Impact of timing of surgery on wound complications and re-operations following closed ankle fracture fixation: a systematic review and meta-analysis

Keywords:

Ankle, fracture, surgery, fixation, timing, wound complications


Published online: Feb 24 2026

https://doi.org/10.52628/91.3.12971

M.M. FARHAN-ALANIE1, R. SAHEMEY2, K. AL-HOURANI3, A. TROMPETER4

1 MBChB, BMedSci(Hons), MRCS(Ed), MSc(Dist), PgCert(MedEd), PgDip, FHEA, MFST(Ed), NIHR Doctoral Research Fellow, Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
2 MBBS, FRCS(Tr+Orth), Consultant Trauma & orthopaedic Surgeon, Department of Trauma & Orthopaedics, University Hospitals Birmingham NHS Foundation Trust, B15 2GW, UK
3 MBChB, MFST, MD, PhD, FRCS(Tr+Orth), Consultant Trauma & Orthopaedic Knee Surgeon, Department of Trauma & Orthopaedics, Frimley Health NHS Foundation Trust, Frimley, GU16 7UJ, UK
4 MBBS, BSc, FRCS(Tr+Orth), Consultant Orthopaedic Trauma Surgeon and Professor of Orthopaedic Trauma, St George’s University Hospital NHS Foundation Trust and St George’s University of London, UK

Abstract

Background: The optimal timing of surgical fixation for closed ankle fractures remains uncertain. Advocates of early surgery suggest it enables faster rehabilitation without additional soft tissue insult, whereas delayed surgery is often favoured due to concerns about wound complications in the presence of swelling. This systematic review evaluated whether surgical timing influences wound complications and unplanned reoperation rates.

Methods: Multiple databases were searched for RCTs and cohort studies. Primary outcomes were wound complications and unplanned re-operation events. Two reviewers independently screened, assessed quality, and extracted data.

Random effects meta-analysis was performed.

Results: Nine studies were included. Three reported significantly fewer wound complications with earlier fixation: within 24 hours (0/60 vs 16/145, p=0.004), four days (6.4% vs 18.6%, p=0.02), six days (2/56 vs 6/29, p=0.01), and seven days (2/98 vs 14/107, p=0.003). However, pooled analyses showed no differences at thresholds of 24 hours (RR 1.04, 95%CI 0.95-1.14, p=0.41), five days (RR 1.03, 95%CI 0.96-1.09, p=0.43), or seven days (RR 1.10, 95%CI 0.99-1.21, p=0.06). Four studies assessed unplanned reoperation; none found significant differences, and pooled analysis showed no difference between surgery performed within versus after five days (RD 0.04, 95%CI -0.07-0.15, p=0.49).

Conclusions: There is low quality evidence from three of nine studies suggesting that earlier fixation is associated with relatively reduced wound complications, but most studies showed no difference. No association was observed with unplanned reoperation. A large, prospective trial powered to wound complications is required to clarify causality. An RCT powered to investigate these outcomes is required to clarify causality.

ActaOrthopBelg-91-2-cover

About this issue

Volume 91, issue 3.

Autumn 2025.

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