Surgical site infection in ankle fracture surgery Risk factors and current management

This thesis investigates complications and optimization of surgical management in ankle fracture surgery, with a focus on surgical site infections (SSI), timing of fixation, implant selection, and clinically relevant outcome measures.
Part I addresses SSI following open reduction and internal fixation (ORIF) of ankle fractures. A large multicenter retrospective study showed an overall SSI incidence of 9.4%, with open fractures identified as the most important independent risk factor. Deep SSI were strongly associated with diabetes mellitus, higher ASA classification, and open fractures. Microbiological analyses demonstrated Staphylococcus aureus as the most common pathogen in both superficial and deep infections, while gram-negative bacteria, particularly Enterobacter cloacae species, were frequently identified in deep SSI and open fractures. These findings support empirical antibiotic treatment targeting both gram-positive and gram-negative microorganisms. A literature review confirmed established risk factors, diagnostic strategies, and treatment options, and highlighted the negative impact of SSI on functional outcome, emphasizing the importance of preventive measures such as timely surgery and appropriate antibiotic prophylaxis.
Part II focuses on refining surgical strategies for ankle fractures. In fracture-dislocations, acute ORIF within 48 hours was shown to be safe when soft tissue conditions permitted, without increased rates of SSI or reoperations compared to delayed fixation. Mini-fragment fibular plates demonstrated favorable functional outcomes and low complication and implant removal rates, suggesting clinical and potential cost benefits compared to traditional small-fragment implants. Finally, this thesis established the minimal clinically important difference (MCID) for the AOFAS Ankle-Hindfoot Scale, enabling meaningful interpretation of patient-reported outcomes following ankle fracture surgery.