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Hackl S, von Rüden C, Trenkwalder K, Keppler L, Hierholzer C, Perl M. Long-Term Outcomes Following Single-Stage Reamed Intramedullary Exchange Nailing in Apparently Aseptic Femoral Shaft Nonunion with Unsuspected Proof of Bacteria. J Clin Med 2024; 13:1414. [PMID: 38592249 PMCID: PMC10933962 DOI: 10.3390/jcm13051414] [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: 02/14/2024] [Revised: 02/25/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
Background: The aim of this study was to evaluate detection rates and risk factors for unsuspected proof of bacteria, as well as clinical and radiologic outcomes following femoral shaft nonunion without clinical signs of infection treated by a single-stage surgical revision procedure including reamed intramedullary exchange nailing. Methods: A retrospective cohort study was performed in a European level I trauma center between January 2015 and December 2022. Fifty-eight patients were included who underwent reamed intramedullary exchange nailing as a single-step procedure for surgical revision of posttraumatic diaphyseal femoral nonunion without any indications of infection in medical history and without clinical signs of local infection. Clinical details of the patients were analyzed and functional and radiologic long-term outcomes were determined. Results: In all patients, with and without proof of bacteria osseous, healing could be observed. The physical component summary of the SF-12 demonstrated significantly better results at least one year after the final surgical revision in case of a negative bacterial culture during exchange nailing. Conclusions: Clinical long-term outcomes demonstrated a trend towards better results following femoral shaft nonunion revision if there was no evidence for the presence of low-grade infected nonunion. In this case, a single-stage surgical procedure may be recommended.
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Affiliation(s)
- Simon Hackl
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Christian von Rüden
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Department of Trauma Surgery, Orthopedics and Hand Surgery, Weiden Medical Center, 92637 Weiden, Germany
| | - Katharina Trenkwalder
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Institute for Biomechanics, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Lena Keppler
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Christian Hierholzer
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Mario Perl
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
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Foster AL, Warren J, Vallmuur K, Jaiprakash A, Crawford R, Tetsworth K, Schuetz MA. A population-based epidemiological and health economic analysis of fracture-related infection. Bone Joint J 2024; 106-B:77-85. [PMID: 38160695 DOI: 10.1302/0301-620x.106b1.bjj-2023-0279.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Aims The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI). Methods This is a retrospective cohort study of operatively managed orthopaedic trauma patients from 1 January 2007 to 31 December 2016, performed in Queensland, Australia. Record linkage was used to develop a person-centric, population-based dataset incorporating routinely collected administrative, clinical, and health economic information. The FRI group consisted of patients with International Classification of Disease 10th Revision diagnosis codes for deep infection associated with an implanted device within two years following surgery, while all others were deemed not infected. Demographic and clinical variables, as well as healthcare utilization costs, were compared. Results There were 111,402 patients operatively managed for orthopaedic trauma, with 2,775 of these (2.5%) complicated by FRI. The development of FRI had a statistically significant association with older age, male sex, residing in rural/remote areas, Aboriginal or Torres Strait Islander background, lower socioeconomic status, road traffic accident, work-related injuries, open fractures, anatomical region (lower limb, spine, pelvis), high injury severity, requiring soft-tissue coverage, and medical comorbidities (univariate analysis). Patients with FRI had an eight-times longer median inpatient length of stay (24 days vs 3 days), and a 2.8-times higher mean estimated inpatient hospitalization cost (AU$56,565 vs AU$19,773) compared with uninfected patients. The total estimated inpatient cost of the FRI cohort to the healthcare system was AU$156.9 million over the ten-year period. Conclusion The results of this study advocate for improvements in trauma care and infection management, address social determinants of health, and highlight the upside potential to improve prevention and treatment strategies.
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Affiliation(s)
- Andrew L Foster
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Jacelle Warren
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, Faculty of Health, Brisbane, Australia
| | - Kirsten Vallmuur
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, Faculty of Health, Brisbane, Australia
| | - Anjali Jaiprakash
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Ross Crawford
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Kevin Tetsworth
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Michael A Schuetz
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
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Nichols DS, Newsum N, Satteson E, Miao G, Struk A, Horodyski M, Matthias R. Open hand fractures: a prospective analysis of functional outcomes and risk factors for infection after initial management in the emergency department. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3449-3459. [PMID: 37191885 DOI: 10.1007/s00590-023-03549-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE Open hand fractures are common orthopaedic injuries, historically managed with early debridement in the operating room. Recent studies suggest immediate operative treatment may not be necessary but have been limited by poor follow-up and lack of functional outcomes. This study sought to prospectively evaluate these injuries treated initially in the emergency department (ED), without immediate operative intervention, to determine long-term infectious and functional outcomes using the Michigan Hand Outcomes Questionnaire (MHQ). METHODS Adult patients with open hand fractures managed initially in the ED at a Level-I trauma center were considered for inclusion (2012-2016). Follow-up and MHQ administration occurred at 6 weeks, 12 weeks, 6 months, and 1 year. Logistic regression and Kruskal-Wallis testing were used for analysis. RESULTS Eighty-one patients (110 fractures) were included. Most had Gustilo Type III injuries (65%). Injury mechanisms most commonly included saw/cut (40%) and crush (28%). Nearly half of all patients (46%) had additional injuries involving a nailbed or tendon. Fifteen percent of patients had surgery within 30 days. The average follow-up was 8.9 months, with 68% of patients completing at least 12 months. Eleven patients (14%) developed an infection, of which 4 (5%) required surgery. Subsequent surgery and laceration size were associated with increased odds of infection, and at one-year, functional outcomes were not significantly different regardless of fracture classification, injury mechanism, or surgery. CONCLUSIONS Initial ED management of open hand fractures results in reasonable infection rates compared to similar literature and functional recovery demonstrated by MHQ score improvements over time.
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Affiliation(s)
- David Spencer Nichols
- University of Florida College of Medicine, P.O. Box 100138, Gainesville, FL, 32610, USA
| | - Nicholas Newsum
- Department of Orthopedic Surgery, University of Florida, 3450 Hull Road, Third Floor, Room 3341, Gainesville, FL, 32607, USA
| | - Ellen Satteson
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida, P.O. Box 100138, Gainesville, FL, 32610, USA
| | - Guanhong Miao
- Department of Biostatistics, University of Florida, 2004 Mowry Rd. 5th Floor, Gainesville, FL, 32603, USA
| | - Aimee Struk
- Department of Orthopedic Surgery, University of Florida, 3450 Hull Road, Third Floor, Room 3341, Gainesville, FL, 32607, USA
| | - MaryBeth Horodyski
- Department of Orthopedic Surgery, University of Florida, 3450 Hull Road, Third Floor, Room 3341, Gainesville, FL, 32607, USA
| | - Robert Matthias
- Department of Orthopedic Surgery, University of Florida, 3450 Hull Road, Third Floor, Room 3341, Gainesville, FL, 32607, USA.
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Reátiga Aguilar J, Gonzalez Edery E, Guzmán Badrán J, Molina Gandara J, Arzuza Ortega L, Ríos Garrido X, Medina Monje C. Open tibial plateau fractures: Infection rate and functional outcomes. Injury 2023; 54 Suppl 6:110720. [PMID: 38143143 DOI: 10.1016/j.injury.2023.04.007] [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: 02/27/2023] [Revised: 03/20/2023] [Accepted: 04/11/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Open tibial plateau fractures are complex injuries that require specialized management to prevent complications. The objective of this study was to compare the infection risk and functional outcomes between open and closed tibial plateau fractures. MATERIALS AND METHODS In this multicenter cohort study the propensity score matching was used to pair participants according to age, sex, and Schatzker classification. 190 patients were followed for 1 year postoperatively. The Fracture-Related Infection (FRI) Consensus Group criteria was used to diagnose infection. Knee functionality was measured using the Oxford Knee Score scale (OKS). RESULTS The proportion of open fractures was 5.1%, and the overall incidence rate of FRI was 8% with 14% of them represented by open fractures and 4% for closed fractures (p = 0.014). Open fractures were found to be a risk factor associated with FRI, with a 5.48 times higher probability of FRI than closed fractures (odds ratio 5.41, 95% confidence interval [CI] 1.55-18.85). Among the study population, 50% had satisfactory functional outcomes of the knee (median OKS 45, IQR = 3). The median OKS was 44 (IQR = 11) in open fractures and 46 (IQR = 7) in closed ones (p = 0.03). Multivariate analysis showed that the OKS was 3 points lower for open fractures (95% CI -5.530--0.478) than closed ones, and the score was 9.7 points lower for FRI. CONCLUSION Open TPF is a risk factor that increases the probability of fracture related infections. Functional outcomes were excellent for both open and closed TPF, with a slight difference numerical that was under the minimal clinical difference (MCID). The presence of FRI significantly decreases the functional outcome.
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Affiliation(s)
| | | | - Julio Guzmán Badrán
- Orthopedics Department, Fundación Campbell, Barranquilla, Atlántico, Colombia
| | | | | | - Ximena Ríos Garrido
- Orthopedics Department, Fundación Campbell, Barranquilla, Atlántico, Colombia
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Schultz BV, Watt K, Rashford S, Wylie J, Bosley E. Epidemiology of open limb fractures attended by ambulance clinicians in the out-of-hospital setting: A retrospective analysis. Australas Emerg Care 2023; 26:216-220. [PMID: 36621412 DOI: 10.1016/j.auec.2023.01.001] [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: 10/27/2022] [Revised: 12/25/2022] [Accepted: 01/02/2023] [Indexed: 01/07/2023]
Abstract
BACKGROUND Open limb fractures are a time-critical orthopaedic emergency that present to jurisdictional ambulance services. This study describes the demographic characteristics and epidemiological profile of these patients METHODS: We undertook a retrospective analysis of all patients that presented to Queensland Ambulance Service with an open limb fracture (fracture to the humerus, radius/ulna, tibia/fibula or femur) over a two-year period (January 2018 - December 2019). RESULTS Overall, 1020 patients were included. Patients were mainly male (65.9%) and middle-aged (age 41 years, IQR 22-59). Fractures predominately occurred in the lower extremities (64.9%) with transport crashes the primary mechanism of injury (47.8%). The location of the fracture varied depending on the cause of injury, with femur fractures associated with motorcycle crashes, and fractures to the radius/ulna attributed to falls of greater than one metre (p = 0.001). The median prehospital episode of care was 83 min (IQR 62-144) with aeromedical air ambulance involvement and the attendance of a critical care paramedic or emergency physician, both independent factors that increased this time interval. CONCLUSION Open limb fractures are a relatively infrequent injury presentation encountered by ambulance clinicians. The characteristics of these patients is consistent with previously described national and international out-of-hospital trauma cohorts.
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Affiliation(s)
- Brendan V Schultz
- Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, QLD, Australia.
| | - Kerrianne Watt
- Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, QLD, Australia; College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD Australia
| | - Stephen Rashford
- Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, QLD, Australia
| | - James Wylie
- Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, QLD, Australia
| | - Emma Bosley
- Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, QLD, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
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Risk of Acute Kidney Injury and Fracture-Related Infection After Antibiotic Prophylaxis With Piperacillin-Tazobactam in Open Fractures. J Orthop Trauma 2023; 37:e73-e79. [PMID: 36001947 DOI: 10.1097/bot.0000000000002473] [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] [Accepted: 08/15/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the effects of prophylactic piperacillin-tazobactam (PT) on inpatient acute kidney injury (AKI) and fracture-related infection (FRI) in patients with open fractures. SETTING The study was conducted at a Level 1 trauma center. PATIENTS We reviewed 358 Gustilo-Anderson type II and III open fractures at our institution from January 2013 to December 2017. INTERVENTION Administration of PT (the PT group) or antibiotics other than PT (the historical control group) during the first 48 hours of arrival for open fracture antibiotic prophylaxis. MAIN OUTCOME MEASUREMENTS The main outcome measurements were rates of inpatient AKI and FRI within six months after definitive fixation. RESULTS There were 176 patients in the PT group and 182 patients in the historical control group. The PT group had worse American Society of Anesthesiologists class ( P = 0.004) and injury severity scores ( P < 0.001), a higher average number of debridements before closure/coverage ( P = 0.043), and higher rates of gross soil contamination ( P = 0.049) and staged procedures ( P = 0.008) compared with the historical control group.There was no difference in the rate of AKI between the PT and historical control groups (5.7% vs. 2.7%, P = 0.166) nor when stratified by Gustilo-Anderson fracture classification (type II: 5.8% vs. 3.6%, P = 0.702; type III: 5.6% vs. 2.0%, P = 0.283). There was no significant difference in the rate of FRI between the PT and historical control groups (23.6% vs. 19.6%, P = 0.469). CONCLUSION The use of PT in prophylactic antimicrobial treatment in patients with Gustilo-Anderson type II and III open fractures does not increase the rate of AKI or FRI. We believe PT can be used as an effective monotherapy in these patients without an increased risk of renal injury, but future investigations are necessary. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Patterson JT, Becerra JA, Brown M, Roohani I, Zalavras C, Carey JN. Antibiotic bead pouch versus negative pressure wound therapy at initial management of AO/OTA 42 type IIIB open tibia fracture may reduce fracture related infection: A retrospective analysis of 113 patients. Injury 2023; 54:744-750. [PMID: 36588031 DOI: 10.1016/j.injury.2022.12.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Fracture related infection (FRI) may be a devastating complication of open tibial shaft fractures. We sought to determine if antibiotic bead pouch, negative pressure wound therapy, or negative pressure wound therapy over antibiotic beads as the initial coverage method for type IIIB open tibial shaft fractures is associated with risk of FRI. PATIENTS AND METHODS Retrospective cohort study with radiograph and chart review of patients aged ≥16 years with isolated, displaced, extra-articular, Gustilo-Anderson type IIIB open diaphyseal AO/OTA 42 tibial fractures requiring rotational or free tissue transfer for soft tissue coverage at one Level 1 trauma center between 2007 and 2020. An association of dressing applied at the first surgical debridement (application of antibiotic bead pouch, negative pressure wound therapy, or combined therapy) with a primary outcome of FRI requiring debridement or amputation was analyzed by multivariable logistic regression considering demographic, injury, and treatment characteristics. RESULTS 113 patients met eligibility criteria. Median follow-up was 33 months (interquartile range 5-88). 41 patients were initially treated with NPWT, 59 with ABP, and 13 with ABP+NPWT at the initial surgical debridement. 39 (35%) underwent subsequent debridement or amputation for FRI. One amputation occurred in the ABP group for refractory deep surgical site infection (p = 0.630). Initial wound management with an antibiotic bead pouch versus either negative pressure wound therapy alone or negative pressure wound therapy combined with an antibiotic bead pouch was associated with lower odds of debridement or amputation for FRI (β = -1.08, 95% CI -2.00 to -0.17, p = 0.02). CONCLUSIONS In our retrospective analysis, antibiotic bead pouch for initial coverage of type IIIB open tibial shaft fractures requiring flap coverage was associated with a lower risk of FRI requiring debridement or amputation than negative pressure wound therapy applied with or without antibiotic beads. A prospective clinical trial is warranted.
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Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
| | - Jacob A Becerra
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Michael Brown
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Idean Roohani
- Department of Surgery, Division of Plastic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA; Department of Surgery, Division of Plastic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Joseph N Carey
- Department of Surgery, Division of Plastic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Sax OC, Douglas SJ, Pervaiz SS, Salem HS, Nabet A, Mont MA, Delanois RE. Intra-articular Hip Injections Prior to Total Hip Arthroplasty: Infection and Cost-Related Associations. Orthopedics 2023; 46:19-26. [PMID: 36206513 DOI: 10.3928/01477447-20221003-05] [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] [Indexed: 02/03/2023]
Abstract
Intra-articular injections prior to total hip arthroplasty (THA) have been associated with postoperative infections. The purpose of this study was to determine whether a temporal relationship exists between hip injections prior to THA and infection. Specifically, we asked (1) Do patients who receive hip injections within 3 months of THA have a higher incidence of prosthetic joint infections (PJIs) or surgical site infections (SSIs)? and (2) Do these patients incur higher 90-day costs? Patients with hip injections prior to THA were identified using a national database from 2010 to 2019. Three laterality-specific groups (injection 0 to 3 months, 3 to 6 months, and 6 to 12 months prior to THA)were compared with a matched cohort without prior injection (n=277,841). Primary outcomes included PJIs, SSIs, and costs. Patients who had injections within 3 months of THA had a higher incidence of PJIs at 90 days (5.1% vs 1.6%, P<.01) and 1 year (6.8% vs 2.1%, P<.01), when compared with the matched cohort. They also had a higher incidence of SSIs at 90 days (2.8% vs 1.2%, P<.01) and 1 year (3.7% vs 1.7%, P<.01). Mean costs were 13.7% higher in this injection cohort. Patients who had injections between 3 and 6 months prior to THA had higher incidence and odds of postoperative PJIs at 90 days (2.6% vs 1.6%, P<.04), whereas those with injections beyond 6 months had no differences in PJIs (P≥.46). Patients who receive hip injections within 3 months of undergoing primary THA are at increased risk for postoperative PJIs, SSIs, and higher costs. This study reaffirms guidelines for when to perform THAs in these populations. [Orthopedics. 2023;46(1):19-26.].
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Garcia DR, Vishwanath N, Minnah A, Allu S, Whitaker CD, Stone BK, Berns EM, Spake CSL, Dockery DM, Barrett CC, Mette M, Connolly W, Clippert D, Antoci V, Born CT. Silver Carboxylate-Eluting Titanium-Dioxide Polydimethylsiloxane Coating Inhibits Multi-Drug-Resistant Acinetobacterium baumannii and Vancomycin-Resistant Enterococcus faecalis Adherence and Proliferation on Orthopedic Trauma Fixation and Spinal Fusion Materials. Surg Infect (Larchmt) 2022; 23:924-932. [PMID: 36413347 DOI: 10.1089/sur.2022.279] [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: 11/24/2022] Open
Abstract
Background: Vancomycin-resistant Enterococcus faecalis and multi-drug-resistant (MDR) Acinetobacter baumannii are rising contributors to spinal fusion and fracture-associated infections (FAI), respectively. These MDR bacteria can form protective biofilms, complicating traditional antibiotic treatment. This study explores the effects of the antibiotic-independent antimicrobial silver carboxylate (AgCar)-doped coating on the adherence sand proliferation of these pathogens on orthopedic implant materials utilized in spinal fusion and orthopedic trauma fixation. Methods: Multi-drug-resistant Acinetobacter baumannii and vancomycin-resistant Enterococcus faecalis were inoculated on five common implant materials: cobalt chromium, titanium, titanium alloy, polyether ether ketone, and stainless steel. Dose response curves were generated to assess antimicrobial potency. Scanning electron microscopy and confocal laser scanning microscopy were utilized to characterize and quantify growth and adherence on each material. Results: The optimal AgCar concentration was a 95% titanium dioxide (TiO2)-5% polydimethylsiloxane (PDMS) matrix combined with 10 × silver carboxylate, which inhibited bacterial proliferation by 89.40% (p = 0.001) for MDR Acinetobacter baumannii and 84.02% (p = 0.001) for vancomycin-resistant Enterococcus faecalis compared with uncoated implants. A 95% TiO2-5% PDMS matrix combined with 10 × AgCar was equally effective at inhibiting bacterial proliferation across all implant materials for MDR Acinetobacter baumannii (p = 0.19) and vancomycin-resistant Enterococcus faecalis (p = 0.07). A 95% TiO2-5% PDMS matrix with 10 × AgCar is effective at decreasing bacterial adherence of both MDR Acinetobacter baumannii and vancomycin-resistant Enterococcus faecalis on implant materials. Conclusions: Application of this antibiotic-independent coating for surgery in which these implant materials might be used may prevent adherence, biofilm formation, spinal infections, and FAI by MDR Acinetobacter baumannii and vancomycin-resistant Enterococcus faecalis.
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Affiliation(s)
- Dioscaris R Garcia
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Neel Vishwanath
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | | | - Sai Allu
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Colin D Whitaker
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Benjamin K Stone
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ellis M Berns
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Carole S L Spake
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Dominique M Dockery
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Caitlin C Barrett
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Makena Mette
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - William Connolly
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Drew Clippert
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Valentin Antoci
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christopher T Born
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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10
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Levin LS. From replantation to transplantation: The evolution of orthoplastic extremity reconstruction. J Orthop Res 2022. [PMID: 36413095 DOI: 10.1002/jor.25488] [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: 08/16/2022] [Revised: 10/20/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022]
Abstract
For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopedic trauma, tumors, infections, and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as a digital artery or nerve repair to more complex procedures such as autologous tissue transplantation. Functional muscle transfers, toe-to-hand transfers, and recently vascularized composite allotransplantation are the highest rungs on this ladder that help restore extremity function. The development of the orthoplastic approach over the last three decades simultaneously integrates the principles and practices of both orthopedic surgery and plastic surgery for optimal care and salvage of extremities. Clinical, anatomic, and basic science research in reconstructive microsurgery has resulted in significant improvements in extremity salvage, reconstruction, and restoration.
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Affiliation(s)
- L Scott Levin
- Department of Orthopaedic Surgery, Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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11
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Buckman SA, Forrester JD, Bessoff KE, Parli SE, Evans HL, Huston JM. Surgical Infection Society Guidelines: 2022 Updated Guidelines for Antibiotic Use in Open Extremity Fractures. Surg Infect (Larchmt) 2022; 23:817-828. [DOI: 10.1089/sur.2022.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Sara A. Buckman
- Division of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Joseph D. Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Kovi E. Bessoff
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Sara E. Parli
- Department of Pharmacy Services, University of Kentucky, Lexington, Kentucky, USA
| | - Heather L. Evans
- Division of General and Acute Care Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jared M. Huston
- Departments of Surgery and Science Education, Zucker School of Medicine, Northwell Health, Manhasset, New York, USA
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12
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Torrez TW, Hicks J, Bonner V, Seidenstein AH, McGwin G, Kothari E, Gilbert SR. Increased open fracture complications following pediatric all-terrain vehicle accidents. Injury 2022; 53:3322-3325. [PMID: 36031440 DOI: 10.1016/j.injury.2022.08.023] [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: 03/09/2022] [Revised: 07/11/2022] [Accepted: 08/06/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND ATV (All-Terrain Vehicle) related open fractures are often high energy and may be highly contaminated. We asked whether they were more complicated than other open fractures in pediatric patients. METHODS A retrospective chart review was performed comparing ATV associated open fractures to open fractures sustained in non-ATV related accidents. 97 pediatric open fractures from 2015 to 2021 were identified based on ICD-10 codes. Of these fractures, 62 were non-ATV related and 35 were ATV related. Charts were reviewed to collect basic demographics, fracture pattern, Gustilo-Anderson classification, procedures performed, operative findings, and complications. RESULTS Our cohort was predominantly male (71% in the ATV group and 76% in the non-ATV group). White race was more common in both the ATV (28 (80%)) and non-ATV (50(78%)) groups. The distribution of AO/OTA fractures was significantly different (p = 0.046), with humerus fractures being more common in the ATV group (8 (22%)) vs. non-ATV group (6 (9.3%)). The ATV group had a higher proportion of more severe type II and III open fractures with 77.1% (n = 27), versus 56% (n = 35) in the non-ATV group (p = 0.020).. Revision and reoperation were more likely in the ATV group (16 (23%)) vs. the non-ATV group (12 (15%)), as was malunion (ATV group 3 (4.3%) Vs. non-ATV 0 (0%)). CONCLUSION Open fractures resulting from ATV injuries tend to be more complex and have higher rates of revision and malunion. This information supports the large body of evidence on the dangers of ATVs to children and can help guide expectations of both clinicians and family members of patients presenting with these injuries.
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Affiliation(s)
- Timothy W Torrez
- University of California Los Angeles, David Geffen School of Medicine, CA, USA; University of Alabama at Birmingham, Department of Orthopedic Surgery, AL, USA
| | - Jimmy Hicks
- University of Alabama at Birmingham, Department of Orthopedic Surgery, AL, USA
| | - Vincent Bonner
- University of Alabama at Birmingham, Department of Orthopedic Surgery, AL, USA
| | | | - Gerald McGwin
- University of Alabama at Birmingham, Department of Orthopedic Surgery, AL, USA
| | - Ezan Kothari
- University of Alabama at Birmingham, Department of Orthopedic Surgery, AL, USA
| | - Shawn R Gilbert
- University of Alabama at Birmingham, Department of Orthopedic Surgery, AL, USA.
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13
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Yu C, Chen L, Zhou W, Hu L, Xie X, Lin Z, Panayi AC, Zhan X, Tao R, Mi B, Liu G. Injectable Bacteria-Sensitive Hydrogel Promotes Repair of Infected Fractures via Sustained Release of miRNA Antagonist. ACS APPLIED MATERIALS & INTERFACES 2022; 14:34427-34442. [PMID: 35866896 PMCID: PMC9354009 DOI: 10.1021/acsami.2c08491] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/13/2022] [Indexed: 06/15/2023]
Abstract
Fracture nonunion can result in considerable physical harm and limitation of quality of life in patients, exerting an extensive economic burden to the society. Nonunion largely results from unresolved inflammation and impaired osteogenesis. Despite advancements in surgical techniques, the indispensable treatment for nonunion is robust anti-inflammation therapy and the promotion of osteogenic differentiation. Herein, we report that plasma exosomes derived from infected fracture nonunion patients (Non-Exos) delayed fracture repair in mice by inhibiting the osteogenic differentiation of bone marrow stromal cells in vivo and in vitro. Unique molecular identifier microRNA-sequencing (UID miRNA-seq) suggested that microRNA-708-5p (miR-708-5p) was overexpressed in Non-Exos. Mechanistically, miR-708-5p targeted structure-specific recognition protein 1, thereby suppressing the Wnt/β-catenin signaling pathway, which, in turn, impaired osteogenic differentiation. AntagomicroRNA-708-5p (antagomiR-708-5p) could partly reverse the above process. A bacteria-sensitive natural polymer hyaluronic-acid-based hydrogel (HA hydrogel) loaded with antagomiR-708-5p exhibited promising effects in an in vivo study through antibacterial and pro-osteogenic differentiation functions in infected fractures. Overall, the effectiveness and reliability of an injectable bacteria-sensitive hydrogel with sustained release of agents represent a promising approach for infected fractures.
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Affiliation(s)
- Chenyan Yu
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Lang Chen
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
- Department
of Physics and Center for Hybrid Nanostructure (CHyN), University of Hamburg, Luruper Chaussee 149, Hamburg 22761, Germany
| | - Wu Zhou
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Liangcong Hu
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Xudong Xie
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Ze Lin
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Adriana C. Panayi
- Division
of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02215, United States
| | - Xingjie Zhan
- Tianyou
Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430022, China
| | - Ranyang Tao
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Bobin Mi
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Guohui Liu
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
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14
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Hackl S, Trenkwalder K, Militz M, Augat P, Stuby FM, von Rüden C. [Infected nonunion: diagnostic and therapeutic work-up]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:602-610. [PMID: 35750886 DOI: 10.1007/s00113-022-01204-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Septic nonunion is one of the major complications in fracture healing. The challenge is to identify the infection as the cause of nonunion first and then to achieve healing of the infection and the bone. OBJECTIVE Because of the more heterogeneous appearance of an infected nonunion, the prevalence of germ detection in surgical nonunion revision is often underestimated. MATERIAL AND METHODS In a retrospective study between 2010 and 2017, 86 patients with radiologically confirmed femoral shaft nonunion without clinical evidence and unremarkable medical history of a florid infection as the cause of nonunion, who had undergone primary single-stage surgical nonunion revision were analyzed. At least four intraoperatively obtained samples were evaluated for microbiological diagnosis. A distinction was made between tissue samples with subsequent 48‑h short-term incubation and tissue samples with 14-day long-term cultivation. The finding "germ detection" was made if at least two of the samples demonstrated bacterial growth. RESULTS In 18 of 86 patients with a nonunion preoperatively judged to be aseptic, positive bacterial evidence was obtained after short-term incubation. After long-term cultivation, positive bacterial detection was possible in 38 of 86 patients with a femoral shaft nonunion initially classified as aseptic. Regarding potential risk factors, the two groups demonstrated no relevant differences. In 29 patients, 1 pathogen was isolated from the obtained samples, whereas in the remaining 9 patients, a mixed culture with an average of 2.9 ± 0.5 different bacteria was detected. Identification revealed mainly low-virulence bacteria, most commonly Staphylococcus epidermidis. CONCLUSION If the preoperative diagnostics including clinical, laboratory and radiological examination as well as a careful anamnesis reveal indications of a possible infectious event, the surgical nonunion revision should be performed in two stages with specimen collection before definitive nonunion revision. For microbiological diagnosis, several representative tissue samples should independently be obtained from the nonunion site and incubated for 14 days. Only in the absence of evidence of septic nonunion is a single-stage procedure suggested.
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Affiliation(s)
- Simon Hackl
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
| | - Katharina Trenkwalder
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Matthias Militz
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Peter Augat
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Fabian M Stuby
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Christian von Rüden
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
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15
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Systemic Antibiotic Prophylaxis in Maxillofacial Trauma: A Scoping Review and Critical Appraisal. Antibiotics (Basel) 2022; 11:antibiotics11040483. [PMID: 35453234 PMCID: PMC9027173 DOI: 10.3390/antibiotics11040483] [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: 02/19/2022] [Revised: 03/27/2022] [Accepted: 04/03/2022] [Indexed: 11/24/2022] Open
Abstract
Infection after maxillofacial trauma remains an important complication, with a significant socio-economic impact. While consensus exists that systemic antibiotic prophylaxis reduces the risk of infection in the management of maxillofacial fractures, the type, and duration remain controversial. Therefore, the purpose of this scoping review was to provide an overview of the current evidence that supports the use of prophylactic antibiotics in the treatment of maxillofacial fractures. A comprehensive literature search on 1 January 2022, in PubMed, Web of Science, Embase, and Cochrane, revealed 16 articles. Most studies focused on the duration of systemic antibiotic prophylaxis and compared a one-day to a five-day regimen. Included studies showed considerable variability in design and research aims, which rendered them difficult to compare. Furthermore, a variety of antibiotic regimens were used, and most studies had a short follow-up period and unclear outcome parameters. This scoping review demonstrates the lack of well-constructed studies investigating the type and duration of systemic antibiotic prophylaxis in the treatment of maxillofacial trauma. Based on the included articles, prolonging antibiotic prophylaxis over 24 h for surgically treated fractures does not appear to be beneficial. Furthermore, there is no evidence for its use in conservatively treated fractures. These results should be interpreted with caution since all included studies had limitations.
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16
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Duration of Perioperative Antibiotic Prophylaxis in Open Fractures: A Systematic Review and Critical Appraisal. Antibiotics (Basel) 2022; 11:antibiotics11030293. [PMID: 35326757 PMCID: PMC8944527 DOI: 10.3390/antibiotics11030293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 02/05/2023] Open
Abstract
Fracture-related infection (FRI) remains a serious complication in open fracture care. Adequate surgical treatment and perioperative antibiotic prophylaxis (PAP) are key factors influencing the outcome. However, data concerning the optimal duration of PAP is scarce. The aim of this systematic review was to provide an overview of current evidence on the association between PAP duration and FRI in open fractures. A comprehensive search on 13 January 2022, in Embase, Medline, Cochrane, Web of Science and Google Scholar revealed six articles. Most studies compared either 1 day versus 5 days of PAP or included a cut-off at 72 h. Although prolonged PAP was not beneficial in the majority of patients, the variety of antibiotic regimens, short follow-up periods and unclear description of outcome parameters were important limitations that were encountered in most studies. This systematic review demonstrates a lack of well-constructed studies investigating the effect of PAP duration on FRI. Based on the available studies, prolonged PAP does not appear to be beneficial in the prevention of FRI in open fractures. However, these results should be interpreted with caution since all included studies had limitations. Future randomized trials are necessary to answer this research question definitively.
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17
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Wynn M, Kesler K, Morellato J, Higginbotham R, Robertson M, Marsh JL, Hogue M. Agricultural Trauma Causing Open Fractures: Is Antibiotic Coverage Against Anaerobic Organisms Indicated? J Orthop Trauma 2022; 36:e51-e55. [PMID: 34050077 DOI: 10.1097/bot.0000000000002192] [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] [Accepted: 05/24/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare deep infection rate and causative organisms in open fractures of the lower extremity from agricultural trauma with similar injuries in nonagricultural trauma. DESIGN Retrospective. SETTING Two tertiary care institutions. METHODS Open lower extremity fractures sustained between 2003 and 2018 caused by agriculture-related trauma in adult patients were reviewed. A nonagriculture open fracture control group (NAG) was identified for comparison. Patient demographics and injury characteristics were assessed. Outcomes included occurrence of deep infection and causative organisms. RESULTS One hundred seventy-eight patients were identified in the agriculture (AG) (n = 89) and control (NAG) (n = 89) groups. Among patients with agricultural injury, farm machinery was the most common mechanism in 69 (77.5%) of them. Open injuries of the foot (38.2%) and tibial shaft injuries (25.8%) were the most common in the AG and NAG groups, respectively. Deep infection was seen in 21% of patients in the AG group compared with 10% in the NAG group (P < 0.05). In the AG group, anaerobic infection occurred in 44% of patients with deep infection compared with 9.1% in the NAG group (P < 0.05). The most common anaerobic organisms included enterococci, Pseudomonas aeruginosa, and Clostridium perfringens. CONCLUSIONS This study supports that open fractures due to agricultural trauma have a high infection rate, with anaerobic infection occurring at higher rates than in injuries due to nonagricultural trauma. Prophylactic treatment with antibiotics directed against anaerobes is indicated in these injuries. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Malynda Wynn
- Department of Orthopedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, IA; and
| | - Kyle Kesler
- Department of Orthopedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, IA; and
| | - John Morellato
- Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS
| | - Robert Higginbotham
- Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS
| | - Michael Robertson
- Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS
| | - John Lawrence Marsh
- Department of Orthopedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, IA; and
| | - Matthew Hogue
- Department of Orthopedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, IA; and
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18
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Vittrup SØ, Hanberg P, Knudsen MB, Tøstesen SK, Kipp JO, Hansen J, Jørgensen NP, Stilling M, Bue M. Tibial bone and soft-tissue concentrations following combination therapy with vancomycin and meropenem - evaluated by microdialysis in a porcine model : should patients with open fractures have higher doses of antibiotics? Bone Joint Res 2022; 11:112-120. [PMID: 35176868 PMCID: PMC8882321 DOI: 10.1302/2046-3758.112.bjr-2021-0321.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Aims Prompt and sufficient broad-spectrum empirical antibiotic treatment is key to preventing infection following open tibial fractures. Succeeding co-administration, we dynamically assessed the time for which vancomycin and meropenem concentrations were above relevant epidemiological cut-off (ECOFF) minimal inhibitory concentrations (T > MIC) in tibial compartments for the bacteria most frequently encountered in open fractures. Low and high MIC targets were applied: 1 and 4 µg/ml for vancomycin, and 0.125 and 2 µg/ml for meropenem. Methods Eight pigs received a single dose of 1,000 mg vancomycin and 1,000 mg meropenem simultaneously over 100 minutes and 10 minutes, respectively. Microdialysis catheters were placed for sampling over eight hours in tibial cancellous bone, cortical bone, and adjacent subcutaneous adipose tissue. Venous blood samples were collected as references. Results Across the targeted ECOFF values, vancomycin displayed longer T > MIC in all the investigated compartments in comparison to meropenem. For both drugs, cortical bone exhibited the shortest T > MIC. For the low MIC targets and across compartments, mean T > MIC ranged between 208 and 449 minutes (46% to 100%) for vancomycin and between 189 and 406 minutes (42% to 90%) for meropenem. For the high MIC targets, mean T > MIC ranged between 30 and 446 minutes (7% to 99%) for vancomycin and between 45 and 181 minutes (10% to 40%) for meropenem. Conclusion The differences in the T > MIC between the low and high targets illustrate how the interpretation of these results is highly susceptible to the defined MIC target. To encompass any trauma, contamination, or individual tissue differences, a more aggressive dosing approach may be considered to achieve longer T > MIC in all the exposed tissues, and thereby lower the risk of acquiring an infection after open tibial fractures. Cite this article: Bone Joint Res 2022;11(2):112–120.
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Affiliation(s)
- Sofus Ørbæk Vittrup
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Pelle Hanberg
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Martin Bruun Knudsen
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
| | - Sara Kousgaard Tøstesen
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Josephine Olsen Kipp
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jakob Hansen
- Department of Forensic Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Maiken Stilling
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mats Bue
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
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19
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Zalavras CG, Aerden L, Declercq P, Belmans A, Metsemakers WJ. Ninety-Day Follow-up Is Inadequate for Diagnosis of Fracture-related Infections in Patients with Open Fractures. Clin Orthop Relat Res 2022; 480:139-146. [PMID: 34351311 PMCID: PMC8673965 DOI: 10.1097/corr.0000000000001911] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/02/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Fracture-related infection (FRI) is a challenging complication in musculoskeletal trauma surgery and often complicates the management of open fractures. The CDC currently advocates a surveillance period of 90 days after fracture fixation, but it is unclear what duration of follow-up constitutes adequate surveillance for FRI. Inadequate follow-up will underestimate infections and, in clinical research, will make any interventions studied appear better than they really are, thereby resulting in misleading conclusions. QUESTIONS/PURPOSES (1) What is the timing of FRI onset in patients with open fractures? (2) What is the proportion of FRIs captured when follow-up is limited to 90 days postoperatively versus when follow-up is extended to 1 year? METHODS This is a secondary analysis of patient data from a previous retrospective cohort study that investigated whether the duration of perioperative antibiotic prophylaxis was independently associated with FRI in patients with open fractures. Of the 530 eligible patients in the source study, 3% (14) died. Of the remaining 516 patients, 97% (502) patients with 559 long-bone open fractures had 2 years of follow-up constituted the base cohort. Forty-seven fractures in 46 patients were complicated by FRI and were the focus of this secondary analysis. Medical records were reviewed in detail specifically for the current study. Seventy-eight percent (36 of 46) of patients were male, and the mean ± SD age was 42 ± 16 years. The most common mechanism of injury was a motor vehicle accident (63% [29 of 46] of patients), and the tibia was the most involved site (53% [25 of 47] of fractures). The median (interquartile range) time to debridement was 3.0 hours (IQR 2.0 to 4.0). FRIs developed in 3% (7 of 247) of Type I open fractures, 7% (11 of 164) of Type II, 17% (18 of 107) of Type IIIA, 29% (9 of 31) of Type IIIB, and 20% (2 of 10) of Type IIIC open fractures. Each clinic visit of each patient was reviewed, and data about the time of onset of any symptoms and signs suggesting or confirming an FRI, as reported by patients and/or determined by treating surgeons, were recorded. The proportions of FRIs with onset by specific time periods were determined. A Kaplan-Meier survival analysis was performed, and the FRI event rates with 95% confidence intervals were calculated. RESULTS The median (IQR) time to the onset of FRI was 52 days (IQR 15 to 153). Follow-up of 90 days captured only 64% (30 of 47) of FRIs, whereas follow-up of 1 year captured 89% (42 of 47) of FRIs. The proportion of FRIs with onset within 1 year increased to 95% (42 of 44) in the presence of an already healed fracture. CONCLUSION Follow-up of 90 days after the management of an open long-bone fracture is inadequate for postoperative surveillance, especially for research purposes. Clinical research on interventions would report results appearing to be much better than they really are, potentially resulting in misleading conclusions. Follow-up of 1 year is preferable because most FRIs will develop before that time, especially when fracture union has occurred. A small percentage of patients may still develop infections beyond the first year after the management of an open fracture. The risk of missing these infections by not extending follow-up beyond 1 year must be balanced against the additional logistical burden. Future prospective multicenter studies and registries with long-term patient follow-up would help clarify this issue.Level of Evidence Level III, diagnostic study.
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Affiliation(s)
- Charalampos G. Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Laurens Aerden
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Declercq
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- KU Leuven – Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - Ann Belmans
- KU Leuven – University of Leuven & Universiteit Hasselt, I-BioStat, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven – Department of Development and Regeneration, University of Leuven, Leuven, Belgium
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20
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Bhatnagar A, Al-Hihi M, Ali R, Sharma N, Lai P, Monga A, Hadidchi S, Kayder O, Amalraj B, Kordbacheh H, Johnson S, Abujudeh H, Paxton JH, Lewis N. Imaging Utilization Patterns and Injury Characteristics Associated with Electric Standing Scooters in a Major Urban Area. J Emerg Med 2021; 62:182-190. [PMID: 34963516 DOI: 10.1016/j.jemermed.2021.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 10/07/2021] [Accepted: 10/17/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The recent proliferation of electric standing scooters in major urban areas of the United States has been accompanied by injuries of varying severity and nature, representing a growing public health concern. OBJECTIVE Our aim was to characterize imaging utilization patterns for injuries associated with electric scooter (e-scooter) use, including their initial emergency department (ED) management. METHODS We conducted a retrospective review of the electronic medical record for all patients presenting to affiliated EDs for e-scooter-related injuries between July 2018 and April 2020. Demographics, date and time of presentation, imaging study type, resultant injury, and procedural details were recorded. RESULTS Ninety-seven patients were included; mean age was 27.6 years. Of these, 55 patients (57%) had injuries identified on imaging and 40% of all imaging studies were positive. Most identified injuries (61%) were musculoskeletal, with a small number of neurological (2%) and genitourinary (1%) injuries. The highest prevalence of presentations occurred in August; most patients (72%) presented between 3 pm and 1 am and granular peaks were between 12 am and 1 am and 5 pm and 6 pm. CONCLUSIONS Patients presenting with e-scooter injuries have a high likelihood of injury to the radial head, nasal bone, and malleoli. Emergency physicians should be especially vigilant for injuries in these areas at presentation. Visceral injuries are uncommon but may be severe enough to warrant surgery.
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Affiliation(s)
- Akash Bhatnagar
- Department of Radiology, Wayne State University, School of Medicine, Detroit, Michigan
| | - Maysoon Al-Hihi
- Department of Radiology, Wayne State University, School of Medicine, Detroit, Michigan
| | - Rehan Ali
- Department of Radiology, Wayne State University, School of Medicine, Detroit, Michigan
| | - Neil Sharma
- Department of Radiology, Wayne State University, School of Medicine, Detroit, Michigan
| | - Patrick Lai
- Department of Radiology, Wayne State University, School of Medicine, Detroit, Michigan
| | - Akarshan Monga
- Department of Radiology, Wayne State University, School of Medicine, Detroit, Michigan
| | - Shahram Hadidchi
- Department of Radiology, Wayne State University, School of Medicine, Detroit, Michigan
| | - Orest Kayder
- Department of Radiology, Wayne State University, School of Medicine, Detroit, Michigan
| | - Benedict Amalraj
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, Michigan
| | - Hamed Kordbacheh
- Department of Radiology, Wayne State University, School of Medicine, Detroit, Michigan
| | - Samuel Johnson
- Department of Radiology, Wayne State University, School of Medicine, Detroit, Michigan
| | - Hani Abujudeh
- Department of Radiology, Wayne State University, School of Medicine, Detroit, Michigan
| | - James H Paxton
- Department of Emergency Medicine, Wayne State University, School of Medicine, Detroit, Michigan
| | - Nicholas Lewis
- Department of Radiology John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan
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O'Connell CR, Kooda KJ, Sawyer MD, Wise KB, Mara KC, Skrupky LP. Evaluation of Piperacillin-Tazobactam for Antibiotic Prophylaxis in Traumatic Grade III Open Fractures. Surg Infect (Larchmt) 2021; 23:41-46. [PMID: 34612703 DOI: 10.1089/sur.2021.122] [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: 11/13/2022] Open
Abstract
Background: Broad-spectrum antibiotic agents are sometimes utilized for prophylaxis of Gustilo grade III open fractures. However, this practice is not recommended by current guidelines, and it is unknown how patient outcomes are impacted. This study aimed to determine if prophylaxis with piperacillin-tazobactam (PT) results in different rates of infection versus guideline-concordant therapy (GCT). Patients and Methods: This was a single-center, retrospective cohort study of adult trauma patients with Gustilo grade III open long bone fractures admitted between January 2008 and August 2018. The primary outcome of infection (superficial or deep) at six weeks and secondary outcomes of delayed union, nonunion, Clostridioides difficile, and development of resistant organisms were abstracted from medical records. Guideline-concordant therapy was defined as a first-generation cephalosporin with or without an aminoglycoside. Univariable and multivariable analyses controlling for injury severity score (ISS) were performed. Results: One hundred twenty patients were included; 97 (81%) received PT, 23 (19%) received GCT. Common injury mechanisms were motor vehicle/motorcycle accident (57%) and falls (17%), and a majority involved a lower extremity (65%). Baseline characteristics were similar except higher median ISS in PT (14; interquartile range [IQR], 9-22) versus GCT (9; IQR, 9-14). Guideline-concordant therapy was given for a median of four (range, 2-8) days and PT for six (range, 3-11) days (p = 0.078). On univariable analysis, PT patients had more infections at six weeks (23.7% vs. 4.3%; p = 0.042), but multivariable analysis demonstrated no difference (odds ratio [OR], 5.81; 95% confidence interval [CI], 0.73-46.25; p = 0.096). Patients receiving prophylaxis with PT had a longer median length of stay at 16 days (range, 10-22) versus nine days (range, 4-16). No statistically significant differences in delayed union, non-union, Clostridioides difficile, or development of resistant organisms were observed. Conclusions: Broad-spectrum antibiotic prophylaxis with PT did not improve infection rates compared to GCT, suggesting it may not be warranted.
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Affiliation(s)
- Casey R O'Connell
- Department of Pharmacy Services, Mayo Clinic Hospital-Rochester, Rochester, Minnesota, USA
| | - Kirstin J Kooda
- Department of Pharmacy Services, Mayo Clinic Hospital-Rochester, Rochester, Minnesota, USA
| | - Mark D Sawyer
- Department of Surgery, Mayo Clinic Hospital-Rochester, Rochester, Minnesota, USA
| | - Kevin B Wise
- Department of Surgery, Mayo Clinic Hospital-Rochester, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic Hospital-Rochester, Rochester, Minnesota, USA
| | - Lee P Skrupky
- Department of Pharmacy Services, Mayo Clinic Hospital-Rochester, Rochester, Minnesota, USA
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Sakong S, Lim EJ, Cho JM, Choi NJ, Cho JW, Oh JK. The Effects of a Trauma Team Approach on the Management of Open Extremity Fractures in Polytrauma Patients: A Retrospective Comparative Study. JOURNAL OF TRAUMA AND INJURY 2021. [DOI: 10.20408/jti.2020.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Evaluation of a bone filler scaffold for local antibiotic delivery to prevent Staphylococcus aureus infection in a contaminated bone defect. Sci Rep 2021; 11:10254. [PMID: 33986462 PMCID: PMC8119729 DOI: 10.1038/s41598-021-89830-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/30/2021] [Indexed: 12/30/2022] Open
Abstract
We previously reported the development of an osteogenic bone filler scaffold consisting of degradable polyurethane, hydroxyapatite, and decellularized bovine bone particles. The current study was aimed at evaluating the use of this scaffold as a means of local antibiotic delivery to prevent infection in a bone defect contaminated with Staphylococcus aureus. We evaluated two scaffold formulations with the same component ratios but differing overall porosity and surface area. Studies with vancomycin, daptomycin, and gentamicin confirmed that antibiotic uptake was concentration dependent and that increased porosity correlated with increased uptake and prolonged antibiotic release. We also demonstrate that vancomycin can be passively loaded into either formulation in sufficient concentration to prevent infection in a rabbit model of a contaminated segmental bone defect. Moreover, even in those few cases in which complete eradication was not achieved, the number of viable bacteria in the bone was significantly reduced by treatment and there was no radiographic evidence of osteomyelitis. Radiographs and microcomputed tomography (µCT) analysis from the in vivo studies also suggested that the addition of vancomycin did not have any significant effect on the scaffold itself. These results demonstrate the potential utility of our bone regeneration scaffold for local antibiotic delivery to prevent infection in contaminated bone defects.
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Tahir M, Ahmed N, Shaikh SA, Jamali AR, Choudry UK, Khan S. Delay in Initial Debridement for Open Tibial Fractures and Its Possible Impact on Patient Outcomes: A Single-Center Prospective Cohort Study. JB JS Open Access 2021; 6:JBJSOA-D-20-00027. [PMID: 33748640 PMCID: PMC7963500 DOI: 10.2106/jbjs.oa.20.00027] [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: 11/14/2022] Open
Abstract
The current consensus regarding the management of open fracture indicates that the initial debridement should be performed within the first 6 hours after injury. Unfortunately, in Pakistan, the emergency medical services are not well-established and patient arrival at the hospital is delayed the majority of the time. In this study, we present our experience with delayed surgical management of open tibial fractures.
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Affiliation(s)
- Muhammad Tahir
- Department of Orthopedic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Nadeem Ahmed
- Department of Orthopedic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Saeed Ahmad Shaikh
- Department of Orthopedic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Allah Rakhio Jamali
- Department of Orthopedic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Usama Khalid Choudry
- Department of General Surgery, Shifa International Hospital, Islamabad, Pakistan
| | - Shoaib Khan
- Department of Orthopedic Surgery, Whiston Hospital, Prescot, United Kingdom
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Impact of duration of perioperative antibiotic prophylaxis on development of fracture-related infection in open fractures. Arch Orthop Trauma Surg 2021; 141:235-243. [PMID: 32409906 DOI: 10.1007/s00402-020-03474-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Infection is a common complication of open fractures potentially leading to nonunion, functional loss, and even amputation. Perioperative antibiotic prophylaxis (PAP) is standard practice for infection prevention in the management of open fractures. However, optimal duration of PAP remains controversial. The objectives were to assess whether PAP duration is independently associated with infection in open fractures and if administration of PAP beyond the commonly-recommended limit of 72 h has any effect on the infection rate. MATERIALS AND METHODS Over a 14-year period from 2003 to 2017, 530 skeletally-mature patients with operatively-treated, non-pathologic, long-bone open fractures were treated at one institution. Twenty-eight patients were excluded because of death or loss to follow-up and the remaining 502 patients (with 559 open fractures) who completed a 24-month follow-up were included in this retrospective study. The outcome was fracture-related infection (FRI), defined by the criteria of a recent consensus definition. A logistic generalized estimating equations regression model was conducted, including PAP duration and variables selected by a least absolute shrinkage and selection operator (LASSO) method, to assess the association between PAP duration and FRI. Propensity score analysis using a 72-h cut-off was performed to further cope with confounding. RESULTS PAP duration, adjusted for the LASSO selected predictors, was independently associated with FRI (OR: 1.11 [95%CI, 1.04-1.19] for every one-day increase in PAP duration, p = 0.003). PAP duration longer than 72 h did not significantly increase the odds for FRI compared to shorter durations (p = 0.06, analysis adjusted for propensity score). CONCLUSIONS This study found no evidence that administration of prophylactic antibiotics beyond 72 h in patients with long-bone open fractures is warranted. Analyses adjusted for known confounders even revealed a higher risk for FRI for longer PAP. However, this effect cannot necessarily be considered as causal and further research is needed.
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van den Kieboom J, Tirumala V, Xiong L, Klemt C, Kwon YM. Concomitant Hip and Knee Periprosthetic Joint Infection in Periprosthetic Fracture: Diagnostic Utility of Serum and Synovial Fluid Markers. J Arthroplasty 2021; 36:722-727. [PMID: 32893059 DOI: 10.1016/j.arth.2020.08.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Diagnosing periprosthetic joint infection (PJI) in patients with a periprosthetic fracture can be challenging due to concerns regarding the reliability of commonly used serum and synovial fluid markers. This study aimed at determining the diagnostic performance of serum and synovial fluid markers for diagnosing PJI in patients with a periprosthetic fracture of a total joint arthroplasty. METHODS A total of 144 consecutive patients were included: (1) 41 patients with concomitant PJI and periprosthetic fracture and (2) 103 patients with periprosthetic fracture alone. Serum markers erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and synovial markers white blood cell (WBC) count and polymorphonuclear percentage were assessed. RESULTS ESR demonstrated 87% sensitivity and 48% specificity at the Musculoskeletal Infection Society threshold, area under the curve (AUC) of 0.74, and optimal threshold of 45.5 mm/h (76% sensitivity, 68% specificity). CRP showed 94% sensitivity and 40% specificity, AUC of 0.68 with optimal threshold of 16.7 mg/L (84% sensitivity, 51% specificity). Synovial WBC count demonstrated 87% sensitivity and 78% specificity, AUC of 0.90 with optimal threshold of 4552 cells/μL (86% sensitivity, 85% specificity). Polymorphonuclear percentage showed 79% sensitivity and 63% specificity, AUC of 0.70 with optimal threshold of 79.5% (74% sensitivity, 63% specificity). The AUC of all combined markers was 0.90 with 84% sensitivity and 79% specificity. CONCLUSION The diagnostic utility of the serum and synovial markers for diagnosing PJI was lower in the setting of concomitant periprosthetic fracture compared to PJI alone. Using the Musculoskeletal Infection Society thresholds, ESR, CRP, and WBC count showed high sensitivity, yet low specificity, thus higher thresholds and utilizing all serum and synovial markers in combination should be considered.
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Affiliation(s)
- Janna van den Kieboom
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Venkatsaiakhil Tirumala
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Liang Xiong
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christian Klemt
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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The influence of biomechanical stability on bone healing and fracture-related infection: the legacy of Stephan Perren. Injury 2021; 52:43-52. [PMID: 32620328 DOI: 10.1016/j.injury.2020.06.044] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/16/2020] [Accepted: 06/24/2020] [Indexed: 02/02/2023]
Abstract
Bone healing is a complicated process of tissue regeneration that is influenced by multiple biological and biomechanical processes. In a minority of cases, these physiological processes are complicated by issues such as nonunion and/or fracture-related infection (FRI). Based on a select few in vivo experimental animal studies, construct stability is considered an important factor influencing both prevention and treatment of FRI. Stephan Perren played a pivotal role in the evolution of our current understanding of the critical relationship between biomechanics, fracture healing and infection. Furthermore, his concept of strain theory and the process of fracture healing is familiar to several generations of surgeons and has influenced implant development and design for the past 50 years. In this review we describe the role of biomechanical stability on fracture healing, and provide a detailed analysis of the preclinical studies addressing this in the context of FRI. Furthermore, we demonstrate how Perren's concepts of stability are still applied to current surgical techniques to aid in the prevention and treatment of FRI. Finally, we highlight the key knowledge gaps in the underlying basic research literature that need to be addressed as we continue to optimize patient care.
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Early complications of antibiotic prophylaxis with cefazolin protocols versus piperacillin-tazobactam for open fractures: a retrospective comparative study. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000932] [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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The Novel Role of Healing from Bacterial Infections of Lower Limb Open Fractures by X-Ray Exposure. Int J Microbiol 2020; 2020:3129356. [PMID: 32256601 PMCID: PMC7106931 DOI: 10.1155/2020/3129356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/25/2020] [Accepted: 02/21/2020] [Indexed: 11/17/2022] Open
Abstract
Objective To confirm the role of X-ray exposure in treating infected wound fractures at the lower limb and determine X-ray exposure times. Methods Fifty-one wound swabs were collected from patients with infected open fractures at the lower limb with grade II, IIIA, B, and C according to the Gustilo and Anderson classification system and then cultured. The bacterial isolates were identified by biochemical tests and the VITEK-2 System and tested against several antibiotics. The X-ray exposure was done for open fractures by radiography (at kV133 and 5 milliambers). Results The higher isolation rate was recorded for Staphylococcus aureus with 21 (41.2%) isolates, and most of them (20, 95.2%) were isolated from grade II fractures. The isolation rate of Gram-negative bacteria was 25.5% for Escherichia coli with 13 isolates, 19.6% for Pseudomonas aeruginosa with 10 isolates, and 13.7% for Klebsiella pneumoniae with 7 isolates, most of which were isolated from grade III fractures. The isolation rate of P. aeruginosa was 60% (6 isolates) from grade IIIA and 71.4% (5 isolates) from grade IIIB for K. pneumoniae, while for E. coli it was 69.2% (9 isolates) from grade IIIC. All the bacterial isolates recorded high levels of antibiotic resistance against most tested antibiotics. Wound cultures of grade II fractures appeared sterile after the first X-ray exposure, and these wounds were infected with S. aureus or P. aeruginosa. However, cultures of grade IIIA and IIIB fractures appeared sterile after the second X-ray exposure for all isolated bacteria, except for S. aureus (grade IIIA fractures) (after the third X-ray exposure). Grade IIIC fractures showed sterile culture after the third X-ray exposure for wounds infected with P. aeruginosa and E. coli. Conclusions The study concluded that X-ray exposure showed high effectiveness in treating infected open fractures.
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Abstract
Segmental bone loss continues to pose substantial clinical and technical challenges to orthopaedic surgeons. While several surgical options exist for the treatment of these complex patients, there is not a clear consensus or specific guidelines on the optimal management of these injuries as a whole. Many factors must be taken into consideration when planning surgery for these individuals. In order for these techniques to yield optimal results, each injury must be approached in a step-wise and multidisciplinary fashion to ensure that care is taken in bone and wound bed preparation, that soft tissues are healthy and free of contaminants, and that the patient's medical condition has been optimized. Through this article, we will answer relevant questions and discuss common obstacles and challenges encountered with these complex injuries. We will also review the many treatment options available or in development to address this problem.
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Foster AL, Moriarty TF, Trampuz A, Jaiprakash A, Burch MA, Crawford R, Paterson DL, Metsemakers WJ, Schuetz M, Richards RG. Fracture-related infection: current methods for prevention and treatment. Expert Rev Anti Infect Ther 2020; 18:307-321. [DOI: 10.1080/14787210.2020.1729740] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Andrew L Foster
- AO Research Institute Davos, Davos, Switzerland
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, Australia
- Department of Orthopaedic Surgery, Royal Brisbane and Women’s Hospital, Queensland, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women’s Hospital, Queensland, Australia
| | | | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Septic Unit Charité-Universitätsmedizin, Berlin, Germany
| | - Anjali Jaiprakash
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, Australia
| | | | - Ross Crawford
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, Australia
| | - David L Paterson
- University of Queensland Centre of Clinical Research (UQCCR), Brisbane, Australia
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Belgium
| | - Michael Schuetz
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, Australia
- Department of Orthopaedic Surgery, Royal Brisbane and Women’s Hospital, Queensland, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women’s Hospital, Queensland, Australia
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32
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Raghuram A, Singh A, Chang DK, Nunez M, Reece EM. Bone Grafts, Bone Substitutes, and Orthobiologics: Applications in Plastic Surgery. Semin Plast Surg 2019; 33:190-199. [PMID: 31384235 DOI: 10.1055/s-0039-1693020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
As reconstructive needs often extend past the soft tissue alone, a plastic surgeon must also be well versed in the methods of bony reconstruction. Understanding of the basic science of fracture healing and the biochemical mechanisms of the different bone grafts, bone substitutes, and orthobiologics is essential to selecting among the many different options available to the modern plastic surgeon. This review provides a broad overview of these different options and the specific applications for plastic surgeons based on anatomic location.
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Affiliation(s)
| | - Aspinder Singh
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Daniel K Chang
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Mervin Nunez
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Hao ZC, Xia Y, Xia DM, Zhang YT, Xu SG. Treatment of open tibial diaphyseal fractures by external fixation combined with limited internal fixation versus simple external fixation: a retrospective cohort study. BMC Musculoskelet Disord 2019; 20:311. [PMID: 31266474 PMCID: PMC6607594 DOI: 10.1186/s12891-019-2679-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 06/12/2019] [Indexed: 02/03/2023] Open
Abstract
Background The treatment of open tibial shaft fractures is challenging. External fixation (EF) is comparatively safe in treating these open injuries, meanwhile it has the advantages of easy application, minimal additional disruption, and convenient subsequent soft tissue repair. Nevertheless, its application is accompanied by a series of problems in alignment and bone healing. Therefore, limited internal fixation (LIF), such as cortical screws, has been used based on the external fixator for better therapeutic effect. The aim of this study is to compare the outcomes of EF combined with LIF and simple EF in the management of open tibial shaft fractures, evaluating the efficacy and safety of using the combined technique in treating such fractures. Methods From January 2012 to December 2016, patients with open tibial shaft fractures treated with EF with or without LIF augmentation were identified. A total of 152 patients were included in the analysis, and there were 85 patients in the simple external fixation group and 67 patients in the EF-LIF group. General assessment indicators included the direct cost of hospitalization and the times of first surgery, full weight bearing, and complete union. Infections and complications in union or limb alignment were compared as primary outcomes. Additionally, the number of patients who changed the fixation system for various reasons were analysed. Results Effective follow-up of all participants for statistical analysis was obtained. The follow-up time averaged 17.15 months (range: 12.00 to 24.00 months) in the EF group and 16.20 months (range: 12.00 to 19.00 months) in the EF-LIF group. Combined fixation provided shortened time to bear full weight and achieve complete bone union, while requiring additional first surgery time. No significant difference was found in infection rates or direct cost of hospitalization. Delayed union and non-union in the EF-LIF group were significantly decreased (20.9% versus 40.0, 1.5% versus 14.1%, p < 0.05). In limb alignment, patients with combined fixation exhibited reduced malreduction, loss of reduction, and malunion. In terms of secondary fixation, the EF-LIF group showed a markedly lower incidence (5.8% versus 34.1%, p < 0.001). Conclusion Compared with simple EF, combined fixation is an effective and safe alternative for management of open tibial diaphyseal fractures. It provides superior initial reduction, better stability and decreases the risk of inferior alignment and delayed union without increasing the risk of infection.
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Affiliation(s)
- Zi-Chen Hao
- Department of Emergency, Trauma Center, Changhai Hospital, The Second Military Medical University, No 168, Changhai Road, Yangpu District, Shanghai, 200433, People's Republic of China
| | - Yan Xia
- Department of Emergency, Trauma Center, Changhai Hospital, The Second Military Medical University, No 168, Changhai Road, Yangpu District, Shanghai, 200433, People's Republic of China
| | - De-Meng Xia
- Department of Emergency, Trauma Center, Changhai Hospital, The Second Military Medical University, No 168, Changhai Road, Yangpu District, Shanghai, 200433, People's Republic of China
| | - Yun-Tong Zhang
- Department of Emergency, Trauma Center, Changhai Hospital, The Second Military Medical University, No 168, Changhai Road, Yangpu District, Shanghai, 200433, People's Republic of China.
| | - Shuo-Gui Xu
- Department of Emergency, Trauma Center, Changhai Hospital, The Second Military Medical University, No 168, Changhai Road, Yangpu District, Shanghai, 200433, People's Republic of China.
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Abstract
There is a significant burden of disease associated with infected fractures, and their management is challenging. Prevention of infection after musculoskeletal trauma is essential because treatment of an established infection continues to be a major obstacle. Despite the need for evidence-based decision making, there is a lack of consensus around strategies for prevention and surgical management of the infected fracture. The current evidence for the prevention of the infected fracture is reviewed here with a focus on evidence for antibiotic therapy and debridement, the induced membrane technique, management of soft-tissue defects, patient optimization, and adjuncts to prevent infection.
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Johnson HC, Bailey AM, Baum RA, Justice SB, Weant KA. Compliance and Related Outcomes of Prophylactic Antibiotics in Traumatic Open Fractures. Hosp Pharm 2019; 55:193-198. [PMID: 32508357 DOI: 10.1177/0018578719836638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: Prophylactic antibiotic therapy is a standard of care for patients who present with open fractures due to the risk of infectious complications. This study was conducted to characterize the use of initial prophylactic antibiotic use in open fractures, guideline compliance, and its impact on care. Methods: Retrospective chart review of adult patients presenting with an open fracture to a Level 1 Trauma Center Emergency Department over a 12-month period was conducted. Results: Of the 202 patients meeting inclusion criteria, overall compliance with guideline recommendations for antibiotic prophylaxis was found to be 33.2%. The duration of prophylactic therapy was significantly longer in the noncompliant group and among those who received a secondary antibiotic (P < .05 for both comparisons). The duration of therapy was found to be significantly longer in those patients who developed an infection (P < .001). Those who developed an infection had a longer hospital length of stay (LOS) (P < .001) and intensive care unit LOS (P = .002). In addition, those who developed an infection had significantly more surgeries (P < .001) and received more red blood cell transfusions (P < .001). Correlation analysis confirmed a significant association between infection and duration of antibiotic prophylaxis (P = .02), number of surgeries (P < .0001), and number of transfusions (P < .0001). Conclusion: Guideline compliance was exceedingly low due to the extended duration of initial antibiotic therapy and did not appear to yield any clinical benefits. Infection was significantly associated with longer duration of initial prophylactic therapy and morbidity. Opportunities exist to elevate compliance with guidelines and to reevaluate prophylactic antimicrobial therapy in this setting.
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Affiliation(s)
| | - Abby M Bailey
- University of Kentucky College of Pharmacy, Lexington, KY, USA.,University of Kentucky HealthCare, Lexington, KY, USA
| | - Regan A Baum
- University of Kentucky College of Pharmacy, Lexington, KY, USA.,University of Kentucky HealthCare, Lexington, KY, USA
| | | | - Kyle A Weant
- Medical University of South Carolina, Charleston, SC, USA
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Chang Y, Bhandari M, Zhu KL, Mirza RD, Ren M, Kennedy SA, Negm A, Bhatnagar N, Naji FN, Milovanovic L, Fei Y, Agarwal A, Kamran R, Cho SM, Schandelmaier S, Wang L, Jin L, Hu S, Zhao Y, Lopes LC, Wang M, Petrisor B, Ristevski B, Siemieniuk RA, Guyatt GH. Antibiotic Prophylaxis in the Management of Open Fractures. JBJS Rev 2019; 7:e1. [DOI: 10.2106/jbjs.rvw.17.00197] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Kasha S, Rathore SS, Kumar H. Antibiotic Cement Spacer and Induced Membrane Bone Grafting in Open Fractures with Bone Loss: A Case Series. Indian J Orthop 2019; 53:237-245. [PMID: 30967691 PMCID: PMC6415560 DOI: 10.4103/ortho.ijortho_110_17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Open fractures are a difficult entity, often complicated by infection and nonunion. Bone loss in such fractures adds to the complexity. Conventional techniques of bone defect management are mainly directed toward fracture union but not against preventing infection or joint stiffness. In this case series, we evaluated Masquelet's technique for management of open fractures with bone loss. MATERIALS AND METHODS Twenty seven open fractures with bone defect, which presented within 3 days of trauma were planned for treatment by Masquelet's technique. Followup ranged from 21 to 60 months. RESULTS Average length of bone defect was 6 cm. Radiological union was obtained at a mean of 280 days since first stage of surgery. Time for union was not related to the size of defect. Union was faster in metaphyseal region (265.6 ± 38.8 days) as compared to diaphysis (300.9 ± 58.6 days). No patient had residual infection after stage 1. All the patients were able to mobilize with full weight bearing after radiological union with a satisfactory range of motion of adjacent joints. CONCLUSION This technique can be routinely applied in compound fractures with bone loss with good results. Chances of infection are reduced using antibiotic cement spacer as an adjunct to thorough debridement. Induced biomembrane revascularizes the graft. Union can be expected in most of the cases, however, long time to union is a limitation. Technique is cost-effective and does not require special training or instrumentation. Although it is a two-stage surgery, requirement of multiple surgeries, as may be needed in conventional methods, is avoided.
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Affiliation(s)
- Srinivas Kasha
- Department of Orthopaedics, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India,Address for correspondence: Dr. Srinivas Kasha, Department of Orthopaedics, Block III, 3rd Floor, Krishna Institute of Medical Sciences, Minister Road, Secunderabad - 500 003, Telangana, India. E-mail:
| | - Sameer Singh Rathore
- Department of Orthopaedics, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
| | - Hemanth Kumar
- Department of Plastic Surgery, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
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Harper KD, Quinn C, Eccles J, Ramsey F, Rehman S. Administration of intravenous antibiotics in patients with open fractures is dependent on emergency room triaging. PLoS One 2018; 13:e0202013. [PMID: 30106964 PMCID: PMC6091925 DOI: 10.1371/journal.pone.0202013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 07/26/2018] [Indexed: 12/28/2022] Open
Abstract
Background Recent literature has demonstrated that emergent administration of antibiotics is perhaps more critical than even emergent debridement. Most recent studies recommend patients receive antibiotics no later than 1 hour after injury to prevent infection. The objective of this study is to evaluate the time to antibiotic administration after patients with open fractures arrive to a trauma center depending on triaging team. Methods A retrospective study at a level 1 Trauma center from January 2013 to March 2015 where 117 patients with open fractures were evaluated. Patients who presented with open fractures of the extremities or pelvis were considered. Subjects were identified using Current Procedural Terminology (CPT) codes. Patients aged 18 and older were analyzed for Gustilo type, antibiotics administered in the emergency room (ER), presence of an antibiotic allergy, post-operative antibiotic regimen and number of debridements, among others. Additionally, whether a patient was triaged by ER doctors or trauma surgeons (and made a trauma activation) was evaluated. Outcome measurements included time to intravenous (IV) antibiotic administration and time to surgical debridement. Results Patients received IV cefazolin a median of 17 minutes after arrival. Eighty-five patients who were made trauma activations received cefazolin 14 minutes after arrival while 24 non-trauma patients received cefazolin 53 minutes after arrival (p = <0.0001). The median time to gentamicin administration for all patients was 180 minutes. Patients not upgraded to a trauma received gentamicin 263 minutes after arrival, while patients upgraded received gentamicin 176 minutes after arrival. There was no statistically significant difference between the timing to cefazolin or gentamicin based on Gustilo type. Conclusions Overall, patients that arrive at our institution with open fractures receive IV cefazolin significantly faster when trauma surgeons evaluate the patient. Additionally, delays in gentamicin administration are demonstrated in both triaging groups. This is due to the fact that cefazolin is stocked in the hospital ER, while gentamicin is commonly not due to weight-based dosing requirements precluding a standard dose. Improvements can be made to antibiotic administration of non-trauma patients and those requiring gentamicin via improved education and awareness of open fractures.
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Affiliation(s)
- Katharine D. Harper
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia PA, United States of America
- * E-mail:
| | - Courtney Quinn
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia PA, United States of America
| | - Joshua Eccles
- Lewis Katz School of Medicine at Temple University, Temple University School of Medicine, Philadelphia, PA, United States of America
| | - Frederick Ramsey
- Lewis Katz School of Medicine at Temple University, Department of Clinical Sciences, Temple University School of Medicine, Philadelphia, PA, United States of America
| | - Saqib Rehman
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia PA, United States of America
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Streifel BC, Lundin JG, Sanders AM, Gold KA, Wilems TS, Williams SJ, Cosgriff‐Hernandez E, Wynne JH. Hemostatic and Absorbent PolyHIPE–Kaolin Composites for 3D Printable Wound Dressing Materials. Macromol Biosci 2018; 18:e1700414. [DOI: 10.1002/mabi.201700414] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/23/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Benjamin C. Streifel
- Chemistry Division Naval Research Laboratory 4555 Overlook Avenue SW Washington DC 20375 USA
| | - Jeffrey G. Lundin
- Chemistry Division Naval Research Laboratory 4555 Overlook Avenue SW Washington DC 20375 USA
| | - Allix M. Sanders
- National Cancer Institute/National Institutes of Health Frederick MD 21701 USA
| | - Karli A. Gold
- Department of Biomedical Engineering Texas A&M University College Station TX 77843 USA
| | - Thomas S. Wilems
- Department of Biomedical Engineering Texas A&M University College Station TX 77843 USA
| | - Sierra J. Williams
- Chemistry Division Naval Research Laboratory 4555 Overlook Avenue SW Washington DC 20375 USA
| | | | - James H. Wynne
- Chemistry Division Naval Research Laboratory 4555 Overlook Avenue SW Washington DC 20375 USA
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Daşar U, Mutlu T, Ülker A, Satılmış AB, Ersan Ö. Erişkin Tibia Diafiz Kırıklarının Cerrahi Tedavisinde Kilitli İntramedüller Çivi Uygulaması. ACTA MEDICA ALANYA 2018. [DOI: 10.30565/medalanya.372916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Hu R, Ren YJ, Yan L, Yi XC, Ding F, Han Q, Cheng WJ. Analysis of Staged Treatment for Gustilo Anderson IIIB/C Open Tibial Fractures. Indian J Orthop 2018; 52:411-417. [PMID: 30078901 PMCID: PMC6055460 DOI: 10.4103/ortho.ijortho_344_16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Gustilo Anderson III B/C open tibial fractures are more difficult to manage than I, II, and III A fractures. These open tibial fractures are often associated with wound infection, soft tissue necrosis, bone nonunion, osteomyelitis or amputation. Staged treatment for this severe trauma is very necessary. MATERIALS AND METHODS 25 cases of Gustilo Anderson IIIB/C open tibial fractures with serious soft-tissue defects treated between January 2010 and January 2015 were included in this study. The treatment was administered in three stages. The first stage included emergency debridement, external fixation, repair of damaged main blood vessels and nerves, covering of the wound, and infection control. The second stage involved skin flap or skin graft placement to repair wounds. The third stage involved replacement of the external fixator with an internal fixator and the placement of bone grafts. RESULTS All the skin flaps or skin grafts survived, and a small necrotic area in the distal flap was observed in only two cases (which resolved spontaneously after the dressing was changed). Bone union occurred at the predicted time in 23 cases, while it was delayed in 2 cases. The rate of excellent and good was 88%. CONCLUSION Staged treatment was safe and effective for Gustilo Anderson IIIB/C tibial fractures. The timing for the placement of internal and external fixators and choosing the appropriate skin flap repair technique are important.
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Affiliation(s)
- Rui Hu
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi-Jun Ren
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,Address for correspondence: Dr. Yi-Jun Ren, Department of Reparative And Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan - 430 033, China. E-mail:
| | - Li Yan
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin-Cheng Yi
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fan Ding
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiong Han
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wen-Jun Cheng
- Department of Reparative and Reconstructive Surgery, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Abstract
Open fractures in children differ from adults owing to their better healing potential. Management strategies for open fracture in children are changing with improvement in our understanding of soft-tissue reconstruction and fracture fixation. A literature review was performed for articles covering management of open fractures in children. The cornerstones of management include prevention of infection, debridement, and skeletal stabilization with soft-tissue coverage. The injury should be categorized according to the established trauma classification systems. Timely administration of appropriate antibiotics is important for preventing infections. Soft-tissue management includes copious irrigation and debridement of the wound. Fractures can be stabilized by a variety of nonoperative and operative means, taking into consideration the special needs of the growing skeleton and the role of a thick and active periosteum in the healing of fractures. The soft-tissue coverage required depends on the grade of injury.
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Affiliation(s)
- Akshat Sharma
- Department of Paediatric Orthopaedics, KUMC GURO Hospital, Seoul, Korea,Address for correspondence: Dr. Akshat Sharma, 15, Nav Vikas Apartments, Sector – 15, Rohini, New Delhi - 110 089, India. E-mail:
| | - Vikas Gupta
- Central Institute of Orthopaedics, Safdarjung Hospital, New Delhi, India
| | - Kumar Shashikant
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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Bankhead-Kendall B, Gutierrez T, Murry J, Holland D, Agrawal V, Almahmoud K, Pearcy C, Truitt MS. Antibiotics and open fractures of the lower extremity: less is more. Eur J Trauma Emerg Surg 2017; 45:125-129. [DOI: 10.1007/s00068-017-0847-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 09/25/2017] [Indexed: 10/18/2022]
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Abstract
High-energy, open tibial shaft fractures may result in significant comminution, bone loss, and soft tissue injuries. Early, thorough debridement of all nonviable tissue is of critical importance in treating these fractures as an inadequate initial debridement increases the risk of infection and nonunion. Large iatrogenic bone and soft tissue defects can result from debridement and will require subsequent reconstruction by both orthopaedic and plastic surgeons. Although a variety of approaches exist to address these reconstructions, successful management of bone defects remains a considerable challenge. In this article, we detail our approach to debridement and reconstruction of segmental tibial defects and provide a review on the literature on this topic.
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Haug AT, Kanz KG, van Griensven M, Biberthaler P. Offene Fraktur. MMW Fortschr Med 2017; 159:56-58. [PMID: 28509014 DOI: 10.1007/s15006-017-9652-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alexander T Haug
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Techn. Universität München, Ismaninger Straße 22, D-81675, München, Deutschland.
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Abstract
Background Deep infection following open both bone forearm fractures is a rare complication. Prophylactic antibiotic regimens are targeted at the most common pathogens, which include primarily Staph aureus followed by gram-negative bacteria. Hafnia alvei is an unusual pathogen that is rarely pathogenic in humans and has never been reported as a cause of infection following open fracture. Methods We present a 12-year-old male with an open forearm fracture who developed a late deep infection. Cultures grew only Hafnia alvei. The patient was treated with debridement, placement of antibiotic beads, and ciprofloxacin. Results At 6 months following the initial debridement, the patient had no clinical evidence of infection and regained full function of the affected forearm without any residual deficits. Conclusions This is the first report of deep infection following an open forearm fracture owing to Hafnia alvei, a pathogen rarely responsible for human infection.
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Affiliation(s)
- Jody Litrenta
- Dept. of Orthopaedic Surgery, Children's National Medical Center, 111 Michigan Ave., Washington, DC 20010, United States
| | - Matthew Oetgen
- Dept. of Orthopaedic Surgery, Children's National Medical Center, 111 Michigan Ave., Washington, DC 20010, United States
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Surgical Site Infections in Patients With Type 3 Open Fractures: Comparing Antibiotic Prophylaxis With Cefazolin Plus Gentamicin Versus Piperacillin/Tazobactam. J Orthop Trauma 2016; 30:415-9. [PMID: 26825490 DOI: 10.1097/bot.0000000000000554] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to compare rates of surgical site infection (SSI) in patients with type 3 open fractures who had received cefazolin plus gentamicin versus piperacillin/tazobactam for antibiotic prophylaxis. DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENTS Seven hundred sixty-six patients admitted between January 1, 2004, and December 31, 2012, with open fractures were identified using the National Trauma Data Bank by searching International Classification of Diseases, Ninth Revision (ICD-9) codes. Electronic medical record review revealed 134 patients with type 3 open fractures, of which 72 were included in the final analysis. INTERVENTION Administration of cefazolin plus gentamicin or piperacillin/tazobactam for type 3 open fracture antibiotic prophylaxis. MAIN OUTCOME MEASUREMENTS SSI, nonunion, death, and rehospitalization rates at 1 year. RESULTS Surgical site infection at 1 year occurred in 12 of 37 patients (32.4%) in the cefazolin plus gentamicin group and 11 of 35 patients (31.4%) in the piperacillin/tazobactam group (P = 1.000). Nonunion, death, and rehospitalization rates at 1 year were similar between the 2 groups. Although there was no statistically significant difference in SSI at 30 days between groups, the rate was higher in the cefazolin plus gentamicin group (21.6% vs. 11.4%; P = 0.246). CONCLUSIONS At our institution, use of piperacillin/tazobactam as compared with cefazolin plus gentamicin for antibiotic prophylaxis in patients with type 3 open fractures showed similar rates of SSI, nonunion, mortality, and rehospitalization at 1 year after injury. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Traumatic Amputation of Finger From an Alligator Snapping Turtle Bite. Wilderness Environ Med 2016; 27:277-81. [PMID: 27116923 DOI: 10.1016/j.wem.2016.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 02/06/2016] [Accepted: 02/09/2016] [Indexed: 11/21/2022]
Abstract
Legend states that the alligator snapping turtle (Macrochelys temminckii) should be handled with extreme caution as it has jaw strength powerful enough to bite a wooden broomstick in half. Tales of bite injuries from what is the largest freshwater turtle in North America exist anecdotally, yet there are few descriptions of medical encounters for such. The risk of infection from reptilian bites to the hand in an aquatic environment warrants thorough antibiotic treatment in conjunction with hand surgery consultation. We present the first case report of a near total amputation of an index finger in an adolescent boy who had been bitten by a wild "gator snapper."
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Kara A, Celik H, Seker A, Karakoyun O, Armagan R, Kuyucu E, Erdil M. Treatment of open fractures with a computer-assisted external fixator system without the use of fluoroscopy. J Orthop Surg Res 2016; 11:51. [PMID: 27117827 PMCID: PMC4847187 DOI: 10.1186/s13018-016-0379-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 03/25/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Developed for the treatment of deformity correction, computer-assisted circular external fixators in recent years have also been used for fracture fixation. In this study, we aimed to present the efficacy of computer-assisted circular external fixator use in open long bone fractures with our new technique. METHODS Between February 2013 and June 2014, 14 patients (mean age 24.5 (range 20-32)) with open tibial or femoral open fractures were treated with the computer-assisted fixation system (Spider Frame-Tasarım Medikal, Istanbul, Turkey). In all patients, appropriate positions of the rings and Schanz screws were determined by measurements on preoperative radiographs. The length of the Schanz screws were determined by depth measure marks on drill bits. Obvious deformities were corrected intraoperatively by manipulations, but residual deformities were corrected by a software program (Spiderfix, Tasarım Medikal, Istanbul, Turkey). We did not use fluoroscopy during the procedures. RESULTS Ten patients had tibia diaphyseal and four patients had femoral diaphyseal fractures. Mean surgical time was 24.2 (range 18-28) min. Average follow-up time was 10.2 (range 9-14) months. Mean time for deformity correction was 3.1 (2-5) days. Complete union was observed in all patients with a mean of 4.9 (range 3-9) months. There were two grade 2 pin site infections treated with oral antibiotherapy and pin site care. We did not detect any Schanz screw breakage, loosening, deep infection, nonunion, or malunion. CONCLUSIONS Computer-assisted external fixation systems can be used in the treatment of open fractures, and they provide the chance for acute or gradual correction. Preoperative planning and assistant devices with depth measures may decrease the procedure time and the need for fluoroscopy use.
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Affiliation(s)
- Adnan Kara
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Haluk Celik
- Department of Orthopaedics and Traumatology, Zonguldak Ataturk State Hospital, Tepebası Mah, Kapuz Cad. Turkuaz apt. No: 28/10, 67030, Zonguldak, Turkey.
| | - Ali Seker
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Ozgur Karakoyun
- Faculty of Medicine, Department of Orthopaedics and Traumatology, Namık Kemal University, Tekirdag, Turkey
| | - Raffi Armagan
- Department of Orthopaedics and Traumatology, Sisli Hamidiye Etfal Research Hospital, Istanbul, Turkey
| | - Ersin Kuyucu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Mehmet Erdil
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
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