Can appropriate surgical wound management prevent surgical site infection after malleolar fracture surgery?

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Sara Sugiura, Yoto Oh, Takumi Kaku, Yusuke Amano, Toshitaka Yoshii This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4568011/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Surgical wound healing failure is the most common complication of malleolar fracture surgery, and appropriate treatment is important to prevent surgical site infection (SSI). This study aimed to determine the incidence of wound healing failure and deep surgical site infection under strict standardized surgical wound management after malleolar fracture surgery. Methods Sixty-two patients who underwent surgery for malleolar fracture (AO/OTA classification 44) were reviewed. Strict assessment and surgical intervention were performed even for trivial failure in all wound healing failure cases. The exclusion criteria were open wound, tibial diaphysis fracture, and follow-up < 6 months. Surgical wound healing failure, deep SSI, and posterior fixation status were evaluated in the 42 patients (44A, n = 5; 44B, n = 30; 44C, n = 7) finally included in the study. Patients with a 44B fracture were divided into a B1/B2 group ( n = 10) and a B3 group ( n = 20) for subgroup analysis to clarify the relationship between severity of malleolar fracture and incidence of surgical wound healing failure. Results The incidence of surgical wound healing failure was 19%, but there were no deep SSI. Two of 6 patients who underwent internal fixation for posterior malleolar fragments were complicated with wound failure. Surgical wound healing failure incidence was higher in the B3 group than in the B1/B2 group (30% vs 10%, p = 0.37). Conclusions More cases of wound healing failure and less deep SSI were detected in this study compared with previous studies. Strict standardized surgical wound management could help to avoid SSI after malleolar fracture surgery. malleolar fracture surgical site infection wound complication wound healing failure Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Surgical site infection (SSI) is one of the complications of orthopedic surgery and leads to increased costs because of prolonged hospitalization and additional surgeries [ 1 ]. Malleolar fractures are common, accounting for 168.7 fractures per 100,000 persons per year and 24.5% of all fracture surgeries [ 2 , 3 ]. Wound complications are also common after malleolar fracture surgery, and prevention of infection is important [ 4 ]. Wound healing failure describes a wound complication without infection that needs early treatment before it progresses to deep infection [ 4 , 5 ]. Patient factors, such as an uncontrolled blood glucose level and surgical invasion of soft tissues, may increase the risk of wound healing failure [ 6 , 7 ], and its diagnosis and treatment relies on subjective evaluation. The purpose of this study was to develop a standardized protocol for surgical wound management after malleolar fracture surgery for use at the authors’ facility and to determine its effects on the incidence of surgical wound healing failure and SSI. 2. Materials and methods 2.1. Ethical considerations This study was approved by the institutional review board of our institution. All procedures involving human participants were performed in accordance with the ethical standards of the relevant institutional and/or national research committees and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was secured via the opt-out route, whereby the purpose of the study was explained in a poster displayed in our orthopedics department and patients were given the opportunity not to have their data included. The study data were fully anonymized, thereby protecting the patients’ privacy and dignity. 2.2. Study design and patients The study had a retrospective single-center design and was performed at a university hospital. Clinical data were evaluated for 62 patients who underwent malleolar fracture surgery under the supervision of the same orthopedic trauma surgeon (blinded for review) between April 2014 and December 2022. For the purposes of this study, malleolar fracture was defined as AO Foundation/Orthopedic Trauma Association (AO/OTA) classification 44. Patients with an open wound (n = 9), those with tibial diaphysis fracture (n = 4), and those in whom late SSI could not be evaluated because of follow-up < 6 months (n = 7) were excluded, leaving 42 patients (26 male, 14 female) for inclusion in the study. The mean age was 52.0 ± 19.2 years and the mean follow-up duration was 21 ± 19.2 months. The AO/OTA classification was 44A in 5 patients, 44B in 30, and 44C in 7. The primary outcome was the incidence of wound healing failure and that of deep SSI under strict standardized wound management conditions after malleolar fracture surgery. As in a previous report [ 4 ], wound healing failure included wound edge necrosis and wound dehiscence. Our diagnostic criteria for surgical wound healing failure and the wound management protocol for surgical intervention are as follows. After removal of the sutures, the scab or skin crust is removed and the wound edge is evaluated (Fig. 1 ). Debridement is performed even for trivial failure (Fig. 2 ). Wound re-closure is performed for minor failure, and negative pressure wound therapy or split-thickness skin grafting is performed for ulceration. Deep SSI is defined according to the Centers for Disease Control and Prevention guidelines and protocols [ 8 ]. The patients were divided into two groups according to surgical wound healing status and compared to determine the risk factors for wound healing failure after malleolar fracture surgery. Given that the risk of soft tissue disruption is known to be higher with advanced/severe malleolar fractures, especially those involving the posterior malleolus [ 9 ], the following analyses were performed. 2.3. Patient demographics and clinical characteristics Information was collected on patient demographics and clinical characteristics, including body mass index, American Society of Anesthesiologists physical status, smoking status, diabetes status, use of any glucocorticoid or immunosuppressive agent, and hemodialysis. Details were reviewed regarding the surgical intervention for malleolar fracture (i.e., preoperative waiting period, surgical approach, implant, presence of posterior malleolus fracture, and posterior fixation status). In addition, the patients were divided into two subgroups according to whether or not they underwent internal fixation for posterior malleolus fragments via a posterior approach, and the incidence of surgical wound healing failure was compared. To clarify the relationship between the advancement/severity of malleolar fracture and the incidence of surgical wound healing failure, the patients with 44B fractures were divided into a B1/B2 group ( n = 10) and B3 group ( n = 20) and compared. 2.4. Statistical analysis The wound healing failure rate was compared between the study groups using Fisher’s exact test. Continuous variables are summarized as the mean ± standard deviation and categorical variables as the number (percentage). Continuous variables were compared between groups using the Mann–Whitney U test and categorical variables using Fisher’s exact test. All statistical analyses were performed using EZR 9 (Saitama Medical Center, Jichi Medical University, Saitama, Japan) [ 10 ]. Differences with a P -value of < 0.05 were considered statistically significant. 3. Results Surgical wound healing failure was detected in 8 (19%) of the 42 patients (44A, n = 1; 44B, n = 7). There were no statistically significant differences in patient characteristics according to wound healing status (Table 1 ). Table 2 shows the characteristics and clinical course for the 8 patients with surgical wound healing failure, all of whom underwent debridement and surgical intervention (primary wound closure, n = 5; negative pressure wound therapy, n = 2; and split-thickness skin grafting, n = 1). Wound healing was achieved in all 8 patients, with no cases of deep SSI. Table 1 Patient demographics according to surgical wound healing status following surgery for malleolar fracture (N = 42) Surgical wound healing failure (+) n = 8 Surgical wound healing failure (-) n = 34 p –value Age, years 57.0 ± 21.0 50.8 ± 18.8 0.41 Male, n (%) 5 (62.5) 21 (61.7) 1.0 BMI, kg/m 2 23.4 ± 4.12 24.4 ± 3.74 0.67 ASA-PS > 1, n (%) 5 (62.5) 24 (70.5) 0.69 Waiting period for ORIF, days 10.1 ± 4.12 7.71 ± 3.67 0.19 Smoking, n (%) 1 (12.5) 5 (14.7) 1.0 Diabetes, n (%) 1 (12.5) 3 (8.82) 1.0 Steroid use, n (%) 1 (12.5) 2 (5.88) 0.48 Hemodialysis, n (%) 0 (0) 0 (0) - AO/OTA classification 44A, n = 1; 44B, n = 7 44A, n = 4; 44B, n = 23; 44C, n = 7 - Data are shown as the mean ± standard deviation, number (percentage), or number. AO/OTA, AO Foundation/Orthopedic Trauma Association; ASA-PS, American Society of Anesthesiologists physical status classification; BMI, body mass index; ORIF, open reduction and internal fixation. Table 2 Clinical characteristics of patients with surgical wound healing failure after malleolar fracture surgery Age, years Sex BMI ASA-PS Smoking Diabetes Glucocorticoid use AO/OTA classification (44) Waiting period for ORIF (days) ORIF incision Surgical interventions for wound healing failure Lateral PL Medial 1 20 M 18.9 1 - - - B2 7 + - + Primary wound closure 2 55 M 26.1 2 - - - B3 10 + - + Primary wound closure 3 35 M 26.5 1 - - - A2 19 - - + Primary wound closure 4 71 F 19.6 2 - + - B3 10 + - - Primary wound closure 5 86 M 23.4 2 - - - B3 10 + - + Negative pressure wound therapy 6 64 F 20.8 1 - - - B3 7 + - + Primary wound closure 7 69 F 23.0 3 - - + B3 12 - + + Split-thickness skin grafting 8 56 M 29.0 2 - - - B3 6 - + + Negative pressure wound therapy AO/OTA, AO Foundation/Orthopedic Trauma Association; ASA-PS, American Society of Anesthesiologists physical status classification; BMI, body mass index; ORIF, open reduction and internal fixation; PL, posterolateral Out of 6 patients who underwent posterior fixation via a posterior surgical approach (44B3, n = 5; 44C3, n = 1), 2 with 44B3 were found to have surgical wound healing failure (33%; Fig. 3 ). In contrast, surgical wound healing failure occurred in 6 of 36 patients (17%) in whom a posterior surgical approach was not used. There was no significant difference between these two subgroups ( p = 0.32). In another subgroup analysis, the incidence of surgical wound healing failure was higher in the B3 group (6/20, 30%) than in the B1/B2 group (1/10, 10%; p = 0.37; Fig. 4 ). 4. Discussion In this study, the incidence of surgical wound healing failure after malleolar fracture surgery was 19%, which is higher than the range of 3.3–6.8% previously reported. However, there were no cases of deep SSI, which have been reported to occur in 1.44–16% of cases in past studies [ 11 – 14 ]. Strict standardized assessment of the surgical wound and use of the postoperative interventions described in this report may have avoided deep SSI. While numerous studies have retrospectively investigated patient factors associated with wound infection after malleolar fracture surgery [ 6 , 7 , 9 , 13 ], this study may be the first to have examined the iatrogenic effects of interventions by surgeons. This study also identified advancement/severity of malleolar fracture to be a risk factor for disruption of soft tissue including surgical wound healing failure. It is generally known that the AO/OTA classification is useful for indicating severity and intractability; indeed, the incidence of surgical wound healing failure was higher in our 44B3 group than in our 44B1/B2 group (30% vs 10%). As expected, this study also found that an additional posterior approach for posterior malleolus fixation may increase the risk of soft tissue failure. This finding is in line with past reports [ 9 ], and orthopedic surgeons should be aware of these types of fractures and potential deterioration of soft tissues as a consequence of additional surgical invasion. This study has several limitations. First, it was performed at a single center and included a small sample size. Our emergency medical care center tends to treat high-energy fractures associated with serious trauma and to refer patients with minor or moderate fractures to a city hospital after initial treatment. Second, because of the lack of standardization of the diagnosis of surgical wound healing failure in the past, it was not possible to include a historical control group. Third, the study included some high-risk patients (e.g., the elderly, smokers, and those with diabetes). Further research in a larger number of patients with inclusion of a control group is needed to confirm our findings. 5. Conclusions Although the incidence of surgical wound healing failure in this study was higher than in previous reports, there were no cases of deep SSI. A posterior surgical approach for internal fixation of a posterior malleolus fracture was considered to be a potential risk factor for wound healing failure. Strict standardized assessment of the surgical wound and appropriate surgical intervention after malleolar fracture surgery could avoid deep SSI. Declarations Acknowledgments The authors did not receive any grants or funds for this study. Ethics This study was approved by the Tokyo Medical and Dental University Faculty of Medicine IRB (approval no. M2023-204). All procedures involving human participants were performed in accordance with the ethical standards of the relevant institutional and/or national research committees and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All eligible patients were registered via the opt-out route, whereby the purpose of the study was explained in a poster displayed in the orthopedics department of the participating university hospital. The data were fully anonymized, thereby protecting the patients’ privacy and dignity. Conflicts of interest The department to which the corresponding author (Y.O.) belongs received funding for operating costs from Saku Central Hospital of the Nagano Prefectural Federation of Agricultural Cooperatives for Health and Welfare, Suwa Central Hospital, Doujin Hospital, Nerima General Hospital, Medtronic Sofamor Danek Co., Ltd., Stryker Japan K.K., HOYA Technosurgical Co., Ltd., and Magic Shields, Inc. The other authors declare that they have no conflicts of interest. References Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol. 2002 Apr;23(4):183-9. PubMed PMID: 12002232. Beerekamp MSH, de Muinck Keizer RJO, Schep NWL, Ubbink DT, Panneman MJM, Goslings JC. Epidemiology of extremity fractures in the Netherlands. Injury. 2017 Jul;48(7):1355-62. PubMed PMID: 28487101. Elsoe R, Ostgaard SE, Larsen P. Population-based epidemiology of 9767 ankle fractures. Foot Ankle Surg. 2018 Feb;24(1):34-9. PubMed PMID: 29413771. Ovaska M. Complications in ankle fracture surgery. Acta Orthop Suppl. 2015 Feb;86(358):1-32. PubMed PMID: 25586467. Depypere M, Morgenstern M, Kuehl R, Senneville E, Moriarty TF, Obremskey WT, et al. Pathogenesis and management of fracture-related infection. Clin Microbiol Infect. 2020 May;26(5):572-8. PubMed PMID: 31446152. Kodner C, Anderson L, Pohlgeers K. Glucose management in hospitalized patients. Am Fam Physician. 2017 Nov 15;96(10):648-54. PubMed PMID: 29431385. Zhao TH, Chen HX, Jia B, Bai YB, Lu J, Ren W. A modified three-incision approach to treating three-column Lisfranc injuries. Chin J Traumatol. 2022 Nov;25(6):362-6. PubMed PMID: 35985903. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784-91. PubMed PMID: 28467526. Sato T, Takegami Y, Sugino T, Bando K, Fujita T, Imagama S. Smoking and trimalleolar fractures are risk factors for infection after open reduction and internal fixation of closed ankle fractures: a multicenter retrospective study of 1,201 fractures. Injury. 2021 Jul;52(7):1959-63. PubMed PMID: 33896610. Kanda Y. Investigation of the freely available easy-to-use software “EZR” for medical statistics. Bone Marrow Transplant. 2013 Mar;48(3):452-8. PubMed PMID: 23208313. Haque AN, Uzzaman KS, Hasan MM, Hasan KR, Hasan MR, Hussain M, et al. Outcome of Danis-Weber Type-B ankle fracture treated by Pre-contoured Distal Fibular Locking Plate. Mymensingh Med J. 2021 Jul;30(3):644-50. PubMed PMID: 34226450. Gerlach R, Toepfer A, Jacxsens M, Zdravkovic V, Potocnik P. Temporizing cast immobilization is a safe alternative to external fixation in ankle fracture-dislocation while posterior malleolar fragment size predicts loss of reduction: a case control study. BMC Musculoskelet Disord. 2022 Jul 22;23(1):698. PubMed PMID: 35869482. Zhao H, Meng J, Sun T, Wan Z, Qin S, Zhang F, et al. Risk factors for deep surgical site infection following surgically treated peri-ankle fractures: a case-control study based on propensity score matching. J Orthop Surg Res. 2022 Dec 15;17(1):542. PubMed PMID: 36522748. Pilskog K, Høvding P, Fenstad AM, Inderhaug E, Fevang JM, Dale H. Risk factors for fracture-related infection after ankle fracture surgery. Injury. 2023 Oct;54(10):111011. PubMed PMID: 37688812. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4568011","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":320707367,"identity":"7cb60817-f813-48f2-8c5a-7e132fb46356","order_by":0,"name":"Sara Sugiura","email":"","orcid":"","institution":"Tokyo Medical and Dental University","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Sugiura","suffix":""},{"id":320707369,"identity":"d5f0ba20-e355-4469-bc65-84bdcbb77f04","order_by":1,"name":"Yoto Oh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvUlEQVRIiWNgGAWjYDACCTB5QA5IGIBYzERqSThgzEOylsQeqBbCgF+6gfFx5Y876fvFDm9g+FHDwG5OSIvknAPMhmcSnuX2SKcVMPYcY2C2bCCgxeBGAptkQ8JhoJYcAwbeBgZmgwNEaknnAWph/EuKlgSQFmaibJGckdhs2JB22LDndlrBYZljEoT9wi+RfPBhg81hefbZyRsfvqmxSSYYYgwMjAhTgU6SSCYydpCAHelaRsEoGAWjYLgDAJcRO1fJrnA5AAAAAElFTkSuQmCC","orcid":"","institution":"Tokyo Medical and Dental University","correspondingAuthor":true,"prefix":"","firstName":"Yoto","middleName":"","lastName":"Oh","suffix":""},{"id":320707370,"identity":"2f0af716-d1cb-4a29-9113-220c7a46654e","order_by":2,"name":"Takumi Kaku","email":"","orcid":"","institution":"Tokyo Medical and Dental University","correspondingAuthor":false,"prefix":"","firstName":"Takumi","middleName":"","lastName":"Kaku","suffix":""},{"id":320707375,"identity":"937ba758-ae6b-4f1b-bccd-1d72f3c0ea9e","order_by":3,"name":"Yusuke Amano","email":"","orcid":"","institution":"Tokyo Medical and Dental University","correspondingAuthor":false,"prefix":"","firstName":"Yusuke","middleName":"","lastName":"Amano","suffix":""},{"id":320707378,"identity":"deff927b-f9a4-45d7-9d9d-1738982d6c96","order_by":4,"name":"Toshitaka Yoshii","email":"","orcid":"","institution":"Tokyo Medical and Dental University","correspondingAuthor":false,"prefix":"","firstName":"Toshitaka","middleName":"","lastName":"Yoshii","suffix":""}],"badges":[],"createdAt":"2024-06-12 06:41:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4568011/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4568011/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60197747,"identity":"006fd1e9-f33b-4b55-81a0-1217ffa7b6be","added_by":"auto","created_at":"2024-07-13 01:59:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3072482,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative example of checking normal wound healing (arrowheads) after malleolar fracture surgery. (A) Removal of threads or skin staples on postoperative days 10–14. (B) Removal of scabs covering wound edge. (C) Careful monitoring of wound edge healing.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-4568011/v1/060f42df4a20ed5313087f44.png"},{"id":60197746,"identity":"7bc23b66-fad6-4288-8f68-7d9af7f8125b","added_by":"auto","created_at":"2024-07-13 01:59:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3297754,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative example of checking failed wound healing (arrowheads). (A) Careful monitoring of wound edges detecting minor wound dehiscence. (B) Debridement and primary wound closure.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-4568011/v1/e8ba4e1ed9a38b4c446a89c9.png"},{"id":60197744,"identity":"916b159b-a092-48c6-97f6-911269147df2","added_by":"auto","created_at":"2024-07-13 01:59:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":567434,"visible":true,"origin":"","legend":"\u003cp\u003eResults of subgroup analysis of wound healing failure according to whether patients underwent internal fixation of posterior malleolar fragment via the posterior approach or not.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-4568011/v1/e48008a2fb5f02c21c4fc27a.png"},{"id":60197745,"identity":"a61ea974-7f92-4f83-93d6-b9caf443594e","added_by":"auto","created_at":"2024-07-13 01:59:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":591268,"visible":true,"origin":"","legend":"\u003cp\u003eResults of subgroup analysis of wound healing failure according to the AO/OTA classification of malleolar fracture. AO/OTA, AO Foundation/Orthopedic Trauma Association\u003c/p\u003e","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-4568011/v1/ca6a59adb488229a6be42ac8.png"},{"id":68665637,"identity":"ab3a2b68-79d3-4a1d-ba9f-c556ca4a42a1","added_by":"auto","created_at":"2024-11-10 19:01:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":16321342,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4568011/v1/6120f752-3378-44db-a62d-d664eb7f56c1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Can appropriate surgical wound management prevent surgical site infection after malleolar fracture surgery?","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eSurgical site infection (SSI) is one of the complications of orthopedic surgery and leads to increased costs because of prolonged hospitalization and additional surgeries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Malleolar fractures are common, accounting for 168.7 fractures per 100,000 persons per year and 24.5% of all fracture surgeries [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Wound complications are also common after malleolar fracture surgery, and prevention of infection is important [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Wound healing failure describes a wound complication without infection that needs early treatment before it progresses to deep infection [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Patient factors, such as an uncontrolled blood glucose level and surgical invasion of soft tissues, may increase the risk of wound healing failure [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and its diagnosis and treatment relies on subjective evaluation.\u003c/p\u003e \u003cp\u003eThe purpose of this study was to develop a standardized protocol for surgical wound management after malleolar fracture surgery for use at the authors\u0026rsquo; facility and to determine its effects on the incidence of surgical wound healing failure and SSI.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Ethical considerations\u003c/h2\u003e \u003cp\u003e This study was approved by the institutional review board of our institution. All procedures involving human participants were performed in accordance with the ethical standards of the relevant institutional and/or national research committees and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was secured via the opt-out route, whereby the purpose of the study was explained in a poster displayed in our orthopedics department and patients were given the opportunity not to have their data included. The study data were fully anonymized, thereby protecting the patients\u0026rsquo; privacy and dignity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Study design and patients\u003c/h2\u003e \u003cp\u003eThe study had a retrospective single-center design and was performed at a university hospital. Clinical data were evaluated for 62 patients who underwent malleolar fracture surgery under the supervision of the same orthopedic trauma surgeon (blinded for review) between April 2014 and December 2022. For the purposes of this study, malleolar fracture was defined as AO Foundation/Orthopedic Trauma Association (AO/OTA) classification 44. Patients with an open wound (n\u0026thinsp;=\u0026thinsp;9), those with tibial diaphysis fracture (n\u0026thinsp;=\u0026thinsp;4), and those in whom late SSI could not be evaluated because of follow-up \u0026lt;\u0026thinsp;6 months (n\u0026thinsp;=\u0026thinsp;7) were excluded, leaving 42 patients (26 male, 14 female) for inclusion in the study. The mean age was 52.0\u0026thinsp;\u0026plusmn;\u0026thinsp;19.2 years and the mean follow-up duration was 21\u0026thinsp;\u0026plusmn;\u0026thinsp;19.2 months. The AO/OTA classification was 44A in 5 patients, 44B in 30, and 44C in 7.\u003c/p\u003e \u003cp\u003eThe primary outcome was the incidence of wound healing failure and that of deep SSI under strict standardized wound management conditions after malleolar fracture surgery. As in a previous report [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], wound healing failure included wound edge necrosis and wound dehiscence.\u003c/p\u003e \u003cp\u003eOur diagnostic criteria for surgical wound healing failure and the wound management protocol for surgical intervention are as follows. After removal of the sutures, the scab or skin crust is removed and the wound edge is evaluated (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Debridement is performed even for trivial failure (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Wound re-closure is performed for minor failure, and negative pressure wound therapy or split-thickness skin grafting is performed for ulceration. Deep SSI is defined according to the Centers for Disease Control and Prevention guidelines and protocols [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe patients were divided into two groups according to surgical wound healing status and compared to determine the risk factors for wound healing failure after malleolar fracture surgery. Given that the risk of soft tissue disruption is known to be higher with advanced/severe malleolar fractures, especially those involving the posterior malleolus [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], the following analyses were performed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Patient demographics and clinical characteristics\u003c/h2\u003e \u003cp\u003eInformation was collected on patient demographics and clinical characteristics, including body mass index, American Society of Anesthesiologists physical status, smoking status, diabetes status, use of any glucocorticoid or immunosuppressive agent, and hemodialysis. Details were reviewed regarding the surgical intervention for malleolar fracture (i.e., preoperative waiting period, surgical approach, implant, presence of posterior malleolus fracture, and posterior fixation status).\u003c/p\u003e \u003cp\u003eIn addition, the patients were divided into two subgroups according to whether or not they underwent internal fixation for posterior malleolus fragments via a posterior approach, and the incidence of surgical wound healing failure was compared. To clarify the relationship between the advancement/severity of malleolar fracture and the incidence of surgical wound healing failure, the patients with 44B fractures were divided into a B1/B2 group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10) and B3 group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20) and compared.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Statistical analysis\u003c/h2\u003e \u003cp\u003eThe wound healing failure rate was compared between the study groups using Fisher\u0026rsquo;s exact test. Continuous variables are summarized as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and categorical variables as the number (percentage). Continuous variables were compared between groups using the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test and categorical variables using Fisher\u0026rsquo;s exact test. All statistical analyses were performed using EZR 9 (Saitama Medical Center, Jichi Medical University, Saitama, Japan) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Differences with a \u003cem\u003eP\u003c/em\u003e-value of \u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eSurgical wound healing failure was detected in 8 (19%) of the 42 patients (44A, n\u0026thinsp;=\u0026thinsp;1; 44B, n\u0026thinsp;=\u0026thinsp;7). There were no statistically significant differences in patient characteristics according to wound healing status (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the characteristics and clinical course for the 8 patients with surgical wound healing failure, all of whom underwent debridement and surgical intervention (primary wound closure, n\u0026thinsp;=\u0026thinsp;5; negative pressure wound therapy, n\u0026thinsp;=\u0026thinsp;2; and split-thickness skin grafting, n\u0026thinsp;=\u0026thinsp;1). Wound healing was achieved in all 8 patients, with no cases of deep SSI.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient demographics according to surgical wound healing status following surgery for malleolar fracture (N\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical wound healing failure (+)\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgical wound healing failure (-)\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;34\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026ndash;value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.0\u0026thinsp;\u0026plusmn;\u0026thinsp;21.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.8\u0026thinsp;\u0026plusmn;\u0026thinsp;18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (61.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA-PS\u0026thinsp;\u0026gt;\u0026thinsp;1, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (70.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWaiting period for ORIF, days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.71\u0026thinsp;\u0026plusmn;\u0026thinsp;3.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSteroid use, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemodialysis, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAO/OTA classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44A, n\u0026thinsp;=\u0026thinsp;1; 44B, n\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44A, n\u0026thinsp;=\u0026thinsp;4; 44B, n\u0026thinsp;=\u0026thinsp;23; 44C, n\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are shown as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, number (percentage), or number. AO/OTA, AO Foundation/Orthopedic Trauma Association; ASA-PS, American Society of Anesthesiologists physical status classification; BMI, body mass index; ORIF, open reduction and internal fixation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical characteristics of patients with surgical wound healing failure after malleolar fracture surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"14\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eASA-PS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGlucocorticoid use\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAO/OTA classification (44)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWaiting period for ORIF (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003eORIF incision\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSurgical interventions for wound healing failure\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eLateral\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003ePL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eMedial\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eB2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003ePrimary wound closure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eB3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003ePrimary wound closure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eA2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003ePrimary wound closure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eB3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003ePrimary wound closure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eB3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eNegative pressure wound therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eB3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003ePrimary wound closure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eB3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eSplit-thickness skin grafting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eB3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eNegative pressure wound therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"14\"\u003eAO/OTA, AO Foundation/Orthopedic Trauma Association; ASA-PS, American Society of Anesthesiologists physical status classification; BMI, body mass index; ORIF, open reduction and internal fixation; PL, posterolateral\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOut of 6 patients who underwent posterior fixation via a posterior surgical approach (44B3, n\u0026thinsp;=\u0026thinsp;5; 44C3, n\u0026thinsp;=\u0026thinsp;1), 2 with 44B3 were found to have surgical wound healing failure (33%; Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In contrast, surgical wound healing failure occurred in 6 of 36 patients (17%) in whom a posterior surgical approach was not used. There was no significant difference between these two subgroups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.32). In another subgroup analysis, the incidence of surgical wound healing failure was higher in the B3 group (6/20, 30%) than in the B1/B2 group (1/10, 10%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.37; Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn this study, the incidence of surgical wound healing failure after malleolar fracture surgery was 19%, which is higher than the range of 3.3\u0026ndash;6.8% previously reported. However, there were no cases of deep SSI, which have been reported to occur in 1.44\u0026ndash;16% of cases in past studies [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Strict standardized assessment of the surgical wound and use of the postoperative interventions described in this report may have avoided deep SSI. While numerous studies have retrospectively investigated patient factors associated with wound infection after malleolar fracture surgery [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], this study may be the first to have examined the iatrogenic effects of interventions by surgeons.\u003c/p\u003e \u003cp\u003eThis study also identified advancement/severity of malleolar fracture to be a risk factor for disruption of soft tissue including surgical wound healing failure. It is generally known that the AO/OTA classification is useful for indicating severity and intractability; indeed, the incidence of surgical wound healing failure was higher in our 44B3 group than in our 44B1/B2 group (30% vs 10%). As expected, this study also found that an additional posterior approach for posterior malleolus fixation may increase the risk of soft tissue failure. This finding is in line with past reports [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and orthopedic surgeons should be aware of these types of fractures and potential deterioration of soft tissues as a consequence of additional surgical invasion.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, it was performed at a single center and included a small sample size. Our emergency medical care center tends to treat high-energy fractures associated with serious trauma and to refer patients with minor or moderate fractures to a city hospital after initial treatment. Second, because of the lack of standardization of the diagnosis of surgical wound healing failure in the past, it was not possible to include a historical control group. Third, the study included some high-risk patients (e.g., the elderly, smokers, and those with diabetes). Further research in a larger number of patients with inclusion of a control group is needed to confirm our findings.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eAlthough the incidence of surgical wound healing failure in this study was higher than in previous reports, there were no cases of deep SSI. A posterior surgical approach for internal fixation of a posterior malleolus fracture was considered to be a potential risk factor for wound healing failure. Strict standardized assessment of the surgical wound and appropriate surgical intervention after malleolar fracture surgery could avoid deep SSI.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive any grants or funds for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Tokyo Medical and Dental University Faculty of Medicine IRB (approval no. M2023-204). All procedures involving human participants were performed in accordance with the ethical standards of the relevant institutional and/or national research committees and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All eligible patients were registered via the opt-out route, whereby the purpose of the study was explained in a poster displayed in the orthopedics department of the participating university hospital. The data were fully anonymized, thereby protecting the patients\u0026rsquo; privacy and dignity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe department to which the corresponding author (Y.O.) belongs received funding for operating costs from Saku Central Hospital of the Nagano Prefectural Federation of Agricultural Cooperatives for Health and Welfare, Suwa Central Hospital, Doujin Hospital, Nerima General Hospital, Medtronic Sofamor Danek Co., Ltd., Stryker Japan K.K., HOYA Technosurgical Co., Ltd., and Magic Shields, Inc. The other authors declare that they have no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWhitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol. 2002 Apr;23(4):183-9. PubMed PMID: 12002232.\u003c/li\u003e\n\u003cli\u003eBeerekamp MSH, de Muinck Keizer RJO, Schep NWL, Ubbink DT, Panneman MJM, Goslings JC. Epidemiology of extremity fractures in the Netherlands. Injury. 2017 Jul;48(7):1355-62. PubMed PMID: 28487101.\u003c/li\u003e\n\u003cli\u003eElsoe R, Ostgaard SE, Larsen P. Population-based epidemiology of 9767 ankle fractures. Foot Ankle Surg. 2018 Feb;24(1):34-9. PubMed PMID: 29413771.\u003c/li\u003e\n\u003cli\u003eOvaska M. Complications in ankle fracture surgery. Acta Orthop Suppl. 2015 Feb;86(358):1-32. PubMed PMID: 25586467.\u003c/li\u003e\n\u003cli\u003eDepypere M, Morgenstern M, Kuehl R, Senneville E, Moriarty TF, Obremskey WT, et al. Pathogenesis and management of fracture-related infection. Clin Microbiol Infect. 2020 May;26(5):572-8. PubMed PMID: 31446152.\u003c/li\u003e\n\u003cli\u003eKodner C, Anderson L, Pohlgeers K. Glucose management in hospitalized patients. Am Fam Physician. 2017 Nov 15;96(10):648-54. PubMed PMID: 29431385.\u003c/li\u003e\n\u003cli\u003eZhao TH, Chen HX, Jia B, Bai YB, Lu J, Ren W. A modified three-incision approach to treating three-column Lisfranc injuries. Chin J Traumatol. 2022 Nov;25(6):362-6. PubMed PMID: 35985903.\u003c/li\u003e\n\u003cli\u003eBerr\u0026iacute;os-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784-91. PubMed PMID: 28467526.\u003c/li\u003e\n\u003cli\u003eSato T, Takegami Y, Sugino T, Bando K, Fujita T, Imagama S. Smoking and trimalleolar fractures are risk factors for infection after open reduction and internal fixation of closed ankle fractures: a multicenter retrospective study of 1,201 fractures. Injury. 2021 Jul;52(7):1959-63. PubMed PMID: 33896610.\u003c/li\u003e\n\u003cli\u003eKanda Y. Investigation of the freely available easy-to-use software \u0026ldquo;EZR\u0026rdquo; for medical statistics. Bone Marrow Transplant. 2013 Mar;48(3):452-8. PubMed PMID: 23208313.\u003c/li\u003e\n\u003cli\u003eHaque AN, Uzzaman KS, Hasan MM, Hasan KR, Hasan MR, Hussain M, et al. Outcome of Danis-Weber Type-B ankle fracture treated by Pre-contoured Distal Fibular Locking Plate. Mymensingh Med J. 2021 Jul;30(3):644-50. PubMed PMID: 34226450.\u003c/li\u003e\n\u003cli\u003eGerlach R, Toepfer A, Jacxsens M, Zdravkovic V, Potocnik P. Temporizing cast immobilization is a safe alternative to external fixation in ankle fracture-dislocation while posterior malleolar fragment size predicts loss of reduction: a case control study. BMC Musculoskelet Disord. 2022 Jul 22;23(1):698. PubMed PMID: 35869482.\u003c/li\u003e\n\u003cli\u003eZhao H, Meng J, Sun T, Wan Z, Qin S, Zhang F, et al. Risk factors for deep surgical site infection following surgically treated peri-ankle fractures: a case-control study based on propensity score matching. J Orthop Surg Res. 2022 Dec 15;17(1):542. PubMed PMID: 36522748.\u003c/li\u003e\n\u003cli\u003ePilskog K, H\u0026oslash;vding P, Fenstad AM, Inderhaug E, Fevang JM, Dale H. Risk factors for fracture-related infection after ankle fracture surgery. Injury. 2023 Oct;54(10):111011. PubMed PMID: 37688812.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"malleolar fracture, surgical site infection, wound complication, wound healing failure","lastPublishedDoi":"10.21203/rs.3.rs-4568011/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4568011/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eSurgical wound healing failure is the most common complication of malleolar fracture surgery, and appropriate treatment is important to prevent surgical site infection (SSI). This study aimed to determine the incidence of wound healing failure and deep surgical site infection under strict standardized surgical wound management after malleolar fracture surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSixty-two patients who underwent surgery for malleolar fracture (AO/OTA classification 44) were reviewed. Strict assessment and surgical intervention were performed even for trivial failure in all wound healing failure cases. The exclusion criteria were open wound, tibial diaphysis fracture, and follow-up \u0026lt;\u0026thinsp;6 months. Surgical wound healing failure, deep SSI, and posterior fixation status were evaluated in the 42 patients (44A, n\u0026thinsp;=\u0026thinsp;5; 44B, n\u0026thinsp;=\u0026thinsp;30; 44C, n\u0026thinsp;=\u0026thinsp;7) finally included in the study. Patients with a 44B fracture were divided into a B1/B2 group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10) and a B3 group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20) for subgroup analysis to clarify the relationship between severity of malleolar fracture and incidence of surgical wound healing failure.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe incidence of surgical wound healing failure was 19%, but there were no deep SSI. Two of 6 patients who underwent internal fixation for posterior malleolar fragments were complicated with wound failure. Surgical wound healing failure incidence was higher in the B3 group than in the B1/B2 group (30% vs 10%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.37).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eMore cases of wound healing failure and less deep SSI were detected in this study compared with previous studies. Strict standardized surgical wound management could help to avoid SSI after malleolar fracture surgery.\u003c/p\u003e","manuscriptTitle":"Can appropriate surgical wound management prevent surgical site infection after malleolar fracture surgery?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-13 01:59:24","doi":"10.21203/rs.3.rs-4568011/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"79b73a6e-9dab-4e35-8e48-983d8b1648fd","owner":[],"postedDate":"July 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-10T18:53:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-13 01:59:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4568011","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4568011","identity":"rs-4568011","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}