How long should surgeons protect the soft tissue envelope after total ankle replacement?
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Eliminate edema
Incision healing problems are among the most significant complications facing the total ankle arthroplasty surgeon.
Not only does it increase the cost of the procedure through additional procedures and hospitalizations, but it can also be devastating to the functional outcome of the arthroplasty itself. Wound deterioration may provide a portal of entry for deep infection, requiring removal of the implant and, in some cases, a below knee amputation. Even under circumstances where no infection develops, the poor soft tissue envelope may allow tendons to be exposed, creating the need for a free flap. All such outcomes are devastating to the patient.
About 10 years ago, I decided to change my strategy in postoperative incision management for total ankle arthroplasty. I had noted my wound care therapists always incorporated the same strategy for managing incision problems. They began by treating the patient with compression wrapping to eliminate edema, followed by topic applications to promote wound healing. Elimination of edema removed the key component of persistent tension on the soft tissues, preventing apposition of the skin ends. This made sense to me, for I lived through the times of Achilles tendon incision complications, when strict immobilization into plantarflexion for prolonged intervals created edema in the skin edges given the vascular congestion in that equally poor soft tissue envelope. The realization that we were doing the same thing to the anterior soft tissues following ankle arthroplasty by immobilizing a maximally dorsiflexed ankle led to the new strategy in postoperative (and preoperative) incision management.
Together with Dawn Franceschina, PT, DPT, we developed a protocol that progressively eliminated edema from distal to proximal with standard compression wrap materials (Artiflex [BSN Medical] multipurpose underpadding bandage and Comprilan [BSN Medical] short-stretch cotton compression bandage). These wraps were changed every 2 days, beginning on day 1 postoperatively. The physical therapist employing the wrapping technique would also promote early passive ankle range of motion at each visit, which I found critical to sustaining the motion achieved with the replacement in the operating theatre. Scar tissue did not have time to accumulate, a problem evident in immobilizing an ankle arthroplasty for as little as 2 weeks. Without edema in the skin, this early motion was found to be safe across the formerly tenuous anterior incisions. As a final benefit, the physical therapist would photograph the incision at each visit and send me the images for review. If we suspected a problematic incision would develop due to complicating factors, we could treat it immediately rather than being surprised at the more traditional 2 week unwrapping of the incision. This also gave the patient confidence that they were getting continued care in the postoperative period, rather than being ignored by the health care team for the critical 2-week interval following surgery.
Following institution of the technique, we performed a follow-up study comparing traditional immobilization vs. those undergoing the new protocol. We found significantly more total wound complications in the immobilization vs. the compression wrap groups (P = .02). Also, should an incision complication develop, a significantly higher proportion of total ankle patients took longer than 3 months to heal in the immobilization group (P = .02). These results gave us confidence to continue the technique to present day, and new physicians to the practice have become converts into the value of the protocols.
This is a simple protocol for any orthopedic surgeon or podiatrist to incorporate into their practice. The wrap can be applied by their physical therapist or physician assistant. Once set up, I can almost guarantee the surgeon will begin incorporating it into other hindfoot and ankle reconstructive procedures, utilizing it preoperatively as well as postoperatively to minimize incision complications.
- References:
- Glazebrook MA, et al. Foot Ankle Int. 2009; doi:10.3113/FAI.2009.0945.
- Hsu AR, et al. Foot Ankle Int. 2014; doi:10.1177/1071100714534217.
- Schipper ON, et al. Foot Ankle Int. 2015; doi:10.1177/1071100715597437.
Steven L. Haddad, MD, is senior orthopedic attending surgeon Emeritus at Illinois Bone and Joint Institute LLC in Buffalo Grove, Illinois.
Soft tissues remain priority
Patients often ask why, if they were able to walk on the day of their knee or hip replacement, cannot they walk on their ankle replacement for weeks after surgery. After all, the implants do not rely on bony ingrowth prior to being mechanically stable and are made of the same materials as all other arthroplasties used in orthopedics.
But as all who perform foot and ankle surgery are aware, the distal extent of our lower extremity presents unique biological and mechanical challenges not seen in other areas of the body. Because most total ankle replacements are performed on a posttraumatic soft tissue envelope with chronic edema and venous stasis, it remains relatively unforgiving when it comes to achieving uneventful healing. For this reason, second only to ensuring time-zero press fit and mechanical alignment, protection of the soft tissues is paramount to the success of total ankle replacement. This does not only refer to how long someone is non-weight-bearing or immobilized postoperatively. Rather, this starts with meticulous attention to atraumatic tissue retraction during the operation. No direct skin retraction with rakes or hooks should be used — only deeper broad retractors should be employed. At the end of the procedure, a well-performed layered closure of the capsule, retinaculum and subcutaneous tissue should be completed preferably with an everted skin suture technique.
In our institution, many use a vacuum-assisted closure device to keep the wound dry. Immobilization with a well-padded splint is placed with the ankle in the plantigrade position, with care to prevent bulking and folding of the bandages on the anterior ankle wound. We have patients keep the limb elevated for 3 weeks non-weight-bearing immobilized and then exchanging the vacuum-assisted closure dressing for a medicated compression wrap at 1 week. At 3 weeks postoperatively when sutures are removed, patients are allowed to walk in a boot as tolerated, removing it to bathe and sleep. Some surgeons allow patients to bear weight immediately, others insist upon 6 weeks of non-weight-bearing.
While there is no gold standard, and these practices are largely nuanced, based on level-4 scientific data and remain deeply personal to each surgeon’s practice, the protection of the soft tissues must remain the priority of all surgeons performing total ankle replacement.
David I. Pedowitz, MD, is a professor of orthopedic surgery and chief of foot and ankle at Rothman Orthopaedic Institute.
Conservative approach
Though this is a simple question to answer, the process by which a surgeon gets to his or her answer can be dictated by a host of factors. It is, in my opinion, the single most important aspect of the operation after the patient has left the OR. Preoperative patient factors have a lot of influence in my decision-making, but as a general preference, I tend to protect the soft tissue envelope for the first 3 weeks after total ankle replacement.
I focus on meticulous closure as described by Christopher W. Reb, DO, and colleagues along with swelling control. Edema-related stress on the incision is an important factor in decreasing wound complications. For simplicity and efficiency, my protocol involves placing a pre-sized adhesive foam dressing with silver, commonly utilized by our knee arthroplasty colleagues. Andrew R. Hsu, MD, and colleagues describe a similar alternative lower cost approach that was effective in controlling postoperative edema. I will place the patient in a posterior splint with an additional bulky Jones compression dressing. Weight-bearing is discouraged and allowed for transfers/balance purposes only during the first 2 weeks, while elevation of the extremity is encouraged during the first 2-week period. The first postoperative visit is within the first 2.5 to 3 weeks. Sutures are inspected and removed at 2.5 to 3 weeks, depending on the appearance. I tend to be cautious and will delay suture removal if there is excessive edema-related tension on the suture line, especially at the central aspect of the incision.
Anterior incision wound complications can occur in up to 20% of patients undergoing total ankle replacement. Preoperative patient factors play an important role in determining the length of time protecting the soft tissue. Diabetes, rheumatoid arthritis, multiple surgeries via the anterior approach, history of smoking, persistent lower extremity edema and other factors associated with wound healing delay will result in a more cautious approach until the first postoperative visit. This is where the preoperative history and examination play a vital role in anticipating the potential for complications before an incision is even made. Finally, factors such as social determinants of care and the patient support network can further influence how compliant a patient is with surgeon postoperative instructions. Wound complications can have a devastating outcome on patients undergoing total ankle replacement. Therefore, a conservative approach to protection of the skin envelope is a simple and cost-effective way to prevent the sequelae associated with delayed healing.
- References:
- Gross CE, et al. Foot Ankle Int. 2017; doi:10.1177/1071100716683341.
- Hsu AR, et al. Foot Ankle Int. 2014; doi:10.1177/1071100714534217.
- Raikin SM, et al. J Bone Joint Surg Am. 2010; doi:10.2106/JBJS.I.00870.
- Reb CW, et al. J Foot Ankle Surg. 2021; doi:10.1053/j.jfas.2020.04.015.
Noman A. Siddiqui, DPM, MHA, FACFAS, is the director of podiatric surgery at International Center for Limb Lengthening and chief of podiatry at Sinai and Northwest Hospital in Baltimore.
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