Assessment of ankle fracture surgical wounds: the development and testing of the Wound after Osteosynthesis Kolding (WOK) score

Introduction: Describing surgical wounds accurately poses challenges due to the diverse terminology used for complications. Existing evaluation methods do not cater specifically to surgical wounds from post-ankle fracture surgery with osteosynthesis. Given the unique anatomical challenges and treatment considerations (limited tissue coverage and blood supply as well as the surgical treatment with osteosynthesis), a targeted wound score is essential for ensuring consistent evaluation and high-quality care and thereby optimizing patient outcomes and satisfaction. The study aimed to develop a wound score specifically for evaluating surgical wounds following ankle fracture surgery. Method: Development of the Wound after Osteosynthesis Kolding score (WOK) proceeded through three phases: 1) identifying WOK domains, 2) developing item and response options, and 3) pilot testing the WOK score. Results: Five domains were identified: erythema, swelling, dehiscence, exudate and warmth. Response options were derived from literature and clinical insights. Content validity was assessed with an S-CVI/Ave of 0.93 for nurses and 0.82 for orthopedic surgeons. Orthopedic surgeons perceived erythema and warmth as less relevant, while nurses considered all five domains to be fairly or very relevant. High agreement between scores was found, but varying kappa scores were observed when assessing intra-rater reliability. Inter-rater reliability was acceptable across all domains (κ = 0.44 to 1.00). Warmth was omitted from the final WOK score due to low content validity among orthopedic surgeons and poor inter-rater reliability. Additionally, assessing warmth in a clinical setting was challenging because ankle brace stabilization affects overall skin humidity and warmth. Conclusions: The Wound after Osteosynthesis Kolding score (WOK) has proven to be a content-valid and reliable tool for assessing minor complications in surgical wounds following ankle fracture surgery.