From the Guidelines
Delayed surgical treatment of ankle fractures is associated with worse outcomes, and ideally, surgical intervention should be performed within 24-72 hours of injury to achieve optimal results. The effects of delayed surgical treatment on ankle fracture outcomes are multifaceted, leading to increased complications such as higher infection rates, wound healing problems, and poorer functional outcomes 1. Prolonged delays, especially over 2 weeks, can result in significant soft tissue swelling, making surgery technically more challenging and potentially requiring temporary external fixation before definitive internal fixation can be performed.
Key considerations in the management of ankle fractures include the risk factors for surgical site infections (SSI), such as BMI, ASA ≥ 3, diabetes, alcohol, open fracture, subluxation/dislocation, incision cleanness grade 2–4, high-energy injury mechanism, chronic heart disease, history of allergy, and the use of antibiotic prophylaxis 1. The use of antibiotic prophylaxis is supported in the management of open fractures, with short course, single agent regimens using cephalosporins recommended to prevent adverse outcomes 1.
In cases where surgery must be delayed, it is crucial to immobilize the ankle in a well-padded splint, elevate it to reduce swelling, and maintain regular ice application and non-weight bearing status until definitive fixation can be performed. The biological basis for the poorer outcomes associated with delayed treatment includes progressive soft tissue compromise, development of fracture hematoma organization, early callus formation making anatomic reduction more difficult, and the potential development of post-traumatic arthritis due to prolonged joint incongruity.
Given the current evidence, early surgical intervention within the recommended timeframe is paramount to minimize complications and optimize outcomes for patients with ankle fractures. This approach is supported by the most recent guidelines and studies, emphasizing the importance of timely management in reducing morbidity, mortality, and improving the quality of life for these patients 1.
From the Research
Effects of Delayed Surgical Treatment on Ankle Fracture Outcomes
- Delayed surgical treatment of ankle fractures can have various effects on patient outcomes, including increased risk of soft tissue complications and prolonged hospital stay 2.
- A study found that delaying ankle fracture repair beyond 12 days after injury may negatively affect long-term patient reported pain scores 3.
- However, another study found that the results and complications of early versus delayed treatment are not significantly different, except for a shorter median hospital stay in the delayed group 4.
Risk Factors for Complications
- Patient-related risk factors for deep surgical site infection include diabetes, alcohol abuse, fracture-dislocation, and soft-tissue injury 5.
- Surgery-related risk factors for infection include suboptimal timing of prophylactic antibiotics, difficulties encountered during surgery, wound complications, and fracture malreduction 5.
- Risk factors for wound complications after ankle fracture surgery include a history of diabetes, peripheral neuropathy, wound-compromising medications, open fractures, and postoperative noncompliance 6.
Timing of Surgery
- The timing of surgery did not impact union rates or wound complications in one study 3.
- Another study found that immediate surgery is particularly indicated in severely displaced ankle fractures, and if not achievable, temporary reduction and immobilization is recommended 2.
- A study found that delayed ORIF is an acceptable alternative when soft-tissue swelling, fracture blisters, or abrasions are present that offer an undesirable environment for surgical incisions 4.
- There was no relationship found between time to surgery and complications in another study 6.