Effect of Antibiotic Prophylaxis on Surgical Site Infections Following Removal of Orthopedic Implants Used for Treatment of Foot, Ankle, and Lower Leg Fractures: A Randomized Clinical Trial

Plasma and tissue concentrations of 2 g prophylactic cefazolin prior to lower extremity surgery

Surgical site infections (SSIs) are among the most clinically relevant complications and the use of prophylactic cefazolin is common practice. However, the knowledge about the pharmacological aspects of prophylactic cefazolin in the lower extremities remains limited. In this prospective cohort, a sub-study of the WIFI-2 randomized controlled trial, adults between 18 and 75 years of age who were scheduled for implant removal below the level of the knee and randomized for cefazolin, was included. A maximum of two venous plasma, target-site plasma, and target-site tissue samples were taken during surgery. The primary outcomes were the cefazolin concentrations in venous plasma, target-site plasma, and target-site tissue. A total of 27 patients [median (interquartile range) age, 42 (29-59) years; 17 (63%) male] with 138 samples were included in the study. A minimum of 6 weeks follow-up was available for all patients. The mean (SD) venous plasma, target-site plasma, and target-site tissue concentrations were 36 (13) µg/mL, 29 (13) µg/mL, and 28 (13) µg/g, respectively, and the cefazolin concentrations between the different locations of surgery did not differ significantly in both target-site plasma and target-site tissue (P = 0.822 and P = 0.840). In conclusion, 2 g of prophylactic cefazolin demonstrates adequacy in maintaining coverage for a duration of at least 80 minutes of surgery below the level of the knee, significantly surpassing the MIC90 required to combat the most prevalent microorganisms. This study represents the first of its kind to assess cefazolin concentrations in the lower extremities by examining both plasma and tissue samples in this magnitude.

Analysis of risk factors, pathogenic bacteria characteristics, and drug resistance of postoperative surgical site infection in adults with limb fractures

PURPOSE

We carried out the study aiming to explore and analyze the risk factors, the distribution of pathogenic bacteria, and their antibiotic-resistance characteristics influencing the occurrence of surgical site infection (SSI), to provide valuable assistance for reducing the incidence of SSI after traumatic fracture surgery.

METHODS

A retrospective case-control study enrolling 3978 participants from January 2015 to December 2019 receiving surgical treatment for traumatic fractures was conducted at Tangdu Hospital of Air Force Medical University. Baseline data, demographic characteristics, lifestyles, variables related to surgical treatment, and pathogen culture were harvested and analyzed. Univariate analyses and multivariate logistic regression analyses were used to reveal the independent risk factors of SSI. A bacterial distribution histogram and drug-sensitive heat map were drawn to describe the pathogenic characteristics.

RESULTS

Included 3978 patients 138 of them developed SSI with an incidence rate of 3.47% postoperatively. By logistic regression analysis, we found that variables such as gender (males) (odds ratio (OR) = 2.012, 95% confidence interval (CI): 1.235 - 3.278, p = 0.005), diabetes mellitus (OR = 5.848, 95% CI: 3.513 - 9.736, p < 0.001), hypoproteinemia (OR = 3.400, 95% CI: 1.280 - 9.031, p = 0.014), underlying disease (OR = 5.398, 95% CI: 2.343 - 12.438, p < 0.001), hormonotherapy (OR = 11.718, 95% CI: 6.269 - 21.903, p < 0.001), open fracture (OR = 29.377, 95% CI: 9.944 - 86.784, p < 0.001), and intraoperative transfusion (OR = 2.664, 95% CI: 1.572 - 4.515, p < 0.001) were independent risk factors for SSI, while, aged over 59 years (OR = 0.132, 95% CI: 0.059 - 0.296, p < 0.001), prophylactic antibiotics use (OR = 0.082, 95% CI: 0.042 - 0.164, p < 0.001) and vacuum sealing drainage use (OR = 0.036, 95% CI: 0.010 - 0.129, p < 0.001) were protective factors. Pathogens results showed that 301 strains of 38 species of bacteria were harvested, among which 178 (59.1%) strains were Gram-positive bacteria, and 123 (40.9%) strains were Gram-negative bacteria. Staphylococcus aureus (108, 60.7%) and Enterobacter cloacae (38, 30.9%) accounted for the largest proportion. The susceptibility of Gram-positive bacteria to Vancomycin and Linezolid was almost 100%. The susceptibility of Gram-negative bacteria to Imipenem, Amikacin, and Meropenem exceeded 73%.

CONCLUSION

Orthopedic surgeons need to develop appropriate surgical plans based on the risk factors and protective factors associated with postoperative SSI to reduce its occurrence. Meanwhile, it is recommended to strengthen blood glucose control in the early stage of admission and for surgeons to be cautious and scientific when choosing antibiotic therapy in clinical practice.

Risk factors contributing to postoperative surgical site infections in patients undergoing ankle fracture fixation: A systematic review and meta-analysis

Surgical site infections (SSIs) following ankle fracture fixation pose significant challenges in patient recovery and healthcare management. Identifying risk factors contributing to SSIs can aid in developing targeted prevention and treatment strategies. This systematic review and meta-analysis were conducted according to the PRISMA guidelines and the PICO framework. A comprehensive literature search across major databases, including PubMed, Embase, Web of Science and the Cochrane Library, was completed on September 26, 2023. The inclusion criteria encompassed peer-reviewed studies of various designs that investigated risk factors for SSIs post-ankle fracture fixation. Quality assessment was performed using the Newcastle-Ottawa Scale. Statistical analyses assessed heterogeneity and calculated combined effect sizes using fixed- or random-effects models, depending on the heterogeneity observed. The initial search yielded 1250 articles, with seven meeting the inclusion criteria after rigorous screening and full-text review. The included studies, conducted between 2006 and 2019, predominantly utilized case-control designs. The meta-analysis identified diabetes, open fractures, smoking, age, alcohol consumption, ASA score ≥3, high BMI, contaminated incisions, fracture dislocation and heart disease as significant risk factors for postoperative SSIs. Publication bias assessment showed no significant bias across studies. The identification of key risk factors such as diabetes, open fractures, smoking, advanced age, alcohol consumption, high ASA score, elevated BMI, contaminated incisions, fracture dislocation and heart disease is essential in managing SSIs post-ankle fracture fixation. Targeted interventions addressing these risk factors are crucial to reduce the incidence of SSIs and improve overall patient outcomes.

Use of ultrasound for hardware removal

INTRODUCTION

Osteosynthesis hardware removal is one of the most frequent practices in Orthopedic electives surgeries and is usually carried out guided under fluoroscopy. There are other tools such as ultrasound that allow us to visualize the hardware with the advantage of being free of ionizing radiation and with better availability. The objective of our study is to analyze the results obtained in patients undergoing hardware removal in the operating room under ultrasound assistance and local anesthesia.

MATERIAL AND METHODS

A descriptive study was carried out collecting variables such as demographic data, reason for the removal, pain during the procedure and in subsequent days, as well as the duration and rate of success of the procedure and the degree of satisfaction.

RESULTS

We obtained a 100% success in ultrasound-guided extraction without the need for conventional radiology, with a mean VAS of 1.91 and need for subsequent analgesia in 36.4% of the cases, with syndesmotic dynamization being the most frequent reason for intervention.

CONCLUSION

Ultrasound is a useful tool in osteosynthesis hardware removal, and that may be sufficient by itself; also saving health personnel and patients from ionizing radiation resulting from the use of conventional fluoroscopy.

Evidence-Based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-Site Infections in Plastic and Reconstructive Surgery

BACKGROUND

After nearly a decade of new data, the Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons was updated for prophylactic systemic antibiotics to prevent surgical-site infections (SSI). Pharmacotherapeutic concepts using antimicrobial stewardship were applied for clinical interpretation and management to optimize patient outcomes and minimize resistance.

METHODS

PRISMA, Cochrane, and GRADE certainty of evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched for randomized controlled trials (RCTs). The authors included patients who had plastic and reconstructive surgery and were treated with prophylactic systemic antibiotics administered perioperatively (preoperatively, intraoperatively, or postoperatively). Comparisons were made between active interventions and nonactive interventions (placebo) at different prespecified durations to determine the development of an SSI. Meta-analyses were performed.

RESULTS

The authors included 138 RCTs that met eligibility criteria. RCTs consisted of 18 breast, 10 cosmetic, 21 hand/peripheral nerve, 61 pediatric/craniofacial, and 41 reconstructive studies. The authors examined bacterial data extracted from studies for patients who did or did not take prophylactic systemic antibiotics for prevention of SSI. Clinical recommendations were provided using level I evidence.

CONCLUSIONS

Surgeons have long been overprescribing systemic antibiotic prophylaxis in plastic and reconstructive surgery. Evidence supports antibiotic prophylaxis to prevent SSI for specific indications and durations. Prolonged antibiotic use has not been linked to reductions in SSIs, and misuse may increase the bacterial diversity of infections. Greater efforts should focus on transitioning from practice-based to pharmacotherapeutic evidence-based medicine.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Validation of the Polish versions of the Lower Limb Task Questionnaire, Lower Limb Functional Index, and Lower Limb Functional Index-10

BACKGROUND

Physicians who treat patients with lower limb diseases should pay attention not only to the patients' clinical condition but also to their individual needs and expectations. For this purpose, many different questionnaires can be employed. This study aimed to validate the Lower Limb Task Questionnaire (LLTQ), Lower Limb Functional Index (LLFI), and Lower Limb Functional Index-10 (LLFI-10) for their use in Polish conditions and to perform a mutual comparison and analysis of differences in subjective assessments by patients who undergo hip or knee arthroplasty.

METHODS

The LLTQ, LLFI, and LLFI-10 were translated into Polish. A total of 103 patients who qualified for hip or knee arthroplasty at a University Hospital in from 2019 to 2021 were included in this study. The patients were asked to complete the Polish versions of the LLTQ, LLFI, LLFI-10, Lower Extremity Functional Scale (LEFS), and Short Form-36 four times - twice before and twice after their surgeries.

RESULTS

The Polish versions of the LLTQ, LLFI, and LLFI-10 had good psychometric properties. One year after surgery, the Cohen's standard response mean revealed high improvement of limb functionality and thus quality of life among all patients. We observed better treatment outcomes among patients who had hip osteoarthritis.

CONCLUSIONS

The questionnaires were validated and can be used both in everyday health practice and in further research in Poland.

Effect of pharmacist intervention on antibiotic prophylaxis in orthopedic internal fixation: A retrospective study

BACKGROUND

Despite the availability of guidelines and official policies, antibiotic prophylaxis in clean surgery remains suboptimal.

OBJECTIVE

The aim of this study was to evaluate the clinical effects and cost-effectiveness of pharmacist-led intervention in the perioperative anti-infection prophylaxis of patients undergoing orthopedic internal fixation.

METHODS

We performed a retrospective analysis based on the medical records of internal fixation surgery in a tertiary hospital from July 2019 to June 2020. Data were divided into two groups based on whether a full-time pharmacist participated in the treatment. The research parameters included use of antibiotics, rationality of medication, postoperative complications, and related cost. To deal with selection bias, propensity score matching method was employed at a ratio of 1:1. Meanwhile, a cost-effectiveness analysis was used to evaluate the impact of pharmacist intervention on antibiotic prevention in internal fixation surgery.

RESULTS

A total of 537 participants were included in this study. After matching, 236 patients were comparable in each group. During the pharmacist intervention period, less pharmacologic prophylaxis (96.6% vs 100.0%, p = 0.007) and shorter prophylaxis duration (1.60 vs 2.28 days, p < 0.001) were observed. The reasonable rate increased dramatically in usage and dosage (96.6% vs 83.9%, p < 0.001), timing of administration (94.5% vs 78.4%, p < 0.001) and medication duration (64.4% vs 37.7%, p < 0.001). In addition, pharmacist intervention yielded net economic benefits. A remarkable reduction was observed in average length of stay (10.43 vs 11.14 days, p = 0.012), drug cost ($610.57 vs $706.60, p = 0.001) and defined daily doses (2.31 vs 3.27, p < 0.001). The cost-effectiveness ratios, divided drug cost savings by cost of pharmacist time, were 28:1 for drug and 2:1 for antibiotics, respectively.

CONCLUSION

Pharmacist-driven antibiotic stewardship for orthopedic internal fixation patients improved compliance with peri-procedure antibiotic prophylaxis, and reduced the cost and utilization of antibiotics. This helped to bring significant clinical and economic benefits.

Additive Manufacturing of Polymer/Mg-Based Composites for Porous Tissue Scaffolds

Due to their commercial availability, superior processability, and biocompatibility, polymers are frequently used to build three-dimensional (3D) porous scaffolds. The main issues limiting the widespread clinical use of monophasic polymer scaffolds in the bone healing process are their inadequate mechanical strength and inappropriate biodegradation. Due to their mechanical strength and biocompatibility, metal-based scaffolds have been used for various bone regenerative applications. However, due to the mismatch in mechanical properties and nondegradability, they lack integration with the host tissues, resulting in the production of fiber tissue and the release of toxic ions, posing a risk to the durability of scaffolds. Due to their natural degradability in the body, Mg and its alloys increasingly attract attention for orthopedic and cardiovascular applications. Incorporating Mg micro-nano-scale particles into biodegradable polymers dramatically improves scaffolds and implants' strength, biocompatibility, and biodegradability. Polymer biodegradable implants also improve the quality of life, particularly for an aging society, by eliminating the secondary surgery often needed to remove permanent implants and significantly reducing healthcare costs. This paper reviews the suitability of various biodegradable polymer/Mg composites for bone tissue scaffolds and then summarizes the current status and challenges of polymer/magnesium composite scaffolds. In addition, this paper reviews the potential use of 3D printing, which has a unique design capability for developing complex structures with fewer material waste at a faster rate, and with a personalized and on-site fabrication possibility.

Cost-effectiveness of on-demand removal of syndesmotic screwsx

Purpose

Syndesmotic screw removal following acute syndesmotic injury is a commonly performed procedure. However, recent studies suggest that the removal does not result in improved patient reported outcome, while the procedure has proved not to be without complications. The aim of this study was to present a health-economic evaluation of on-demand removal (ODR) compared to routine removal (RR) of the syndesmotic screw.

Methods

Data were collected from the RODEO trial, a randomized controlled non-inferiority trial comparing functional outcome of ODR with RR. Economic evaluation resulted in total costs, costs (in Euro) per quality adjusted life year (QALY) and costs per point improvement on the Olerud Molander Ankle Score (OMAS). This included both direct and indirect costs.

Results

Total costs for ODR were significantly lower with a mean difference of 3160 euro compared to RR (p < 0.001). The difference in QALY was not significant. The difference in OMAS at 12 months was 1.79 with an incremental cost-effectiveness ratio (ICER) of €-1763 (p = 0.512). The ICER was well below the willingness to pay. Although unit costs might vary between hospitals and countries, these results provide relevant data of cost-effectiveness.

Conclusion

The clinical effectiveness of both ODR and RR can be considered equal. The costs are lower for patients treated with ODR, which leads to the conclusion that ODR is cost-effective.

Interaction of basic diseases and low red blood cell count as critical murderer of wound infection after osteosarcoma resection: Wound infection after osteosarcoma resection

BACKGROUND

Surgical wound infection is one of the common complications in patients after osteosarcoma resection. It is imperative to grasp the risk factors comprehensively. Therefore, this study aimed to explore the risk factors of wound infection and deeply analyze the correlation between risk factors and wound infection.

METHODS

The study subjects were 101 patients who underwent osteosarcoma resection between April 2018 and August 2021. The diagnosis of postoperative wound infection was confirmed by postoperative observation of the incision, ultrasound imaging, and pathogenic examination. This study included a series of potential factors, mainly laboratory examination indicators and patients' general information. The statistical methods had Pearson Chi-square test, Spearman-rho correlation test, multifactorial linear regression model, logistic regression analysis, and receiver operating characteristic (ROC) curve.

RESULTS

Pearson Chi-square test and Spearman correlation test showed that red blood cell (RBC) count (P = .033) and basic diseases (P = .020) were significantly correlated with a surgical wound infection after osteosarcoma resection. Logistic regression analysis manifested that basic disease (OR = 0.121, 95% CI: 0.015-0.960, P = .046) and RBC (OR = 0.296, 95% CI: 0.093-0.944, P = .040) have a clear correlation with whether the patients have surgical wound infection after osteosarcoma resection. And the interaction of basic diseases and RBC could diagnose the surgical wound infection sensitively and accurately (AUC = 0.700, P = .014, 95% CI = 0.564-0.836) via the ROC analysis.

CONCLUSION

Patients with basic diseases and low RBC were risk factors for surgical wound infection after osteosarcoma resection.

Outcomes of Hardware Removal Surgery for Children

Hardware removal is among the most common orthopedic procedures performed in the United States. The goal of this study was to report the outcomes of deep hardware removal for children. This study received institutional review board approval. Patients younger than 18 years who underwent deep hardware removal between 2007 and 2017 were studied. We reviewed 227 procedures involving 132 boys and 95 girls. Mean follow-up was 25 months (range, 14-36 months). Mean age at the time of surgery was 12.8 years (range, 2-17 years). Mean time from initial surgery to hardware removal was 8.4 months (range, 1-72 months). Of the 227 cases, 75 used a tourniquet. Mean tourniquet time was 30.1 minutes (range, 1-118 minutes). Mean length of surgery was 44.0 minutes (range, 4-173 minutes). Mean resident level performing the surgery was postgraduate year 3 (range, postgraduate year 2 to fellow). There were 3 complications. Locations of the implanted hardware included: femur, 85; humerus, 49; tibia, 46; hip/pelvis, 17; ulna, 11; miscellaneous foot, 10; radius, 6; and fibula, 3. Indications for surgery included surgeon recommendations in 122 cases; symptomatic hardware in 68 cases, and parent wishes in 37 cases. Hardware removal for children was safe, and the outcomes were excellent. Complications of hardware removal at a teaching hospital can be minimized when a more senior resident is the primary surgeon. Despite the challenging and historically troublesome nature of deep hardware removal, the current study shows that hardware removal for children is safe and effective. [Orthopedics. 2022;45(2):e91-e95.].

Skin preparation for prevention of surgical site infection after obstetrics and gynecological abdominal surgery: A quality improvement project

BACKGROUND

One of the most common causes of postoperative morbidity is postoperative surgical site infection (SSI). Healthcare-associated infection is a subject of great concern in healthcare services. The goal of the present study is to estimate the relative effectiveness of skin preparation solution chlorhexidine scrub followed by povidone-iodine painting in the prevention of SSIs after caesarean delivery and abdominal gynecological surgery.

MATERIAL AND METHODS

This is a 1-year randomized prospective research done at a tertiary care institution in western Rajasthan. Women who underwent caesarean and gynecological operations were randomly assigned to one of two groups. Enrolled patients were randomly assigned to have the surgical site painted with 10% povidone-iodine or a chlorhexidine-alcohol preparatory scrub followed by povidone-iodine paint. According to the Centres for Disease Control and Prevention criteria, the outcomes were any SSI occurring within a week or during the 30-day follow-up period following the operation, including any superficial or deep SSI.

RESULTS

A total of 251 patients were randomly assigned to two groups. Group A (povidone-iodine paint) received 121 patients, whereas Group B (chlorhexidine scrub + povidone-iodine paint) received 129 cases. The overall SSI rate in the present study was 8.76%. The SSI rate was lower in Group B (chlorhexidine scrub + povidone-iodine paint) as compared to Group A (povidone-iodine paint only) (5.4% vs. 12.4%; p = 0.04).

CONCLUSION

This study highlighted that chlorhexidine-alcohol scrubbing followed by povidone-iodine painting provides superior skin antisepsis in comparison to povidone-iodine painting alone.

The Effect of Pharmacist-Led Intervention on Surgical Antibacterial Prophylaxis (SAP) at an Orthopedic Unit

Perioperative antibiotic use is a common reason for antibiotic misuse. Evidence suggests that adherence to SAP guidelines may improve outcomes. The purpose of this study was to analyze the impact of pharmacist-led antibiotic stewardship interventions on SAP guideline compliance. The study was conducted at an Orthopedic Department of a tertiary care medical center. SAP compliance and antibiotic exposure in the pre-intervention and intervention period was compared using chi-square, Fisher exact, and Mann-Whitney tests, as appropriate. Prophylactic antibiotic use in orthopedic joint arthroplasties (overall guideline adherence: agent, dose, frequency, duration), clinical outcomes (length of stay-LOS, number of surgical site infections-SSIs), antibiotic exposure and direct antibiotic costs were compared between pre-intervention and intervention periods. Significant improvement in mean SAP duration (by 42.9%, 4.08 ± 2.08 vs. 2.08 ± 1.90 days, p ˂ 0.001), and overall guideline adherence regarding antibiotic use (by 56.2%, from 2% to 58.2%, p ˂ 0.001) were observed. A significant decrease was observed in antibiotic exposure in SAP (by 41%, from 6.07 ± 0.05 to 3.58 ± 4.33 DDD/patient, p ˂ 0.001), average prophylactic antibiotic cost (by 54.8%, 9278.79 ± 6094.29 vs. 3598.16 ± 3354.55 HUF/patient), and mean LOS (by 37.2%, from 11.22 ± 6.96 to 7.62 ± 3.02 days, p < 0.001); and a slight decrease in the number of confirmed SSIs was found between the two periods (by 1.8%, from 3% to 1.2%, p = 0.21). Continuous presence of the clinical pharmacist led to significant improvement in SAP guideline adherence, which was accompanied by decreased antibiotic exposure and cost.

Cefazolin Improves Anesthesia and Surgery-Induced Cognitive Impairments by Modulating Blood-Brain Barrier Function, Gut Bacteria and Short Chain Fatty Acids

Emerging evidence suggests that anesthesia and surgery may induce gut dysbiosis. Gut dysbiosis leads to imbalance in circulating contents of microbiota-derived metabolites and disrupts the integrity of the blood-brain barrier (BBB), contributing to postoperative cognitive dysfunction (POCD). The composition of gut microbiota may be influenced by various antibiotics. However, how perioperative use of antibiotics affects POCD needs more explorations. In the present study, we explored the effect of cefazolin, a common antibiotic used in perioperative period, on cognitive function, BBB integrity, gut bacteria and short chain fatty acids (SCFAs), a group of widely studied metabolites in aged mice, using 18-month-old male mice. Significant BBB disruptions and decreased levels of tight junction proteins, zonula occludens-1 (ZO-1) and Occludin (OCLN) were seen in the mice of POCD model. Cefazolin treatment attenuated these changes induced by anesthesia and surgery. Furthermore, cefazolin reversed the changes in several fecal bacteria (β-, γ/δ-, ε-Proteobacteria, and Bacteroidetes) as determined by qPCR tests. Analysis of plasma SCFAs showed that almost all types of SCFAs were reduced in POCD and cefazolin administration reversed the changes in expression of the two most abundant SCFAs (acetic and propionic acids). In conclusion, this study demonstrated that cefazolin improved POCD. Mechanistically, cefazolin suppressed the disruption of BBB, gut microbiota or SCFAs, thereby ameliorating POCD.

Surgical experience as a decisive factor for the outcome of calcaneal fractures using locking compression plate: results of 3 years

INTRODUCTION

Calcaneal fractures account for 60-75% of all tarsal fractures and represent surgical challenges because of their frequency and complexity. Despite standardized procedures and new implants, literature reports high revision rates and unsatisfactory results. The study aims to describe the role of the surgeon with respect to the clinical outcome.

METHODS

Between 2014 and 2017, 94 calcaneal fractures (all type AO C1-3) were re-examined in 86 patients (67 male and 19 female; mean age: 51 years). The treatment was always carried out by means of locking compression plate via the extensile lateral approach. A comparison was made between treatment by an experienced (ES) and less experienced surgeon (LES). Annually, the ES performed at least 30 procedures for calcaneus fracture treatment as compared to < 10 operations performed by the LES.

RESULTS

The mean AOFAS, VAS FA, and Kiel Score in the ES group were 77.0 (SD 15.9), 69.0 (SD 18.8), and 65.0 (SD 20.6), respectively. The corresponding values in the LES group were 68.1 (SD 21.0), 60.3 (SD 22.4), and 53.0 (SD 21.9) (p < 0.05). The operation time was on average 14 min shorter in the ES group than the LES group (p < 0.05).

CONCLUSION

The significantly better scores, along with shorter operation time, shorter duration of incapacity to work, and lower complication rate prove the importance of having an experienced surgeon perform complex intra-articular calcaneal fracture repairs. The extensile lateral approach is still considered the standard method.

LEVEL OF EVIDENCE

Level III, comparative series.

Treatment of Fractures of Metatarsal Shaft Using a Cemented K-wire Frame

The purpose of this retrospective study was to report on percutaneous reduction and fixation for the treatment of fractures of metatarsal shaft. Between March 2015 and October 2017, 29 patients (37 fractures of metatarsal shaft) were treated using a cemented Kirschner wire (K-wire) frame. The accuracy of reduction of the fragments was assessed as anatomic (0 to 8 points), good (9 to 11 points), fair (12 to 15 points), or poor (>15 points). The Maryland foot score was used to assess pain and functional outcomes. All fractures were reduced using percutaneous techniques. Anatomic reduction was achieved in 31 metatarsal fractures (84%), and good reduction was achieved in 6 (16%). The average bone healing time was 7 weeks (range, 4 to 16). Pin tract infection was noted in 2 metatarsal bones, which healed with pin site care. The mean cost of the cemented K-wire frame was US$335 (range, $283 to $385) per patient. Based on the Maryland foot score, there were 26 excellent results (90%) and 3 good results (10%). The cemented K-wire frame is a useful external fixator and can be an alternative for treating fractures of metatarsal shaft, especially when open surgeries are a major concern owing to severely damaged soft-tissue envelope. The system is cheap and easy to apply and provides rigid fixation, resulting in good function of the foot.

Surgical Site Infections After Routine Syndesmotic Screw Removal: A Systematic Review

OBJECTIVES

To investigate the incidence of surgical site infections (SSIs) after routine removal of syndesmotic screws (SSs) placed to stabilize syndesmotic injuries.

DATA SOURCES

A systematic literature search was performed in the PubMed, Cochrane, and EMBASE databases for studies published online before February 2020, using the key words and synonyms of "syndesmotic screw" ("ankle fractures" or "syndesmotic injury") and "implant removal."

STUDY SELECTION

Studies were eligible for inclusion when they described >10 adult patients undergoing elective/scheduled removal of the SS.

DATA EXTRACTION

The 15 included articles were assessed for quality and risk of bias using the Newcastle-Ottawa Scale. Baseline characteristics of the studies, the study population, the intervention, the potential confounders, and the primary outcome (% of SSIs) were extracted using a customized extraction sheet.

DATA SYNTHESIS

The primary outcome was presented as a proportion of included patients and as a weighted mean, using inverse variance, calculated in RStudio. Furthermore, potential confounders were identified.

CONCLUSIONS

The percentage of SSIs ranged from 0% to 9.2%, with a weighted mean of 4%. The largest proportion of these infections were superficial (3%, 95% confidence interval: 2-5), compared with 2% deep infections (95% confidence interval: 1-4). These rates were comparable to those of other foot/ankle procedures indicating that the individual indication for SS removal (SSR) should be carefully considered. Future studies should focus on valid indications for SSR, the influence of prophylactic antibiotics on an SSI after SSR, and complications of retaining the SS to enable a fair benefits/risks comparison of routine versus on-demand removal of the SS.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Improved Early Clinical Outcomes After Elective Implant Removal

OBJECTIVES

To determine preoperative factors predictive of improvement in pain and function after elective implant removal. We hypothesized that patients undergoing orthopaedic implant removal to relieve pain would have significant improvements in both pain and function.

DESIGN

Prospective cohort study.

SETTING

Level I Trauma Center.

PATIENTS/PARTICIPANTS

One hundred eighty-nine patients were enrolled after consenting for orthopaedic implant removal to address residual pain. One hundred sixty-three were available for 3-month follow-up.

MAIN OUTCOME MEASUREMENT

Preoperative and postoperative outcome measures including Patient Reported Outcomes Measurement Information System (PROMIS) scores were compared. Preoperative scores, surgeon prediction of pain improvement, and palpable implants were analyzed as predictors of outcomes.

RESULTS

Median PROMIS physical function and pain interference scores and visual analogue scale significantly improved by 6, 8, and 2 points, respectively (P < 0.001 for all). Worse preinjury scores predicted improvement in respective postoperative outcomes (P < 0.001 for all). Surgeon prediction of improvement was associated with improved PROMIS pain interference (P = 0.005), patient subjective assessment of pain improvement (P = 0.03), and subjective percent of pain remaining at 3 months (P = 0.02). Implant superficial palpability was not predictive for any postoperative outcomes.

CONCLUSIONS

Although the primary indication for implant removal in this population was pain relief, many patients also had a clinically relevant improvement in physical function. In addition, patients who start with worse global indices of pain and function are more likely to improve after implant removal. This suggests that implant-related pain directly contributes to global dysfunction.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Wound infection following implant removal of foot, ankle, lower leg or patella; a protocol for a multicenter randomized controlled trial investigating the (cost-)effectiveness of 2 g of prophylactic cefazolin compared to placebo (WIFI-2 trial)

Background

Elective implant removal (IR) after fracture fixation is one of the most common procedures within (orthopedic) trauma surgery. The rate of surgical site infections (SSIs) in this procedure is quite high, especially below the level of the knee. Antibiotic prophylaxis is not routinely prescribed, even though it has proved to lower SSI rates in other (orthopedic) trauma surgical procedures. The primary objective is to study the effectiveness of a single intravenous dose of 2 g of cefazolin on SSIs after IR following fixation of foot, ankle and/or lower leg fractures.

Methods

This is a multicenter, double-blind placebo controlled trial with a superiority design, including adult patients undergoing elective implant removal after fixation of a fracture of foot, ankle, lower leg or patella. Exclusion criteria are: an active infection, current antibiotic treatment, or a medical condition contraindicating prophylaxis with cefazolin including allergy. Patients are randomized to receive a single preoperative intravenous dose of either 2 g of cefazolin or a placebo (NaCl). The primary analysis will be an intention-to-treat comparison of the proportion of patients with a SSI at 90 days after IR in both groups.

Discussion

If 2 g of prophylactic cefazolin proves to be both effective and cost-effective in preventing SSI, this would have implications for current guidelines. Combined with the high infection rate of IR which previous studies have shown, it would be sufficiently substantiated for guidelines to suggest protocolled use of prophylactic antibiotics in IR of foot, ankle, lower leg or patella.

Trial registration Nederlands Trial Register (NTR): NL8284, registered on 9th of January 2020, https://www.trialregister.nl/trial/8284

In vitro evaluation of novel low-pressure spark plasma sintered HA–BG composite scaffolds for bone tissue engineering

The low-pressure spark plasma sintering (SPS) technique is adopted to fabricate hydroxyapatite–bioglass (HA–BG) scaffolds while maintaining the physical properties of both components, including their bulk and relative density and hardness. However, prior to their orthopaedic and dental applications, these scaffolds must be validated via pre-clinical assessments. In the present study, scaffolds with different ratios of HA : BG, namely, 100 : 0 (HB 0 S), 90 : 10 (HB 10 S), 80 : 20 (HB 20 S) and 70 : 30 (HB 30 S) were fabricated. These scaffolds were characterized by investigating their physicochemical properties (X-ray diffraction (XRD) and surface wettability), bioactivity in a simulated body fluid (SBF) (field emission scanning electron microscopy (FESEM), Fourier-transform infrared spectroscopy (FTIR) and calcium dissolution), antimicrobial properties, biocompatibility and osteoinduction of human bone marrow-derived mesenchymal stromal cells (hBMSCs) and human monocyte immune cell response. The XRD and surface wettability results confirmed no formation of undesirable phases and the enhanced surface hydrophilicity of the scaffolds, respectively. The bioactivity in SBF indicated the formation of bone-like apatite on the surface of the scaffolds, corresponding to an increase in BG%, which was confirmed through FTIR spectra and the increasing trend of calcium release in SBF. The scaffolds showed inhibition properties against Staphylococcus aureus and Staphylococcus epidermidis. The scanning electron microscopy (SEM) micrographs and Alamar Blue proliferation assay indicated the good attachment and significant proliferation, respectively, of hBMSCs on the scaffolds. Alizarin Red S staining confirmed that the scaffolds supported the mineralisation of hBMSCs. The osteogenic protein secretion (bone morphogenetic protein-2 (BMP2), type-I collagen (COL1) and osterix (OSX)) was significant on the HB 30 S-seeded hBMSCs when compared with that of HB 0 S. The monocyte migration was significantly halted in response to HA–BG-conditioned media when compared with the positive control (monocyte chemoattractant protein-1: MCP-1). In conclusion, the HB 30 S composite scaffold has a greater potential to substitute bone grafts in orthopaedic and dental applications.

HB 30 S composite scaffold inhibits Staphylococcus spp., supports the biocompatibility and osteogenic differentiation of hBMSCs and resists monocyte migration.

Commercially available antibiotic-laden PMMA-covered locking nails for the treatment of fracture-related infections - A retrospective case analysis of 10 cases

Introduction: Fracture-related infections (FRIs) are a devastating complication. FRIs are challenging and should be addressed with a multidisciplinary approach. An FRI should be addressed surgically by non-viable bone debridement, local antibiotic deposition, minimization of dead space and fracture stabilization. Antibiotic-laden PMMA-covered nails are a viable option to face these complications. To demonstrate the safety and utility of commercially available antibiotic-laden PMMA-covered nails, we performed a review of the cases operated in our institution and a cost analysis to compare the cost of a commercial nail to other available alternatives.

Material and methods: We designed a retrospective study of consecutive cases to demonstrate the safety and efficacy of antibiotic-laden PMMA-covered commercial nails and designed a cost analysis of commercial coated nails compared to other custom-made alternatives.

Results: We treated seven tibias and three femurs. Nine patients fully fit the criteria for FRI. There was one case of reintervention because of persistent drainage. All fractures healed, and in the first year post-intervention, there were no signs or symptoms of infection. There were no complications related to the commercially available nail that was used. There is a small increase in the direct quantifiable cost in commercially available nails, but non-quantifiable cost should be assessed individually.

Conclusions: Commercially available antibiotic-laden PMMA-covered nails are a safe and useful treatment option for complicated cases of lower limb long bone reconstruction. The low complication rate and the straightforward technique compensate for the direct cost increase in most situations.

Are Prophylactic Perioperative Antibiotics Required for Isolated Forefoot Procedures, Such as Hammertoes?

RECOMMENDATION

Though limited clinical data exists, the administration of perioperative antibiotics is not required for isolated forefoot procedures in the absence of any risk factors, such as immunodeficiency or diabetes mellitus.

LEVEL OF EVIDENCE

Moderate.

DELEGATE VOTE

Agree: 67%, Disagree: 25%, Abstain: 8% (Super Majority, Weak Consensus).

Trends in Foot and Ankle Studies Published in High-Impact General Medical Journals: A Systematic Review

The foot and ankle surgery literature lacks an analysis of studies published in general medical journals. Studies published in general medical journals have high visibility and significant impact on decision making by medical practitioners and health care policy makers. Knowledge of the subject matter and methodologic characteristics of foot and ankle publications being read by general medical practitioners and the lay public is important to the practicing foot and ankle surgeon. A systematic review of foot and ankle studies published from 2000 to 2017 in 5 high-impact general medical journals was undertaken. Data extracted included study topic, study design, study demographics, and methodologic characteristics of randomized controlled trials (RCTs). There were 47 foot and ankle studies published in the selected medical journals examined during the study time period. Most common topics were diabetic foot ulcers (n = 25 [53.2%]), plantar fasciitis (n = 6 [12.8%]), and Achilles tendinopathy (n = 5 [10.6%]). The most common study types were reviews (n = 24 [51.1%]), RCTs (n = 12 [25.4%], and prospective studies (n = 6 [12.8%]). Of the published RCTs, the most common journal of publication was the Journal of the American Medical Association (n = 7 [58.3%]). The median number of citations for RCTs published before 2016 was 242.5. Of the small number of RCTs that compared operative with nonoperative treatment, the majority supported nonoperative management (n = 3 [75%]). Diabetic foot ulcers, plantar fasciitis, and Achilles tendinopathy are the most commonly published foot and ankle topics in general medical journals.

Complications of implant removal in ankle fractures

Background

Although the complications of internal fixation in ankle fractures are well-known in a number of reports, there have been few reports revealing the complications of implant removal in ankle fractures. The aim of this study was to investigate the perioperative complications of implant removal in ankle fractures and analyze the associated factors of such complications.

Methods

Patients who underwent open reduction and internal fixation using metal implants for ankle fractures and had their implants removed between 2010 and 2015 were enrolled in the study. We investigated the rate and details of perioperative complications and collected information on the possible risk factors including the age, comorbidities, fracture type, number of skin incisions, operative time, and surgeon's grade from the medical charts.

Results

A total of 80 patients were included for analysis. Perioperative complications occurred in 11 patients (14%) including arterial injury in one patient, blistering in three, nerve injuries in three, skin necrosis in two, and infection in two. In patients with perioperative complications, the rate of patients with peripheral vascular disease and multiple skin incision was significantly higher (18% vs 3%, p = 0.031 and 64% vs 32%, p = 0.042, respectively) and the operative time was significantly longer (102 min vs 57 min, p < 0.001) than those without perioperative complications.

Conclusion

The indication of implant removal in ankle fractures should be considered carefully, especially in patients with possible risk factors and without implant-related symptoms, due to the high incidence of perioperative complications.

A novel implant removal technique by endoscopy

BACKGROUND

Routine implant removal after fracture healing remains controversial. However, it has been suggested that implant removal should be performed in cases of joint impingement, painful scar adhesion, and implant malposition. Entrance selection is relatively critical in patients with poor soft tissue conditions or sloughing coverage. We propose an innovative technique using endoscopy.

METHODS

Consecutive surgeries of endoscopic implant removal performed between 2005 and 2016 by a single experienced arthroscopic surgeon were included. Overall, 73 patients were enrolled; 44 were not eligible for inclusion and were excluded from the study.

RESULTS

Twenty-nine patients, including 32 surgical sites, were included. Twenty-four plates and 166 screws were removed using this technique. There were five complications during the follow-up period (range, 0.5 to 104 months; mean, 8.8), including one broken screw, one persistent knee joint contracture, and three wound dehiscence. There were no infections or neurovascular injuries.

CONCLUSION

Implant removal using endoscopy is a minimally invasive surgery that ensures that the screw axis does not strip, and treats the intra-articular pathology concomitantly. This innovative technique may be considered as an alternative to the traditional open method in cases with good surgical indications.

Preoperative disinfection of foot and ankle: microbiological evaluation of two disinfection methods

BACKGROUND

The aim of the current study was to investigate the effect of a footbath in alcohol prior to preoperative disinfection on bacterial flora of the foot and ankle.

METHODS

Twenty-two volunteers underwent skin preparation mimicking pre-surgical disinfection. One foot was submerged in a bag filled with 70% ethanol containing 10% IPA for 5 min after which it was painted with regular 0.5% chlorhexidine in 70% alcohol. The other foot was only painted with 0.5% chlorhexidine in 70% alcohol. Swabs were taken at four locations: (1) under the nailfold of the first toe, (2) first webspace, (3) sinus tarsi and (4) pre-tibial. A quantitative and qualitative analysis of the cultures was performed.

RESULTS

No statistically significant difference between the number of positive cultures between the two methods was observed. The number of colony forming units was statistically significantly lower on two locations in the footbath group (i.e., subungual and the first webspace) (median 1 versus median 92 p =0.03 and median 0 versus median 1 p =0.03, respectively). The number of cultures with heavy growth was lower in the footbath group under the nailfold of the first toe (5 versus 13 p =0.008). Thirty-eight different microorganisms were cultured.

CONCLUSION

A footbath in alcohol prior to regular preoperative skin antisepsis significantly reduces the amount of bacteria under the nailfold and in the first webspace. The number of cultures with heavy growth is lower after a footbath in alcohol.

LEVEL OF EVIDENCE

IV.