Anterior Ankle Incision Complications

Abstract

Category: Ankle Introduction/Purpose: The anterior incision is commonly used for total ankle replacement (TAR), and anterior approach ankle arthrodesis. Historically, the anterior incision has demonstrated a high incidence of complications, specifically with early generation TAR. Modern TAR designs have provided instrumentation and techniques that better respect the vulnerability of the anterior soft tissues, potentially reducing the incidence of anterior incision related complications. To our knowledge, anterior wound healing rates have not been evaluated in the context of modern anterior approach ankle arthrodesis and arthroplasty. The purpose of this study was to evaluate and compare the incisional healing and complications of the anterior approach for ankle arthrodesis and arthroplasty. Methods: This was an IRB-approved retrospective review of wound healing and complications among 304 patients who underwent primary TAR or ankle arthrodesis via the anterior approach between August 1, 2011 and August 31, 2015. Of the 304 patients, 191 (62.8%) underwent TAR and 113 (37.2%) underwent arthrodesis. The surgical approach, intraoperative soft tissue handling, and postoperative protocol for the first 30 days was the same between groups. Demographics, clinical characteristics of the wound healing, and neurovascular status were analyzed using two-sample t-tests or Wilcoxon rank sum tests for continuous variables and chi-square or Fisher’s exact tests for categorical variables. To diminish the effect of selection bias, a subgroup analysis was performed comparing 91 TAR patients matched to an equal number of ankle arthrodesis patients based upon gender, age, diabetes, and smoking status. Results: The mean follow-up was 11.8 (range, 1.4 to 62.2) months. Overall, 19.7% of patients experienced delayed wound healing greater than 30 days, 15.8% required office-based wound care, 12.2% had a wound infection, 15.1% were prescribed antibiotics, 9.5% underwent wound debridement in the office, 4.6% had nerve injury, and 0.7% had a vascular injury. Implant revision or removal occurred in 10.5%, with a bias towards hardware removal in ankle arthrodesis. In the entire group of 304 patients, there was no difference between TAR and arthrodesis in risk of incisional wound challenges or complications nor neurovascular injury. In the subgroup matched for gender, age, diabetes status and smoking history there was no difference in outcomes. Conclusion: In this large cohort of 304 patients undergoing anterior approach to the ankle, postoperative complication rates were constant at all levels of analysis, with no difference seen between anterior ankle arthrodesis or ankle approach total ankle arthroplasty. This suggests that the primary determinates of complications were neither the demographic nor implant factors considered herein. The anterior ankle incision has a documented wound complication risk, regardless of the surgical procedure, and any modifiable risk factors remain elusive.