Infection after fracture fixation of the tibia: Analysis of healthcare utilization and related costs

Development of an ex vivo model to study Staphylococcus aureus invasion of the osteocyte lacuno-canalicular network

Staphylococcus aureus has multiple mechanisms to evade the host's immune system and antibiotic treatment. One such mechanism is the invasion of the osteocyte lacuno-canalicular network (OLCN), which may be particularly important in recurrence of infection after debridement and antibiotic therapy. The aim of this study was to develop an ex vivo model to facilitate further study of S. aureus invasion of the OLCN and early-stage testing of antibacterial strategies against bacteria in this niche. The diameter of the canaliculi of non-infected human, sheep, and mouse bones was measured microscopically on Schmorl's picrothionin stained sections, showing a large overlap in canalicular diameter. S. aureus successfully invaded the OLCN in all species in vitro as revealed by presence in osteocyte lacunae in Brown and Brenn-stained sections and by scanning electron microscopy. Murine bones were then selected for further experiments, and titanium pins with either a wild-type or ΔPBP4 mutant S. aureus USA300 were placed trans-cortically and incubated for 2 weeks in tryptic soy broth. Wild-type S. aureus readily invaded the osteocyte lacunae in mouse bones while the ΔPBP4 showed a significantly lower invasion of the OLCN (p = 0.0005). Bone specimens were then treated with gentamicin, sitafloxacin, R14 bacteriophages, or left untreated. Gentamicin (p = 0.0027) and sitafloxacin (p = 0.0280) significantly reduced the proportion of S. aureus-occupied lacunae, whilst bacteriophage treatment had no effect. This study shows that S. aureus is able to invade the OLCN in an ex vivo model. This ex vivo model can be used for future early-stage studies before proceeding to in vivo studies.

Weight-bearing timing after the operative management of ankle fractures: Single center audit and critical appraisal of literature

The postoperative weight-bearing policy following internal fixation of unstable ankle fractures varies greatly and is largely surgeon-dependent. While early weight-bearing is favoured for its superior functional and economic outcomes, late weight-bearing may be safer initially. However, consensus on the preferred treatment protocol is lacking. We audited practices at University Hospitals Leuven, Belgium, comparing them to existing literature to establish an updated protocol. In a retrospective study of 236 patients with unstable ankle fractures, we compared outcomes between early (EWB) and late weight-bearing (LWB) strategies, with or without braces and/or vacuum casts. Most patients followed a LWB protocol, while EWB was reserved for younger, lower BMI individuals. The difference in brace or vacuum cast usage was insignificant. All open fractures followed a LWB protocol. No disparities in union rates, complications, or length of stay were found between EWB and LWB. Surgical management cost €6,419 (6,921 US $) on average, with length of stay being the main cost driver. Total healthcare costs did not differ significantly between EWB and LWB. FRI was revealed in 6 cases, (1 [4%] vs. 5 [2.5%], EWB vs. LWB respectively, P=0.922) In conclusion, while no significant differences in outcomes were observed between EWB and LWB rehabilitation, differences in group characteristics may have influenced these findings. Despite limited EWB cases, it appears safe for younger patients with low BMI. Vacuum casts and braces aid in EWB. Reducing length of stay, rather than restricting orthotic use, may help control healthcare costs.

Antibacterial Immunonegative Coating with Biocompatible Materials on a Nanostructured Titanium Plate for Orthopedic Bone Fracture Surgery

Periprosthetic infections resulting from bacterial biofilm formation following surgical bone fracture fixation present important clinical challenges. Conventional orthopedic implant materials, such as titanium, are prone to biofilm formation. This study introduces a novel surface for orthopedic titanium plates, optimized for clinical application in human bone fractures. Leveraging nanostructure-based surface coating technology, the plate achieves an antibacterial/immunonegative surface using biocompatible materials, including poloxamer 407, epigallocatechin gallate, and octanoic acid. These materials demonstrate high biocompatibility and thermal stability after autoclaving. The developed plate, named antibacterial immunonegative surface, releases antibacterial agents and prevents adhesion between human tissue and metal surfaces. Antibacterial immunonegative surface plates exhibit low cell toxicity, robust antibacterial effects against pathogens such as Staphylococcus aureus and Pseudomonas aeruginosa, high resistance to biofilm formation on the implant surface and surrounding tissues, and minimal immune reaction in a rabbit femoral fracture model. This innovation holds promise for addressing periprosthetic infections and improving the performance of orthopedic implants.

Costs of fracture-related infection: the impact on direct hospital costs and healthcare utilisation

PURPOSE

Fracture-Related Infection (FRI) is associated with high medical costs and prolonged healthcare utilization. However, limited data is available on the financial impact. The purpose of this study was to investigate the impact of FRI on direct hospital costs and healthcare utilization.

METHODS

This was a retrospective cohort study in a level-1 trauma centre in the Netherlands. Patients ≥ 18 years, after open reduction and internal fixation of a long bone fracture between January 1st 2016 and November 1st 2021, were included. Exclusion criteria were Injury Severity Score (ISS) ≥ 16, indefinable data on costs or incomplete follow-up. Hospital costs related to fracture treatment were individually calculated based on procedure codes raised with a fixed percentage of overhead expenses, in line with hospital billing policies.

RESULTS

In total, 246 patients were included with a median follow-up of 1 year (IQR 0.6-1.8). A total of 45 patients developed FRI, of whom 15 patients had an FRI recurrence. Compared to non-FRI patients, median hospital costs from an FRI patient without and with recurrence, were respectively three (3.1) and seven (7.6) times higher. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries, and 21 or 55 days of intravenous antibiotic treatment.

CONCLUSION

Direct healthcare costs of patients with single occurrence of FRI after long bone fracture treatment are three times higher compared to non-FRI patients. In case of FRI-recurrence, the differences in costs might even increase to sevenfold. To put this in perspective, cost of severely injured trauma patients were recently established at approximately 25.000 euros. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries and 21 or 55 days of intravenous antibiotic treatment. Not only from patient perspective but also from a financial aspect, it is important to focus on prevention of (recurrent) FRI.

Pathogens in FRI - Do bugs matter? - An analysis of FRI studies to assess your enemy

Fracture-related infection (FRI) is a devasting complication for both patients and their treating Orthopaedic surgeon that can lead to loss of limb function or even amputation. The unique and unpredictable features of FRI make its diagnosis and treatment a significant challenge. It has substantial morbidity and financial implications for patients, their families and healthcare providers. In this article, we perform an in-depth and comprehensive review of FRI through recent and seminal literature to highlight evolving definitions, diagnostic and treatment approaches, focusing on common pathogens such as Staphylococcus aureus, polymicrobial infections and multi-drug-resistant organisms (MDRO). Furthermore, multiple resistance mechanisms and adaptations for microbial survival are discussed, as well as modern evidence-based medical and surgical advancements in treatment strategies in combating FRI.

Clinical characteristics and outcomes associated with culture-negative status in limb osteomyelitis patients

Aims

This study aimed to investigate the clinical characteristics and outcomes associated with culture-negative limb osteomyelitis patients.

Methods

A total of 1,047 limb osteomyelitis patients aged 18 years or older who underwent debridement and intraoperative culture at our clinic centre from 1 January 2011 to 31 December 2020 were included. Patient characteristics, infection eradication, and complications were analyzed between culture-negative and culture-positive cohorts.

Results

Of these patients, 264 (25.2%) had negative cultures. Patients with a culture-negative compared with a culture-positive status were more likely to have the following characteristics: younger age (≤ 40 years) (113/264 (42.8%) vs 257/783 (32.8%); p = 0.004), a haematogenous aetiology (75/264 (28.4%) vs 150/783 (19.2%); p = 0.002), Cierny-Mader host A (79/264 (29.9%) vs 142/783 (18.1%); p < 0.001), antibiotic use before sampling (34/264 (12.9%) vs 41/783 (5.2%); p＜0.001), fewer taken samples (n＜3) (48/264 (18.2%) vs 60/783 (7.7%); p＜0.001), and less frequent presentation with a sinus (156/264 (59.1%) vs 665/783 (84.9%); p < 0.001). After initial treatments of first-debridement and antimicrobial, infection eradication was inferior in culture-positive osteomyelitis patients, with a 2.24-fold increase (odds ratio 2.24 (95% confidence interval 1.42 to 3.52)) in the redebridement rate following multivariate analysis. No statistically significant differences were found in long-term recurrence and complications within the two-year follow-up.

Conclusion

We identified several factors being associated with the culture-negative result in osteomyelitis patients. In addition, the data also indicate that culture negativity is a positive prognostic factor in early infection eradication. These results constitute the basis of optimizing clinical management and patient consultations.

Psychiatric Diagnosis Does Not Influence Management or Resolution of Confirmed Fracture-Related Infection

BACKGROUND

The purpose of this study was to determine if the presence of a standing Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, psychiatric diagnosis is associated with worse outcomes for patients who develop a confirmed fracture-related infection (FRI).

MATERIALS AND METHODS

Included patients had open or closed fractures managed with internal fixation and had confirmed FRIs. Baseline demographics, injury information, and outcomes were collected via chart review. All patients who had a diagnosis of psychiatric illness, which included depression, bipolar disorder, anxiety disorder, and schizophrenia, were identified. Patients with and without a psychiatric diagnosis were statistically compared.

RESULTS

Two hundred eleven patients were diagnosed with a confirmed FRI. Fifty-seven (27.0%) patients had a diagnosis of a psychiatric illness at the time of FRI diagnosis. Patients with a psychiatric diagnosis had a higher rate of smoking (56% vs 40%, P=.039) and drug use (39% vs 19%, P=.004) and a higher American Society of Anesthesiologists (ASA) classification (2.35±1.33 vs 1.96±1.22, P=.038); however, there were no other demographic differences. Clinical outcomes also did not differ between the groups, as patients with an FRI and a psychiatric diagnosis had a similar time to FRI diagnosis, similar confirmatory FRI characteristics, and a similar rate of reoperation. Furthermore, there was no difference between patients with FRI with and without a psychiatric diagnosis regarding rate of infection resolution (89% vs 88%, P=.718) or time to final follow-up (20.13±24.93 vs 18.11±21.81 months, P=.270).

CONCLUSION

The presence of a psychiatric diagnosis does not affect clinical outcomes in the patient population with FRI. This is the first study exploring the impact of psychiatric illness on patient outcomes after a confirmed FRI diagnosis. [Orthopedics. 2024;47(4):198-204.].

3DFRINet: A Framework for the Detection and Diagnosis of Fracture Related Infection in Low Extremities Based on 18F-FDG PET/CT 3D Images

Fracture related infection (FRI) is one of the most devastating complications after fracture surgery in the lower extremities, which can lead to extremely high morbidity and medical costs. Therefore, early comprehensive evaluation and accurate diagnosis of patients are critical for appropriate treatment, prevention of complications, and good prognosis. 18Fluoro-deoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is one of the most commonly used medical imaging modalities for diagnosing FRI. With the development of deep learning, more neural networks have been proposed and become powerful computer-aided diagnosis tools in medical imaging. Therefore, a fully automated two-stage framework for FRI detection and diagnosis, 3DFRINet (Three Dimension FRI Network), is proposed for 18F-FDG PET/CT 3D imaging. The first stage can effectively extract and fuse the features of both modalities to accurately locate the lesion by the dual-branch design and attention module. The second stage reduces the dimensionality of the image by using the maximum intensity projection, which retains the effective features while reducing the computational effort and achieving excellent diagnostic performance. The diagnostic performance of lesions reached 91.55% accuracy, 0.9331 AUC, and 0.9250 F1 score. 3DFRINet has an advantage over six nuclear medicine experts in each classification metric. The statistical analysis shows that 3DFRINet is equivalent or superior to the primary nuclear medicine physicians and comparable to the senior nuclear medicine physicians. In conclusion, this study first proposed a method based on 18F-FDG PET/CT three-dimensional imaging for FRI location and diagnosis. This method shows superior lesion detection rate and diagnostic efficiency and therefore has good prospects for clinical application.

The global burden of fracture-related infection: can we do better?

Fracture-related infection is a major complication related to musculoskeletal injuries that not only has important clinical consequences, but also a substantial socioeconomic impact. Although fracture-related infection is one of the oldest disease entities known to mankind, it has only recently been defined and, therefore, its global burden is still largely unknown. In this Personal View, we describe the origin of the term fracture-related infection, present the available data on its global impact, and discuss important aspects regarding its prevention and management that could lead to improved outcomes in both high-resource and low-resource settings. We also highlight the need for health-care systems to be adequately compensated for the high cost of human resources (trained staff) and well-equipped facilities required to adequately care for these complex patients. Our aim is to increase awareness among clinicians and policy makers that fracture-related infection is a disease entity that deserves prioritisation in terms of research, with the goal to standardise treatment and improve patient outcomes on a global scale.

Analysis of risk factors, pathogenic bacteria characteristics, and drug resistance of postoperative surgical site infection in adults with limb fractures

PURPOSE

We carried out the study aiming to explore and analyze the risk factors, the distribution of pathogenic bacteria, and their antibiotic-resistance characteristics influencing the occurrence of surgical site infection (SSI), to provide valuable assistance for reducing the incidence of SSI after traumatic fracture surgery.

METHODS

A retrospective case-control study enrolling 3978 participants from January 2015 to December 2019 receiving surgical treatment for traumatic fractures was conducted at Tangdu Hospital of Air Force Medical University. Baseline data, demographic characteristics, lifestyles, variables related to surgical treatment, and pathogen culture were harvested and analyzed. Univariate analyses and multivariate logistic regression analyses were used to reveal the independent risk factors of SSI. A bacterial distribution histogram and drug-sensitive heat map were drawn to describe the pathogenic characteristics.

RESULTS

Included 3978 patients 138 of them developed SSI with an incidence rate of 3.47% postoperatively. By logistic regression analysis, we found that variables such as gender (males) (odds ratio (OR) = 2.012, 95% confidence interval (CI): 1.235 - 3.278, p = 0.005), diabetes mellitus (OR = 5.848, 95% CI: 3.513 - 9.736, p < 0.001), hypoproteinemia (OR = 3.400, 95% CI: 1.280 - 9.031, p = 0.014), underlying disease (OR = 5.398, 95% CI: 2.343 - 12.438, p < 0.001), hormonotherapy (OR = 11.718, 95% CI: 6.269 - 21.903, p < 0.001), open fracture (OR = 29.377, 95% CI: 9.944 - 86.784, p < 0.001), and intraoperative transfusion (OR = 2.664, 95% CI: 1.572 - 4.515, p < 0.001) were independent risk factors for SSI, while, aged over 59 years (OR = 0.132, 95% CI: 0.059 - 0.296, p < 0.001), prophylactic antibiotics use (OR = 0.082, 95% CI: 0.042 - 0.164, p < 0.001) and vacuum sealing drainage use (OR = 0.036, 95% CI: 0.010 - 0.129, p < 0.001) were protective factors. Pathogens results showed that 301 strains of 38 species of bacteria were harvested, among which 178 (59.1%) strains were Gram-positive bacteria, and 123 (40.9%) strains were Gram-negative bacteria. Staphylococcus aureus (108, 60.7%) and Enterobacter cloacae (38, 30.9%) accounted for the largest proportion. The susceptibility of Gram-positive bacteria to Vancomycin and Linezolid was almost 100%. The susceptibility of Gram-negative bacteria to Imipenem, Amikacin, and Meropenem exceeded 73%.

CONCLUSION

Orthopedic surgeons need to develop appropriate surgical plans based on the risk factors and protective factors associated with postoperative SSI to reduce its occurrence. Meanwhile, it is recommended to strengthen blood glucose control in the early stage of admission and for surgeons to be cautious and scientific when choosing antibiotic therapy in clinical practice.

Predictive factors for infection after osteosynthesis of tibial plateau fractures: a retrospective study of 314 patients

INTRODUCTION

The reported incidence of infection related with tibial plateau fractures (IRTPF) ranges from 2 to 23%. This complication can result in catastrophic consequences such as deformity, post-traumatic osteoarthritis, chronic pain, loss of function, and substantial economic burdens on healthcare systems due to extended hospital stays and the resources required for treatment. Consequently, it is imperative to emphasize the identification of infection risk factors.

METHODS

A retrospective case-control study was designed, encompassing patients who underwent surgery for tibial plateau fractures between 2015 and 2020. Frequencies and measures of central tendency were compared between infected patients (cases) and non-infected patients (controls) using rank-based statistical tests. Subsequently, two logistic regression models were employed to control for potential confounding variables.

RESULTS

A total of 314 patients were included, predominantly male (71.15%). Average age of 44.41 years. IRTPF were observed in 7.64% of the patients. In the univariate inferential statistical analysis, high-energy fractures (OR 6.35, p < 0.001), fractures with compartment syndrome (OR 7.10, p < 0.001), two-stage management with temporary external fixation (OR 8.18, p < 0.001), the use of 2 or more approaches in definitive surgery (OR 2.93, p = 0.011), and the use of two or more plates (OR 9.17, p < 0.001) were identified as risk factors for infection. On average, the duration of surgery in infected patients was 201.2 min, compared to 148.4 min in non-infected patients (p < 0.001). When performing two logistic regression models, the following independent risk factors were identified: high-energy fractures (OR 5.04, p = 0.012), the presence of compartment syndrome (OR 4.53, p = 0.007), and the use of two or more plates in definitive surgery (OR 5.04, p = 0.023).

CONCLUSIONS

High-energy tibial plateau fractures (Schatzker IV, V, and VI), the presence of concomitant compartment syndrome, and the use of 2 or more plates in definitive surgery are associated with a higher risk of infection related to fracture following open reduction and osteosynthesis treatment.

LEVEL OF EVIDENCE

Case-Control Study.

LEVEL III EVIDENCE

The Impact of Smoking on Hospital Course and Postoperative Outcomes in Patients With Fracture-Related Infections

OBJECTIVES

To assess the relationship between patient smoking status and fracture-related infection (FRI) characteristics including patient symptoms at FRI presentation, bacterial species of FRI, and rates of fracture union.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Urban level 1 trauma center.

PATIENT SELECTION CRITERIA

All patients undergoing reoperation for FRI from January 2013 to April 2021 were identified through manual review of an institutional database.

OUTCOME MEASURES AND COMPARISONS

Data including patient demographics, fracture characteristics, infection presentation, and hospital course were collected through review of the electronic medical record. Patients were grouped based on current smoker versus nonsmoker status. Hospital course and postoperative outcomes of these groups were then compared. Risk factors of methicillin-resistant Staphylococcus aureus (MRSA) infection, Staphylococcus epidermidis infection, and sinus tract development were evaluated using multivariable logistic regression.

RESULTS

A total of 301 patients, comprising 155 smokers (51%) and 146 nonsmokers (49%), undergoing FRI reoperation were included. Compared with nonsmokers, smokers were more likely male (69% vs. 56%, P = 0.024), were younger at the time of FRI reoperation (41.7 vs. 49.5 years, P < 0.001), and had lower mean body mass index (27.2 vs. 32.0, P < 0.001). Smokers also had lower prevalence of diabetes mellitus (13% vs. 25%, P = 0.008) and had higher Charlson Comorbidity Index 10-year estimated survival (93% vs. 81%, P < 0.001). Smokers had a lower proportion of S. epidermidis infections (11% vs. 20%, P = 0.037), higher risk of nonunion after index fracture surgery (74% vs. 61%, P = 0.018), and higher risk of sinus tracts at FRI presentation (38% vs. 23%, P = 0.004). On multivariable analysis, smoking was not found to be associated with increased odds of MRSA infection.

CONCLUSIONS

Among patients who develop a FRI, smokers seemed to have better baseline health regarding age, body mass index, diabetes mellitus, and Charlson Comorbidity Index 10-year estimated survival compared with nonsmokers. Smoking status was not significantly associated with odds of MRSA infection. However, smoking status was associated with increased risk of sinus tract development and nonunion and lower rates of S. epidermidis infection at the time of FRI reoperation.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Time to Positivity in Blood Culture Bottles Inoculated with Sonication Fluid from Fracture-Related Infections

The timely and accurate identification of causative agents is crucial for effectively managing fracture-related infections (FRIs). Among various diagnostic methods, the "time to positivity" (TTP) of cultures has emerged as a valuable predictive factor in infectious diseases. While sonication of implants and inoculation of blood culture bottles with sonication fluid have enhanced sensitivity, data on the TTP of this microbiological technique remain limited. Therefore, patients with ICM criteria for confirmed FRI treated at our institution between March 2019 and March 2023 were retrospectively identified and their microbiological records were analyzed. The primary outcome parameter was TTP for different microorganism species cultured in a liquid culture collected from patients with confirmed FRI. A total of 155 sonication fluid samples from 126 patients (average age 57.0 ± 17.4 years, 68.3% males) was analyzed. Positive bacterial detection was observed in 78.7% (122/155) of the liquid culture pairs infused with sonication fluid. Staphylococcus aureus was the most prevalent organism (42.6%). Streptococcus species exhibited the fastest TTP (median 11.9 h), followed by Staphylococcus aureus (median 12.1 h) and Gram-negative bacteria (median 12.5 h), all of which had a 100% detection rate within 48 h after inoculation. Since all Gram-negative pathogens yielded positive culture results within 24 h, it could be discussed if empirical antibiotic therapy could be de-escalated early and limited towards the Gram-positive germ spectrum if no Gram-negative pathogens are detected up to this time point in the context of antibiotic stewardship.

The surgical management of fracture-related infection. Surgical strategy selection and the need for early surgical intervention

The aim of this narrative review is to describe the various surgical management strategies employed in fracture-related infection (FRI), to explore how they are selected and discuss the rationale for early surgical intervention. Surgical treatment options in patients with FRI include debridement, antibiotics and implant retention (DAIR), revision (exchange) or removal. In selecting a treatment strategy, a variety of factors need to be considered, including the condition of the bone, soft tissues, host and causative microorganism. Irrespective of the selected treatment strategy, prompt surgical intervention should be considered in order to confirm the diagnosis of an FRI, to identify the causative organism, remove necrotic or non-viable tissue that can serve as a nidus for ongoing infection, ensure a healthy soft tissue envelope and to prevent the vicious cycle of infection associated with skeletal and/or implant instability. Ultimately, the objective is to prevent the establishment of a persistent infection. Urgent surgery may be indicated in case of active, progressive disease with systemic deterioration, local progression of infection, deterioration of soft tissues, or progressive fracture instability. In case of static disease, the patient should be monitored closely and surgery can be performed on an elective basis, allowing adequate time for optimisation of the host through risk factor modification, optimisation of the soft tissues and careful planning of the surgery.

Bones on fire: illuminating osteomyelitis through the radiant lens of 18F-FDG PET/CT

Osteomyelitis is an inflammatory process that is caused by an infecting microorganism and leads to progressive bone destruction and loss. Osteomyelitis can occur at any age and can involve any bone. The infection can be limited to a single portion of the bone or can involve several regions, such as marrow, cortex, periosteum, and the surrounding soft tissue. Early and accurate diagnosis plays a crucial role in reducing unnecessary treatment measures, improving the patient's prognosis, and minimizing time and financial costs. In recent years, the use of functional metabolic imaging has become increasingly widespread. Among them, 18F-FDG PET/CT has emerged as a cutting-edge imaging modality that combines anatomical and functional metabolic information. It has seen rapid development in the field of infectious diseases. 18F-FDG PET/CT has been demonstrated to yield acceptable diagnostic accuracy in a number of infectious and inflammatory diseases. This review aims to provide information about the 18F-FDGPET/CT in the use of chronic osteomyelitis,osteomyelitis secondary to a contiguous focus of infection and osteomyelitis associated with peripheral vascular disease.

Estimating the economic impact of complications after open tibial fracture: A secondary analysis of the pilot Gentamicin Open Tibia trial (pGO-Tibia)

Objectives

To estimate the indirect economic impact of tibial fractures and their associated adverse events (AEs) in Tanzania.

Design

A secondary analysis of the pilot Gentamicin Open (pGO)-Tibia randomized control trial estimating the indirect economic impact of suffering an AE, defined as a fracture-related infection (FRI) and/or nonunion, after an open tibial fracture in Tanzania.

Setting

The pGO-Tibia trial was conducted from November 2019 to August 2021 at the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania.

Patients/Participants

One hundred adults with open tibial shaft fractures participated in this study.

Intervention

Work hours were compared between AE groups. Cost data were analyzed using a weighted-average hourly wage and converted into purchasing power parity-adjusted USD.

Main Outcome Measurements

Indirect economic impact was analyzed from the perspective of return to work (RTW), lost productivity, and other indirect economic and household costs. RTW was analyzed using a survival analysis.

Results

Half of patients returned to work at 1-year follow-up, with those experiencing an AE having a significantly lower rate of RTW. Lost productivity was nearly double for those experiencing an AE. There was a significant difference in the mean outside health care costs between groups. The total mean indirect cost was $2385 with an AE, representing 92% of mean annual income and an increase of $1195 compared with no AE. There were significantly more patients with an AE who endorsed difficulty affording household expenses postinjury and who borrowed money to pay for their medical expenses.

Conclusions

This study identified serious economic burden after tibial fractures, with significant differences in total indirect cost between those with and without an AE.

Level of Evidence

II.

Developing an antibiogram for empiric antibiotic prescribing for adult non-spinal orthopaedic infections in a developing world setting

PURPOSE

Empiric antibiotic strategies in the treatment of fracture-related infections, chronic osteomyelitis, prosthetic joint infection, and septic arthritis should be based on local microbiological antibiograms. This study aims to describe the microbiology and review the antibiogram profiles of bacterial isolates from patients undergoing surgical treatment for non-spinal orthopaedic infections, to identify the most appropriate empiric antibiotic strategy.

METHODS

A retrospective review was performed of all cases of non-spinal orthopaedic infections treated surgically from 1 January 2018 to 31 December 2018. The National Health Laboratory Service microbiology database was used to identify all intra-operative microbiological specimens obtained from orthopaedic patients, and data were correlated with the orthopaedic surgical database. Cases were divided into fracture-related infections, chronic osteomyelitis, prosthetic joint infection, and septic arthritis. Antibiotic susceptibility data were used to predict the efficacy of different empiric antibiotic regimens.

RESULTS

A total of 107 cases were included in the study; 184 organisms were cultured. Overall, the most common organism cultured was Staphylococcus aureus (25%) followed by Acinetobacter baumannii (9%), Enterococcus faecalis (7%) and Enterobacter cloacae (5%). Across all categories the oral antibiotic combination with the highest effectiveness (81%) would have been a combination of co-trimoxazole, ciprofloxacin and amoxicillin. The most effective intravenous antibiotic combination would have been either piperacillin-tazobactam, amikacin and vancomycin or meropenem and vancomycin; 90% of tested isolates were susceptible to either of these combinations.

CONCLUSION

Antibiogram profiles can serve to guide to empiric antibiotic choice in the management of different categories of non-spinal orthopaedic infections.

[Importance of local antibiotics in the prophylaxis and treatment of fracture-associated infections]

BACKGROUND

Fracture-associated infections (FRI) are a severe complication that lead to higher morbidity and high costs for the healthcare system. An effective prophylaxis and treatment of FRI are therefore of great interest.

OBJECTIVE

The aim of this review is to summarize the available evidence on the use of local antibiotics for the prophylaxis and treatment of FRI.

MATERIAL AND METHODS

A thorough search and a narrative synthesis of the available literature were performed. Their depiction is supplemented by an illustrative presentation of a case report.

RESULTS

A robust consensus definition of FRI has existed since 2018. The current use of local antibiotics for the prophylaxis and treatment of FRI in Germany is heterogeneous. There is no consensus on local antibiotic treatment of FRI. The available literature shows an advantage for the additive local antibiotic treatment of open fractures. In closed fractures there is a tendency towards an advantage especially in the presence of further risk factors (long duration of external fixation, higher degree of closed tissue damage, compartment syndrome). According to analogous data from the field of endoprosthetics, additive local antibiotic treatment could also be advantageous under closed soft tissue conditions. The evidence is insufficient to enable the recommendation for a specific antibiotic or a specific mode of application. Local and systemic adverse reactions are frequently discussed in the literature but their incidence is low.

CONCLUSION

Overall, additive local antibiotic treatment is to be recommended for open fractures and in closed fractures in the presence of other risk factors. Local and systemic adverse reactions as well as the development of antibiotic resistance must be weighed up in individual cases.

A population-based epidemiological and health economic analysis of fracture-related infection

Aims

The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

Methods

This is a retrospective cohort study of operatively managed orthopaedic trauma patients from 1 January 2007 to 31 December 2016, performed in Queensland, Australia. Record linkage was used to develop a person-centric, population-based dataset incorporating routinely collected administrative, clinical, and health economic information. The FRI group consisted of patients with International Classification of Disease 10th Revision diagnosis codes for deep infection associated with an implanted device within two years following surgery, while all others were deemed not infected. Demographic and clinical variables, as well as healthcare utilization costs, were compared.

Results

There were 111,402 patients operatively managed for orthopaedic trauma, with 2,775 of these (2.5%) complicated by FRI. The development of FRI had a statistically significant association with older age, male sex, residing in rural/remote areas, Aboriginal or Torres Strait Islander background, lower socioeconomic status, road traffic accident, work-related injuries, open fractures, anatomical region (lower limb, spine, pelvis), high injury severity, requiring soft-tissue coverage, and medical comorbidities (univariate analysis). Patients with FRI had an eight-times longer median inpatient length of stay (24 days vs 3 days), and a 2.8-times higher mean estimated inpatient hospitalization cost (AU$56,565 vs AU$19,773) compared with uninfected patients. The total estimated inpatient cost of the FRI cohort to the healthcare system was AU$156.9 million over the ten-year period.

Conclusion

The results of this study advocate for improvements in trauma care and infection management, address social determinants of health, and highlight the upside potential to improve prevention and treatment strategies.

Deep Surgical Site Infection after Fracture Has a Profound Effect on Functional Outcomes

Background

Fracture-related infection is one of the most challenging complications in orthopaedic trauma surgery. However, the effect of infection on functional and pain-related outcomes has not been well established. The aims of this study were to evaluate functional recovery for patients with fracture and a deep surgical site infection compared with patients with fracture without infection and to evaluate whether pain severity, social support, and preinjury mental health have a moderating effect on the magnitude and direction of the relationship between deep surgical site infection and functional recovery.

Methods

This is a secondary retrospective cohort study using prospectively collected data from the VANCO trial (Local Antibiotic Therapy to Reduce Infection After Operative Treatment of Fractures at High Risk of Infection) and the OXYGEN (Supplemental Perioperative Oxygen to Reduce Surgical Site Infection After High Energy Fracture Surgery) trial. In this study, 2,116 patients with tibial plateau, pilon, or calcaneal fractures at high risk for infection were included. Patients were divided into cohorts of patients who experienced a deep surgical site infection and those who did not. The primary outcome measure was the functional outcome using the Veterans RAND 12-Item Health Survey (VR-12).

Results

After controlling for covariates, deep surgical site infection was independently associated with functional outcome, with a 3.3-point reduction in the VR-12 Physical Component Score, and pain severity was independently associated with functional outcome, with a 2.5-point reduction in the VR-12 Physical Component Score. Furthermore, the Brief Pain Inventory pain severity demonstrated an important moderating effect on the relationship between infection and functional outcome. In patients with lower pain scores, infection had a large negative impact on functional outcome, whereas, in patients with higher pain scores, infection had no significant impact on functional outcome. Furthermore, the functional outcome in the entire cohort remains at only 61% of baseline.

Conclusions

This study documents the negative impact of postoperative infection on functional recovery after injury, as well as the novel finding of pain severity as an important moderating factor. This study emphasizes not only the importance of developing effective interventions designed to reduce postoperative infection, but also the role that factors that moderate pain severity plays in limiting recovery of physical function.

Level of evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fracture-related infection: Analysis of healthcare utilisation and associated costs

AIMS

A consensus definition of fracture related infection (FRI) has been created with the aim of standardising diagnosis and eliminating heterogeneity that prevents accurate comparison between existing studies. FRI remains one of the most challenging complications in musculoskeletal trauma surgery and carries with it a significant cost burden. A review of UK finances has not been completed utilising consensus diagnostic criteria. The goal of this study was to investigate the hospital-associated healthcare cost related to the treatment of FRI within an NHS major trauma centre.

METHOD

Through retrospective case-control analysis, 1240 patients with close fractures were identified. Of those, 21 patients with FRI were compared to 63 uninfected patients. Patients were matched based on fracture location, type of procedure and proximity in age. The costs assessed included hospitalisation, imaging, outpatient consultation, pharmaceuticals and procedure charges. Cost data was retrieved from healthcare resource group (HRG) guidelines, NHS Business Service Authority's (NBSA) prescription rates and internal costing.

RESULTS

The FRI group were found to incur a 2.51 increase in total medial healthcare cost compared to the control group (£22,058 vs £8798 [p < 0.001]), which was primarily due to increased procedural costs (£13,020 vs £6291 [p < 0.001]) and length of hospital stay (£7552 vs £2124 [p < 0.001]).

CONCLUSION

Whilst diagnosis of FRI has a more rigorous definition following the new consensus, prevalence and cost outcomes are similar to previous studies. Given the deficiency in funding and ongoing challenges of resource allocation to the NHS, it is prudent to incorporate studies such as this into stratifying departmental budgets and quality improvement.

LEVEL OF EVIDENCE

III.

Relevance of a bone and joint registry for fracture-related infections

The UK Bone and Joint Infection Registry (BAJIR) is a national project established in 2018 with the aim of collecting information about demographics, co-morbidities, pathogens, treatment strategies and outcomes on all patients who are diagnosed with, and treated for, a bone or joint infection in the UK with the objective of providing an understanding of the burden of disease. In time these data will be used to inform best practice, direct research and provide information for commissioners of healthcare. In this fracture-related infection special edition article, we discuss the registry's development, relevance and how we see it directing our practice in the future. Equally, we have highlighted some potential limitations and lessons learned.

High Nonunion and Amputations Rates With Either Early Intramedullary Nail Removal or Retention for Tibial Shaft Fracture-Related Infections

OBJECTIVES

To compare debridement, antibiotics, and implant retention (DAIR) and intramedullary nail (IMN) removal with subsequent strategy for fracture stabilization in the treatment of tibia fracture-related infections (FRIs) occurring within 90 days of initial IMN placement.

DESIGN

Retrospective case-control.

SETTING

Four academic, Level 1 trauma centers.

PATIENTS

Sixty-six patients who subsequently received unplanned operative treatment for FRI diagnosed within 90 days of initial tibia IMN.

INTERVENTION

DAIR versus IMN removal pathways.

MAIN OUTCOME MEASUREMENTS

Fracture union.

RESULTS

Twenty-eight patients (42.4%) were treated with DAIR and 38 (57.6%) via IMN removal with subsequent strategy for fracture stabilization. Mean follow-up was 16.3 months. At final follow-up, ultimate bone healing was achieved in 75.8% (47/62), whereas 24.2% (15/62) had persistent nonunion or amputation. No significant difference was observed in ultimate bone healing ( P = 0.216) comparing DAIR and IMN removal. Factors associated with persistent nonunion or amputation were time from injury to initial IMN ( P < 0.001), McPherson systemic host grade B ( P = 0.046), and increasing open-fracture grade, with Gustilo-Anderson IIIB/IIIC fractures being the worst ( P = 0.009). Fewer surgeries after initial FRI treatment were positively associated with ultimate bone healing ( P = 0.029).

CONCLUSIONS

Treatment of FRI within 90 days of tibial IMN with DAIR or IMN removal with subsequent strategy for fracture stabilization results in a high rate, nearly 1 in 4, of persistent nonunion or amputation, with neither appearing superior for improving bone healing outcomes.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A deep surgical site infection risk score for patients with open tibial shaft fractures treated with intramedullary nail

OBJECTIVES

To identify deep infection risk factors in patients with open tibial shaft fractures and to develop a scoring algorithm to predict the baseline deep infection risk in this patient population.

METHODS

A retrospective cohort study conducted at a single academic trauma center identified patients with open tibial shaft fractures treated with intramedullary nail fixation from December 2006 to October 2020. The primary outcome was a deep surgical site infection requiring surgical debridement. The outcome was identified by Current Procedural Terminology codes and confirmed with a medical chart review documenting evidence of a tibial draining wound or sinus tract.

RESULTS

Deep surgical site infection occurred in 13% of patients (97/769). Factors that predicted deep surgical site infection were identified. Gustilo-Anderson type IIIB or IIIC was the strongest predictor with a 12-fold increase in the odds of deep infection (OR 11.8, p < 0.001). Additional factors included age >40 years (OR 1.7, p = 0.03), American Society of Anesthesiologists score ≥3 (OR 1.9, p < 0.01), Gustilo-Anderson type IIIA vs. type I or II (OR 2.8, p = 0.004), and gunshot wounds (OR 2.9, p = 0.02). The risk scoring model predicted patients who would develop an infection with an acceptable level of accuracy (AUC 0.79). The risk score categorized patients from a low probability of deep infection 2%-6% with <10 points to high risk (58%-69%) with >40 points.

CONCLUSIONS

This risk score model predicts deep postoperative infection in patients with open tibial shaft fractures treated with intramedullary nails. The ability to accurately estimate deep infection risk at the time of presentation might aid patient expectation management and allow clinicians to focus infection prevention strategies on the high-risk subset of this population.

[Antibiotic use for prophylaxis and empirical therapy of fracture-related infections in Germany : A survey of 44 hospitals]

BACKGROUND

Antibiotics play an important role in the prophylaxis and treatment of infections in orthopedic trauma surgery; however, there seems to be remarkable differences in the clinical antibiotic practice between hospitals, particularly for open fractures and for the empirical therapy of fracture-related infections (FRI).

METHODS

Therefore, we intended to evaluate the current clinical praxis in university and workers' compensation hospitals in Germany with a questionnaire on prophylaxis and empirical treatment of FRI. The results were compared with the resistance profile of 86 FRI patients in order to analyze the hypothetical effectiveness of the empirical treatment.

RESULTS

A total of 44 hospitals (62.0%) responded. A homogeneous antibiotic prophylaxis (95.5% of all hospitals) with cephalosporins was reported for perioperative prophylaxis of internal fixation of closed fractures. For open fractures, eight different monotherapy and combination treatment concepts were reported. In empirical treatment of FRI, 12 different therapeutic concepts were reported, including aminopenicillins/beta lactamase inhibitors (BLI) (31.8%), cephalosporins (31.8%), and ampicillin/sulbactam + vancomycin (9.1%). In terms of the hypothetical effectiveness of these antibiotic regimes, low sensitivity rates of 65.1% and 74.4% for cephalosporins and aminopenicillins/BLI, respectively, were found. For the combination vancomycin + meropenem, the highest hypothetical sensitivity (91.9%) was detected.

DISCUSSION

Based on the existing, institution-specific pathogen spectrum, the combination therapy including meropenem and vancomycin seems to be of value but should be restricted to patients with multiple revision procedures or a septic course of infection in order to prevent the selection of highly resistant pathogens.

Microbiological Profile of Fracture Related Infection at a UK Major Trauma Centre

Fracture Related Infection (FRI) represents one of the biggest challenges for Trauma and Orthopaedic surgery. A better understanding of the microbiological profile should assist with decision-making and optimising outcomes. Our primary aim was to report on the microbiological profile of FRI cases treated over a six-year period at one of Europe's busiest trauma centres. Secondarily, we sought to correlate our findings with existing anti-microbiological protocols and report on diagnostic techniques employed in our practice. All adult cases of FRI treated in our institution between 2016 and 2021 were identified, retrospectively. We recorded patient demographics, diagnostic strategies, causative organisms and antibiotic susceptibilities. There were 330 infection episodes in 294 patients. A total of 463 potentially pathogenic organisms (78 different species) were identified from cultures, of which 57.2% were gram-positive and 39.7% gram-negative. Polymicrobial cultures were found in 33.6% of cases and no causative organism was found in 17.5%. The most prevalent organisms were Staphylococcus aureus (24.4%), coagulase-negative Staphylococci (14%), Pseudomonas aeruginosa (8.2%), Enterobacter species (7.8%) and Escherichia coli (6.9%). Resistant gram-positive organisms (methicillin resistant Staphylococcus aureus or vancomycin-resistant Enterococci) were implicated in 3.3% of infection episodes and resistant gram-negatives (extended-spectrum beta-lactamase, ampC or carbapenemase-producing bacteria) in 13.6%. The organisms cultured in 96.3% of infection episodes would have been covered by our empirical systemic antibiotic choice of teicoplanin and meropenem. To our knowledge, this is the largest reported single-centre cohort of FRIs from a major trauma centre. Our results demonstrate patterns in microbiological profiles that should serve to inform the decision-making process regarding antibiotic choices for both prophylaxis and treatment.

Fracture-related infections

Fracture-related infection is a serious complication which can occur following musculoskeletal injury and is associated with significant morbidity. These complications can be challenging to recognise, and experts have provided a clearer definition of fracture-related infection to help with the diagnosis and detection of these infections. This system includes clinical, radiological and laboratory-based diagnostic features which are either confirmatory or suggestive of fracture-related infection. Treatment requires a multifaceted approach with multidisciplinary involvement, and generally a combination of surgical techniques and prolonged antibiotics, the timing and choice of which should be optimised. This article provides an evidence-based review of the British Orthopaedic Association Standards for Trauma for the diagnosis and management of fracture-related infections.

A systematic review of cost and well-being in hip and knee replacements surgical site infections

This systematic review examined peer-reviewed literature published from 2010 to 2020 to investigate the health care system costs, hidden out-of-pocket expenses and quality of life impact of surgical site infections (SSIs) and to develop an overall summary of the burden they place on patients. SSI can significantly impact patients' treatment experience and quality of life. Understanding patients' SSI-related burden may assist in developing more effective strategies aimed at lessening the effects of SSI in financial and well-being consequences. Peer-reviewed articles on adult populations (over 18 years old) in orthopaedic elective hip and knee surgeries published from 2010 to 2020 were considered. Only publications in English and studies conducted in high-income countries were eligible for inclusion. A search strategy based on the MESH term and the CINAHL terms classification was developed. Five databases (Scopus, EMBASE, CINAHL, Medline, Web of Science) were searched for relevant sources. Reviewers categorised and uploaded identified citations to Covidence and EndNoteX9. Reviewers will assess article titles, abstracts and the full text for compliance with the inclusion criteria. Ongoing discussions between reviewers resolved disagreements at each selection process stage. The final scoping review reported the citation inclusion process and presented search results in a PRISMA flow diagram. Four main themes were extracted from a thematic analysis of included studies (N = 30): Hospital costing (n = 21); Societal perspective of health system costing (n = 2); Patients and societal well-being (n = 6) and Epidemiological database and surveillance (n = 22). This systematic review has synthesised a range of themes associated with the overall incidence and impact of SSI that can inform decision making for policymakers. Further analysis is required to understand the burden on SSI patients.

Treatment and outcome of fracture-related infection of the clavicle

INTRODUCTION

The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication.

METHODS

All patients with a clavicle fracture who underwent open reduction and internal fixation (ORIF) between 1 January 2015 and 1 March 2022 were retrospectively evaluated. This study included patients with an FRI who were diagnosed and treated according to the recommendations of a multidisciplinary team at the University Hospitals Leuven, Belgium.

RESULTS

We evaluated 626 patients with 630 clavicle fractures who underwent ORIF. In total, 28 patients were diagnosed with an FRI. Of these, eight (29%) underwent definitive implant removal, five (18%) underwent debridement, antimicrobial treatment and implant retention, and fourteen patients (50%) had their implant exchanged in either a single-stage procedure, a two-stage procedure or after multiple revisions. One patient (3.6%) underwent resection of the clavicle. Twelve patients (43%) underwent autologous bone grafting (tricortical iliac crest bone graft (n = 6), free vascularized fibular graft (n = 5), cancellous bone graft (n = 1)) to reconstruct the bone defect. The median follow-up was 32.3 (P₂₅-P₇₅: 23.9-51.1) months. Two patients (7.1%) experienced a recurrence of infection. The functional outcome was satisfactory, with 26 out of 28 patients (93%) having full range of motion. The median healthcare cost was € 11.506 (P₂₅-P₇₅: € 7.953-23.798) per patient.

CONCLUSION

FRI is a serious complication that can occur after the surgical treatment of clavicle fractures. In our opinion, when treated adequately using a multidisciplinary patient-specific approach, the outcome of patients with an FRI of the clavicle is good. The median healthcare costs of these patients are up to 3.5 times higher compared to non-infected operatively treated clavicle fractures. Although not studied individually, we consider factors such as the size of the bone defect, condition of the soft tissue, and patient demand important when it comes to guiding our surgical decision making in cases of osseous defects.

Trends and Risk Factors for Surgical Site Infection after Treatment of the Ankle Fracture: National Cohort Study

Surgical site infection (SSI) is a major complication after the surgical treatment of ankle fractures that can result in catastrophic consequences. This study aimed to determine the incidence of SSI in several cohorts from national insurance databases over the past 12 years and identify its predictors. The claimed data for patients (n = 1,449,692) with ankle fractures between 2007 and 2019 were investigated, and a total of 41,071 patients were included in the final analysis. The covariates included were age, sex, season, fracture type (closed vs. open), type of surgical fixation procedure, and comorbidities of each patient. All subjects were divided into two groups according to the SSI after the surgical fixation of the ankle fracture (no infection group vs. infection group). The number of SSIs after the surgical treatment of ankle fractures was 874 (2.13%). Open fractures [odds ratio, (OR) = 4.220] showed the highest risk for SSI, followed by the male sex (OR = 1.841), an increasing number of comorbidities (3-5, OR = 1.484; ≥6, OR = 1.730), a history of dementia (OR = 1.720) or of myocardial infarction (OR = 1.628), and increasing age (OR = 1.010). The summer season (OR = 1.349) showed the highest risk among the four seasons for SSI after ankle fracture surgery.

Efficacy and safety of different antimicrobial DURATions for the treatment of Infections associated with Osteosynthesis Material implanted after long bone fractures (DURATIOM): Protocol for a randomized, pragmatic trial

BACKGROUND

Infection associated with osteosynthesis material (IOM) is one of the most feared and challenging complications of trauma surgery and can cause significant functional loss, requiring multiple interventions and excessive consumption of antimicrobials. Evidence is needed about the best surgical procedure and the duration of antibiotic treatment according to the age of the implant or onset of infection symptoms, as it considers the biofilm formation and the state of fracture healing. There were not clinical trials evaluating the optimal duration of antibiotic therapy in IOM when implant is retained. Because there are antibiotics that have proven to be effective for the treatment of infection associated to implant, mainly in PJI, these antibiotics could be used in these infections. Investigating whether shorter duration of treatment is a priority in infectious diseases, as a way to reduce the exposure to antibiotics and help in controlling antimicrobial resistance and avoiding unnecessary adverse events and cost. We aim to describe the hypothesis, objectives, design, variables and procedures for a pragmatic randomized controlled trial comparing different durations of antibiotic treatment in IOM after long bone fractures treated with debridement and implant retention.

METHODS AND DESIGN

This is a multicenter, open-label, non-inferiority, randomized, controlled, pragmatic phase 3 trial, comparing different durations of antibiotic treatment in IOM after long bone fractures treated with debridement and implant retention. Patients with microbiologically confirmed IOM will be included. Eligible patients are those older than 14 years, with early IOM (up to 2 weeks after the implant surgery) and delayed IOM (between 3 and 10 weeks after the implant surgery) with stabilized fracture and absence of bone exposure who sign the informed consent. Randomization will be 1:1 to receive a short-term antibiotic treatment (8 weeks in early IOM and 12 weeks in delayed IOM) or a long-term antibiotic treatment (12 weeks in early IOM or until fracture healing or implant removal in delayed IOM). The antibiotic treatment will be that used in routine practice by the specialist in infectious diseases. The primary outcome is the composited variable "cure" that includes clinical cure, radiological healing, and definitive soft tissue coverage, which will be evaluated in the test of cure at 12 months after the end of antibiotic therapy. Adverse events, resistance development during therapy and functional status will be collected. A total of 364 patients are needed to show a 10% non-inferiority margin, with 80% power and 5% one-sided significance level.

DISCUSSION

If the hypothesis of non-inferiority of short vs. long antibiotic treatments is demonstrated, and the efficacy of antibiotics with less ecological impact in long treatments, the impact on reduction of bacterial resistance, toxicity and health costs will be observed.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov (NCT05294796) on Jan 26th 2022 and at the European Union Drug Regulating Authorities Clinical Trials (EUDRACT) (2021-003914-38) on Jul 16th 2021. The Sponsor Study Code is DURATIOM.

American Academy of Orthopaedic Surgeons Appropriate Use Criteria: Prevention of Surgical Site Infections After Major Extremity Trauma

High-energy extremity trauma rates can be difficult to precisely state given the complexity of contributing combined mechanisms; however, the rate of open fractures in the United States is 11.5 to 13 per 100,000 people. The management of high-energy extremity fractures presents many challenges for treating surgeons, including elevated risk of surgical site infections (SSIs). In recent studies, higher risk closed injuries are associated with deep SSI rates as high as 19% after surgical treatment and for severe open injuries, which rate surpasses 30%. Fracture-related infections are associated with notable costs and decreased long-term functional outcomes. Identified risk factors for the development of deep SSIs are primarily related to the severity of injury and its location. The quality of the vast literature identifying available interventions to decrease the risk of developing SSIs is highly variable, and it is unclear how consistently these interventions are applied.

Predictors for surgical site infection after fasciotomy in patients with acute leg compartment syndrome

BACKGROUND

Surgical site infection (SSI) is one of the most common complications of orthopedic surgery, which can result in fever, pain, and even life-threatening sepsis. This study aimed to determine the predictors of SSI after fasciotomy in patients with acute leg compartment syndrome (ALCS).

METHODS

We collected information on 125 ALCS patients who underwent fasciotomy in two hospitals between November 2013 and January 2021. Patients with SSI were considered as the SSI group and those without SSI as the non-SSI group. Univariate analysis, logistic regression analysis, and receiver operating characteristic (ROC) curve analyses were used to evaluate patient demographics, comorbidities, and admission laboratory examinations.

RESULTS

In our research, the rate of SSI (26 of 125) was 20.8%. Several predictors of SSI were found using univariate analysis, including body mass index (BMI) (p = 0.001), patients with open fractures (p = 0.003), and patients with a history of smoking (p = 0.004). Besides, the levels of neutrophil (p = 0.022), glucose (p = 0.041), globulin (p = 0.010), and total carbon dioxide were higher in the SSI group than in the non-SSI group. According to the results of the logistic regression analysis, patients with open fractures (p = 0.023, OR 3.714), patients with a history of smoking (p = 0.010, OR 4.185), and patients with a higher BMI (p = 0.014, OR 1.209) were related predictors of SSI. Furthermore, ROC curve analysis indicated 24.69 kg/m² as the cut-off value of BMI to predict SSI.

CONCLUSIONS

Our results revealed open fractures, BMI, and smoking history as independent risk factors for SSI following fasciotomy in patients with ALCS and determined the cut-off value of BMI, enabling us to individualize the evaluation of the risk for SSI to implement early targeted treatments.

Intramedullary application of local antibiotic bullets for the treatment of long bone fracture related infection

PURPOSE

The optimal means of local antibiotic delivery for fracture related infection is unknown. Until now, intramedullary application of calcium sulphate based local antibiotics has been challenging. We report on the use of a newly available mode of preparation and delivery: the Stimulan Bullet Mat and Introducer (Biocomposites Ltd, Staffordshire, England).

METHODS

A retrospective analysis of prospectively collected data for infection cases at two separate tertiary referral institutions was performed. We included cases of long bone FRI with a retained intramedullary nail, treated with a single stage protocol of metalwork removal, debridement, local antibiotic application using the novel mould and applicator, with additional bony stabilisation and soft tissue reconstruction where required.

RESULTS

All 13 patients achieved infection remission rate with an average follow-up of 19.7 months (range 12-28). All 6 patients with infection around an unhealed fracture achieved union at an average 8 months (range 4-12) from debridement. No patients developed aseptic wound leak.

CONCLUSIONS

Antibiotic impregnated calcium sulphate can be used safely as part of a single stage treatment protocol for the treatment of long bone fracture related infection following intramedullary nailing. We have demonstrated high rates of infection remission and union, using a newly available intramedullary applicator.

Multidisciplinary Treatment of Fracture-Related Infection Has a Positive Impact on Clinical Outcome-A Retrospective Case Control Study at a Tertiary Referral Center

OBJECTIVES

Fracture-related infection (FRI) is a major complication in orthopedic and trauma surgery. The management and choice of treatment can be difficult depending on multiple factors. Therefore, we implemented a weekly multidisciplinary team discussion to determine diagnostic and treatment strategies in FRI patients and aimed to analyze its effect on clinical outcomes.

METHODS

Clinical outcomes of FRI patients treated before and after implementation of a structured multidisciplinary treatment (MDT) approach with a weekly case discussion were compared at a follow-up of 12 months.

RESULTS

In total, n = 117 were eligible for enrolment, whereby n = 58 patients (72.4% male, mean age 56.7 ± 16.8 years) constituted the MDT group and n = 59 patients (72.9% male, mean age 55.0 ± 16.5 years) the control group. In the MDT group more cases were treated with local antibiotics (67.2% vs. 27.1%, p < 0.001) and significant less amputations (3.4% vs. 6.8%, p = 0.014), as well as less revision surgeries (1.5 ± 1.2 (0-5) vs. 2.2 ± 1.2 (0-7), p = 0.048) were performed. A trend towards less debridement, antibiotics and implant retention (DAIR) procedures, lower rates of recurrence of infection and less treatment failures in the MDT group was observable, even though not statistically significant.

CONCLUSION

An MDT approach providing a patient tailored treatment concept in the treatment of FRI patients appears to be beneficial for the affected patients. Quality and efficacy of implemented MDT meetings should further be evaluated to provide sufficient evidence to further implement this valuable tool in clinical practice and decision making.

Diagnosis of fracture-related infection in patients without clinical confirmatory criteria: an international retrospective cohort study

Background: fracture-related infection (FRI) remains a serious complication in orthopedic trauma. To standardize daily clinical practice, a consensus definition was established, based on confirmatory and suggestive criteria. In the presence of clinical confirmatory criteria, the diagnosis of an FRI is evident, and treatment can be started. However, if these criteria are absent, the decision to surgically collect deep tissue cultures can only be based on suggestive criteria. The primary study aim was to characterize the subpopulation of FRI patients presenting without clinical confirmatory criteria (fistula, sinus, wound breakdown, purulent wound drainage or presence of pus during surgery). The secondary aims were to describe the prevalence of the diagnostic criteria for FRI and present the microbiological characteristics, both for the entire FRI population. Methods: a multicenter, retrospective cohort study was performed, reporting the demographic, clinical and microbiological characteristics of 609 patients (with 613 fractures) who were treated for FRI based on the recommendations of a multidisciplinary team. Patients were divided in three groups, including the total population and two subgroups of patients presenting with or without clinical confirmatory criteria. Results: clinical and microbiological confirmatory criteria were present in 77 % and 87 % of the included fractures, respectively. Of patients, 23 % presented without clinical confirmatory criteria, and they mostly displayed one (31 %) or two (23 %) suggestive clinical criteria (redness, swelling, warmth, pain, fever, new-onset joint effusion, persisting/increasing/new-onset wound drainage). The prevalence of any suggestive clinical, radiological or laboratory criteria in this subgroup was 85 %, 55 % and 97 %, respectively. Most infections were monomicrobial (64 %) and caused by Staphylococcus aureus. Conclusion: clinical confirmatory criteria were absent in 23 % of the FRIs. In these cases, the decision to operatively collect deep tissue cultures was based on clinical, radiological and laboratory suggestive criteria. The combined use of these criteria should guide physicians in the management pathway of FRI. Further research is needed to provide guidelines on the decision to proceed with surgery when only these suggestive criteria are present.

Effect of Local Antibiotic Prophylaxis on Postoperative Deep Infection in Fracture Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

Despite the use of systemic antibiotic prophylaxis, postoperative infection after fracture surgery remains an issue. The purpose of this systematic review and meta-analysis was to evaluate the effect of locally applied antibiotics on deep infection in fracture surgery in both the open and closed fractures.

DATA SOURCES

A comprehensive search of MEDLINE, Embase, and PubMed was performed from the date of inception to April 15, 2021, and included studies in all languages.

STUDY SELECTION

Cohort studies were eligible if they investigated the effect on the infection rate of local antibiotic prophylaxis on deep infection after fracture surgery.

DATA EXTRACTION

This study was conducted according to the Cochrane Handbook for Systematic Reviews and reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials and the Methodological Index for Nonrandomized Studies tool where applicable.

DATA SYNTHESIS

An inverse variance random-effects model was the primary analysis model because of the anticipated diversity in the evaluated populations. Univariate models were used when a single outcome was of interest.

CONCLUSIONS

The risk of deep infection was significantly reduced when local antibiotics were applied compared with the control group receiving systemic prophylaxis only. This beneficial effect was observed in open fractures but failed to reach statistical significance in closed fractures. This meta-analysis suggests that there may be a significant risk reduction in deep infection rate after fracture surgery when local antibiotics are added to standard systemic prophylaxis, particularly in open fractures. Further high-powered Level I studies are needed to support these findings.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Long-term outcomes of lower limb post-traumatic osteomyelitis

PURPOSE

Whilst recurrence and amputation rates in post-traumatic osteomyelitis (PTOM) are described, limb specific functional outcomes are not, leading to a knowledge gap when counselling patients prior to management. We aim to investigate the patient reported outcomes (PROMS) of this patient group to provide reference for discussions with patients prior to embarking on treatment.

METHODS

Single institution cross-sectional retrospective study of all patients presenting with PTOM of the tibia/femur over a 7-year period. Alongside recurrence and amputation rates, patient reported outcomes were recorded including the lower extremity functional scale (LEFS), EQ-5D-3L and EQ-VAS.

RESULTS

Seventy-two patients (59 male; median age 46 years) were identified. Treatment was principle-based and included debridement (with Reamer-Irrigator-Aspirator (RIA) in 31/72), local antibiotics (52/72), soft tissue reconstruction (21/72) and systemic antibiotic therapy in all cases. PROMS were collected in 84% of all eligible patients at a median of 112-month post-treatment. Twelve patients experienced recurrence, whilst nine underwent amputation. The median LEFS was 60, the EQ-5D-3L index score was 0.760, and the EQ-VAS was 80. These scores are substantially lower than those seen in the general population (77, 0.856 and 82.2, respectively). LEFS was significantly higher, where RIA was utilised (69.6 vs 52.8; p = 0.02), and in those classified as BACH uncomplicated (74.4 vs 58.4; p = 0.02). EQ-5D-3L was also higher when RIA was utilised (0.883 vs 0.604; p = 0.04), with no difference in EQ-VAS scores.

CONCLUSIONS

Patients with PTOM report functional outcomes below that of the general population, even when in remission. Improved outcomes were associated with uncomplicated disease and the use of RIA.

Outcomes of fracture-related infections - do organism, depth of involvement, and temporality count?

Purpose: To determine mortality and outcomes of patients diagnosed with fracture-related infections (FRIs).Methods: FRI patients treated at a trauma centre between 2001 and 2020 were analysed. The primary outcome was 1-year mortality; mortality associations with FRI organism, depth of involvement, and temporality were investigated with multivariable survival analysis. Healthcare-associated and serological outcomes were reported as secondary outcomes. Results: 311 FRIs with mean age of 67.0 and median Charlson comorbidity index of 0 were analysed. Methicillin-sensitive Staphylococcus aureus (MSSA) (29.9%) was the most frequently implicated organism. The majority of FRIs were deep infections (62.7%). FRIs were diagnosed at a median of 40 (IQR 15-200) days post index surgery. The mean follow-up was 5.9 years. One-year mortality amounted to 17.7%. MSSA FRIs were associated with better survival (adj HR 0.34, 95%CI 0.15-0.76, p = 0.008). There was no difference in survivorship between deep or superficial FRI (adj HR 0.86, 95%CI 0.62-1.19, p = 0.353) or in relation to onset time (adj HR 1.0, 95%CI 0.99-1.00, p = 0.943). Implant removal or debridement alone was performed in 61.7% and 17% respectively. Antibiotics was prescribed for 53 (IQR 23-110) days, and patients were hospitalised for 39 (IQR 19-78) days. CRP and ESR normalised in 70.3% (median 46 days) and 53.8% (median 86 days) patients respectively. Conclusion: Fracture-related infections are associated with significant mortality and morbidity regardless of depth and temporality. Non-MSSA FRIs are associated with inferior survival.

The management of fracture related infections: What practices can be supported by high-level evidence?

Fracture related infections (FRIs) are a disabling condition causing significant concern within the orthopaedic community. FRIs have a huge societal and economic burden leading to prolonged recovery times and the potential for becoming chronic conditions or being life-threatening. Despite its importance in our field, the surgical community has just recently agreed on a definition which, added to the lack of surgical trials assessing preventive and treatment interventions have limited our understanding and precipitated wide variations in surgeons' practice. This article aims to review the current practices that can be supported with high-quality evidence. Currently, we have a limited body of high-quality evidence on FRI prevention and treatment. A handful of measures have proven effective, such as the use of prophylactic antibiotics, the use of saline and low pressure as the preferred irrigation solution and the safety of delaying initial surgical débridement more than 6 hours without impacting infection rates for open fracture wounds débridement. Future multicentre trials, properly powered, will shed light on current areas of controversy regarding the benefit of different preoperative and perioperative factors for the prevention and treatment of FRIs. Higher quality evidence is needed to guide surgeons to offer an evidence-based approach to prevent FRI occurrence and to treat patients suffering from them.

Development and Characterization of a Subcutaneous Implant-Related Infection Model in Mice to Test Novel Antimicrobial Treatment Strategies

Orthopedic-device-related infection is one of the most severe complications in orthopedic surgery. To reduce the associated morbidity and healthcare costs, new prevention and treatment modalities are continuously under development. Preclinical in vivo models serve as a control point prior to clinical implementation. This study presents a mouse model of subcutaneously implanted titanium discs, infected with Staphylococcus aureus, to fill a gap in the early-stage testing of antimicrobial biomaterials. Firstly, three different inocula were administered either pre-adhered to the implant or pipetted on top of it following implantation to test their ability to reliably create an infection. Secondly, the efficacy of low-dose (25 mg/kg) and high-dose (250 mg/kg) cefazolin administered systemically in infection prevention was assessed. Lastly, titanium implants were replaced by antibiotic-loaded bone cement (ALBC) discs to investigate the efficacy of local antibiotics in infection prevention. The efficacy in infection prevention of the low-dose perioperative antibiotic prophylaxis (PAP) depended on both the inoculum and inoculation method. Bacterial counts were significantly lower in animals receiving the high dose of PAP. ALBC discs with or without the additional PAP proved highly effective in infection prevention and provide a suitable positive control to test other prevention strategies.

Microbiology of fracture related infections

Fracture related infection remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families, treating physicians and healthcare systems. Even current curative approaches (radical debridement, revision surgery and long-term antibiotics) often result in significant socioeconomic costs and the risk of life-long functional impairment to the patient. The prevalence of osteomyelitis due to trauma and surgical complications does not seem to be diminishing in our society and the emergence of antimicrobial resistance is a major health related concern with global relevance. Despite multi-drug resistant bacteria being on the rise universally, perioperative antibiotic prophylaxis in orthopaedic trauma care has only slightly changed in the last 25 years. Staphylococcus infections remain an increasing global concern, partially due to the resistance mechanisms developed by staphylococci to evade the host immune system and antibiotic treatment, and as such antibiotics are becoming increasingly ineffective. This paper will address fracture related infections in trauma patients, looking at the bacteriology of these infections, its clinical implications and evolving nature.

Healthcare resource use and costs related to surgical infections of tibial fractures in a Spanish cohort

Surgical site infection constitutes a serious complication in the healing process of bone fractures and has been associated with increases in medical resource use and healthcare costs. This study evaluates the economic impact of surgical site infection in tibial fractures in a Spanish cohort. It is a retrospective, single-centre, comparative cohort study of patients with tibial fractures with longitudinal follow-up for up to 18 months post-surgery. Included patients (n = 325) were adults, with tibial fracture, either isolated or polyfracture, or polytrauma with an Injury Severity Score >15. Patients had been surgically treated within 30 days of the tibial fracture by external or internal fixation, or external followed by internal fixation. Most patients (84.9%) had an American Society of Anaesthesiology score of 1–2. 20% of the patients had one open tibial fracture, 12.3% had polytrauma, and 20% had multiple fractures. Most patients were treated with a nail (41.8%) or a plate (33.8%). 56 patients (17.2%) developed surgical site infection. Patients with infection had significantly higher hospital length of stay (34.9 vs 12.0 days; p<0.001; +191%), readmissions (1.21 vs 0.25; p<0.001; +380%) and mean operating theatre time (499 vs 219 min; p<0.001; +128%) than patients without infection. Mean length of stay in intensive care did not significantly increase with infection (2.8 vs 1.7 days; p = 0.25). Total in-hospital costs for patients with infection increased from €7,607 to €17,538 (p<0.001; +131%). Overall, infections were associated with significantly increased healthcare resource use and costs. Preventive strategies to avoid infections could lead to substantial cost savings.

Outcomes of Intramedullary Nailing and External Fixation of Open Tibial Fractures: Three to Five-Year Follow-up of a Randomized Clinical Trial

BACKGROUND

While surgeons in low and middle-income countries have increasing experience with intramedullary nailing (IMN), external fixation (EF) continues to be commonly used for the management of open tibial fractures. We examined outcomes with extended follow-up of the participants enrolled in a clinical trial comparing these treatments.

METHODS

Adults who were ≥18 years old with acute AO/OTA type-42 open tibial shaft fractures were randomly assigned to statically locked, hand-reamed IMN or uniplanar EF. These participants were reevaluated 3 to 5 years after treatment. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Unresolved complications such as persistent fracture-related infection, nonunion, or malalignment were collected and analyzed. Secondary outcomes included the EuroQol-5 Dimension-3 Level (EQ-5D-3L) questionnaire, the Function IndeX for Trauma (FIX-IT) score, radiographic alignment, and the modified Radiographic Union Scale for Tibial fractures (mRUST).

RESULTS

Of the originally enrolled 240 participants,126 (67 managed with IMN and 59 managed with EF) died or returned for follow-up at a mean of 4.0 years (range, 2.9 to 5.2 years). Thirty-two composite primary events occurred, with rates of 23.9% and 27.1% in the IMN and EF groups, respectively. Six of these events (3 in the IMN group and 3 in the EF group) were newly detected after the original 1-year follow-up. Unresolved complications in the form of chronic fracture-related infection or nonunion were present at long-term follow-up in 25% of the participants who sustained a primary event. The EQ-5D-3L index scores were similar between the 2 groups and only returned to preinjury levels after 1 year among patients without complications or those whose complications resolved.

CONCLUSIONS

This observational study extended follow-up for a clinical trial assessing IMN versus EF for the treatment of open tibial fractures in sub-Saharan Africa. At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of the participants who experienced these complications, regardless of reintervention.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Injectable hydrogel as a carrier of vancomycin and a cathelicidin-derived peptide for osteomyelitis treatment

A local drug delivery system that attempts to find a suitable balance between antimicrobial and regenerative actions was developed for osteomyelitis treatment (OM). This system combines the angiogenic and immunomodulatory peptide LLKKK18 (LL18) and vancomycin hydrochloride (VH), loaded into an injectable oxidized dextrin (ODEX)-based hydrogel (HG). In vitro cytotoxicity was analyzed in MC3T3-E1 pre-osteoblasts and erythrocytes. The kinetics of LL18 release was studied. Antimicrobial activity was assessed in vitro against a clinical Methicillin-Resistant Staphylococcus aureus (MRSA) strain. A rat model of acute OM was developed by direct inoculation into a tibia defect, concomitantly with the implantation of the drug-loaded HG. The local bioburden was quantified and damage in surrounding tissues was examined histologically. In vitro, ODEX-based HG displayed a safe hemolytic profile. Half of LL18 (53%) is released during the swelling phase at physiological pH, then being gradually released until complete HG degradation. LL18-loaded HG at 300 μM was the most effective peptide formulation in decreasing in vivo infection among concentrations ranging from 86 to 429 μM. The histopathological scores observed in vivo varied with the LL18 concentration in a dose-dependent manner. VH at 28 mM completely eradicated bacteria, although with substantial tissue injury. We have found that sub-millimolar doses of VH combined with LL18 at 300 μM may suffice to eradicate the infection, with reduced tissue damage. We propose an easy-to-handle, shape-fitting HG formulation with the potential to treat MRSA-infected bone with low VH doses associated with LL18.

Fracture-related infection

Musculoskeletal trauma leading to broken and damaged bones and soft tissues can be a life-threating event. Modern orthopaedic trauma surgery, combined with innovation in medical devices, allows many severe injuries to be rapidly repaired and to eventually heal. Unfortunately, one of the persisting complications is fracture-related infection (FRI). In these cases, pathogenic bacteria enter the wound and divert the host responses from a bone-healing course to an inflammatory and antibacterial course that can prevent the bone from healing. FRI can lead to permanent disability, or long courses of therapy lasting from months to years. In the past 5 years, international consensus on a definition of these infections has focused greater attention on FRI, and new guidelines are available for prevention, diagnosis and treatment. Further improvements in understanding the role of perioperative antibiotic prophylaxis and the optimal treatment approach would be transformative for the field. Basic science and engineering innovations will be required to reduce infection rates, with interventions such as more efficient delivery of antibiotics, new antimicrobials, and optimizing host defences among the most likely to improve the care of patients with FRI.

How Can Negative Pressure Wound Therapy Pay for Itself?-Reducing Complications Is Important

INTRODUCTION

Orthopaedic trauma demonstrates a relatively high rate of surgical site infections (SSI) as compared with other surgical specialties. SSIs provide significant clinical challenges and create significant health care costs. Incisional negative pressure wound therapy (iNPWT) has reduced the risk of SSI in orthopaedic surgery and other surgical specialties.

PURPOSE

The purpose of this study is to investigate potential cost savings with the use of iNPWT (3M Prevena Therapy, 3M, St. Paul, MN) in high-risk orthopaedic trauma patients with closed OTA/AO 41C and 43C fractures.

METHODS

This is a retrospective cohort study performed at a single, level-1 trauma center using data from a lower extremity fracture registry. Using the results from the registry and baseline infection rates derived from the literature, a health economic model was developed to evaluate the potential cost savings.

RESULTS

A total of 79 patients included in the registry underwent open reduction and internal fixation of OTA/AO 41C and 43C fractures. A total of 10.1% developed a SSI. For those who received iNPWT, the rate of SSI was 7.4%. A health economic model suggests that the use of iNPWT may reduce the costs per patient by approximately $1381 to $4436 per patient.

CONCLUSIONS

This health economic assessment and model suggests that judicious use of iNPWT may reduce health care costs in patients undergoing open reduction and internal fixation of OTA/AO 41C and 43C fractures.

LEVEL OF EVIDENCE

Economic Level IV.

A major trauma centre experience with gentamicin-coated tibial intramedullary nails (ETN PROtect™) in acute primary open fracture fixation and complex revision surgery

PURPOSE

Fracture-related infections (FRI) following intramedullary nailing for tibial shaft fractures remain challenging to treat with associated high patient morbidity and health care costs. Recently, antibiotic-coated nails have been introduced as a strategy to reduce implant related infection rates in high-risk patients. We present the largest single-centre case series on ETN PROtect® outcomes reporting on fracture union, infection rates and treatment complications.

METHODS

Fifty-six adult patients underwent surgery with ETN PROtect® between 01/09/17 and 31/12/20. Indications consisted of acute open fractures and complex revision cases (previous FRI, non-union surgery and re-fracture) with a mean of three prior surgical interventions. We report on patient demographics, union rates and deep infection. Minimum follow-up was one year.

RESULTS

One (1.8%) patient developed a deep surgical infection and associated non-union requiring further surgery. In addition, we identified three cases (5.4%) of aseptic non-union following facture treatment with ETN PROtect®. Of the five patients who underwent staged complex revision surgery for established FRI with ETN PROtect®, all had treatment failure with ongoing symptoms of deep infection requiring implant removal and further treatment.

CONCLUSION

Use of the ETN PROtect® nail in high-risk patients (open fractures and those initially treated with external fixation) and in those patients with aseptic non-unions, demonstrates promising outcomes in the prevention of implant-related infection. In our limited series we have failed to observe any benefit over uncoated nails, when used in treating cases of previously established FRI/osteomyelitis and would therefore advise caution in their use, especially in view of the high cost.

Public Insurance Payment Does Not Compensate Hospital Cost for Care of Long-Bone Fractures Requiring Additional Surgery to Promote Union

OBJECTIVES

To quantify the total hospital costs associated with the treatment of lower extremity long-bone fracture aseptic and septic unhealed fracture, to determine if insurance adequately covers these costs, and to examine whether insurance type correlates with barriers to accessing care.

DESIGN

Retrospective cohort study.

SETTING

Academic Level II trauma center.

PATIENTS

All patients undergoing operative treatment of OTA/AO classification 31, 32, 33, 41, 42, and 43 fractures between 2012 and 2020 at a single Level II trauma center with minimum of 1-year follow-up.

MAIN OUTCOME MEASURES

The primary outcome was the total cost of treatment for all hospital-based episodes of care. Distance traveled from primary residence was measured as a surrogate for barriers to care.

RESULTS

One hundred seventeen patients with uncomplicated fracture healing, 82 with aseptic unhealed fracture, and 44 with septic unhealed fracture were included in the final cohort. The median cost of treatment for treatment of septic unhealed fracture was $148,318 [interquartile range(IQR) 87,241-256,928], $45,230 (IQR 31,510-68,030) for treatment of aseptic unhealed fracture, and $33,991 (IQR 25,609-54,590) for uncomplicated fracture healing. The hospital made a profit on all patients with commercial insurance, but lost money on all patients with public insurance. Among patients with unhealed fracture, those with public insurance traveled 4 times further for their care compared with patients with commercial insurance (P = 0.004).

CONCLUSIONS

Septic unhealed fracture of lower extremity long-bone fractures is an outsized burden on the health care system. Public insurance for both septic and aseptic unhealed fracture does not cover hospital costs. The increased distances traveled by our Medi-Cal and Medicare population may reflect the economic disincentive for local hospitals to care for publicly insured patients with unhealed fractures.

LEVEL OF EVIDENCE

Economic Level V. See Instructions for Authors for a complete description of levels of evidence.

Effect of Supplemental Perioperative Oxygen on SSI Among Adults with Lower-Extremity Fractures at Increased Risk for Infection: A Randomized Clinical Trial

BACKGROUND

Supplemental perioperative oxygen is a low-cost intervention theorized to reduce the risk of surgical site infections, but its effect among patients undergoing surgery for a tibial plateau, tibial pilon, or calcaneal fracture is unknown. We aimed to determine the effectiveness of a high fraction of inspired oxygen (FiO 2 , 80%) versus low FiO 2 (30%) in reducing surgical site infections in these patients.

METHODS

A randomized controlled trial was conducted at 29 U.S. trauma centers. We enrolled 1,231 patients who were 18 to 80 years of age and had a tibial plateau, tibial pilon, or calcaneal fracture and were thought to be at elevated risk for infection based on their injury characteristics. Patients were randomized to receive 80% FiO 2 (treatment group) or 30% FiO 2 (control group) in the operating room and for up to 2 hours in the recovery room. The primary outcome was a composite of either deep surgical site infection (treated with surgery) or superficial surgical site infection (treated with antibiotics alone) within 182 days following definitive fixation. Secondary outcomes included these surgical site infections at 90 and 365 days after surgery.

RESULTS

The modified intention-to-treat analysis included 1,136 patients with 94% of expected follow-up through 182 days. Surgical site infection occurred in 40 (7.0%) of the patients in the treatment group and 60 (10.7%) of the patients in the control group (relative risk [RR], 0.65; 95% confidence interval [CI], 0.45 to 0.96; risk difference [RD], -3.8%; 95% CI, -7.2% to -0.4%; p = 0.03). The treatment intervention demonstrated a similar effect at 90 days (RR, 0.59; 95% CI, 0.37 to 0.93) and 365 days (RR, 0.62; 95% CI, 0.44 to 0.87). Secondary analyses demonstrated that the effect was driven by a reduction in superficial surgical site infections.

CONCLUSIONS

Among tibial plateau, pilon, or calcaneal fracture patients at elevated risk for surgical site infection, a high perioperative FiO 2 lowered the risk of surgical site infection. The findings support the use of this intervention, although the benefit appears to mostly be in reduction of superficial infections.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.