JAAOS - 2026-04-10 - Journal Article
Impact of Preoperative Heel Ulceration on Surgical Outcomes Following Open Reduction and Internal Fixation of Rotational Ankle Fractures.
Tummala S, Wood BA, Wukich DK
Topics
Key Takeaway
Preoperative heel decubitus ulceration within 4 weeks of ORIF for rotational ankle fractures is associated with significantly elevated rates of 90-day SSI, sepsis, and mortality, as well as markedly higher 1- and 3-year rates of nonunion, revision surgery, and below-knee amputation (all P < 0.0125).
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Summary
This study asked whether preoperative heel decubitus ulceration within 4 weeks of surgery independently worsens outcomes after ORIF for rotational ankle fractures. Using a nationally representative database (2010–2022) with 1:1 propensity score matching, the ulcer cohort showed significantly higher 90-day rates of SSI, sepsis, pneumonia, UTI, deep infection, and mortality (all P < 0.005). At 1 and 3 years, nonunion, revision surgery, and below-knee amputation rates were all significantly elevated (all P < 0.0125).
Key Limitation
The database design prevents determination of whether ulcer treatment or resolution prior to surgery mitigates the observed complication risk, which is the most actionable clinical question this study raises.
Original Abstract
BACKGROUND
As surgical treatment with open reduction and internal fixation (ORIF) becomes more common, attention to preoperative risk stratification has grown. Although multiple modifiable risk factors and comorbidities have been associated with adverse outcomes, the impact of preexisting decubitus heel ulcers in this context remains yet to be defined.
METHODS
Using a nationally representative multi-institutional database, a retrospective analysis was conducted on adults undergoing ORIF for rotational ankle fractures between 2010 and 2022. Patients with a documented decubitus heel ulcer within 4 weeks before surgery were compared with ulcer-free controls. After applying strict exclusion criteria and employing 1:1 propensity score matching for key demographic and clinical variables, 90-day medical complications and 1- and 3-year surgical outcomes were evaluated.
RESULTS
The presence of a preoperative heel ulcer was associated with markedly higher risks of 90-day surgical site infection, sepsis, pneumonia, urinary tract infection, mortality, and deep infection (all P < 0.005). At 1 and 3 years postoperatively, the ulcer cohort demonstrated markedly elevated rates of nonunion, revision surgery, and below-knee amputation (all P < 0.0125).
CONCLUSIONS
Preoperative decubitus heel ulceration is associated with elevated risks of both short-term complications and long-term surgical failure following ORIF for ankle fractures. These findings underscore the importance of thorough preoperative foot assessment and may inform surgical planning and perioperative management in this high-risk population.
LEVEL OF EVIDENCE
Therapeutic Level III, Retrospective Cohort Study.