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Chiu YC, Yang SC, Kao YH, Tu YK. Interim Use of Antibiotic-Loaded Cement Spacer for Patients with Infected Cervical Fusion. World Neurosurg 2024; 184:e511-e517. [PMID: 38316175 DOI: 10.1016/j.wneu.2024.01.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE The management of postoperative deep infection after anterior cervical discectomy and fusion (ACDF) remains challenging for spine surgeons. Our institution uses handmade antibiotic-loaded cement spacers to treat these complex cases. This study aimed to determine the efficacy and feasibility of this treatment. METHODS This study included 4 patients with deep cervical spine infections after ACDF who underwent our treatment between March 2012 and January 2022. Patients' laboratory data, visual analog scale scores, comorbidities, complications, and neurological status were recorded. Their clinical conditions were also evaluated based on the Neck Disability Index, Japanese Orthopaedic Association score, and Odom criteria. RESULTS Infection eradication was achieved in all patients after treatment. The average preoperative visual analog scale score was 7.5 (range: 7-8); this decreased to 1.25 (range: 1-2) at 1 year postoperatively. None of the patients experienced severe complications, such as neurological deterioration or bone graft dislodgement. The Neck Disability Index improved from a preoperative value of 54% (range: 48-60%) to 6% (range: 4-8%) at 1 year postoperatively. The Japanese Orthopaedic Association score improved from a preoperative score of 10.25 (range: 10-11)-14.75 (range: 14-16) at 1 year postoperatively. All patients achieved excellent outcomes based on Odom criteria at 1 year postoperatively. CONCLUSIONS Good clinical outcomes were achieved in this study. Although 2-stage surgery is required, this technique could be an alternative for patients with postoperative deep infection after ACDF.
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Affiliation(s)
- Yen-Chun Chiu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan; School of Chinese Medicine for Post Baccalaureate, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Shih-Chieh Yang
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
| | - Yu-Hsien Kao
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
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Vural S, Kuşdoğan M, Kaya HB, İkiz V, Albayrak L. Adalimumab (Humira®) Induced Recurrent Peritonsillar Abscess in A Patient Received Three Different Anti-TNF Therapies: A Case Report. Indian J Otolaryngol Head Neck Surg 2023; 75:1013-1015. [PMID: 37274971 PMCID: PMC10235369 DOI: 10.1007/s12070-022-03203-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 09/23/2022] [Indexed: 12/12/2022] Open
Abstract
Anti-tumor necrosis factor agents are widely used in treating ankylosing spondylitis, but they increase the risk of infection by suppressing the immune response. Therefore, physicians should be careful about recurrent infections in patients under anti-tumor necrosis factor agents.
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Affiliation(s)
- Sevilay Vural
- Department of Emergency Medicine, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Department of Emergency Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Mikail Kuşdoğan
- Department of Emergency Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Hasan Burak Kaya
- Department of Emergency Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Venhar İkiz
- Department of Emergency Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Levent Albayrak
- Department of Emergency Medicine, Yozgat Bozok University, Yozgat, Turkey
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Vosoughi AR, Medhati P, Hosseini E, Labidi M, Hoveidaei AH. Clinical outcomes following treatment of deep surgical site infection after fixation of calcaneal fractures: A retrospective case-control study. Foot Ankle Surg 2023; 29:334-340. [PMID: 37032190 DOI: 10.1016/j.fas.2023.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 03/20/2023] [Accepted: 04/01/2023] [Indexed: 04/11/2023]
Abstract
INTRODUCTION Deep surgical site infection (SSI) may be a complication of open reduction and internal fixation (ORIF) of calcaneal fractures. This study aimed to describe the characteristics of patients with deep SSI following ORIF of calcaneal fractures via extensile lateral approach (ELA). We compared clinical outcomes of these patients, with a minimum follow-up of one year after successful treatment of deep SSI with a matched control group. METHODS In this retrospective case-control study, demographic data, fracture characteristics, bacterial pathogens, medical treatments and surgical approaches were collected, also the outcome was evaluated by the visual analog scale (VAS) for pain, foot function index (FFI) and AOFAS ankle-hindfoot score. The differences in Böhler and Gissane's angles between infected and contralateral feet were measured. By matching a control group of uninfected cases, clinical outcomes were compared between 2 groups using the Mann-Whitney U test. RESULTS Among 331 calcaneus fractures in 308 patients (mean age, 38.0 ± 13.1; male/female ratio, 5.5), 21 had deep SSI (6.3 %). There were 16 (76.2 %) males and 5 (23.8 %) females with a mean age of 35.1 ± 11.7 years. Thirteen (61.9 %) patients had unilateral fractures. The most common Sanders Type was found to be type II. The most frequent type of detected microorganisms was Staphylococcus species. Intravenous antibiotic therapy, mostly clindamycin, imipenem and vancomycin, based on the microbiological results, was prescribed with a mean±SD duration of 28.1 ± 16.5 days. The mean number of surgical debridements was 1.8 ± 1.3. Implants needed to be removed in 16 (76.2 %) cases. Antibiotic-impregnated bone cement was applied in three (14.3 %) cases. The clinical outcomes of 15 cases (follow up, 35.5 ± 13.8; range, 12.6-64.5 months) were 4.1 ± 2.0, 16.7 ± 12.3 and 77.5 ± 20.8 for VAS for pain, FFI % and AOFAS ankle-hindfoot score, respectively. Comparing with the control group (VAS for pain, 2.3 ± 2.7; FFI %, 12.2 ± 16.6, and AOFAS, 84.6 ± 18.0), only VAS pain was statistically lower in this group (p-value: 0.012). The differences in Böhler and Gissane's angles between both feet of infected cases were - 14.3 ± 17.9 and - 7.7 ± 22.5 (worse in the infected side), respectively. CONCLUSION Proper on-time approaches to deep infection following ORIF of calcaneal fractures may lead to acceptable clinical and functional outcomes. Sometimes aggressive approaches with intravenous antibiotic therapy, multiple sessions of surgical debridement, removal of implants and antibiotic impregnated cement are necessary to eradicate deep infection. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Amir Reza Vosoughi
- Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Pourya Medhati
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elahe Hosseini
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
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Ashkenazi I, Amzallag N, Snir N, Morgan S, Garceau S, Kotz L, Gold A, Warschawski Y. Does addition of gentamicin for antibiotic prophylaxis in total knee arthroplasty reduce the rate of periprosthetic joint infection? Arch Orthop Trauma Surg 2022. [PMID: 36576575 DOI: 10.1007/s00402-022-04744-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND First-generation cephalosporins are used as antibiotic prophylaxis in total joint arthroplasty patients. However, this regimen does not address Gram-negative bacteria causing periprosthetic joint infection (PJI). Previous studies have suggested that the addition of an aminoglycoside as antibiotic prophylaxis in THA reduces surgical site infection (SSI), and less is known on its effect in TKA. This study aimed to investigate if the addition of a single-dose gentamicin, administered pre-operatively, is associated with lower rates of infection in TKA patients. PATIENTS AND METHODS This is a retrospective study of patients who underwent primary TKA as treatment for osteoarthritis between January 2011 and April 2021, with a minimum 1-year follow-up. The mean age was 69.9 (± 9.8), the mean BMI was 29.7 (± 5.5), and most patients had American Society of Anaesthesiology (ASA) score of 2-3 (92.9%). Patients were stratified based on the peri-operative antibiotic prophylaxis they received: cefazolin with addition of gentamicin (case group) or cefazolin (control group). Our primary study endpoints were rates of PJI and SSI, which were compared between groups using the chi-square test. Statistical significance was set as p < 0.05. RESULTS The final study population consisted of 1590 patients, 1008 (63.4%) in the control group and 582 (36.6%) patients in the case group. The total infection rate for patients that received gentamicin dropped by 34%; however, this finding did not reach statistical significance (1.3% (control) vs. 0.86% (case), p = 0.43). The same drop was seen after subdivision of infections to PJI (0.5% vs. 0.34%, 32% drop, p = 0.66) and SSI (0.8% vs. 0.52%, 35% drop, p = 0.52). CONCLUSIONS A single dose of gentamicin administered pre-operatively to a standard antibiotic prophylaxis was not associated with a statistically significant lower rate of PJI. Although the difference in infection rate did not reach statistical significance, the current study noted a drop in the rate of infection by 1/3 in the gentamicin cohort. Further investigation to evaluate the potential benefit of adding gentamicin to a peri-operative antibiotic regimen is warranted.
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van den Kieboom J, Tirumala V, Klemt C, Kwon YM. Outcome of Two-Stage Revision Total Hip and Knee Arthroplasty as a Salvage Procedure for Deep Infection of Peri-Articular Fracture Fixation: Propensity Score-Matched Study. Arch Bone Jt Surg 2022; 10:576-584. [PMID: 36032643 PMCID: PMC9382256 DOI: 10.22038/abjs.2022.51393.2541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 01/02/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Failed open reduction internal fixation (ORIF) of peri-articular fractures due to deep infection is associated with decreased functional outcomes and increased mortality rates. Two-stage revision total joint arthroplasty (TJA) is often needed as a salvage procedure. The aim of this study was to evaluate the outcome of two-stage revision total hip and knee arthroplasty as a salvage procedure for the treatment of deep infection of peri-articular fracture fixation. METHODS Using propensity score-matching, a total of 120 patients was evaluated: 1) 40 consecutive patients were treated with planned salvage two-stage revision for the treatment of deep peri-articular infection, and 2) a control group of 80 patients who underwent two-stage revision for periprosthetic joint infection (PJI) after non-IF TJA. An infection occurred after a fracture of the acetabulum (27.5%), femoral neck (22.5%), intertrochanteric femur (15.0%), subtrochanteric femur (5.0%), femoral shaft (7.5%), distal femur (5.0%), and tibia (15.0%). RESULTS At an average follow up of 4.5 years (range, 1.0-25.8), the overall failure rate was 42.5% for the IF group compared to 21.3% for the non-ORIF group (P=0.03). There was a significantly higher reinfection rate for the IF group compared to the non-IF group (35.0% vs. 11.3%, p=0.005). Tissue cultures for the IF patients demonstrated significantly higher polymicrobial growth (30.0% vs. 11.3%, P=0.01) and methicillin-resistant Staphylococcus aureus (20.0% vs. 7.5%, P=0.04). CONCLUSION Salvage two-stage revision arthroplasty for infected IF of peri-articular fractures was associated with poor outcome. The overall post-operative complications after salvage two-stage revision for infected IF of peri-articular fractures was high with 35% reinfection rates associated with the presence of mixed and resistant pathogens.
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Affiliation(s)
- Janna van den Kieboom
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Venkatsaiakhil Tirumala
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Christian Klemt
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Campbell ST, Taylor M, Dunbar RP, Firoozabadi R. Long-term sequelae of septic arthritis after tibial plateau fracture fixation: does timing matter? Arch Orthop Trauma Surg 2022; 142:955-959. [PMID: 33417025 DOI: 10.1007/s00402-020-03730-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/06/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Septic arthritis following surgical treatment of a tibial plateau fracture is a rare complication, but it does occur, and the impact on long-term function is relatively unknown. The purpose of this study was to determine the long-term sequelae of septic arthritis among patients treated with internal fixation for a tibial plateau fracture and to determine the effect of timing (early or late infection) on the rate of such sequela. MATERIALS AND METHODS A retrospective comparative study was designed using the trauma database of a single level I academic trauma center. Patients who developed culture-positive septic knee arthritis after internal fixation of a tibial plateau fracture, with 1-year follow-up, were included in the study. The number of debridement procedures required was recorded. Rates of long-term complications and implant removal were identified. Complications rates were compared between patients who developed early (within 30 days of definitive fixation) and late (more than 30 days) septic arthritis. RESULTS The mean number of debridement procedures per patient was six. Fourteen patients (88%) required implant removal, and thirteen (81%) developed knee arthritis. There was a significantly lower rate of complications in the early septic arthritis group compared to the late group (3 of 6 patients or 50%, vs 10 of 10 patients or 100%; p = 0.036). CONCLUSIONS Patients who developed septic arthritis following internal fixation of a tibial plateau fracture were likely to endure long-term sequelae. Early infection and detection led to fewer complications. Surgeons treating infectious complications in tibial plateau fracture patients should specifically seek to rule out septic arthritis, anticipate that implant removal may be necessary, and counsel these patients appropriately regarding the anticipated natural history of their condition. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Sean T Campbell
- Department of Orthopaedic Surgery, Harborview Medical Center, 325 9th Ave, Box 359798, Seattle, WA, 98104, USA.
| | - Mario Taylor
- Department of Orthopaedic Surgery, Harborview Medical Center, 325 9th Ave, Box 359798, Seattle, WA, 98104, USA
| | - Robert P Dunbar
- Department of Orthopaedic Surgery, Harborview Medical Center, 325 9th Ave, Box 359798, Seattle, WA, 98104, USA
| | - Reza Firoozabadi
- Department of Orthopaedic Surgery, Harborview Medical Center, 325 9th Ave, Box 359798, Seattle, WA, 98104, USA
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Abstract
AIMS This study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma. METHODS Data from the Wound Healing in Surgery for Trauma (WHiST) trial, which collected outcomes from 1,547 adult participants using self-completed questionnaires over a six-month period following major trauma, was used as the basis of this empirical investigation. Associations between deep SSI and NHS and personal social services (PSS) costs (£, 2017 to 2018 prices), and between deep SSI and quality-adjusted life years (QALYs), were estimated using descriptive and multivariable analyses. Sensitivity analyses assessed the impact of uncertainty surrounding components of the economic analyses. RESULTS Compared to participants without deep SSI, those with deep SSI had higher mean adjusted total NHS and PSS costs (adjusted mean difference £1,577 (95% confidence interval (CI) -951 to 4,105); p = 0.222), and lower mean adjusted QALYs (adjusted mean difference -0.015 (95% CI -0.032 to 0.002); p = 0.092) over six months post-injury, but this difference was not statistically significant. The results were robust to the sensitivity analyses performed. CONCLUSION This study found worse economic outcomes during the first six months post-injury in participants who experience deep SSI following orthopaedic surgery for major trauma to the lower limb. However, the increase in cost associated with deep SSI was less than previously reported in the orthopaedic trauma literature. Cite this article: Bone Jt Open 2022;3(5):398-403.
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Affiliation(s)
- May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ruth Knight
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - James Masters
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford, Oxford, UK
| | - Juul Achten
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford, Oxford, UK
| | - Matthew L. Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford, Oxford, UK
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Heiner JA, Banner KA, Wu VJ, Achor TS, Gary JL, Munz JW, Choo AM, Kellam JF, Warner SJ. The injury characteristics of open pilon fractures predictive of complications. Injury 2022; 53:1510-6. [PMID: 35067342 DOI: 10.1016/j.injury.2022.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 01/04/2022] [Accepted: 01/11/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Determine predictive injury factors for wound complications in open pilon fractures (OTA/AO 43B and 43C). DESIGN Retrospective Case Series. SETTING Level I Trauma Center. PATIENTS/PARTICIPANTS A total of 61 open pilon fractures in 60 patients were evaluated after meeting inclusion and exclusion criteria. INTERVENTION The majority of injuries underwent a staged protocol with immediate antibiotics, debridement, irrigation and external fixation. Following soft tissue stabilization, internal fixation was performed and wound closure achieved in a coordinated fashion depending on the type of closure required. MAIN OUTCOME MEASUREMENTS Early amputation rate, 90-day major (wound dehiscence or deep infection requiring operative intervention) and minor (superficial infection) wound complications. RESULTS Four patients incurred early amputations, 11 had major wound complications and 5 had minor wound complications. An early amputation was more likely if they presented with an OTA Open Fracture Classification (OTA-OFC) Bone Loss Grade 3. A major wound complication was more likely if they presented with a fall from > 3 m, a multifragmentary articular surface, a segmental fibula fracture, or an OTA-OFC Contamination Grade 3. A multifragmentary articular surface was also predictive of developing any wound complication. CONCLUSIONS Open pilon fractures are severe, limb-threatening injuries and are at risk for wound complications. Patients presenting with these injuries and a predictive factor should be counseled regarding the possibility of early limb loss or experiencing a wound complication that will require additional treatment. LEVEL OF EVIDENCE Level III.
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Hemmingsen MN, Larsen A, Ørholt M, Rasmussen LE, Weltz TK, Andersen PS, Sarmady F, Elberg JJ, Vester-Glowinski PV, Herly M. Hematoma and deep surgical site infection following primary breast augmentation: A retrospective review of 1128 patients. J Plast Reconstr Aesthet Surg 2021; 75:1197-1203. [PMID: 34924323 DOI: 10.1016/j.bjps.2021.11.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 04/22/2021] [Accepted: 11/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Breast augmentation is one of the most frequently performed cosmetic surgery worldwide. Some of the most severe short-term complications after breast augmentation are hematoma and deep surgical site infection. However, these complications are relatively rare; therefore, large patient populations are required to perform statistical analyses. In this study, we provide a detailed analysis of the complications after primary breast augmentation with an emphasis on deep surgical site infection and hematoma. METHOD We retrospectively reviewed the medical records of women who underwent primary breast augmentation without the use of pocket irrigation between 2012 and 2019 in a single private clinic. A cumulative hazard function and a multivariate analysis on the risk of hematoma were performed. RESULTS We included 1128 patients in the study. Thirty patients (2.7%) developed postoperative hematoma after a median time of 14 h (IQR 5 h-9 days). Six patients (0.5%) contracted a deep surgical site infection after a median time of 14 days (range 4-41 days). Age, BMI, implant volume, or implant placement was not significantly associated with hematoma. CONCLUSION Our findings support that the risk of hematoma after primary breast augmentation is highest within the first 24 h after the surgery. This time period should be considered when planning postoperative care for these patients. We did not find an increased rate of deep surgical site infection compared with studies of breast augmentations with pocket irrigation. Further studies and meta-analyses are needed to explore the effect of pocket irrigation and other risk factors.
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Affiliation(s)
- Mathilde N Hemmingsen
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen DK-2100, Denmark.
| | - Andreas Larsen
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Mathias Ørholt
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Louise E Rasmussen
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Tim K Weltz
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Peter S Andersen
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen DK-2100, Denmark; Amalieklinikken, Copenhagen, Denmark
| | - Faye Sarmady
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen DK-2100, Denmark; Amalieklinikken, Copenhagen, Denmark
| | | | - Peter V Vester-Glowinski
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Mikkel Herly
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen DK-2100, Denmark
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Higgin R, Dean M, Qureshi A, Hancock N. Outcomes following the delayed management of open tibial fractures. Injury 2021; 52:2434-2438. [PMID: 34158158 DOI: 10.1016/j.injury.2021.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/10/2021] [Accepted: 05/26/2021] [Indexed: 02/02/2023]
Abstract
AIMS National guidelines set standards for the definitive management of open fractures within 72 h. This study aims to investigate our outcomes where this timeline was unachievable for most cases due to a split-site orthoplastic service. PATIENTS & METHODS 116 consecutive Gustilo-Anderson grade IIIB & IIIC open tibial fractures presenting to our major trauma centre (MTC) between September 2012 and April 2018 were reviewed. The mean follow up was 46 months (17 to 88). 110 (95%) were grade IIIB and 6 (5%) grade IIIC. The most common injury mechanism included road traffic accidents (59%) and falls (28%). Primary outcomes were recorded according to; timing of initial debridement and definitive cover, rates of superficial and deep infection, non-union and amputation. Subgroups were statistically analysed according to time to initial debridement, definitive soft-tissue cover and injury severity score (ISS). RESULTS The mean time to initial debridement was 11.3 h (2.9 to 38.9) and definitive soft-tissue cover 9.9 days (0 to 37). We recorded rates of: superficial infection; 42 cases (36%), deep infection; 14 cases (12%) and non-union requiring revision; 19 cases (16%). There were 20 amputations (17%) with 9 (8.6%) performed early and 11 (9.5%) delayed. Subgroup analysis showed higher rates of superficial infection (50%, p = 0.002) and amputation (26.6%, p = 0.01) for those debrided <12 h. A greater presenting ISS related to a delay to definitive cover >7 days (p = 0.05). Primary outcomes trended worse for those covered >7 days but did not reach significance. CONCLUSION Major trauma patients are particularly vulnerable to poor outcomes resulting from the delay in definitive management of open fractures. MTC's need resources and a co-located orthoplastic service to achieve national standards and better outcomes. Current guidelines do not advise for the management of patients where a delay in definitive surgery is anticipated.
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Affiliation(s)
- Ryan Higgin
- Trauma & Orthopaedic Department, University Hospital Southampton, Tremona Road, Southampton SO16 6YD United Kingdom.
| | - Michael Dean
- Trauma & Orthopaedic Department, University Hospital Southampton, Tremona Road, Southampton SO16 6YD United Kingdom
| | - Amir Qureshi
- Trauma & Orthopaedic Department, University Hospital Southampton, Tremona Road, Southampton SO16 6YD United Kingdom.
| | - Nicholas Hancock
- Trauma & Orthopaedic Department, University Hospital Southampton, Tremona Road, Southampton SO16 6YD United Kingdom.
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Agni NR, Costa ML, Achten J, O'Connor H, Png ME, Peckham N, Dutton SJ, Wallis S, Milca S, Reed M. A randomized clinical trial of low dose single antibiotic-loaded cement versus high dose dual antibiotic-loaded cement in patients receiving a hip hemiarthroplasty after fracture: A protocol for the WHiTE 8 COPAL study. Bone Jt Open 2021; 2:72-78. [PMID: 33630700 PMCID: PMC7925209 DOI: 10.1302/2633-1462.22.bjo-2020-0174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture. METHODS The WHiTE 8 Copal Or Palacos Antibiotic Loaded bone cement trial (WHiTE 8 COPAL) is a multicentre, multi-surgeon, parallel, two-arm, randomized clinical trial. The pragmatic study will be embedded in the World Hip Trauma Evaluation (WHiTE) (ISRCTN 63982700). Participants, including those that lack capacity, will be allocated on a 1:1 basis stratified by recruitment centre to either a low dose single antibiotic-loaded bone cement or a high dose dual antibiotic-loaded bone cement. The primary analysis will compare the differences in deep SSI rate as defined by the Centers for Disease Control and Prevention within 90 days of surgery via medical record review and patient self-reported questionnaires. Secondary outcomes include UK Core Outcome Set for hip fractures, complications, rate of antibiotic prescription, resistance patterns of deep SSI, and resource use (more specifically, cost-effectiveness) up to four months post-randomization. A minimum of 4,920 patients will be recruited to obtain 90% power to detect an absolute difference of 1.5% in the rate of deep SSI at 90 days for the expected 3% deep SSI rate in the control group. CONCLUSION The results of this trial will provide evidence regarding clinical and cost-effectiveness between low dose single and high dose dual antibiotic-loaded bone cement, which will inform policy and practice guidelines such as the National Institute for Health and Care Excellence guidance on management of hip fractures. Cite this article: Bone Jt Open 2021;2(2):72-78.
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Affiliation(s)
- Nickil Ramesh Agni
- Trauma and Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - Matthew L Costa
- Oxford Trauma and Emergency Care, NDORMS, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Juul Achten
- Oxford Trauma and Emergency Care, NDORMS, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Heather O'Connor
- Oxford Clinical Trial Research Unit, NDORMS, University of Oxford, Oxford, UK
| | - May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicholas Peckham
- Oxford Clinical Trial Research Unit, NDORMS, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trial Research Unit, NDORMS, University of Oxford, Oxford, UK
| | - Stephanie Wallis
- Oxford Trauma and Emergency Care, NDORMS, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Svetlana Milca
- Oxford Trauma and Emergency Care, NDORMS, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Mike Reed
- Trauma and Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Ashington, UK
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12
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Santolini E, Stella M, Divano S, Ceccarelli M, Vicenti G, Bizzoca D, Santolini F. Optimum timing of conversion from DCO to definitive fixation in closed fractures of the lower limb: When and how? Injury 2020; 54 Suppl 1:S63-S69. [PMID: 32958344 DOI: 10.1016/j.injury.2020.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/18/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In damage control orthopaedics (DCO), fractures are initially stabilised with external fixation followed by delayed conversion to definitive internal fixation. The aim of this study is to determine whether the timing of the conversion influences the development of deep infection and fracture healing in a cohort of patients treated by DCO after a closed fracture of the lower limb. Furthermore, we wanted to evaluate whether the one-stage conversion procedure is always safe. MATERIALS AND METHODS A retrospective cohort study was conducted at a single level 1 trauma centre. Ninety-four cases of closed fractures of lower limb treated by DCO subsequently converted to internal fixation from 2012 to 2019 were included. Development of deep infection, superficial infection, non-union and time to union were recorded. Patients were then divided into three groups according to the timing of conversion: Group A (<7 days), Group B (7-13 days), Group C (> 14 days). Comparison between groups was performed to assess intergroup variabilty. RESULTS The mean number of days between DCO and conversion was 6.7±4.52 (range 1-22). We observed one case of deep infection (1.1%), one case of non-union (1.1%), four cases of superficial infection (4.3%) and mean time to union was ±1.38 months. Comparison between groups demonstrated no significant correlation between timing of conversion and development of superficial or deep infection and non-union, while it highlighted that complexity of the fracture and longer surgical time of conversion procedure were significantly higher in Group C. CONCLUSIONS One-stage conversion to definitive internal fixation within 22 days from DCO is a safe and feasible procedure, which does not influence the incidence of infection or non-union.
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Affiliation(s)
- Emmanuele Santolini
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10 - 16132, Genoa, Italy.
| | - Marco Stella
- Orthopedics and Trauma Unit, Ente Ospedaliero Ospedali Galliera, Mura delle Cappuccine 14 - 16148, Genoa, Italy
| | - Stefano Divano
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10 - 16132, Genoa, Italy
| | - Michele Ceccarelli
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10 - 16132, Genoa, Italy
| | - Giovanni Vicenti
- Department of Neuroscience and Sense Organs, Orthopaedics Section, University of Bari Aldo Moro, Bari, Italy
| | - Davide Bizzoca
- Department of Neuroscience and Sense Organs, Orthopaedics Section, University of Bari Aldo Moro, Bari, Italy
| | - Federico Santolini
- Orthopedics and Trauma Unit, Emergency Department, Ospedale Policlinico San Martino, Largo R. Benzi 10 - 16132, Genoa, Italy
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Hadeed MM, Evans CL, Werner BC, Novicoff WM, Weiss DB. Does external fixator pin site distance from definitive implant affect infection rate in pilon fractures? Injury 2019; 50:503-507. [PMID: 30409731 DOI: 10.1016/j.injury.2018.10.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/01/2018] [Accepted: 10/28/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Tibial pilon fractures are often treated with initial external fixation followed by delayed definitive fixation. It has been postulated that the external fixator pin site may correlate with infection risk. The purpose of this study was to determine whether external fixator pin-site distance from definitive implants impacts the risk of deep infection in pilon fractures. MATERIALS AND METHODS A retrospective cohort study was completed at a single level 1 trauma center. All patients ages 15-65 who underwent open reduction and internal fixation (ORIF) of a distal tibial fracture (AO/OTA Classification 43) from 2007 to 2013 were included. The final study population was 133 patients. The impact of external fixation pin location (relative to the definitive implant location) on postoperative infection was measured. RESULTS As a continuous variable, the distance between the closest pin site and plate was 62.1 ± 44.1 mm in the infected cohort and 62.2 ± 49.7 mm in the non-infected cohort (p = 0.991). Further analysis was performed by grouping the distances into less than 0 mm (i.e. overlapping), >0.0 - 25.0 mm, >25.0 - 50.0 mm, >50.0 - 75.0 mm, >75.0 - 100.0 mm, and >100.0 mm of separation. No significant differences were noted with regards to the risk for infection. CONCLUSIONS Staged care has been shown to be an effective treatment strategy for AO/OTA type 43 fractures. There are many variables to consider when placing an external fixator construct. In this cohort, pin site distance from definitive implant location was not associated with an increase in deep infections. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Michael M Hadeed
- University of Virginia, Department of Orthopaedic Surgery, Charlottesville, VA, United States.
| | - Cody L Evans
- University of Virginia, Department of Orthopaedic Surgery, Charlottesville, VA, United States
| | - Brian C Werner
- University of Virginia, Department of Orthopaedic Surgery, Charlottesville, VA, United States
| | - Wendy M Novicoff
- University of Virginia, Department of Orthopaedic Surgery, Charlottesville, VA, United States
| | - David B Weiss
- University of Virginia, Department of Orthopaedic Surgery, Charlottesville, VA, United States
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14
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Forsblom E, Kakriainen A, Ruotsalainen E, Järvinen A. Methicillin-sensitive Staphylococcus aureus bacteremia in aged patients: the importance of formal infectious specialist consultation. Eur Geriatr Med 2018; 9:355-363. [PMID: 29887924 PMCID: PMC5972166 DOI: 10.1007/s41999-018-0038-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 02/21/2018] [Indexed: 12/14/2022]
Abstract
Background Infectious specialist consultations (ISC) provide ever more evidence for improved outcome in Staphylococcus aureus bacteremia (SAB). Most ISC are formal (bedside). However, the impact of ISC on clinical management and prognosis lacks evaluation in aged patients with SAB. Methods Multicenter retrospective analysis of methicillin-sensitive (MS) SAB. Patients were stratified according to age ≥ 60 years (sub-analyses for ≥ 75 years and females) and formal (bedside) ISC given within 7 days of SAB diagnosis. The impact on management and outcome of formal ISC was explored. Statistics were performed with univariate analysis, Cox proportional hazards regression model analysis, including propensity-score adjustment, and graphic Kaplan–Meier interpretation. Results Altogether 617 patients were identified and 520 (84%) had formal ISC. Presence of formal ISC resulted in equivalent clinical management regardless of age over or under 60 years: localization and eradication of infection foci (80 vs. 82% and 34 vs. 36%) and use of anti-staphylococcal antibiotics (65 vs. 61%). Patients aged ≥ 60 years managed without formal ISC, compared to those with formal ISC, had less infection foci diagnosed (53 vs. 80%, p < 0.001). Lack of formal ISC in patients aged ≥ 60 years resulted in no infection eradication and absence of first-line anti-staphylococcal antibiotics. Formal ISC, compared to absence of formal ISC, lowered mortality at 90 days in patients aged ≥ 60 years (24 vs. 47%, p = 0.004). In Cox proportional regression, before and after propensity-score adjustment, formal ISC was a strong positive prognostic parameter in patients aged ≥ 60 years (HR 0.45; p = 0.004 and HR 0.44; p = 0.021), in patients aged ≥ 75 years (HR 0.18; p = 0.001 and HR 0.11; p = 0.003) and in female patients aged ≥ 75 years (HR 0.13; p = 0.005). Conclusion Formal ISC ensures proper active clinical management irrespective of age and improve prognosis in aged patients with MS-SAB.
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Affiliation(s)
- E Forsblom
- Division of Infectious Diseases, Inflammation Center, University of Helsinki and Helsinki University Central Hospital, Aurora Hospital, Nordenskiöldinkatu 26, Building 5, P.O. Box 348, 00029 HUS Helsinki, Finland
| | - A Kakriainen
- Division of Infectious Diseases, Inflammation Center, University of Helsinki and Helsinki University Central Hospital, Aurora Hospital, Nordenskiöldinkatu 26, Building 5, P.O. Box 348, 00029 HUS Helsinki, Finland
| | - E Ruotsalainen
- Division of Infectious Diseases, Inflammation Center, University of Helsinki and Helsinki University Central Hospital, Aurora Hospital, Nordenskiöldinkatu 26, Building 5, P.O. Box 348, 00029 HUS Helsinki, Finland
| | - A Järvinen
- Division of Infectious Diseases, Inflammation Center, University of Helsinki and Helsinki University Central Hospital, Aurora Hospital, Nordenskiöldinkatu 26, Building 5, P.O. Box 348, 00029 HUS Helsinki, Finland
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15
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Metsemakers WJ, Smeets B, Nijs S, Hoekstra H. Infection after fracture fixation of the tibia: Analysis of healthcare utilization and related costs. Injury 2017; 48:1204-1210. [PMID: 28377260 DOI: 10.1016/j.injury.2017.03.030] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 03/21/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION One of the most challenging complications in musculoskeletal trauma surgery is the development of infection after fracture fixation (IAFF). It can delay healing, lead to permanent functional loss, or even amputation of the affected limb. The main goal of this study was to investigate the total healthcare costs and length-of-stay (LOS) related to the surgical treatment of tibia fractures and furthermore identify the subset of clinical variables driving these costs within the Belgian healthcare system. The hypothesis was that deep infection would be the most important driver for total healthcare costs. PATIENTS AND METHODS Overall, 358 patients treated operatively for AO/OTA type 41, 42, and 43 tibia fractures between January 1, 2009 and January 1, 2014 were included in this study. A total of 26 clinical and process variables were defined. Calculated costs were limited to hospital care covered by the Belgian healthcare financing system. The five main cost categories studied were: honoraria, materials, hospitalization, day care admission, and pharmaceuticals. RESULTS Multivariate analysis showed that deep infection was the most significant characteristic driving total healthcare costs and LOS related to the surgical treatment of tibia fractures. Furthermore, this complication resulted in the highest overall increase in total healthcare costs and LOS. Treatment costs were approximately 6.5-times higher compared to uninfected patients. CONCLUSION This study shows the enormous hospital-related healthcare costs associated with IAFF of the tibia. Treatment costs for patients with deep infection are higher than previously mentioned in the literature. Therefore, future research should focus more on prevention rather than treatment strategies, not only to reduce patient morbidity but also to reduce the socio-economic impact.
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Affiliation(s)
- Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium.
| | - Bart Smeets
- University Hospitals Leuven, Care Program Management, B-3000 Leuven, Belgium
| | - Stefaan Nijs
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
| | - Harm Hoekstra
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
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16
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Su H, Li L, Cheng B, Zhu J, Zhang Q, Xu J, Zhu M. Trichophyton rubrum Infection Characterized by Majocchi's Granuloma and Deeper Dermatophytosis: Case Report and Review of Published Literature. Mycopathologia. 2017;182:549-554. [PMID: 28004227 DOI: 10.1007/s11046-016-0099-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023]
Abstract
Infections caused by Trichophyton rubrum are very common in dermatological disease. It most often appears as superficial cutaneous mycosis, such as tinea manuum, tinea pedis, and tinea corporis. However, deep infection caused by T. rubrum was rarely reported. We describe a case of mixed type of deep infection caused by T. rubrum in a 45-year-old man with no significant immunodeficiency. This patient had a history of onychomycosis on the toenails without regular treatment for nearly 6 years. And, he had erythema, papule, and nodules on the submandibular area, neck, and chest for almost 1 year. After treated with intravenous infusion of cefotiam for 2 weeks, the lesion aggravated. The fungal direct microscopic examination of pyogenic fluid was positive, and the fungal cultures that produced reddish-brown and yellow pigment showed cottony, wooly, and white colony. After the DNA sequencing, it was identified as T. rubrum. We gave the patient oral terbinafine 250 mg per day and bifonazole cream for external use. Six months later, the patient's skin lesion was disappeared, and healthy nail growth was seen in two-thirds of nail bed. The terbinafine is effective against deep infection caused by T. rubrum.
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17
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Reilly RM, Robertson T, O'Toole RV, Manson TT. Are antibiotic nails effective in the treatment of infected tibial fractures? Injury 2016; 47:2809-2815. [PMID: 27823759 DOI: 10.1016/j.injury.2016.10.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 10/16/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Antibiotic-impregnated cement nails are used to treat postoperative deep infections after primary intramedullary nail insertion for the treatment of tibial fractures. Few data exist regarding the efficacy of this treatment strategy. We hypothesized that such treatment with antibiotic nails results in a high rate of infection clearance at intermediate follow-up. METHODS We conducted a retrospective review at our Level I trauma center. Patients who received intramedullary nails to stabilize tibial fractures (from 2000 to 2011) and subsequently required antibiotic nails to treat deep postoperative infection (n=55) were considered for study inclusion. Patients with less than 6 months of follow-up were excluded, leaving 41 patients in the study group (average age, 41 years; average follow-up, 20 months). RESULTS Thirty-one patients (76%) had no evidence of infection after treatment. The 10 patients for whom treatment failed were shown to have infection within the first 6 months. Two experienced persistent infection after antibiotic nail removal, necessitating massive débridement and ring fixator placement. Four patients underwent repeat antibiotic nail insertion after persistent infection. Three infections resulted in eventual above-knee amputations, and one chronic infection resulted in the need for multiple débridement and saucerization procedures. No complications associated with use of the antibiotic nails were observed. CONCLUSION The use of antibiotic nails for treatment of tibial infections seems to be a reasonable option, clearing 76% of infections at the 6-month time frame. Further investigation is needed to compare this treatment algorithm with other strategies, such as antibiotic treatment without nail removal and massive débridement with ring fixator placement.
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Affiliation(s)
- Rachel M Reilly
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Thomas Robertson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Theodore T Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States.
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18
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Nakano N, Matsumoto T, Ishida K, Tsumura N, Muratsu H, Hiranaka T, Kuroda R, Kurosaka M. Factors influencing the outcome of deep infection following total knee arthroplasty. Knee 2015; 22:328-32. [PMID: 25937092 DOI: 10.1016/j.knee.2015.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/10/2015] [Accepted: 04/15/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Whereas clinical studies have revealed a number of important risk factors for postoperative infection following total knee arthroplasty (TKA), it is unclear which factor influences clinical results. A multicenter study was therefore performed by reviewing 51 patients with deep infection after TKA and seeking for the factors related to clinical outcomes. METHODS Fifty-one deep infections after TKA were treated from 2000 to 2011 at the multicenter including a university or three arthroplasty centers. Among them, two clinical outcome measures including retention of prosthesis at initial treatment and functional prosthetic knee were assessed for several factors such as age, sex, primary diagnosis, onset time after primary TKA, type of hospital where the primary TKA was performed and the organism's resistance to methicillin using the logistic regression analysis model. RESULTS Among the factors, type of hospital where the primary TKA was performed and onset time after primary TKA had higher multivariable-adjusted odds ratios (ORs) for retention of primary prosthesis (ORs 35.21 and 11.69, respectively.). The cases which primary surgery were performed in arthroplasty centers had higher multivariable-adjusted ORs for functional prosthetic knee (OR 4.9). Thirty-one infection cases with non-methicillin-resistant organisms were all able to keep functional prosthetic knee after the operation, whereas 13 out of 20 infection cases with methicillin-resistant organisms lost their knee function after the operation. CONCLUSIONS Onset time after primary TKA, type of hospital where the primary surgery was performed and the organism's resistance to methicillin are important factors influencing the clinical outcomes after infected TKA. LEVEL OF EVIDENCE Level 3. Retrospective comparative study.
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Affiliation(s)
- Naoki Nakano
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
| | - Kazunari Ishida
- Department of Orthopaedic Surgery, Kobe Kaisei Hospital, 3-11-15 Shinoharakitamachi, Nada-ku, Kobe 657-0068, Japan
| | - Nobuhiro Tsumura
- Department of Orthopaedic Surgery, Hyogo Rehabilitation Center Hospital, 1070, Akebono-cho, Nishi-ku, Kobe 651-2134, Japan
| | - Hirotsugu Muratsu
- Department of Orthopaedic Surgery, Steel Memorial Hirohata Hospital, 3-1 Yumesaki-cho, Hirohata-ku, Himeji 671-1122, Japan
| | - Takafumi Hiranaka
- Department of Orthopaedic Surgery, Takatsuki General Hospital, 1-3-13, Kosobe-cho, Takatsuki 569-1115, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Masahiro Kurosaka
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
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19
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Schroeder JE, Girardi FP, Sandhu H, Weinstein J, Cammisa FP, Sama A. The use of local vancomycin powder in degenerative spine surgery. Eur Spine J 2015; 25:1029-33. [PMID: 26249032 DOI: 10.1007/s00586-015-4119-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/08/2015] [Accepted: 07/08/2015] [Indexed: 12/27/2022]
Abstract
PURPOSE Wound infection after spine surgery is a debilitating complication. Local placement of vancomycin powder into the surgical wounds prior to closing of the fascia has been introduced as a method to reduce deep infection rates. METHODS The infection rates of all the patients who were treated with intra-operative local vancomycin between June 2012 and June 2013 were compared to all cases that were not treated with vancomycin between January 2009 and December 2010. Patients for both groups were operated by four senior, fellowship-trained spine surgeons with a combined experience of 55 years of practice at a referral orthopedic center. Patients' charts and microbiology reports were reviewed. RESULTS 1224 cases were performed with the use of vancomycin. The average age was 56.3 years (SD -13.2; NS). The male to female ratio was 1:1.12 (NS). 2253 cases were performed without the use of vancomycin. The average patient age was 57.1 years (SD 14.5). The male to female ratio was 1:1.14. There were 30 cases of deep infections needing a surgical irrigation and debridement without vancomycin versus 5 when vancomycin was used (P = 0.04). Infections in patients treated with vancomycin were not vancomycin-resistant bacteria. CONCLUSION In conclusion, the use of vancomycin reduces the rate of deep wound infections and irrigation and debridement procedures after spine surgery in a referral center among surgeons with a high surgical volume.
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Affiliation(s)
- Josh E Schroeder
- Spine Surgery, Hospital for Special Surgery, 525 East 70 St, New York, NY, 10021, USA.
| | - Fredrico P Girardi
- Spine Surgery, Hospital for Special Surgery, 525 East 70 St, New York, NY, 10021, USA
| | - Harvinder Sandhu
- Spine Surgery, Hospital for Special Surgery, 525 East 70 St, New York, NY, 10021, USA
| | - Joseph Weinstein
- Spine Surgery, Hospital for Special Surgery, 525 East 70 St, New York, NY, 10021, USA
| | - Frank P Cammisa
- Spine Surgery, Hospital for Special Surgery, 525 East 70 St, New York, NY, 10021, USA
| | - Andrew Sama
- Spine Surgery, Hospital for Special Surgery, 525 East 70 St, New York, NY, 10021, USA
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Ovaska MT, Madanat R, Honkamaa M, Mäkinen TJ. Contemporary demographics and complications of patients treated for open ankle fractures. Injury 2015; 46:1650-5. [PMID: 25935358 DOI: 10.1016/j.injury.2015.04.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 04/10/2015] [Indexed: 02/02/2023]
Abstract
Open ankle fractures are rare injuries with a high likelihood of wound complications and subsequent infections. There is limited information about the complications and outcomes of these injuries in different age groups. The aim of this study was to assess the contemporary demographics and complications related to this injury. We performed a chart review of all the 3030 patients treated for ankle fractures at a Level 1 trauma centre from 2006 to 2011. 137 (4.5%) patients had an open ankle fracture. The demographic data, injury mechanism, comorbidities, and fracture type were collected. Treatment, complications, length of stay and number of outpatient visits were also recorded. The mean age of the patients was 60 years and 56% were women. Most fractures were Weber type B with a medial sided wound (93%). Only 20% of the fractures were the result of high-energy trauma, and 31% were Gustilo grade III injuries. Immediate internal fixation was performed in 82% of patients, and the wound was primarily closed in most cases (80%). The incidence of postoperative wound necrosis and deep infection was 18% and 17%, respectively. There were more deep infections if pulsatile lavage was used during the wound debridement (p=0.029). About 14 (10%) patients required a flap reconstruction to cover the soft-tissue defect. Every other patient (54%) had a complication, and 21 patients (15%) suffered a long-term disability related to the injury. The number complications did not differ for nighttime and daytime operations (p=0.083). High-energy injuries were more common in younger patients (p<0.001) and these patients also had more lateral sided open wounds than older patients (p=0.002). Interestingly, younger patients also had significantly more complications (p=0.024), suffered more often from chronic pain (p=0.003), and required more flap reconstructions (p=0.026), reoperations (p=0.026), and outpatient clinic visits (p=0.006). Open ankle fractures have a high complication rate and often require multiple surgical procedures. In young patients these injuries are more likely to be the consequence of high-energy trauma leading to more complications and subsequently increased healthcare resource utilisation.
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Affiliation(s)
- Mikko T Ovaska
- Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland.
| | - Rami Madanat
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Maija Honkamaa
- Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
| | - Tatu J Mäkinen
- Mount Sinai Hospital and University of Toronto Toronto, ON, Canada
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Molina CS, Stinner DJ, Fras AR, Evans JM. Course of treatment and rate of successful salvage following the diagnosis of deep infection in patients treated for pilon fractures (AO/OTA: 43). J Orthop 2015; 12:S18-24. [PMID: 26719624 DOI: 10.1016/j.jor.2015.01.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 01/27/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/AIMS The purpose of this study is to report the rate of successful salvage and describe typical treatment course for patients with infected pilon fractures. METHODS This investigation was performed after gathering a Six-year retrospective database from a single academic trauma center including patients with pilon fractures diagnosed with post-operative deep infection. RESULTS These include a rate of successful salvage in patients diagnosed with deep infection of 88.5% (46/52). Patients who were successfully salvaged required an average of 3.5 (±2.3) procedures following diagnosis of infection, 2.5 (±1.5) debridements and 1.1 (±1.2) reconstructive procedures. CONCLUSIONS Considerable morbidity follows the diagnosis of deep infection, with 14% of patients ultimately treated with amputation. Successful salvage can be reliably anticipated in over 80% of patients, but typically requires more than 3 additional procedures.
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Affiliation(s)
- Cesar S Molina
- Vanderbilt Department of Orthopedics and Rehabilitation, Orthopedic Trauma Institute, Nashville, TN 37232, USA
| | - Daniel J Stinner
- Vanderbilt Department of Orthopedics and Rehabilitation, Orthopedic Trauma Institute, Nashville, TN 37232, USA
| | - Andrew R Fras
- Vanderbilt Department of Orthopedics and Rehabilitation, Orthopedic Trauma Institute, Nashville, TN 37232, USA
| | - Jason M Evans
- Vanderbilt Department of Orthopedics and Rehabilitation, Orthopedic Trauma Institute, Nashville, TN 37232, USA
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22
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Molina CS, Stinner DJ, Fras AR, Evans JM. Risk factors of deep infection in operatively treated pilon fractures (AO/OTA: 43). J Orthop 2015; 12:S7-S13. [PMID: 26719630 DOI: 10.1016/j.jor.2015.01.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 01/27/2015] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND/AIMS The purpose of this study is to evaluate risk factors of deep infection following pilon fractures. METHODS This investigation was performed after gathering a six-year retrospective database from a single academic trauma center. RESULTS These include an overall incidence of deep infection of 16.1% (57/355). Deep infection was diagnosed at an average of 88 days (±64 days) from initial injury with a range of 10-281 days. Development of deep infection occurred in 23.2% (33/142) of open fractures, vs 11.3% (24/213) of closed fractures. CONCLUSION Open fractures, hypertension and male gender were associated with an increased risk of developing deep infection. In addition, even optimal surgical management may not significantly modify rates of deep surgical site infection.
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Affiliation(s)
- Cesar S Molina
- Vanderbilt Department of Orthopaedic Surgery and Rehabilitation, Orthopaedic Trauma Institute, Nashville, TN 37232, United States
| | - Daniel J Stinner
- Vanderbilt Department of Orthopaedic Surgery and Rehabilitation, Orthopaedic Trauma Institute, Nashville, TN 37232, United States
| | - Andrew R Fras
- Vanderbilt Department of Orthopaedic Surgery and Rehabilitation, Orthopaedic Trauma Institute, Nashville, TN 37232, United States
| | - Jason M Evans
- Vanderbilt Department of Orthopaedic Surgery and Rehabilitation, Orthopaedic Trauma Institute, Nashville, TN 37232, United States
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Xiong L, Pan Q, Jin G, Xu Y, Hirche C. Topical intrawound application of vancomycin powder in addition to intravenous administration of antibiotics: A meta-analysis on the deep infection after spinal surgeries. Orthop Traumatol Surg Res 2014; 100:785-9. [PMID: 25281550 DOI: 10.1016/j.otsr.2014.05.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 04/03/2014] [Accepted: 05/02/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND The intrawound application of vancomycin powder in addition to intravenous administration of antibiotics has been reported to be an easy and cost-efficient technique for reducing the deep infection, which is a serious complication of spinal surgeries. The aim of the present meta-analysis was to derive a preliminary estimation on the clinical performance of this technique. HYPOTHESIS The intrawound application of vancomycin powder in addition to intravenous administration of antibiotics may significantly reduce the risk of deep infection after spinal surgeries. MATERIALS AND METHODS Studies were identified from PubMed and EMBASE searches. After comprehensive review, data were extracted from eligible studies. A meta-analysis was performed to generate pooled odds ratio (OR) of this technique. RESULTS Eight studies (4592 patients) were included. The pooled OR (95% CI) was 0.22 (0.07-0.63). I(2) value was 65.2% (P=0.005). The pooled ORs were stable in sensitivity analyses. No analysis of subgroup, meta-regression or publication bias was performed because of inadequate included studies. DISCUSSION The intrawound application of vancomycin powder in addition to intravenous administration of antibiotics may significantly reduce the risk of deep infection after spinal surgeries. Further studies with large sample size and high quality are needed to provide more evidences. LEVEL OF EVIDENCE II.
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Affiliation(s)
- L Xiong
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen, Germany.
| | - Q Pan
- Department of Pharmacy, the First Hospital of Yichang, China Three Gorges University, 443000 Yichang, China
| | - G Jin
- Department of Pharmacy, the First Hospital of Yichang, China Three Gorges University, 443000 Yichang, China
| | - Y Xu
- Department of Pharmacy, the First Hospital of Yichang, China Three Gorges University, 443000 Yichang, China
| | - C Hirche
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen, Germany
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LeBlanc MR, Lalonde DH, Thoma A, Bell M, Wells N, Allen M, Chang P, McKee D, Lalonde J. Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery. Hand (N Y) 2011; 6:60-3. [PMID: 22379440 PMCID: PMC3041895 DOI: 10.1007/s11552-010-9301-9] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Over 70% of Canadian carpal tunnel syndrome (CTS) operations are performed outside of the main operating room (OR) with field sterility and surgeon-administered pure local anesthesia [LeBlanc et al., Hand 2(4):173-8, 14]. Is main OR sterility necessary to avoid infection for this operation? This study evaluates the infection rate in carpal tunnel release (CTR) using minor procedure room field sterility. METHODS This is a multicenter prospective study reporting the rate of infection in CTR performed in minor procedure room setting using field sterility. Field sterility means prepping of the hand with iodine or chlorhexidine, equivalent of a single drape, and a sterile tray with modest instruments. Sterile gloves and masks are used, but surgeons are not gowned. No prophylactic antibiotics are given. RESULTS One thousand five hundred four consecutive CTS cases were collected from January 2008 to January 2010. Six superficial infections were reported and four of those patients received oral antibiotics. No deep postoperative wound infection was encountered, and no patient required admission to hospital, incision and drainage, or intravenous antibiotics. CONCLUSIONS A superficial infection rate of 0.4% and a deep infection rate of 0% following CTR using field sterility confirm the low incidence of postoperative wound infection using field sterility. This supports the safety and low incidence of postoperative wound infection in CTR using minor procedure field sterility without prophylactic antibiotics. The higher monetary and environmental costs of main OR sterility are not justified on the basis of infection for CTR cases.
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Affiliation(s)
- Martin R. LeBlanc
- Dalhousie University, Apartment 102, 72 Fairfax Drive, Halifax, NS B3H1P3 Canada
| | - Donald H. Lalonde
- Dalhousie University, Suite C204, 600 Main St., Saint John, NB E2K 1J5 Canada
| | - Achilleas Thoma
- Plastic Surgery, McMaster University, Suite 101, 206 James Street South, Hamilton, ON L8P 3A9 Canada
| | - Mike Bell
- Plastic Surgery, Ottawa University, 402-1919 Riverside Drive, Ottawa, ON K1H 1A2 Canada
| | - Neil Wells
- Plastic Surgery, University of British Columbia, 808-1200 Burrard St, Vancouver, BC V62 2G7 Canada
| | - Murray Allen
- Plastic Surgery, Ottawa University, 1385 Bank St. #415, Ottawa, ON K1H 8N4 Canada
| | - Peter Chang
- Plastic Surgery, University of Saskatchewan, 2125 11th Avenue #605, Regina, SK S4P 3X3 Canada
| | - Daniel McKee
- Ottawa University, 6 Hastings St., Nepean, ON K2H 8C3 Canada
| | - Jan Lalonde
- Dalhousie University, Suite C204, 600 Main St., Saint John, NB E2K 1J5 Canada
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Yokoyama K, Itoman M, Uchino M, Fukushima K, Nitta H, Kojima Y. Immediate versus delayed intramedullary nailing for open fractures of the tibial shaft: a multivariate analysis of factors affecting deep infection and fracture healing. Indian J Orthop 2008; 42:410-9. [PMID: 19753228 PMCID: PMC2740339 DOI: 10.4103/0019-5413.43385] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate contributing factors affecting deep infection and fracture healing of open tibia fractures treated with locked intramedullary nailing (IMN) by multivariate analysis. MATERIALS AND METHODS We examined 99 open tibial fractures (98 patients) treated with immediate or delayed locked IMN in static fashion from 1991 to 2002. Multivariate analyses following univariate analyses were derived to determine predictors of deep infection, nonunion, and healing time to union. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type, fracture grade by AO type, fracture location, timing or method of IMN, reamed or unreamed nailing, debridement time (< or =6 h or >6 h), method of soft-tissue management, skin closure time (< or =1 week or >1 week), existence of polytrauma (ISS< 18 or ISS> or =18), existence of floating knee injury, and existence of superficial/pin site infection. The predictive variables of nonunion selected for analysis was the same as those for deep infection, with the addition of deep infection for exchange of pin site infection. The predictive variables of union time selected for analysis was the same as those for nonunion, excluding of location, debridement time, and existence of floating knee and superficial infection. RESULTS Six (6.1%; type II Gustilo n=1, type IIIB Gustilo n=5) of the 99 open tibial fractures developed deep infections. Multivariate analysis revealed that timing or method of IMN, debridement time, method of soft-tissue management, and existence of superficial or pin site infection significantly correlated with the occurrence of deep infection (P< 0.0001). In the immediate nailing group alone, the deep infection rate in type IIIB + IIIC was significantly higher than those in type I + II and IIIA (P = 0.016). Nonunion occurred in 17 fractures (20.3%, 17/84). Multivariate analysis revealed that Gustilo type, skin closure time, and existence of deep infection significantly correlated with occurrence of nonunion (P < 0.05). Gustilo type and existence of deep infection were significantly correlated with healing time to union on multivariate analysis (r(2) = 0.263, P = 0.0001). CONCLUSION Multivariate analyses for open tibial fractures treated with IMN showed that IMN after EF (especially in existence of pin site infection) was at high risk of deep infection, and that debridement within 6 h and appropriate soft-tissue managements were also important factor in preventing deep infections. These analyses postulated that both the Gustilo type and the existence of deep infection is related with fracture healing in open fractures treated with IMN. In addition, immediate IMN for type IIIB and IIIC is potentially risky, and canal reaming did not increase the risk of complication for open tibial fractures treated with IMN.
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Affiliation(s)
- Kazuhiko Yokoyama
- Department of Orthopaedic Surgery, Machida Municipal Hospital, Machida, Tokyo, Japan,Correspondence: Dr. Kazuhiko Yokoyama, Department of Orthopedic Surgery, Machida Municipal Hospital, 2-15-41 Asahi-Machi, Machida, Tokyo 194-0023, Japan. E-mail:
| | - Moritoshi Itoman
- School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Masataka Uchino
- School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Kensuke Fukushima
- School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Hiroshi Nitta
- School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Yoshiaki Kojima
- School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
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