title: Effect of Delay to Definitive Surgical Fixation on Wound Complications in the Treatment of Closed, Intra-articular Calcaneus Fractures.
abstract: BACKGROUND
  There are conflicting data regarding the benefits of delaying operative fixation of calcaneus fractures to decrease wound complication rates. The purpose of this study was to examine the effect of delaying fixation on wound complication rates as well as to identify other risk factors.
  
  
  METHODS
  A retrospective review at 4 institutions, including 24 surgeons, identified 405 closed, operatively treated, intra-articular calcaneus fractures. We compared fractures with and without wound complications with regards to patient demographics, medical risk factors, fracture severity, time to fixation, operative approach, primary subtalar arthrodesis, and surgeon experience.
  
  
  RESULTS
  Wound complications were observed in 21% (87/405) of fractures, of which 33% (29/87) required operative intervention. Male sex (P = .032), smoking (P = .028), and the extensile lateral approach (P < .001) were associated with higher complication rates. Fractures treated with an extensile lateral approach had an overall wound complication rate of 32.1%, while those treated with a sinus tarsi or percutaneous approach had an overall wound complication rate of 8.3% (odds ratio [OR], 5.3; 95% confidence interval [CI], 2.9-9.5; P < .001). Among patients treated with an extensile lateral approach, delayed operative fixation did not decrease wound complication rates despite comparable fracture severity across time points. In contrast, among fractures treated with less invasive approaches, delayed fixation beyond 2 weeks resulted in a significantly increased wound complication rate of 15.2% as compared to a wound complication rate of only 2.1% among fractures treated within a week of injury (OR, 3.2; 95% CI, 1.3-9.5; P = .01). This was observed despite similar fracture severity across time points. Primary subtalar arthrodesis did not impact complication rates. A higher wound complication rate among senior surgeons was likely secondary to their predilection for the extensile lateral approach.
  
  
  CONCLUSIONS
  Delaying definitive fixation of closed, intra-articular calcaneus fractures did not decrease wound complication rates when using the extensile lateral approach, and we found an increased wound complication rate when using less invasive approaches.
  
  
  METHODS
  Level III, observational study.
authors.affiliation: Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
authors.forename: John Y
authors.initials: JY
authors.lastname: Kwon
authors.affiliation: Massachusetts General Hospital, Boston, Massachusetts, USA dguss@partners.org.
authors.forename: Daniel
authors.initials: D
authors.lastname: Guss
authors.affiliation: Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Darius E
authors.initials: DE
authors.lastname: Lin
authors.affiliation: Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Mostafa
authors.initials: M
authors.lastname: Abousayed
authors.affiliation: Mercy Medical Center, Baltimore, Maryland, USA.
authors.forename: Clifford
authors.initials: C
authors.lastname: Jeng
authors.affiliation: University of Southern California, Los Angeles, California, USA.
authors.forename: Steve
authors.initials: S
authors.lastname: Kang
authors.affiliation: OrthoCarolina, Charlotte, North Carolina, USA.
authors.forename: J Kent
authors.initials: JK
authors.lastname: Ellington
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001174:Arthrodesis; D002111:Calcaneus / Q000293:injuries*; D015897:Comorbidity; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods*; D005596:Fractures, Closed / Q000453:epidemiology / Q000601:surgery*; D006801:Humans; D057072:Intra-Articular Fractures / Q000453:epidemiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: calcaneus; delay; fracture; operative approach; risk factors; time to fixation; wound complication