Standards of external fixation in prolonged applications to allow safe conversion to definitive extremity surgery: the Aachen algorithm for acute ex fix conversion

Incidence of Infection in Operatively Treated Distal Radius Fractures After Conversion From External to Internal Fixation

PURPOSE

The purpose of this study was to report the incidence of infection after conversion from external fixation (EF) to internal fixation (IF) of distal radius fractures and to evaluate the relationship between infection and secondary variables, including time to conversion from EF to IF, internal hardware overlapping EF pin sites, and definitive fixation with a dorsal-spanning bridge plate.

METHODS

A retrospective review was performed at 2 level 1 trauma centers including all patients aged ≥18 years from 2006 to 2019 with a distal radius fracture treated initially with EF followed by subsequent IF. The patients were excluded from analysis if they had <10 weeks of clinical follow-up, a history of prior distal radius surgery, or evidence of infection before EF to IF conversion. Patient demographic data, mechanism of injury, presence of hardware overlapping pin sites, and timing to definitive fixation were obtained from the medical records. Infection was defined as positive intraoperative cultures or documented return to the operating room for debridement after IF.

RESULTS

A total of 64 fractures in 61 patients with a median age of 50 years (range, 18-75 years) were included. Infections developed in 6 patients (6 of 64 fractures). The incidence of infection was higher in patients with a time to conversion from EF to IF of >14 days (infection in 2 of 5 patients vs 4 of 59 patients). The incidence of infection was similar in patients with and without hardware overlapping EF pin sites (3 of 27 vs 3 of 37, respectively).

CONCLUSIONS

Infections occurred in 6 of 64 distal radius fractures following conversion from EF to IF, and delay in conversion of >14 days was associated with an increased infection risk.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Preoperative antibiotics reduce early surgical site infections after orthopaedic implant removal: a propensity-matched cohort study

BACKGROUND

Implant removal in orthopaedics after fracture consolidation is a very common procedure but is still associated with a high rate of surgical site infection (SSI). Antibiotic prophylaxis is not recommended but advocated by some.

AIM

To assess the efficacy of antibiotic prophylaxis in the prevention of early SSI following orthopaedic implant removal.

METHODS

A monocentric retrospective cohort study was conducted. Patients who underwent orthopaedic implant removal procedures performed from 2016 to 2021 were included. A 1:1 propensity score matching function was used to create a cohort with matched baseline characteristics and associated risk factors for SSI. Inter-cohort comparison of the occurrence of SSI (superficial or deep) and revision surgery for SSI, after propensity score matching, was performed using the odds ratio to determine the effect of preoperative antibiotic prophylaxis.

FINDINGS

In total, 965 distinct surgical procedures were included. Of these, 69 (7.15%) had an SSI, 24 (35.7%) of which required surgical revision; 214 procedures (22.18%) were performed under preoperative antibiotic prophylaxis. The propensity-matched cohort consisted of 396 procedures (198 with and without antibiotic prophylaxis). The SSI rates were 11.11% and 3.03%, respectively, in the control and antibiotic prophylaxis groups (odds ratio: 0.25; 95% confidence interval: 0.099; 0.63; P = 0.011). No difference was found for revision surgery.

CONCLUSION

Preoperative administration of antibiotic prophylaxis considerably reduces the risk of SSI during the removal of an orthopaedic implant without increasing the risk of side-effects.

A new technology using a customized 3D printed fixator to assist fracture reduction and fixation: Technical note

BACKGROUND

Poor reduction can lead to complications such as deformity and delayed fracture healing. We introduce a 3D printed external fixator technology that can assist in fracture reduction and fixation.

METHODS

A fractured long bone was first fixed by a temporary external fixator and then scanned with computed tomography. Three-dimensional reconstruction of the contour and bone fragments of the affected limb was performed using Mimics software, and the fracture reduction was simulated. Subsequently, data were imported into SolidWorks software for customized external fixator design and 3D printing. Through the precise assembly of the 3D printed external fixator and external fixation pins, automatic fracture reduction.

RESULTS

The patient's fractures were well reduced, firmly fixed, and the postoperative fractures healed well with no complications.

CONCLUSION

The technique we introduce not only assists in fracture reduction for temporary external fixation but can also be used as a definitive treatment for long bone fractures.

Optimum timing of conversion from DCO to definitive fixation in closed fractures of the lower limb: When and how?

INTRODUCTION

In damage control orthopaedics (DCO), fractures are initially stabilised with external fixation followed by delayed conversion to definitive internal fixation. The aim of this study is to determine whether the timing of the conversion influences the development of deep infection and fracture healing in a cohort of patients treated by DCO after a closed fracture of the lower limb. Furthermore, we wanted to evaluate whether the one-stage conversion procedure is always safe.

MATERIALS AND METHODS

A retrospective cohort study was conducted at a single level 1 trauma centre. Ninety-four cases of closed fractures of lower limb treated by DCO subsequently converted to internal fixation from 2012 to 2019 were included. Development of deep infection, superficial infection, non-union and time to union were recorded. Patients were then divided into three groups according to the timing of conversion: Group A (<7 days), Group B (7-13 days), Group C (> 14 days). Comparison between groups was performed to assess intergroup variabilty.

RESULTS

The mean number of days between DCO and conversion was 6.7±4.52 (range 1-22). We observed one case of deep infection (1.1%), one case of non-union (1.1%), four cases of superficial infection (4.3%) and mean time to union was ±1.38 months. Comparison between groups demonstrated no significant correlation between timing of conversion and development of superficial or deep infection and non-union, while it highlighted that complexity of the fracture and longer surgical time of conversion procedure were significantly higher in Group C.

CONCLUSIONS

One-stage conversion to definitive internal fixation within 22 days from DCO is a safe and feasible procedure, which does not influence the incidence of infection or non-union.

[External fixator for temporary stabilization of complex periarticular knee fractures]

OBJECTIVE

Temporary stabilization of the knee joint in order to minimize soft tissue strain until definitive surgery is possible.

INDICATIONS

Bicondylar distal femoral and tibial plateau fractures, additional vascular injury, open fractures (second or third degree), severe soft tissue damage, unicondylar fracture with contralateral ligament tear, (open) knee dislocation, polytrauma.

CONTRAINDICATIONS

Unsafe pin placement, severe osteoporosis.

SURGICAL TECHNIQUE

Two femoral and tibial pins are connected by two rods and are spanned over the knee with two additional longitudinal rods via a tube-to-tube clamp. Alternatively, this can be facilitated by a direct connection of two rods in case of anteriorly placed femoral pins. A reasonable distance should be kept to open wounds, the fracture, and later operative approaches. The knee is fixed in 5-15° of flexion.

POSTOPERATIVE MANAGEMENT

Definitive treatment depending on patient well-being and amenable soft tissue.

Induced membrane technique with sequential internal fixation: use of a reinforced spacer for reconstruction of infected bone defects

PURPOSE

To evaluate a novel sequential internal fixation strategy using a reinforced spacer for infected bone defect reconstruction by the induced membrane technique (IMT).

METHODS

A retrospective case study was performed among patients treated for infected bone defects by applying this strategy. Following radical debridement, temporary stabilization was provided by a massive cement spacer combined with minimal intramedullary fixation during step 1. Definitive internal fixation was performed together with bone grafting at step 2.

RESULTS

Eight patients with a mean age of 58 years were reviewed. The mean bone defect length was 8.8 cm. The spacer armature mostly consisted of elastic nails and Steinmann pins. Iterative debridement was required in one case after step 1. The mean interval between steps was 12 weeks. Definitive internal fixation was performed by intramedullary nailing (n = 4) or plating (n = 4). At a mean follow-up of 21 months, bone union was achieved in seven cases without additional bone grafting or infection recurrence.

CONCLUSIONS

Sequential internal fixation using a reinforced cement spacer seems to be a valuable option for avoiding external fixation between IMT steps and limiting the recurrence of infection.

Standards for external fixation application: national survey under the auspices of the German Trauma Society

INTRODUCTION

External fixation is widely accepted as a provisional or sometimes definitive treatment for long-bone fractures. Indications include but are not limited to damage control surgery in poly-traumatized patients as well as provisional bridging to definite treatment with soft tissue at risk. As little is known about surgeon's habits in applying this treatment strategy, we performed a national survey.

METHODS

We utilized the member database of the German Trauma Society (DGU). The questionnaire encompassed 15 questions that addresses topics including participants' position, experience, workplace, and questions regarding specifics of external fixation application in different anatomical regions. Furthermore, we compared differences between trauma centre levels and surgeon-related factors.

RESULTS

The participants predominantly worked in level 1 trauma centres (42.7%) and were employed as attendings (54.7%). There was widespread consensus for planning and intra-operative radiographical control of external fixation. Surgeons appointed at a level I trauma centre preferred significantly more often supra-acetabular pin placement in external fixation of the pelvis rather than the utilization of iliac pins (75.8%, p = 0.0001). Moreover, they were more likely to favor a mini-open approach to insert humeral pins (42.4%, p = 0.003). Overall, blunt dissection and mini-open approaches seemed equally popular (38.2 and 34.1%). Department chairmen indicated more often than their colleagues to follow written pin-care protocols for minimization of infection (16.7%, p = 0.003).

CONCLUSION

Despite the fact that external fixation usage is widespread and well established among trauma surgeons in Germany, there are substantial differences in the method of application.

Epidemiology of open tibia fractures in a population-based database: update on current risk factors and clinical implications

BACKGROUND

Open tibia fractures usually occur in high-energy mechanisms and are commonly associated with multiple traumas. The purposes of this study were to define the epidemiology of open tibia fractures in severely injured patients and to evaluate risk factors for major complications.

METHODS

A cohort from a nationwide population-based prospective database was analyzed (TraumaRegister DGU^®). Inclusion criteria were: (1) open or closed tibia fracture, (2) Injury Severity Score (ISS) ≥ 16 points, (3) age ≥ 16 years, and (4) survival until primary admission. According to the soft tissue status, patients were divided either in the closed (CTF) or into the open fracture (OTF) group. The OTF group was subdivided according to the Gustilo/Anderson classification. Demographic data, injury mechanisms, injury severity, surgical fracture management, hospital and ICU length of stay and systemic complications (e.g., multiple organ failure (MOF), sepsis, mortality) were collected and analyzed by SPSS (Version 23, IBM Inc., NY, USA).

RESULTS

Out of 148.498 registered patients between 1/2002 and 12/2013; a total of 4.940 met the inclusion criteria (mean age 46.2 ± 19.4 years, ISS 30.4 ± 12.6 points). The CTF group included 2000 patients (40.5%), whereas 2940 patients (59.5%) sustained open tibia fractures (I°: 49.3%, II°: 27.5%, III°: 23.2%). High-energy trauma was the leading mechanism in case of open fractures. Despite comparable ISS and NISS values in patients with closed and open tibia fractures, open fractures were significantly associated with higher volume resuscitation (p < 0.001), more blood (p < 0.001), and mass transfusions (p = 0.006). While the rate of external fixation increased with the severity of soft tissue injury (37.6 to 76.5%), no major effect on mortality and other major complications was observed.

CONCLUSION

Open tibia fractures are common in multiple trauma patients and are therefore associated with increased resuscitation requirements, more surgical procedures and increased in-hospital length of stay. However, increased systemic complications are not observed if a soft tissue adapted surgical protocol is applied.

Temporary fixation of limbs and pelvis

"Urgent, complete, definitive" treatment still today seems to be an appropriate attitude in many trauma cases. There are, however, several situations in which emergency definitive fixation is not the optimal strategy for all cases of fracture. Temporary fixation has a role to play in the orthopedic "trauma damage control" design comprising successive steps, as applied in multiple trauma, multiple fracture, severe multi-tissue limb lesions and soft-tissue lesions of unpredictable progression. The aim of this study is to define the strategies, indications, principles and limitations of temporary fixation in limb and pelvis fracture.

Prevalence and risk factors for re-interventions following reamed intramedullary tibia nailing

INTRODUCTION

This study aimed to identify the prevalence and the risk factors for re-interventions following reamed intramedullary nailing (IMN) of tibial shaft fractures.

PATIENTS AND METHODS

We retrospectively analysed a prospectively populated data of adult patients that underwent reamed intramedullary nailing for stabilization of tibial shaft fractures over a period of three years. Exclusion criteria were immature patients, pathological and periarticular fractures. Data collected included patient demographics, mechanism of injury, open or closed injury pattern, ISS, perioperative complications, reintervention characteristics (time, cause, number), smoking habits, medical co-morbidities and progress to radiological fracture union. Fractures were classified according to AO/OTA system. The cohort of these patients was divided in two groups: Group 1 included the patients who healed uneventfully and Group 2 included the patients who underwent a re-intervention for the healing of the fracture. A logistic regression analysis model was used to assess the odds ratio (OR) of identified risk factors predicting the necessity of re-interventions.

RESULTS

181 (129 male) patients with a mean age of 37 (range 16-87) met the inclusion criteria. 30 patients were excluded due to inadequate follow up, leaving 151 patients for the study group. 119 patients were included in Group 1. 32 (21.2%) patients who had at least one re-intervention (range 1-3) were included in Group 2. The most common causes for re-intervention were aseptic non-union (31.3%) and removal of implants due to soft tissue irritation/anterior knee pain (31.3%), followed by early metalwork failure (12.5%), infected non-union (9.4%), correction of rotational deformities (9.4%) and canal intramedullary sepsis with evident fracture healing (6.3%). 29 (25.8%) from the study cohort patients sustained an open fracture and 8 of them underwent a re-intervention (20.5% of interventions). Incidence of fracture pattern 42-B, C was statistically significant greater in the reintervention (40.6%) compared to the non-re-intervention group (23.53%) (p = 0.026). Risk factors predicting the need for re-interventions included the type of fracture B, C (p = 0.026 OR: 2.528, range: 1.117-5.721) and increased alcohol consumption (p = 0.027/OR: 2.618, range: 1.116-6.141).

CONCLUSION

Fracture pattern and alcohol abuse were highly predictive for re-interventions following reamed IM nailing for stabilization of acute tibial shaft fractures.