0198-0211/83/0402-0102$02.
00/0
FOOT & ANKLE
Copyright © 1983 by the American Orthopaedic Foot and Ankle Society, Inc.
Postoperative Wound Infection in Foot and Ankle Surgery
ABSTRACT
In 20 years through 1981, the author performed 1841
clean foot and ankle operations without any prophylactic
antibiotics. Excluded from this study group are patients
with compound fractures or open wounds, prior infection,
toenail procedures, and other superficial operations. All
postoperative wound infections were recorded in a timely
manner and healing was documented. Infections oc-
curred in 41 cases (gross infection rate, 2.2%). Thirty-
seven cases healed without further surgery and without
sequellae from the infection. Three cases required further
surgery. One patient developed narrowing of the ankle
joint (permanent damage rate, 0.05%). These four pa-
tients represent 0.22% of the study group.
The keys to the analysis of postoperative wound
infections are a simple definition and classification.
The classification must stress the damage from infec-
tion. The definition must prevent the fallacious exclu-
sion of patients with infection.
DEFINITION
A postoperative wound infection is defined as a
clinical condition caused by the action of pathogenic
microorganisms in the surgical site. It is usually man-
ifested by drainage or abscess formation. It may de-
velop at any time after a surgical procedure. A positive
culture must be obtained to prove the presence of
infection. Tolerable exceptions to this requirement are
few. Cases yielding cultures of bacteria which are
usually nonpathogenic should be called infections
only if drainage or tissue reaction is persistent. This
latter situation usually occurs as a reaction to foreign
material. particularly nonabsorbable sutures or fixa-
tion devices.
This definition is broad enough to avoid exclusion
of any case of an operative wound with drainage
containing pathogenic organisms, no matter how
* Clinical Professor of Orthopedic Surgery. University of Okla-
homa College of Medicine. 707 NW 13th St., Oklahoma City.
Oklahoma 73103.
102
Downloaded from fai.sagepub.com at UNIV NEBRASKA LIBRARIES on December 22, 2015
William A. Miller. M.D. *
Oklahoma City, Oklahoma
bland the appearance or clinical course. It is narrow
enough to prevent inclusion of cases with trivial inter-
ruption of wound healing with normal skin flora, such
as stitch abscesses or blistered wounds.
CLASSIFICATION
Postoperative wound infections vary from the incon-
sequential to the disastrous. Failure to categorize this
difference has accounted for much confusion in arti-
cles concerned with the use of prophylactic antibi-
otics. Some reports classify infections as superficial
or deep. Deep is an accurate term for infections traced
to the bone by surgery or radiologic techniques or by
wound separation through the fascia. Beyond that, the
criteria for differentiating superficial from deep infec-
tions remain unexplained. Often the assumption has
been that if the infection cleared up quickly, it must
have been superficial.
Infections fall into three categories. First, healing
occurred without residual disability from the infection.
Second, the infection required one or more unantici-
pated operations, but then healed without sequellae.
Third, the infection produced permanent damage by
lowering the quality of the result expected from the
original operation, and also may have required addi-
tional surgery.
MATERIAL AND METHODS
In 20 years (1962 through 1981), the author per-
sonally performed 1841 foot and ankle operations
exclusive of patients with compound fractures or open
wounds, previous infection at the operative site, and
toenail or other superficial operations. Most of the
patients were adults. No perioperative prophylactic
antibiotics were used during this time. Postoperative
wound infections were recorded in a timely manner as
they occurred. Complete healing of all infections has
been documented. No postoperative wound infections
have been excluded, although many cases had factors
predisposing to infection, including impaired circula-
tion and previous operations.
Foot & Ankle/Vol. 4, NO.1 POSTOPERATIVE WOUND INFECTION 103

RESULTS (44%) in this series, as compared with 35 of 64

patients (55%) in the general series. The latest pre-
Forty-one patients in this series of 1841 developed sentation of infection was 75 days after surgery. To
postoperative wound infections (2.2%) (Table 1). One this date, there has been no late flare up of infection.
patient had permanent damage from the infection Eight of the 41 patients (20%) with postoperative
(permanent damage rate, 0.05%). Three patients re- infection in this series had hematomas, sanguineous,
quired surgery because of infection. The patient with or sanguinopurulent drainage as compared with 25 of
permanent damage and the three patients requiring
64 patients (39%) with postoperative infection in the
unanticipated surgery comprise 0.22% of the study
general orthopaedic series.
group. The permanent damage case developed nar- Thirty-four of the 41 patients (83%) cultured coag-
rowing of the ankle joint 6 months after lateral ankle ulase-positive Staphylococcus aureus, as compared
ligament repair. Seven years later, the patient had with 48 of 64 patients (75%) in the general series.
30% restriction of ankle motion and x-ray changes of The ankle ligament case with permanent damage cul-
traumatic arthritis. Two secondary operations for sep- tured S. aureus. In the secondary surgery group,
sis required removal of deep sutures, after excision of Pseudomonas aeruginosa was cultured from the fifth
an accessory navicular and after repair of a ruptured metatarsal head, and Staphylococcus epidermidis
Achilles tendon. The third secondary procedure was from the accessory navicular and the Achilles tendon,
removal of a fifth metatarsal head after fifth toe am- with the Achilles tendon discharge also containing
putation. Acinetobacter calcoaceticus.
When infection was suspected, some or all of the The 41 patients with infection had 11 7 incisions;
skin sutures were removed if they were still present, only four patients developed infection in more than
and a culture was taken. Usually an antibiotic was one incision.
then started. No patients required incision and drain-
age, as adequate spontaneous drainage had oc-
curred. DISCUSSION
Only three infections in the group of 41 infections
Most of the operative wounds in this series were
(7%) presented while the patients were still hospital-
routinely dressed 48 hours after surgery, and dress-
ized, compared with 27 of 64 cases (42%) with post-
ings were changed again within 10 days. Nearly half
operative infection in a personal general orthopedic
of the infections developed more than 2 weeks after
series of 2264 operations, excluding foot and ankle
surgery and were not merely discovered late. Late
surgery. Other than the three patients requiring un-
development of the infection and the short hospital
anticipated surgery, only one patient was rehospital-
stay of most patients with foot and ankle surgery
ized because of infection.
account for the small percentage of cases presenting
The time elapsed after surgery when infection pre-
postoperative wound infection while still hospitalized.
sented was more than 2 weeks in 18 of the 41 patients
The presence of hematomas and bloody drainage in
20% of the cases with infection is considerable but
TABLE 1
Operations Developing Infection only about half that found in the general orthopaedic
No. of times
infections.
Operation infection developed The mild nature of most of these 41 postoperative
Lateral ankle ligament repair 5
wound infections may be indicated by the fact that 24
Plantar neuroma excision 5 patients received only tetracycline, and two patients
Bunionectomy 4 received no antibiotics at all. Eleven received eryth-
Achilles tendon surgery 4 romycin. Nine received cephalosporins, Three pa-
Multiple metatarsal head removal 3 tients received oxacillin. One patient received genta-
Accessory navicular removal 3
Fifth metatarsal head removal 3
mycin and carbenicillin. Only three patients received
Toe spur removal 3 intravenous antibiotics.
Plantar fasciotomy 2 The infection rates for the three categories of infec-
Hardware removal 2 tion in foot and ankle surgery are similar to the rates
Ankle fusion 1 in the general orthopaedic series. The gross rate of
Tibiofibular diastasis 1
Calcaneal spur removal 1
infection was 2.8% in the general series and 2.2% in
Osteotomy fifth metatarsal 1 the foot and ankle group. Four patients in the general
Osteotomy big toe 1 series of 2264 patients developed permanent damage
Tarsometatarsal ganglion 1 (0.18%) as against one in 1841 (0.05%) in the foot
Amputation little toe 1
and ankle group. Seven patients in the general series

Downloaded from fai.sagepub.com at UNIV NEBRASKA LIBRARIES on December 22, 2015

104 MILLER Foot & Ankle/Vol. 4, NO.1

required secondary operations. The rate of infection
in the 11 cases in the general series requiring sec-
ondary surgery or with permanent damage (0.49%) is
not significantly greater than that of the four cases
(0.22%) in the foot and ankle study group.
This series presents a benchmark from which to
judge the usefulness of prophylactic antibiotics, par-
ticularly in the prevention of damaging infections. The
literature contains few references to infection rates in
foot and ankle surgery when adequate drug prophy-
laxis has been used. Pavel et a1. 1 , 2 presented a series
of 96 foot and ankle operations in which the infection
rate was actually higher in the patients receiving pro-
phylactic perioperative antibiotics than it was in their
control group without any antibiotics.
manent disability and only three patients required
unanticipated surgery as a result of postoperative
wound infection.
ACKNOWLEDGMENTS
Some of the material in this report is reprinted by
permission from the author's paper "Postoperative
Wound Infection in Orthopedic Surgery" published in
The Journal of the Oklahoma State Medical Associa-
tion, Volume 74, No. 11, November 1981, pages 353-
356, Copyright 1981 by Oklahoma State Medical
Association.
REFERENCES

CONCLUSION
In a series of 1841 consecutive foot and ankle
operations performed without prophylactic antibiotics,
serious postoperative wound infections have not been
a frequent problem. Only one patient developed per-
1. Pavel, A., Smith, R.L., Ballard, A., and Larsen, I.J.: Prophy-
lactic antibiotics in clean orthopaedic surgery. J. Bone Joint
Surg., 56A:777-782, 1974.
2. Pavel, A., Smith, R.L., Ballard, A., and Larsen, I.J.: Prophy-
lactic antibiotics in elective orthopaedic surgery: a postopera-
tive study of 1,591 cases, South Med J., 70(Suppl. 1 ):50-55,
1977.

REQUEST FOR PAPERS

The American Orthopaedic Foot and Ankle Society requests the submission of
manuscripts for Foot & Ankle. Request is also being made for review articles and
symposia on the foot and ankle.
Manuscripts, with illustrations, should be submitted in duplicate to Melvin H. Jahss,
M.D., Editor-in-Chief, 64 East 86th Street, New York, New York 10028. Telephone:
(212)535-8866.

Downloaded from fai.sagepub.com at UNIV NEBRASKA LIBRARIES on December 22, 2015