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Christy MN, Shah NS, Hurn MT, Beltran MJ. Unplanned reoperation is common following intramedullary nailing of open femoral shaft fractures: A retrospective review. J Clin Orthop Trauma 2024; 49:102350. [PMID: 38333743 PMCID: PMC10848029 DOI: 10.1016/j.jcot.2024.102350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 01/12/2024] [Accepted: 01/19/2024] [Indexed: 02/10/2024] Open
Abstract
Background The objective of this study is to investigate the incidence of unplanned reoperation, nonunion and infection following open femoral shaft fractures treated with an intramedullary nail and correlate these occurrences with patient variables and injury characteristics. Methods A retrospective review of open femur fractures from a level 1 trauma center between 2012 and 2020 was performed. Ninety-five patients who sustained an open femur fracture, were treated definitively with an intramedullary nail, and had at least 3 months of follow-up were included in the analysis for surgical site infection. Seventy-three of these patients had at least one year of follow-up. After excluding planned bone grafting for segmental defects, 67 patients were included in the analysis of unplanned reoperation. Results The rate of unplanned reoperation was 31.3 %, with 57 % of these operations occurring to address nonunion. The overall nonunion rate was 18 %. In patients who did not require reoperation to obtain union, the median time to union for the cohort was 6 months, with an interquartile range of 3-7.5 months. Post-operative surgical site infection occurred in 11.6 % of patients. Conclusions In conclusion, unplanned reoperation following intramedullary nailing of open femur fractures occurs in nearly 1/3rd of patients and the rates of nonunion and surgical site infection may be higher than previously reported in the literature. Reoperation most closely correlates with the OTA Open Fracture Classification System. Patients with open femur fractures should be counseled that reoperation is often required to obtain fracture union, with soft tissue and fracture injury severity predicting complications.
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Affiliation(s)
- Michele N. Christy
- University of Cincinnati Medical Center, Department of Orthopaedic Surgery, Cincinnati, OH, USA
- Washington University in St. Louis, Barnes Jewish Hospital Department of Orthopaedic Surgery, St. Louis, MO, USA
| | - Nihar S. Shah
- University of Cincinnati Medical Center, Department of Orthopaedic Surgery, Cincinnati, OH, USA
| | - Matthew T. Hurn
- University of Cincinnati Medical Center, Department of Orthopaedic Surgery, Cincinnati, OH, USA
- University of Louisville Health Center, Department of Orthopaedic Surgery, Louisville, KY, USA
| | - Michael J. Beltran
- University of Cincinnati Medical Center, Department of Orthopaedic Surgery, Cincinnati, OH, USA
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2
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Ferreira N, Britz E, Gould A, Harrison WD. The management of segmental femur fractures: the radiographic 'cover-up' test to guide decision making. Injury 2022; 53:2865-2871. [PMID: 35690487 DOI: 10.1016/j.injury.2022.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 05/04/2022] [Accepted: 05/24/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Segmental femur fractures often pose management challenges regarding the optimal fixation choice and sequence of surgical events. METHODS Retrospective review of clinical records and radiographic data of adult patients with segmental femur fractures treated by a conceptual radiographic cover-up test to determine the ideal fixation method between January 2019 and December 2020. RESULTS Forty patients with 84 individual fractures underwent fracture fixation. The most consistent fracture combinations were intertrochanter-diaphysis (AO31A-AO32) fractures (25%, n = 10) and femur neck-diaphysis (AO31B-AO32) fractures (20%, n = 8). Compared to evidence-based fracture management, the gold standard treatment was used for the fixation of 78 fractures (93%). One patient required revision for fixation failure of a diaphyseal fracture, and two fractures, both open diaphysis injuries, developed fracture-related infections. CONCLUSION Anatomical alignment and high union rates are possible for segmental femur fractures treated by evidence-based fracture fixation principles. A conceptual radiographic cover-up test assists in matching the best possible implant for each fracture.
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Affiliation(s)
- Nando Ferreira
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa.
| | - Elsabe Britz
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Alan Gould
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - William D Harrison
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
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3
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Chen YH, Liao HJ, Lin SM, Chang CH, Rwei SP, Lan TY. Radiographic outcomes of the treatment of complex femoral shaft fractures (AO/OTA 32-C) with intramedullary nailing: a retrospective analysis of different techniques. J Int Med Res 2022; 50:3000605221103974. [PMID: 35676773 PMCID: PMC9189532 DOI: 10.1177/03000605221103974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To assess the results of open versus closed reduction in intramedullary nailing (IMN) for complex femoral fractures (Arbeitsgemeinschaft für Osteosynthesefragen Foundation/Orthopaedic Trauma Association [AO/OTA]: 32-C) and to determine the factors involved in bone healing. METHODS This retrospective study involved 47 consecutive patients with complex femoral diaphyseal fractures who underwent reduction and fixation. RESULTS All open-reduction and 12 closed-reduction patients (52.17%) had an anatomical-to-small gap. The closed-small group had the highest bone union rate (100%), followed by the open-reduction (79.17%) and closed-large groups (72.73%); intergroup differences were significant. The closed-small group had the shortest mean union time (7.31 months), followed by the open-reduction group (7.58 months). The closed-large group had a significantly longer union time (9.75 months) than those in the closed-small and open-reduction groups. Femoral radiographic union scores in the closed-small and open-reduction groups were similar at three timepoints; scores were higher than those in the closed-large group, with a significant difference 6 and 9 months post-operatively. CONCLUSION IMN with closed reduction for complex femoral shaft fractures had better outcomes and fewer complications versus open reduction. For unsatisfactory closed reduction outcomes (i.e., residual gap >10 mm), minimally invasive techniques or open reduction with minimal stripping should be considered.
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Affiliation(s)
- Yu-Hung Chen
- Department of Orthopedic Surgery, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., New Taipei City
| | - Hsiu-Jung Liao
- Department of Orthopedic Surgery, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., New Taipei City
| | - Shang Ming Lin
- Department of Materials and Textiles, Asia Eastern University of Science and Technology, No. 58, Sec. 2, Sihchuan Rd., New Taipei City
| | - Chih-Hung Chang
- Department of Orthopedic Surgery, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., New Taipei City
| | - Syang-Peng Rwei
- Institute of Organic and Polymeric Materials, National Taipei University of Technology, 1, Sec. 3, Zhongxiao E. Rd., Taipei.,Research and Development Center for Smart Textile Technology, National Taipei University of Technology, 1, Sec. 3, Zhongxiao E. Rd., Taipei
| | - Tsung-Yu Lan
- Department of Orthopedic Surgery, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., New Taipei City.,Department of Materials and Textiles, Asia Eastern University of Science and Technology, No. 58, Sec. 2, Sihchuan Rd., New Taipei City.,Institute of Organic and Polymeric Materials, National Taipei University of Technology, 1, Sec. 3, Zhongxiao E. Rd., Taipei
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4
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Myatt A, Saleeb H, Robertson GAJ, Bourhill JK, Page PRJ, Wood AM. Management of Gustilo-Anderson IIIB open tibial fractures in adults-a systematic review. Br Med Bull 2021; 139:48-58. [PMID: 34227647 DOI: 10.1093/bmb/ldab013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/29/2021] [Accepted: 05/19/2021] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Open tibial fractures are the most common open long bone fracture, despite this, the management of these complex injuries still remains a topic of discussion amongst orthopaedic surgeons. SOURCES OF DATA We searched the EMBASE, MEDLINE and Google Scholar and a systematic review of 7500 articles, leaving 23 after exclusion criteria were applied, in order to analyse the management of open tibial fractures. AREAS OF AGREEMENT AND CONTROVERSY Infection was noted to be the most significant concern amongst authors, with definitive external fixation having a high rate of superficial pin-site infection and internal fixation having a high deep infection rate. GROWING POINTS It is essential to have a combined ortho-plastic approach to the management of these fractures as muscle flaps were the most common form of soft tissue coverage. AREAS TIMELY FOR DEVELOPING RESEARCH A national pragmatic trial into the management of open tibial fractures is required looking at fixation methods and soft tissue coverage, with at least a 2-year follow-up in order to ascertain the most appropriate management of these fractures and patient-related outcomes.
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Affiliation(s)
- A Myatt
- Department of Trauma & Orthopaedics, ST4 Orthopaedic Registrar Leeds General Infirmary MRCSEd, Great George St, Leeds LS1 3EX, UK
| | - H Saleeb
- Department of Trauma & Orthopaedics, Orthopaedic Registrar Oxford University Hospital MRCS, Headley Way, Headington, Oxford OX3 9DU, UK
| | - G A J Robertson
- Department of Trauma & Orthopaedics, Orthopaedic Registrar Royal Infirmary of Edinburgh FRCSEd (T&O), 51 Little France Cres, Old Dalkeith Rd, Edinburgh EH16 4SA, UK
| | - Jana Keren Bourhill
- Medical Sciences Divisional Office, University of Oxford, Level 3, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - P R J Page
- Department of Trauma & Orthopaedics, Trauma Fellow, John Radcliffe Hospital Oxford, FRCS(T&O), Headley Way, Headington, Oxford OX3 9DU, UK
| | - A M Wood
- Department of Trauma & Orthopaedics, Trauma Fellow, John Radcliffe Hospital Oxford, FRCS(T&O), Headley Way, Headington, Oxford OX3 9DU, UK
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5
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Lovisetti G, Rohilla R, Siwach K. Circular external fixation as definitive treatment for open or comminuted femoral fractures: Radiologic and functional outcomes. J Clin Orthop Trauma 2019; 10:S115-S122. [PMID: 31700208 PMCID: PMC6823893 DOI: 10.1016/j.jcot.2019.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Ring external fixation can be a definitive treatment of high energy femoral fractures. A retrospective analysis of outcomes is presented. MATERIALS AND METHODS 23 patients with open or comminuted femoral fractures treated with circular external fixators were included. Mean age was 33 (range, 13-81) years. Lesions were classified according to AO/ASIF. 12 fractures were open. Mean follow up period has been 26.3, (range 20-144) months. The results were assessed according to the modified criteria of Association for the Study and Application of the Method of Ilizarov. Knee functional results were assessed with Hospital for Special Surgery knee scoring system. RESULTS 22 fractures united primarily, one showed nonunion. Knee stiffness developed in two patients. No patient had deep pin tract infection. Bone results were quoted as excellent, good, fair and poor in 19, 1, 1 and 2. The functional results were excellent, good, and fair in 16, 6, and 1, on the basis of ASAMI criteria. Mean HSS knee score has been 90.1 (range 60-100). CONCLUSION Circular external fixation can achieve reliable rates of union and good to excellent functional outcome in open or comminuted femoral fractures. A strict rehabilitation protocol was effective in preserving knee joint function.
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Affiliation(s)
- Giovanni Lovisetti
- Senior Consultant, Orthopaedics and Traumatology Unit of the Menaggio Hospital, Italy
| | - Rajesh Rohilla
- Senior Professor. Pt B D Sharma PGIMS, Rohtak, Haryana, India,Corresponding author. MS Orthopaedics Senior Professor, Pt BDS PGIMS, 9J-28, Medical Campus, PGIMS campus, Rohtak, Haryana. 124001, India.
| | - Karan Siwach
- Senior Resident. Pt B D Sharma PGIMS, Rohtak, Haryana, India
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6
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Johnson HC, Bailey AM, Baum RA, Justice SB, Weant KA. Compliance and Related Outcomes of Prophylactic Antibiotics in Traumatic Open Fractures. Hosp Pharm 2019; 55:193-198. [PMID: 32508357 DOI: 10.1177/0018578719836638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: Prophylactic antibiotic therapy is a standard of care for patients who present with open fractures due to the risk of infectious complications. This study was conducted to characterize the use of initial prophylactic antibiotic use in open fractures, guideline compliance, and its impact on care. Methods: Retrospective chart review of adult patients presenting with an open fracture to a Level 1 Trauma Center Emergency Department over a 12-month period was conducted. Results: Of the 202 patients meeting inclusion criteria, overall compliance with guideline recommendations for antibiotic prophylaxis was found to be 33.2%. The duration of prophylactic therapy was significantly longer in the noncompliant group and among those who received a secondary antibiotic (P < .05 for both comparisons). The duration of therapy was found to be significantly longer in those patients who developed an infection (P < .001). Those who developed an infection had a longer hospital length of stay (LOS) (P < .001) and intensive care unit LOS (P = .002). In addition, those who developed an infection had significantly more surgeries (P < .001) and received more red blood cell transfusions (P < .001). Correlation analysis confirmed a significant association between infection and duration of antibiotic prophylaxis (P = .02), number of surgeries (P < .0001), and number of transfusions (P < .0001). Conclusion: Guideline compliance was exceedingly low due to the extended duration of initial antibiotic therapy and did not appear to yield any clinical benefits. Infection was significantly associated with longer duration of initial prophylactic therapy and morbidity. Opportunities exist to elevate compliance with guidelines and to reevaluate prophylactic antimicrobial therapy in this setting.
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Affiliation(s)
| | - Abby M Bailey
- University of Kentucky College of Pharmacy, Lexington, KY, USA.,University of Kentucky HealthCare, Lexington, KY, USA
| | - Regan A Baum
- University of Kentucky College of Pharmacy, Lexington, KY, USA.,University of Kentucky HealthCare, Lexington, KY, USA
| | | | - Kyle A Weant
- Medical University of South Carolina, Charleston, SC, USA
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7
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Chang Y, Bhandari M, Zhu KL, Mirza RD, Ren M, Kennedy SA, Negm A, Bhatnagar N, Naji FN, Milovanovic L, Fei Y, Agarwal A, Kamran R, Cho SM, Schandelmaier S, Wang L, Jin L, Hu S, Zhao Y, Lopes LC, Wang M, Petrisor B, Ristevski B, Siemieniuk RA, Guyatt GH. Antibiotic Prophylaxis in the Management of Open Fractures. JBJS Rev 2019; 7:e1. [DOI: 10.2106/jbjs.rvw.17.00197] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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8
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Christiano AV, Goch AM, Leucht P, Konda SR, Egol KA. Radiographic union score for tibia fractures predicts success with operative treatment of tibial nonunion. J Clin Orthop Trauma 2019; 10:650-654. [PMID: 31316233 PMCID: PMC6611993 DOI: 10.1016/j.jcot.2018.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/28/2018] [Accepted: 10/18/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The purpose of this study is to evaluate the ability of preoperative and postoperative radiographic union scores for tibia fractures (RUST) to predict treatment success of tibia fracture nonunion. MATERIALS AND METHODS Patients presenting for operative treatment of tibia fracture nonunion were enrolled in a prospective data registry. Enrolled patients were followed at regular intervals for 12 months. Preoperative and 12 week postoperative radiographs were reviewed and scored using the RUST criteria. Postoperative time to union was determined by clinical and radiographic measures. Multivariate regressions were conducted to predict time to union using preoperative and postoperative RUST while controlling for treatment method. Receiver operating characteristic (ROC) curve was conducted to determine the accuracy of preoperative RUST in predicting failure of treatment. RESULTS Sixty-eight patients with aseptic tibia fracture nonunion treated operatively were identified. Sixty-one patients achieved union. Mean preoperative RUST was 7.5 (SD 1.4). Mean postoperative RUST was 9.2 (SD 1.4). Multivariate linear regressions demonstrated that preoperative (p = 0.043) and postoperative (p = 0.007) RUST are significant predictors of time to union after tibia fracture nonunion surgery. ROC curve demonstrated preoperative RUST below 7 was a good predictor of developing persistent tibia fracture nonunion (AUC = 0.83, Sensitivity = 1.000, Specificity = 0.745). CONCLUSIONS RUST preoperatively and postoperatively predicts outcome after nonunion surgery. RUST can be used as part of the complete clinical picture to shape patient expectations and guide treatment.
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Affiliation(s)
- Anthony V. Christiano
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Corresponding author. 1 Gustave L Levy Pl, Box 1188, New York, NY, 10029, USA.
| | | | | | - Sanjit R. Konda
- NYU Hospital for Joint Diseases, New York, NY, USA,Jamaica Hospital Medical Center, New York, NY, USA
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9
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Vicenti G, Carrozzo M, Caiaffa V, Abate A, Solarino G, Bizzoca D, Maddalena R, Colasuonno G, Nappi V, Rifino F, Moretti B. The impact of the third fragment features on the healing of femoral shaft fractures managed with intramedullary nailing: a radiological study. INTERNATIONAL ORTHOPAEDICS 2018; 43:193-200. [PMID: 30488127 DOI: 10.1007/s00264-018-4214-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 09/18/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Femoral shaft fractures with third fragments have a high non-union rate, which may reach 14%. This study aims to assess the impact of the radiological features of the third fragment, evaluated on post-operative X-rays, on the outcome of femoral shaft fractures type 32-B managed with intramedullary nailing, in order to obtain an algorithm which could predict the fracture healing time. MATERIALS AND METHODS We have retrospectively evaluated a series of 52 patients. On post-operative X-rays, four radiological parameters were evaluated: the third fragment angle, the fracture gap, the third fragment size, and the mean third fragment displacement. All the patients underwent a radiologic follow-up at one, two, three, six, nine and 12 months post-operatively, to assess the bone healing. The patients were then divided into three groups, according to the fracture healing time: within six months (group A), between six and 12 months (group B), or fracture non-union after 12 months (group C). RESULTS In 28 patients, out of 52 (53.85%), the fracture healing was observed at 6-month follow-up; in 18 patients, out of 52 (34.62%), the fracture healed within 12 months after trauma; and in six patients, out of 52 (11.54%), no fracture healing was observed at 12-month follow-up. The mean third fragment size was significantly different in each group (p < 0.05), while the mean third fragment displacement was significantly higher in group C, compared with group A (p = 0.0006) and group B (p = 0.0027). In group B, a positive correlation was found between the fracture healing time and the mean third fragment size (R = 0.594, p = 0.036); in group C, the fracture union time was positively related to the third fragment size (R = 0.689, p = 0.013) and the mean third fragment displacement (R = 0.7107, p = 0.006). Regression analysis showed that the third fragment size and the mean third fragment displacement are the most important features which affect the fracture healing time. CONCLUSIONS The third fragment size (cutoff 40 mm) is the leading parameter to influence the fracture healing within or in more than six months. The mean third fragment displacement (cutoff 12 mm); on the other hand, impacts on the fracture delayed rather than absent healing.
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Affiliation(s)
- Giovanni Vicenti
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Policlinico Consorziale, Bari, Italy
| | - Massimiliano Carrozzo
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Policlinico Consorziale, Bari, Italy.
| | - Vincenzo Caiaffa
- Department of Orthopaedics and Traumatology, Di Venere Hospital, Bari, Italy
| | - Antonella Abate
- Department of Orthopaedics and Traumatology, Di Venere Hospital, Bari, Italy
| | - Giuseppe Solarino
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Policlinico Consorziale, Bari, Italy
| | - Davide Bizzoca
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Policlinico Consorziale, Bari, Italy
| | - Roberto Maddalena
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Policlinico Consorziale, Bari, Italy
| | - Giulia Colasuonno
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Policlinico Consorziale, Bari, Italy
| | - Vittorio Nappi
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Policlinico Consorziale, Bari, Italy
| | - Francesco Rifino
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Policlinico Consorziale, Bari, Italy
| | - Biagio Moretti
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Policlinico Consorziale, Bari, Italy
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10
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Saleeb H, Tosounidis T, Papakostidis C, Giannoudis PV. Incidence of deep infection, union and malunion for open diaphyseal femoral shaft fractures treated with IM nailing: A systematic review. Surgeon 2018; 17:257-269. [PMID: 30166239 DOI: 10.1016/j.surge.2018.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 07/27/2018] [Accepted: 08/02/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND and purpose: We have undertaken a systematic review to evaluate the clinical results of intramedullary nailing (IMN) for open diaphyseal femoral fractures on the rates of union, delayed union, malunion, superficial and deep infection and bone grafting. METHODS We searched the electronic databases of EMBASE, MEDLINE, from their inception until December 1st, 2017 with no language restrictions. The reference lists of all included articles and relevant reviews were also examined for potentially eligible studies. Hand search using electronic database of recent major orthopaedic journals was also carried. Two reviewers working independently extracted study characteristics and data to estimate the diagnostic odds ratio and 95% confidence interval for each result. RESULTS Seventeen studies were eligible. Pooled estimate of effect size for union rate was 97% (95% CI: 94-99%). Deep infection rate was 6% (95% CI: 3-9.3%) and more prominent in Gustilo type III injuries; superficial infection was 5.6% (95% CI: 3-9.3%). Delayed union rate 3% (95% CI: 1-5.6%) while, malunion rate was 8.4% (95% CI: 5.7-11.6%). The need for bone grafting ranged from 0 to 9%. CONCLUSIONS IMN remains the treatment of choice for open femoral diaphyseal fractures with very good union rates. Gustilo grade III injuries demonstrate a distinct higher deep infection rate and strict adherence to established surgical debridement and fixation protocols is advocated. The need for bone grafting can be as high as 9% and patients should be made aware of the possibility of requiring this additional procedure.
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Affiliation(s)
- Hany Saleeb
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, School of Medicine, University of Leeds, Leeds, United Kingdom.
| | - Theodoros Tosounidis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, School of Medicine, University of Leeds, Leeds, United Kingdom; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Costas Papakostidis
- Department of Trauma and Orthopaedics, "G. Hatzikostas" General Hospital, Ioannina, Greece
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, School of Medicine, University of Leeds, Leeds, United Kingdom; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom
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11
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Lee JR, Kim HJ, Lee KB. Effects of third fragment size and displacement on non-union of femoral shaft fractures after locking for intramedullary nailing. Orthop Traumatol Surg Res 2016; 102:175-81. [PMID: 26826804 DOI: 10.1016/j.otsr.2015.11.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 11/06/2015] [Accepted: 11/13/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The femoral shaft fractures with large fragments makes anatomical reduction challenging and often results in non-union. In some studies, the degree of fragment displacement was reported to have affected non-union, but the association between the one fragment size and degree of displacement has not been fully clarified. Therefore we performed a retrospective study to assess: (1) the more influential factor of non-union: the degree of fragment displacement, or the fragment size? (2) the non-union rates according to different sizes and degrees of displacement. HYPOTHESIS The degree of displacement is the more potent factor of non-union than the third fragment size in femoral shaft fractures. PATIENTS AND METHODS We assessed retrospectively 64 cases, which could be followed up for longer than one year. Fragments were divided according to the length of their long axis into three groups: group A (0-3.9cm), (n=21); group B (4-7.9cm), (n=22); group C (8cm or more), (n=21). Fragment displacement was also assessed in the proximal (P) or distal (D) end to the nearest cortex of the femoral shaft, and divided into the following groups: group P1 (n=44) or D1 (n=47), (0-9mm); group P2 (n=10) or D2 (n=11), (10-19mm); group P3 (n=7) or D3 (n=3), (20-29mm); and group P4 (n=3) or D4 (n=3), (30mm or more). RESULTS The bone union rate was 86% in the small (less than 8cm) fragment groups and 71% in the large (8cm or more) fragment group (P=0.046). With respect to the degree of displacement, the union rate was lower (P=0.001) and the average union time was longer (P=0.012) in the 20mm or more group for both the proximal fragment part and the distal fragment part (P=0.002, P=0.014). A logistic regression analysis underlined the displacement in the proximal site (OR: 0.298, 95% CI: 0.118-0.750) as in the distal site (OR: 0.359, 95% CI: 0.162-0.793) as a larger effect on union rate than the fragment size that as no effect in logistic regression (OR 3.8, 95% CI: 0.669-21.6). CONCLUSION Non-union develops significantly more frequently in femoral shaft fractures with fragments 8cm or longer or when the displacement in the proximal area is 20mm or greater and 10mm or greater in the distal area during the intramedullary nailing procedure. Regarding union rate, the degree of displacement has more influence than the third fragment size in femoral shaft fractures. LEVEL OF EVIDENCE IV, retrospective cohort study.
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Affiliation(s)
- J R Lee
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital Chonbuk National University Medical School, 634-18, Keum Am-dong, Dukjin-gu, Jeonju, Chonbuk, 561-712, Korea
| | - H-J Kim
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital Chonbuk National University Medical School, 634-18, Keum Am-dong, Dukjin-gu, Jeonju, Chonbuk, 561-712, Korea
| | - K-B Lee
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital Chonbuk National University Medical School, 634-18, Keum Am-dong, Dukjin-gu, Jeonju, Chonbuk, 561-712, Korea.
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Barton CA, McMillian WD, Crookes BA, Osler T, Bartlett CS. Compliance with the Eastern Association for the Surgery of Trauma guidelines for prophylactic antibiotics after open extremity fracture. Int J Crit Illn Inj Sci 2012; 2:57-62. [PMID: 22837892 PMCID: PMC3401818 DOI: 10.4103/2229-5151.97268] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Prophylactic antibiotics, paired with wound care and surgical intervention, is considered the standard of care for patients with open fracture. Guidelines from the Eastern Association for the Surgery of Trauma (EAST) recommend specific prophylactic antimicrobial therapy based on the type of open fracture. AIMS We quantified adherence to EAST guideline recommendations and documented the incidence of infection in patients with open fracture. SETTINGS AND DESIGN A retrospective, observational study of all patients with open fracture admitted to our facility from January 2004 to December 2008 was conducted. MATERIALS AND METHODS Patients were divided into compliant and noncompliant groups according to the EAST guideline recommendations. Compliance was defined as an appropriate spectrum of therapy for guideline suggested duration. We assessed for surgical and non-surgical site infections, and morbidity outcomes. STATISTICAL ANALYSIS Nominal data were explored using summary measures. Continuous variables were compared using the Student t-test or the Mann-Whitney U-test. Dichotomous data were compared using χ(2) statistic or Fisher's exact test. RESULTS The final analysis included 214 patients. Prophylactic antibiotics were guideline compliant in 28.5% of patients, and ranged from 10.0% in type 3b fractures to 52.7% in type 1 fractures. The most common reason for non-compliance was the use of guideline recommended coverage that exceeded the suggested duration (71.2%). Patients who received non-compliant therapy required prolonged hospital lengths of stay (6 vs. 3 days, P = 0.0001). The overall incidence of infection was similar regardless of guideline compliance (17.0% vs. 11.5%, P = 0.313). CONCLUSIONS Prophylactic antibiotics for open fracture frequently exceeded guideline recommendations in duration and spectrum of coverage, especially in more severe fracture types. Non-compliance with EAST recommendations was associated with increased in-hospital morbidity.
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Affiliation(s)
- Cassie A Barton
- Department of Pharmacy, Fletcher Allen Health Care, Burlington, VT, USA
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