Impact of surgical procedures on soft tissue microcirculation in calcaneal fractures: A prospective longitudinal cohort study

Predictors for wound healing complications and prolonged hospital stay in patients with isolated calcaneal fractures

Purpose

Surgically treated calcaneal fractures have a high risk of postoperative wound healing complications and a prolonged length of hospital stay (LOS). The aim of this study was to identify predictor variables of impaired wound healing (IWH) and LOS in surgically treated patients with isolated calcaneal fractures.

Methods

This retrospective cohort study analyzed data on patients aged 18 years or older who were admitted to a level I trauma center with isolated calcaneal fractures between 2008 and 2018. Multivariable regression models were used to identify predictor variables.

Results

In total, 89 patients (age: 45.4 years; SD: 15.1) were included. In 68 of these patients, low-profile locking plate osteosynthesis was performed, and a minimally invasive approach (MIA) (percutaneous single screws/K-wire or low-profile locking plating via a sinus tarsi approach) was applied in 21 patients. Multivariable regression analysis revealed that a higher preoperative Böhler’s angle (β = − 0.16 days/degree, 95% CI [− 0.25, − 0.08], p = 0.004) and MIA (β = − 5.04 days, 95% CI [− 8.52, − 1.56], p = 0.002) reduced the LOS. A longer time-to-surgery (β = 1.04 days/days, 95% CI [0.66, 1.42] p = 0.001) and IWH increased the LOS (β = 7.80 days, 95% CI [4.48, 11.12], p = 0.008). In a subsequent multivariable regression analysis, two variables, open fractures (OR: 14.6, 95% CI [1.19, 180.2], p = 0.030) and overweight (BMI > 24) (OR: 3.65, 95% CI [1.11, 12.00], p = 0.019), increased the risk of IWH.

Conclusion

Advanced treatment algorithms for open fractures are needed to reduce the risk of IWH.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01863-1.

Trochanteric Femur Fractures: Application of Skeletal Traction during Surgery Does Not Alter Soft-Tissue Microcirculation

Background and Objectives: Wound infections provoked by alterations in microcirculation are major complications in the treatment of trochanteric femur fractures. Surgical fracture fixation on a traction table is the gold standard for treatment, but the effect on tissue microcirculation is unknown. Microcirculation could be impaired by the pull on the soft-tissue or by a release of vasoactive factors. We hypothesized that intraoperative traction impairs soft-tissue microcirculation. Materials and Methods: In 22 patients (14 women, eight men), average age 78 years (range 36–96 ± 14), with trochanteric femur fractures, non-invasive laser-Doppler spectrophotometry was used to assess oxygen saturation, hemoglobin content, and blood flow in the skin and subcutaneous tissue before and after application of traction. Measurements were recorded in nine locations around the greater trochanter at a depth of 2, 8, and 15 mm before and after fracture reduction by traction. Results: No differences were found in any depth with traction compared to without (oxygen saturation: p = 0.751, p = 0.308, and p = 0.955, haemoglobin content: p = 0.651, p = 0.928, and p = 0.926, blood flow: p = 0.829, p = 0.866, and p = 0.411). Conclusion: In this pilot study, the application of traction does not affect skin and subcutaneous microcirculation in the surgery of proximal femur fractures.

Reduced pre-operative skin oxygen saturation predicts revision after open reduction and internal fixation in calcaneal fractures : A reduced pre-operative oxygen saturation as measured by laser-Doppler spectrophotometry in 8 mm depth is associated with revision surgery after open reduction and internal fixation of calcaneal fractures through an extended lateral approach

PURPOSE

To assess which pre-operative parameters correlate with wound revisions after an extended lateral approach to the calcaneus.

METHODS

Pre-operative laser-Doppler spectrophotometry was applied in patients undergoing open reduction and internal fixation. The number of wound revisions was recorded during pos-toperative follow-up. Spearman rho analysis was used to identify factors associated with wound revision and receiver operator characteristics curves were calculated for the identified factors.

RESULTS

Thirty-four patients (29 men, 5 women; 37 calcanei) with a mean patient age of 43 ± 14 years were analyzed. The minimal oxygen saturation value at the five measurement locations as well as the minimal value for flow correlated negatively with wound revisions (p value = 0.025 and 0.038, respectively). The area under the curve for the pre-operative minimal value of oxygen saturation was 0.841 (95%CI 0.64-1.00, p = 0.028), indicating a good accuracy as a test to predict wound revision.

CONCLUSION

A pre-operative oxygen saturation of at least 20.5% across five measurement points along the anticipated incision identified all patients not needing a wound revision (negative predictive value 100%). On the other hand, patients with at least one measurement below 20.5% were at risk for wound revision surgery (sensitivity 100%, specificity 48.5%). ClinicalTrials.gov NCT01264146.

Evaluation of the optimal cooling temperature for the face measured by the tissue perfusion during hilotherapy using laser Doppler spectrophotometry

After craniofacial trauma, symptoms like swelling and pain occur. Cooling reduces these symptoms but the optimal cooling temperature for a maximum benefit without adverse effects is unclear. 30 participants were cooled at 10 °C, 15 °C, 20 °C, 25 °C and 30 °C for 30 min. Before cooling and at 15, 30, 45 and 60 min after cooling, the skin blood flow, oxygen saturation (SO) and haemoglobin concentration (Hb) were measured by laser Doppler spectrophotometry at 2 mm and 8 mm depth. The skin temperature was measured, and the participant’s satisfaction was marked on a visual analogue scale. There were significant differences between males and females in the blood flow, SO and Hb (p < 0.0001). After cooling, the blood flow, SO and Hb was reduced. The measured values rose slightly above the initial values 60 min after cooling. Depending on the cooling temperature the decrease in blood flow, SO and Hb was significantly different. Both sexes were most comfortable with a 25 °C cooling temperature and satisfaction decreased with lower temperatures. Significant differences for the satisfaction between both sexes were measured (10 °C: p < 0.0001, 15 °C: p < 0.0001, 20 °C: p = 0.0168, 25 °C: p = 0.0293). After 60 min, the males and females exhibited mild skin hyperthermia. The optimal cooling temperatures their physiological effects and their perception for females and males were different. For females, around 20 °C is an optimal cooling temperature. For males, it is around 15–20 °C.

Long-term results of displaced intra-articular calcaneal fractures treated with minimal invasive surgery using percutaneous screw fixation

INTRODUCTION

Over the last 20 years, minimally invasive surgery using Percutaneous Screw Fixation (PSF) has been performed increasingly frequently in the treatment of Displaced Intra-Articular Calcaneal Fractures (DIACFs). The purposes of this study were to assess the long-term postoperative outcomes of mobility, foot function, stability, pain and patient satisfaction.

METHODS

All patients had DIACFs and underwent PSF between 1998 and 2006 according to the method reported by Forgon and Zadravecz. Functional outcomes, range of motion and change in footwear were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). All patients completed a general health status form (Short Form-36 [SF-36]) and visual analogue scale (VAS) for patient satisfaction. Anatomical restoration was assessed based on the pre- and postoperative radiographic images.

RESULTS

Sixty-six patients with an DIACF were observed in the period 1998-2006. Patients who had open fractures, died or were <18 years of age at trauma were excluded. A total of 46 patients were asked to complete the questionnaires, during the last quarter of 2018. Of these patients, 27 with 29 DIACFs responded (58%). Nineteen were males, and the mean age at trauma was 45 years. Seven cases were classified as Sanders type II, 14 as Sanders type III, and 8 as Sanders type IV. The mean pre- and postoperative Böhler angles were 10 ͦ and 26 ͦ, respectively. The average follow-up period was 16 years, and at the follow-up, the mean AOFAS, MFS, SF-36 and VAS scores were 76, 74, 63 and 7.7 points, respectively. In comparison to the results at 5-10 years postoperatively in a previous study, we observed a decline in the average AOFAS and MFS scores by 8 and 11 points, respectively. Patient satisfaction decreased by 0.1 points and general health by 14 points.

CONCLUSION

The long-term results of this study show relatively good functional outcomes is two-thirds of the treated patients. According to the reported scores, patients described their level of function as essentially normal. PSF should therefore be considered as a good option in patients with DIAC fractures, especially in patients with Sanders II and III fractures.

LEVEL OF EVIDENCE

Therapeutic Level III.

Patient-specific instrument-assisted minimally invasive internal fixation of calcaneal fracture for rapid and accurate execution of a preoperative plan: A retrospective study

Background

Traditional methods for minimally invasive internal fixation (MIIF) of calcaneal fractures require extensive intraoperative fluoroscopy, and fracture recovery is usually not ideal. We developed a new surgical procedure using digital surgical simulation and constructed a patient-specific instrument (PSI) for calcaneal fracture that we used during the operation. This study investigated whether PSI-assisted MIIF of calcaneal fracture enables rapid and accurate execution of the preoperative plan.

Methods

We retrospectively analyzed patients with Sanders type III or IV fresh calcaneal fractures who had undergone PSI-assisted MIIF at our hospital from January 2016 to December 2018. We analyzed perioperative data including intraoperative fluoroscopy time, concurrence of internal fixation actual usage (IFAU) with the preoperative plan, surgery time, and complications. We also compared pre- and postoperative actual measurements from X-ray radiographs and computed tomography images including Böhler, Gissane, and calcaneus valgus angles; subtalar joint width; and calcaneal volume overlap ratio with the preoperative design. All patients had been followed up and their American Orthopedic Foot and Ankle Score (AOFAS) score was available.

Results

Mean intraoperative fluoroscopy time was 3.95 ± 1.78 h; IFAU in 16 patients (16 ft) was the same as the preoperative plan; mean surgery time was 28.16 ± 10.70 min; and none of the patients developed complications. Böhler, Gissane, and calcaneus valgus angles and subtalar joint width did not differ between pre- and postoperative plans; however, the actual preoperative values of each of these parameters differed significantly from those measured postoperatively. The calcaneal volume overlap ratio with the preoperative design was 91.2% ± 2.3%. AOFAS scores increased with time, with significant differences in the score at each time point.

Conclusions

The newly developed PSI-assisted calcaneal fracture MIIF method can rapidly and accurately execute the preoperative plan.