elst M. The timing of ankle fracture surgery and the effect on infectious complications; A case series and systematic review of the literature. International Orthopaedics. 2013;37(3):489-494. Saithna A, Moody W, Jenkinson E, Almazedi B, Sargeant I. The influence of timing of surgery on soft tissue complications in closed ankle fractures. European Journal of Orthopaedic Surgery & Traumatology. 2009;19(7):481-484. Westacott DJ, Abosala AA, Kurdy NM. The Factors Associated with Prolonged Inpatient Stay after Surgical Fixation of Acute Ankle Fractures. The Journal of Foot and Ankle Surgery. 2010;49(3):259-262.