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González-Morgado D, Fabado-Tortajada P, Nomdedéu J, Teixidor-Serra J, Tomàs-Hernández J, Joshi-Jubert N, Minguell-Monyart J, Andrés-Peiró JV. External fixation to intramedullary nailing for femoral and tibial fractures: an eleven-year cohort study at a level I trauma center. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2025; 35:219. [PMID: 40423840 PMCID: PMC12116692 DOI: 10.1007/s00590-025-04282-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2024] [Accepted: 03/30/2025] [Indexed: 05/28/2025]
Abstract
PURPOSE To identify factors that contribute to the incidence of postoperative complications following staged treatment of femoral and tibial fractures with external fixation (EF) and intramedullary nailing (IMN). METHODS This retrospective cohort study involved patients with tibial and/or femoral fractures temporarily immobilized using EF, followed by IMN. Patient characteristics, types of injury, treatments, and outcomes were recorded. Primary outcomes were pin tract infection (PTI) and fracture-related infection (FRI). RESULTS The study had 103 patients involving 119 fractures: 73 tibial (61.3%) and 46 femoral (38.7%). Of these, 44.5% were open. 31.1% of the EFs were implanted by an orthopedic trauma (OT) specialist. In femoral fractures, OT specialists placed the pins a mean 78.2 mm from the fracture site, versus just 37.3 mm by non-OT surgeons (p < 0.01). This difference was not observed in the tibia. The average time of EF was 12.6 ± 7.8 days. PTI occurred in seven cases (5.9%), on average 14.9 ± 10.9 days after EF placement. FRI occurred in nine patients (7.6%): two in the femur (4.5%) and seven in the tibia (10.6%). All FRIs occurred in cases where the EF had been implanted by a surgeon without specialization in OT (p = 0.03). FRI was more frequent in patients with prior PTI than in those without (57.1% vs. 4.5%, respectively; p < 0.01). CONCLUSION PTI was a risk factor for FRI after IMN of tibial and femoral fractures. Surgeon specialization in OT was a protective factor against FRI, probably related to pin placement further from the fracture site.
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Affiliation(s)
- Diego González-Morgado
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
- Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | | | - Josep Nomdedéu
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
- Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Jordi Teixidor-Serra
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
- Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | | | - Nayana Joshi-Jubert
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
- Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Joan Minguell-Monyart
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
- Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - José Vicente Andrés-Peiró
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Vall d'Hebron Hospital Universitari, Barcelona, Spain.
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Gonzalez MR, Mendez-Guerra C, Inchaustegui ML, de la Blanca JCG, Pretell-Mazzini JA. Perioperative Risks Associated with the Use of External Fixators in Adult and Pediatric Patients with Trauma. Orthop Clin North Am 2025; 56:81-91. [PMID: 40044351 DOI: 10.1016/j.ocl.2024.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2025]
Abstract
External fixation is used in acute and elective cases in both adult and pediatric patients. Adequate selection of patients for external fixation is critical, especially in patients with polytrauma where the application of damage control orthopedics is considered. Deterioration of the bone-pin interface is the most common source of local postoperative complications. Pin loosening and pin track infection are the 2 most common complications. Treatment of pin loosening without infections consists of pin removal and reinsertion outside the affected area. Pin track infections are managed according to the infection severity, which is assessed using the Checketts-Otterburn classification.
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Affiliation(s)
- Marcos R Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Carolina Mendez-Guerra
- Medicine Department, Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | | | - Juan Carlos G de la Blanca
- Limb Reconstruction Unit, Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Juan A Pretell-Mazzini
- Division of Orthopedic Oncology, Baptist Health System South Florida, Miami Cancer Institute, Plantation, FL, USA.
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Mickley J, Philips W, Colosimo S, Kurtic D, Gitlin A, Young P. Does maintaining external fixators during definitive fixation of bicondylar tibial plateau fractures influence fracture alignment and deep infection rates? Injury 2025; 56:112180. [PMID: 39864400 DOI: 10.1016/j.injury.2025.112180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2024] [Revised: 01/06/2025] [Accepted: 01/18/2025] [Indexed: 01/28/2025]
Abstract
INTRODUCTION External fixators are utilized to temporarily stabilize bicondylar tibial plateau fractures. They can be prepped during definitive surgery to help maintain fracture length and alignment. However, there is a potential for increased infection by leaving the external fixator on during the surgery. We hypothesize that maintaining the external fixator during surgery will result in no difference in rates of deep infection but improve reduction quality. METHODS We performed a retrospective cohort study of all bicondylar tibial plateau fractures treated at an academic, level one trauma center over a 10-year period. The primary outcome analyzed was the rate of deep infection. Secondary outcomes analyzed included reduction quality by comparing the medial proximal tibia angle (MPTA) and posterior proximal tibia angle (PPTA), complication rate, and reoperation rate. RESULTS One hundred and thirty-nine fractures in 133 patients met the inclusion criteria. There was no difference between the external fixator removed and prepped groups in terms of baseline patient characteristics except for more motor vehicle collisions in the removed group (42 % vs 22.99 %, p = 0.0193) and more open fractures in the prepped group (6 % vs 18.39 %). Operative characteristics were also not statistically different except for more patients in the prepped group underwent preoperative skin shaving (22 % vs 48.28 %, p = 0.0023) and more patients in the removed group had fixation constructs with plate and pin site overlap (46 % vs 24.14 %, p = 0.0083). There was no difference in deep infection between the groups (16.00 % vs 8.05 %, p = 0.1511). There was no difference in reduction quality when comparing the MPTA (87.64° vs 87.40°, p = 0.6607) and PPTA (83.18° vs 83.97°, p = 0.3592). The rates of superficial infection (20 % vs 29.89 %, p = 0.2056), unplanned reoperation (30 % vs 18.39 %, p = 0.1179), complications (58 % vs 44.83 %, p = 0.1376), and nonunion (8 % vs 6.89 %, p = 0.8111) were also similar. CONCLUSIONS Bicondylar tibial plateau fractures are challenging injuries with a high complication profile. Our findings suggest that maintaining the external fixator is not associated with increased rates of deep infection or complications. However, maintaining the external fixator during surgery did not lead to differences in final coronal or sagittal alignment reduction quality.
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Affiliation(s)
- John Mickley
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida-Jacksonville, Jacksonville, FL USA
| | - William Philips
- University of Florida College of Medicine, Gainesville, FL USA
| | - Sara Colosimo
- Department of Research Affairs, University of Florida-Jacksonville, Jacksonville, FL USA
| | - Dinela Kurtic
- Department of Research Affairs, University of Florida-Jacksonville, Jacksonville, FL USA
| | - Adam Gitlin
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida-Jacksonville, Jacksonville, FL USA
| | - Porter Young
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida-Jacksonville, Jacksonville, FL USA.
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Aljuhani WS, Alshabi YA, Alanazi AM, Alothri MA, Almutairi SA, Aljaafri ZA, Alzahrani AM. Risk of infection and conversion time from external to definitive fixation in open tibial fracture. J Orthop Surg Res 2024; 19:867. [PMID: 39710740 PMCID: PMC11665134 DOI: 10.1186/s13018-024-05350-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Accepted: 12/08/2024] [Indexed: 12/24/2024] Open
Abstract
BACKGROUND An open fracture of the tibia is one of the most common and dangerous type of open fractures. In the management of these injuries, the primary focus is on reducing the infection rate, as this is crucial for achieving the best clinical outcomes. This study aims to explore how provisional external fixation duration influences the rates of infection and union in open tibial shaft fractures. METHODS A retrospective study with a total of 55 patients who received temporary external fixation. Groups A (less than 12 days), B (12-24), C (25-36), and D (more than 36) were the four groups into which they were split according to the conversion time. RESULTS 12.8%, 18.2%, 50%, and 100% of the infections were found in Groups A, B, C, and D, respectively. Significant (P < 0.05) differences were found throughout the four groups. The conversion time from external to definitive fixation was found to have a relationship with the occurrence of an infection (P = 0.004). A higher prevalence of infection was observed over time. However, no association was observed between infection and antibiotic duration or initial debridement time (P = 0.689 and P = 0.963, respectively). CONCLUSIONS Results of this study demonstrate that the likelihood of infection increases when the change from external fixation to definitive internal fixation is delayed. Therefore, it is important to convert to definitive internal fixation immediately when the local and general conditions are favorable for doing so.
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Affiliation(s)
- Wazzan S Aljuhani
- Department of Orthopedic Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Yasir A Alshabi
- Department of Orthopedic Surgery, King Fahad Hospital, Ministry of Health, Madinah, Saudi Arabia
| | - Abdullah M Alanazi
- Department of Orthopedic Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Meshal A Alothri
- Department of Orthopedic Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Saleh A Almutairi
- Department of Orthopedic Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ziad A Aljaafri
- Department of Orthopedic Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Abdullah M Alzahrani
- Department of Orthopedic Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Santolini E, Giordano V, Giannoudis PV. Effect of mechanical stability of osteosynthesis on infection rates: Timing of temporary and definitive fixation. Injury 2024; 55 Suppl 6:111845. [PMID: 39482028 DOI: 10.1016/j.injury.2024.111845] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 08/25/2024] [Accepted: 08/26/2024] [Indexed: 11/03/2024]
Abstract
Fracture related infection (FRI) remains one of the most challenging complications of orthopaedic trauma surgery. Several factors contribute to FRI development but, among those, particularly interesting from the orthopaedic surgeon's perspective is the contribution of mechanical stability and timing of fracture fixation. These are indeed crucial factors both in prevention and treatment of FRI and are directly influenced by the surgeon's work. While the role of stability has been studied and discussed, the pathophysiological process regulating such role and how this influences surgeon's treatment decision making is still debated. The same applies to the ideal timing of temporary or definitive fixation which varies according to the clinical scenario considered. In the present narrative review, we described the influence of mechanical stability on both FRI pathophysiology and on the decision making of FRI treatment. In addition, we analysed the impact of the timing of fracture fixation on the risk of FRI development particularly in those clinical scenarios where it has been shown to be specifically relevant, such as fractures affecting segments with poor soft tissue envelope, open fractures, damage control orthopaedics, and the need for soft tissue coverage.
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Affiliation(s)
- Emmanuele Santolini
- Orthopaedics and Trauma Unit, Emergency Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rua Mário Ribeiro 117/2° Andar, Gávea, Rio de Janeiro, RJ 22430‑160, Brazil
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK.
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Wynn MS, Jang Y, Ochenjele G, Natoli RM. External Fixation Before Planned Conversion to Internal Fixation in Orthopaedic Trauma: Controversies and Current Trends. J Am Acad Orthop Surg 2024; 32:873-880. [PMID: 38657184 DOI: 10.5435/jaaos-d-23-01256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Indexed: 04/26/2024] Open
Abstract
External fixation is a widely used technique for a myriad of bone fractures and pathologies in all extremities. Despite its widespread use, controversies and unknowns still exist. This review article seeks to discuss current literature surrounding pin insertion technique, pin-site care, intraoperative use during conversion to definitive fixation, the relationship of pin sites to definitive fixation, and pin-site management after removal for temporary external fixation.
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Affiliation(s)
- Malynda S Wynn
- From the Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis, IN (Wynn, Jang, and Natoli), and the Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH (Ochenjele)
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Le Baron M, Maman P, Volpi R, Flecher X. External fixation as definitive treatment or external fixation followed by early fixation in open fractures of the tibial shaft: A descriptive study. Injury 2024; 55 Suppl 1:111477. [PMID: 39069345 DOI: 10.1016/j.injury.2024.111477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/08/2024] [Accepted: 02/25/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Treatment options for open tibial shaft fractures include external fixation with or without early conversion to internal fixation. OBJECTIVES The aim of this study was to describe 1) early conversion to internal fixation and definitive external fixation and 2) in case of conversion, to identify risk factors for complications. METHODS Seventy-two external fixations of open fractures of the tibial shaft (Gustilo classification, 7 fractures (9.7 %) grade I, 25 fractures (34.7 %) grade II, 40 fractures (55.6 %) grade III (31 grade IIIA and 9 grade IIIB)) were included in a continuous non-randomised study. Thirty-three fractures without infection signs were converted to internal fixation at a mean time of 40.5 +/-15 days (IF group). External fixation was maintened in the remaining 39 fractures (EF group). RESULTS In the "IF" group, the union rate was 69.7 % at 6.3 +/-3.6 months (3-16). All patients had complete union at 16 months, requiring 2.8 +/-0.8 reoperations. Fixation with external fixation only ("EF" group) showed a union rate of 51.3 % at 8.9 +/-4 (5-22) months and 96 % at 16 months after 3.7 +/-0.9 reoperations. Superficial infection (12.1 %; p = 0.011) and numerous surgeries (2.76; p = 0.004) were found to be risk factors for deep infection. Time to wound closure >7 days (p = 0.049), time to reoperation >28 days (p = 0.00), numerous surgeries (2.76; p = 0.004) and deep infection (6.1 %; p = 0.027) were found to be union failure factors. CONCLUSION Early conversion of external fixation to internal fixation is an effective option to achieve bone union of open tibial fractures in selected patients.
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Affiliation(s)
- Marie Le Baron
- Centre de Chirurgie orthopédique et traumatologie, Centre Hospitalo-Universitaire Nord, Marseille, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, France.
| | - Pascal Maman
- Centre de Chirurgie orthopédique et traumatologie, Centre Hospitalo-Universitaire Nord, Marseille, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, France
| | - Richard Volpi
- Centre de Chirurgie orthopédique et traumatologie, Centre Hospitalo-Universitaire Nord, Marseille, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, France
| | - Xavier Flecher
- Centre de Chirurgie orthopédique et traumatologie, Centre Hospitalo-Universitaire Nord, Marseille, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, France
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Shen M, Tejwani N. Open tibial shaft fracture fixation strategies: intramedullary nailing, external fixation, and plating. OTA Int 2024; 7:e316. [PMID: 38840705 PMCID: PMC11149753 DOI: 10.1097/oi9.0000000000000316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 06/07/2024]
Abstract
Tibial shaft fractures are one of the most common orthopaedic injuries. Open tibial shaft fractures are relatively common because of the paucity of soft tissue surrounding the bone. Despite the prevalence of these injuries, the optimal fixation strategy is still a topic of debate. The purpose of this article was to review the current literature on open tibial shaft fracture fixation strategies including intramedullary nailing, external fixation, and plating.
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Affiliation(s)
- Michelle Shen
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Nirmal Tejwani
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
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Weatherford B, Dubina A, Pensy RA, Paryavi E, O'Toole RV. Risk Factors for Wound Failure After Primary Closure of Type IIIA Open Tibia Fractures. Orthopedics 2024; 47:108-112. [PMID: 37561105 DOI: 10.3928/01477447-20230804-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
The objective of our investigation was to explore risk factors associated with primary closure of type IIIA tibial fractures resulting in subsequent flap coverage. A retrospective study identified 278 patients with acute type IIIA open tibial fractures who underwent primary closure at a single center during an 8-year period. Treatment factors, including the number of debridements before closure, duration of external fixation, and timing of wound closure, were reported. The primary outcome was complication requiring unplanned operation of the study injury resulting in flap coverage. Fifty-five (20%) patients underwent flap coverage following complication after attempted primary closure. Patients who required a flap experienced a 42% complication rate after delayed flap coverage. The limb salvage rate was 95% for the study population. Three significant complication predictors were identified: 3 or more debridements before closure (odds ratio [OR], 29.8; 95% CI, 5.9-150.1; P<.001), wound closure more than 2 days after injury (OR, 9.8; 95% CI, 1.6-60.2; P=.01), and external fixation more than 14 days (OR, 7.3; 95% CI, 1.6-34.6; P=.01). Patients who had 3 or more debridements before closure had a 70.7% chance of having a complication resulting in a flap (29 of 41) compared with only a 6.8% chance of complication for those who had 2 or fewer debridements (14 of 205; P<.001). Risk factors for complication after primary closure of type IIIA open tibial fractures include number of debridements, wound closure after 2 days, and external fixation use for more than 14 days. Wounds requiring 3 or more debridements failed 70.7% after closure, suggesting alternative approaches should be considered in more severe cases. [Orthopedics. 2024;47(2):108-112.].
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Fraisse B, Marleix S, Lucas G, Violas P. Open fractures of the limbs in children and adolescents. Orthop Traumatol Surg Res 2024; 110:103771. [PMID: 38000507 DOI: 10.1016/j.otsr.2023.103771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 11/26/2023]
Abstract
Open fracture is rare in children, raising dual issues of sepsis and mechanics. Here, we address certain practical questions regarding childhood open fracture. Should the recognized adult classifications be used in children? Two classifications exist for adults, without pediatric specificities; of these, we recommend Gustilo's, as being more precise in its description of severe grades. Is there any consensus on emergency prophylactic antibiotic therapy in children? The risks seem to be the same, and 24hours' prophylactic antibiotic therapy should be initiated as soon as possible, as in adults. What are the most recent guidelines on time to treatment, type of internal fixation and possible associated procedures in tibial fracture in children? Wound cleansing is indispensable. Treatment under anesthesia can be delayed up to 24hours in the absence of neurovascular complications on condition that antibiotic therapy is implemented immediately. In Gustilo grade I and II, or IIIA, external fixation is not systematic and non-operative treatment or intramedullary nailing is possible. In grades IIIB and IIIC, external fixation is the rule, although conversion is possible if indicated early enough. Do the particular cases of nail bed injury or lawn mower foot injury in children require specific management? Nail bed injury is not to be minimized and should be treated strictly. In case of serious accidents with garden equipment, initial wound care in surgery should be economic, but experienced practitioners should weigh the risk/benefit ratio between conservation and early amputation. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Bernard Fraisse
- Service de Chirurgie Pédiatrique, CHRU de Rennes, 16, boulevard de Bulgarie, 35203 Rennes cedex, France.
| | - Sylvette Marleix
- Service de Chirurgie Pédiatrique, CHRU de Rennes, 16, boulevard de Bulgarie, 35203 Rennes cedex, France
| | - Grégory Lucas
- Service de Chirurgie Pédiatrique, CHRU de Rennes, 16, boulevard de Bulgarie, 35203 Rennes cedex, France
| | - Philippe Violas
- Service de Chirurgie Pédiatrique, CHRU de Rennes, 16, boulevard de Bulgarie, 35203 Rennes cedex, France
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Fritz EM, Donato DP, Westberg JR, Geissler JA, Ward CM. Incidence of Infection in Operatively Treated Distal Radius Fractures After Conversion From External to Internal Fixation. J Hand Surg Am 2024; 49:184.e1-184.e7. [PMID: 35931630 DOI: 10.1016/j.jhsa.2022.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/18/2022] [Accepted: 06/07/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to report the incidence of infection after conversion from external fixation (EF) to internal fixation (IF) of distal radius fractures and to evaluate the relationship between infection and secondary variables, including time to conversion from EF to IF, internal hardware overlapping EF pin sites, and definitive fixation with a dorsal-spanning bridge plate. METHODS A retrospective review was performed at 2 level 1 trauma centers including all patients aged ≥18 years from 2006 to 2019 with a distal radius fracture treated initially with EF followed by subsequent IF. The patients were excluded from analysis if they had <10 weeks of clinical follow-up, a history of prior distal radius surgery, or evidence of infection before EF to IF conversion. Patient demographic data, mechanism of injury, presence of hardware overlapping pin sites, and timing to definitive fixation were obtained from the medical records. Infection was defined as positive intraoperative cultures or documented return to the operating room for debridement after IF. RESULTS A total of 64 fractures in 61 patients with a median age of 50 years (range, 18-75 years) were included. Infections developed in 6 patients (6 of 64 fractures). The incidence of infection was higher in patients with a time to conversion from EF to IF of >14 days (infection in 2 of 5 patients vs 4 of 59 patients). The incidence of infection was similar in patients with and without hardware overlapping EF pin sites (3 of 27 vs 3 of 37, respectively). CONCLUSIONS Infections occurred in 6 of 64 distal radius fractures following conversion from EF to IF, and delay in conversion of >14 days was associated with an increased infection risk. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Erik M Fritz
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN
| | - Daniel P Donato
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Jerald R Westberg
- Department of Orthopedics, Hennepin County Medical Center, Minneapolis, MN
| | | | - Christina M Ward
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN.
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Bezerra BS, Araujo TA, Cardonia GG, Couto JRL, Rodrigues FL. The Applicability of Dynamic External Fixator in a Prospective Evaluation of Open Tibial Fracture Treatment. Strategies Trauma Limb Reconstr 2024; 19:36-39. [PMID: 38752189 PMCID: PMC11091899 DOI: 10.5005/jp-journals-10080-1606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 03/27/2024] [Indexed: 05/18/2024] Open
Abstract
Aim This prospective study assessed the clinical and radiological outcomes of open tibia fractures treated with a dynamic external fixator. Materials and methods Twenty-five patients underwent surgical debridement and stabilisation with a dynamic external fixator between November 2016 and April 2022. Regular follow-up evaluated bone healing progression. Results Favourable outcomes were demonstrated in 20 patients. However, there were three cases of non-union, two of which subsequently deformed, and two cases of pin site-related infection. There were no fracture site infections. Conclusion This study demonstrates the use of dynamic external fixation in the treatment of open tibia fractures. The low incidence of complications suggests its effectiveness and potential. How to cite this article Bezerra BS, Araujo TA, Cardonia GG, et al. The Applicability of Dynamic External Fixator in a Prospective Evaluation of Open Tibial Fracture Treatment. Strategies Trauma Limb Reconstr 2024;19(1):36-39.
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Affiliation(s)
- Bruna S Bezerra
- Department of Orthopaedics and Traumatology, Teaching Hospital, Faculty of Medicine, ABC-Mário Covas State Hospital, São Paulo, Brazil
| | - Thaisa A Araujo
- Department of Orthopaedics and Traumatology, Teaching Hospital, Faculty of Medicine, ABC-Mário Covas State Hospital, São Paulo, Brazil
| | - Gustavo G Cardonia
- Department of Orthopaedics and Traumatology, Teaching Hospital, Faculty of Medicine, ABC-Mário Covas State Hospital, São Paulo, Brazil
| | - João R Lima Couto
- Department of Orthopaedics and Traumatology, Teaching Hospital, Faculty of Medicine, ABC-Mário Covas State Hospital, São Paulo, Brazil
| | - Fábio L Rodrigues
- Department of Orthopaedics and Traumatology Discipline, Faculty of Medicine ABC (FMABC), Santo André, São Paulo; Trauma and External Fixators Group at FMABC, Santo Andre, Brazil
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Monaco E, Cavaignac E, Criseo N, Annibaldi A, Cantagalli M, Pucciatti R, Carrozzo A, Feretti A. Surgical Treatment of an Unusual Ski Injury: Combined Tibial Fracture With Anterior Cruciate Ligament Avulsion and Segond Lesion. VIDEO JOURNAL OF SPORTS MEDICINE 2023; 3:26350254231200039. [PMID: 40308438 PMCID: PMC11966004 DOI: 10.1177/26350254231200039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/21/2023] [Indexed: 05/02/2025]
Abstract
Background Alpine skiing is considered to be a high-risk sport due to frequent knee injuries and lower limb fractures. The most common lower limb fracture is tibial shaft fracture, while the most common ligament injuries include anterior cruciate ligament (ACL) or medial collateral ligament tears. An injury rarely described in the literature is the association of a bony leg fracture with an ACL injury and Segond fracture. Indications While the tibial fracture can be managed with intermedullary nailing and proximal ACL tears can be managed with primary repair, the combination of treatments including fixation of the Segond fracture is uncommon. Technique Description We report combination treatment with nailing for the tibial fracture, primary repair for the ACL avulsion, and primary fixation of Segond fracture. Results Simultaneous reduction and fixation of the fracture and stabilization of the knee with ACL and anterolateral ligament repair in a single stage resulted in an excellent outcome with complete healing of tibial fracture, ACL repair, and Segond fixation at final follow-up. Discussion/Conclusion Even if combined leg fracture associated with ipsilateral ACL tear and Segond fracture is a very rare injury, the described technique based on 1-stage fixation of the 3 injuries is a viable option. This surgical technique can be considered a reparative treatment, with the goal of preserving the joint. Patient Consent Disclosure Statement The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
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Affiliation(s)
| | | | - Natale Criseo
- Orthopaedic Surgery, University of Rome La Sapienza, Rome, Italy
| | | | | | | | | | - Andrea Feretti
- CONI, Istituto di Medicina e Scienza dello Sport, Rome, Italy
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Yeramosu T, Young P, Cinats DJ, Toney CB, Satpathy J, Patel TT, Kates SL, Perdue PW. Safety of Prepping the External Fixator In Situ During Staged Internal Fixation of Pilon Fractures: A Retrospective Comparative Cohort Study. J Orthop Trauma 2023; 37:469-474. [PMID: 37053112 PMCID: PMC10524202 DOI: 10.1097/bot.0000000000002617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVE (1) To assess the rate of fracture-related infection (FRI) and unplanned reoperation of disinfecting and prepping in the external fixator (Ex-Fix) instrument during definitive open reduction and internal fixation (ORIF) of pilon fractures treated by a staged protocol and (2) to determine whether the amount of time from external fixation to ORIF influences the risk of FRI. DESIGN Retrospective cohort study. SETTING Level 1 academic trauma center. PATIENTS One hundred thirty-three patients who underwent operative treatment for pilon fracture between 2010 and 2020. INTERVENTION External fixation and ORIF with or without the Ex-Fix prepped in situ during definitive fixation. MAIN OUTCOME MEASUREMENTS FRI and unplanned reoperation rates. RESULTS 133 patients were enrolled, of which 47 (35.3%) had Ex-Fix elements prepped in situ. There was an overall infection rate of 23.3% and unplanned reoperation rate of 11.3%, and there was no significant difference in rates between the 2 cohorts. Patients with Ex-Fix elements prepped in situ who developed an FRI had a higher rate of MRSA and MSSA . Diabetes ( P = 0.0019), open fracture ( P = 0.0014), and longer (≥30 days) interval to ORIF ( P = 0.0001) were associated with postoperative FRI. CONCLUSIONS Prepping elements of the Ex-Fix in situ did not lead to an increase in rates of FRI or unplanned reoperation. Although diabetes and open fracture were associated with FRI risk, a stronger association was a longer interval of Ex-Fix utilization before definitive internal fixation, specifically 30 days or greater. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Teja Yeramosu
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Porter Young
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - David J. Cinats
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Clarence B. Toney
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Jibanananda Satpathy
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Tejas T. Patel
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen L. Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Paul W. Perdue
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
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Luo J, Zhou M, Lin F, Wang J, Rui Y. Clinical effectiveness of early internal fixation combined with free flap technique in the treatment of Gustilo IIIB open forearm fracture. Orthop Traumatol Surg Res 2023; 109:103346. [PMID: 35697251 DOI: 10.1016/j.otsr.2022.103346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 03/17/2022] [Accepted: 03/29/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Gustilo IIIB open forearm fractures are severe injuries often associated with extensive bone and soft tissue injuries. The treatment of Gustilo IIIB open forearm fractures remains a challenging problem, with a high morbidity rate such as infection, nonunion, even amputation. External fixation is preferred for open lower limb fractures. However, there are significant differences between open bone injuries of the upper and lower extremity in terms of treatment plans. Use of internal fixation methods for open fractures is a controversial issue, as it requires early coverage of skin and soft tissue defects after radical debridement and irrigation. The optimal approach for open forearm fractures remains to be determined. The present study evaluated whether early internal fixation combined with free flap placement is effective for the treatment of Gustilo IIIB open forearm fracture. HYPOTHESIS Early internal fixation combined with the free flap technique in the treatment of Gustilo IIIB open forearm fracture provides good consolidation results. MATERIAL AND METHODS From January 2015 to January 2020, 20 patients with Gustilo IIIB open forearm fracture treated with early internal fixation combined with free skin flap placement were retrospectively analyzed. There were 9 males and 11 females, with an average age of 40 years. In all cases, the injuries were classified as Gustilo type IIIB. The area of the wounds ranged from 9×3cm to 27×10cm. Fist-stage plate fixation was adopted in 16 cases. Four patients presenting with major contamination received first-stage fixation with Kirschner wires and external fixation, and the second-stage surgery of surgical treatment included flap placement and internal fixation within 10 days. The rates of limb salvage and complications were recorded. The Anderson scoring system was utilized to assess limb function. RESULTS Limb salvage was successful in all 20 cases. The average length of hospital was 19 days (range, 7-28 days). Four patients developed superficial infections. After debridement, the wounds were covered with skin grafts. No deep infections or osteomyelitis occurred. Three patients developed nonunion, and bone grafts achieved bone healing later. The donor skin flaps healed well, with partial pigmentation. No complete necrosis of the flaps occurred. Only the distal part of flaps became necrotic in two cases, which were then successfully treated by debridement and skin grafting. The average follow-up duration was 14.7 months (range, 8-24 months). According to the Anderson scoring system, 7 cases were graded as excellent, 6 cases as good, 5 cases as fair, and 2 cases as poor. CONCLUSION For Gustilo IIIB type injuries, early and thorough debridement along with early internal fixation and skin flap coverage of the wound can achieve satisfactory clinical results, shorten the treatment cycle, and maximize limb function recovery. LEVEL OF EVIDENCE IV, retrospective study without control group.
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Affiliation(s)
- Junhao Luo
- Department of Orthopaedics, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi 214062, China
| | - Ming Zhou
- Department of Orthopaedics, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi 214062, China
| | - Fang Lin
- Department of Orthopaedics, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi 214062, China
| | - Jianbing Wang
- Department of Orthopaedics, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi 214062, China
| | - Yongjun Rui
- Department of Orthopaedics, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi 214062, China.
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Xiao H, Wang S, Wang F, Dong S, Shen J, Xie Z. Locking Compression Plate as an External Fixator for the Treatment of Tibia Infected Bone Defects. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023; 161:311-317. [PMID: 34496424 DOI: 10.1055/a-1545-5363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE This study was designed to observe the medium-term efficacy of an induced membrane technique combined with a locking compression plate as an external fixator for the treatment of tibia infected bone defects. METHODS Patients with a tibial infection were admitted to our department between January 2013 and November 2014. All patients were treated with the induced membrane technique. In the first stage, polymethyl methacrylate (PMMA) cement was implanted in the defects after debridement and then fixed with a locking compression plate (LCP) as an external fixator. In the second stage, bone grafts were implanted to rebuild the defects. The external plates were replaced with nails in 57 patients (internal group), and the remaining 30 patients were not exchanged with fixation (external group). The infection control rate, bone union rate, and complications of the two groups were compared. RESULTS Eighty-seven patients were enrolled in this study, and all patients had a minimum follow-up of 5 years (average 62.8 months) after grafting. Eighty-three patients (95.4%) achieved bone union, and the average union time was 6.77 months. Five patients (5.7%) experienced recurrence of infection. Complications included pin tract infection, fixation loosening, deformity connection, and limitation of joint range of motion (ROM). No significant differences in the infection control rate or bone defect union rate were noted between the two groups. The overall rate of complications in the external group was 50%, which was greater than that noted in the internal group (21.1%). CONCLUSIONS Locking compression plates are external fixators with smaller sizes that are easier to operate than conventional annular fixators or assembled external fixators. The use of locking compression plates in combination with the induced membrane technique in the treatment of tibia infected bone defects can achieve good clinical efficacy after medium-term follow-up.
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Affiliation(s)
- Hong Xiao
- Department of Orthopaedics, No. 958 Hospital of Army, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shulin Wang
- Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Feibo Wang
- Department of Orthopaedics, No. 958 Hospital of Army, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Sun Dong
- Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Shen
- Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhao Xie
- Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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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 2023; 54 Suppl 1:S63-S69. [PMID: 32958344 DOI: 10.1016/j.injury.2020.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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 4.9±1.38 months 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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18
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Conversion of External Fixator to Intramedullary Nail in Tibial fractures. J Am Acad Orthop Surg 2023; 31:41-48. [PMID: 36215677 DOI: 10.5435/jaaos-d-21-00857] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/05/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Conversion of provisional external fixation to intramedullary nail (IMN) in femur fractures has been reported to be safe within 14 days of initial surgery. However, there is no current literature guiding this practice in tibial fractures. The purpose of this study was to identify the time period when conversion of external fixation to nail in tibial fractures is safe. METHODS After obtaining IRB approval, tibial fractures (OTA 41A, 42, 43A) that received provisional ex-fix and were converted to IMN from 2009 to 2019 were retrospectively reviewed. Skeletally mature patients with minimum 6 months of follow-up were included. The primary outcome was deep infection. External fixation days were categorized as less than 7, 8 to 14, and 15+ days. Risk ratios of infection were estimated using generalized linear regression with a Poisson distribution. A separate regression model evaluated risk factors for infection using both the external fixation and non-external fixation tibial cohorts. RESULTS Twenty-eight patients (32%) were treated for deep infection. The infection rate for closed fractures was 28% (11 of 39 patients) and for open fractures was 35% (17 of 49 patients) ( P = 0.56). Examining both tibial cohorts, external fixation (odds ratio [OR] = 2.39, P = 0.017), open fracture (OR = 3.13, P = 0.002), and compartment syndrome (OR = 2.58, P = 0.01) were all associated with infection in regression modeling. Median external fixation days for patients with deep infection was 8 days (Inter-quartile range, 3 to 18 days) as compared with 4 days (IQR, 2 to 9 days) in patients without infection ( P = 0.06). While controlling for open fractures, the 8- to 14-day group had RR = 1.81 ( P = 0.2), and the 15+-day group had RR = 2.67 ( P = 0.003) as compared with the <7-day group. DISCUSSION Infection rates of tibial fracture patients treated with external fixation and converted to IMN were high. Surgeons should strongly consider the necessity of external fixation for these fractures. Earlier conversion of external fixation to definitive fixation reduced infection rates. LEVEL OF EVIDENCE Level IV-case series.
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Yamamoto R, Udagawa K, Yusho Nishida, Soichiro Ono, Junichi Sasaki. Clinical parameters and optimal candidates for early definitive fixation of extremity injury: A nationwide study. J Orthop Sci 2023; 28:255-260. [PMID: 34728113 DOI: 10.1016/j.jos.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/09/2021] [Accepted: 10/12/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND While various strategies of fracture fixation for trauma patients have been discussed, optimal candidates remain unclear for early definitive fixation. The aim of this study was to integrate several clinical parameters into a scoring system and determine a cut-off value for safe early definitive surgery for extremity fractures. METHODS We retrospectively identified patients with fracture in an extremity in Japanese Trauma Data Bank from 2004 to 2019. We included adult patients who underwent open reduction and internal fixation for extremity injury before any other surgical intervention and excluded those who arrived with cardiac arrest. Several clinical parameters, such as age, vital signs, abbreviated injury scale (AIS) in the chest, and injury severity score (ISS), were examined with multivariate logistic regression models to predict in-hospital mortality, and then integrated into a scoring system based on each odds ratio. To determine a cut-off value of the scoring system for safe early definitive surgery, in-hospital mortality and/or postoperative complications were compared between patients who underwent definitive fixation within 24 h of injury and patients who did not in subgroups based on the scores. RESULTS Of 50,631 patients eligible for this study, 16,119 (31.8%) underwent early definitive fixation. A 0-15 scoring system with parameters including age >70 years, GCS <8, systolic blood pressure <90 mmHg, AIS in the chest ≥3, ISS ≥20, and transfusion requirement within 24 h of arrival was developed. At scores ≥10, early definitive fixation was found to be significantly associated with high in-hospital mortality, and at scores <10, in-hospital mortality was comparable between the two groups. CONCLUSIONS We integrated clinical parameters into the scoring system with a scale of 0-15 and determined that a score of 10 is the cut-off score. We determined that patients with a score <10 can safely undergo early definitive fixation.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Kazuhiko Udagawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Yusho Nishida
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Soichiro Ono
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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20
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Which external fixation method is better for the treatment of tibial shaft fractures due to gunshot injury? Orthop Traumatol Surg Res 2022; 108:102948. [PMID: 33930584 DOI: 10.1016/j.otsr.2021.102948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/10/2020] [Accepted: 12/30/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The present study aimed to evaluate the functional and radiological outcomes of AO type monolateral external fixator (AO-EF) and Ilizarov type external fixator (I-EF) in definitive fixation of tibial shaft fractures due to gunshot injury. HYPOTHESIS Patients undergoing I-EF would have faster fracture healing with the help of early weight-bearing and the functional scores would be better compared to AO-EF. MATERIAL AND METHODS The study consisted of 76 (67M, 9F) patients who underwent surgery between 2010 and 2016 for tibial shaft fracture due to low-velocity gunshot injury (LVGI). The patients were divided into two groups according to the fixation method (AO-EF and I-EF) which was discussed by the surgeon team due to their experience. The average age at the time of injury was 37.8±9.8 (20 to 59 years). Groups are compared according to LEFS score, coronal-sagittal-rotational angle, Johner-Rush score, and complications such as nonunion, malunion, osteomyelitis, and pin-tract infection. The mean follow-up time 31.61±3.83 months (between 24 and 44 months). RESULTS No statistical difference was found between groups in terms of demographic characteristics. There was no statistical difference between groups regarding body mass index (BMI). LEFS score and operation duration were higher in the I-EF group (p=0.000 and p=0.006 respectively, p˂0.05). In the I-EF group, hospitalization period, full weight-bearing time, and healing time was shorter than the AO-EF group (p=0.001, p=0.000, and p=0.025 respectively, p˂0.05). DISCUSSION Although AO-EF has advantages such as ease of application and short surgery time in the definitive fixation of LVGI tibia shaft fractures, I-EF is a superior technique in terms of functional scores. However, I-EF is a surgical approach that requires relatively more experience. Therefore, the choice of fixator should be determined according to the surgeon's experience in the permanent treatment of LVGI tibial shaft fractures. LEVEL OF EVIDENCE IV; retrospective, case-control study.
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Patel KH, Galanis A, Balasubramanian P, Iliadis AD, Heidari N, Vris A. A major trauma centre experience with gentamicin-coated tibial intramedullary nails (ETN PROtect™) in acute primary open fracture fixation and complex revision surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03338-4. [PMID: 35943591 DOI: 10.1007/s00590-022-03338-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Fracture-related infections (FRI) following intramedullary nailing for tibial shaft fractures remain challenging to treat with associated high patient morbidity and health care costs. Recently, antibiotic-coated nails have been introduced as a strategy to reduce implant related infection rates in high-risk patients. We present the largest single-centre case series on ETN PROtect® outcomes reporting on fracture union, infection rates and treatment complications. METHODS Fifty-six adult patients underwent surgery with ETN PROtect® between 01/09/17 and 31/12/20. Indications consisted of acute open fractures and complex revision cases (previous FRI, non-union surgery and re-fracture) with a mean of three prior surgical interventions. We report on patient demographics, union rates and deep infection. Minimum follow-up was one year. RESULTS One (1.8%) patient developed a deep surgical infection and associated non-union requiring further surgery. In addition, we identified three cases (5.4%) of aseptic non-union following facture treatment with ETN PROtect®. Of the five patients who underwent staged complex revision surgery for established FRI with ETN PROtect®, all had treatment failure with ongoing symptoms of deep infection requiring implant removal and further treatment. CONCLUSION Use of the ETN PROtect® nail in high-risk patients (open fractures and those initially treated with external fixation) and in those patients with aseptic non-unions, demonstrates promising outcomes in the prevention of implant-related infection. In our limited series we have failed to observe any benefit over uncoated nails, when used in treating cases of previously established FRI/osteomyelitis and would therefore advise caution in their use, especially in view of the high cost.
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Affiliation(s)
- Kavi H Patel
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK.
| | | | - Prabu Balasubramanian
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - Alexios D Iliadis
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - Nima Heidari
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - Alex Vris
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
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Engorn JR, Vivace BJ, Seligson D, Parkulo T, Arrington DD, Rashid SF, Roberts C, Zamora R. Intramedullary nailing of concurrent ipsilateral fractures of the tibia and femur: primary synchronous nailing versus staged osteosynthesis with temporizing external fixation. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03340-w. [PMID: 35932307 DOI: 10.1007/s00590-022-03340-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION The optimal timing to definitive osteosynthesis in the polytraumatized patient remains an unanswered question. Early total care, damage control orthopaedics, and early appropriate care have been described to manage the fractures in these patients, but there is a paucity of literature specific to ipsilateral tibial and femoral fractures. We sought the perioperative outcomes of primary simultaneous intramedullary nailing (IMN) versus temporizing external fixation (EF) of both fractures. METHODS A chart review of all patients who sustained fractures of the ipsilateral femur and tibia that were definitively treated with (IMN) from January 2010 to December 2020 was performed. Patients who underwent initial EF and those that were primarily treated with IMNs were examined. RESULTS IMNs and EF were the initial treatment in 23 and 16 patients, respectively. The mean (range) injury severity score (ISS) was 23.3 (33) in the EF group vs. 18.5 (34) in the IMN group, (p = 0.0686). The EF group had a higher total transfused units of packed red blood cells 7.4 vs. 2.8, the mean initial operative time was 236 vs. 282.6 (min), (p = 0.7399), a longer mean total operative time 601.78 vs. 236 (min), and longer mean length of stay 15.6 vs. 11 (days), (p < 0.5). Rates of complications were not significantly different between groups. CONCLUSION Primary IMN is as safe as provisional EF in the adequately resuscitated patient with ipsilateral femoral and tibial fractures. This implies the fixation of both fractures into a single surgery without increasing perioperative complications, and decreasing total hospital stay in patients with sufficient preoperative resuscitation.
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Affiliation(s)
- Jeffrey R Engorn
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40292, USA
| | - Bradley J Vivace
- Department of Orthopaedic Surgery, University of Missouri, University of Missouri School of Medicine, Columbia, USA
| | - David Seligson
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40292, USA
| | - Travis Parkulo
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40292, USA
| | | | - Salwa F Rashid
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40292, USA
| | - Craig Roberts
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40292, USA
| | - Rodolfo Zamora
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40292, USA.
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Is It Safe to Prep the External Fixator In Situ During Staged ORIF of Bicondylar Tibial Plateau Fractures? A Retrospective Comparative Cohort Study. J Orthop Trauma 2022; 36:382-387. [PMID: 34962237 DOI: 10.1097/bot.0000000000002334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the risk of deep infection and unplanned reoperation after staged open reduction internal fixation (ORIF) of bicondylar tibial plateau (BTP) fractures whether elements of the temporizing external fixator were prepped into the surgical field or completely removed before definitive fixation. DESIGN Retrospective comparative cohort study. SETTING Two academic Level 1 trauma centers. PATIENTS/PARTICIPANTS One hundred forty-seven OTA/AO 41-C (Schatzker 6) BTP fractures treated with a 2-stage protocol of acute spanning ex-fix followed by definitive ORIF between 2001 and 2018. INTERVENTION Seventy-eight fractures had retained elements of the original ex-fix prepped in situ during surgery for definitive internal fixation, and 69 had the ex-fix construct completely removed before prepping and draping. MAIN OUTCOME MEASURES Deep infection and unplanned reoperation. RESULTS Among 147 patients treated with staged ORIF, the overall deep infection rate was 26.5% and the reoperation rate was 33.3%. There were high rates of deep infection (26.9% vs. 26.1%, P = 0.909) and unplanned reoperation (30.8% vs. 36.2%, P = 0.483) in both groups, but no difference whether the ex-fix was prepped in or completely removed. Within the retained ex-fix group, there was no difference in infection with retention of the entire ex-fix compared with only the ex-fix pins (28.1% vs. 26.1%, P = 0.842). CONCLUSIONS We observed high complication rates in this cohort of OTA/AO 41C BTP fractures treated with staged ORIF, but prepping in the ex-fix did not lead to a significant increase in rates of infection or reoperation. This study provides the treating surgeon with clinical data about a common practice used to facilitate definitive fixation of unstable BTP fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Retrospective Analysis of Infection Factors in Secondary Internal Fixation after External Fixation for Open Fracture of a Long Bone: A Cohort of 117 Patients in a Two-Center Clinical Study. BIOMED RESEARCH INTERNATIONAL 2022; 2022:7284068. [PMID: 35813227 PMCID: PMC9262577 DOI: 10.1155/2022/7284068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/10/2022] [Indexed: 11/18/2022]
Abstract
Purpose To investigate infection risk factors after secondary internal fixation (IF) of open fracture of a long bone with removed fixation frame and explore the safe range of feasible operation for abnormal inflammatory indicators. Methods Clinical data of 117 cases of open fracture of a long bone that underwent temporary external fixation (EF) in one stage and IF in two stages were retrospectively analyzed. Collected data included age, sex, Gustilo type, multiple injuries, debridement time, duration of EF, needle infection, interval of conversion to IF after external fixator, preoperative white blood cell (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin (ALB), blood glucose, and prognosis. We selected these factors for univariate analysis of postoperative surgical site infection (SSI) and multivariate logistic regression analysis of statistically significant risk factors and created receiver operating characteristic (ROC) curves to compare the diagnostic efficiency of each index and determine the optimal screening point. Results We followed up 117 patients, with 130 limbs affected. Univariate analysis showed that ESR, CRP, ALB, WBC, EF time, and Gustilo fracture type were significantly associated with SSI. Multivariate logistic regression analysis showed that CRP, duration of EF, and Gustilo fracture type were independently associated with postoperative infection. Area under ROC curves for WBC, ESR, and CRP were 69.7%, 73.2%, and 81.2%. Conclusions We demonstrated the role of Gustilo classification of open fractures in predicting postoperative infection, especially for open fractures above type III. If the inflammatory indexes return to normal or show a downward trend, and the second-stage IF operation is performed within the cutoff values, postoperative recurrent infection was reduced.
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Jin L, Zhang S, Zhang Y, Lin X, Feng D, Hu K. Management algorithm of external fixation in lower leg arterial injury for limb salvages. BMC Surg 2022; 22:79. [PMID: 35241049 PMCID: PMC8895514 DOI: 10.1186/s12893-022-01486-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/17/2022] [Indexed: 11/10/2022] Open
Abstract
Purpose The aim of this study is to investigate the outcome of these limb-threatening injuries through external fixation treatment and to discuss the case of patients’ functional recovery after external fixation. Methods Demographics, surgical treatment and outcomes in 88 patients with lower leg arterial injuries treated by external fixation at two trauma centers from 2009 to 2018 were reviewed. The primary outcome was the rate of successful lower leg salvage, while secondary outcomes were complications and functional recovery. Results Eighty-eight patients were identified and 80 patients (90 legs) maintained a successful lower leg salvage. The mean age was 32.7 ± 10.8 years, and 81.8% were male. The primary outcomes included the following complications: pin-tract infection (8 legs), pins loosening (4 pins), wound superficial infection (7 legs), deep infection developed osteomyelitis (3 legs), bone nonunion or bone defect (17 legs) and amputation (8 legs). The average healing time of fracture was 5.6 ± 4.3 months. The maintain of external fixation average time was 5.8 ± 3.6 months. The improvement of scores of the pain, function and quality of life in our follow-up was statistically significant. Conclusion For the lower extremity fracture patients with vascular injuries, using external fixation correctly can improve clinical outcomes and produce the improvement of pain, function and the quality of life. Level of evidence Retrospective cohort, level IV.
The success rate of the lower leg salvage is high, reach the percentage of 91.8% (90/98). External fixation is less invasive, with achieving adequate stability to repair the arterial injury timely, can lower the ischemic time, and beneficial for the following bone or soft tissue repair. Treating the patients with external fixators timely is beneficial to the following vascular anticoagulation, bone defect and vein graft, as a result, the protection of lower limb can be improved.
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Affiliation(s)
- Lei Jin
- Department of Orthopedics, Wuxi Hongqiao Hospital, Jiangnan University School of Medicine, Wuxi, 214026, China.,Department of Orthopedics, Wuxi Orthopedics Hospital, Soochow University, Wuxi, 214062, China
| | - Song Zhang
- School of Basic Medicine, Naval Medical University, Shanghai, 200433, China
| | - Yuxuan Zhang
- Department of Orthopedics, Wuxi Orthopedics Hospital, Soochow University, Wuxi, 214062, China
| | - Xin Lin
- Department of Orthopedics, Wuxi Hongqiao Hospital, Jiangnan University School of Medicine, Wuxi, 214026, China
| | - Dehong Feng
- Department of Orthopedics, Wuxi People's Hospital, Nanjing Medical University, Wuxi, 214023, China. .,Laboratory of Digital Medicine, Wuxi People's Hospital, Nanjing Medical University, Wuxi, 214023, China.
| | - Kejia Hu
- Laboratory of Digital Medicine, Wuxi People's Hospital, Nanjing Medical University, Wuxi, 214023, China. .,Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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Natalwala I, Chuo CB, Shariatmadari I, Barlow G, Moulder E, Bates J, Sharma H. Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail. Strategies Trauma Limb Reconstr 2022; 16:161-167. [PMID: 35111255 PMCID: PMC8778722 DOI: 10.5005/jp-journals-10080-1536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction High-energy grade III open fractures of tibia are associated with significant complications and generate debate over the ideal fixation method. This study compares the clinical outcomes for circular frame fixation (CFF) vs intramedullary nail fixation (IMF) in grade III open tibial fractures. Materials and methods Single-centre retrospective study of patients admitted from January 2008 to December 2016. All patients with grade III open diaphyseal tibial fractures (AO 42 A, B, C), treated with either CFF or IMF, were included. The primary outcome was deep bone infection (DBI). Secondary outcomes were delayed or non-union, secondary intervention, and amputation. Results A total of 48 limbs in 47 patients had CFF, and 25 limbs in 23 patients had IMF. Median time to definitive fixation was significantly longer for CFF at 9 days (IQR 3–13) compared to IMF at 1 day (IQR 0–3.5) (p <0.001). The DBI rate was significantly lower (2 vs 16%) in the CFF group (p = 0.04). There were 14 limbs (29%) with delayed or non-union in the CFF group vs 5 limbs (20%) in the IMF group. In the CFF group, significantly more limbs required bone grafting for delayed or non-union (p = 0.03). However, there was a greater proportion of limbs in the CFF group with segmental fractures or bone loss (46 vs 4%) and these high-energy fracture patterns were associated with secondary bone grafting (p = 0.005), and with delayed or non-union (p = 0.03). A subgroup analysis of patients without segmental fractures or bone loss treated with either CFF or IMF showed no significant difference in secondary bone grafting (p >0.99) and delayed or non-union rates (p = 0.72). Overall, one patient in each group went on to have an amputation. Conclusion Our study found that CFF had a lower rate of DBI compared to IMF. Injuries with high-energy fracture patterns (segmental fractures or bone loss) were more likely to have delayed or non-union and require secondary bone grafting. These factors should be considered when selecting the appropriate method of definitive fixation. How to cite this article Natalwala I, Chuo CB, Shariatmadari I, et al. Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail. Strategies Trauma Limb Reconstr 2021;16(3):161–167.
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Affiliation(s)
- Ibrahim Natalwala
- Department of Plastic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
- Ibrahim Natalwala, Department of Plastic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom, e-mail:
| | - Cher Bing Chuo
- Department of Plastic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Isla Shariatmadari
- Department of General Surgery, Bristol Hospitals NHS Trust, Bristol, United Kingdom
| | - Gavin Barlow
- Department of Infectious Diseases, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Elizabeth Moulder
- Department of Trauma and Orthopaedic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Joanna Bates
- Department of Radiology, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Hemant Sharma
- Department of Trauma and Orthopaedic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
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Mohanty K, Agarwal R. Trauma. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1007/978-3-030-78529-1_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Patel KH, Logan K, Krkovic M. Strategies and outcomes in severe open tibial shaft fractures at a major trauma center: A large retrospective case-series. World J Orthop 2021; 12:495-504. [PMID: 34354937 PMCID: PMC8316841 DOI: 10.5312/wjo.v12.i7.495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/16/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe open tibia fractures are challenging to treat with a lack of published clear management strategies. Our aim was to provide an overview of the largest single-center experience in the literature, with minimum 1-year follow-up, of adult type 3 open tibial shaft fractures at Cambridge University Hospitals (a United Kingdom major trauma center). We sought to define patient characteristics and our main outcome measures were infection, union and re-fracture. AIM To retrospectively define patient and injury characteristics, present our surgical methods and analyze our outcomes-namely infection, union and re-fracture rates. METHODS Consecutive series of 74 patients with 75 open tibial fractures treated between 2014 and 2020 (26 classified as Gustilo-Anderson 3A, 47 were 3B and two were 3C). Nine patients underwent intramedullary nailing (IMN), 61 underwent Taylor spatial frame (TSF) fixation and 5 were treated with Masquelet technique (IMN and subsequent bone grafting). RESULTS Mean follow-up was 16 mo (IMN) and 25 mo (TSF). We had an infection rate of 6.7% (5), non-union rate of 4% (3) and re-fracture rate of 2.7% (2). Average time to union was 22 wk for IMN and 38.6 wk for TSF. Thirty-three cases had a bone defect with a mean of 5.4 cm (2-11). Patient age, sex, diabetes, smoking status or injury severity did not have a significant effect on union time with either fixation method. Our limb salvage rate was 98.7%. CONCLUSION Grade 1 to 3A injuries can effectively be treated with reamed or unreamed IMN. Grade 3B/C injuries are best treated by circular external fixators as they provide good, reproducible outcomes and allow large bone defects to be addressed via distraction osteogenesis.
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Affiliation(s)
- Kavi H Patel
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
| | - Karl Logan
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
| | - Matija Krkovic
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
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Park KH, Park HW, Oh CW, Lee JH, Kim JW, Oh JK, Park IH, Ha SS. Conventional bicortical pin substitution with a novel unicortical pin in external fixation: A biomechanical study. Injury 2021; 52:1673-1678. [PMID: 33906742 DOI: 10.1016/j.injury.2021.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION As most patients with polytrauma or open fractures are converted from temporary external fixation to definite stabilization, the prevention of complications such as infection is especially important. To overcome the high risk of infection associated with the use of the conventional bicortical pin for temporary external fixation, the authors developed a novel unicortical pin and analyzed it in a biomechanical study. METHODS The unicortical pin consisted of an inner screw, purchasing the cortical bone, and an outer sleeve with 6 spikes. A bicortical pin was used for the purpose of comparison. A fracture gap model was stabilized using a monoplanar configuration. Both the unicortical pins (Uni group) and bicortical pins (Bi group) underwent axial compressive and torsional load testing using a servo-hydraulic testing machine. Stiffness, load to failure, and mode of failure were documented. RESULTS Stiffness and load to failure of the Uni group (average, 40.5 N/mm and 1098.4 N, respectively) were greater than that of the Bi group (average, 33.7 N/mm and 968.6 N, respectively) in the axial compressive load test (P = 0.008 and 0.032). Stiffness and load to failure of the Uni group (average, 1.2 Nm/degree and 1.7 Nm, respectively) were also significantly higher than those of the Bi group (average, 0.8 Nm/degree and 0.6 Nm, respectively) in the torsional load test (P = 0.008 and 0.016). All pins in the Bi group were bent at the pin-synthetic bone interface without synthetic bone failure. Contrarily, the Uni group did not show any pin bending or failure. However, in the axial compression test, partial cracks in the synthetic bone were found at the interface with spikes in the outer shell. In addition, in the torsion test, incomplete fractures were seen through the inner screws' holes. CONCLUSION Compared with the conventional bicortical pin, the newly designed unicortical pin significantly increased fracture stability under both axial compressive and torsional loads. The unicortical pin can be considered an alternative biomechanical solution to obtain adequate stability when performing external fixation of fractures.
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Affiliation(s)
- Kyeong-Hyeon Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| | - Ho-Won Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea.
| | - Jin-Han Lee
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| | - Joon-Woo Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, School of Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Il-Hyung Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| | - Sung-Soo Ha
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
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Acute Femoral Nailing and Ipsilateral Knee-Spanning External Fixation: Improved Early Stability for Floating Knee Injuries Involving the Tibial Plateau. J Orthop Trauma 2021; 35:e258-e262. [PMID: 32898080 DOI: 10.1097/bot.0000000000001944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 02/02/2023]
Abstract
Ipsilateral femoral shaft and tibial plateau fractures, termed a "floating knee," are rare and challenging injuries. There is limited literature guiding the operative technique and the outcomes associated with these injuries. The author's preferred technique is early intramedullary of the femoral shaft fracture with knee-spanning external fixation of any length unstable plateau fractures in the same operative setting. Early fixation of the femur fracture allows for improved hemodynamic and inflammatory stability. External fixation of the tibial plateau restores length and alignment and allows for soft tissue rest until definitive fixation. The purpose of this study is to describe this operative technique and determine the infection rate and complications requiring return to the operating room in patients with femoral shaft fractures and length unstable plateau fractures.
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Extreme Nailing or Less Invasive Plating of Lower Extremity Periarticular Fractures. Orthop Clin North Am 2021; 52:111-121. [PMID: 33752832 DOI: 10.1016/j.ocl.2021.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Periarticular fractures of the lower extremity can be difficult injuries to stabilize effectively. Modern advances in technique and implant design now allow many of these fractures to be fixed with an extreme intramedullary nail. When nailing is not possible, less invasive plating through percutaneous incisions is a reliable option. The decision to perform extreme nailing is multifactorial and is based on the fracture pattern, the condition of the soft tissues, the medical condition of the patient, and the importance of earlier or immediate weightbearing.
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"Nailable" External Fixation of the Tibia: A Novel Technique to Accommodate Delayed Intramedullary Nailing of the Tibia. J Orthop Trauma 2020; 34:e430-e433. [PMID: 33065669 DOI: 10.1097/bot.0000000000001768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
External fixation is often used for temporary stabilization of the tibia in several clinical scenarios. Conventional placement of external fixation pins may impede instrumentation with intramedullary nailing, thus requiring pin removal, loss of reduction, and increased operative time during definite fixation. In this article, we describe a strategic pin placement routinely used at our institution in which we create a medially based inverted triangular construct that allows for pins to remain in place during definitive fixation.
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Yang JZ, Zhu WB, Li LB, Dong QR. Early complications of preoperative external traction fixation in the staged treatment of tibial fractures: A series of 402 cases. World J Clin Cases 2020; 8:4743-4752. [PMID: 33195642 PMCID: PMC7642547 DOI: 10.12998/wjcc.v8.i20.4743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/20/2020] [Accepted: 09/15/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Different external skeletal fixators have been widely used in preoperative traction of high-energy tibial fractures prior to a definitive surgical treatment. However, the early complications associated with this staged treatment for traction and soft tissue injury recovery have rarely been discussed.
AIM To analyze the early complications associated with preoperative external traction fixation in the staged treatment of tibial fractures.
METHODS A total of 402 patients with high-energy tibial fractures treated using preoperative external traction fixation at a Level 1 trauma center from 2014 to 2018 were enrolled in this retrospective study. Data regarding the demographic information, Tscherne soft tissue injury, fracture site, entry point placement, and duration of traction were recorded. Procedure-related complications such as movement and sensation disorder, vessel injury, discharge, infection, loosening, and iatrogenic fractures were analyzed.
RESULTS The mean patient age was 42.5 (18-71) years, and the mean duration of traction was 7.5 (0-26) d. In total, 19 (4.7%) patients presented with procedure-related complications, including technique-associated complications in 6 patients and nursing-associated complications in 13. Differences in the incidence of complications with respect to sex, affected side, soft tissue injury classification, and fracture sites were not observed. However, the number of complications due to hammer insertion was significantly reduced than those due to drill insertions (2.9% vs 7.4%).
CONCLUSION We found a low incidence of early complications related to the fixation. Furthermore, the complications were not significantly associated with the severity of the soft tissue injury and fracture site. Although relatively rough and more likely to cause pain, the number of complications associated with hammer insertion was significantly smaller than that of complications associated with drill insertion.
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Affiliation(s)
- Jia-Zhao Yang
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
- Department of Traumatic Orthopedics, The First Affiliated Hospital of USTC, Hefei 230000, Anhui Province, China
| | - Wan-Bo Zhu
- Department of Traumatic Orthopedics, Affiliated Anhui Provincial Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Liu-Bing Li
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Qi-Rong Dong
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
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Singh J, Dhillon MS, Dhatt SS. Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study. Malays Orthop J 2020; 14:61-73. [PMID: 32296484 PMCID: PMC7156180 DOI: 10.5704/moj.2003.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Introduction: Grade 3B/C open tibial fractures with grossly contaminated degloving injuries have poor outcomes, with or without vascular injuries. Treatment decision oscillates between limb salvage and amputation. The standard protocol of repeated debridement and delayed wound cover is a challenge in developing countries due to overcrowded emergencies and limited operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate wound cover as an aggressive modality of treatment. Material and Methods: Thirty-three patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent debridement, external fixation and immediate wound cover with free distant/local rotational muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures. Intra-articular fractures were excluded. Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes. Results: Wound cover was achieved with 24 distant free muscle flaps, four local rotational muscle flaps and five fasciocutaneous flaps. All fractures united with an average time to union of 40.3 weeks (16-88). Fifteen patients (45.4%) underwent only a single major surgery using primary definitive external fixation. Deep infection was seen in four patients (12.1%). Nineteen patients had excellent to good outcomes, six were fair, and eight were poor. Conclusion: “Fix and Flap” in the same sitting, using immediate wound cover and external fixation, has given good results in our hands despite the delayed presentation, the neurovascular deficit and the degloving injury. This may be a better management strategy in overcrowded tertiary care centres of developing countries, with a single surgical procedure in almost half the cases.
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Affiliation(s)
- J Singh
- Department of Orthopaedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - M S Dhillon
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S S Dhatt
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Is Systemic Inflammatory Response Syndrome Relevant to Pulmonary Complications and Mortality in Multiply Injured Children? J Pediatr Orthop 2020; 40:1-7. [PMID: 31815855 DOI: 10.1097/bpo.0000000000001085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Systemic inflammatory response syndrome (SIRS) is a well-recognized phenomenon in adult trauma populations. The "initial hit" of the traumatic event is often coupled with a systemic immune response characterized by changes in vital signs and laboratory indicators. A "second hit" from surgery during this time frame often results in acute lung injury, along with deterioration of the patient's clinical condition. We hypothesized that children and adolescents would experience SIRS physiology, but would not experience adult respiratory distress syndrome (ARDS) or "second hit" related death to the extent seen in the adult populations. METHODS We queried the trauma database of our level 1 pediatric trauma center from January 2005 to December 2015 for patients with injury severity scores of >16. We used the electronic medical record to track SIRS criteria in patients days 1 to 4 posttrauma. Trends were examined in patients with an orthopaedic injury (OI) and with no orthopaedic injury. Patients were further subcategorized and analyzed by age group based on the convention for definition of pediatric SIRS. Patients in the orthopaedic cohort were further examined for pulmonary complications and death. Logistic regression was used to identify risk factors for SIRS physiology in the first 4 days of hospitalization. RESULTS 81.4% (OI) and 69.1% no orthopaedic injury reached the threshold for SIRS within their first 4 days of hospitalization. Nine patients died in the hospital. Only 3 OI patients developed the criteria for ARDS, and only 3 patients with orthopaedic injuries died, 2 died within 24 hours of presentation and 1 within 48 hours, all had severe brain trauma. Increasing age groups showed increasing proportion of patients with SIRS. Increasing injury severity score and increasing age were independent predictors of SIRS during days 1 to 4. DISCUSSION SIRS seems to be as common in children as the reported rates for adults, and the proportion of SIRS in children increases with increasing age and injury severity. The high mortality rate and rate of ARDS observed in adults was not observed in our cohort. The presence or absence of major orthopaedic injuries was not a significant predictor. The SIRS response in polytraumatized children is poorly understood. The clinical phenomenon of acute lung injury/ARDS is observed less often in children, but the exact mechanism by which this occurs is unknown. LEVEL OF EVIDENCE Level III-case control.
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Damage control orthopedics and decreased in-hospital mortality: A nationwide study. Injury 2019; 50:2240-2246. [PMID: 31591006 DOI: 10.1016/j.injury.2019.09.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/20/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION While various strategies of fracture fixation in trauma victims have been discussed, the effect of damage control orthopedics (DCO) on significant clinical outcome is inconclusive. We examined the mortality of patients managed with DCO, comparing those without DCO, using a nationwide trauma database. PATIENTS AND METHODS We retrospectively identified patients with extremity injury, defined as patients with an Abbreviated Injury Scale (AIS) of ≥2 in an upper or lower extremity, in the database that included more than 200 major hospitals from 2004 to 2016. We included those who were age ≥15 years and underwent ORIF. Patients with missing survival data or invalid vital signs at hospital arrival were excluded. Patient data were divided into DCO or non-DCO groups, and propensity scores were developed to estimate the probability of being assigned to the DCO group, using multivariate logistic regression analyses adjusted for known survival predictors, such as age, vital signs at arrival, Abbreviated Injury Scale in extremity, ISS, presence of vascular injury, surgical procedure before fracture treatment, and transfusion requirement. The primary outcome, in-hospital mortality, was compared between the two groups after propensity score matching. Survival analyses were performed, and hazard ratio was adjusted according to age, systolic blood pressure on arrival, and Injury Severity Score. RESULTS Of the 19,319 patients included in this study, 4407 (22.8%) underwent DCO. After the propensity score matching, 3858 pairs were selected. In-hospital mortality was significantly lower among patients in the DCO than those in the non-DCO groups (40 [1.0%] vs. 66 [1.7%]; odds ratio = 0.60; 95% confidence interval [CI] = 0.41-0.89; P = 0.01). Survival analyses showed that DCO was independently associated with decreased mortality in patients with extremity injury (adjusted hazard ratio = 0.30; 95% CI = 0.20-0.46; P < 0.01). CONCLUSIONS DCO was associated with decreased in-hospital mortality in patients with major fractures. Further clinical study on DCO by selecting patient population should be considered eventually to develop an appropriate strategy for major fractures.
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Potter JM, van der Vliet QMJ, Esposito JG, McTague MF, Weaver M, Heng M. Is the proximity of external fixator pins to eventual definitive fixation implants related to the risk of deep infection in the staged management of tibial pilon fractures? Injury 2019; 50:2103-2107. [PMID: 31530380 DOI: 10.1016/j.injury.2019.09.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/03/2019] [Accepted: 09/09/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In the staged management of tibial pilon fractures, overlap between definitive internal fixation and external fixation pin sites has been investigated as a risk factor for infection with equivocal conclusions. Our aim was to determine if overlap or proximity of definitive internal fixation to external fixation pin sites influences the risk of deep infection. PATIENTS AND METHODS We reviewed 280 AO/OTA 43B or 43C type distal tibia fractures in 277 patients at two level-one trauma centers. Patients underwent staged management using early temporizing external fixation followed by definitive open reduction and plate fixation. Primary outcome was the association between pin site overlap and the development of deep infection. Secondary outcome was the relationship between development of deep infection and the distance from pin site to definitive fixation. RESULTS The average duration between external fixation and definitive internal fixation was 14 days. 24% of fractures developed deep infection requiring surgical intervention. There was no association between pin site overlap and the development of deep infection (p = 0.18). There was no relationship between infection and the distance between proximal plate extent and pin site (p = 0.13). DISCUSSION We identified no association between pin site overlap and the development of deep infection. We suggest that temporizing external fixation pins should be placed so as to obtain optimal stability of the construct with lesser emphasis on aiming to be absolutely outside the zone of future fixation. LEVEL OF EVIDENCE Level III Therapeutic Retrospective Comparative study.
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Affiliation(s)
- Jeffrey M Potter
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Quirine M J van der Vliet
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, USA
| | - John G Esposito
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, USA
| | - Michael F McTague
- Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Weaver
- Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Marilyn Heng
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, USA.
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Clinical outcome of conversion from external fixation to definitive internal fixation for open fracture of the lower limb. J Orthop Sci 2019; 24:888-893. [PMID: 30772125 DOI: 10.1016/j.jos.2019.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 01/06/2019] [Accepted: 01/10/2019] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Few reports have examined the outcomes and complications of temporary bridging external fixation (EF) in open fracture of the lower limb followed by conversion to open reduction internal fixation (ORIF). The purpose of this study was to evaluate healing rates and complications in patients treated with conversion from external fixation to definitive internal fixation for open fracture of the lower limb. METHOD Patients who underwent temporary bridging EF and subsequent conversion to internal fixation (IF) for open fracture of the lower limb, with follow-up period ≥12 months were included in this study. Demographic data, Gustilo-Anderson classification, fracture type, duration to definitive surgery, surgical procedure, perioperative complications, and additional procedures for cases with complications were obtained. RESULTS In total, 58 patients (43 males, 15 females), 63 fractures were included in this study. Four fractures (6.3%) were Gustilo grade I, 11 fractures (17.5%) were grade II, 34 fractures (54.0%) were grade IIIa, 12 fractures (19.0%) were grade IIIb, and two fractures (3.2%) were grade IIIc. Mean duration of the application of EF was 12.4 days (range, 3-45 days) until conversion to definitive IF. Rates of deep infection and nonunion were both 9.5%, with two cases showing concomitant infection and nonunion. Rates of infection were 8.8% (3/34) in grade IIIa and 25% (3/12) in grade IIIb. Rates of nonunion were 9.1% (1/11) in grade II, 2.9% (1/34) in grade IIIa and 33% (4/12) in grade IIIb. CONCLUSION Temporary EF for open fracture of the lower limb followed by conversion to IF, as early as soft tissue and general condition permit, may be a safe and effective procedure for patients with lower-limb open fracture of Gustilo grade IIIa or less. LEVEL OF EVIDENCE Level IV, Case series.
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Guerado E, Cano JR, Fernandez-Sanchez F. Pin tract infection prophylaxis and treatment. Injury 2019; 50 Suppl 1:S45-S49. [PMID: 31003703 DOI: 10.1016/j.injury.2019.03.044] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023]
Abstract
Pin tract infection in external fixation (ExFix) is a frequent finding which can eventually lead to loosening, osteomyelitis and loss of fixation. Its diagnosis is based on high empiricism and low validity, although it is possible to distinguish between minor and major infection. The first is limited to soft tissues, whereas the latter includes bone involvement. The rate of infection after conversion of external fixation to intramedullary nailing (IMN) is not well known. Unfortunately, papers referring to infection after the conversion of ExFix to intramedullary nailing (IMN) are of evidence level IV or V. It is suggested that conversion of ExFix to IMN should be carried out in a 2 step regimen. The time interval of 2 step regimen is uncertain although some authors have recommended to occur within 9 days. There is no consensus as to which prophylaxis protocol should be applied prior to conversion. In order to throw more light into this important issue, registries capturing important related parameters to the development of infection should be established.
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Affiliation(s)
- Enrique Guerado
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Costa del Sol, University of Malaga, Marbella (Malaga), Spain.
| | - Juan Ramon Cano
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Costa del Sol, University of Malaga, Marbella (Malaga), Spain
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Chen H, Cui X, Ma B, Rui Y, Li H. Staged procedure protocol based on the four-column concept in the treatment of AO/OTA type 43-C3.3 pilon fractures. J Int Med Res 2019; 47:2045-2055. [PMID: 30890008 PMCID: PMC6567754 DOI: 10.1177/0300060519836512] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 02/18/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE We herein introduce a staged management protocol for AO/OTA type 43-C3.3 pilon fractures based on the four-column theory designed to protect the soft tissue. METHODS Twenty-three patients with 25 type C3.3 pilon fractures underwent a staged procedure with four-column osteosynthesis from April 2014 to December 2016. The first stage involved immediate calcaneal traction or external fixation to span the ankle joint. When the soft tissue swelling decreased, the posterolateral approach was used to restore the lateral column and initially fix the posterior column. After 10 to 12 days, the third stage involved treatment of the anterior and medial columns through the anterior approach. Charts and radiographs were reviewed, and the American Orthopaedic Foot and Ankle Society (AOFAS) evaluation system was used to evaluate the postoperative outcomes. RESULTS All fractures achieved union after a mean of 3.3 months (range, 2.0-5.7 months) after the third stage. A good or acceptable reduction rate was observed in 85.7% of the patients. Results from the AOFAS evaluation system indicated excellent or good postoperative ankle function in 81.0% of the patients. CONCLUSION This staged procedure protocol combined with the four-column theory is a feasible way to protect the soft tissue and reduce the fracture.
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Affiliation(s)
- Hui Chen
- Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, PR China
- Trauma Center, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China
| | - Xueliang Cui
- Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, PR China
- Trauma Center, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China
| | - Binbin Ma
- Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, PR China
- Trauma Center, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China
| | - Yunfeng Rui
- Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, PR China
- Trauma Center, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China
| | - He Li
- Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, PR China
- Trauma Center, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China
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Alhammoud A, Maaz B, Alhaneedi GA, Alnouri M. External fixation for primary and definitive management of open long bone fractures: the Syrian war experience. INTERNATIONAL ORTHOPAEDICS 2019; 43:2661-2670. [PMID: 30905046 DOI: 10.1007/s00264-019-04314-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 02/15/2019] [Indexed: 11/25/2022]
Abstract
AIMS To report on the experience of one field hospital in using external fixation as a primary and definitive treatment for open long bone fractures during the Syrian war. METHODS A total of 955 patients with open long bone fractures (femur, tibia, humerus) who were operated and followed up at a field hospital in Aleppo, Syria, from 2011 to 2016, were retrospectively reviewed. Different types of uniplanar and some multiplanar external fixators were used solely as a primary and definitive tool until bone union was achieved. Union rate and infection rate were reported in association with age, gender, Gustilo/Anderson classification, type of fixator, and presence of neurovascular injuries. RESULTS Out of 955 patients, 404 (42.3%) continued to follow up until bone union or until removal of the external fixator. The average age was 27.5 ± 11 years, with 91.6% males and 8.2% females. The overall union rate was 68.3% (276/404), with 60.9% (95/156) in open femur, 70.3% (137/195) in open tibia, and 83% (44/53) in open humerus fractures. The overall infection rate was 16.7% (67/401), with 18.6% in open femur, 18.1% in open tibia, and 5.8% in open humerus fractures. CONCLUSION The use of external fixation for definitive treatment of open long bone shaft fractures caused by high energy trauma during times of wars or conflicts is reliable and should be used in early frontline intervention and in areas with limited access to resources.
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Affiliation(s)
| | | | | | - Mason Alnouri
- Department of Orthopaedic Surgery, Royal National Orthopaedic Hospital -NHS Trust, London, UK.
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Cao Y, Zhang Y, Huang L, Huang X. The impact of plate length, fibula integrity and plate placement on tibial shaft fixation stability: a finite element study. J Orthop Surg Res 2019; 14:52. [PMID: 30767784 PMCID: PMC6376681 DOI: 10.1186/s13018-019-1088-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 02/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tibial shaft fractures account for approximately 15% of long bone fractures. Locked plates with minimally invasive plate osteosynthesis techniques are used widely by surgeons. The purpose of this study is to investigate the impact of factors meaning the plate length, fibula integrity, and placement of the plate on the stability of tibial shaft fracture fixation. METHODS A finite element model of the tibial shaft fracture was built. An axial force of 2500 N was applied to simulate the axial compressive load on an adult knee during single-limb stance. The equivalent von Mises stress and displacement of the fractured ends were used as the output measures. RESULTS In models with plates on the lateral side of the tibia, displacement in models fixed with a 12-hole plate showed the smallest value. In models with plates on the medial side of the tibia, displacement in models fixed with 14-hole plate showed the smallest value. The peak stress of plates implanted on the medial side of the tibia was higher than that of plates on the lateral side. The peak stress and the displacement of models involved with the fibula were lower than that of models without fibula, regardless of the length or location of plates. CONCLUSIONS For models with plates on the medial side of the tibia, the 14-hole plate is the best choice in terms of stability. While for models with plates on the lateral side of the tibia, the 12-hole plate demonstrated the optimal biomechanical stability. The integrity of the fibula improves the anti-vertical compression stability of the construct. The peak stress of plates implanted on the medial side of the tibia was higher than that of plates on the lateral side, which indicated that the construct with medially implanted plate has a higher risk of implant failure.
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Affiliation(s)
- Yasen Cao
- The First Affiliated Hospital of Soochow University, 188, Shi Zi Road, Suzhou, 215006, China
| | - Yong Zhang
- The First Affiliated Hospital of Soochow University, 188, Shi Zi Road, Suzhou, 215006, China
| | - Lixin Huang
- The First Affiliated Hospital of Soochow University, 188, Shi Zi Road, Suzhou, 215006, China
| | - Xiaowei Huang
- The First Affiliated Hospital of Soochow University, 188, Shi Zi Road, Suzhou, 215006, China.
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Oh Y, Kurosa Y, Okawa A. Staged internal plate fixation of severe lower extremity fractures that use a temporary external fixator for the initial treatment as an intraoperative retention tool: a technical note. Arch Orthop Trauma Surg 2019; 139:53-59. [PMID: 30328508 DOI: 10.1007/s00402-018-3049-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Indexed: 11/29/2022]
Abstract
Staged treatment for severe lower extremity fractures is coming into widespread use, and some reports have described internal fixation (IF) using a temporary external fixator for primary care as an intraoperative retention tool. However, the infection risk with this procedure has not been examined sufficiently. To our knowledge, this article is the first report focusing exclusively on this specific surgical technique. A key point of our developed protocol for internal plate fixation with this technique to avoid postoperative infection is a precisely structured sterilization procedure, which required multiple changes of sterile surgical gloves. In all 19 fractures treated with our set protocol, postoperative infection did not occur. In this regard, however, a goal of definitive IF at the time of initial treatment is essential for this specific procedure. This technique could help orthopaedic trauma surgeons to import a temporary external fixator into the operative field for definitive IF, with less concern regarding risk of infection.
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Affiliation(s)
- Yoto Oh
- Department of Orthopaedic and Trauma Research, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Yoshiro Kurosa
- Department of Orthopaedic Surgery, Saku Central Hospital, Nagano, Japan
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Oliveira PR, Leonhardt MC, Carvalho VC, Kojima KE, Silva JS, Rossi F, Lima ALL. Incidence and risk factors associated with infection after intramedullary nailing of femoral and tibial diaphyseal fractures: Prospective study. Injury 2018; 49:1905-1911. [PMID: 30082109 DOI: 10.1016/j.injury.2018.07.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/12/2018] [Accepted: 07/26/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Diaphyseal fractures of femur and tibia are prominent due to its high incidence and high economic and social impact. Intramedullary nailing (IN) is the surgical procedure of choice. Surgical site infection (SSI) related to this procedure is considered a difficult to treat complication. AIMS Determine the incidence of SSI after IN of femoral and tibial diaphyseal fractures and evaluate possible risk factors. METHODS Prospective observational cohort study. SSI was defined according to CDC-NHSN criteria and surveillance period for the occurrence of infection was 12 months. Incidence of SSI was calculated as the ratio between the number of patients with SSI and total number of patients. Analysis of potential risk factors included patients-related factors (age, gender, body mass index, active foci of infection, immunosuppressive conditions, ASA score, alcohol or illicit drug abuse, smoking, polytrauma, etiology of fracture, type of fracture if closed or open, classification of fracture according to Müller AO, Tcherne classification for closed fractures, Gustilo-Anderson classification for open fractures, previous surgical manipulation, use of blood products); environmental and surgical-related factors (surgical wound classification, duration of surgery, hair removal, intraoperative contamination, antimicrobial use, presence of drains, hypothermia or hypoxia in the perioperative period, type of IN used, reaming, need for soft tissue reconstruction, use of negative pressure therapy) and microbiota-related factors (cultures of nasopharyngeal swabs forStaphylococcus aureus and axillary/inguinal/perineal swab for Acinetobacter baumannii). RESULTS 221 patients were included and completed the 12-month follow-up period. Incidence of SSI was 11.8%. In the initial analysis by unadjusted logistic regression, following factors were associated SSI: Müller AO classification of the fracture morphology groups 2 or 3, previous use of external fixator, presence of drains, use of negative pressure therapy and need for muscle or skin flap repair. In the multiple logistic regression-adjusted analysis, previous use of external fixator and need for muscle or skin flap repair remained associated with SSI. CONCLUSIONS Incidence of SSI associated with IN for femoral and tibial diaphyseal fractures was 11.8%. Previous use of external fixators and need for muscle or skin flap repair were factors associated with occurrence of infection.
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Affiliation(s)
- Priscila R Oliveira
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil.
| | - Marcos C Leonhardt
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Vladimir C Carvalho
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Kodi E Kojima
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Jorge S Silva
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Flavia Rossi
- Laboratorio de Microbiologia DLC, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Ana Lucia L Lima
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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Russo AP, Caubere A, Ghabi A, Grosset A, Mangin P, Rigal S, Mathieu L. Sequential management of tibial fractures using a temporary unicortical external fixator. SICOT J 2018; 4:39. [PMID: 30192226 PMCID: PMC6128168 DOI: 10.1051/sicotj/2018035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/29/2018] [Indexed: 12/27/2022] Open
Abstract
Introduction: The development of damage control orthopedics (DCO) procedures has led to the development of temporary unicortical external fixators (TUEFs) intended to limit deep infectious complications and facilitate early conversion to internal fixation. Methods: A retrospective study was conducted in two French military trauma centers, including on patients being treated for tibial fractures with a TUEF (UNYCO® − Orthofix®) followed by an early conversion to intramedullary nailing. Results: Eleven patients with an average age of 41 were included between September 2015 and June 2017. A total of 12 TUEFs were implanted for one closed fracture and 11 open fractures, including one type I, eight types II, and two Gustilo types IIIB. The indication of DCO was related to hemodynamic instability in three cases, to the severity of soft tissue lesions in eight cases, and to the context of treatment in one case. The conversion to IM nailing was made after an average of 7.6 days. No significant loss of reduction was observed until internal osteosynthesis, which was performed with “fixator in place” in ten cases. The coverage of Gustilo type III injuries was performed by free flap transfers at the same time as IM nailing. All the patients were reviewed with an average follow-up of 16.5 months. Bone union was achieved in all cases. Two IM nailing dynamizations were carried out, but no bone grafting was required. Two cases of pandiaphysitis were observed and treated without functional complications. Discussion: Despite a limited number of patients, this study demonstrates the reliability of the TUEF to maintain the reduction of tibial fractures and facilitate early conversion to IM nailing. Unicortical fixation does not prevent septic complications related to the severity of soft tissue injuries.
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Affiliation(s)
- Anne-Pauline Russo
- Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Alexandre Caubere
- Department of Orthopedic Surgery and Traumatology, Sainte-Anne Military Hospital, Toulon, France
| | - Ammar Ghabi
- Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Antoine Grosset
- Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Philippe Mangin
- Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Sylvain Rigal
- Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France - Department of Surgery, French Military Health Service Academy, École du Val-de-Grâce, Paris, France
| | - Laurent Mathieu
- Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France - Department of Surgery, French Military Health Service Academy, École du Val-de-Grâce, Paris, France
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Rigal S, Mathieu L, de l'Escalopier N. Temporary fixation of limbs and pelvis. Orthop Traumatol Surg Res 2018; 104:S81-S88. [PMID: 29197635 DOI: 10.1016/j.otsr.2017.03.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/05/2017] [Accepted: 03/07/2017] [Indexed: 02/02/2023]
Abstract
"Urgent, complete, definitive" treatment still today seems to be an appropriate attitude in many trauma cases. There are, however, several situations in which emergency definitive fixation is not the optimal strategy for all cases of fracture. Temporary fixation has a role to play in the orthopedic "trauma damage control" design comprising successive steps, as applied in multiple trauma, multiple fracture, severe multi-tissue limb lesions and soft-tissue lesions of unpredictable progression. The aim of this study is to define the strategies, indications, principles and limitations of temporary fixation in limb and pelvis fracture.
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Affiliation(s)
- S Rigal
- Service de chirurgie orthopédique, traumatologie et chirurgie réparatrice des membres, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France.
| | - L Mathieu
- Service de chirurgie orthopédique, traumatologie et chirurgie réparatrice des membres, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - N de l'Escalopier
- Service de chirurgie orthopédique, traumatologie et chirurgie réparatrice des membres, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
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Luo F, Wang X, Wang S, Fu J, Xie Z. Induced membrane technique combined with two-stage internal fixation for the treatment of tibial osteomyelitis defects. Injury 2017; 48:1623-1627. [PMID: 28483358 DOI: 10.1016/j.injury.2017.04.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/19/2017] [Accepted: 04/25/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to observe the effects of induced membrane technique combined with two-stage internal fixation in the treatment of tibial osteomyelitis defects. METHODS A retrospective analyses for 67 cases of tibialosteomyelitis defects were admitted to our department between September 2012 to February 2015, which were treated with induced membrane technique. At the first stage, implanted with a PMMA cement spacer in the defects after radical debridement and fixed with reconstructive locked plate. Bone grafting and exchanged the plate with intramedullary nail at the second stage. RESULTS In current study, all patients were followed up for 18-35 months. Sixty-six patients achieved bone union with the average radiographic and clinical healing times of 5.55±2.19 and 7.45±1.69months, respectively. Seven patients required a second debridement before grafting, while four patients experienced a recurrence of infection or a relapse following second stage treatment. Twelve patients experienced either knee or ankle dysfunctions and 2 patients faced delayed wound healing. Donor site complications includes pain and infection were found in 7 and 3 patients, respectively with delayed stress fracture in 1 patient only. CONCLUSIONS Induced membrane technique for the treatment of tibial osteomyelitis defects, seems a reliable method. The use of reconstructive locked plate as a temporary internal fixation at the first stage and exchanged with intramedullary nail at the second stage, potentially achieves good clinical efficacy. Care should be taken to restore the joint function especially in distal tibia.
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Affiliation(s)
- Fei Luo
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
| | - Xiaohua Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
| | - Shulin Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
| | - Jingshu Fu
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
| | - Zhao Xie
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
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Weinberg DS, Narayanan AS, Moore TA, Vallier HA. Assessment of resuscitation as measured by markers of metabolic acidosis and features of injury. Bone Joint J 2017; 99-B:122-127. [PMID: 28053267 DOI: 10.1302/0301-620x.99b1.bjj-2016-0418.r2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 09/27/2016] [Indexed: 12/19/2022]
Abstract
AIMS The best time for definitive orthopaedic care is often unclear in patients with multiple injuries. The objective of this study was make a prospective assessment of the safety of our early appropriate care (EAC) strategy and to evaluate the potential benefit of additional laboratory data to determine readiness for surgery. PATIENTS AND METHODS A cohort of 335 patients with fractures of the pelvis, acetabulum, femur, or spine were included. Patients underwent definitive fixation within 36 hours if one of the following three parameters were met: lactate < 4.0 mmol/L; pH ≥ 7.25; or base excess (BE) ≥ -5.5 mmol/L. If all three parameters were met, resuscitation was designated full protocol resuscitation (FPR). If less than all three parameters were met, it was designated an incomplete protocol resuscitation (IPR). Complications were assessed by an independent adjudication committee and included infection; sepsis; PE/DVT; organ failure; pneumonia, and acute respiratory distress syndrome (ARDS). RESULTS In total, 66 patients (19.7%) developed 90 complications. An historical cohort of 1441 patients had a complication rate of 22.1%. The complication rate for patients with only one EAC parameter at the point of protocol was 34.3%, which was higher than other groups (p = 0.041). Patients who had IPR did not have significantly more complications (31.8%) than those who had FPR (22.6%; p = 0.078). Regression analysis showed male gender and injury severity score to be independent predictors of complications. CONCLUSIONS This study highlights important trends in the IPR and FPR groups, suggesting that differences in resuscitation parameters may guide care in certain patients; further study is, however, required. We advocate the use of the existing protocol, while research is continued for high-risk subgroups. Cite this article: Bone Joint J 2017;99-B:122-7.
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Affiliation(s)
- D S Weinberg
- MetroHealth Medical Center, Case Western Reserve University, Department of Orthopaedic Surgery, 2500 MetroHealth Drive, Cleveland, Ohio, 44109, USA
| | - A S Narayanan
- University of North Carolina, School of Medicine, Department of Orthopaedics, CB# 7055, Chapel Hill, North Carolina 27599, USA
| | - T A Moore
- MetroHealth Medical Center, Case Western Reserve University, Department of Orthopaedic Surgery, 2500 MetroHealth Drive, Cleveland, Ohio, 44109, USA
| | - H A Vallier
- MetroHealth Medical Center, Case Western Reserve University, Department of Orthopaedic Surgery, 2500 MetroHealth Drive, Cleveland, Ohio, 44109, USA
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Nieto H, Baroan C. Limits of internal fixation in long-bone fracture. Orthop Traumatol Surg Res 2017; 103:S61-S66. [PMID: 28082050 DOI: 10.1016/j.otsr.2016.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 11/09/2016] [Accepted: 11/09/2016] [Indexed: 02/02/2023]
Abstract
Alternatives to internal fixation of long-bone fracture comprise, depending on location, external fixation or joint replacement. Limitations comprise risk of infection and functional outcome quality, which vary according to technique. The present study examines these limitations, based on comparative or large-scale studies from which certain significant results emerge. Four main questions are dealt with: (1) the present role of locking plates; (2) conditions for intramedullary nailing in Gustilo grade IIIb open fracture; (3) the limitations of conversion from external fixation to intramedullary nailing in open lower leg fracture; (4) and the limitations of definitive anterograde femoral nailing in multiple trauma. Locking plate fixation has yet to prove clinical superiority in any of the anatomic sites for which good-quality comparative analyses are available. Infection risk in Gustilo grade IIIb open lower leg fracture is equivalent when treated by intramedullary nailing or external fixation, if wound care and debridement are effective, antibiotherapy is initiated rapidly and skin cover is restored within 7days. Conversion from primary external fixation to intramedullary nailing is possible if the external fixator was fitted less than 28days previously and skin cover was restored within 7days. The pulmonary and systemic impact of peripheral lesions or definitive anterograde intramedullary nailing of femoral fracture in multiple trauma calls for caution and what is known as "damage-control orthopedics" (DCO), a term covering the general consequences of both the initial trauma and its treatment. Femoral intramedullary nailing is thus contraindicated in case of hemorrhagic shock (blood pressure<90mmHg), hypothermia (<33°C), coagulation disorder (platelet count<90,000) or peripheral lesions such as multiple long-bone fractures, crushed limb or primary pulmonary contusion. In such cases, external fixation or retrograde nailing with a small-diameter nail and without reaming are preferable.
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Affiliation(s)
- H Nieto
- Service de chirurgie orthopédique, centre hospitalier Georges-Renon, 40, avenue Charles-de-Gaulle, 79021 Niort cedex, France.
| | - C Baroan
- Service de chirurgie orthopédique, centre hospitalier Georges-Renon, 40, avenue Charles-de-Gaulle, 79021 Niort cedex, France
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50
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Fang C, Wong TM, Lau TW, To KK, Wong SS, Leung F. Infection after fracture osteosynthesis - Part I. J Orthop Surg (Hong Kong) 2017; 25:2309499017692712. [PMID: 28215118 DOI: 10.1177/2309499017692712] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Bone and surgical site infections after osteosynthesis are notoriously difficult to manage and pose a tremendous burden in fracture management. In this article, we use the term osteosynthesis-associated infection (OAI) to refer to this clinical entity. While relatively few surgically treated fractures become infected, it is challenging to perform a rapid diagnosis. Optimal management strategies are complex and highly customized to each scenario and take into consideration the status of fracture union, the presence of hardware and the degree of mechanical stability. At present, a high level of relevant evidence is unavailable; most findings presented in the literature are based on laboratory work and non-randomized clinical studies. We present this overview of OAI in two parts: an examination of recent literature concerning OAI pathogenesis, diagnosis and classification and a review of treatment options.
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Affiliation(s)
- Christian Fang
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Tak-Man Wong
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China.,3 Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Tak-Wing Lau
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Kelvin Kw To
- 2 Department of Microbiology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Samson Sy Wong
- 2 Department of Microbiology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Frankie Leung
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China.,3 Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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