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High-Grade Limbs Open Fractures: Time to Find Milestones in the Emergency Setting. Life (Basel) 2021; 11:life11111226. [PMID: 34833102 PMCID: PMC8617751 DOI: 10.3390/life11111226] [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: 09/16/2021] [Revised: 10/30/2021] [Accepted: 11/10/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: The Gustilo–Anderson (G/A) grading system is a universally accepted tool used to classify high-grade limb open fractures. The purpose of this study is to find early independent predictors of amputation in emergency settings. (2) Methods: A retrospective analysis involving patients treated at our center between 2010 and 2016 was conducted. Patients with at least one G/A grade III fracture or post-traumatic amputation were included. Three groups were identified: G/A IIIA (A group), G/A IIIB-C (BC group), and Amputation group (AMP group). Each group was further divided into two subgroups considering timing of coverage (early vs. delayed). Univariate and multivariate logistic regression models were developed to identify independent predictors of the limb’s outcome. (3) Results: One-hundred-six patients with G/A III A-B-C fractures or amputation of the affected limb were selected from the Niguarda Hospital Trauma Registry. The patients were divided into the A group (26), BC group (66), and AMP group (14). The rate of infectious complications following early or delayed coverage was evaluated: A group, 9.1% vs. 66.7% (p > 0.05); BC group, 32% vs. 63.6% (p = 0.03); and AMP group, 22% vs. 18.5% (p > 0.05). After further recategorization, the BC subgroups were analyzed: multivariate logistic regression model identified systolic blood pressure (SBP) <90 mmHg (p = 0.03) and Mangled Extremity Severity Score MESS ≥ 7 (p = 0.001) were determined to be independent predictors of limb amputation. (4) Conclusion: MESS and SBP serve as predictors of amputation. Based on the results, we propose a new management algorithm for mangled extremities. Early coverage is related to lower rates of infectious complications. Referral to high-volume centers with specific expertise is mandatory to guarantee the best results.
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Abstract
SUMMARY The relationship between wound irrigation and healing has been recognized for centuries. However, there is little evidence and no official recommendations from any health care organization regarding best wound irrigation practices. This is the first review of wound irrigation that systematically summarizes the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and distills the evidence into a practical format. In this comprehensive review, the authors outline the irrigation fluids and delivery methods used in the identified studies, analyze reported treatment outcomes, summarize irrigation effectiveness, and propose evidence-based guidelines to improve wound healing outcomes and enhance the consistency of wound irrigation. Thirty-one high-quality studies with a combined total of 61,808 patients were included. Based on the current evidence provided by this review, the authors propose the following guidelines: (1) acute soft-tissue wounds should receive continuous gravity flow irrigation with polyhexanide; (2) complex wounds should receive continuous negative-pressure wound therapy with instillation with polyhexanide; (3) infected wounds should receive continuous negative-pressure wound therapy with instillation with silver nitrate, polyhexanide, acetic acid, or povidone-iodine; (4) breast implant wounds should receive gravity lavage with povidone-iodine or antibiotics; and (5) surgical-site infection rates can be reduced with intraoperative povidone-iodine irrigation.
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Metsemakers WJ, Kortram K, Ferreira N, Morgenstern M, Joeris A, Pape HC, Kammerlander C, Konda S, Oh JK, Giannoudis PV, Egol KA, Obremskey WT, Verhofstad MHJ, Raschke M. Fracture-related outcome study for operatively treated tibia shaft fractures (F.R.O.S.T.): registry rationale and design. BMC Musculoskelet Disord 2021; 22:57. [PMID: 33422025 PMCID: PMC7797092 DOI: 10.1186/s12891-020-03930-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/28/2020] [Indexed: 01/12/2023] Open
Abstract
Background Tibial shaft fractures (TSFs) are among the most common long bone injuries often resulting from high-energy trauma. To date, musculoskeletal complications such as fracture-related infection (FRI) and compromised fracture healing following fracture fixation of these injuries are still prevalent. The relatively high complication rates prove that, despite advances in modern fracture care, the management of TSFs remains a challenge even in the hands of experienced surgeons. Therefore, the Fracture-Related Outcome Study for operatively treated Tibia shaft fractures (F.R.O.S.T.) aims at creating a registry that enables data mining to gather detailed information to support future clinical decision-making regarding the management of TSF’s. Methods This prospective, international, multicenter, observational registry for TSFs was recently developed. Recruitment started in 2019 and is planned to take 36 months, seeking to enroll a minimum of 1000 patients. The study protocol does not influence the clinical decision-making procedure, implant choice, or surgical/imaging techniques; these are being performed as per local hospital standard of care. Data collected in this registry include injury specifics, treatment details, clinical outcomes (e.g., FRI), patient-reported outcomes, and procedure- or implant-related adverse events. The minimum follow up is 12 months. Discussion Although over the past decades, multiple high-quality studies have addressed individual research questions related to the outcome of TSFs, knowledge gaps remain. The scarcity of data calls for an international high-quality, population-based registry. Creating such a database could optimize strategies intended to prevent severe musculoskeletal complications. The main purpose of the F.R.O.S.T registry is to evaluate the association between different treatment strategies and patient outcomes. It will address not only operative techniques and implant materials but also perioperative preventive measures. For the first time, data concerning systemic perioperative antibiotic prophylaxis, the influence of local antimicrobials, and timing of soft-tissue coverage will be collected at an international level and correlated with standardized outcome measures in a large prospective, multicenter, observational registry for global accessibility. Trial registration ClinicalTrials.gov: NCT03598530. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-020-03930-x.
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Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium. .,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - Kirsten Kortram
- Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nando Ferreira
- Division of Orthopaedics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Alexander Joeris
- AO Innovation Translation Center, AO Foundation, Dübendorf, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, UniversitätsSpital Zürich, University of Zurich, Raemistrasse, Zurich, Switzerland
| | - Christian Kammerlander
- Department of General Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Sanjit Konda
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital and Jamaica Hospital Medical Center, New York, NY, USA
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, Guro-gu, Seoul, Republic of Korea
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michael Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany
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Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017. J Trauma Acute Care Surg 2020; 88:e53-e76. [PMID: 32150031 DOI: 10.1097/ta.0000000000002407] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries. METHODS The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held. RESULTS The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb. CONCLUSION Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. LEVEL OF EVIDENCE Systematic review of predominantly level II studies, level II.
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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: 25] [Impact Index Per Article: 5.0] [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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Mavrogenis AF, Quaile A, Pećina M, Scarlat MM. Citations, non-citations and visibility of International Orthopaedics in 2017. INTERNATIONAL ORTHOPAEDICS 2018; 42:2499-2505. [PMID: 30298386 DOI: 10.1007/s00264-018-4198-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Marko Pećina
- Department of Orthopaedics, School of Medicine, University of Zagreb, Zagreb, Croatia
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