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The Bioburden Associated with Severe Open Tibial Fracture Wounds at the Time of Definitive Closure or Coverage: The BIOBURDEN Study. J Bone Joint Surg Am 2024; 106:858-868. [PMID: 38489393 DOI: 10.2106/jbjs.23.00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND Infection is common following high-energy open tibial fractures. Understanding the wound bioburden may be critical to infection risk reduction strategies. This study was designed to identify the bioburden profile of high-energy open tibial fractures at the time of definitive wound closure or coverage and determine the relationship to subsequent deep infection. METHODS This multicenter prospective study enrolled 646 patients with high-energy open tibial fractures requiring a second debridement surgery and delayed wound closure or coverage. Wound samples were obtained at the time of definitive closure or coverage and were cultured in a central laboratory. Cultures were also subsequently obtained from patients who underwent a fracture-site reoperation. RESULTS Two hundred and six (32%) of the wounds had a positive culture at the time of closure or coverage. A single genus was identified in 154 (75%) of these positive cultures and multiple genera, in 52 (25%). Gram-positive cocci (GPCs) were identified in 98 (47%) of the positive cultures. Staphylococci were identified in 64 (31%) of the cultures, and 53 (83%) of these were coagulase-negative (CONS). Enterococci were identified in 26 (13%) of the cultures. Gram-negative rods (GNRs) were identified in 100 (49%) of the cultures; the most frequent GNR genera identified were Enterobacter (39, 19%) and Pseudomonas (21, 10%). Positive cultures were subsequently obtained from 154 (50%) of 310 revision surgeries. A single genus was identified in 85 (55%) of the 154 and multiple genera, in 69. GPCs were identified in 134 (87%) of the 154 positive cultures, staphylococci were identified in 94 (61%), and GNRs were identified in 100 (65%). CONCLUSIONS The bioburden in high-energy open tibial fractures at delayed closure or coverage was often characterized by pathogens of multiple genera and of genera that are nonresponsive to typically employed antibiotic prophylaxis. Awareness of the final wound bioburden might inform strategies to lower the infection rate. LEVEL OF EVIDENCE Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Wellings EP, Moran SL, Tande AJ, Hidden KA. Approach to Tibial Shaft Nonunions: Diagnosis and Management. J Am Acad Orthop Surg 2024; 32:237-246. [PMID: 38190574 DOI: 10.5435/jaaos-d-23-00453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 11/27/2023] [Indexed: 01/10/2024] Open
Abstract
The tibia is the most common long bone at risk for nonunion with an annual incidence ranging from 12% to 19%. This topic continues to be an area of research as management techniques constantly evolve. A foundational knowledge of the fundamental concepts, etiology, and risk factors for nonunions is crucial for success. Treatment of tibial shaft nonunions often requires a multidisciplinary effort. This article provides guidance based on the most recent literature that can be used to aid the treating provider in the diagnosis, workup, and management of tibial shaft nonunions.
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Affiliation(s)
- Elizabeth P Wellings
- From the Department of Orthopedic Surgery, Mayo Clinic (Wellings and Hidden), Division of Plastic Surgery, Department of Surgery, Mayo Clinic (Moran), and the Division of Infectious Diseases, Department of Medicine (Tande)
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Wally MK, Seymour R, Roomian T, Churchill C, Haines N, Hsu JR, Bosse M, Karunakar MA. How Many Patients Do We Need? Predictors of Consent to Participate in Clinical Research Studies in Orthopaedic Trauma. J Orthop Trauma 2023; 37:e170-e174. [PMID: 36729512 DOI: 10.1097/bot.0000000000002538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To characterize the recruitment rates at a Level I trauma center enroling for multiple prospective orthopaedic trauma research studies and identify patient-related and study-related predictors of consent. DESIGN We conducted a case-control study to identify predictors of study consent. The authors categorized studies based on intensity of the study intervention (low, intermediate, or high). A 2-level generalized linear model with random intercept for study was used to predict study consent. SETTING This analysis includes data from 10 federally funded studies conducted as part of a large, national consortium that were enroling patients in 2013-2014. PATIENTS/PARTICIPANTS Three hundred thirty-four patients were approached for at least 1 study and included in the analysis. INTERVENTION N/A. MAIN OUTCOME MEASURES Consent to participate in the research study. RESULTS A total of 315 patients consented to be in a study (71% of approached patients). Consent rate varied by study (45%-95%). No patient characteristics (race, age, or sex) were associated with consent. Patients approached for studies of intermediate intensity were 83% less likely to consent (odds ratio = 0.17; 95% confidence interval: 0.04-0.67), and those approached for studies of high intensity were 91% less likely to consent (odds ratio = 0.09; 95% confidence interval: 0.03-0.32). CONCLUSION Patient factors were not associated with consent. Study intensity is a major driver of consent rates. Studies of higher intensity will require the study team to approach up to twice as many patients as the target enrolment. This study provides a framework that can be used in study planning and determination of feasibility.
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Affiliation(s)
- Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
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Type III Open Tibia Fractures Treated With Single-Stage Immediate Medullary Nailing and Attempted Primary Closure Yield Low Rates of Flap Coverage. J Am Acad Orthop Surg 2023; 31:252-257. [PMID: 36729759 DOI: 10.5435/jaaos-d-22-00469] [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: 05/11/2022] [Accepted: 10/23/2022] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE The purpose of this study was to determine whether type III open high-energy tibia fractures treated with immediate intramedullary nailing (IMN) and primary closure yield low rates of flap coverage. METHODS Patients with high-energy type IIIA open tibia (OTA/AO42/43) fractures treated with IMN over a 10-year period at a level 1 academic center with at least 90 days of in-person postoperative follow-up were included. Single-stage reamed IMN with acute primary skin closure using Allgower-Donati suture technique was utilized in patients without notable skin loss. The primary outcome was treatment failure of acute primary skin closure requiring subsequent soft-tissue coverage procedures. RESULTS A total of 111 patients with type IIIA tibia fractures met inclusion criteria. Of 107 of the 111 patients (96%) with skin closure at the index surgery, 95 of the 107 patients (89%) healed their soft-tissue envelop uneventfully. Among the patients who failed primary closure (11%), five required free tissue transfers, five required local rotational flaps, and two underwent split thickness skin grafting only. Patients who failed acute primary closure declared within an average of 8 weeks postoperatively. DISCUSSION Treatment of type IIIA open high-energy tibia fractures with immediate IMN and primary closure using meticulous soft-tissue handling yields low rates of flap coverage.
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Gani MH, Liang K, Muzafar K, Dev B, Bhat KA, Ghani A. Outcomes after primary intramedullary nail fixation of open tibial and femoral fractures in low resource settings. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03329-5. [PMID: 35829964 DOI: 10.1007/s00590-022-03329-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/20/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Open fractures are unique in the urgency they impart to the injury and the therapeutic challenge they pose. Non-union and infection are among the major concerns. Open tibial and femoral shaft fractures are among the commonest orthopaedic urgencies. Primary intramedullary (IM) nailing requires a skillset and knowledge of the principles of open fracture management and also a well-equipped operating room with the necessary implants and instruments. In a low resource setting, one or more of these prerequisites may not be met, and the outcome may thus be affected similarly. The objective of this study was to study these outcomes. METHODS We prospectively studied primary IM nailing of open 1, 2 and 3A tibial and femoral fractures done in our hospital, in a simple non-modular operating room without an image intensifier. RESULTS There were 106 fractures in 104 patients: 93 tibial and 13 femoral. The mean time from injury to surgical debridement was 19.6 h. Mean duration of antibiotics therapy was 4.3 days, and the mean duration of hospital stay was 4.1 days. All patients were followed up to union. Mean time to radiographic union was 6.1 months for the tibia and 5.7 months for the femur. Non-union was seen in 4 tibial and 1 femoral fractures. There were 3 superficial infections but no deep infection. CONCLUSION The outcomes were comparable to, and in some cases better than, those found in existing literature. We conclude that primary IM nailing in open long bone fractures can be performed in austere environments with good success, in expert hands if the principles are adhered to.
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Affiliation(s)
| | - Kaifeng Liang
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Khalid Muzafar
- Department of Orthopaedics, Government Medical College, Doda, Jammu & Kashmir, India
| | - Bias Dev
- Department of Orthopaedics, Government Medical College Jammu, Jammu, Jammu & Kashmir, India
| | | | - Abdul Ghani
- Department of Orthopaedics, Government Medical College Jammu, Jammu, Jammu & Kashmir, India
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Modern External Ring Fixation Versus Internal Fixation for Treatment of Severe Open Tibial Fractures: A Randomized Clinical Trial (FIXIT Study). J Bone Joint Surg Am 2022; 104:1061-1067. [PMID: 36149241 DOI: 10.2106/jbjs.21.01126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Modern external ring fixation has been hypothesized to reduce complications requiring hospital readmission compared with internal fixation when treating patients with high-energy open tibial shaft fractures. In this study, the 1-year probability of a major limb complication was compared between external and internal fixation of severe open tibial fractures. METHODS This multicenter randomized clinical trial included patients 18 to 64 years of age with severe open tibial shaft fractures randomly assigned to either modern external ring fixation (n = 127) or internal fixation (n = 133). The primary outcome was a major limb complication within 365 days after randomization; these complications included amputation, infection, a soft-tissue problem, nonunion, malunion, and a loss of reduction/implant failure. RESULTS Of 260 randomized patients, 254 were included in the final analysis. Their mean age (standard deviation) was 39 (13) years; 214 (84%) were men. The probability of at least 1 major limb complication was higher for external fixation (62.1% [95% confidence interval (CI): 53.4% to 70.8%]) than internal fixation (43.7% [95% CI: 35.5% to 52.9%]), with a risk difference of 18.4% (95% CI: 5.8% to 30.4%); p = 0.005). The most notable difference was in loss of reduction/implant failure, the rate of which was higher for external fixation (risk difference: 14.4% [95% CI: 7.0% to 21.6%]; p = 0.002). There was no appreciable difference in the probability of deep infection between external fixation (26.1%) and internal fixation (29.7%) (risk difference: -3.5% [95% CI: -14.8% to 7.8%]; p = 0.54). There were also no appreciable differences in the probabilities of amputation, nonunion, soft-tissue problems, malunion, or fracture healing between the groups. CONCLUSIONS These results argue against routine use of modern external ring fixation for the treatment of these severe open tibial fractures. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Castillo RC, Carlini AR, Chaffee T, Bosse MJ, O'Toole RV, Kleweno CP, McKinley TO, Agel J, Higgins TF, Morshed S, Staguhn ED, Aaron RV, Reider L, Wu AW, MacKenzie EJ. Long-Term Consequences of Major Extremity Trauma: A Pilot Study. J Orthop Trauma 2022; 36:S21-S25. [PMID: 34924515 DOI: 10.1097/bot.0000000000002297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY Limited data are available on the longer-term physical and psychosocial consequences after major extremity trauma apart from literature on the consequences after major limb amputation. The existing literature suggests that although variations in outcome exist, a significant proportion of service members and civilians sustaining major limb trauma will have less than optimal outcomes or health and rehabilitation needs over their life course. The proposed pilot study will address this gap in current research by locating and consenting METRC participants with the period of 5-7 years postinjury, identifying potential participation barriers and appropriate use of incentives, and conducting the follow-up examination at several data collection sites. The resulting data will inform the primary objective of refining and developing specific hypotheses to determine the design, scope, and feasibility of the main long-term consequences of major extremity trauma. Three METRC enrollment centers will contact past participants to achieve the goal of completing an interview, select patient-reported outcomes, perform a medical record review, and conduct an in-person clinic visit that will consist of a physical examination, blood draw, and x-ray of the study injury area. If successful, it will be possible to design studies to further examine these effects and develop future therapeutic interventions.
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Affiliation(s)
- Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Anthony R Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Trisha Chaffee
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Michael J Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Conor P Kleweno
- Department of Orthopaedics and Sports Medicine, University of Washington Harborview Medical Center, Seattle, WA
| | - Todd O McKinley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Julie Agel
- Department of Orthopaedics and Sports Medicine, University of Washington Harborview Medical Center, Seattle, WA
| | - Thomas F Higgins
- Department of Orthopaedic Surgery, The University of Utah; Salt Lake City, UT
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA; and
| | - Elena D Staguhn
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Rachel V Aaron
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD
| | - Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Albert W Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ellen J MacKenzie
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Carlini AR, Collins SC, Staguhn ED, Frey KP, O’Toole RV, Archer KR, Obremskey WT, Agel J, Kleweno CP, Morshed S, Weaver MJ, Higgins TF, Bosse MJ, Levy JF, Wu AW, Castillo RC. Streamlining Trauma Research Evaluation With Advanced Measurement (STREAM) Study: Implementation of the PROMIS Toolbox Within an Orthopaedic Trauma Clinical Trials Consortium. J Orthop Trauma 2022; 36:S33-S39. [PMID: 34924517 PMCID: PMC8694658 DOI: 10.1097/bot.0000000000002291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 02/02/2023]
Abstract
LEVEL OF EVIDENCE Prognostic Level II.
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Affiliation(s)
- Anthony R. Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Susan C. Collins
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elena D. Staguhn
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Katherine P. Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Robert V. O’Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Kristin R. Archer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Center for Musculoskeletal Research and Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Nashville, TN
| | - William T. Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Julie Agel
- Department of Orthopaedics and Sports Medicine, University of Washington Harborview Medical Center, Seattle, WA
| | - Conor P. Kleweno
- Department of Orthopaedics and Sports Medicine, University of Washington Harborview Medical Center, Seattle, WA
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael J. Weaver
- Department of Orthopedic Surgery, Harvard Orthopaedic Trauma Service, Boston, MA
| | - Thomas F. Higgins
- Department of Orthopaedic Surgery, The University of Utah; Salt Lake City, UT
| | - Michael J. Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Joseph F. Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Albert W. Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Renan C. Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Use of a Motorized Intramedullary Bone Transport Nail for Trauma: Tips, Tricks, Corticotomy Techniques, and Rate and Rhythm. J Orthop Trauma 2021; 35:S31-S38. [PMID: 34533484 DOI: 10.1097/bot.0000000000002121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Abstract
The introduction of internal magnetic nails (IMNs) for bone lengthening and bone transport has given us exciting new tools with which to treat segmental bone loss. Distraction osteogenesis has a long record of success in recreating even large segments of bone, but the availability of IMNs now offers the possibility of performing distraction osteogenesis without the drawbacks of external fixation. However, there are aspects of treatment with IMNs that are critical to understand to achieve success and minimize complications. These include assessment of feasibility in relation to available bone stock and segment configuration, the condition of the soft tissue envelope, and the presence of contamination or infection. They also include execution aspects such as bone end preparation, nail placement, need for and positioning of adjuvant fixation, corticotomy techniques, rate and rhythm of distraction, staged screw exchange, docking site preparation, and nail extraction. We discuss these issues in detail and introduce some novel techniques not previously described including the comminuted wedge osteotomy, testing of the nail with initial compression, and retention plug application for nail extraction to assist in optimizing success in certain clinical situations.
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Wang X, Zhang Z, Hou X, Wang B, Li Y, Zhang T. Application of unilateral external fixation by the "joystick technique" in the treatment of pediatric tibia shaft fractures: technical note. J Orthop Surg Res 2021; 16:493. [PMID: 34384451 PMCID: PMC8359599 DOI: 10.1186/s13018-021-02625-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/23/2021] [Indexed: 11/16/2022] Open
Abstract
Background The aims of current study were to present the clinical outcomes in patients with pediatric tibia shaft fractures who were treated with unilateral external fixation combined with joystick for fracture reduction and describe the details of our technique. Methods We retrospectively analyzed the patients with pediatric tibia shaft fractures who were treated with unilateral external fixation combined with joystick for fracture reduction between July 2018 and March 2020. The clinical outcomes were evaluated. Results A total of 23 patients were included in the current study with the average age of 8.0 years (ranged 4–14 years). The average duration of hospital and follow-up were 5.9 days (ranged 4–8 days) and 17.4 months (ranged 8–27 months), respectively. At postoperative 3 days, the visual analog scale (VAS) score was 3.1 ± 1.43, which was significantly lower than the preoperative score of 7.3 ± 1.5. Of these, 2 cases showed redness and swelling of pin-tract and exudation at postoperative 1 month, who improved after oral antibiotics without causing fixation failure. The average time to full weight-bearing without crutches was 5.1 weeks (ranged 3–8 weeks). All patients achieved fracture healing and good functional recovery. No complications including fixation failure, reoperation, epiphyseal injury occurred, infection around implants, vessel damage, nerve damage, and limitation of joint movement were observed. The Johner-Wruh scores showed that 21 cases (91.3%) were “excellent” and 2 cases (8.7%) were “good.” Conclusions This procedure had advantages of simple operation, minimum trauma, early recovery of lower limb function, and no risk of complications. It may provide a new choice for children with tibia shaft fractures who require surgical treatment.
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Affiliation(s)
- Xinhui Wang
- Emergency, Trauma Center, The Third Hospital of Hebei Medical University, No.139 Ziqiang Road of Qiao'xi District, Shijiazhuang, 050000, Hebei, China
| | - Zhe Zhang
- Monitoring and Evaluation Office, Health Guidance Center of Hebei Provincial Health Commission, Shijiazhuang, China
| | - Xizhi Hou
- Three Wards of Traumatology Orthopedics, The Third Hospital of Shijiazhuang City, Shijiazhuang, Hebei Province, China
| | - Bao Wang
- Emergency, Trauma Center, The Third Hospital of Hebei Medical University, No.139 Ziqiang Road of Qiao'xi District, Shijiazhuang, 050000, Hebei, China
| | - Yongdong Li
- Emergency, Trauma Center, The Third Hospital of Hebei Medical University, No.139 Ziqiang Road of Qiao'xi District, Shijiazhuang, 050000, Hebei, China
| | - Tao Zhang
- Emergency, Trauma Center, The Third Hospital of Hebei Medical University, No.139 Ziqiang Road of Qiao'xi District, Shijiazhuang, 050000, Hebei, China.
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Patel KH, Logan K, Krkovic M. Strategies and outcomes in severe open tibial shaft fractures at a major trauma center: A large retrospective case-series. World J Orthop 2021; 12:495-504. [PMID: 34354937 PMCID: PMC8316841 DOI: 10.5312/wjo.v12.i7.495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/16/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe open tibia fractures are challenging to treat with a lack of published clear management strategies. Our aim was to provide an overview of the largest single-center experience in the literature, with minimum 1-year follow-up, of adult type 3 open tibial shaft fractures at Cambridge University Hospitals (a United Kingdom major trauma center). We sought to define patient characteristics and our main outcome measures were infection, union and re-fracture.
AIM To retrospectively define patient and injury characteristics, present our surgical methods and analyze our outcomes–namely infection, union and re-fracture rates.
METHODS Consecutive series of 74 patients with 75 open tibial fractures treated between 2014 and 2020 (26 classified as Gustilo-Anderson 3A, 47 were 3B and two were 3C). Nine patients underwent intramedullary nailing (IMN), 61 underwent Taylor spatial frame (TSF) fixation and 5 were treated with Masquelet technique (IMN and subsequent bone grafting).
RESULTS Mean follow-up was 16 mo (IMN) and 25 mo (TSF). We had an infection rate of 6.7% (5), non-union rate of 4% (3) and re-fracture rate of 2.7% (2). Average time to union was 22 wk for IMN and 38.6 wk for TSF. Thirty-three cases had a bone defect with a mean of 5.4 cm (2-11). Patient age, sex, diabetes, smoking status or injury severity did not have a significant effect on union time with either fixation method. Our limb salvage rate was 98.7%.
CONCLUSION Grade 1 to 3A injuries can effectively be treated with reamed or unreamed IMN. Grade 3B/C injuries are best treated by circular external fixators as they provide good, reproducible outcomes and allow large bone defects to be addressed via distraction osteogenesis.
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Affiliation(s)
- Kavi H Patel
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
| | - Karl Logan
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
| | - Matija Krkovic
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
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Sun DD, Lv D, Zhou K, Chen J, Gao LL, Sun ML. External fixator combined with three different fixation methods of fibula for treatment of extra-articular open fractures of distal tibia and fibula: a retrospective study. BMC Musculoskelet Disord 2021; 22:1. [PMID: 33397351 PMCID: PMC7780413 DOI: 10.1186/s12891-020-03840-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 11/26/2020] [Indexed: 12/02/2022] Open
Abstract
Background To compare the efficacy of three different fixation methods of fibula combined with external fixation of tibia for the treatment of extra-articular open fractures of distal tibia and fibula. Methods From January 2017 to July 2019, 91 cases of open fractures of distal tibia and fibula were treated with external fixator, and the fibula was fixed with non-fixation (group A, n = 35), plate-screw (group B, n = 30) and Kirschner wire (group C, n = 26). The operation time, intraoperative blood loss, surgical and implants costs, fracture healing time, postoperative complications, and American Orthopaedic Foot and Ankle surgery (AOFAS) scores were compared among the groups. Results Four patients were lost to follow-up, and 87 patients were followed up for 5–35 months (average, 14.2 months). The operation time of group C (114.92 ± 36.09 min) was shorter than that of group A (142.27 ± 47.05 min) and group B (184.00 ± 48.56 min) (P < 0.05). There was no difference in intraoperative blood loss among the three groups (P > 0.05). The surgical and implants costs in group C (5.24 ± 1.21, thousand dollars) is lower than that in group A (6.48 ± 1.11, thousand dollars) and group B (9.37 ± 2.16, thousand dollars) (P < 0.05). The fracture healing time of group C (5.67 ± 1.42 months) was significantly less than that of group A (6.90 ± 1.33 months) and group B (6.70 ± 1.12 months) (P < 0.05). The postoperative complications such as fractures delayed union and nonunion in group C (2 cases, 8.00%) is less than that in group A (13 cases, 39.39%) and group B (11cases, 37.93%) (P < 0.05). The wound infection and needle-tract infection did not differ among the three groups (P > 0.05). The excellent or good rate of ankle function was 69.70% in group A, 72.41% in group B and 84.00% in group C, with no statistical difference among the three groups (P > 0.05). Conclusion Compared with simple external fixator fixation and external fixator combined with plate-screw osteosynthesis, external fixator combined with K-wire intramedullary fixation shortens the operative time and fracture healing time, reduced costs and complications of fracture healing, while the blood loss, infection complications and ankle function recovery showed no difference with the other two groups. External fixator combined with plate-screw osteosynthesis had no advantage in treating extra-articular open fractures of distal tibia and fibula when compared with simple external fixation.
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Affiliation(s)
- Dong-Dong Sun
- Department of Orthopedic, Characteristic Medical center of Chinese People's Armed Police Force, No. 220 Cheng Lin Road, Tianjin, 300171, China.,Logistics University of People's Armed Police, Tianjin, 300300, China
| | - Dan Lv
- Department of Orthopedic, Characteristic Medical center of Chinese People's Armed Police Force, No. 220 Cheng Lin Road, Tianjin, 300171, China
| | - Kun Zhou
- Logistics University of People's Armed Police, Tianjin, 300300, China
| | - Jian Chen
- Logistics University of People's Armed Police, Tianjin, 300300, China
| | - Li-Lan Gao
- School of Mechanical Engineering, Tianjin University of Technology, No. 391 Bin Shui West Road, Tianjin, 300384, China.
| | - Ming-Lin Sun
- Department of Orthopedic, Characteristic Medical center of Chinese People's Armed Police Force, No. 220 Cheng Lin Road, Tianjin, 300171, China.
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Variability in Discharge Disposition Across US Trauma Centers After Treatment for High-Energy Lower Extremity Injuries. J Orthop Trauma 2020; 34:e78-e85. [PMID: 31868766 DOI: 10.1097/bot.0000000000001657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the association between patient- and center-level characteristics and discharge to an inpatient facility versus home after treatment for lower extremity trauma, as well as examine the variability in discharge disposition across clinical centers after controlling for these factors. DESIGN This is an analysis of data collected prospectively across 5 multicenter studies of extremity trauma. SETTING US Trauma Centers. PARTICIPANTS Patients 18-80 years with lower extremity trauma treated at 1 of 55 participating centers. MAIN OUTCOME MEASURE Discharge disposition. RESULTS Among 2365 patients treated at 1 of 55 centers across 13 states, 673 (28.5%) were discharged to an inpatient facility, and 1692 (71.5%) were discharged home. Individuals who were older, female, unmarried, insured, higher body mass index, history of severe alcohol abuse, Gustilo type IIIB or IIIC open injuries, bilateral, spine and upper extremity injuries, higher injury severity score scores, or intensive care unit stay were more likely to be discharged to an inpatient facility. Even after accounting for patient- and center-level characteristics, there was substantial variation in discharge disposition across centers (likelihood ratio test: P < 0.001). CONCLUSION Variation in discharge disposition may represent a potential for improvement in resource utilization and cost savings. Further studies are needed to examine the relationship between utilization of postdischarge inpatient facility after trauma and outcomes. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Kerzner B, Martin HL, Weiser M, Fontana G, Russell N, Murphy WL, Lund EA, Doro CJ. A Reliable and Reproducible Critical-Sized Segmental Femoral Defect Model in Rats Stabilized with a Custom External Fixator. J Vis Exp 2019. [PMID: 30958483 DOI: 10.3791/59206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Orthopedic research relies heavily on animal models to study mechanisms of bone healing in vivo as well as investigate the new treatment techniques. Critical-sized segmental defects are challenging to treat clinically, and research efforts could benefit from a reliable, ambulatory small animal model of a segmental femoral defect. In this study, we present an optimized surgical protocol for the consistent and reproducible creation of a 5 mm critical diaphyseal defect in a rat femur stabilized with an external fixator. The diaphyseal ostectomy was performed using a custom jig to place 4 Kirschner wires bicortically, which were stabilized with an adapted external fixator device. An oscillating bone saw was used to create the defect. Either a collagen sponge alone or a collagen sponge soaked in rhBMP-2 was implanted into the defect, and the bone healing was monitored over 12 weeks using radiographs. After 12 weeks, rats were sacrificed, and histological analysis was performed on the excised control and treated femurs. Bone defects containing only collagen sponge resulted in non-union, while rhBMP-2 treatment yielded the formation of a periosteal callous and new bone remodeling. Animals recovered well after implantation, and external fixation proved successful in stabilizing the femoral defects over 12 weeks. This streamlined surgical model could be readily applied to study bone healing and test new orthopedic biomaterials and regenerative therapies in vivo.
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Affiliation(s)
- Benjamin Kerzner
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison
| | - Hannah L Martin
- Department of Biomedical Engineering, University of Wisconsin-Madison
| | - Michael Weiser
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison
| | - Gianluca Fontana
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison;
| | - Nicholas Russell
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison
| | - William L Murphy
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison; Department of Biomedical Engineering, University of Wisconsin-Madison
| | | | - Christopher J Doro
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison
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Abstract
Open fractures of the lower extremity are the most common open long bone injuries, yet their management remains a topic of debate. This article discusses the basic tenets of management and the subsequent impact on clinical outcome. These include the rationale for initial debridement, antimicrobial cover, addressing the soft-tissue injury and definitive skeletal management. The classification of injury severity continues to be a useful tool in guiding treatment and predicting outcome and prognosis. The Gustilo-Anderson classification continues to be the mainstay, but the adoption of severity scores such as the Ganga Hospital score may provide additional predictive utility. Recent literature has challenged the perceived need for rapid debridement within 6 hours and the rationale for prolonged antibiotic therapy in the open fracture. The choice of definitive treatment must be decided against known efficacy and injury severity/type. Recent data demonstrate better outcomes with internal fixation methods in most open tibial fractures, but external fixation continues to be an appropriate choice in more severe injuries. The incidence of infection and non-union has decreased with new treatment approaches but continues to be a source of significant morbidity and mortality. Assessment of functional outcome using various measures has been prevalent in the literature, but there is limited consensus regarding the best measures to be used.
Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170072
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Affiliation(s)
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, University of Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, UK
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A Prospective Randomized Trial to Assess Fixation Strategies for Severe Open Tibia Fractures: Modern Ring External Fixators Versus Internal Fixation (FIXIT Study): Erratum. J Orthop Trauma 2018; 32:e197. [PMID: 29677093 DOI: 10.1097/bot.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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17
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A Prospective Randomized Trial to Assess Fixation Strategies for Severe Open Tibia Fractures: Modern Ring External Fixators versus Internal Fixation (FIXIT Study): Erratum. J Orthop Trauma 2017; 31:e307. [PMID: 28876274 DOI: 10.1097/01.bot.0000524645.09426.0a] [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] [Indexed: 02/02/2023]
Abstract
In the article that appeared on page S10, several investigators were not included in the METRC group authorship acknowledgement. The correct acknowledgement should include: University of Wisconsin: Christopher Doro, MD; Paul Whiting, MD; David Goodspeed, MD; Gerald Lang, MD. Jose Santayo is incorrectly listed under University of Texas Health Science Center at Houston. The correct affiliation is University of Texas Southwestern Medical Center.
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