Factors associated with surgical site infection after ankle fracture fixation: a retrospective study in northern Sweden
DOI:
https://doi.org/10.2340/17453674.2026.46313Keywords:
ankle fractures, complication, Foot and ankle, Fractures, ImplantsAbstract
Background and purpose: Ankle fractures are common, and open reduction and internal fixation (ORIF) is standard treatment for unstable injuries. Surgical site infections (SSI) remain a significant clinical challenge. We aimed to estimate incidence and to identify patient- and treatment-related factors associated with SSI after ankle ORIF.
Methods: In this retrospective cohort, we included all adults (≥ 18 years) who underwent ankle ORIF at 2 trauma centers in northern Sweden from 2015 to 2024. Data from medical records covered demographics, comorbidities, injury characteristics, surgical details, and peri/postoperative care. The primary outcome was incidence of SSI and the secondary outcome was independent factors associated with SSI. SSI was defined as an infection occurring at or near the surgical incision within 30 days after surgery or up to 1 year later in the presence of an implant.
Results: We included 781 patients (mean age 54 years; 61% women). SSI occurred in 11%; 27% of infections underwent revision surgery, and 39 infections (43%) were categorized as fracture-related infection (FRI). Other complications included urinary tract infections (2.2%), pneumonia (0.8%), deep vein thrombosis (0.5%), and pulmonary embolism (0.4%). In adjusted analyses, higher odds of SSI were observed with smoking (aOR 2.3, 95% confidence interval [CI] 1.1–4.8, P = 0.02), initial external fixation (aOR 5.6, CI 1.7–17.6, P = 0.004), and longer operative time (OR per minute 1.0, CI 1.0–1.0, P = 0.004). The American Society of Anesthesiologists (ASA) class estimate suggested increased risk but was imprecise (aOR 9.7, CI 1.0–93.6, P = 0.049). Age, sex, and open fracture were not associated with SSI in the adjusted model.
Conclusion: After ankle ORIF, SSI occurred in 11%. Smoking, initial external fixation, and longer operative time were associated with higher risk of infection, while ASA estimate was imprecise. These findings support perioperative risk mitigation (e.g., smoking cessation and operative efficiency) and motivate study of physiological risk (ASA).
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Basques B A, Miller C P, Golinvaux N S, Bohl D D, Grauer J N. Morbidity and readmission after open reduction and internal fixation of ankle fractures are associated with preoperative patient characteristics. Clin Orthop Relat Res 2015; 473(3): 1133-9. doi: 10.1007/s11999-014-4005-z. DOI: https://doi.org/10.1007/s11999-014-4005-z
Gundtoft P H, Pedersen A B, Viberg B. Incidence, treatment, and mortality of ankle fractures: a Danish population-based cohort study. Acta Orthop 2025; 96: 203-8. doi: 10.2340/17453674.2025.43006. DOI: https://doi.org/10.2340/17453674.2025.43006
Aigner R, Salomia C, Lechler P, Pahl R, Frink M. Relationship of prolonged operative time and comorbidities with complications after geriatric ankle fractures. Foot Ankle Int 2017; 38(1): 41-8. doi: 10.1177/1071100716667315. DOI: https://doi.org/10.1177/1071100716667315
Davidovitch R I, Walsh M, Spitzer A, Egol K A. Functional outcome after operatively treated ankle fractures in the elderly. Foot Ankle Int 2009; 30(8): 728-33. doi: 10.3113/FAI.2009.0728. DOI: https://doi.org/10.3113/FAI.2009.0728
Thangarajah T, Prasad P S V, Narayan B. Surgical site infections following open reduction and internal fixation of ankle fractures. Open Orthop J 2009; 22(3): 56-60. doi: 10.2174/1874325000903010056. DOI: https://doi.org/10.2174/1874325000903010056
Sporer S M, Weinstein J N, Koval K J. The geographic incidence and treatment variation of common fractures of elderly patients. J Am Acad Orthop Surg 2006; 14(4): 246-55. doi: 10.5435/00124635-200604000-00006. DOI: https://doi.org/10.5435/00124635-200604000-00006
Lynde M J, Sautter T, Hamilton G A, Schuberth J M. Complications after open reduction and internal fixation of ankle fractures in the elderly. Foot Ankle Surg 2012; 18(2): 103-7. doi: 10.1016/j.fas.2011.03.010. DOI: https://doi.org/10.1016/j.fas.2011.03.010
Anderson S A, Li X, Franklin P, Wixted J J. Ankle fractures in the elderly: initial and long-term outcomes. Foot Ankle Int 2008; 29(12): 1184-8. doi: 10.3113/FAI.2008.1184. DOI: https://doi.org/10.3113/FAI.2008.1184
Chaudhary S B, Liporace F A, Gandhi A, Donley B G, Pinzur M S, Lin S S. Complications of ankle fracture in patients with diabetes. J Am Acad Orthop Surg 2008; 16(3): 159-70. doi: 10.5435/00124635-200803000-00007. DOI: https://doi.org/10.5435/00124635-200803000-00007
Korim M T, Payne R, Bhatia M. A case-control study of surgical site infection following operative fixation of fractures of the ankle in a large U.K. trauma unit. Bone Joint J 2014; 96-B(5): 636-40. doi: 10.1302/0301-620X.96B5.33143. DOI: https://doi.org/10.1302/0301-620X.96B5.33143
Miller A G, Margules A, Raikin S M. Risk factors for wound complications after ankle fracture surgery. J Bone Joint Surg Am 2012; 94(22): 2047-52. doi: 10.2106/JBJS.K.01088. DOI: https://doi.org/10.2106/JBJS.K.01088
Ovaska M. Complications in ankle fracture surgery. Acta Orthop 2015; 86(Suppl 358): 1-32. doi: 10.3109/17453674.2014.100227. DOI: https://doi.org/10.3109/17453674.2014.1002273
Ovaska M T, Mäkinen T J, Madanat R, Huotari K, Vahlberg T, Hirvensalo E, et al. Risk factors for deep surgical site infection following operative treatment of ankle fractures. J Bone Joint Surg Am 2013; 95(4): 348-53. doi: 10.2106/JBJS.K.01672. DOI: https://doi.org/10.2106/JBJS.K.01672
Nasell H, Ottosson C, Törnqvist H, Linde J, Ponzer S. The impact of smoking on complications after operatively treated ankle fractures: a follow-of study of 906 patients. J Orthop Trauma 2011; 25(12): 748-55. doi: 10.1097/BOT.0b013e318213f217. DOI: https://doi.org/10.1097/BOT.0b013e318213f217
Naumann M G, Sigurdsen U, Utvag S E, Stavem K. Incidence and risk factors for removal of an internal fixation following surgery for ankle fracture: a retrospective cohort study of 997 patients. Injury 2016; 47(8): 1783-8. doi: 10.1016/j.injury.2016.05.011. DOI: https://doi.org/10.1016/j.injury.2016.05.011
Shao J, Zhang H, Yin B, Li J, Zhu Y, Zhang Y. Risk factors for surgical site infection following operative treatment of ankle fractures: a systematic review and meta-analysis. Int J Surg 2018; 56: 124-32. doi: 10.1016/j.ijsu.2018.06.018. DOI: https://doi.org/10.1016/j.ijsu.2018.06.018
Metsemakers W, Morgenstern M, McNally, Moriarty T F, McFadyen I, Scarborough M, et al. Fracture-related infection: a consensus on definition from an international expert group. Injury 2018; 3: 505-10. doi: 10.1016/j.injury.2017.08.040. DOI: https://doi.org/10.1016/j.injury.2017.08.040
Tausendfreund J, Penning D, Naryapragi M A, Reisinger K W, Tanis E, Joosse P, et al. Predicting surgical site infections after open reduction and internal fixation for ankle fractures. Arch Orthop Trauma Surg 2025; 145(1): 135. doi: 10.1007/s00402-024-05623-9. DOI: https://doi.org/10.1007/s00402-024-05623-9
Meng J, Sun T, Zhang F, Qin S, Li Y, Zhao H. Deep surgical site infection after ankle fractures treated by open reduction and internal fixation in adults: a retrospective case-control study. Int Wound J 2018; 15(6): 971-7. doi: 10.1111/iwj.12957. DOI: https://doi.org/10.1111/iwj.12957
Sun R, Mingqiao M, Xiaofeng W, Xiaodong L, Wu L, Chen Z, et al. Surgical site infection following open reduction and internal fixation of a closed ankle fractures: a retrospective multicenter cohort study. Int J Surg 2017; 48: 86-91. doi: 10.1016/j.ijsu.2017.10.002. DOI: https://doi.org/10.1016/j.ijsu.2017.10.002
Sun Y, Wang H, Tang Y, Zhao H, Qin S, Xu L. Incidence and risk factors for surgical site infection after open reduction and internal fixation of ankle fracture: a retrospective multicenter study. Medicine (Baltimore) 2018; 97(7): e9901. doi: 10.1097/MD.0000000000009901. DOI: https://doi.org/10.1097/MD.0000000000009901
Saithna A, Moody M, Jenkinson E, Almazedi B. The influence of timing of surgery on soft tissue complications in closed ankle fractures. Eur J Orthop Surg Traumatol 2009; 19(7): 481-4. doi:10.1007/s00590-009-0455-5. DOI: https://doi.org/10.1007/s00590-009-0455-5
Tan L T, Oh J Y, Kwek E B K. Infection rates in Singaporeans with and without complicated diabetes after ankle fracture surgery. J Orthop Surg (Hong Kong) 2015; 23(1): 59-61. doi: 10.1177/230949901502300114. DOI: https://doi.org/10.1177/230949901502300114
Olsen L L, Møller A M, Brorson S, Hasselager R B, Sort R. The impact of lifestyle risk factors on the rate of infection after surgery for a fracture of the ankle. Bone Joint J 2017; 99-B(2): 225-30. doi:10.1302/0301-620X.99B2.BJJ-2016-0344.R1. DOI: https://doi.org/10.1302/0301-620X.99B2.BJJ-2016-0344.R1
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