title: An algorithmic approach for managing orthopaedic surgical wounds of the foot and ankle.
abstract: BACKGROUND
  Wound breakdown after orthopaedic foot and ankle surgery may necessitate secondary soft tissue coverage. The foot and ankle region is challenging to reconstruct for orthopaedic and plastic surgeons owing to its complex bony anatomy and unique functional demands. Therefore, identifying strategies for plastic surgery of these wounds may help guide surgeons in defining the best treatment plan.
  
  
  OBJECTIVE
  We evaluated our current algorithmic approach for managing orthopaedic surgical wounds of the foot and ankle with respect to whether (1) prophylactic or simultaneous soft tissue coverage affected wound-healing complications (secondary plastic surgery, orthopaedic hardware removal, malunion, further orthopaedic surgery, ultimate failure) and (2) postoperative referral for soft tissue management was associated with wound location, size, and orthopaedic procedure.
  
  
  METHODS
  We retrospectively reviewed 112 patients who underwent elective orthopaedic foot or ankle surgery and required concomitant plastic surgery at our institution. Study end points included secondary plastic surgery procedures, hardware removal for infection, foot or ankle malunion, further orthopaedic surgery, and wound-healing failure as defined by a chronic nonhealing wound or need for amputation. Minimum followup was 0.6 months (mean, 24.9 months; range, 0.6-197 months). Four patients were lost to complete followup. We developed an algorithm that centers on two critical points of care: preoperative evaluation by the orthopaedic surgeon and evaluation and treatment by the plastic surgeon after referral.
  
  
  RESULTS
  Compared with postoperative intervention, prophylactic or simultaneous soft tissue coverage did not lead to differences in frequency of secondary plastic surgery procedures (p = 0.55), hardware removal procedures (p = 0.13), malunions (p = 0.47), further orthopaedic surgery (p = 0.48), and ultimate failure (p = 0.27). Patients referred postoperatively for soft tissue management most frequently had dorsal ankle wounds (p < 0.001) of smaller size (p = 0.03), most commonly associated with total ankle arthroplasty (p = 0.004).
  
  
  CONCLUSIONS
  Using our algorithmic approach, prophylactic or simultaneous soft tissue coverage did not improve the study end points. In addition, unexpected postoperative wound breakdown necessitating a plastic surgery consultation most commonly occurred on the dorsal ankle after total ankle arthroplasty. Our algorithm facilitates early identification of skin instability and enables prompt soft tissue coverage before or concurrently with orthopaedic procedures. The effect of prophylactic or simultaneous soft tissue coverage on postoperative wound healing requires further investigation.
  
  
  METHODS
  Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Box 3974, Durham, NC, 27710, USA.
authors.forename: Eugenia H
authors.initials: EH
authors.lastname: Cho
authors.forename: Ryan
authors.initials: R
authors.lastname: Garcia
authors.forename: Irene
authors.initials: I
authors.lastname: Pien
authors.forename: Steven
authors.initials: S
authors.lastname: Thomas
authors.forename: L Scott
authors.initials: LS
authors.lastname: Levin
authors.forename: Scott T
authors.initials: ST
authors.lastname: Hollenbeck
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000842:Ankle / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D020878:Device Removal; D017558:Elective Surgical Procedures; D005260:Female; D005528:Foot / Q000601:surgery*; D017759:Fractures, Malunited / Q000209:etiology / Q000601:surgery; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000009:adverse effects* / Q000295:instrumentation; D010348:Patient Care Team; D011183:Postoperative Complications / Q000175:diagnosis / Q000601:surgery*; D019651:Plastic Surgery Procedures; D012086:Reoperation; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000209:etiology / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome; D014945:Wound Healing; D055815:Young Adult