Correlation of Soft Tissue Swelling and Timing to Surgery With Acute Wound Complications for Operatively Treated Ankle and Other Lower Extremity Fractures

Background: 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. Methods: 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. Results: 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. Conclusions: 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 of Evidence: Level II, prognostic, prospective cohort study.

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What is Too Swollen? Correlation of Soft Tissue Swelling and Timing to Surgery with Acute Wound Complications for Operatively-Treated Lower Extremity Fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00361 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0036

Author(s):

Matthew D. Riedel ◽

Amber Parker ◽

Mingxin Zheng ◽

Jorge Briceno ◽

Steven J. Staffa ◽

...

Keyword(s):

Risk Factors ◽

Soft Tissue ◽

Lower Extremity ◽

Tobacco Use ◽

Wound Complication ◽

Timing Of Surgery ◽

Ankle Fractures ◽

Patient Specific ◽

Wound Complications ◽

Heel Pad

Category: Trauma, Soft Tissue Introduction/Purpose: Considerable debate exists regarding how soft-tissue edema should influence timing of surgery for lower extremity fractures. Assessment of swelling is subjective and timing varies amongst 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 are: 1) determine whether objective measures of swelling, timing to surgery, and patient-specific risk factors correlate with wound complications and; 2) create a prediction model for post-operative wound complications based on identified modifiable and non-modifiable risk factors. Methods: Patients with closed 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. Results: 93 subjects completed the study with 71/93 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 3.4x increase in wound complications with a heel- pad edema index >1.4. Tobacco history and BMI >25 kg/m2 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. Conclusion: Timing to surgery had no correlation with wound complications. Heel-pad edema index >1.4, BMI >25, and tobacco- use correlated with wound complications. 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.

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An analysis of limb-threatening lower extremity wound complications after 1090 consecutive coronary artery bypass procedures

Vascular Medicine ◽

10.1177/1358836x9900400205 ◽

1999 ◽

Vol 4 (2) ◽

pp. 83-88 ◽

Cited By ~ 14

Author(s):

Terisa A Thomas ◽

Spence M Taylor ◽

Martin M Crane ◽

Wendy R Cornett ◽

Eugene M Langan ◽

...

Keyword(s):

Risk Factors ◽

Coronary Artery ◽

Soft Tissue ◽

Lower Extremity ◽

Coronary Artery Bypass ◽

Artery Bypass ◽

Significant Risk ◽

Wound Complications ◽

Additional Surgery ◽

Lower Extremity Wound

The objective of this study was to examine and characterize limb-threatening lower extremity wound or soft tissue complications after coronary artery bypass (CABG) and determine risk factors for their cause. While minor wound problems of the leg after CABG are not uncommon, serious limb-threatening complications, though less frequent, do occur and are often de-emphasized in the surgical literature. A review of 1090 consecutive CABG procedures performed from January 1, 1995 through December 31, 1995 was instituted, which screened for limb-threatening lower extremity wound or soft tissue complications defined as wounds that: required additional surgery for treatment; prolonged the length of stay; or which required lengthy home health nursing for treatment. Minor lymph leaks, leg swelling, infections or wound problems treated as an outpatient were excluded. Of 1090 patients, 54 (5.0%) experienced a limb-threatening lower extremity complication. Complications were categorized as vein harvest incision non-healing (n = 36, 66.7%), decubitus ulceration (n = 11, 20.4%), forefoot ischemia/embolization (n = 10, 18.5%), groin hematoma/abscess (n = 6, 11.1%), severe cellulitis (n = 3, 5.6%), or a combination (n = 12, 22.2%). Statistically significant risk factors by univariate and bivariate analysis for a complication included older age (68 years vs 62 years, p = 0.007), female sex (57% vs 28%, p, 0.001), diabetes (57% vs 33%, p = 0.005) and longer pump time (129 min vs 114 min, p = 0.009). These complications necessitated five major lower extremity amputations and nine revascularization procedures. Chronic lower extremity ischemia from peripheral vascular disease (PVD) was a major contributing factor for the development of wounds in at least 23 (42.6%) of these patients, though suspected in only 10 (43.5%) preoperatively. A non-healing vein harvest incision below the knee of a patient retrospectively found to have inadequate distal circulation for healing occurred in 17 (31.5%) of the total 54 cases. It was concluded that non-healing vein incisions, decubitus ulcers and forefoot ischemic lesions frequently occurring in older diabetic females with undetected pre-existing PVD, comprise the majority of limb-threatening leg complications after CABG. Nearly one-third of the complications may have been avoided had the vein harvest incision not been made at the ankle of a patient with unappreciated PVD.

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ARST1321: Pazopanib neoadjuvant trial in non-rhabdomysarcoma soft tissue sarcomas: A report of major wound complications.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.11059 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. 11059-11059

Author(s):

Thomas Scharschmidt ◽

Yen-Lin Chen ◽

Dian Wang ◽

Yueh-Yun Chi ◽

Mark Kayton ◽

...

Keyword(s):

Soft Tissue ◽

Lower Extremity ◽

Tyrosine Kinase ◽

Tyrosine Kinase Inhibitor ◽

Kinase Inhibitor ◽

Soft Tissue Sarcomas ◽

Wound Complication ◽

Wound Complications ◽

High Grade ◽

Grade Iii

11059 Background: The care of soft tissue sarcomas is complex and multidisciplinary in nature. Even without radiation or chemotherapy wound complications are common after surgical resection with a reported incidence of 6-42%. Wound complication rates with the use of neoadjuvant chemoradiation for high-grade soft tissue sarcomas has been reported and supported in the literature to be approximately 30%. Relevant to this study, a trial evaluating the use of a VEGF receptor inhibitor (bevacizumab) in combination with radiation pre-operatively in soft tissue sarcomas reported a wound complication rate of 25%. ARST 1321 is a phase II/III study evaluating the tyrosine kinase inhibitor Pazopanib +/- chemotherapy and radiation in select high-grade soft tissue sarcomas. The dose-finding phase has been completed and the objective of this report is to detail the major wound complications observed with this protocol. Methods: Patient enrolled on all arms of the study (Pre-operative radiation, +/- pazopanib, +/- doxorubicin and ifosphamide) were evaluated for wound complications (Grade I/II and Grade III). Patient demographics, tumor characteristics, and complication details were compiled and analyzed. Results: There were a total of 130 evaluable patients (100 patients on chemotherapy arm, 30 on non-chemotherapy arm). There were 38 overall wound complications reported (38/130, 29%). 23/38 (60%) occurred on the chemotherapy arm; therefore that cohort had 23/100 (23%) wound complication rate, while the non-chemotherapy cohort had an overall rate of 50% (15/30). Grade III wound complications represented 23/38 (66%) of all the complications. 30/38 (79%) of the complications were in the lower extremity. 23/38 (60%) patients were aged > 18 years. Conclusions: The overall rate of wound complications observed was 29% (38/130) which remains within the accepted historical rate based upon literature review without the use of a tyrosine kinase inhibitor. The overall major wound complication (grade III) rate was 19% (25/130). Also consistent with the literature is the finding that a majority of the complications occurred in the lower extremity. In conclusion, the addition of a tyrosine kinase inhibitor (pazopanib) has a wound complication toxicity profile comparable to current and historical literature. Clinical trial information: NCT02180867.

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The influence of timing of surgery on soft tissue complications in closed ankle fractures

European Journal of Orthopaedic Surgery & Traumatology ◽

10.1007/s00590-009-0455-5 ◽

2009 ◽

Vol 19 (7) ◽

pp. 481-484 ◽

Cited By ~ 6

Author(s):

Adnan Saithna ◽

W. Moody ◽

E. Jenkinson ◽

B. Almazedi ◽

I. Sargeant

Keyword(s):

Soft Tissue ◽

Timing Of Surgery ◽

Ankle Fractures

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Perineal reconstruction using an inferior gluteal artery perforator flap after abdominoperineal resection

BMJ Case Reports ◽

10.1136/bcr-2018-228613 ◽

2019 ◽

Vol 12 (9) ◽

pp. e228613

Author(s):

Miguel Nico Albano ◽

João Mendes Louro ◽

Iris Brito ◽

Sara Ramos

Keyword(s):

Risk Factors ◽

Abdominoperineal Resection ◽

Perforator Flap ◽

Perineal Wound ◽

Wound Complication ◽

Perineal Hernia ◽

Wound Complications ◽

Neoadjuvant Radiotherapy ◽

Radiographic Findings ◽

Persistent Perineal Sinus

The abdominoperineal resection is a surgical procedure which implies the removal of rectum, anal canal and the creation of a terminal colostomy. The most frequent complications of this type of surgery are haemorrhage, surgical wound complications, persistent perineal sinus and perineal hernia. Intraoperative haemorrhage or contamination and neoadjuvant radiotherapy are risk factors for the development of perineal complications. Perineal wound infection, with subsequent healing delay, has multifactorial aetiology and its incidence can reach up to 66% according to literature. The prevention of these complications requires adequate surgical technique to avoid or minimise the known risk factors. The treatment of a perineal wound complication depends on the clinical and radiographic findings. When there is no wound resolution in 6 months, it is considered a persistent sinus and treatment will probably require a flap. Several options of surgical treatment are available however, there are no randomised studies to determine which one is the best.

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Operative wound-related complications after cranial revascularization surgeries

Journal of Neurosurgery ◽

10.3171/2014.12.jns132602 ◽

2015 ◽

Vol 123 (5) ◽

pp. 1145-1150 ◽

Cited By ~ 21

Author(s):

Keisuke Takanari ◽

Yoshio Araki ◽

Sho Okamoto ◽

Hideyoshi Sato ◽

Shunjiro Yagi ◽

...

Keyword(s):

Risk Factors ◽

Logistic Regression ◽

Regression Analysis ◽

Blood Supply ◽

Operative Technique ◽

Multivariate Logistic Regression Analysis ◽

Wound Complication ◽

Wound Complications ◽

Multivariate Logistic Regression ◽

The Relationship

OBJECT Intracranial revascularization surgeries are an effective treatment for moyamoya disease and other intracranial vascular obliterative diseases. However, in some cases, wound-related complications develop after surgery. Although the incidence of wound complication is supposed to be higher than that with a usual craniotomy, this complication has rarely been the focus of studies in the literature that report the outcomes of revascularization surgeries. Here, the relationship between intracranial revascularization surgeries and their complications is statistically assessed. METHODS Between October 2004 and February 2010, 71 patients were treated using cerebral revascularization surgeries on 98 sides of the head. The relationship between wound complications and operative technique was retrospectively assessed. Multivariate logistic regression analysis was performed to identify the risk factors of wound complication, including operative technique, age, sex, diabetes mellitus (DM), hypertension, hyperlipidemia, and smoking history. RESULTS In total, there were 21 (21.4%) operative wound complications. Of these 21 complications, there were 14 (66.7%) minor complications and 7 (33.3%) major complications. No statistically significant relationship was found between wound complications and any surgical procedure. A trend toward severer complications was demonstrated for the procedures that used both STA branches (“double” procedures) in comparison with the procedures that used only 1 STA branch (“single” procedures, p = 0.016, Cochran-Armitage trend test). Multivariate logistic regression analysis also revealed that double procedures demonstrated a significantly higher incidence of wound complications than single procedures (OR 3.087, p = 0.048). DM was found to be a risk factor for wound complication (OR 9.42, p = 0.02), but age, sex, hypertension, and hyperlipidemia were not associated with the incidence of complications. Even though the blood supply to the scalp is abundant due to 5 arteriovenous systems, sometimes cutaneous necrosis develops after intracranial revascularization surgeries. The galeal blood supply is thought to be crucial for preventing wound-related complications. Special care is also thought to be required for DM patients. CONCLUSIONS Revascularization surgeries seemed to demonstrate a higher risk of wound-related complications. Double-type procedures, which use both branches of the STA, and a history of DM were found to be risk factors for wound-related complications. Attention should be paid to the design of the galeal incision and vessel harvest line. Also, special attention should be paid to patients with DM.

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Adverse Radiographic Outcomes Following Operative Treatment of Medial Malleolar Fractures

Foot & Ankle International ◽

10.1177/1071100718786502 ◽

2018 ◽

Vol 39 (11) ◽

pp. 1301-1311 ◽

Cited By ~ 4

Author(s):

Jianping Hu ◽

Chunlin Zhang ◽

Kunpeng Zhu ◽

Lei Zhang ◽

Weiping Wu ◽

...

Keyword(s):

Risk Factors ◽

Multivariate Analysis ◽

Soft Tissue ◽

Tobacco Use ◽

Fracture Union ◽

Aofas Score ◽

Malleolar Fractures ◽

Radiographic Outcomes ◽

Trimalleolar Fractures ◽

Vertical Fractures

Background: We initiated a retrospective study on ankle fractures to assess (1) the time needed for fracture union; (2) the incidence of adverse radiographic outcomes (AROs); (3) factors that might lead to AROs; and (4) whether AROs were associated with worse function and higher incidence of post-trauma osteoarthritis (PTOA). Methods: From 2007 to 2016, a total of 296 patients (169 women, 127 men; average age, 48.6 years; range, 20-84) were diagnosed with a medial malleolar fracture, whether isolated or in the setting of bi- or trimalleolar fractures, and underwent open reduction and internal fixation (ORIF) or percutaneous screw fixation (PSF). The interval to fracture union, radiographic outcomes, American Orthopaedic Foot & Ankle Society (AOFAS) score at 6 months postoperatively, and the incidence of PTOA were recorded. Risk factors were identified both in univariate and multivariate analysis. The average follow-up period was 52.0 months (range, 12-118). Results: The incidence of delayed union, nonunion, and malunion were 20.3%, 3.7%, and 4.4%, respectively. The interval to fracture union was 10.3 ± 6.4 weeks. In the multivariate analysis, the risk factors for AROs were tobacco use, vertical fractures, interposed soft tissue, and fair/poor reduction. Patients with AROs had significantly worse AOFAS score at 6 months postoperatively ( P < .001) and higher incidence of PTOA ( P < .001). Conclusion: AROs of medial malleolar fractures have an underestimated incidence rate and are associated with worse ankle function and higher incidence of PTOA. Risk factors including tobacco use, vertical fractures, interposed soft tissue, poor/fair reduction should be prudently taken into consideration when treating medial malleolar fractures. Level of Evidence: Level III, retrospective cohort study.

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Thirty-Day Outcomes after Surgery for Primary Sarcomas of the Extremities: An Analysis of the NSQIP Database

Journal of Oncology ◽

10.1155/2020/7282846 ◽

2020 ◽

Vol 2020 ◽

pp. 1-8 ◽

Cited By ~ 2

Author(s):

Kathryn E. Gallaway ◽

Junho Ahn ◽

Alexandra K. Callan

Keyword(s):

Soft Tissue ◽

Lower Extremity ◽

Soft Tissue Sarcomas ◽

Surgical Site Infections ◽

Small Sample ◽

Wound Complications ◽

Complication Rates ◽

Improvement Program ◽

Primary Bone ◽

Tract Infections

Background. Primary bone and soft tissue sarcomas are rare tumors requiring wide surgical resection and reconstruction to achieve local control. Postoperative complications can lead to delays in adjuvant therapy, potentially affecting long-term oncologic outcomes. Understanding postoperative complication risks is essential; however, past studies are limited by small sample sizes. Purpose. This study uses a large national registry to characterize the incidence of complications and mortality in the first thirty days following surgical management of primary bone and soft tissue sarcomas of the extremities. Methods. A retrospective review of patients in the National Surgical Quality Improvement Program database was performed. Cases were identified using diagnosis codes for malignant neoplasm of soft tissue or bone and procedure codes for amputation and radical resection. The cohort was subdivided by bone versus soft tissue sarcoma, upper versus lower extremity, and amputation versus limb salvage. Results. One thousand, one hundred eleven patients were identified. The most frequent complications were surgical site infections, sepsis, and venous thromboembolism. The overall incidence of complications was 14.0%. Unplanned readmission and reoperation occurred after 7.0% and 8.0% of cases, respectively. Thirty-day mortality was 0.3%, with one intraoperative death. Patient factors and complication rates varied by tumor location and surgical modality. Lower extremity cases were associated with higher rates of wound complications and infectious etiologies such as surgical site infections, urinary tract infections, and systemic sepsis. In contrast, patients undergoing amputation were more likely to experience major medical complications including acute renal failure, cardiac arrest, and myocardial infarction. Conclusion. Approximately 1 in 7 patients will experience a complication in the first thirty days following surgery for primary bone and soft tissue sarcomas of the extremities. The unique risk profiles of lower extremity and amputation cases should be considered during perioperative planning and surveillance.

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Soft-tissue defects after spinal instrumentation in 5 children: risk factors, management strategies, and outcomes

Journal of Neurosurgery Pediatrics ◽

10.3171/2014.8.peds13664 ◽

2014 ◽

Vol 14 (6) ◽

pp. 644-653 ◽

Cited By ~ 1

Author(s):

Christina Sayama ◽

Sudhakar Vadivelu ◽

Andrew Livingston ◽

Allen Ho ◽

Shayan A. Izaddoost ◽

...

Keyword(s):

Risk Factors ◽

Soft Tissue ◽

Management Strategies ◽

Spinal Instrumentation ◽

Neurological Deficits ◽

Wound Complications ◽

Soft Tissue Defects ◽

Poor Nutritional Status ◽

Tissue Flaps ◽

Tissue Defects

Object Wound-related complications following complex posterior spine procedures in children may result in the need for serial debridements and may place spinal instrumentation at risk. In this study, the authors review their experience with the management of soft-tissue defects from spinal instrumentation in 5 high-risk pediatric patients. The use of various rotational and transpositional flaps in the management of these complicated cases is discussed, as well as their outcomes. Methods The authors retrospectively reviewed the medical records of 5 patients who returned to the Neuro-Spine service at Texas Children's Hospital for erosion of spinal instrumentation through the skin between September 1, 2007, and October 31, 2012. Patient demographics and clinical and operative data were recorded. Results Risk factors such as young age (1 case), poor nutritional status (1 case), multiple previous surgeries (3 cases), severe neurological deficits (2 cases), and history of radiation therapy for malignancy (2 cases) were noted in the 5 patients. The paraspinous flap (4 cases) was the mainstay of the treatment. Follow-up ranged from 7.5 to 17.5 months (mean 11 ± 4.2 months). One of the patients required more than 1 procedure for revision of the wound. Cultures were positive in 2 of the 5 cases. Spinal instrumentation was removed in 3 of the 5 cases; however, in all 3 of the cases there was evidence of delayed instability that developed after the removal of spinal instrumentation. Conclusions The use of local tissue flaps is safe and efficacious for treatment of posterior wound complications due to spinal instrumentation in children. Removal of spinal instrumentation should be avoided due to the development of delayed instability. Highly vascularized tissue is used to speed healing, clear bacteria, and eliminate dead space, obviating the need to remove contaminated spinal instrumentation.

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