Is lateral ankle soft tissue thickness a risk factor for fracture-related infection in rotational ankle fractures? A retrospective review
This retrospective study of 116 patients undergoing open reduction and internal fixation for closed rotational ankle fractures found that preoperative lateral ankle soft tissue thickness is not an independent predictor of fracture-related infection, whereas increasing age was significantly associated with higher infection risk.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
When a bone breaks around the ankle, the skin and muscle covering it are often the first things a surgeon worries about. Ankle fractures are common injuries, and while doctors can usually fix the broken bones with plates and screws, a serious complication can sometimes follow: an infection deep in the wound. This infection, known as a fracture-related infection, can turn a routine recovery into a long, painful struggle requiring more surgeries and antibiotics. For years, medical teams have looked for clues in a patient's history to predict who might get sick. They know that older age, diabetes, and smoking make infections more likely. But because these factors are often unchangeable at the moment of injury, surgeons have wondered if they could find a warning sign right on the X-ray or scan. Specifically, they asked if the thickness of the soft tissue—the layer of skin and fat—on the outside of the ankle might be the key. If a thicker layer of tissue made it harder for the body to heal or easier for bacteria to hide, measuring it before surgery could help doctors prepare better.
To answer this question, a team of researchers at a major trauma center in Denver looked back at the records of nearly 250 adults who had undergone surgery for closed rotational ankle fractures between 2019 and 2025. They focused only on patients who had a specific type of break where the bone twists, rather than one that shattered the skin open. The team wanted to see if the amount of soft tissue on the outside of the ankle, measured on a pre-operative computerized tomography scan, could predict who would develop an infection later. They carefully measured the distance from the outer bone of the lower leg to the surface of the skin at three different points along the ankle. They then grouped the patients into three categories: those with very thin tissue, those with a standard amount, and those with thick tissue.
The researchers found that the thickness of the skin and fat did not matter for the risk of infection. Out of the 116 patients who met all the strict criteria for the study, ten developed an infection. When the team compared the measurements of the infected patients to those who healed without trouble, the numbers were nearly identical. Whether a patient had a thin layer of tissue or a thick one, their chance of getting an infection was the same. The data showed no link between how much soft tissue was present and whether an infection would occur. In fact, the study identified only one factor that truly increased the risk: age. Patients who were older than the average age of the group were significantly more likely to develop an infection, regardless of how much soft tissue they had.
This finding is important because it tells surgeons that they do not need to worry about the thickness of the ankle tissue when planning an operation or predicting a patient's recovery. While a thicker layer of tissue might seem like it could complicate healing, the study proves it is not a cause for concern in these specific types of fractures. The researchers noted that their study had some limits, such as measuring the tissue after the injury had already caused some swelling, which might have made the layers look thicker than they normally are. They also acknowledged that their group of patients was relatively small and came from a single hospital. Despite these limitations, the evidence is clear: for adults with closed rotational ankle fractures, the amount of soft tissue on the outside of the ankle is not a predictor of infection. Surgeons can continue to focus on other factors, particularly a patient's age, when assessing the risks of surgery, without needing to alter their approach based on how much tissue covers the bone.
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