Current Concept Review: Perioperative Soft Tissue Management for Foot and Ankle Fractures

The timing of surgery relative to soft tissue swelling, surgical skin preparation, wound closure materials and technique, drain placement, and postoperative mobilization regimen are extrinsic factors that affect wound healing and require careful consideration by the orthopaedic surgeon during the perioperative period to minimize the incidence of soft tissue complications after foot and ankle surgery. The current data in the orthopaedic literature fails to provide strong evidence to guide decision-making, due to limitations in the power, design and scope of the available studies. The concepts that appear to guide the management of the soft tissues after foot and ankle trauma include: 1. Delaying surgery in the setting of significant soft-tissue swelling is supported in the literature for high-energy injuries of the tibial plafond and calcaneus and the "wrinkle test" is a suggested practical sign to guide the timing of surgery. There is evidence to support the repair of rotational fractures of the ankle within 8 hours after injury, but there is no data to determine the efficacy of delaying surgery on the incidence of wound complications. 2. Skin preparation with an alcohol solution and bristles reduces the presence of bacteria. Although this would appear to be beneficial, there is no evidence proving that it decreases the incidence of postoperative wound infection. 3. There is insufficient evidence to support the use of a particular suture or suturing technique for wound closure. The use of tissue adhesives to close wounds over mobile regions may be disadvantageous for maintaining the closure. There is fair evidence from a single study supporting the use of a layered closure after ORIF of calcaneus fractures. 4. The placement of a closed-suction drain does not affect the incidence of wound complications after orthopaedic procedures and there is no evidence to support its routine use following foot and ankle surgery. 5. Earlier postoperative mobilization does not appear to impact the long-term outcome after ankle and tibial plafond fractures. No evidence exists to support any specific protocol for mobilization of the patient or surgical site to reduce the incidence of wound complications Copyright © 2009 by the American Orthopaedic Foot & Ankle Society.