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Noorlander-Borgdorff MP, Kievit W, Giannakópoulos GF, Botman M, Tromp TN, Oflazoglu K, Rakhorst HA, de Jong T. The economic impact of open lower limb fractures in the Netherlands: a cost-of-illness study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02637-1. [PMID: 39187598 DOI: 10.1007/s00068-024-02637-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 08/06/2024] [Indexed: 08/28/2024]
Abstract
PURPOSE To estimate the one-year sum of direct costs related to open lower limb fracture treatment in an academic setting in the Netherlands. The secondary objective was to estimate the impact of deep infection and nonunion on one-year total direct costs. METHODS A multi-center, retrospective cost analysis of open lower limb fractures treated in an academic setting in the Netherlands, between 1 January 2017 and 31 December 2018, was conducted. The costing methodology was based on patient level aggregation using a bottom-up approach. A multiple linear regression model was used to predict the total costs based on Fracture-related-infections, multitrauma, intensive care unit (ICU) admission, Gustilo-Anderson grade and nonunion. RESULTS Overall, 70 fractures were included for analysis, the majority Gustilo-Anderson grade III fractures (57%). Median (IQR) one-year hospital costs were €31,258 (20,812-58,217). Costs were primarily attributed to the length of hospital stay (58%) and surgical procedures (30%). The median length of stay was 16 days, with an increase to 50 days in Fracture-related infections. Subsequent costs (46,075 [25,891-74,938] vs. 15,244 [8970-30,173]; p = 0.002), and total hospital costs (90,862 [52,868-125,004] vs. 29,297 [21,784-40,677]; p < 0.001) were significantly higher for infected cases. It was found that Fracture-related infection, multitrauma, and Gustilo-Anderson grade IIIA-C fractures were significant predictors of increased costs. CONCLUSION In treatment of open lower limb fractures, deep infection, higher Gustilo-Anderson classification, and multitrauma significantly increase direct hospital costs. Considering the impact of infection on morbidity and total healthcare costs, future research should focus on preventing Fracture-related infections.
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Affiliation(s)
- M P Noorlander-Borgdorff
- Department of Plastic, Reconstructive, and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands.
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - W Kievit
- Department for Health Evidence, Radboud University Medical Center, IQ Healthcare, Nijmegen, The Netherlands
| | - G F Giannakópoulos
- Trauma Unit, Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - M Botman
- Department of Plastic, Reconstructive, and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - T N Tromp
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - K Oflazoglu
- Department of Plastic, Reconstructive, and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - H A Rakhorst
- Department of Plastic, Reconstructive and Hand Surgery, Medisch Spectrum Twente, ZGT Almelo, Enschede, The Netherlands
| | - T de Jong
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Haidari S, Buijs MAS, Plate JDJ, Zomer JJ, IJpma FFA, Hietbrink F, Govaert GAM. Costs of fracture-related infection: the impact on direct hospital costs and healthcare utilisation. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02497-9. [PMID: 38592465 DOI: 10.1007/s00068-024-02497-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/10/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE Fracture-Related Infection (FRI) is associated with high medical costs and prolonged healthcare utilization. However, limited data is available on the financial impact. The purpose of this study was to investigate the impact of FRI on direct hospital costs and healthcare utilization. METHODS This was a retrospective cohort study in a level-1 trauma centre in the Netherlands. Patients ≥ 18 years, after open reduction and internal fixation of a long bone fracture between January 1st 2016 and November 1st 2021, were included. Exclusion criteria were Injury Severity Score (ISS) ≥ 16, indefinable data on costs or incomplete follow-up. Hospital costs related to fracture treatment were individually calculated based on procedure codes raised with a fixed percentage of overhead expenses, in line with hospital billing policies. RESULTS In total, 246 patients were included with a median follow-up of 1 year (IQR 0.6-1.8). A total of 45 patients developed FRI, of whom 15 patients had an FRI recurrence. Compared to non-FRI patients, median hospital costs from an FRI patient without and with recurrence, were respectively three (3.1) and seven (7.6) times higher. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries, and 21 or 55 days of intravenous antibiotic treatment. CONCLUSION Direct healthcare costs of patients with single occurrence of FRI after long bone fracture treatment are three times higher compared to non-FRI patients. In case of FRI-recurrence, the differences in costs might even increase to sevenfold. To put this in perspective, cost of severely injured trauma patients were recently established at approximately 25.000 euros. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries and 21 or 55 days of intravenous antibiotic treatment. Not only from patient perspective but also from a financial aspect, it is important to focus on prevention of (recurrent) FRI.
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Affiliation(s)
- S Haidari
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M A S Buijs
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J D J Plate
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Tilburg, The Netherlands
| | - J J Zomer
- Finance Department, University Medical Centre Utrecht, Utrecht, The Netherlands
- Finance Department, Wageningen University and Research, Wageningen, The Netherlands
| | - F F A IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - F Hietbrink
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - G A M Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
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Hutaif M, Issa MAN, Humaid H. Assessing the effectiveness of intramedullary nailing for tibial shaft fractures in a low-income setting: a prospective study in Yemen. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:995-1002. [PMID: 37828298 DOI: 10.1007/s00590-023-03753-1] [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: 07/16/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Tibial shaft fractures are common injuries that can be treated with various methods, including interlocked intramedullary nail (IMN). However, there is limited data on the clinical outcomes of IMN for tibial shaft fractures in Yemen. OBJECTIVE To evaluate the clinical outcomes of primary IMN for tibial shaft fractures in Yemen. METHODS This was a prospective study of 134 patients who underwent primary IMN for tibial shaft fractures et al.-Thawra Modern General Hospital in Sana'a, Yemen, between June 2016 and June 2020. The patients were between 18 and 70 years old, and the fractures were classified according to the AO classification system. The fractures were treated with IMN using a standard technique. The patients were followed up for a minimum of 2 years. The outcome measures included union time, complications, and functional scores. RESULTS The mean union time was 17 weeks. The overall complication rate was 18.7%. The most common complications were infection (8.2%), delayed union (6.7%), and nonunion (3.7%). The mean functional scores at the final follow-up were 91.4 for the Knee Society Score and 90.2 for the American Orthopaedic Foot and Ankle Society Score. CONCLUSION Primary IMN is an effective and reliable method for treating tibial shaft fractures in Yemen, with acceptable union time, complication rate, and functional outcomes.
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Affiliation(s)
| | | | - Hakim Humaid
- Orthopedic Department, Sanaa University, Sanaa, Yemen.
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Gitajn IL, Werth PM, Carlini AR, Bosse MJ, Gary JL, Firoozabadi R, Obremskey W, McKinley TO, Castillo RC, O’Toole RV. Deep Surgical Site Infection after Fracture Has a Profound Effect on Functional Outcomes. JB JS Open Access 2024; 9:e23.00042. [PMID: 38196850 PMCID: PMC10773708 DOI: 10.2106/jbjs.oa.23.00042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
Background Fracture-related infection is one of the most challenging complications in orthopaedic trauma surgery. However, the effect of infection on functional and pain-related outcomes has not been well established. The aims of this study were to evaluate functional recovery for patients with fracture and a deep surgical site infection compared with patients with fracture without infection and to evaluate whether pain severity, social support, and preinjury mental health have a moderating effect on the magnitude and direction of the relationship between deep surgical site infection and functional recovery. Methods This is a secondary retrospective cohort study using prospectively collected data from the VANCO trial (Local Antibiotic Therapy to Reduce Infection After Operative Treatment of Fractures at High Risk of Infection) and the OXYGEN (Supplemental Perioperative Oxygen to Reduce Surgical Site Infection After High Energy Fracture Surgery) trial. In this study, 2,116 patients with tibial plateau, pilon, or calcaneal fractures at high risk for infection were included. Patients were divided into cohorts of patients who experienced a deep surgical site infection and those who did not. The primary outcome measure was the functional outcome using the Veterans RAND 12-Item Health Survey (VR-12). Results After controlling for covariates, deep surgical site infection was independently associated with functional outcome, with a 3.3-point reduction in the VR-12 Physical Component Score, and pain severity was independently associated with functional outcome, with a 2.5-point reduction in the VR-12 Physical Component Score. Furthermore, the Brief Pain Inventory pain severity demonstrated an important moderating effect on the relationship between infection and functional outcome. In patients with lower pain scores, infection had a large negative impact on functional outcome, whereas, in patients with higher pain scores, infection had no significant impact on functional outcome. Furthermore, the functional outcome in the entire cohort remains at only 61% of baseline. Conclusions This study documents the negative impact of postoperative infection on functional recovery after injury, as well as the novel finding of pain severity as an important moderating factor. This study emphasizes not only the importance of developing effective interventions designed to reduce postoperative infection, but also the role that factors that moderate pain severity plays in limiting recovery of physical function. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Paul M. Werth
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Michael J. Bosse
- Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Joshua L. Gary
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Reza Firoozabadi
- University of Washington Harborview Medical Center, Seattle, Washington
| | | | - Todd O. McKinley
- Indiana University School of Medicine, Indianapolis, Indiana and
| | - Renan C. Castillo
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Jana Neto FC, Martimbianco ALC, de Medeiros DV, Felix FC, Mesquita-Ferrari RA, Bussadori SK, Duran CCG, Motta LJ, Barbosa EC, Fernandes KPS. Cost analysis of photobiomodulation in tibia fracture in the Brazilian public health system. PLoS One 2023; 18:e0294290. [PMID: 38064443 PMCID: PMC10707925 DOI: 10.1371/journal.pone.0294290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/28/2023] [Indexed: 12/18/2023] Open
Abstract
Managing tibial fractures requires substantial health resources, which costs the health system. This study aimed to describe the costs of photobiomodulation (PBM) with LEDs in the healing process of soft tissue lesions associated with tibial fracture compared to a placebo. Economic analysis was performed based on a randomized controlled clinical trial, with a simulation of the cost-effectiveness and incremental cost model. Adults (n = 27) hospitalized with tibia fracture awaiting definitive surgery were randomized into two distinct groups: the PBM Group (n = 13) and the Control Group with simulated phototherapy (n = 14). To simulate the cost-effectiveness and incremental cost model, the outcome was the evolution of wound resolution by the BATES-JENSEN scale and time of wound resolution in days. The total cost of treatment for the Control group was R$21,164.56, and a difference of R$7,527.10 more was observed when compared to the treatment of the PBM group. The proposed intervention did not present incremental cost since the difference in the costs to reduce measures between the groups was smaller for the PBM group. When analyzing the ICER (Incremental cost-effectiveness ratio), it would be possible to save R$3,500.98 with PBM and decrease by 2.15 points in the daily average on the BATES-JENSEN scale. It is concluded, therefore, that PBM can be a supportive therapy of clinical and economic interest in a hospital setting.
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Affiliation(s)
- Frederico Carlos Jana Neto
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
- Orthopedics and Traumatology Group Conjunto Hospitalar do Mandaqui, São Paulo, SP, Brazil
- Medicine School Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
| | - Ana Luiza Cabrera Martimbianco
- Postgraduate Program in Health and Environment. Universidade Metropolitana de Santos (UNIMES), Santos, SP, Brazil
- Health Technology Assessment Center, Hospital Sírio-Libanês (NATS-HSL), São Paulo, SP, Brazil
| | | | | | - Raquel Agnelli Mesquita-Ferrari
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
- Postgraduate Program in Rehabilitation Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
| | - Sandra Kalil Bussadori
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
- Postgraduate Program in Rehabilitation Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
| | - Cinthya Cosme Gutierrez Duran
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
- Postgraduate Program in Medicine, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
| | - Lara Jansiski Motta
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
| | - Estela Capelas Barbosa
- Population Health Sciences, Bristol Medical School, Bristol University, Bristol, United Kingdom
| | - Kristianne Porta Santos Fernandes
- Postgraduate Program in Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
- Postgraduate Program in Medicine, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
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Woffenden H, Yasen Z, Burden E, Douthwaite A, Elcock SB, Mclean L, Hoven PJV, Fenton P. Fracture-related infection: Analysis of healthcare utilisation and associated costs. Injury 2023; 54:111109. [PMID: 37871348 DOI: 10.1016/j.injury.2023.111109] [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: 04/13/2023] [Revised: 09/16/2023] [Accepted: 10/05/2023] [Indexed: 10/25/2023]
Abstract
AIMS A consensus definition of fracture related infection (FRI) has been created with the aim of standardising diagnosis and eliminating heterogeneity that prevents accurate comparison between existing studies. FRI remains one of the most challenging complications in musculoskeletal trauma surgery and carries with it a significant cost burden. A review of UK finances has not been completed utilising consensus diagnostic criteria. The goal of this study was to investigate the hospital-associated healthcare cost related to the treatment of FRI within an NHS major trauma centre. METHOD Through retrospective case-control analysis, 1240 patients with close fractures were identified. Of those, 21 patients with FRI were compared to 63 uninfected patients. Patients were matched based on fracture location, type of procedure and proximity in age. The costs assessed included hospitalisation, imaging, outpatient consultation, pharmaceuticals and procedure charges. Cost data was retrieved from healthcare resource group (HRG) guidelines, NHS Business Service Authority's (NBSA) prescription rates and internal costing. RESULTS The FRI group were found to incur a 2.51 increase in total medial healthcare cost compared to the control group (£22,058 vs £8798 [p < 0.001]), which was primarily due to increased procedural costs (£13,020 vs £6291 [p < 0.001]) and length of hospital stay (£7552 vs £2124 [p < 0.001]). CONCLUSION Whilst diagnosis of FRI has a more rigorous definition following the new consensus, prevalence and cost outcomes are similar to previous studies. Given the deficiency in funding and ongoing challenges of resource allocation to the NHS, it is prudent to incorporate studies such as this into stratifying departmental budgets and quality improvement. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Hugo Woffenden
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom.
| | - Zaid Yasen
- The Royal London Hospital, Whitechapel Rd, London E1 1FR, United Kingdom
| | - Eleanor Burden
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom
| | - Anna Douthwaite
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom
| | - S B Elcock
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom
| | - Lucille Mclean
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom
| | - Peter James von Hoven
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom
| | - Paul Fenton
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom
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Vargas-Hernández JS, Sánchez CA, Renza S, Leal JA. Effectiveness of antibiotic-coated intramedullary nails for open tibia fracture infection prevention. A systematic review and meta-analysis. Injury 2023; 54 Suppl 6:110857. [PMID: 38143139 DOI: 10.1016/j.injury.2023.110857] [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: 02/28/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Open Tibia fractures are associated with high rates of Fracture Related Infection (FRI). Given the negative outcomes and increased costs related to the latter, several prophylactic local antibiotic delivery methods have been proposed, aiming to decrease the FRI rate. Our objective with this study was to determine the effectiveness of antibiotic-coated intramedullary nails for open tibia FRI prevention. PATIENTS AND METHODS We conducted a PRISMA compliant systematic review and meta-analysis. Queries were performed on Embase, PubMed, Lilacs and Cochrane data libraries. Seventeen studies were included for qualitative analysis and 2 studies were amenable for meta-analysis. RESULTS Global infection, deep infection and non-union rates were 8.4%, 5.4% and 3.7% in the antibiotic-coated nail group and 22%, 14% and 14% in the non-antibiotic-coated nail group respectively. The meta-analysis showed a protective trend that favored the antibiotic-coated nail group although it didn't achieve statistical significance: deep infection Relative Risk (RR) (RR = 0.17 CI95% [0.02 - 1.31]); global infection RR = 0.36 CI95% [0.10 - 1.35]) and non-union (RR = 0.14 CI95% [0.02 - 1.22]), CONCLUSIONS: Our findings suggest a favorable trend towards antibiotic-coated nail, with decreased risk of global infection, deep infection and non-union as compared to non-antibiotic-coated nail in patients with open tibia fractures. Nonetheless, higher level evidence studies are required to confirm our findings.
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Affiliation(s)
| | - Carlos A Sánchez
- Department of Orthopedic Surgery, Hospital Universitario de la Samaritana, Bogotá, Colombia
| | - Stephanie Renza
- Department of Orthopedic Surgery, Hospital Universitario de la Samaritana, Bogotá, Colombia
| | - Jaime Andrés Leal
- Department of Orthopedic Surgery, Hospital Universitario de la Samaritana, Bogotá, Colombia
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Zamorano ÁI, Albarrán CF, Vaccia MA, Parra RI, Turner T, Rivera IA, Garrido OA, Suárez PF, Zecchetto P, Bahamonde LA. Gentamicincoated tibial nail is an effective prevention method for fracture-related infections in open tibial fractures. Injury 2023; 54 Suppl 6:110836. [PMID: 38143136 DOI: 10.1016/j.injury.2023.05.067] [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: 02/28/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 12/26/2023]
Abstract
Fracture-related infection (FRI) is a common complication following open tibia fracture (OTF), especially in patients with high-energy trauma or comorbidities. The use of gentamicin-coated nail (GCN) has been proposed as a local adjuvant to prevent FRI in high-risk patients. HYPOTHESIS The incidence of FRI is expected to be lower in OTF treated with a GCN, alongside with no detrimental effects on fracture healing time. OBJECTIVES This study aimed to evaluate the effectiveness of GCNs as a definitive fixation method and prophylaxis for FRI in OTFs. Secondary outcomes included non-union rates and time to healing. METHODS The study design was a mixed cohort, including a prospective group of patients treated with GCN (Expert Tibial Nail PROtect™, Depuy Synthes, Johnson&Johnson Company Inc, New Jersey, USA) and a retrospectively evaluated group treated with non-gentamicin-coated nail (NGCN). Patients with at least 12 months of follow-up were included. The treatment protocol consisted of timely administration of antibiotics, surgical debridement, and early soft-tissue coverage. Exclusion criteria included protocol infringement, traumatic amputation, and loss of follow-up. Statistical analysis was performed using Stata v14.0, with a significance level of p < 0.05. RESULTS The study included 243 patients, 104 in GCN group and 139 NGCN group. External Fixator use was higher in the NGCN group, but this did not significantly affect the FRI rate. GCN use was associated with a significantly lower incidence of FRI (2.88% GCN group vs. 15.83% NGCN group, OR 0.16, p < 0.01). Furthermore, GCN use was found to be a protective factor against tibial non-union (OR 0.41, p = 0.03). There were no adverse effects attributed to locally administered gentamycin. The NGCN cohort had a higher incidence of polytrauma, although the difference was not statistically significant. A longer time to heal as well as more FRI and Non-union according to the progression in Gustilo-Anderson classification was observed in the GCN group. CONCLUSION Our findings suggest that GCN is an effective prophylactic method to reduce the risk of FRI in open tibial fractures at 12-month follow-up, as well as, probably derived from this protective effect, leading to lower fracture consolidation times when compared with cases treated without GCN.
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Affiliation(s)
- Álvaro I Zamorano
- Head of Lower Extremities Trauma Unit, Orthopaedic and Traumatology Service, Hospital Clínico Mutual de Seguridad, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile; University of Chile Clinical Hospital, Orthopaedic Surgery Service Attending, Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile.
| | - Carlos F Albarrán
- Orthopaedic and Traumatology Resident, Medical School, University of Chile, Postgraduate School. Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile
| | - Matías A Vaccia
- University of Chile Clinical Hospital, Orthopaedic Surgery Service Attending, Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile; Lower Extremities Trauma Unit Staff, Orthopaedic and Traumatology Service, Hospital Clínico Mutual de Seguridad, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile
| | - Rodrigo I Parra
- Lower Extremities Trauma Unit Intern, Hospital Clínico Mutual de Seguridad, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile
| | - Tomás Turner
- Lower Extremities Trauma Unit Intern, Hospital Clínico Mutual de Seguridad, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile
| | - Ignacio A Rivera
- Emergency Department Mutual de Seguridad Clinical Hospital, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile
| | - Osvaldo A Garrido
- University of Chile Clinical Hospital, Orthopaedic Surgery Service Attending, Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile
| | - Pablo F Suárez
- University of Chile Clinical Hospital, Orthopaedic Surgery Service Attending, Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile
| | - Pierluca Zecchetto
- University of Chile Clinical Hospital, Orthopaedic Surgery Service Attending, Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile; Lower Extremities Trauma Unit Staff, Orthopaedic and Traumatology Service, Hospital Clínico Mutual de Seguridad, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile
| | - Luis A Bahamonde
- Lower Extremities Trauma Unit Staff, Orthopaedic and Traumatology Service, Hospital Clínico Mutual de Seguridad, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile; Chairman, Orthopaedic and Traumatology Service, University of Chile Clinical Hospital, Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile
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Valderrama-Molina CO, Pesántez R. Fracture-Related infection - the role of the surgeon and surgery in prevention and treatment. J Orthop Surg (Hong Kong) 2022; 30:10225536221118520. [PMID: 36545936 DOI: 10.1177/10225536221118520] [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] [Indexed: 12/24/2022] Open
Abstract
Fracture-related infection (FRI) is a complication that impacts care costs, quality of life, and patient function. Great strides have been made in the last decade to obtain a common language for definition and diagnosis with the contribution of the Fracture-Related Infection Consensus. Although FRI treatment requires the participation of clinical specialists in infectious diseases for the management of antibiotics, it is necessary to understand that this complication is an eminently surgical pathology. The orthopedic surgeon must play a leadership role in the prevention and treatment of this complex disease. In this review, the most relevant aspects of prevention are updated, and a strategy for a sequential and comprehensive approach to the patient with this complication is presented.
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Affiliation(s)
| | - Rodrigo Pesántez
- Department of Orthopedics and Traumatology, 173061Fundación Santa Fe de Bogotá, Bogotá, Colombia
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Healthcare resource use and costs related to surgical infections of tibial fractures in a Spanish cohort. PLoS One 2022; 17:e0277482. [DOI: 10.1371/journal.pone.0277482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 10/27/2022] [Indexed: 11/13/2022] Open
Abstract
Surgical site infection constitutes a serious complication in the healing process of bone fractures and has been associated with increases in medical resource use and healthcare costs. This study evaluates the economic impact of surgical site infection in tibial fractures in a Spanish cohort. It is a retrospective, single-centre, comparative cohort study of patients with tibial fractures with longitudinal follow-up for up to 18 months post-surgery. Included patients (n = 325) were adults, with tibial fracture, either isolated or polyfracture, or polytrauma with an Injury Severity Score >15. Patients had been surgically treated within 30 days of the tibial fracture by external or internal fixation, or external followed by internal fixation. Most patients (84.9%) had an American Society of Anaesthesiology score of 1–2. 20% of the patients had one open tibial fracture, 12.3% had polytrauma, and 20% had multiple fractures. Most patients were treated with a nail (41.8%) or a plate (33.8%). 56 patients (17.2%) developed surgical site infection. Patients with infection had significantly higher hospital length of stay (34.9 vs 12.0 days; p<0.001; +191%), readmissions (1.21 vs 0.25; p<0.001; +380%) and mean operating theatre time (499 vs 219 min; p<0.001; +128%) than patients without infection. Mean length of stay in intensive care did not significantly increase with infection (2.8 vs 1.7 days; p = 0.25). Total in-hospital costs for patients with infection increased from €7,607 to €17,538 (p<0.001; +131%). Overall, infections were associated with significantly increased healthcare resource use and costs. Preventive strategies to avoid infections could lead to substantial cost savings.
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Muacevic A, Adler JR. The Impact of Sterile Instrument Set Wrapping Defects on Trauma and Orthopaedic Surgery Theatre Lists. Cureus 2022; 14:e29861. [PMID: 36337817 PMCID: PMC9628278 DOI: 10.7759/cureus.29861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Surgical site infections (SSIs) are a universally dreaded complication of any surgical procedure. The goal of this single-center study was to examine the issue of orthopaedic instrument wrapping defects with a focus on the importance of a high level of surveillance to enable identification of these defects in order to reduce the risk of instrument contamination. We also evaluated the impact on patient care, theatre staff, hospital finances and resource utilization during a defined study period in order to stimulate critical discussion and further research into potentially eliminating this problem via change in practice and advances in technology. To the best of our knowledge, this will be the first paper that looks at this problem from the above perspective within the United Kingdom National Health Service. Methods We conducted a prospective service evaluation project over a 30-week period from December 2021 to July 2022 across our three hospital sites within the United Kingdom National Health Service. We collated data on defects found in orthopaedic instrument wrappings as detected by visual inspection under ambient or theater lighting and the resulting surgical case cancellations. Defect types included in the study were all puncture holes, abrasions or tears visible to the naked eye irrespective of their size. Results A total of 601 orthopaedic sets were rejected during the study period due to defects identified in the sterile instrument wrappings. Of these, 437 were due to holes/tears in the wrapping, 129 were due to wet inner wrappings and 35 were due to insecure wrappings. This directly resulted in same-day cancellation of 13 surgical cases or 0.27% of booked cases with extra sets required for the other affected cases. These 13 cases could not proceed as they involved loan kits where no remedial action could be taken. Remedial action was required for the other 588 operation list cases affected by the sterile wrapping defects. The majority of the identified defects and resulting theatre case cancellations (61.5%) were in hip and knee arthroplasty surgery. The calculated potential financial loss due to these problems was £145,000 over the seven-month study period. This financial cost is equivalent to the best practice top-up tariff in England for treating approximately 108 hip fracture patients based on £1,335 per patient. Conclusion Our study identified defects in the sterile instrument wrappings affecting both the inner with or without involving the outer wrapping layer and resulting in cancellation of elective and trauma orthopaedic cases with resultant clinical and financial implications. There is a need to be more vigilant in identifying defects in drapes. Further research is warranted to improve ways of identifying defects in sterile wrappings and devise new protective mechanisms during sterilisation that can eliminate the use of sterile instrument wrappings.
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Wu Z, Chan B, Low J, Chu JJH, Hey HWD, Tay A. Microbial resistance to nanotechnologies: An important but understudied consideration using antimicrobial nanotechnologies in orthopaedic implants. Bioact Mater 2022; 16:249-270. [PMID: 35415290 PMCID: PMC8965851 DOI: 10.1016/j.bioactmat.2022.02.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 12/11/2022] Open
Abstract
Microbial resistance to current antibiotics therapies is a major cause of implant failure and adverse clinical outcomes in orthopaedic surgery. Recent developments in advanced antimicrobial nanotechnologies provide numerous opportunities to effective remove resistant bacteria and prevent resistance from occurring through unique mechanisms. With tunable physicochemical properties, nanomaterials can be designed to be bactericidal, antifouling, immunomodulating, and capable of delivering antibacterial compounds to the infection region with spatiotemporal accuracy. Despite its substantial advancement, an important, but under-explored area, is potential microbial resistance to nanomaterials and how this can impact the clinical use of antimicrobial nanotechnologies. This review aims to provide a better understanding of nanomaterial-associated microbial resistance to accelerate bench-to-bedside translations of emerging nanotechnologies for effective control of implant associated infections.
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Affiliation(s)
- Zhuoran Wu
- Institute of Health Innovation & Technology, National University of Singapore, 117599, Singapore
| | - Brian Chan
- Department of Biomedical Engineering, National University of Singapore, 117583, Singapore
| | - Jessalyn Low
- Department of Biomedical Engineering, National University of Singapore, 117583, Singapore
| | - Justin Jang Hann Chu
- Biosafety Level 3 Core Facility, Yong Loo Lin School of Medicine, National University of Singapore, 117599, Singapore
- Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore, 117545, Singapore
- Infectious Disease Programme, Yong Loo Lin School of Medicine, National University of Singapore, 117547, Singapore
- Institute of Molecular and Cell Biology, 35 Agency for Science, Technology and Research, 138673, Singapore
| | - Hwee Weng Dennis Hey
- National University Health System, National University of Singapore, 119228, Singapore
| | - Andy Tay
- Institute of Health Innovation & Technology, National University of Singapore, 117599, Singapore
- Department of Biomedical Engineering, National University of Singapore, 117583, Singapore
- Tissue Engineering Programme, National University of Singapore, 117510, Singapore
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Saiz AM, Stwalley D, Wolinsky P, Miller AN. Patient Comorbidities Associated With Acute Infection After Open Tibial Fractures. J Am Acad Orthop Surg Glob Res Rev 2022; 6:e22.00196. [PMID: 36155604 PMCID: PMC9512323 DOI: 10.5435/jaaosglobal-d-22-00196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Open tibial shaft fractures are high-risk injuries for developing acute infection. Prior research has focused on injury characteristics and treatment options associated with acute inpatient infection in these injuries without primary analysis of host factors. The purpose of this study was to determine the patient comorbidities associated with increased risk of acute infection after open tibial shaft fractures during initial hospitalization. METHODS A total of 147,535 open tibial shaft fractures in the National Trauma Data Bank from 2007 to 2015 were identified that underwent débridement and stabilization. Infection was defined as a superficial surgical site infection or deep infection that required subsequent treatment. The International Classification of Diseases, ninth revision codes were used to determine patient comorbidities. Comparative statistical analyses including odds ratios (ORs) for patient groups who did develop infection and those who did not were conducted for each comorbidity. RESULTS The rate of acute inpatient infection was 0.27% with 396 patients developing infection during hospital management of an open tibial shaft fracture. Alcohol use (OR, 2.26, 95% confidence interval [CI], 1.73-2.96, P < 0.0001), bleeding disorders (OR, 4.50, 95% CI, 3.13-6.48, P < 0.0001), congestive heart failure (OR, 3.25, 95% CI, 1.97-5.38, P < 0.0001), diabetes (OR, 1.73, 95% CI, 1.29-2.32, P = 0.0002), psychiatric illness (OR, 2.17, 95% CI, 1.30-3.63, P < 0.0001), hypertension (OR, 1.56, 95% CI, 1.23-1.95, P < 0.0001), obesity (OR, 3.05, 95% CI, 2.33-3.99, P < 0.0001), and chronic obstructive pulmonary disease (OR, 2.09, 95% CI, 1.51-2.91, P < 0.0001) were all associated with increased infection rates. Smoking (OR, 0.957, 95% CI, 0.728-1.26, P = 0.722) and drug use (OR, 1.11, 95% CI, 0.579-2.11, P = 0.7607) were not associated with any difference in infection rates. DISCUSSION Patients with open tibial shaft fractures who have congestive heart failure, bleeding disorders, or obesity are three to 4.5 times more likely to develop an acute inpatient infection than patients without those comorbidities during their initial hospitalization. Patients with diabetes, psychiatric illness, hypertension, or chronic obstructive pulmonary disease are 1.5 to 2 times more likely to develop subsequent infection compared with patients without those comorbidities. Patients with these comorbidities should be counseled about the increased risks. Furthermore, risk models for the infectious complications after open tibial shaft fractures can be developed to account for this more at-risk patient population to serve as modifiers when evaluating surgeon/hospital performance. CONCLUSION Patient comorbidities are associated with increased risk of acute inpatient infection of open tibial shaft fractures during hospitalization.
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Affiliation(s)
- Augustine M. Saiz
- From the Department of Orthopaedic Surgery, UC Davis Health, Sacramento, CA (Dr. Saiz, Jr and Dr. Wolinsky); the Department of Medicine, Washington University in St. Louis, St. Louis, MO (Mr. Stwalley); and the Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Miller)
| | - Dustin Stwalley
- From the Department of Orthopaedic Surgery, UC Davis Health, Sacramento, CA (Dr. Saiz, Jr and Dr. Wolinsky); the Department of Medicine, Washington University in St. Louis, St. Louis, MO (Mr. Stwalley); and the Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Miller)
| | - Philip Wolinsky
- From the Department of Orthopaedic Surgery, UC Davis Health, Sacramento, CA (Dr. Saiz, Jr and Dr. Wolinsky); the Department of Medicine, Washington University in St. Louis, St. Louis, MO (Mr. Stwalley); and the Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Miller)
| | - Anna N. Miller
- From the Department of Orthopaedic Surgery, UC Davis Health, Sacramento, CA (Dr. Saiz, Jr and Dr. Wolinsky); the Department of Medicine, Washington University in St. Louis, St. Louis, MO (Mr. Stwalley); and the Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Miller)
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Patel KH, Galanis A, Balasubramanian P, Iliadis AD, Heidari N, Vris A. A major trauma centre experience with gentamicin-coated tibial intramedullary nails (ETN PROtect™) in acute primary open fracture fixation and complex revision surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03338-4. [PMID: 35943591 DOI: 10.1007/s00590-022-03338-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Fracture-related infections (FRI) following intramedullary nailing for tibial shaft fractures remain challenging to treat with associated high patient morbidity and health care costs. Recently, antibiotic-coated nails have been introduced as a strategy to reduce implant related infection rates in high-risk patients. We present the largest single-centre case series on ETN PROtect® outcomes reporting on fracture union, infection rates and treatment complications. METHODS Fifty-six adult patients underwent surgery with ETN PROtect® between 01/09/17 and 31/12/20. Indications consisted of acute open fractures and complex revision cases (previous FRI, non-union surgery and re-fracture) with a mean of three prior surgical interventions. We report on patient demographics, union rates and deep infection. Minimum follow-up was one year. RESULTS One (1.8%) patient developed a deep surgical infection and associated non-union requiring further surgery. In addition, we identified three cases (5.4%) of aseptic non-union following facture treatment with ETN PROtect®. Of the five patients who underwent staged complex revision surgery for established FRI with ETN PROtect®, all had treatment failure with ongoing symptoms of deep infection requiring implant removal and further treatment. CONCLUSION Use of the ETN PROtect® nail in high-risk patients (open fractures and those initially treated with external fixation) and in those patients with aseptic non-unions, demonstrates promising outcomes in the prevention of implant-related infection. In our limited series we have failed to observe any benefit over uncoated nails, when used in treating cases of previously established FRI/osteomyelitis and would therefore advise caution in their use, especially in view of the high cost.
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Affiliation(s)
- Kavi H Patel
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK.
| | | | - Prabu Balasubramanian
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - Alexios D Iliadis
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - Nima Heidari
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - Alex Vris
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
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15
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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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16
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Bhanushali A, Kovoor JG, Stretton B, Kieu JT, Bright RA, Hewitt JN, Ovenden CD, Gupta AK, Afzal MZ, Edwards S, Jaarsma RL, Graff C. Outcomes of early versus delayed weight-bearing with intramedullary nailing of tibial shaft fractures: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2022; 48:3521-3527. [PMID: 35238986 PMCID: PMC9532312 DOI: 10.1007/s00068-022-01919-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/12/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Early weight bearing (EWB) is often recommended after intramedullary nailing of tibial shaft fractures, however, the risks and benefits have not been critically evaluated in a systematic review or meta-analysis. Therefore, the aims of this study were to perform a systematic review and meta-analysis comparing EWB and delayed weight-bearing (DWB) after intramedullary nailing of tibial shaft fractures and assess the relationship between weight-bearing, fracture union and healing. METHOD This review included studies comparing the effects of EWB, defined as weight-bearing before 6 weeks, and DWB on fracture union and healing. PubMed, Embase, CINAHL, and the Cochrane Library were searched from inception to 9 May 2021. Risk of bias was assessed using the Down's and Black Checklist and Cochrane Risk of Bias Tool 2.0. Data were synthesised in a meta-analysis, as well as narrative and tabular synthesis. RESULTS Eight studies were included for data extraction and meta-analysis. The analysis produced mixed results and found a significant decrease in mean union time (-2.41 weeks, 95% confidence interval: -4.77, -0.05) with EWB and a significant Odd's Ratio (OR) for complications with DWB (OR: 2.93, 95% CI: 1.40, 6.16). There was no significant difference in rates of delayed union, non-union, re-operation and malunion. CONCLUSION The included studies were of moderate risk of bias and demonstrated shorter union time and fewer complications with EWB. However, current evidence is minimal and has significant limitations. The role of EWB in high-risk patients is yet to be examined. Further well-designed, randomised studies are required on the topic.
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Affiliation(s)
- Ameya Bhanushali
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua G Kovoor
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA, 5011, Australia
| | | | - James T Kieu
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Joseph N Hewitt
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA, 5011, Australia
| | - Christopher D Ovenden
- Discipline of Surgery, University of Adelaide, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mohamed Z Afzal
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- School of Public Health, Adelaide Health Technology Assessment, University of Adelaide, Adelaide, South Australia, Australia
| | - Ruurd L Jaarsma
- Flinders Medical Centre, Department of Orthopaedics and Trauma, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Christy Graff
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia. .,Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA, 5011, Australia. .,Discipline of Surgery, University of Adelaide, Women's and Children's Hospital, Adelaide, South Australia, Australia.
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Rates and timing of short-term complications following operative treatment of tibial shaft fractures. OTA Int 2021; 4:e158. [PMID: 34765906 PMCID: PMC8575429 DOI: 10.1097/oi9.0000000000000158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 10/04/2021] [Indexed: 10/31/2022]
Abstract
Introduction Tibial shaft fractures are a relatively common injury in orthopaedic surgery, with management options including intramedullary nail (IMN) fixation or open reduction internal fixation (ORIF) with plate osteosynthesis. Using a large national database, we sought to compare the prevalence and timing of short-term complications following either IMN or ORIF for tibial shaft fractures. Methods The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients undergoing IMN or ORIF for the treatment of tibial shaft fracture between 2012 and 2018. Multivariate Poisson hurdle regression models were utilized to determine predictors of postoperative complications as well as the timing of postoperative complications. Results A total of 4963 tibial shaft fracture were identified, with 3601 patients undergoing IMN (72.6%) and 1362 undergoing ORIF (27.4%). Patients undergoing IMN had a lower mean age of 48.8 compared with 53.9 for plate osteosynthesis (P < .001). IMN patients were also more likely to be male (53.5%) compared with ORIF patients (44.2%, P < .001). In multivariate analysis, ORIF patients were significantly more likely to experience surgical site complications, including dehiscence, superficial, and deep infections (OR 2.04, P = .003). There was no difference in probability of VTE between constructs; however, patients who underwent ORIF were diagnosed with VTE earlier than those who underwent IMN (relative rate 0.50, P < .001). There was no difference between ORIF and IMN with regard to probability or timing of subsequent blood transfusion, major complications, or return to the operating room. Many patient factors, such as higher American Society of Anesthesiologists score, congestive heart failure, and hypertension, were independently associated with an increased risk of postoperative complications. Conclusions Postoperative complications within 30 days are common after the surgical treatment of tibial shaft fractures. The risk of developing specific complications and the timing of these complications vary depending on numerous factors, including potentially modifiable risk factors such as the method of fixation or operative time, as well as nonmodifiable risk factors such as medical comorbidities.
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Iliaens J, Onsea J, Hoekstra H, Nijs S, Peetermans WE, Metsemakers WJ. Fracture-related infection in long bone fractures: A comprehensive analysis of the economic impact and influence on quality of life. Injury 2021; 52:3344-3349. [PMID: 34474918 DOI: 10.1016/j.injury.2021.08.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Fracture-related infection (FRI) is a feared complication with substantial clinical and economic consequences. The main objective of this study was to compare direct and indirect healthcare costs related to long bone fractures in patients with and without FRI and to assess its impact on the patient's quality of life (QoL). PATIENTS AND METHODS Between January 2015 and March 2019, 175 patients with FRI were treated at the University Hospitals Leuven (Belgium). Using a matched-pair analysis, patients with an FRI were matched by age, sex, and fracture location (humeral, femoral, or tibial shaft) to a non-FRI cohort treated during the same time period. Clinical and process-related variables, direct hospital-related healthcare costs, and indirect costs due to absenteeism were compared between the two groups. Furthermore, the patient's QoL was evaluated using Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and pain interference. RESULTS After matched-pair analysis, 15 patients in both the FRI and non-FRI group were included. FRI was associated with direct hospital-related costs being eight times that of non-FRI patients (€ 47,845 [€ 43,072-€ 82,548] vs. € 5,983 [€ 4,519-€ 8,428], p < 0.001). Furthermore, FRI was associated with prolonged absenteeism (340 [340-676] vs. 86 [65-216] days, p = 0.007) and a median indirect cost that was nearly four times that of patients without FRI (€ 77,909 vs. € 19,706). Lastly, FRI patients showed significantly poorer outcomes on both physical function (35.6 vs. 48.4, p < 0.001) and pain interference (60.4 vs. 46.3, p < 0.001) PROMIS scales. CONCLUSION Direct hospital-related healthcare costs of FRI are eight times that of non-FRI long bone fractures. Total healthcare costs are mainly driven by hospitalisation costs, wherein FRI is associated with prolonged length of stay. To the best of our knowledge, this study is the first to demonstrate that FRI is also associated with substantial absenteeism, which is almost four times higher compared to non-FRI patients. In addition to this economic impact, FRI significantly deteriorates QoL. Generalizing the outcome of this study should be done cautiously due to the small sample size of 15 patients in both the FRI and non-FRI group after matched-pair analysis.
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Affiliation(s)
- Jorien Iliaens
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Development and Regeneration, KU Leuven, Belgium
| | - Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Development and Regeneration, KU Leuven, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Development and Regeneration, KU Leuven, Belgium
| | - Willy E Peetermans
- Department of general internal medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, Laboratory of clinical infectious and inflammatory disease, KU Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Development and Regeneration, KU Leuven, Belgium.
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Hong P, Rai S, Liu X, Tang X, Liu R, Li J. Which is the better choice for open tibial shaft fracture in overweight adolescent with open physis: A comparative study of external fixator plus elastic stable intramedullary nail versus external fixator alone. Injury 2021; 52:3161-3165. [PMID: 34246479 DOI: 10.1016/j.injury.2021.06.021] [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: 03/18/2021] [Revised: 06/20/2021] [Accepted: 06/24/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the clinical outcomes of external fixator + elastic stable intramedullary nail (EF+ESIN) vs. external fixator (EF) in the treatment for open tibial shaft fracture in overweight adolescents. METHODS Patients of open tibial shaft fractures younger than 14 years old with body weight over 50 Kg treated with EF + ESIN or EF at our institute from 2010 to 2018 were reviewed. Patients with Gustilo Type III open fractures, pathological fractures, previous fracture or instrumentation in the operative leg were excluded. Baseline information and clinical data were collected from the hospital database and during out-patient visits. RESULTS Forty-six patients, including 27 males and 19 females, were included in the EF group, whereas 35 patients, including 18 males and 17 females, were included in the EF + ESIN group (p = 0.527). The incidence of superficial infection was higher in the EF group (26/46, 56.5%) than the EF + ESIN group (12/35, 34.3%), p < 0.001. The frontal and sagittal angulation was higher in the EF group (p < 0.001), but the degrees in both groups were within the acceptable range. The union time was longer in the EF group (68.0 ± 12.7, d) than the EF + ESIN group (61.9 ± 11.9), p < 0.001. The retaining of EF (11.9 ± 3.2, w) was longer in the EF group than the EF +ESIN group (5.7 ± 1.2, w), p < 0.001. CONCLUSION EF+ESIN is a safe and alternative choice for selected overweight adolescents with open tibial shaft fracture.
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Affiliation(s)
- Pan Hong
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Department of Orthopaedics and Trauma Surgery, National Trauma Center, National Academy of Medical Sciences, Mahankal, Kathmandu, Nepal
| | - Xiangyang Liu
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Tang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruikang Liu
- First Clinical School, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jin Li
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Wong Wei Kang N, Tan WPJ, Phua YMC, Min ATG, Naidu K, Umapathysivam K, Smitham PJ. Intramedullary nail: the past, present and the future - a review exploring where the future may lead us. Orthop Rev (Pavia) 2021; 13:25546. [PMID: 34745479 PMCID: PMC8567815 DOI: 10.52965/001c.25546] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/02/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Intramedullary nails (IMNs) are the current gold standard treatment for long bone diaphyseal and selected metaphyseal fractures. The design of IMNs has undergone many revisions since its invention in the 16th century, with a dramatic increase in novel designs in recent years aiming to further improve intramedullary fixation techniques. AIMS To map the evolution of IMNs in orthopedic surgery, discuss the limitations and complications of current IMNs and identify novel IMNs that may influence future design innovations. METHODS We undertook a scoping review on the status of orthopedic IMNs by reviewing Google Scholar with the following keywords. Publications and patents selected for retrieval were initially assessed on the title and abstract by five independent reviewers. 52 papers were retrieved for complete text examination, and secondary references were checked from these papers. The results were discussed within the research group and consensus was obtained describing novel IMNs. RESULTS Novel IMN designs include growth factor and/or antimicrobial coatings targeting fracture healing and perioperative infection risk, respectively; minimally invasive expandable IMNs to avoid the need for interlocking screws; and novel materials such as carbon fiber for their theoretically superior biomechanical properties and avoidance of artifact on CT and MRI imaging. CONCLUSION The novel IMNs proposed in recent years collectively aim to improve intramedullary fixation techniques by reducing operative time and radiation exposure, improving fracture healing or monitoring bone cancer progression. However, more research and development are necessary to solve these complex problems.
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Affiliation(s)
| | | | | | | | | | | | - Peter Jonathan Smitham
- Adelaide Medical School; Department of Orthopedics and Trauma, Royal Adelaide Hospital & Discipline of Orthopedics & Trauma, The University of Adelaide
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Strategies to Improve Bone Healing: Innovative Surgical Implants Meet Nano-/Micro-Topography of Bone Scaffolds. Biomedicines 2021; 9:biomedicines9070746. [PMID: 34203437 PMCID: PMC8301359 DOI: 10.3390/biomedicines9070746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 12/17/2022] Open
Abstract
Successful fracture healing is dependent on an optimal mechanical and biological environment at the fracture site. Disturbances in fracture healing (non-union) or even critical size bone defects, where void volume is larger than the self-healing capacity of bone tissue, are great challenges for orthopedic surgeons. To address these challenges, new surgical implant concepts have been recently developed to optimize mechanical conditions. First, this review article discusses the mechanical environment on bone and fracture healing. In this context, a new implant concept, variable fixation technology, is introduced. This implant has the unique ability to change its mechanical properties from “rigid” to “dynamic” over the time of fracture healing. This leads to increased callus formation, a more homogeneous callus distribution and thus improved fracture healing. Second, recent advances in the nano- and micro-topography of bone scaffolds for guiding osteoinduction will be reviewed, particularly emphasizing the mimicry of natural bone. We summarize that an optimal scaffold should comprise micropores of 50–150 µm diameter allowing vascularization and migration of stem cells as well as nanotopographical osteoinductive cues, preferably pores of 30 nm diameter. Next to osteoinduction, such nano- and micro-topographical cues may also reduce inflammation and possess an antibacterial activity to further promote bone regeneration.
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Giannoudis PV, Gardner MJ. Bone infections: local delivery of antibiotics and their effectiveness. OTA Int 2021; 4:e103(1-1). [PMID: 37609477 PMCID: PMC10441673 DOI: 10.1097/oi9.0000000000000103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/10/2020] [Accepted: 12/13/2020] [Indexed: 08/24/2023]
Affiliation(s)
- Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, LGI, University of Leeds
- NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Palo Alto, CA
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Makaram NS, Leow JM, Clement ND, Oliver WM, Ng ZH, Simpson C, Keating JF. Risk factors associated with delayed and aseptic nonunion following tibial diaphyseal fractures managed with intramedullary nailing. Bone Jt Open 2021; 2:227-235. [PMID: 33843259 PMCID: PMC8085614 DOI: 10.1302/2633-1462.24.bjo-2021-0012.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Aims The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion. Methods A consecutive series of 647 patients who underwent intramedullary nailing for tibial diaphyseal fractures were identified from a trauma database. Demographic data, comorbidities, smoking status, alcohol consumption, use of non-steroidal anti-inflammatory drugs (NSAIDs), and steroid use were documented. Details regarding mechanism of injury, fracture classification, complications, and further surgery were recorded. Nonunion was defined as the requirement for revision surgery to achieve union. Delayed union was defined as a RUST score < 10 at six months postoperatively. Results There were 41 nonunions (6.3%), of which 13 were infected (31.7%), and 77 delayed unions (11.9%). There were 127 open fractures (19.6%). Adjusting for confounding variables, NSAID use (odds ratio (OR) 3.50; p = 0.042), superficial infection (OR 3.00; p = 0.026), open fractures (OR 5.44; p < 0.001), and high-energy mechanism (OR 2.51; p = 0.040) were independently associated with nonunion. Smoking (OR 1.76; p = 0.034), open fracture (OR 2.82; p = 0.001), and high-energy mechanism (OR 1.81; p = 0.030) were independent predictors associated with delayed union. The RUST score at six-week follow-up was highly predictive of nonunion (sensitivity and specificity of 75%). Conclusion NSAID use, high-energy mechanisms, open fractures, and superficial infection were independently associated with nonunion in patients with tibial diaphyseal fractures treated with intramedullary nailing. The six-week RUST score may be useful in identifying patients at risk of nonunion. Cite this article: Bone Jt Open 2021;2(4):227–235.
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Affiliation(s)
- Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jun Min Leow
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - William M Oliver
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Zhan H Ng
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Cameron Simpson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - John F Keating
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
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Current concepts in the prevention, diagnosis and treatment of fracture-related infection (FRI). EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:957-966. [PMID: 33778904 DOI: 10.1007/s00590-021-02956-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/21/2021] [Indexed: 12/24/2022]
Abstract
Fracture-related infection (FRI) is one of the most challenging complications following operative management of fractures. It can have profound implications for the patient, can be associated with considerable morbidity and often lead to impaired outcomes. There are significant healthcare-related costs. In recent years, there has been significant progress towards developing preventative strategies. Furthermore, diagnostic algorithms and management protocols have recently been reported. Lack of a strong evidence base has previously hindered efforts to implement these and develop established standards of care. There are multiple aspects of care that need to be considered and a multi-disciplinary approach is recommended. In this narrative review, we present the most up-to-date recommendations in the prevention, diagnosis and management of FRI.
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