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Ativor V, Konadu-Yeboah D, O'Marr J, Brown K, Rodarte P, Kumah R, Quartey R, Awariyah D, Konadu P, Baidoo PK, Okike K, Morshed S, Shearer D, Roberts H. Predictors of quality of life, economic impact, and loss to follow-up after open tibial shaft fractures in Ghana. OTA Int 2024; 7:e340. [PMID: 39006124 PMCID: PMC11239167 DOI: 10.1097/oi9.0000000000000340] [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] [Received: 04/30/2023] [Revised: 04/05/2024] [Accepted: 05/15/2024] [Indexed: 07/16/2024]
Abstract
Objectives Open tibia fractures are associated with substantial morbidity and impact on quality of life. Despite increasing incidence in low-resource settings, most open tibia fracture research comes from high-resource settings. This study aimed to assess the impact of socioeconomic status on treatment modality and evaluate predictors of health-related quality of life following open tibia fractures in Ghana. Design A single-center prospective observational study was conducted in Kumasi, Ghana, from May 2020 to April 2022. Adults with open tibial shaft fractures presenting within 2 weeks of injury were eligible. Demographics, comorbidities, socioeconomic factors, and hospital course were collected at enrollment. Follow-up was scheduled at 8, 12, 26, and 52 weeks. A telephone survey assessing reasons for loss to follow-up was initiated on enrollment completion. Results A total of 180 patients were enrolled. Most patients were employed before injury (79.9%), had government insurance (67.2%), and were from rural areas (59.4%). Fracture classification was primarily Gustilo-Anderson type 3A (49.1%). No relationship between socioeconomic predictors and treatment modality was identified. The largest barriers to follow-up were preference for bonesetter treatment (63.1%), treatment cost (48.8%), and travel cost (29.8%). Of the lost to follow-up patients contacted, 67 (79.8%) reported receiving traditional bonesetter care. Reasons for seeking traditional bonesetter care included ease of access (83.6%), lower cost (77.6%), and familial influence (50.7%). Conclusion No association was identified between socioeconomic predictors and choice of treatment. Bonesetter treatment plays a substantial role in the care of open tibia fractures in Ghana, largely because of ease of access and lower cost.
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Affiliation(s)
- Vincent Ativor
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Dominic Konadu-Yeboah
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Jamieson O'Marr
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| | - Kelsey Brown
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| | - Patricia Rodarte
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| | - Ralph Kumah
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Ralph Quartey
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Dominic Awariyah
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Peter Konadu
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Paa Kwesi Baidoo
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana
| | - Kanu Okike
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| | - Saam Morshed
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| | - David Shearer
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
| | - Heather Roberts
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA
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Florek CA, Cozzone E, Williams DL, Armbruster DA. A controlled release antibiotic wound protectant gel formulated for use in austere environments. J Biomed Mater Res B Appl Biomater 2024; 112:e35455. [PMID: 39177322 DOI: 10.1002/jbm.b.35455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 06/10/2024] [Accepted: 07/08/2024] [Indexed: 08/24/2024]
Abstract
Battlefield wounds are at high risk of infection due to gross contamination and delays in evacuation from forward-deployed locations. The aim of this study was to formulate an antibiotic wound gel for application by a field medic in austere environments to protect traumatic wounds from infection during transport. Formulation development was conducted over multiple phases to meet temperature, handling, in vitro elution, and in vivo tissue response requirements. Thermal properties were evaluated by vial inversion, DSC, and syringe expression force in a temperature range of 4-49°C. Handling was evaluated by spreading onto blood-contaminated tissue and irrigation resistance. Controlled antibiotic release was evaluated by a modified USP immersion cell dissolution method. Local tissue effects were evaluated in vivo by subcutaneous implantation in rats for 7 and 28 days. An oleogel composition of cholesterol, hydrogenated castor oil, soybean oil, and glyceryl monocaprylocaprate met the target performance criteria. Peak expression force from a 5 mL syringe at 4°C was 48.3 N, the dropping point temperature was 68°C, and the oleogel formulation could be spread onto blood-contaminated tissue and resisted aqueous irrigation. The formulation demonstrated sustained release of tobramycin in PBS at 32°C for 5 days. Implantation in a rat dorsal pocket demonstrated a slight tissue reaction after 7 days with minimal to no reaction after 28 days, comparable to a commercial hemostat control. Material resorption was evident after 28 days. The formulation met target characteristics and is appropriate for further evaluation in a large animal contaminated blast wound model.
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Affiliation(s)
| | | | - Dustin L Williams
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Johnson DJ, O'Hara NN, Reider L, Gary JL, Obremskey W, Quinnan SM, Iii PT, Vallier HA, Carroll EA, O'Toole RV. Risk factors for infection in severe open tibial shaft fractures. Injury 2024; 55:111822. [PMID: 39180868 DOI: 10.1016/j.injury.2024.111822] [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: 01/08/2024] [Revised: 06/04/2024] [Accepted: 08/11/2024] [Indexed: 08/27/2024]
Abstract
OBJECTIVE To evaluate risk factors for infection in severe open tibial shaft fractures. METHODS A secondary analysis of a multicenter prospective study investigated internal versus external fixation of severe open tibia fractures at 20 US Level I trauma centers. Adult patients, aged <65 years, with a Gustilo-Anderson Type IIIB or severe IIIA metaphyseal or diaphyseal tibia fracture were included. All fractures underwent definitive fixation with either a modern ring external fixator, intramedullary device, and/or plate. Fourteen variables previously identified as risk factors for infection were included in the analysis. Deep surgical site infection was defined as an infection treated with surgical debridement within 1 year of index surgery. RESULTS The study cohort included 430 patients. Deep surgical site infection requiring reoperation occurred in 108 (25 %) patients. The final model identified four risk factors for infection: age >40 years (OR, 2.00; 95 % CI, 1.3-3.1), Gustilo-Anderson Type IIIB (OR, 1.80; 95 % CI, 1.1-3.0), embedded wound contamination (OR, 1.69; 95 % CI, 1.1-2.7), and wound length (OR, 1.02/cm; 95 % CI, 1.0-1.05). The model performed poorly at distinguishing infected from uninfected patients (Area Under the Curve=0.57; 95 % CI, 0.51-0.63). CONCLUSIONS Surgeons can now counsel patients with these risk factors that they are at a markedly higher risk of infection. The identification of these risk factors may direct future research aimed at mitigating the risk of deep surgical site infection in this patient population.
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Affiliation(s)
- Daniel J Johnson
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Nathan N O'Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Joshua L Gary
- Department of Orthopaedics, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - William Obremskey
- Department of Orthopaedics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Stephen M Quinnan
- Paley Orthopedic & Spine Institute, St. Mary's Medical Center, West Palm Beach, FL, United States
| | - Paul Tornetta Iii
- Department of Orthopaedics, Boston University Medical Center, Boston, MA, United States
| | - Heather A Vallier
- Department of Orthopaedics, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Eben A Carroll
- Department of Orthopaedics, Atrium Health Wake Forest Baptist, Winston-Salem, NC, United States
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States.
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Stahel PF, Kaufman AM. Contemporary management of open extremity fractures: What you need to know. J Trauma Acute Care Surg 2024; 97:11-22. [PMID: 38374531 DOI: 10.1097/ta.0000000000004288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
ABSTRACT Open extremity fractures are high-risk injuries prone to significant complications, including soft tissue loss, bone defects, infection, infected nonunion, and the necessity for limb amputation. Large-scale multicenter prospective studies from the Lower Extremity Assessment Project and the Major Extremity Trauma Research Consortium have provided novel scientific insights pertinent to the timeliness and appropriateness of specific treatment modalities aimed at improving outcomes of patients with open extremity injuries. These include the imperative for early administration of intravenous antibiotics within 3 hours of injury, preferably within 1 hour of hospital admission. Unlike the proven value of early antibiotics, the time to initial surgical debridement does not appear to affect infection rates and patient outcomes. Recent evidence-based consensus guidelines from the American Academy of Orthopedic Surgeons provide scientific guidance for preventing surgical site infections in patients with open extremity fractures and support the decision making of limb salvage versus amputation in critical open extremity injuries. Patient survival represents the overarching priority in the management of any trauma patient with associated orthopedic injuries. Therefore, the timing and modality of managing open fractures must take into account the patient's physiology, response to resuscitation, and overall injury burden. The present review was designed to provide a state-of-the-art overview on the recommended diagnostic workup and management strategies for patients with open extremity fractures, based on the current scientific evidence.
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Affiliation(s)
- Philip F Stahel
- From the Department of Surgery (P.F.S.), Brody School of Medicine, East Carolina University, Greenville, North Carolina; College of Osteopathic Medicine (P.F.S.), Rocky Vista University, Parker, Colorado; and Mission Health, HCA Healthcare (P.F.S., A.M.K.), North Carolina Division, Asheville, North Carolina
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Barone N, Ziolkowski N, Haykal S. The Role of Negative Pressure Wound Therapy in Temporizing Traumatic Wounds before Lower Limb Soft Tissue Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6003. [PMID: 39071768 PMCID: PMC11281775 DOI: 10.1097/gox.0000000000006003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 05/31/2024] [Indexed: 07/30/2024]
Abstract
Background In practice, there is often a delay from initial debridement and temporary fixation to definitive soft tissue coverage of traumatic leg wounds. Without clear evidence, conservative negative pressure wound therapy (NPWT) is increasingly used to temporize these wounds. This systematic review summarizes and synthesizes the literature on using NPWT to temporize traumatic leg wounds before surgery in adult surgical patients. Methods A comprehensive search of Medline, Embase, and Cochrane Library was performed from inception until July 2022, inclusively. Two independent reviewers performed screening, data extraction, and risk of bias assessment. Primary English studies, including adult patients (≥16 years old) with a fracture below the knee up to and including the ankle that received NPWT to temporize wounds before definitive soft tissue reconstruction with a flap and/or graft, were included. Results Thirty-four studies, including 804 patients who received NPWT, were included. The partial/total flap loss rate was 6.95% (n = 9 studies), the infection rate was 19.5% (n = 25 studies), the nonunion rate was 18% (n = 15 studies), the delayed union rate was 9.31% (n = 3 studies), and the amputation rate was 15.4% (n = 6 studies). The mean late stay was 43.1 days (n = 9 studies), and the follow-up length was 23.7 months (n = 9 studies). The mean time to wound healing was 5.63 months (n = 2 studies), and the time to soft tissue coverage was 40.8 days (n = 12 studies). The mean time to achieve bone union was 7.26 months (n = 6 studies). Conclusion NPWT can be used to temporize traumatic wounds while awaiting soft tissue reconstruction.
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Affiliation(s)
- Natasha Barone
- From the Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Natalia Ziolkowski
- From the Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Siba Haykal
- From the Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science and Toronto General Hospital Research Institute, University of Toronto, Toronto, Ontario, Canada
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, Yale New Haven Hospital, New Haven, Conn
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Mahmood A, Subbaraman K, Gadullah M, Hawkes D, Bose D, Fenton P. Circular frame versus reamed intramedullary tibial nail in the treatment of grade III open tibial diaphyseal fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2505-2510. [PMID: 38662197 DOI: 10.1007/s00590-024-03946-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Grade III open tibial diaphyseal fractures are challenging to treat and controversy exists on whether to treat them with an intramedullary nail (IMN) or a circular frame (CF). This study aims to compare outcomes for intramedullary nail and circular frame in the treatment of open tibial diaphyseal fractures. METHODOLOGY Retrospective study at a major trauma center of all patients admitted with a grade III open tibial diaphyseal fracture between January 2016 and January 2022. The primary outcome measures were major complications: non-union, malunion, refracture, DBI and amputation. Secondary outcome measures were time to union and reoperation rates. RESULTS Fifty-five patients were included in the study, 32 patients in CF group and 23 patients in IMN group. There were no significant differences in the baseline demographics of patients in both groups. Major complications were recorded in 13 limbs (54%) in IMN group and in 18 limbs (56%) in CF group which were not statistically significant (p = 0.797). Deep bone infection rates were noted in 4 (12.5%) in the CF group, compared to 1 (4%) in IMN group; however, the result was not statistically significant (p = 0.240). Amputation rates as a result of infected non-unions were seen in 1 limb (4%) in IMN group and 2 limbs (6%) in CF group (p = 0.99). Median time to union was significantly shorter in IMN group at 30 weeks compared to 30 weeks for CF group (p = 0.04). CONCLUSION IMN should be the treatment of choice in the treatment of grade III open tibial diaphyseal fracture, but CF should be considered for delayed treatment and in patients with bone loss.
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Affiliation(s)
- Aatif Mahmood
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK.
| | | | - Moheeb Gadullah
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - David Hawkes
- Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, UK
| | - Deepa Bose
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Paul Fenton
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
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Kwee E, Borgdorff M, Schepers T, Halm JA, Winters HAH, Weenink RP, Ridderikhof ML, Giannakópoulos GF. Adjunctive hyperbaric oxygen therapy in the management of severe lower limb soft tissue injuries: a systematic review. Eur J Trauma Emerg Surg 2024; 50:1093-1100. [PMID: 38386077 PMCID: PMC11249575 DOI: 10.1007/s00068-023-02426-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/11/2023] [Indexed: 02/23/2024]
Abstract
PURPOSE Traumatic crush injuries of the lower limb often accompany severe complications. The incorporation of hyperbaric oxygen therapy to standard trauma care may have the potential to diminish injury-related complications and improve outcome in such cases. This systematic review aims to evaluate the effectiveness of hyperbaric oxygen therapy in the management of severe lower limb soft tissue injuries. METHODS The electronic databases Medline, Embase and Cochrane Library were searched to identify studies involving patients with crush-associated sever lower limb soft tissue injuries who received hyperbaric oxygen therapy in conjunction with standard trauma care. Relevant data on type of injury, hyperbaric oxygen therapy protocol and outcome related to wound healing were extracted. RESULTS In total seven studies met the inclusion criteria, involving 229 patients. The studies included two randomized clinical trials, one retrospective cohort study, three case series and one case report. The randomized placebo-controlled clinical trial showed a significant increase in wound healing and decrease in the need for additional surgical interventions in the patient group receiving hyperbaric oxygen therapy when compared to those undergoing sham therapy. The randomized non-placebo-controlled clinical trial revealed that early hyperbaric oxygen therapy reduces tissue necrosis and the likelihood of long-term complications. The retrospective cohort study indicated that hyperbaric oxygen therapy effectively reduces infection rates and the need for additional surgical interventions. The case series and case report presented beneficial results with regard to wound healing when hyperbaric oxygen therapy was added to the treatment regimen. CONCLUSION Hyperbaric oxygen therapy is generally considered a safe therapeutic intervention and seems to have a beneficial effect on wound healing in severe lower limb soft tissue injuries when implemented as an addition to standard trauma care.
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Affiliation(s)
- Esmee Kwee
- Trauma Unit, Department of Surgery, Amsterdam UMC (Location AMC), J1A-214 Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marieke Borgdorff
- Department of Plastic, Reconstructive Surgery and Handsurgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Tim Schepers
- Trauma Unit, Department of Surgery, Amsterdam UMC (Location AMC), J1A-214 Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jens A Halm
- Trauma Unit, Department of Surgery, Amsterdam UMC (Location AMC), J1A-214 Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Hay A H Winters
- Department of Plastic, Reconstructive Surgery and Handsurgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Robert P Weenink
- Department of Hyperbaric Medicine, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Milan L Ridderikhof
- Department of Hyperbaric Medicine, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Emergency Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Georgios F Giannakópoulos
- Trauma Unit, Department of Surgery, Amsterdam UMC (Location AMC), J1A-214 Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Bihari A, McClure JA, Inculet C, Del Balso C, Vinden C, Schemitsch E, Sanders D, Lawendy AR. Fasciotomy and rate of amputation after tibial fracture in adults: a population-based cohort study. OTA Int 2024; 7:e333. [PMID: 38623265 PMCID: PMC11013697 DOI: 10.1097/oi9.0000000000000333] [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] [Received: 01/02/2022] [Revised: 12/13/2023] [Accepted: 02/16/2024] [Indexed: 04/17/2024]
Abstract
Objectives Limb amputation is a possible outcome of acute compartment syndrome. We undertook this study to investigate the occurrence of fasciotomy and amputation in patients with tibial fractures in the Ontario adult population, aiming to evaluate variables that may be associated with each of these outcomes. Design Retrospective, population-based cohort study (April 1, 2003-March 31, 2016). Setting Canadian province of Ontario. Participants Patients with tibial fracture, aged 14 years and older. Interventions Fasciotomy after tibial fracture. Main Outcomes and Measures The primary outcomes were fasciotomy and amputation within 1 year of fasciotomy. Secondary outcomes included repeat surgery, new-onset renal failure, and mortality, all within 30 days of fasciotomy. Results We identified 76,299 patients with tibial fracture; the mean (SD) age was 47 (21) years. Fasciotomy was performed in 1303 patients (1.7%); of these, 76% were male and 24% female. Patients who were younger, male, or experienced polytrauma were significantly more likely to undergo fasciotomy. Limb amputation occurred in 4.3% of patients undergoing fasciotomy, as compared with 0.5% in those without fasciotomy; older age, male sex, presence of polytrauma, and fasciotomy were associated with an increased risk of amputation (age odds ratio [OR] of 1.03 [95% CI, 1.02-1.03], P < 0.0001; sex OR of 2.04 [95% CI, 1.63-2.55], P < 0.0001; polytrauma OR of 9.37 [95% CI, 7.64-11.50], P < 0.0001; fasciotomy OR of 4.35 [95% CI, 3.21-5.90], P < 0.0001), as well as repeat surgery within 30 days (sex OR of 1.54 [95% CI, 1.14-2.07], P = 0.0053; polytrauma OR of 4.24 [95% CI, 3.33-5.38], P < 0.0001). Conclusions Among tibial fracture patients, those who were male and who experienced polytrauma were at significantly higher risk of undergoing fasciotomy and subsequent amputation. Fasciotomy was also significantly associated with risk of amputation, a finding that is likely reflective of the severity of the initial injury.
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Affiliation(s)
- Aurelia Bihari
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada
| | | | - Clayton Inculet
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - Christopher Del Balso
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | | | - Emil Schemitsch
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - David Sanders
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - Abdel-Rahman Lawendy
- Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre, London, ON, Canada
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada
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9
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Ata AM, Borman P, Bilir EE, Alemdaroğlu E, Tezen Ö, Söyler O, Yaşar E. The effect of medium-tension bandage and stump stocking on residual limb maturation in earthquake survivors. Prosthet Orthot Int 2024:00006479-990000000-00252. [PMID: 38775756 DOI: 10.1097/pxr.0000000000000356] [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: 07/31/2023] [Accepted: 03/14/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Residual limb maturation is a crucial stage in postamputation care. OBJECTIVE It was aimed to examine the effect of medium tension bandages and stump stockings on postamputation stump maturation in patients who underwent lower extremity amputations. STUDY DESIGN In this prospective observational study, patients who were earthquake survivors and had undergone emergency amputation of their lower extremities were included. METHODS Medium-tension elastic bandage or personalized stump stockings were used for stump maturation. Residual limb volume was measured once a week for 3 weeks. RESULTS The study included 23 patients and 29 amputated limbs. Because of the larger stump volume of transfemoral amputations and the higher number of these patients in the stocking group ( p < 0.001), the stump volume differed across groups before and during the follow-up ( p < 0.001). There was no difference in mean volumetric measurement between the bandage and stocking groups over time ( p = 0.272). Although the group interaction was significant (p < 0.001), the group × time interaction was not ( p = 0.306). CONCLUSION Medium-tension bandages and stump stockings had a similar effect on postamputation stump maturation in patients with lower extremity amputations. So, depending on the patient's and physician's preferences, both procedures can be used for stump maturation.
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Affiliation(s)
- Ayşe Merve Ata
- Ankara Bilkent City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey
| | - Pınar Borman
- Ankara Bilkent City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey
| | - Emine Esra Bilir
- Ankara Bilkent City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey
| | - Ebru Alemdaroğlu
- Ankara Bilkent City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey
| | - Özge Tezen
- Ankara Bilkent City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey
| | - Osman Söyler
- European University of Lefke, Northern Cyprus, Mersin, Turkey
| | - Evren Yaşar
- Ankara Bilkent City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey
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Olivieri R, Koch M, Laso J, Franulic N, Zanetta H. Predictive factors for infection after osteosynthesis of tibial plateau fractures: a retrospective study of 314 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1831-1838. [PMID: 38427052 DOI: 10.1007/s00590-024-03856-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/08/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION The reported incidence of infection related with tibial plateau fractures (IRTPF) ranges from 2 to 23%. This complication can result in catastrophic consequences such as deformity, post-traumatic osteoarthritis, chronic pain, loss of function, and substantial economic burdens on healthcare systems due to extended hospital stays and the resources required for treatment. Consequently, it is imperative to emphasize the identification of infection risk factors. METHODS A retrospective case-control study was designed, encompassing patients who underwent surgery for tibial plateau fractures between 2015 and 2020. Frequencies and measures of central tendency were compared between infected patients (cases) and non-infected patients (controls) using rank-based statistical tests. Subsequently, two logistic regression models were employed to control for potential confounding variables. RESULTS A total of 314 patients were included, predominantly male (71.15%). Average age of 44.41 years. IRTPF were observed in 7.64% of the patients. In the univariate inferential statistical analysis, high-energy fractures (OR 6.35, p < 0.001), fractures with compartment syndrome (OR 7.10, p < 0.001), two-stage management with temporary external fixation (OR 8.18, p < 0.001), the use of 2 or more approaches in definitive surgery (OR 2.93, p = 0.011), and the use of two or more plates (OR 9.17, p < 0.001) were identified as risk factors for infection. On average, the duration of surgery in infected patients was 201.2 min, compared to 148.4 min in non-infected patients (p < 0.001). When performing two logistic regression models, the following independent risk factors were identified: high-energy fractures (OR 5.04, p = 0.012), the presence of compartment syndrome (OR 4.53, p = 0.007), and the use of two or more plates in definitive surgery (OR 5.04, p = 0.023). CONCLUSIONS High-energy tibial plateau fractures (Schatzker IV, V, and VI), the presence of concomitant compartment syndrome, and the use of 2 or more plates in definitive surgery are associated with a higher risk of infection related to fracture following open reduction and osteosynthesis treatment. LEVEL OF EVIDENCE Case-Control Study. LEVEL III EVIDENCE
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Affiliation(s)
- Rodrigo Olivieri
- Orthopedics Department, Knee Unit, Hospital del Trabajador ACHS, Ramón Carnicer 185, Providencia, Santiago, Chile.
| | - Marco Koch
- Orthopedics and Traumatology Resident, Universidad Andrés Bello, Santiago, Chile
| | - José Laso
- Orthopedics Department, Knee Unit, Hospital del Trabajador ACHS, Ramón Carnicer 185, Providencia, Santiago, Chile
- Hospital Barros Luco Trudeau, Santiago, Chile
| | - Nicolás Franulic
- Orthopedics Department, Knee Unit, Hospital del Trabajador ACHS, Ramón Carnicer 185, Providencia, Santiago, Chile
- Hospital Militar de Santiago, Santiago, Chile
| | - Hugo Zanetta
- Orthopedics and Traumatology Resident, Universidad Andrés Bello, Santiago, Chile
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11
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Gao C, Wang H, Ju J, Zhang K, Gao Y, Guo S, Yin D, Hou R, Guo Q. Distribution of pathogens and risk factors for post-replantation wound infection in patients with traumatic major limb mutilation. PLoS One 2024; 19:e0301353. [PMID: 38558019 PMCID: PMC10984543 DOI: 10.1371/journal.pone.0301353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
PURPOSE Even though replantation of limb mutilation is increasing, postoperative wound infection can result in increasing the financial and psychological burden of patients. Here, we sought to explore the distribution of pathogens and identify risk factors for postoperative wound infection to help early identification and managements of high-risk patients. METHODS Adult inpatients with severed traumatic major limb mutilation who underwent replantation from Suzhou Ruixing Medical Group between November 09, 2014, and September 6, 2022 were included in this retrospective study. Demographic, and clinical characteristics, treatments, and outcomes were collected. Data were used to analyze risk factors for postoperative wound infection. RESULTS Among the 249 patients, 185 (74.3%) were males, the median age was 47.0 years old. Postoperative wound infection in 74 (29.7%) patients, of whom 51 (20.5%) had infection with multi-drug resistant bacteria. Ischemia time (OR 1.31, 95% CI 1.13-1.53, P = 0.001), wound contamination (OR 6.01, 95% CI 2.38-15.19, P <0.001), and stress hyperglycemia (OR 23.37, 95% CI 2.30-236.93, P = 0.008) were independent risk factors, while the albumin level after surgery (OR 0.94, 95% CI 0.89-0.99, P = 0.031) was significant associated with the decrease of postoperative wound infection. Ischemia time (OR 1.21, 95% CI 1.05-1.40, P = 0.010), wound contamination (OR 8.63, 95% CI 2.91-25.57, P <0.001), and MESS (OR 1.32, 95% CI 1.02-1.71, P = 0.037 were independent risk factors for multi-drug resistant bacteria infection. CONCLUSIONS Post-replantation wound infection was common in patients with severe traumatic major limb mutilation, and most were multi-drug resistant bacteria. Ischemia time and wound contamination were associated with the increase of postoperative wound infection, including caused by multi-drug resistant. Positive correction of hypoproteinemia and control of stress hyperglycemia may be beneficial.
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Affiliation(s)
- Chang Gao
- Department of Emergency and Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
- Medical Center of Soochow University, Suzhou, Jiangsu, China
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Haiyan Wang
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Jihui Ju
- Department of Orthopaedic, Suzhou Ruihua Orthopaedic Hospital (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Keran Zhang
- Department of Critical Care Medicine, Suzhou Ruihua Orthopaedic Hospital (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Ye Gao
- Department of Critical Care Medicine, Taicang Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shiqi Guo
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Di Yin
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Ruixing Hou
- Department of Orthopaedic, Suzhou Ruihua Orthopaedic Hospital (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Qiang Guo
- Department of Emergency and Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
- Medical Center of Soochow University, Suzhou, Jiangsu, China
- The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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12
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Kalantar SH, Saffar H, Hoveidaei AH. Bone reconstruction with modified Masquelet technique in open distal femoral fractures: a case series. BMC Musculoskelet Disord 2024; 25:26. [PMID: 38167118 PMCID: PMC10759597 DOI: 10.1186/s12891-023-07091-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 12/03/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Large bone defects require complex treatment, multidisciplinary resources, and expert input, with surgical procedures ranging from reconstruction and salvage to amputation. The aim of this study was to provide the results of a case series of open comminuted intra-articular distal femoral fractures with significant bone loss that were managed by early fixation using anatomical plates and a modified Masquelet technique with the addition of surgical propylene mesh. METHODS This retrospective study included all patients referred to our institution with OTA/AO C3 distal femur open fractures and meta-diaphyseal large bone loss between April 2019 and February 2021. We treated the fractures with irrigation and debridement, acute primary screw and plate fixation in the second look operation, and Masquelet method using shell-shaped antibiotic beads supplemented by propylene surgical mesh to keep the cements in place. The second step of the procedure was conducted six to eight weeks later with bone grafting and mesh augmentation to contain bone grafts. Surprisingly, hard callus formation was observed in all patients at the time of the second stage of Masquelet procedure. RESULTS All five patients' articular and meta-diaphyseal fractures with bone loss healed without major complications. The average union time was 159 days. The mean knee range of motion was 5-95 degrees. The average Lower Extremity Functional Score (LEFS) was 49 out of 80. CONCLUSIONS Combination of early plate fixation and the modified Masquelet technique with polypropylene mesh is an effective method for managing large bone defects in open intra-articular distal femoral fractures with bone loss, resulting in shorter union time possibly associated with the callus formation process. This technique may also be applicable to the management of other similar fractures specially in low-income and developing areas.
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Affiliation(s)
- Seyed Hadi Kalantar
- Joint Reconstruction Research Center, IKHC, Tehran University of Medical Science, Tehran, Iran
| | - Hana Saffar
- Cancer Institute, IKHC, Tehran University of Medical Science, Tehran, Iran
| | - Amir Human Hoveidaei
- Sports Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran.
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Awad ME, Chung JY, Griffin N, Stoneback JW, Alfonso NA. Prophylactic Intrawound Antibiotics Significantly Reduce the Risk of Deep Infections in Fracture Fixation: Subgroup Meta-analyses of the Type of Fracture, Antibiotics, and Organism. J Orthop Trauma 2023; 37:e400-e409. [PMID: 37296086 DOI: 10.1097/bot.0000000000002641] [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: 05/26/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To analyze the efficacy of subgroups of various intrawound local antibiotics in reducing the rate of fracture-related infections. DATA SOURCES AND STUDY SELECTION PubMed, MEDLINE via Ovid, Web of Science, Cochrane database, and Science Direct were searched for articles in English on July 5, 2022, and December 15, 2022. STUDY SELECTION All clinical studies comparing the incidence of fracture-related infection between the administration of prophylactic systemic and topical antibiotics in fracture repair were analyzed. DATA EXTRACTION Cochrane collaboration's assessment tool and the methodological bias and the methodological index for nonrandomized studies were used to detect bias and evaluate the quality of included studies, respectively. DATA SYNTHESIS RevMan 5.3 software (Nordic Cochrane Centre, Denmark) was used to conduct the meta-analyses and generate forest plots. CONCLUSIONS From 1990 to 2021, 13 studies included 5309 patients. Nonstratified meta-analysis showed that intrawound administration of antibiotics significantly decreased the overall incidence of infection in both open and closed fractures, regardless of the severity of open fracture and antibiotics class [OR = 0.58, ( P = 0.007)] [OR = 0.33, ( P < 0.00001)], respectively. The stratified analysis revealed that prophylactic intrawound antibiotics significantly lowered infection rate in open fracture patients with Gustilo-Anderson type I (OR = 0.13, P = 0.004), type II (OR = 0.29, P = 0.0002), type III (OR = 0.21, P < 0.00001), when either tobramycin PMMA beads (OR = 0.29, P < 0.00001) or vancomycin powder (OR = 0.51, P = 0.03) was applied. This study demonstrates prophylactic administration of intrawound antibiotics significantly decreases the overall incidence of infection in all subgroups of surgically fixated fractures but does not affect the patient's length of hospital stay. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mohamed E Awad
- Orthopedic Trauma and Fracture Surgery Service, Orthopedic Surgery Department, University of Colorado Anschutz Medical Campus, Aurora, CO
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14
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Yeramosu T, Young P, Cinats DJ, Toney CB, Satpathy J, Patel TT, Kates SL, Perdue PW. Safety of Prepping the External Fixator In Situ During Staged Internal Fixation of Pilon Fractures: A Retrospective Comparative Cohort Study. J Orthop Trauma 2023; 37:469-474. [PMID: 37053112 PMCID: PMC10524202 DOI: 10.1097/bot.0000000000002617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVE (1) To assess the rate of fracture-related infection (FRI) and unplanned reoperation of disinfecting and prepping in the external fixator (Ex-Fix) instrument during definitive open reduction and internal fixation (ORIF) of pilon fractures treated by a staged protocol and (2) to determine whether the amount of time from external fixation to ORIF influences the risk of FRI. DESIGN Retrospective cohort study. SETTING Level 1 academic trauma center. PATIENTS One hundred thirty-three patients who underwent operative treatment for pilon fracture between 2010 and 2020. INTERVENTION External fixation and ORIF with or without the Ex-Fix prepped in situ during definitive fixation. MAIN OUTCOME MEASUREMENTS FRI and unplanned reoperation rates. RESULTS 133 patients were enrolled, of which 47 (35.3%) had Ex-Fix elements prepped in situ. There was an overall infection rate of 23.3% and unplanned reoperation rate of 11.3%, and there was no significant difference in rates between the 2 cohorts. Patients with Ex-Fix elements prepped in situ who developed an FRI had a higher rate of MRSA and MSSA . Diabetes ( P = 0.0019), open fracture ( P = 0.0014), and longer (≥30 days) interval to ORIF ( P = 0.0001) were associated with postoperative FRI. CONCLUSIONS Prepping elements of the Ex-Fix in situ did not lead to an increase in rates of FRI or unplanned reoperation. Although diabetes and open fracture were associated with FRI risk, a stronger association was a longer interval of Ex-Fix utilization before definitive internal fixation, specifically 30 days or greater. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Teja Yeramosu
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Porter Young
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - David J. Cinats
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Clarence B. Toney
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Jibanananda Satpathy
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Tejas T. Patel
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen L. Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Paul W. Perdue
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
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15
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Xu X, Wang H, Liu Y, Wang D, Diao S, Gao Y, Zhou J. The Role of Combined Inflammatory Biomarkers in the Diagnosis of High- and Low-Virulence FRI Among High-Risk Lower Extremity Fractures. Int J Gen Med 2023; 16:3363-3371. [PMID: 37576914 PMCID: PMC10422992 DOI: 10.2147/ijgm.s426608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023] Open
Abstract
Objective The aim of this study is to evaluate the diagnostic accuracy of infection-related biomarkers in high-risk lower limb injury patients with fracture-related infection (FRI) caused by high-/low-virulence microorganisms. Methods This study was a retrospective analysis of patients with high-risk lower extremity fractures (including tibial plateau, calcaneus, and Pilon fractures) who underwent open reduction internal fixation (ORIF) surgery from January 2017 to February 2022. Peripheral blood samples were collected within 24 hours of admission, and the following information was evaluated: gender, age, BMI, smoking, comorbidities, injury information, surgical details, values for serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), as well as neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR). Results A total of 576 patients receiving lower extremity fracture surgery were included in this study. Fifty-one patients (8.85%) were identified as FRI, and 28 (54.9%) of these 51 cases were further classified as high-virulence group. The median levels of CRP, ESR, NLR, and MLR were significantly higher in the FRI group than in the non-FRI group (p < 0.01). Similarly, the marginally significantly higher levels of CRP and NLR presented in the high-virulence group, compared to the low-virulence group (p < 0.1). The AUC areas of CRP, NLR, and CRP+NLR were 0.826, 0.650, and 0.873, respectively. We calculated the optimal cut-off points for CRP+NLR as diagnostic markers of high-virulent infection was 0.377. Conclusion This study showed the incidence of FRI in high-risk lower extremity fractures was 8.9%, and identified preoperative serum biomarkers, including CRP, ESR, NLR, and PLR, as useful tools for assisting in the diagnosis of infection. Additionally, the combination of CRP with NLR played a discriminating clinical role in postoperative infections caused by different virulence. Level of Evidence Clinical study.
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Affiliation(s)
- Xiaopei Xu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Hanzhou Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Yang Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Dong Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Shuo Diao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Yuling Gao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Junlin Zhou
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
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16
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Toro G, Cecere AB, Braile A, Cicco AD, Liguori S, Tarantino U, Iolascon G. New insights in lower limb reconstruction strategies. Ther Adv Musculoskelet Dis 2023; 15:1759720X231189008. [PMID: 37529331 PMCID: PMC10387789 DOI: 10.1177/1759720x231189008] [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] [Received: 04/11/2023] [Accepted: 07/04/2023] [Indexed: 08/03/2023] Open
Abstract
High Energy Musculoskeletal Traumas (HEMTs) represent a relevant problem for healthcare systems, considering the high social costs, and both the high morbidity and mortality. The poor outcomes associated with HEMT are related to the high incidence of complications, including bone infection, fracture malunion and non-union. The treatment of each of these complications could be extremely difficult. Limb reconstruction often needs multiple procedures, rising some questions on the opportunity in perseverate to try to save the affected limb. In fact, theoretically, amputation may guarantee better function and lower complications. However, amputation is not free of complication, and a high long-term social cost has been reported. A comprehensive literature review was performed to suggest possible ways to optimize the limb preservation surgeries of HEMT's complications in order to ameliorate their management.
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Affiliation(s)
- Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Antonio Benedetto Cecere
- Unit of Orthopaedics and Traumatology, San Giuliano Hospital, Giugliano in Campania, Naples, Italy
| | | | - Annalisa De Cicco
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy Unit of Orthopaedics and Traumatology, Santa Maria delle Grazie Hospital, Pozzuoli, Italy
| | - Sara Liguori
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
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17
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Harrington CJ, Wade SM, Hoyt BW, Tintle SM, Potter BK, Souza JM. A Longitudinal Perspective on Conversion to Amputation for Combat-Related Extremity Injuries Treated With Flap-Based Limb Salvage. J Orthop Trauma 2023; 37:361-365. [PMID: 36750445 DOI: 10.1097/bot.0000000000002582] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVES To define the rate and primary drivers behind early and late amputation after flap-based limb salvage in the setting of combat extremity trauma. DESIGN Retrospective review. SETTING Level II trauma center. PATIENTS 307 (303 men, 4 women) patients who underwent flap-based limb salvage treatment between 2003 and 2014. INTERVENTION We reviewed patient medical records, radiographs, and clinical photographs. MAIN OUTCOME MEASUREMENTS Early and late amputation rates, time to amputation, reason for amputation. RESULTS 307 patients accounted for 323 limbs that underwent flap-based limb salvage treatment (187 lower extremities, 136 upper extremities). A total of 58 extremities (18%) initially treated with flap-based limb salvage ultimately underwent amputation at a median of 480 days (IQR, 285-715 days) from injury. Periarticular fractures and lower extremity injuries were risk factors for early and late amputation. Other independent risk factors for early amputation were flap complications and vascular injuries, whereas risk factors for late amputation were fractures that went on to nonunion. CONCLUSIONS This study highlights that a subset of patients ultimately require major limb amputation despite having achieved what is initially considered "successful" limb salvage. Flap-related complications, vascular injury, and lower extremity site of injury were associated with early amputation after successful expeditionary efforts at limb preservation. Conversion to late amputation was associated with lower extremity periarticular fractures and fracture nonunion. Chronic pain and persistent limb dysfunction were the most common reasons for late amputation. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Colin J Harrington
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Sean M Wade
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Benjamin W Hoyt
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Scott M Tintle
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Benjamin K Potter
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
- Uniformed Services University-Walter Reed Department of Surgery, 4301 Jones Bridge Road, Bethesda, MD; and
| | - Jason M Souza
- Departments of Plastic and Reconstructive Surgery and Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43212
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Haonga BT, O'Marr JM, Ngunyale P, Ngahyoma J, Kessey J, Sasillo I, Rodarte P, Belaye T, Berhaneselase E, Eliezer E, Porco TC, Morshed S, Shearer DW. GO-Tibia: a masked, randomized control trial evaluating gentamicin versus saline in open tibia fractures. Trials 2023; 24:406. [PMID: 37322521 PMCID: PMC10268448 DOI: 10.1186/s13063-023-07410-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/24/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The rate of open tibia fractures is rapidly increasing across the globe due to a recent rise in road traffic accidents, predominantly in low- and low-middle-income countries. These injuries are orthopedic emergencies associated with infection rates as high as 40% despite the use of systemic antibiotics and surgical debridement. The use of local antibiotics has shown some promise in reducing the burden of infection in these injuries due to increasing local tissue availability; however, no trial has yet been appropriately powered to evaluate for definitive evidence and the majority of current studies have taken place in a high-resource countries where resources and the bio-burden may be different. METHODS This is a prospective randomized, masked, placebo-controlled superiority trial designed to evaluate the efficacy of locally administered gentamicin versus placebo in the prevention of fracture-related infection in adults (age > 18 years) with primarily closeable Gustillo-Anderson class I, II, and IIIA open tibia fractures. Eight hundred ninety patients will be randomized to receive an injection of either gentamicin (treatment group) or saline (control group) at the site of their primarily closed open fracture. The primary outcome will be the occurrence of a fracture-related infection occurring during the course of the 12-month follow-up. DISCUSSION This study will definitively assess the effectiveness of local gentamicin for the prevention of fracture-related infections in adults with open tibia fractures in Tanzania. The results of this study have the potential to demonstrate a low-cost, widely available intervention for the reduction of infection in open tibia fractures. TRIAL REGISTRATION Clinicaltrials.gov NCT05157126. Registered on December 14, 2021.
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Affiliation(s)
- Billy T Haonga
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Jamieson M O'Marr
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - Patrick Ngunyale
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Joshua Ngahyoma
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Justin Kessey
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Ibrahim Sasillo
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Patricia Rodarte
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Tigist Belaye
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - Eleni Berhaneselase
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - Edmund Eliezer
- Muhimbili Orthopaedic Institute, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Travis C Porco
- F.I. Proctor Foundation, University of California San Francisco, 513 Parnassus Avenue, San Francisco, CA, 94122, USA
- Department of Ophthalmology, University of California San Francisco, 10 Koret Way, San Francisco, CA, 94143, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St. 2nd Floor, San Francisco, CA, 94158, USA
| | - Saam Morshed
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA
| | - David W Shearer
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco School of Medicine, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA, 94110, USA.
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19
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Open tibial shaft fractures: treatment patterns in sub-Saharan Africa. OTA Int 2023; 6:e228. [PMID: 36919118 PMCID: PMC10005832 DOI: 10.1097/oi9.0000000000000228] [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] [Received: 04/21/2022] [Accepted: 10/17/2022] [Indexed: 06/18/2023]
Abstract
Objective Open tibial shaft fractures are a leading cause of disability worldwide, particularly in low and middle-income countries (LMICs). Guidelines for these injuries have been developed in many high-income countries, but treatment patterns across Africa are less well-documented. Methods A survey was distributed to orthopaedic service providers across sub-Saharan Africa. Information gathered included surgeon and practice setting demographics and treatment preferences for open tibial shaft fractures across 3 domains: initial debridement, antibiotic administration, and fracture stabilization. Responses were grouped according to country income level and were compared between LMICs and upper middle-income countries (UMICs). Results Responses from 261 survey participants from 31 countries were analyzed, with 80% of respondents practicing in LMICs. Most respondents were male practicing orthopaedic surgeons at a tertiary referral hospital. For all respondents, initial debridement occurred most frequently in the operating room (OR) within the first 24 hours, but LMIC surgeons more frequently reported delays due to equipment availability, treatment cost, and OR availability. Compared with their UMIC counterparts, LMIC surgeons less frequently confirmed tetanus vaccination status and more frequently used extended courses of postoperative antibiotics. LMIC surgeons reported lower rates of using internal fixation, particularly for high-grade and late-presenting fractures. Conclusions This study describes management characteristics of open tibial shaft fractures in sub-Saharan Africa. Notably, there were reported differences in wound management, antibiotic administration, and fracture stabilization between LMICs and UMICs. These findings suggest opportunities for standardization where evidence is available and further research where it is lacking. Level of Evidence VI-Cross-Sectional Study.
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20
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Haonga BT, Ngunyale P, von Kaeppler EP, Donnelley CA, Won NY, Eliezer EN, Brown K, Flores M, O'Marr JM, Rodarte P, Urva M, Cortez A, Porco T, Morshed S, Shearer DW. A pilot, masked, randomized controlled trial to evaluate local gentamicin versus saline in open tibial fractures (pGO-Tibia). OTA Int 2023; 6:e268. [PMID: 37719315 PMCID: PMC10503693 DOI: 10.1097/oi9.0000000000000268] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/29/2023] [Indexed: 09/19/2023]
Abstract
Background Open tibial fractures have a high risk of infection that can lead to severe morbidity. Antibiotics administered locally at the site of the open wound are a potentially effective preventive measure, but there are limited data evaluating aminoglycoside antibiotics. The objective of this study was to assess the feasibility of a clinical trial to test the efficacy of local gentamicin in reducing the risk of fracture-related infection after open tibial fracture. Methods This study is a single-center, pilot, masked, randomized controlled trial conducted at the Muhimbili Orthopaedic Institute. Participants were randomized intraoperatively after wound closure to receive gentamicin solution or normal saline solution injected at the fracture site. Follow-ups were completed at 2 weeks, 6 weeks, 3 months, 6 months, 9 months, and 1 year postoperatively. The primary feasibility outcomes were the rate of enrollment and retention. The primary clinical outcome was the occurrence of fracture-related infection. Results Of 199 patients screened, 100 eligible patients were successfully enrolled and randomized over 9 months (11.1 patients/month). Complete data were recorded at baseline and follow-up for >95% of cases. The rate of follow-up at 6 weeks, 3 months, 6 months, 9 months, and 1 year were 70%, 68%, 69%, 61%, and 80%, respectively. There was no difference in adverse events or any of the measured primary and secondary outcomes. Conclusion This pilot study is among the first to evaluate locally administered gentamicin in open tibial fractures. Results indicate a rigorous clinical trial with acceptable rates of enrollment and follow-up to address this topic is possible in this setting.
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Affiliation(s)
| | | | - Ericka P. von Kaeppler
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Claire A. Donnelley
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Nae Y. Won
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | | | - Kelsey Brown
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Michael Flores
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Jamieson M. O'Marr
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Patricia Rodarte
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Mayur Urva
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Abigail Cortez
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - Travis Porco
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Saam Morshed
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
| | - David W. Shearer
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA; and
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Cao ZM, Sui XL, Xiao Y, Qing LM, Wu PF, Tang JY. Efficacy comparison of vascularized iliac crest bone flap and Ilizarov bone transport in the treatment of traumatic bone defects of the tibia combined with large soft tissue defects. J Orthop Surg Res 2023; 18:349. [PMID: 37170110 PMCID: PMC10176677 DOI: 10.1186/s13018-023-03783-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 04/05/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Traumatic tibial defect complicated with soft tissue defect is a difficult problem in clinic. Vascularized iliac crest bone flap (VIBF) and Ilizarov bone transport are effective methods to treat tibial defects with limited defect length, which most need to be explored accordingly. METHODS In this study, a total of 68 patients with traumatic tibial defect (ranging from 4 to 10 cm) and large soft tissue defect were collected retrospectively. The soft tissue defects were repaired by latissimus dorsal musculocutaneous flap (LD), anterolateral thigh flap (ALTF) or both. Thirty-three cases were treated with vascularized iliac crest bone flap transplantation and 35 cases were treated with Ilizarov bone transport. Intraoperative and postoperative follow-up data (including operation time, blood loss, bone union time, external fixation time, external fixation index, complication rate, reoperation rate, and functional evaluation) were recorded, and comparative analysis was performed. RESULTS The median follow-up time was 32 months. Compared with Ilizarov group, the VIBF group exhibited statistically faster bone union time (6.3 ± 1.0 vs. 18.2 ± 3.0 months). Moreover, the VIBF group showed shorter EFT (7.3 ± 1.0 vs. 19.2 ± 3.0 months) and a better EFI (34.8 ± 9.2 vs. 84.2 ± 23.7 days/cm). The excellent and good rate of lower limb appearance evaluation in VIBP group was significantly better than that in Ilizarov group. The complication rate and reoperation rate were significantly higher in Ilizarov group. CONCLUSION In summary, compared with Ilizarov bone transport, VIBP has the advantages of faster healing, shorter external fixation time, lower complication and reoperation rate, and better appearance within the limited defect length. Ilizarov bone transport is still preferred when the defect length exceeds the maximum repair length of the iliac flap. The daily handling required by bone transport process is painful. LEVEL OF EVIDENCE III, Case-control study.
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Affiliation(s)
- Zhe-Ming Cao
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Xin-Lei Sui
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Yu Xiao
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Li-Ming Qing
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Pan-Feng Wu
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
| | - Ju-Yu Tang
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
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22
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Demidov VV, Clark MA, Streeter SS, Sottosanti JS, Gitajn IL, Elliott JT. High-energy open-fracture model with initial experience of fluorescence-guided bone perfusion assessment. J Orthop Res 2023; 41:1040-1048. [PMID: 36192829 PMCID: PMC10067537 DOI: 10.1002/jor.25443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/12/2022] [Indexed: 02/04/2023]
Abstract
High-energy orthopedic injuries cause severe damage to soft tissues and are prone to infection and healing complications, making them a challenge to manage. Further research is facilitated by a clinically relevant animal model with commensurate fracture severity and soft-tissue damage, allowing evaluation of novel treatment options and techniques. Here we report a reproducible, robust, and clinically relevant animal model of high-energy trauma with extensive soft-tissue damage, based on compressed air-driven membrane rupture as the blast wave source. As proof-of-principle showing the reproducibility of the injury, we evaluate changes in tissue and bone perfusion for a range of different tibia fracture severities, using dynamic contrast-enhanced fluorescence imaging and microcomputed tomography. We demonstrate that fluorescence tracer temporal profiles for skin, femoral vein, fractured bone, and paw reflect the increasing impact of more powerful blasts causing a range of Gustilo grade I-III injuries. The maximum fluorescence intensity of distal tibial bone following 0.1 mg/kg intravenous indocyanine green injection decreased by 35% (p < 0.01), 75% (p < 0.001), and 87% (p < 0.001), following grade I, II, and III injuries, respectively, compared to uninjured bone. Other kinetic parameters of bone and soft tissue perfusion extracted from series of fluorescence images for each animal also showed an association with severity of trauma. In addition, the time-intensity profile of fluorescence showed marked differences in wash-in and wash-out patterns for different injury severities and anatomical locations. This reliable and realistic high-energy trauma model opens new research avenues to better understand infection and treatment strategies. Level of evidence: Level III; Case-control.
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Affiliation(s)
- Valentin V. Demidov
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Centre, Lebanon, NH
- Geisel School of Medicine, Dartmouth College, Hanover, NH
| | - Megan A. Clark
- Thayer School of Engineering, Dartmouth College, Hanover, NH
| | | | | | - I. Leah Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Centre, Lebanon, NH
| | - Jonathan Thomas Elliott
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Centre, Lebanon, NH
- Geisel School of Medicine, Dartmouth College, Hanover, NH
- Thayer School of Engineering, Dartmouth College, Hanover, NH
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23
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Wang H, Liu Y, Shi Z, Wang D, Zhang H, Diao S, Xu X, Waheed MZ, Lu T, Zhou J. Intrawound application of vancomycin reduces the proportion of fracture-related infections in high-risk tibial plateau fractures. Injury 2023; 54:1088-1094. [PMID: 36740472 DOI: 10.1016/j.injury.2023.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Despite the improvements in surgical techniques and the use of prophylactic intravenous antibiotics, the fracture-related infection (FRI) incidence after high-risk tibial plateau fractures remains high. This study aimed to evaluate the clinical effect of the intrawound application of vancomycin on the FRI after high-risk tibial plateau fracture surgery. METHODS A total of 243 patients who underwent high-risk tibial plateau fracture surgery from May 2013 to June 2021 were retrospectively reviewed. Of these, 233 cases were enrolled. Considering the preoperative patient condition, surgeons applied vancomycin powder directly into the surgical site before wound closure in 105 cases (intrawound application of vancomycin powder with preoperative intravenous cephalosporin). The remaining 128 cases served as the control group (preoperative intravenous cephalosporin alone). Clinical data and surgical details were recorded. The Cox proportional hazards regression analysis was used to assess risk factors for FRI. The Kaplan-Meier method and the log rank test illustrated the infection status of patients based on the application of intrawound vancomycin. The primary outcome was an FRI within one year. Secondary outcomes included bacterial culture and vancomycin-related complications. RESULTS Our study demonstrated a significant difference in the incidence of FRI between the vancomycin group and the control group (3.8% versus 10.9%; p=0.041). Multivariable Cox regression showed the intrawound application of vancomycin powder decreased the rate of FRI. There were no complications related to intrawound vancomycin observed during follow-up. The presence of Gram-positive FRI was higher in the control group compared with the vancomycin group. CONCLUSIONS Intrawound application of vancomycin was associated with a significant lower rate of FRI after high-risk tibial plateau fracture surgery compared to the control group.
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Affiliation(s)
- Hanzhou Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Yang Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Zongxin Shi
- Department of Orthopedic Surgery, Beijing Liangxiang Hospital, Beijing 102446, PR China
| | - Dong Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Hui Zhang
- Department of Orthopedic Surgery, Beijing Liangxiang Hospital, Beijing 102446, PR China
| | - Shuo Diao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Xiaopei Xu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Muhammad Zeeshan Waheed
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Tianchao Lu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Junlin Zhou
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China.
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Pacha TO, Mommsen P, Brauckmann V, Aktas G, Krempec M, Wilhelmi B, Clausen JD, März V, Krezdorn N, Vogt PM, Sehmisch S, Hinrichs JB, Ernst J. [Interdisciplinary extremity board in the treatment of complex injuries]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:175-183. [PMID: 36746799 DOI: 10.1007/s00113-023-01290-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Interdisciplinary case conferences are well-established in the field of oncology in order to provide the best possible treatment for patients with complex disease patterns which overlap several disciplines. METHODS After studying the available literature the aims, indications, frequency, patient enrolment and documentation modalities, disciplines necessary to create the reconstruction plan and evaluation parameters of the board, were agreed in an interdisciplinary discussion among colleagues. The utilization of the extremity board and demographic features of the cases presented in the extremity board within the first 6 months were subsequently descriptively analyzed. RESULTS The agreed primary aim of an extremity board is the timely and transparent preparation of a high-quality holistic reconstruction plan for optimized treatment of a challenging patient collective with complex injuries of the extremities. Decisive interfaces of an extremity board are the participation of interdisciplinary disciplines, established enrolment and documentation modalities and a longitudinal analysis of parameters of the acute medical treatment, the long-term function and quality of life of those affected. The patient collective so far mostly includes men under 40 years old with traumatic soft tissue defects and combined injuries. On average, reconstruction plans for 1-2 patients were approved in an interdisciplinary team per session. CONCLUSION The extremity board serves as a platform for coordinated planning of treatment for patients with complex injuries. The limited personnel and time resources represent the greatest challenge for the successful implementation. The extremity board enables a high degree of interdisciplinary networking. The digital registration and documentation modality within the internal hospital documentation system is of utmost relevance. The preparation of the reconstruction plan is of decisive importance for the qualitative success of treatment and the restoration of function. The longitudinal analysis of appropriate parameters is imperative to measure the quality of treatment.
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Affiliation(s)
- T Omar Pacha
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - P Mommsen
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - V Brauckmann
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - G Aktas
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - M Krempec
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - B Wilhelmi
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - J-D Clausen
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - V März
- Klinik für Plastische, Ästhetische, Hand- und Wiederherstellungschirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - N Krezdorn
- Klinik für Plastische, Ästhetische, Hand- und Wiederherstellungschirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - P M Vogt
- Klinik für Plastische, Ästhetische, Hand- und Wiederherstellungschirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - S Sehmisch
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - J B Hinrichs
- Klinik für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - J Ernst
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
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25
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Limb salvage versus primary amputation in Gustilo-Anderson IIIB and IIIC tibial fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04804-2. [PMID: 36781435 DOI: 10.1007/s00402-023-04804-2] [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: 09/05/2022] [Accepted: 01/28/2023] [Indexed: 02/15/2023]
Abstract
INTRODUCTION The last systematic review on this topic was published in 2008. With advances in surgical techniques, patients with mangled extremities may now be potentially salvageable with comparable outcomes. This review aims to evaluate the outcomes of limb salvage compared to primary amputation in patients with severe open tibial fractures. MATERIALS AND METHODS A comprehensive search on PubMed, MEDLINE, Embase, Web of Science, Scopus, CENTRAL and CINAHL was performed from inception to 19 January 2022. The primary outcome was to evaluate clinical and functional outcomes. Secondary outcomes were to evaluate pain, patient preference, quality of life, and patient preferences. Methodological quality was evaluated using the MINORS criteria. Pooled estimates of relative risk (RR) and mean difference (MD) with 95% confidence interval (CI) were used as a summary statistic for dichotomous variables and continuous variables, respectively. RESULTS Sixteen studies with 645 patients met inclusion criteria. The methodological quality was moderate based on the MINORS score. The majority were male. Mean age was 36.3 years. There was no significant differences in the length of hospitalization (n = 8), return to work rates (n = 9), return to sport rates (n = 4) and quality of life scores (n = 4). Patients with primary amputation had a significantly lower risk of total complications (RR 0.21, 95% CI 0.08-0.53, p = 0.001) (n = 10), infections (RR 0.46, 95% CI 0.25-0.85, p = 0.01) (n = 9), and number of surgeries (MD - 4.17, 95% CI - 6.49 to - 1.85, p = 0.0004) (n = 6). Patients with primary amputation were able to ambulate significantly earlier (MD - 4.06, 95% CI - 7.65 to - 0.46, p = 0.03) (n = 3). Three studies found a significantly higher cost of hospitalization in limb salvage patients. Functional outcomes were similar in both groups. CONCLUSION While patients with primary amputation had better clinical outcomes in the short-term, functional outcomes were not significantly different in both groups. Despite the heterogenicity of the results in this review, surgeons need to contextualize the decision making for their patients and incorporate these findings. LEVEL OF EVIDENCE III. TRIAL REGISTRATION PROSPERO CRD42022303357.
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Guo M, Thomas B, Goyal S, Rivedal D, Mehdi M, Schmeling GJ, Neilson JC, Martin J, Harkin EA, Wooldridge A, King DM, Hackbarth DA, Doren EL, Hettinger P, LoGiudice JA. Outcome comparison between muscle and fasciocutaneous flaps after secondary orthopedic procedures. J Plast Reconstr Aesthet Surg 2023; 77:111-116. [PMID: 36563636 DOI: 10.1016/j.bjps.2022.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/10/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022]
Abstract
Lower extremity wounds associated with fractures and bony defects often require secondary orthopedic procedures after flap coverage has been performed. In this study, we compare complications between muscle and fasciocutaneous flaps after secondary orthopedic procedures. A retrospective chart review study of all lower extremity soft tissue reconstructions by a single surgeon over seven years yielded a subgroup of patients who underwent secondary orthopedic procedures, including hardware removal, hardware revision, and bone grafting after flap reconstruction. Of 355 lower extremity, soft tissue reconstructions for orthopedic coverage performed in the time period studied, 102 patients underwent secondary orthopedic procedures after flap reconstruction. Of these, 54 received muscle flaps (52.94%), and 48 received fasciocutaneous flaps (47.06%). Using this subgroup of 102 patients, we compared muscle and fasciocutaneous flaps using three categories of wound complications following these secondary procedures: There were no superficial wounds requiring local wound care only in the muscle flap group (0%, n = 0) versus 4.17% (n = 2; p = 0.130) in the fasciocutaneous flap group. There were 2 lost flaps requiring surgical debridement and additional skin grafting in the muscle flaps group (3.70%) versus 2 (4.17%; p = 0.904) in the fasciocutaneous flap group. In the third category, flap loss requiring additional soft tissue reconstruction was 18.52% (n = 10) in the muscle group versus 2.08% (n = 1; p = 0.008) in the fasciocutaneous flap group. Our data support the existing literature indicating that fasciocutaneous flaps can tolerate secondary procedures better than muscle flaps and should initially be considered in patients with higher probability of needing additional orthopedic procedures after reconstruction.
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Affiliation(s)
- Meng Guo
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - Bejoy Thomas
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - Samita Goyal
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - David Rivedal
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - Maahum Mehdi
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - Gregory J Schmeling
- Department of Orthopaedic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - John C Neilson
- Department of Orthopaedic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - Jill Martin
- Department of Orthopaedic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - Elizabeth A Harkin
- Department of Orthopaedic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - Adam Wooldridge
- Department of Orthopaedic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - David M King
- Department of Orthopaedic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - Donald A Hackbarth
- Department of Orthopaedic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - Erin L Doren
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - Patrick Hettinger
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, WI
| | - John A LoGiudice
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, WI; Department of Orthopaedic Surgery, The Medical College of Wisconsin, Milwaukee, WI.
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Outcomes of Tibiotalocalcaneal Hindfoot Fusion Nails Used for Acute Lower Extremity Trauma in a High-Risk Patient Population. J Orthop Trauma 2023; 37:e7-e12. [PMID: 36518067 DOI: 10.1097/bot.0000000000002466] [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: 08/09/2021] [Accepted: 07/21/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the outcomes of high-risk patients treated with tibiotalocalcaneal hindfoot fusion nails. DESIGN Retrospective case series. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Between January 2007 and December 2016, 50 patients with significant medical comorbidities treated with a tibiotalocalcaneal hindfoot fusion nail in the setting of acute distal tibia and ankle trauma considered to be limb-threatening. INTERVENTION Tibiotalocalcaneal hindfoot fusion nail. MAIN OUTCOME MEASUREMENTS Two-year cumulative incidence of unplanned reoperation and estimated survival with limb salvage at 2 years. RESULTS Of the 50 patients, 20 (38%) had an unplanned reoperation (mean: 2.5 reoperations), including 19 for implant removal, 11 for irrigation and debridement and/or placement of an antibiotic delivery device, and 4 for revision fusion. Three patients required amputation and 3 patients died within 2 years of injury, resulting in an estimated survival with limb salvage at 2 years of 79% (95% confidence interval: 67%-91%). After accounting for the competing risk of death and incomplete follow-up, the 2-year cumulative incidence of unplanned reoperation was 64% (95% confidence interval: 62%-67%). CONCLUSIONS Patients in this series experienced a high rate of return to the operating room but a relatively low rate of amputation. Because patients were indicated for this course of treatment on the basis of comorbidities felt to put them at high risk of loss of limb with traditional treatment, acute hindfoot fusion nailing might represent a viable option in select high-risk patients and injuries. Clinicians should be aware that complications are still common. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Effect of Local Antibiotic Prophylaxis on Postoperative Deep Infection in Fracture Surgery: A Systematic Review and Meta-Analysis. J Orthop Trauma 2023; 37:e28-e35. [PMID: 36084224 DOI: 10.1097/bot.0000000000002487] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Despite the use of systemic antibiotic prophylaxis, postoperative infection after fracture surgery remains an issue. The purpose of this systematic review and meta-analysis was to evaluate the effect of locally applied antibiotics on deep infection in fracture surgery in both the open and closed fractures. DATA SOURCES A comprehensive search of MEDLINE, Embase, and PubMed was performed from the date of inception to April 15, 2021, and included studies in all languages. STUDY SELECTION Cohort studies were eligible if they investigated the effect on the infection rate of local antibiotic prophylaxis on deep infection after fracture surgery. DATA EXTRACTION This study was conducted according to the Cochrane Handbook for Systematic Reviews and reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials and the Methodological Index for Nonrandomized Studies tool where applicable. DATA SYNTHESIS An inverse variance random-effects model was the primary analysis model because of the anticipated diversity in the evaluated populations. Univariate models were used when a single outcome was of interest. CONCLUSIONS The risk of deep infection was significantly reduced when local antibiotics were applied compared with the control group receiving systemic prophylaxis only. This beneficial effect was observed in open fractures but failed to reach statistical significance in closed fractures. This meta-analysis suggests that there may be a significant risk reduction in deep infection rate after fracture surgery when local antibiotics are added to standard systemic prophylaxis, particularly in open fractures. Further high-powered Level I studies are needed to support these findings. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
Fracture related infection remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families, treating physicians and healthcare systems. Even current curative approaches (radical debridement, revision surgery and long-term antibiotics) often result in significant socioeconomic costs and the risk of life-long functional impairment to the patient. The prevalence of osteomyelitis due to trauma and surgical complications does not seem to be diminishing in our society and the emergence of antimicrobial resistance is a major health related concern with global relevance. Despite multi-drug resistant bacteria being on the rise universally, perioperative antibiotic prophylaxis in orthopaedic trauma care has only slightly changed in the last 25 years. Staphylococcus infections remain an increasing global concern, partially due to the resistance mechanisms developed by staphylococci to evade the host immune system and antibiotic treatment, and as such antibiotics are becoming increasingly ineffective. This paper will address fracture related infections in trauma patients, looking at the bacteriology of these infections, its clinical implications and evolving nature.
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Affiliation(s)
- David Graan
- John Hunter Department of Traumatology, 549461John Hunter Hospital, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- Department of Traumatology and Discipline of Surgery, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
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Flores MJ, Brown KE, Morshed S, Shearer DW. Evidence for Local Antibiotics in the Prevention of Infection in Orthopaedic Trauma. J Clin Med 2022; 11:jcm11247461. [PMID: 36556077 PMCID: PMC9782030 DOI: 10.3390/jcm11247461] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/18/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
Prevention of fracture-related infection (FRI) remains a substantial challenge in orthopaedic trauma care. There is evolving evidence to support the use of local antibiotics for both the prevention and treatment of musculoskeletal infection. Local antibiotics can achieve higher local tissue concentrations with a lower risk of systemic complications compared to intravenously administered antibiotics. These antibiotics may be administered in powder or liquid form without carrier, or if sustained release is desired, using a carrier. Polymethylmethacrylate (PMMA), ceramics, and hydrogels are examples of antibiotic carriers. Unlike PMMA, ceramics and hydrogels have the advantage of not requiring a second surgery for removal. The VANCO trial supported the use of powdered vancomycin in high-risk fracture cases for the reduction of Gram-positive infections; although, data is limited. Future studies will evaluate the use of aminoglycoside antibiotics to address Gram-negative infection prevention. While theoretical concerns exist with the use of local antibiotics, available studies suggest local antibiotics are safe with a low-risk of adverse effects.
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31
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Cortez A, Urva M, Haonga B, Donnelley CA, von Kaeppler EP, Roberts HJ, Shearer DW, Morshed S. Outcomes of Intramedullary Nailing and External Fixation of Open Tibial Fractures: Three to Five-Year Follow-up of a Randomized Clinical Trial. J Bone Joint Surg Am 2022; 104:1877-1885. [PMID: 35980080 DOI: 10.2106/jbjs.22.00016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND While surgeons in low and middle-income countries have increasing experience with intramedullary nailing (IMN), external fixation (EF) continues to be commonly used for the management of open tibial fractures. We examined outcomes with extended follow-up of the participants enrolled in a clinical trial comparing these treatments. METHODS Adults who were ≥18 years old with acute AO/OTA type-42 open tibial shaft fractures were randomly assigned to statically locked, hand-reamed IMN or uniplanar EF. These participants were reevaluated 3 to 5 years after treatment. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Unresolved complications such as persistent fracture-related infection, nonunion, or malalignment were collected and analyzed. Secondary outcomes included the EuroQol-5 Dimension-3 Level (EQ-5D-3L) questionnaire, the Function IndeX for Trauma (FIX-IT) score, radiographic alignment, and the modified Radiographic Union Scale for Tibial fractures (mRUST). RESULTS Of the originally enrolled 240 participants,126 (67 managed with IMN and 59 managed with EF) died or returned for follow-up at a mean of 4.0 years (range, 2.9 to 5.2 years). Thirty-two composite primary events occurred, with rates of 23.9% and 27.1% in the IMN and EF groups, respectively. Six of these events (3 in the IMN group and 3 in the EF group) were newly detected after the original 1-year follow-up. Unresolved complications in the form of chronic fracture-related infection or nonunion were present at long-term follow-up in 25% of the participants who sustained a primary event. The EQ-5D-3L index scores were similar between the 2 groups and only returned to preinjury levels after 1 year among patients without complications or those whose complications resolved. CONCLUSIONS This observational study extended follow-up for a clinical trial assessing IMN versus EF for the treatment of open tibial fractures in sub-Saharan Africa. At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of the participants who experienced these complications, regardless of reintervention. LEVEL OF EVIDENCE Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Abigail Cortez
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California.,Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Mayur Urva
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Billy Haonga
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Claire A Donnelley
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Ericka P von Kaeppler
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Heather J Roberts
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - David W Shearer
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Saam Morshed
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California
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32
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Cholok D, Saberski E, Lowenberg DW. Approach to Complex Lower Extremity Reconstruction. Semin Plast Surg 2022; 36:233-242. [PMID: 36561427 PMCID: PMC9762997 DOI: 10.1055/s-0042-1758205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Composite injuries to the lower extremity from etiologies including trauma and infection present a complex dilemma for the reconstructive surgeon, and require multidisciplinary collaboration amongst plastic, vascular, and orthopaedic surgical specialties. Here we present our algorithm for lower-extremity reconstructive management, refined over the last decades to provide an optimized outcome for our patients. Reconstruction is predicated on the establishment of a clean and living wound, where quality of the wound-bed is prioritized over timing to soft-tissue coverage. Once established, soft-tissues and fractures are provisionally stabilized; our preference for definitive coverage is for microvascular free-tissue, due to the paucity of healthy soft-tissue available at the injury, and ability to avoid the zone of injury for microvascular anastomosis. Finally, definitive bony reconstruction is dictated by the length and location of long-bone defect, with a preference to utilize bone transport for defects longer than 5 cm.
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Affiliation(s)
- David Cholok
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Ean Saberski
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - David W. Lowenberg
- Department of Orthopedic Surgery, Stanford University School of Medicine, Palo Alto, California
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Hoellwarth JS, Tetsworth K, Oomatia A, Akhtar MA, Xu H, Al Muderis M. Association Between Osseointegration of Lower Extremity Amputation and Mortality Among Adults. JAMA Netw Open 2022; 5:e2235074. [PMID: 36227599 PMCID: PMC9561949 DOI: 10.1001/jamanetworkopen.2022.35074] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Transcutaneous osseointegration post amputation (TOPA) creates a direct linkage between residual bone and an external prosthetic limb, providing superior mobility and quality of life compared with a socket prosthesis. The causes and potential risks of mortality after TOPA have not been investigated. OBJECTIVE To investigate the association between TOPA and mortality and assess the potential risk factors. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study included all patients with amputation of a lower extremity who underwent TOPA between November 1, 2010, and October 31, 2021, at a specialty orthopedic practice and tertiary referral hospital in a major urban center. Patients lived on several continents and were followed up as long as 10 years. EXPOSURES Transcutaneous osseointegration post amputation, consisting of a permanent intramedullary implant passed transcutaneously through a stoma and connected to an external prosthetic limb. MAIN OUTCOMES AND MEASURES Death due to any cause. The hypotheses tested-that patient variables (sex, age, level of amputation, postosseointegration infection, and amputation etiology) may be associated with subsequent mortality-were formulated after initial data collection identifying which patients had died. RESULTS A total of 485 patients were included in the analysis (345 men [71.1%] and 140 women [28.9%]), with a mean (SD) age at osseointegration of 49.1 (14.6) years among living patients or 61.2 (12.4) years among patients who had died. Nineteen patients (3.9%) died a mean (SD) of 2.2 (1.7) years (range, 58 days to 5 years) after osseointegration, including 17 (3.5%) who died of causes unrelated to osseointegration (most commonly cardiac issues) and 2 (0.4%) who died of direct osseointegration-related complications (infectious complications), of which 1 (0.2%) was coclassified as a preexisting health problem exacerbated by osseointegration (myocardial infarction after subsequent surgery to manage infection). No deaths occurred intraoperatively or during inpatient recuperation or acute recovery after index osseointegration (eg, cardiopulmonary events). Kaplan-Meier survival analysis with log-rank comparison and Cox proportional hazards regression modeling identified increased age (hazard ratio, 1.06 [95% CI, 1.02-1.09]) and vascular (odds ratio [OR], 4.73 [95% CI, 1.35-16.56]) or infectious (OR, 3.87 [95% CI, 1.31-11.40]) amputation etiology as risk factors. Notable factors not associated with mortality risk included postosseointegration infection and male sex. CONCLUSIONS AND RELEVANCE These findings suggest that patients who have undergone TOPA rarely die of problems associated with the procedure but instead usually die of unrelated causes.
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Affiliation(s)
- Jason Shih Hoellwarth
- Limb Salvage and Amputation Reconstruction Center, Hospital for Special Surgery, New York, New York
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane and Women’s Hospital, Queensland, Australia
| | - Atiya Oomatia
- Limb Reconstruction Centre, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
| | - Muhammad Adeel Akhtar
- Trauma and Orthopaedic Department, Victoria Hospital Kirkcaldy, NHS (National Health Service) Fife, Kirkcaldy, Scotland
| | - Haikun Xu
- Inter-American Tropical Tuna Commission, La Jolla, California
| | - Munjed Al Muderis
- Limb Reconstruction Centre, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
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Microsurgical Strategies after Free Flap Failure in Soft Tissue Reconstruction of the Lower Extremity: A 17-Year Single-Center Experience. J Pers Med 2022; 12:jpm12101563. [PMID: 36294702 PMCID: PMC9604543 DOI: 10.3390/jpm12101563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/10/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background: There is no clear consensus on the optimal surgical strategy for providing safe coverage in salvage free flap surgery after total free flap failure. Methods: A retrospective study was conducted to evaluate patients with total failure of the primary free flap in lower extremity reconstruction between 2000 and 2017. Results: In a cohort of 1.016 patients, we identified 43 cases of total flap failure (4.2%). A total of 30 patients received a salvage free flap with a success rate of 83.3% (25/30). One patient received a secondary salvage free flap. Overall limb salvage after primary free flap loss was 83.7% (36/43). Conclusions: Microsurgical management of free flap loss in the lower extremity is challenging and requires a decisive re-evaluation of risk factors and alternative strategies. This should include reconsidering the flap choice with a tendency towards traditional and safe workhorse flaps, a low-threshold switch to different recipient vessels, including arteriovenous (AV) loops, bypasses (especially in case of venous insufficiency) and back-up procedures, such as negative pressure wound therapy or dermal regeneration templates with skin grafting in cases of lower demand and critically ill patients. We derived one suggestion from our previous practice: replacing perforator flaps with axial pattern flaps (“safe workhorses”).
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Grimm PD, Wheatley BM, Tomasino A, Leonhardt C, Hunter DA, Wood MD, Moore AM, Davis TA, Tintle SM. Controlling axonal regeneration with acellular nerve allograft limits neuroma formation in peripheral nerve transection: An experimental study in a swine model. Microsurgery 2022; 42:603-610. [PMID: 35925036 DOI: 10.1002/micr.30943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/06/2022] [Accepted: 07/14/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Symptomatic neuromata are a common indication for revision surgery following amputation. Previously described treatments, including traction neurectomy, nerve transposition, targeted muscle re-innervation, and nerve capping, have provided inconsistent results or are technically challenging. Prior research using acellular nerve allografts (ANA) has shown controlled termination of axonal regrowth in long grafts. The purpose of this study was to determine the ability of a long ANA to prevent neuroma formation following transection of a peripheral nerve in a swine model. MATERIALS AND METHODS Twenty-two adult female Yucatan miniature swine (Sus scrofa; 4-6 months, 15-25 kg) were assigned to control (ulnar nerve transection only, n = 10), treatment (ulnar transection and coaptation of 50 mm ANA, n = 10), or donor (n = 2) groups. Nerves harvested from donor group animals were treated to create the ANA. After 20 weeks, the transected nerves including any neuroma or graft were harvested. Both qualitative (nerve architecture, axonal sprouting) and quantitative histologic analyses (myelinated axon number, cross sectional area of nerve tissue) were performed. RESULTS Qualitative histologic analysis of control specimens revealed robust axon growth into dense scar tissue. In contrast, the treatment group revealed dwindling axons in the terminal tissue, consistent with attenuated neuroma formation. Quantitative analysis revealed a significantly decreased number of myelinated axons in the treatment group (1232 ± 540) compared to the control group (44,380 ± 7204) (p < .0001). Cross sectional area of nerve tissue was significantly smaller in treatment group (2.83 ± 1.53 mm2 ) compared to the control group (9.14 ± 1.19 mm2 ) (p = .0012). CONCLUSIONS Aberrant axonal growth is controlled to termination with coaptation of a 50 mm ANA in a swine model of nerve injury. These early results suggest further investigation of this technique to prevent and/or treat neuroma formation.
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Affiliation(s)
- Patrick D Grimm
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA.,Orthopaedics, Uniformed Services University of the Health Sciences-Walter Reed Department of Surgery, Bethesda, Maryland, USA
| | - Benjamin M Wheatley
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA.,Orthopaedics, Uniformed Services University of the Health Sciences-Walter Reed Department of Surgery, Bethesda, Maryland, USA
| | - Allison Tomasino
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Crystal Leonhardt
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Daniel A Hunter
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Amy M Moore
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Thomas A Davis
- Department of Surgery, Uniformed Services University of the Health Sciences-Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Scott M Tintle
- Orthopaedics, Uniformed Services University of the Health Sciences-Walter Reed Department of Surgery, Bethesda, Maryland, USA
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Godwin Y, Ahmed A, Shaat HY. A review of the first wave of lower limb amputees from the Great March of Return in Gaza: Taking stock and preparing for the task ahead. Injury 2022; 53:2541-2549. [PMID: 35643556 DOI: 10.1016/j.injury.2022.05.031] [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: 01/22/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 02/02/2023]
Abstract
AIM Ballistic injuries during the Great March of Return (GMR) protests in Gaza have resulted in young, civilian amputees. This article defines this unique population, their injuries and clinical variables that impacted on amputation. METHOD A multidisciplinary team (MDT) assessed 103 lower limb amputees (104 stumps). Individualized prescriptions of care were formulated and applied for both stump and prosthesis management. The cohort's health state was assessed at screening by applying the EQ-5D-L5 questionnaire. The EQ-5D-L5 will be repeated on completion of the prescription of care. RESULTS The population is predominantly young, male, suffering unilateral amputation with an equal ratio of above knee (AKA) to below knee (BKA) amputations. 18% were amputated immediately and 82% with delay. Most amputations occur within 15 days of gunshot wound (GSW). All tissue elements were affected by the severe, ballistic injury. Division, gapping and tissue loss consolidated the decision for amputation rather than limb salvage. Knee zone injury was common, influencing the high numbers AKAs. Primary injury ramified beyond the amputated leg: 38% have contralateral leg injuries. 20% had physiological challenges requiring Intensive care unit (ICU) admissions. Infection was reported in 49% of amputees with 12% reporting acute sepsis. Psychologically, 49% reported severe, or extreme, anxiety and depression. AKAs were associated with greater morbidity: amputees are significantly younger, have more proximal vascular injuries, receive delayed amputations and experience longer time intervals to stump healing. ICU care and contralateral leg injuries were more frequent. One third of amputees used their prostheses', one third did not and one third do not have a prosthesis yet. The limiting factor for repair was supply of materials. 11% of amputees needed no adjustment to stump or prosthesis. Surgical stump revision was recommended in 26% of stumps and prosthetic management in 41%. A further 22%, subject to the success or failure of prescribed prosthetic adjustment, could require stump revision. CONCLUSION Youth, proximal injury, high numbers of AKA, psychosocial issues and the need for stump and prosthetic support define this group of amputees. Unifying expertise within a National MDT will promote continuity of care necessary for decades to come. The ultimate aim is an evidence-based amputee care system in Gaza, with lower limb specialists promoting best outcomes, judicious allocation of funds and maximising amputee quality of life.
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Affiliation(s)
- Yvette Godwin
- Department of Plastic Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.
| | - Almaqadma Ahmed
- Department of Orthopaedic and Plastic Surgery, Al-Awda Hospital, Gaza strip, Tal al-Zatar, Palestine
| | - Hammad Yousef Shaat
- Al Shifa Hospital, Department of Orthopaedics, Ezden Qassam Street, Rimal District, Gaza City, Palestine
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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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Gitajn I, Werth P, O'Toole RV, Joshi M, Jevsevar D, Wise B, Rane A, Horton S, McClure EA, Ross B, Nadell C. Microbial Interspecies Associations in Fracture-Related Infection. J Orthop Trauma 2022; 36:309-316. [PMID: 35703847 DOI: 10.1097/bot.0000000000002314] [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: 11/16/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Describe co-occurrence or clustering of microbial taxa in fracture-related infections to inform further exploration of infection-related interactions among them. DESIGN Retrospective review. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Four hundred twenty-three patients requiring surgical intervention for deep surgical site infection between January 2006 and December 2015. INTERVENTION None. MAIN OUTCOME MEASUREMENT Connection between microbial taxa. RESULTS Methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, and coagulase-negative Staphylococcus represented the majority of monomicrobial observations (71%). Gram-negative rods, gram-positive rods, and anaerobes presented more frequently in polymicrobial infections. Enterobacter, vancomycin-sensitive Enterococcus, and Pseudomonas are present in polymicrobial infections with the highest frequencies and represent the top 3 most important nodes within the microorganism framework, with the highest network centrality scores. CONCLUSIONS The present study indicates that there are common microbial taxa (Enterobacter, Enterococcus, and Pseudomonas) that tend to co-occur with other microbes greater than 75% of the time. These commonly co-occurring microbes have demonstrated interactive relationships in other disease pathologies, suggesting that there may be similar important interactions in fracture-related infections. It is possible that these microbial communities play a role in the persistently high failure rate associated with management of infection after trauma. Future studies are needed to study the intermicrobial interactions that explain the frequency at which taxa co-occur. Understanding and potentially disrupting these intermicrobial relationships could inform improvements in the treatment of established infections and in the prevention of infection in high-risk patients. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ida Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Paul Werth
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Robert V O'Toole
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Mandarin Joshi
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - David Jevsevar
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Brent Wise
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Ajinya Rane
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Steven Horton
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Emily A McClure
- Department of Microbiology and Immunology, Dartmouth, Geisel School of Medicine, Hanover, NH; and
| | - Benjamin Ross
- Department of Microbiology and Immunology, Dartmouth, Geisel School of Medicine, Hanover, NH; and
| | - Carey Nadell
- Department of Biological Sciences, Dartmouth, Hanover, NH
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A database study on incidence and trends in traumatic lower extremity amputations in the United States. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Pulse oximetry for the diagnosis of vascular injury following limb trauma. J Plast Reconstr Aesthet Surg 2022; 75:3182-3189. [DOI: 10.1016/j.bjps.2022.04.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 03/06/2022] [Accepted: 04/12/2022] [Indexed: 11/22/2022]
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41
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Chan JKK, Aquilina AL, Lewis SR, Rodrigues JN, Griffin XL, Nanchahal J. Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs. Cochrane Database Syst Rev 2022; 4:CD013555. [PMID: 35363374 PMCID: PMC8973274 DOI: 10.1002/14651858.cd013555.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Open fractures of the major long bones are complex limb-threatening injuries that are predisposed to deep infection. Treatment includes antibiotics and surgery to debride the wound, stabilise the fracture and reconstruct any soft tissue defect to enable infection-free bone repair. There is a need to assess the effect of timing and duration of antibiotic administration and timing and staging of surgical interventions to optimise outcomes. OBJECTIVES To assess the effects (risks and benefits) of the timing of antibiotic administration, wound debridement and the stages of surgical interventions in managing people with open long bone fractures of the upper and lower limbs. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and clinical trial registers in February 2021. We also searched conference proceedings and reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs that recruited adults with open fractures of the major long bones, comparing: 1) timings of prophylactic antibiotic treatment, 2) duration of prophylactic antibiotic treatment, 3) timing of wound debridement following injury or 4) timing of the stages of reconstructive surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We aimed to collect data for the following outcomes: limb function, health-related quality of life (HRQoL), deep surgical site infection, delayed or non-union, adverse events (in the short- and long-term course of recovery), and resource-related outcomes. MAIN RESULTS We included three RCTs of 613 randomised participants with 617 open fractures. Studies were conducted in medical and trauma centres in the USA and Kenya. Where reported, there was a higher proportion of men and a mean age of participants between 30 and 34 years old. Fractures were in the upper and lower limbs in one study, and were tibia fractures in two studies; where reported, these were the result of high-energy trauma such as road traffic accidents. No studies compared the timing of antibiotic treatment or wound debridement. Duration of prophylactic antibiotic treatment (1 study, 77 participants available for analysis) One study compared antibiotic treatment for 24 hours with antibiotic treatment for five days. We are very uncertain about the effects of different durations of antibiotic treatment on superficial infections (risk ratio (RR) 1.19, 95% CI 0.49 to 2.87, favours 5 day treatment; 1 study, 77 participants); this was very low-certainty evidence derived from one small study with unclear and high risks of bias, and with an imprecise effect estimate. This study reported no other review outcomes. Reconstructive surgery: timing of the stages of surgery (2 studies, 458 participants available for analysis) Two studies compared the timing of wound closure, which was completed immediately or delayed. In one study, the mean time of delay was 5.9 days; in the other study, the time of delay was not reported. We are very uncertain about the effects of different timings of wound closure on deep infections (RR 0.82, 95% CI 0.37 to 1.80, favours immediate closure; 2 studies, 458 participants), delayed union or non-union (RR 1.13, 95% CI 0.83 to 1.55, favours delayed closure; 1 study, 387 participants), or superficial infections (RR 6.45, 95% CI 0.35 to 120.43, favours delayed closure; 1 study, 71 participants); this was very low-certainty evidence. We downgraded the certainty of the evidence for very serious risks of bias because both studies had unclear and high risks of bias. We also downgraded for serious imprecision because effect estimates were imprecise, including the possibility of benefits as well as harms, and very serious imprecision when the data were derived from single small study. These studies reported no other review outcomes. AUTHORS' CONCLUSIONS We could not determine the risks and benefits of different treatment protocols for open long bone fractures because the evidence was very uncertain for the two comparisons and we did not find any studies addressing the other possible comparisons. Well-designed randomised trials with adequate power are needed to guide surgical and antibiotic treatment of open fractures, particularly with regard to timing and duration of antibiotic administration and timing and staging of surgery.
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Affiliation(s)
- James K-K Chan
- Department of Plastic Surgery, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | - Alexander L Aquilina
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Jeremy N Rodrigues
- Department of Plastic Surgery, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
- Warwick Clinical Trials Unit, Warwick Medical School, Coventry, UK
| | - Xavier L Griffin
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Jagdeep Nanchahal
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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42
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Hoffman DB, Raymond-Pope CJ, Sorensen JR, Corona BT, Greising SM. Temporal changes in the muscle extracellular matrix due to volumetric muscle loss injury. Connect Tissue Res 2022; 63:124-137. [PMID: 33535825 PMCID: PMC8364566 DOI: 10.1080/03008207.2021.1886285] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE/AIM Volumetric muscle loss (VML) is a devastating orthopedic injury resulting in chronic persistent functional deficits, loss of joint range of motion, pathologic fibrotic deposition and lifelong disability. However, there is only limited mechanistic understanding of VML-induced fibrosis. Herein we examined the temporal changes in the fibrotic deposition at 3, 7, 14, 28, and 48 days post-VML injury. MATERIALS AND METHODS Adult male Lewis rats (n = 39) underwent a full thickness ~20% (~85 mg) VML injury to the tibialis anterior (TA) muscle unilaterally, the contralateral TA muscle served as the control group. All TA muscles were harvested for biochemical and histologic evaluation. RESULTS The ratio of collagen I/III was decreased at 3, 7, and 14 days post-VML, but significantly increased at 48 days. Decorin content followed an opposite trend, significantly increasing by day 3 before dropping to below control levels by 48 days. Histological evaluation of the defect area indicates a shift from loosely packed collagen at early time points post-VML, to a densely packed fibrotic scar by 48 days. CONCLUSIONS The shift from early wound healing efforts to a fibrotic scar with densely packed collagen within the skeletal muscle occurs around 21 days after VML injury through dogmatic synchronous reduction of collagen III and increase in collagen I. Thus, there appears to be an early window for therapeutic intervention to prevent pathologic fibrous tissue formation, potentially by targeting CCN2/CTGF or using decorin as a therapeutic.
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Affiliation(s)
- Daniel B. Hoffman
- School of Kinesiology, University of Minnesota, Minneapolis MN 55455
| | | | - Jacob R. Sorensen
- School of Kinesiology, University of Minnesota, Minneapolis MN 55455
| | | | - Sarah M. Greising
- School of Kinesiology, University of Minnesota, Minneapolis MN 55455;,For reprints contact: Sarah M. Greising, Ph.D., 1900 University Ave SE, 220A Cooke Hall, Minneapolis MN, 55455, , Phone: 612-626-7890, Fax: 612-626-7700
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43
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Bridgeman J, Crist B. Innovations in Limb Salvage: A Multidisciplinary Team Approach. MISSOURI MEDICINE 2022; 119:122-124. [PMID: 36036025 PMCID: PMC9339405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The University of Missouri's Limb Preservation Center is a multi-disciplinary team helping patients with acute and chronic traumatic limb injuries, especially when faced with the difficult decision of limb preservation versus amputation. The team focuses on acute trauma and the chronic effects of a prior failed treatment, including possible amputation. This approach results in improved care, outcomes, and a decrease in failed treatment plans for patients. New advances in amputation techniques also provides better outcomes for patients.
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Affiliation(s)
- Jay Bridgeman
- Department of Orthopaedic Surgery, University of Missouri - Columbia School of Medicine, Columbia, Missouri
| | - Brett Crist
- Department of Orthopaedic Surgery, University of Missouri - Columbia School of Medicine, Columbia, Missouri
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44
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Vantucci CE, Guyer T, Leguineche K, Chatterjee P, Lin A, Nash KE, Hastings MA, Fulton T, Smith CT, Maniar D, Frey Rubio DA, Peterson K, Harrer JA, Willett NJ, Roy K, Guldberg RE. Systemic Immune Modulation Alters Local Bone Regeneration in a Delayed Treatment Composite Model of Non-Union Extremity Trauma. Front Surg 2022; 9:934773. [PMID: 35874126 PMCID: PMC9300902 DOI: 10.3389/fsurg.2022.934773] [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] [Received: 05/03/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022] Open
Abstract
Bone non-unions resulting from severe traumatic injuries pose significant clinical challenges, and the biological factors that drive progression towards and healing from these injuries are still not well understood. Recently, a dysregulated systemic immune response following musculoskeletal trauma has been identified as a contributing factor for poor outcomes and complications such as infections. In particular, myeloid-derived suppressor cells (MDSCs), immunosuppressive myeloid-lineage cells that expand in response to traumatic injury, have been highlighted as a potential therapeutic target to restore systemic immune homeostasis and ultimately improve functional bone regeneration. Previously, we have developed a novel immunomodulatory therapeutic strategy to deplete MDSCs using Janus gold nanoparticles that mimic the structure and function of antibodies. Here, in a preclinical delayed treatment composite injury model of bone and muscle trauma, we investigate the effects of these nanoparticles on circulating MDSCs, systemic immune profiles, and functional bone regeneration. Unexpectedly, treatment with the nanoparticles resulted in depletion of the high side scatter subset of MDSCs and an increase in the low side scatter subset of MDSCs, resulting in an overall increase in total MDSCs. This overall increase correlated with a decrease in bone volume (P = 0.057) at 6 weeks post-treatment and a significant decrease in mechanical strength at 12 weeks post-treatment compared to untreated rats. Furthermore, MDSCs correlated negatively with endpoint bone healing at multiple timepoints. Single cell RNA sequencing of circulating immune cells revealed differing gene expression of the SNAb target molecule S100A8/A9 in MDSC sub-populations, highlighting a potential need for more targeted approaches to MDSC immunomodulatory treatment following trauma. These results provide further insights on the role of systemic immune dysregulation for severe trauma outcomes in the case of non-unions and composite injuries and suggest the need for additional studies on targeted immunomodulatory interventions to enhance healing.
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Affiliation(s)
- Casey E Vantucci
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States of America.,Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, United States of America
| | - Tyler Guyer
- Knight Campus or Accelerating Scientific Impact, University of Oregon, Eugene, OR, United States of America
| | - Kelly Leguineche
- Knight Campus or Accelerating Scientific Impact, University of Oregon, Eugene, OR, United States of America
| | - Paramita Chatterjee
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, United States of America.,Marcus Center for Therapeutic Cell Characterization and Manufacturing, Georgia Institute of Technology, Atlanta, GA, United States of America
| | - Angela Lin
- Knight Campus or Accelerating Scientific Impact, University of Oregon, Eugene, OR, United States of America
| | - Kylie E Nash
- Knight Campus or Accelerating Scientific Impact, University of Oregon, Eugene, OR, United States of America
| | - Molly Ann Hastings
- Knight Campus or Accelerating Scientific Impact, University of Oregon, Eugene, OR, United States of America
| | - Travis Fulton
- The Atlanta Veterans Affairs Medical Center Atlanta, Decatur, GA, United States of America.,Department of Orthopaedics, Emory University, Atlanta, GA, United States of America
| | - Clinton T Smith
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States of America
| | - Drishti Maniar
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States of America.,Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, United States of America
| | - David A Frey Rubio
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States of America
| | - Kaya Peterson
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States of America
| | - Julia Andraca Harrer
- Knight Campus or Accelerating Scientific Impact, University of Oregon, Eugene, OR, United States of America
| | - Nick J Willett
- Knight Campus or Accelerating Scientific Impact, University of Oregon, Eugene, OR, United States of America.,The Atlanta Veterans Affairs Medical Center Atlanta, Decatur, GA, United States of America.,Department of Orthopaedics, Emory University, Atlanta, GA, United States of America
| | - Krishnendu Roy
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States of America.,Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, United States of America
| | - Robert E Guldberg
- Knight Campus or Accelerating Scientific Impact, University of Oregon, Eugene, OR, United States of America
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45
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Bumbaširević M, Matić S, Palibrk T, Glišović Jovanović I, Mitković M, Lesić A. Mangled extremity- Modern concepts in treatment. Injury 2021; 52:3555-3560. [PMID: 33766434 DOI: 10.1016/j.injury.2021.03.028] [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: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Abstract
A mangled extremity is the most devastating limb injury and presents a challenge for the orthopedic surgeon. There are two main treatment options, reconstruction or amputation, but sometimes indications for either are not clear. There are many pro and contra arguments for both options. To make the decision easier numerous score systems have been introduced, but the final decision is based on the judgment and experience of the treating surgeon. Early extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. The goal in reconstruction of a lower extremity is to restore and maintain balance and ambulation, while restoration of an upper extremity's numerous functions is more demanding. In this paper the authors describe and suggest treatment approaches in patients with a severely mangled extremity, including assessment and treatment of all injured tissues, using defined protocols, with special attention to bone stabilization, revascularization, soft-tissue coverage and nerve reconstruction. These have a great impact on the outcome and function of the injured extremity. Rehabilitation and return to the preinjury level is slow and sometimes uncertain.
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Affiliation(s)
- M Bumbaširević
- School of Medicine, University of Belgrade; Clinic for orthopedic surgery and traumatology, Clinical Centre of Serbia; Serbian Academy of Sciences and Arts, Belgrade
| | - S Matić
- School of Medicine, University of Belgrade; Clinic for orthopedic surgery and traumatology, Clinical Centre of Serbia
| | - T Palibrk
- School of Medicine, University of Belgrade; Clinic for orthopedic surgery and traumatology, Clinical Centre of Serbia
| | | | - M Mitković
- Clinic for orthopedic surgery and traumatology, Clinical Centre Nis
| | - A Lesić
- School of Medicine, University of Belgrade; Clinic for orthopedic surgery and traumatology, Clinical Centre of Serbia
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46
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Lumley ES, Ramsay G, Wohlgemut HS, Jansen JO. Complex lower limb trauma and reconstructive surgery: understanding health service resource use. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01803-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Roberts HJ, Donnelley CA, Haonga BT, Kramer E, Eliezer EN, Morshed S, Shearer D. Intramedullary nailing versus external fixation for open tibia fractures in Tanzania: a cost analysis. OTA Int 2021; 4:e146. [PMID: 34746677 PMCID: PMC8568384 DOI: 10.1097/oi9.0000000000000146] [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] [Received: 06/01/2020] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Open tibia fractures pose a clinical and economic burden that is disproportionately borne by low-income countries. A randomized trial conducted by our group showed no difference in infection and nonunion comparing 2 treatments: external fixation (EF) and intramedullary nailing (IMN). Secondary outcomes favored IMN. In the absence of clear clinical superiority, we sought to compare costs between EF and IMN. DESIGN Secondary cost analysis. SETTING Single institution in Tanzania. PATIENTS/PARTICIPANTS Adult patients with acute diaphyseal open tibia fractures who participated in a previous randomized controlled trial. INTERVENTION SIGN IMN versus monoplanar EF. MAIN OUTCOME MEASUREMENTS Direct costs of initial surgery and hospitalization and subsequent reoperation: implant, instrumentation, medications, disposable supplies, and personnel costs.Indirect costs from lost productivity of patient and caregiver.Societal (total) costs: sum of direct and indirect costs.All costs were reported in 2018 USD. RESULTS Two hundred eighteen patients were included (110 IMN, 108 EF). From a payer perspective, costs were $365.83 (95% CI: $332.75-405.76) for IMN compared with $331.25 ($301.01-363.14) for EF, whereas from a societal perspective, costs were $2664.59 ($1711.22-3955.25) for IMN and $2560.81 ($1700.54-3715.09) for EF. The largest drivers of cost were reoperation and lost productivity. Accounting for uncertainty in multiple variables, probabilistic sensitivity analysis demonstrated that EF was less costly than IMN from the societal perspective in only 55% of simulations. CONCLUSIONS Intramedullary nail fixation compared with external fixation of open tibia fractures in a resource-constrained setting is not associated with increased cost from a societal perspective.
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Affiliation(s)
- Heather J Roberts
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA
| | - Claire A Donnelley
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA
| | - Billy T Haonga
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Erik Kramer
- Yale University School of Medicine, New Haven, CT
| | | | - Saam Morshed
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA
| | - David Shearer
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA
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48
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Tillmann BW, Guttman MP, Nathens AB, de Mestral C, Kayssi A, Haas B. The timing of amputation of mangled lower extremities does not predict post-injury outcomes and mortality: A retrospective analysis from the ACS TQIP database. J Trauma Acute Care Surg 2021; 91:447-456. [PMID: 34039934 DOI: 10.1097/ta.0000000000003302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While limb salvage does not result in improved functional outcomes among patients with a mangled lower extremity, the impact of attempted limb salvage on mortality and complications is poorly understood. The objective of this study was to evaluate the relationship between attempted limb salvage and in-hospital outcomes among patients with a mangled lower extremity. METHODS We performed a retrospective cohort study of adults, 16 years or older, with a mangled lower extremity. Data were derived from the American College of Surgeons' Trauma Quality Improvement Program (2012-2017). We compared mortality, complications (severe sepsis, acute kidney injury [AKI], decubitus ulcers) and length of stay between patients managed with the intention of limb salvage (amputation beyond 24 hours or no amputation) and those who underwent early amputation (within 24 hours of presentation). Instrumental variable analysis was used to evaluate the relationship between management strategy and outcomes. RESULTS We identified 5,527 patients with a mangled lower extremity, of which 901 (16.3%) underwent early amputation. Among those managed with attempted limb salvage, 42.5% underwent amputation prior to discharge. After adjusting for patient and hospital characteristics, there was no association between initial management strategy and mortality (odds ratio, 1.20; 95% confidence interval [CI], 0.83-1.74 early amputation vs. attempted limb salvage). Early amputation was associated with lower odds of AKI (OR, 0.59; 95% CI, 0.39-0.88) and a trend toward shorter length of stay (relative risk, 0.77; 95% CI, 0.52-1.14). CONCLUSION Over half of patients who sustain a mangled lower extremity undergo amputation during their initial hospital course. While a limb salvage strategy is associated with an elevated risk of AKI, there is no association between attempted limb preservation and mortality. These findings suggest that in patients in which there is no clear indication for early amputation, attempts at limb salvage do not come at the cost of increased mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Affiliation(s)
- Bourke W Tillmann
- From the Institute of Health Policy, Management, and Evaluation (B.W.T., M.P.G., A.B.N., B.H.), University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine (B.W.T., B.H.), University of Toronto, Toronto, Ontario, Canada; Department of Critical Care Medicine (B.W.T., B.H.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery (M.P.G., A.B.N., C.dM., A.K., B.H.), University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute (A.B.N., A.K., B.H.), Toronto, Ontario, Canada; Division of Vascular Surgery (C.dM.), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; and Division of Vascular Surgery (A.K.), Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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49
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O'Toole RV, Joshi M, Carlini AR, Murray CK, Allen LE, Huang Y, Scharfstein DO, O'Hara NN, Gary JL, Bosse MJ, Castillo RC, Bishop JA, Weaver MJ, Firoozabadi R, Hsu JR, Karunakar MA, Seymour RB, Sims SH, Churchill C, Brennan ML, Gonzales G, Reilly RM, Zura RD, Howes CR, Mir HR, Wagstrom EA, Westberg J, Gaski GE, Kempton LB, Natoli RM, Sorkin AT, Virkus WW, Hill LC, Hymes RA, Holzman M, Malekzadeh AS, Schulman JE, Ramsey L, Cuff JAN, Haaser S, Osgood GM, Shafiq B, Laljani V, Lee OC, Krause PC, Rowe CJ, Hilliard CL, Morandi MM, Mullins A, Achor TS, Choo AM, Munz JW, Boutte SJ, Vallier HA, Breslin MA, Frisch HM, Kaufman AM, Large TM, LeCroy CM, Riggsbee C, Smith CS, Crickard CV, Phieffer LS, Sheridan E, Jones CB, Sietsema DL, Reid JS, Ringenbach K, Hayda R, Evans AR, Crisco MJ, Rivera JC, Osborn PM, Kimmel J, Stawicki SP, Nwachuku CO, Wojda TR, Rehman S, Donnelly JM, Caroom C, Jenkins MD, Boulton CL, Costales TG, LeBrun CT, Manson TT, Mascarenhas DC, Nascone JW, Pollak AN, Sciadini MF, Slobogean GP, Berger PZ, Connelly DW, Degani Y, Howe AL, Marinos DP, Montalvo RN, Reahl GB, Schoonover CD, Schroder LK, Vang S, Bergin PF, Graves ML, Russell GV, Spitler CA, Hydrick JM, Teague D, Ertl W, Hickerson LE, Moloney GB, Weinlein JC, Zelle BA, Agarwal A, Karia RA, Sathy AK, Au B, Maroto M, Sanders D, Higgins TF, Haller JM, Rothberg DL, Weiss DB, Yarboro SR, McVey ED, Lester-Ballard V, Goodspeed D, Lang GJ, Whiting PS, Siy AB, Obremskey WT, Jahangir AA, Attum B, Burgos EJ, Molina CS, Rodriguez-Buitrago A, Gajari V, Trochez KM, Halvorson JJ, Miller AN, Goodman JB, Holden MB, McAndrew CM, Gardner MJ, Ricci WM, Spraggs-Hughes A, Collins SC, Taylor TJ, Zadnik M. Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial. JAMA Surg 2021; 156:e207259. [PMID: 33760010 DOI: 10.1001/jamasurg.2020.7259] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Importance Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. Objective To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. Design, Setting, and Participants This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. Interventions A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. Main Outcomes and Measures The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. Results The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. Conclusions and Relevance Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. Trial Registration ClinicalTrials.gov Identifier: NCT02227446.
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Affiliation(s)
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Manjari Joshi
- Department of Infectious Diseases, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Anthony R Carlini
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Clinton K Murray
- Department of Medicine, San Antonio Military Medical Center, San Antonio, Texas
| | - Lauren E Allen
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yanjie Huang
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Daniel O Scharfstein
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nathan N O'Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Joshua L Gary
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Michael J Bosse
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Renan C Castillo
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center/University of Washington, Seattle
| | - Joseph R Hsu
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Madhav A Karunakar
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Rachel B Seymour
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Stephen H Sims
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Christine Churchill
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael L Brennan
- Department of Orthopaedic Surgery, Baylor Scott and White Memorial Center, Temple, Texas
| | - Gabriela Gonzales
- Department of Orthopaedic Surgery, Baylor Scott and White Memorial Center, Temple, Texas
| | - Rachel M Reilly
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Robert D Zura
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Cameron R Howes
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Hassan R Mir
- Florida Orthopaedic Institute/Tampa General Hospital, Tampa
| | - Emily A Wagstrom
- Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Jerald Westberg
- Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Greg E Gaski
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Laurence B Kempton
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Anthony T Sorkin
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Walter W Virkus
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Lauren C Hill
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Robert A Hymes
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Michael Holzman
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - A Stephen Malekzadeh
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Jeff E Schulman
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Lolita Ramsey
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Jaslynn A N Cuff
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Sharon Haaser
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Greg M Osgood
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Vaishali Laljani
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Olivia C Lee
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Peter C Krause
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Cara J Rowe
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Colette L Hilliard
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Massimo Max Morandi
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, Shreveport
| | - Angela Mullins
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, Shreveport
| | - Timothy S Achor
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Andrew M Choo
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - John W Munz
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Sterling J Boutte
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | | | - Mary A Breslin
- Department of Orthopaedics, MetroHealth, Cleveland, Ohio
| | - H Michael Frisch
- Orthopaedic Trauma Service, Mission Health, Asheville, North Carolina
| | - Adam M Kaufman
- Orthopaedic Trauma Service, Mission Health, Asheville, North Carolina
| | - Thomas M Large
- Orthopaedic Trauma Service, Mission Health, Asheville, North Carolina
| | - C Michael LeCroy
- Orthopaedic Trauma Service, Mission Health, Asheville, North Carolina
| | | | - Christopher S Smith
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Colin V Crickard
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Laura S Phieffer
- Department of Orthopaedics, Ohio State University, Wexner Medical Center, Columbus
| | - Elizabeth Sheridan
- Department of Orthopaedics, Ohio State University, Wexner Medical Center, Columbus
| | | | | | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Penn State Health, Hershey, Pennsylvania
| | - Kathy Ringenbach
- Department of Orthopaedics and Rehabilitation, Penn State Health, Hershey, Pennsylvania
| | - Roman Hayda
- Department of Orthopedic Surgery, Brown University/Rhode Island Hospital, Providence
| | - Andrew R Evans
- Department of Orthopedic Surgery, Brown University/Rhode Island Hospital, Providence
| | - M J Crisco
- Department of Orthopedic Surgery, Brown University/Rhode Island Hospital, Providence
| | - Jessica C Rivera
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Patrick M Osborn
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Joseph Kimmel
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Stanislaw P Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Chinenye O Nwachuku
- Department of Orthopedic Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Thomas R Wojda
- Department of Family Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Saqib Rehman
- Department of Orthopaedic Surgery and Sports Medicine, Temple University, Philadelphia, Pennsylvania
| | - Joanne M Donnelly
- Department of Orthopaedic Surgery and Sports Medicine, Temple University, Philadelphia, Pennsylvania
| | - Cyrus Caroom
- Department of Orthopaedics, Texas Tech University Health Sciences Center, Lubbock
| | - Mark D Jenkins
- Department of Orthopaedics, Texas Tech University Health Sciences Center, Lubbock
| | - Christina L Boulton
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Timothy G Costales
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Christopher T LeBrun
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Theodore T Manson
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Daniel C Mascarenhas
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Jason W Nascone
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Andrew N Pollak
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Marcus F Sciadini
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Gerard P Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Peter Z Berger
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Daniel W Connelly
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Yasmin Degani
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Andrea L Howe
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Dimitrius P Marinos
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Ryan N Montalvo
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - G Bradley Reahl
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Carrie D Schoonover
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Lisa K Schroder
- Department of Orthopaedic Surgery, University of Minnesota-Regions Hospital, St Paul
| | - Sandy Vang
- Department of Orthopaedic Surgery, University of Minnesota-Regions Hospital, St Paul
| | - Patrick F Bergin
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - Matt L Graves
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - George V Russell
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - Josie M Hydrick
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - David Teague
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City
| | - William Ertl
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City
| | - Lindsay E Hickerson
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City
| | - Gele B Moloney
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John C Weinlein
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, Memphis
| | - Boris A Zelle
- Department of Orthopaedics, University of Texas Health at San Antonio, San Antonio
| | - Animesh Agarwal
- Department of Orthopaedics, University of Texas Health at San Antonio, San Antonio
| | - Ravi A Karia
- Department of Orthopaedics, University of Texas Health at San Antonio, San Antonio
| | - Ashoke K Sathy
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Brigham Au
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Medardo Maroto
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Drew Sanders
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas
| | | | - Justin M Haller
- Department of Orthopaedics, University of Utah, Salt Lake City
| | | | - David B Weiss
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville
| | - Seth R Yarboro
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville
| | - Eric D McVey
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville
| | - Veronica Lester-Ballard
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville
| | - David Goodspeed
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison
| | - Gerald J Lang
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison
| | - Paul S Whiting
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison
| | - Alexander B Siy
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - A Alex Jahangir
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Basem Attum
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eduardo J Burgos
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cesar S Molina
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Vamshi Gajari
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karen M Trochez
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jason J Halvorson
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest Baptist University Medical Center, Winston-Salem, North Carolina
| | - Anna N Miller
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest Baptist University Medical Center, Winston-Salem, North Carolina
| | - James Brett Goodman
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest Baptist University Medical Center, Winston-Salem, North Carolina
| | - Martha B Holden
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest Baptist University Medical Center, Winston-Salem, North Carolina
| | - Christopher M McAndrew
- Department of Orthopedic Surgery, Washington University in St Louis/Barnes Jewish Hospital, St Louis, Missouri
| | - Michael J Gardner
- Department of Orthopedic Surgery, Washington University in St Louis/Barnes Jewish Hospital, St Louis, Missouri
| | - William M Ricci
- Department of Orthopedic Surgery, Washington University in St Louis/Barnes Jewish Hospital, St Louis, Missouri
| | - Amanda Spraggs-Hughes
- Department of Orthopedic Surgery, Washington University in St Louis/Barnes Jewish Hospital, St Louis, Missouri
| | - Susan C Collins
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Tara J Taylor
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mary Zadnik
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Masquelet technique for reconstructing bone defects in open lower limb fracture: Analysis of the relationship between bone defect and bone graft. Injury 2021; 52:988-995. [PMID: 33386161 DOI: 10.1016/j.injury.2020.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 11/06/2020] [Accepted: 12/13/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this study was to retrospectively analyze the experience of treating long segmental bone defects. Bone union was used as the criteria for the assessment of the quantitative relationship between tibial bone defects and bone grafts, which could help reduce the complication incidence in patients. METHODS A total of 45 patients with tibial bone defects treated with the Masquelet technique at the Ninth People's Hospital of Wuxi Affiliated to Soochow University between February 2013 and December 2017 were recruited. The age, sex, body mass index (BMI), complications, site of bone defect, length of bone defect, time from the first to the second stage of operation, and postoperative complications (including deep infection, absorption of bone graft, and bone union) were assessed. RESULTS Forty-two patients, including 17 males (40.5%) and 25 females (59.5%), with segmental bone defect, met the inclusion criteria. The mean age of the patients was 38.5 years (22-55 years). Nineteen patients (45.2%) underwent multiple traumas. The mean length of the bone defect was 6.3 cm. Six patients experienced complications, resulting in the incidence of complications of 14.3%. The relationship between the length of bone defect and volume of bone grafts was Y = 7.210 + 6.954 × X in patients treated with steel plates; Y = 10.962 + 5.029 × X for patients treated with intramedullary nails, and Y = 11.498 + 5.474 × X regardless of methods of internal fixation. CONCLUSION Masquelet technique is effective and safe for the treatment of long segmental tibial bone defects. The present study revealed the quantitative relationship between the size of bone defects and bone grafts, thus providing evidence for the selection of treatment strategies for long segmental bone defects in clinical practices, as well as helping to reduce the incidence of complications in Masquelet technique.
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