Complications and its impact in patients with closed and open tibial shaft fractures requiring open reduction and internal fixation

Prolonged Opioid Use and Associated Factors After Open Reduction and Internal Fixation of Tibial Shaft Fractures

BACKGROUND

The aim of this retrospective cohort study was to determine the rate of prolonged opioid use and identify associated risk factors after perioperative opioid exposure for tibial shaft fracture surgery.

MATERIALS AND METHODS

We used the MarketScan Commercial Claims and Encounters database (IBM) to identify patients 18 to 64 years old who filled a peri-operative opioid prescription after open reduction and internal fixation of a tibial shaft fracture from January 2016 to June 2020. Multivariable logistic regression identified factors (eg, demographics, comorbidities, medications) associated with prolonged opioid use (ie, filling an opioid prescription 91 to 180 days postoperatively); adjusted odds ratios (ORs) and 95% CIs were reported.

RESULTS

The rate of prolonged opioid use was 10.5% (n=259/2475) in the full cohort and 6.1% (n=119/1958) in an opioid-naive subgroup. In the full cohort, factors significantly associated with increased odds of prolonged use included preoperative opioid use (OR, 4.76; 95% CI, 3.60-6.29; P<.001); perioperative oral morphine equivalents in the 4th (vs 1st) quartile (OR, 2.68; 95% CI, 1.75-4.09; P<.001); age (OR, 1.03; 95% CI, 1.02-1.04; P<.001); and alcohol or substance-related disorder (OR, 1.66; 95% CI, 1.15-2.40; P=.01). Patients in the Northeast and North Central (vs South) regions had decreased odds of prolonged use (OR, 0.61-0.69; P=.02-.04). When removing preoperative use, findings were similar in the opioid-naive subgroup.

CONCLUSION

Prolonged opioid use is not uncommon in this orthopedic trauma population, with the strongest risk factor being preoperative opioid use. Nevertheless, shared risk factors exist between the opioid-naive and opioid-tolerant subgroups that can guide clinical decision-making. [Orthopedics. 2024;47(4):e188-e196.].

Preventing Atrophic Long-Bone Nonunion: Retrospective Analysis at a Level I Trauma Center

Background: Among the risk factors for nonunion are unchangeable patient factors such as the type of injury and comorbidities, and factors that can be influenced by the surgeon such as fracture treatment and the postoperative course. While there are numerous studies analyzing unchangeable factors, there is poor evidence for factors that can be affected by the physician. This raises the need to fill the existing knowledge gaps and lay the foundations for future prevention and in-depth treatment strategies. Therefore, the goal of this study was to illuminate knowledge about nonunion in general and uncover the possible reasons for their development; Methods: This was a retrospective analysis of 327 patients from 2015 to 2020 from a level I trauma center in Germany. Information about patient characteristics, comorbidities, alcohol and nicotine abuse, fracture classification, type of osteosynthesis, etc., was collected. Matched pair analysis was performed, and statistical testing performed specifically for atrophic long-bone nonunion; Results: The type of osteosynthesis significantly affected the development of nonunion, with plate osteosynthesis being a predictor for nonunion. The use of wire cerclage did not affect the development of nonunion, nor did the use of NSAIDs, smoking, alcohol, osteoporosis and BMI; Conclusion: Knowledge about predictors for nonunion and strategies to avoid them can benefit the medical care of patients, possibly preventing the development of nonunion.

Patient Comorbidities Associated With Acute Infection After Open Tibial Fractures

INTRODUCTION

Open tibial shaft fractures are high-risk injuries for developing acute infection. Prior research has focused on injury characteristics and treatment options associated with acute inpatient infection in these injuries without primary analysis of host factors. The purpose of this study was to determine the patient comorbidities associated with increased risk of acute infection after open tibial shaft fractures during initial hospitalization.

METHODS

A total of 147,535 open tibial shaft fractures in the National Trauma Data Bank from 2007 to 2015 were identified that underwent débridement and stabilization. Infection was defined as a superficial surgical site infection or deep infection that required subsequent treatment. The International Classification of Diseases, ninth revision codes were used to determine patient comorbidities. Comparative statistical analyses including odds ratios (ORs) for patient groups who did develop infection and those who did not were conducted for each comorbidity.

RESULTS

The rate of acute inpatient infection was 0.27% with 396 patients developing infection during hospital management of an open tibial shaft fracture. Alcohol use (OR, 2.26, 95% confidence interval [CI], 1.73-2.96, P < 0.0001), bleeding disorders (OR, 4.50, 95% CI, 3.13-6.48, P < 0.0001), congestive heart failure (OR, 3.25, 95% CI, 1.97-5.38, P < 0.0001), diabetes (OR, 1.73, 95% CI, 1.29-2.32, P = 0.0002), psychiatric illness (OR, 2.17, 95% CI, 1.30-3.63, P < 0.0001), hypertension (OR, 1.56, 95% CI, 1.23-1.95, P < 0.0001), obesity (OR, 3.05, 95% CI, 2.33-3.99, P < 0.0001), and chronic obstructive pulmonary disease (OR, 2.09, 95% CI, 1.51-2.91, P < 0.0001) were all associated with increased infection rates. Smoking (OR, 0.957, 95% CI, 0.728-1.26, P = 0.722) and drug use (OR, 1.11, 95% CI, 0.579-2.11, P = 0.7607) were not associated with any difference in infection rates.

DISCUSSION

Patients with open tibial shaft fractures who have congestive heart failure, bleeding disorders, or obesity are three to 4.5 times more likely to develop an acute inpatient infection than patients without those comorbidities during their initial hospitalization. Patients with diabetes, psychiatric illness, hypertension, or chronic obstructive pulmonary disease are 1.5 to 2 times more likely to develop subsequent infection compared with patients without those comorbidities. Patients with these comorbidities should be counseled about the increased risks. Furthermore, risk models for the infectious complications after open tibial shaft fractures can be developed to account for this more at-risk patient population to serve as modifiers when evaluating surgeon/hospital performance.

CONCLUSION

Patient comorbidities are associated with increased risk of acute inpatient infection of open tibial shaft fractures during hospitalization.

Risk factors for nonunion following surgically managed, traumatic, diaphyseal fractures: a systematic review and meta-analysis

Background

Methods

Results

Conclusion

C-reactive Protein Is a Diagnostic Tool for Postoperative Infection in Orthopaedics

Background

Orthopedic fracture-associated infection is a prevalent complication with a huge burden on the healthcare infrastructure. C-reactive protein (CRP) is a widely used serum inflammatory marker in patients with infections in orthopaedics. It could be difficult to distinguish between CRP elevation caused by surgical site infection and CRP elevation caused by surgery and trauma in orthopaedic procedures. In most situations, a clinical diagnosis of post-surgical infection is sufficient, however, the use of a biomarker with predictive value for acute post-op complications could prompt an earlier diagnosis. This study, therefore, aims at assessing CRP levels in post-operative orthopaedic trauma patients and determining the reliability of CRP as an early indicator of postoperative infection.

Materials and methods

A prospective study was conducted between December 2020 and November 2021 in the department of orthopaedics in Sri Devaraj Urs medical college, Kolar. Patients with an open and closed fracture of the upper and lower extremities treated by osteosynthesis on an elective or emergency basis were included. The clinical parameters were studied on the day of trauma, postoperative days first, third and seventh. Blood samples for CRP were taken prior to the surgical procedure and on the same days as clinical monitoring. The CRP levels were compared between patients with postoperative infection and patients without postoperative infections using independent samples t-test. A p-value of < 0.05 was considered statistically significant.

Results

A total of 51 patients were included in the study meeting the inclusion criteria, of which mean standard deviation for age was 37.5 (15.7%), 44 were men (86.2%) and seven were women (13.7%), Patients according to Tscherene classification grade I were 10 (19.6%), grade II were eight (15.6%), grade III were 15 (29.4%) and grade IV was 18 (35.2%), type of fracture surgery diaphyseal were 27 (52.9%), proximal was 11 (21.5%) and distal were 13 (25.4%). 15 patients developed postoperative infection with CRP levels of 96 µg/mL in nine (17.6%), 48 µg/mL in four (7.8%) and 24 µg/mL in two (3.9%). Thirty-six patients who did not develop post-operative infection had CRP levels of 6 µg/mL in 31 (60.8%) and 12 µg/mL in five (9.8%). The p-value for the first postoperative day was 0.289 and statistically insignificant and on the third and seventh postoperative days was <0.001 and was found to be statistically significant.

Conclusion

C-reactive protein is a useful parameter to detect and monitor post-operative infections in orthopaedic trauma surgeries. The rise in C-reactive protein on the third and seventh postoperative days can be used as a reliable predictor of post-operative infections.

Analysis of Risk Factors and Association of Cluster of Differentiation (CD) Markers With Conventional Markers in Delayed Fracture Related Infection for Closed Fracture

Background: Fracture-related infections (FRI) remain a difficult consequence for orthopedic trauma patients, their relatives, the treating physicians, and the healthcare systems. Delayed fracture-related infection is an important step in the infection process that can be controlled by diagnosing and preventing it from moving to the next level. Neutrophils CD64 and CD66b were identified as sensitive indicators in the event of infection. Normal sequential changes, on the other hand, occur after surgery and are extremely high. They are back to normal on the 10^th day after the operation. The aim of this study was, therefore, to examine the risk factors associated with fracture-related infection by comparing cluster of differentiation (CD) indicators with conventional markers and comparing them with gold standards culture reports. As a result, it could be an early sign of a closed fracture infection.

Material & Methods: Between February 2020 and March 2021, 510 patients from the Department of Orthopedics at King George Medical University in Lucknow agreed to participate in the study. The study included patients who had a closed fracture and had undergone elective or emergency surgery. Blood was withdrawn before the surgery (baseline) on day one and again on the third, seventh, and 10^th day after the operation to measure the quantitative measurements of the biomarkers (total leucocyte count [TLC], erythrocyte sedimentation rate [ESR], C reactive protein [CRP], CD64, and CD66b) in all follow-up examinations. Patients were monitored for delayed signs of the infection for 2 to 10 weeks. The biomarkers were evaluated and linked to the culture reports.

Results: Of the 510 patients included, 272 were men (53.3%) and 238 women (46.7%), the mean age was 40 (20-78), the mean age for fracture related infection with positive culture (FRI POS) was 48.0 (SD: 19.47), for fracture related infection with negative culture (FRI NEG) was 46.20 (SD: 17.18), and for patient with no signs of infections (NON-FRI) was 45.13 (SD: 17.62) (p <0.001), the mean duration of the fracture to admission (in hours) was 4.90 (SD: 1.92), 4.91 (SD: 2.65), and 5.14 (SD: 2.66) (p <0.001), respectively. The mean duration of admission to surgery (in hours) was 31.54 (SD: 85.14), 43.14 (SD: 105.64), and 61.84 (134.14), respectively (p <0.001). The mean duration of surgery was 4.63 (SD: 1.85), 5.14 (SD: 2.16), and 5.05 (SD: 2.16) (p <0.001). The risk factors such as bone type (p = 0.04) and addiction (p = 0.01) were identified as statistically significant. There was no correlation between the CD66b markers on the third, seventh, and 10^th days. CD64 was significantly correlated with ESR, TLC, and CRP on the 10^th day in the FRI-positive group (r = 0.638; p = 0.03) (r = 0.744; p = 0.009) (r = 0.817; p = 0.002).

Conclusion: The risk factors for infection in fracture patients are significantly influenced by the type of bone and addiction the patient is using. Elevated CD64 levels could be used as a diagnostic marker for infection early on the 10^th day after surgery before the appearance of clinical signs.

Evaluation of the costing methodology of published studies estimating costs of surgical site infections: A systematic review

OBJECTIVES

Surgical site infections (SSIs) are associated with increased length of hospitalization and costs. Epidemiologists and infection control practitioners, who are in charge of implementing infection control measures, have to assess the quality and relevance of the published SSI cost estimates before using them to support their decisions. In this review, we aimed to determine the distribution and trend of analytical methodologies used to estimate cost of SSIs, to evaluate the quality of costing methods and the transparency of cost estimates, and to assess whether researchers were more inclined to use transferable studies.

METHODS

We searched MEDLINE to identify published studies that estimated costs of SSIs from 2007 to March 2021, determined the analytical methodologies, and evaluated transferability of studies based on 2 evaluation axes. We compared the number of citations by transferability axes.

RESULTS

We included 70 studies in our review. Matching and regression analysis represented 83% of analytical methodologies used without change over time. Most studies adopted a hospital perspective, included inpatient costs, and excluded postdischarge costs (borne by patients, caregivers, and community health services). Few studies had high transferability. Studies with high transferability levels were more likely to be cited.

CONCLUSIONS

Most of the studies used methodologies that control for confounding factors to minimize bias. After the article by Fukuda et al, there was no significant improvement in the transferability of published studies; however, transferable studies became more likely to be cited, indicating increased awareness about fundamentals in costing methodologies.

Intramedullary nailing versus external fixation for open tibia fractures in Tanzania: a cost analysis

OBJECTIVES

Open tibia fractures pose a clinical and economic burden that is disproportionately borne by low-income countries. A randomized trial conducted by our group showed no difference in infection and nonunion comparing 2 treatments: external fixation (EF) and intramedullary nailing (IMN). Secondary outcomes favored IMN. In the absence of clear clinical superiority, we sought to compare costs between EF and IMN.

DESIGN

Secondary cost analysis.

SETTING

Single institution in Tanzania.

PATIENTS/PARTICIPANTS

Adult patients with acute diaphyseal open tibia fractures who participated in a previous randomized controlled trial.

INTERVENTION

SIGN IMN versus monoplanar EF.

MAIN OUTCOME MEASUREMENTS

Direct costs of initial surgery and hospitalization and subsequent reoperation: implant, instrumentation, medications, disposable supplies, and personnel costs.Indirect costs from lost productivity of patient and caregiver.Societal (total) costs: sum of direct and indirect costs.All costs were reported in 2018 USD.

RESULTS

Two hundred eighteen patients were included (110 IMN, 108 EF). From a payer perspective, costs were $365.83 (95% CI: $332.75-405.76) for IMN compared with $331.25 ($301.01-363.14) for EF, whereas from a societal perspective, costs were $2664.59 ($1711.22-3955.25) for IMN and $2560.81 ($1700.54-3715.09) for EF. The largest drivers of cost were reoperation and lost productivity. Accounting for uncertainty in multiple variables, probabilistic sensitivity analysis demonstrated that EF was less costly than IMN from the societal perspective in only 55% of simulations.

CONCLUSIONS

Intramedullary nail fixation compared with external fixation of open tibia fractures in a resource-constrained setting is not associated with increased cost from a societal perspective.

Diagnosing fracture related infections: Where are we now?

Accurate diagnosis of fracture related infection (FRI) is critical for preventing poor outcomes such as loss of function or amputation. Due to the multiple variables associated with FRI, however, accurate diagnosis is challenging and complicated by a lack of standardized diagnostic criteria. Limitations with the current gold standard for diagnosis, which is routine microbiology culture, further complicate the diagnostic and management process. Efforts to optimize the process rely on a foundation of data derived from prosthetic joint infections (PJI), but differences in PJI and FRI make it clear that unique approaches for these distinct infections are required. A more concerted effort focusing on FRI has dominated more recent investigations and publications leading to a consensus definition by the American Orthopedics (AO) Foundation and the European Bone and Joint Infection Society (EBJIS). This has the potential to better standardize the diagnostic process, which will not only improve patient care but also facilitate more robust and reproducible research related to the diagnosis and management of FRI. The purpose of this review is to explore the consensus definition, describe the foundation of data supporting current FRI diagnostic techniques, and identify pathways for optimization of clinical microbiology-based strategies and data.