Children with open tibial fractures show significantly lower infection rates than adults: clinical comparative study

Antibiotics Within One Hour for Pediatric Open Lower Extremity Fractures May Not be Warranted as a Quality Metric

BACKGROUND

Open fractures have been associated with a higher risk of infection if antibiotics are not administered within 1 h of presentation in adult trauma patients. Time to antibiotic administration for open fractures is frequently used as a quality metric for trauma centers, but there have been no large studies evaluating this topic for pediatric patients.

METHODS

The 2019 Trauma Quality Improvement Program dataset was queried for patients ≤ 16 years old with isolated open femur or tibia fractures undergoing operative intervention after blunt trauma. Patients transferred from another hospital were excluded. Pediatric patients receiving early antibiotics (EA) within 1 h were compared to patients receiving delayed antibiotics (DA) greater than or equal to 1 h from arrival. Multivariate logistic regression was used to evaluate risk of surgical site infection (SSI).

RESULTS

There were 150 patients with open lower extremity fractures: 98 (64.9%) EA vs 52 (34.4%) DA. There was no difference in the rate of SSI between the 2 groups (EA: 1.0% vs DA: 1.9%, P = 0.65). There remained similar associated risk of infection after adjusting for lower extremity abbreviated injury scale >3, blood transfusion requirement, and vital signs on arrival (OR 0.62, 95% CI 0.04-10.24, P = 0.74).

CONCLUSIONS

Most pediatric trauma patients with open lower extremity fracture received antibiotics within 1 h of presentation. However, SSI was rare and the risk of SSI was not associated with antibiotic administration within 1 h. Therefore, timing of antibiotic administration for pediatric open lower extremity fractures should be re-evaluated as a quality metric.Level of Evidence: Level III.

Bone and periosteum protein analysis via tandem mass tag quantitative proteomics in pediatric patients with osteomyelitis

Bone healing is crucial in managing osteomyelitis after fracture fixation. Understanding the mechanism of extensive callus formation in pediatric osteomyelitis is highly important. This study aims to analyze bone and periosteum samples from pediatric patients to elucidate the essential processes involved in callus formation during osteomyelitis. The study included eight patients from our hospital: four with positive microbial culture who underwent osteomyelitis debridement and four who had osteotomy surgery as contral. We used tandem mass tag quantitative proteomics to investigate proteomic changes in bone and periosteum tissues obtained from these patients. Differential expression proteins were analyzed for their pathways through Gene Ontology (GO) annotation, GO enrichment analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis, and protein-protein interaction networks. A total of 4737 proteins were successfully identified. About 2224 differentially expressed proteins were detected in the bone tissues group and periosteum tissues group. Among the differentially expressed proteins, 10 protein genes in the bone group were associated with inflammation and osteogenesis, while in the periosteum group were nine. Cytochrome b-245, beta polypeptide (CYBB), nicotinamide phosphoribosyltransferase (NAMPT), tissue inhibitor of metalloproteinases 1 (TIMP-1), Raf-1 proto-oncogene, serine/threonine kinase (RAF-1), RELA proto-oncogene, NF-KB subunit (RELA), and sphingomyelin synthase 2 (SGMS2) may play an important role in callus formation in patients with osteomyelitis. This study provides novel clues for understanding callus formation in pediatric patients with osteomyelitis.

Finite element analysis of modified Slongo's external fixation in the treatment of supracondylar humeral fractures in older children

Older children over 8 years old are at higher risk of elbow joint stiffness after treatment of supracondylar humeral fractures. The objective of this study was to improve the Slongo's external fixation system for treating supracondylar humeral fractures in older children. This would be achieved by increasing fixation strength and providing a theoretical basis through finite element analysis and mechanical testing. A 13-year-old female patient with a history of previous fracture was selected for CT data processing to create a three-dimensional model of the distal humerus fracture. Two internal fixation models were established, using the Slongo's external fixation method with Kirschner wire (Group A) and modifying the Slongo's external fixation (Kirschner wire tail fixation) (Group B). The fracture models were then subjected to mechanical loading analysis using Finite Element Analysis Abaqus 6.14 software to simulate separation, internal rotation, and torsion loads. A PVC humeral bone model was used to create a supracondylar fracture model, and the A and B internal fixation methods were applied separately. The anterior-posterior and torsional stresses were measured using the Bose Electroforce3510 testing system, followed by a comparative analysis. The finite element simulation results showed that under the same tensile, torsion, and inversion forces, the osteotomy model fixed with Kirschner wire at the distal end in Group B exhibited smaller tensile stress and deformation compared to the unfixed osteotomy model in Group A. This indicated that the fixation strength of Group B was superior to that of Group A. According to the test results of the Bose Electroforce3510 testing system, a simple linear regression analysis was conducted using SPSS software. The K values of rotation angle-torque tests and front and rear displacement-stress tests were calculated for Groups A and B, with Group B showing higher values than Group A. The results of this study supported the significantly enhanced biomechanical reliability and stability of fracture fixation in Group B, which utilized the modified Slongo's external fixation (Kirschner wire tail fixation). This optimized method provides a new choice for the clinical treatment of supracondylar humeral fractures in older children, backed by both clinical evidence and theoretical basis.

Management of Open Pediatric Fractures: Proposal of a New Multidisciplinary Algorithm

BACKGROUND

An algorithm for managing open fractures in children is still being debated; the present study suggests an evidence-based way to manage these patients in the emergency department.

METHODS

The literature on "Open fractures in children" was carefully analyzed using keywords. The primary sources were The Cochrane Library, PubMed, and Researchgate.

CONCLUSION

We proposed an evidence-based algorithm for managing open fractures in children to standardize clinical practice and improve the care of these patients.

Comparison of nonoperative versus operative management in pediatric gustilo-anderson type I open tibia fractures

BACKGROUND

Recent studies suggest pediatric Gustilo-Anderson type I fractures, especially of the upper extremity, may be adequately treated without formal operative debridement, though few tibial fractures have been included in these studies. The purpose of this study is to provide initial data suggesting whether Gustilo-Anderson type I tibia fractures may be safely treated nonoperatively.

METHODS

Institutional retrospective review was performed for children with type I tibial fractures managed with and without operative debridement from 1999 through 2020. Incomplete follow-up, polytrauma, and delayed diagnosis of greater than 12 h since the time of injury were criteria for exclusion. Data including age, sex, mechanism of injury, management, time-to-antibiotic administration, and complications were recorded.

RESULTS

Thirty-three patients met inclusion criteria and were followed to union. Average age was 9.9 ± 3.7 years. All patients were evaluated in the emergency department and received intravenous antibiotics within 8 h of presentation. Median time-to-antibiotics was 2 h. All patients received cefazolin except one who received clindamycin at an outside hospital and subsequent cephalexin. Three patients (8.8%) received augmentation with gentamicin. Twenty-one patients (63.6%) underwent operative irrigation and debridement (I&D), and of those, sixteen underwent surgical fixation of their fracture. Twelve (36.4%) patients had bedside I&D with saline under conscious sedation, with one requiring subsequent operative I&D and intramedullary nailing. Three infections (14.3%) occurred in the operative group and none in the nonoperative group. Complications among the nonoperative patients include delayed union (8.3%), angulation (8.3%), and refracture (8.3%). Complications among the operative patients include delayed union (9.5%), angulation (14.3%), and one patient experienced both (4.8%). Other operative group complications include leg-length discrepancy (4.8%), heterotopic ossification (4.8%), and symptomatic hardware (4.8%).

CONCLUSION

No infections were observed in a small group of children with type I tibia fractures treated with bedside debridement and antibiotics, and similar non-infectious complication rates were observed relative to operative debridement. This study provides initial data that suggests nonoperative management of type I tibial fractures may be safe and supports the development of larger studies.

A Comparison Between the Perioperative Outcomes of Female Adolescent Idiopathic Scoliosis (AIS) Versus Adult Idiopathic Scoliosis (AdIS) Following Posterior Spinal Fusion: A Propensity Score Matching Analysis Involving 425 Patients

STUDY DESIGN

Retrospective propensity score matching (PSM) study.

OBJECTIVE

To investigate the perioperative outcomes comparing adolescent idiopathic scoliosis (AIS) and adult idiopathic scoliosis (AdIS) patients following posterior spinal fusion (PSF).

METHODS

425 female AIS and AdIS patients who were operated (between January 2015 to March 2020) using a dual attending surgeon strategy were stratified into G1 (AIS aged 10-16 years old) and G2 (AdIS > 20 years old). PSM analysis with one-to-one, nearest neighbor matching technique with match tolerance of 0.001 was used to matched 357 AIS patients to 68 AdIS patients. Operation duration, intraoperative blood loss (IBL), blood loss percentage, hemoglobin drift, blood salvaged, postoperative wound length, allogenic blood transfusion requirement, postoperative hospital stay, postoperative Cobb, correction rate and postoperative complications were documented and reported.

RESULTS

Following PSM, G1 and G2 each had 50 patients with comparable and balanced covariates. As anticipated, G2 patients were heavier, taller and had higher body mass index compared to G1 patients (P < 0.05). We could not find any significant differences in the perioperative outcome comparing this 2 groups. AIS and AdIS patients had similar operation duration (125.9 ± 27.2 min vs 127.3 ± 37.8 min), IBL (749.8 ± 315.7 ml vs 723.8 ± 342.1 ml) and length of hospital stay (3.3 ± 0.4 days vs 3.5 ± 0.8 days) (P > 0.05). Hemoglobin drift and amount of blood salvaged were comparable (P > 0.05). G2 had stiffer curves. There was a trend toward a lower correction rate in G2 in the immediate postoperative period, however it did not reach statistical significance (61.8 ± 11.2% vs. 66.3 ± 11.6%, P = 0.051). No patients required blood transfusion and none had any postoperative complications.

CONCLUSION

Adolescent and adult female scoliosis patients had comparable perioperative outcome following PSF surgery that was carried out using a dual attending surgeon strategy.

Systemic Antibiotic Prophylaxis in Maxillofacial Trauma: A Scoping Review and Critical Appraisal

Infection after maxillofacial trauma remains an important complication, with a significant socio-economic impact. While consensus exists that systemic antibiotic prophylaxis reduces the risk of infection in the management of maxillofacial fractures, the type, and duration remain controversial. Therefore, the purpose of this scoping review was to provide an overview of the current evidence that supports the use of prophylactic antibiotics in the treatment of maxillofacial fractures. A comprehensive literature search on 1 January 2022, in PubMed, Web of Science, Embase, and Cochrane, revealed 16 articles. Most studies focused on the duration of systemic antibiotic prophylaxis and compared a one-day to a five-day regimen. Included studies showed considerable variability in design and research aims, which rendered them difficult to compare. Furthermore, a variety of antibiotic regimens were used, and most studies had a short follow-up period and unclear outcome parameters. This scoping review demonstrates the lack of well-constructed studies investigating the type and duration of systemic antibiotic prophylaxis in the treatment of maxillofacial trauma. Based on the included articles, prolonging antibiotic prophylaxis over 24 h for surgically treated fractures does not appear to be beneficial. Furthermore, there is no evidence for its use in conservatively treated fractures. These results should be interpreted with caution since all included studies had limitations.

Which is the better choice for open tibial shaft fracture in overweight adolescent with open physis: A comparative study of external fixator plus elastic stable intramedullary nail versus external fixator alone

PURPOSE

To compare the clinical outcomes of external fixator + elastic stable intramedullary nail (EF+ESIN) vs. external fixator (EF) in the treatment for open tibial shaft fracture in overweight adolescents.

METHODS

Patients of open tibial shaft fractures younger than 14 years old with body weight over 50 Kg treated with EF + ESIN or EF at our institute from 2010 to 2018 were reviewed. Patients with Gustilo Type III open fractures, pathological fractures, previous fracture or instrumentation in the operative leg were excluded. Baseline information and clinical data were collected from the hospital database and during out-patient visits.

RESULTS

Forty-six patients, including 27 males and 19 females, were included in the EF group, whereas 35 patients, including 18 males and 17 females, were included in the EF + ESIN group (p = 0.527). The incidence of superficial infection was higher in the EF group (26/46, 56.5%) than the EF + ESIN group (12/35, 34.3%), p < 0.001. The frontal and sagittal angulation was higher in the EF group (p < 0.001), but the degrees in both groups were within the acceptable range. The union time was longer in the EF group (68.0 ± 12.7, d) than the EF + ESIN group (61.9 ± 11.9), p < 0.001. The retaining of EF (11.9 ± 3.2, w) was longer in the EF group than the EF +ESIN group (5.7 ± 1.2, w), p < 0.001.

CONCLUSION

EF+ESIN is a safe and alternative choice for selected overweight adolescents with open tibial shaft fracture.

Modern management of paediatric tibial shaft fractures: an evidence-based update

AIMS

This review provides a summary of recent evidence surrounding the treatment of paediatric tibial shaft fractures and presents an algorithm to aid management of these injuries. This article reviews the relevant anatomy, epidemiology and aetiology of tibial shaft fractures and summarises contemporary treatment principles. Management recommendations and supporting evidence are given for fractures according to age (< 18 months, 18 months-5 years, 6-12 years, and 13-18 years). The relative merits of casting, plate fixation, elastic and rigid intramedullary nailing, and external fixation are discussed. Special attention is paid to the management of open tibial shaft fractures and to complications including infection and acute compartment syndrome.

CONCLUSIONS

There has been a shift away from non-operative management of paediatric tibial shaft fractures over the last 30 years. However, recent evidence highlights that a non-operative approach produces acceptable outcomes when used in simple closed fractures at any age. Operative management may be indicated for unstable fractures where satisfactory alignment cannot be maintained or in specific circumstances including open injuries and polytrauma. Open injuries require urgent assessment by a combined orthopaedic and plastic surgery team at a specialist tertiary centre.

Type of bone graft and primary diagnosis were associated with nosocomial surgical site infection after high tibial osteotomy: analysis of a national database

PURPOSE

Although several small-scale studies have reported risk factors for surgical site infection (SSI) after high tibial osteotomy (HTO), no study has collectively analysed risk factors in a large cohort. The present study aimed to clarify the risk factors for SSI after HTO using a national database.

METHODS

Data of inpatients who underwent HTO from 2010 to 2017 were obtained from the Diagnosis Procedure Combination database in Japan. Outcome measures were the incidence of SSI and deep SSI after HTO. Associations between SSI and patient data were examined with multivariable logistic regression analysis.

RESULTS

Among 12,853 patients who underwent HTO, 195 developed SSI (1.52%) and 50 developed deep SSI (0.39%). Univariate analysis showed that male sex, smoking, and longer anaesthesia duration were associated with higher incidences of SSI, whereas a primary diagnosis of osteonecrosis and use of natural bone grafts were associated with lower incidences. In multivariable analysis, SSI was positively associated with male sex, anaesthesia duration longer than 210 min (vs. 150-210 min), and use of artificial bone graft (vs. natural bone graft). SSI was negatively associated with age ≤ 49 years (vs. 50-59 years) and a primary diagnosis of osteonecrosis (vs. osteoarthritis).

CONCLUSION

The present study revealed novel risk factors for SSI after HTO that previous studies have failed to find, including use of artificial bone graft and longer anaesthesia duration; primary diagnosis of osteonecrosis and younger age were novel protective factors. These findings will help surgeons assess risks of SSI after HTO in individual patients.

LEVEL OF EVIDENCE

III.

Lower limb paediatric trauma with bone and soft tissue loss: Ortho-plastic management and outcome in a major trauma centre

AIM

We examined the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss.

METHOD

Patients were identified from our prospective trauma database (2013-2018). Inclusion criteria were age (<18 years) and open lower-limb trauma. We assessed severity of soft tissue and/or bone loss, fracture complexity, surgical techniques and time to surgery. Paediatric quality of life and psychological trauma impact scores (HRQOL and CRIES), Ganga Hospital Injury Severity score (GHISS), union and complication rates were measured.

RESULTS

We identified 32 patients aged between 4 and 17 years. Twenty-nine patients had open tibia fractures including 14 patients with bone loss, one patient had an open femur fracture, one patient an open talus fracture and one an open ankle fracture with dorsal degloving. Thirty injuries were classified intra-operatively as Gustilo IIIB (or equivalent) and two injuries as Gustilo IIIC. In 10 patients primary skin closure was achieved by acute shortening following segmental bone loss. Twenty-two patients required soft tissue coverage: 17 free vascularised flaps, two fascio-cutaneous flaps and three split skin grafts were used. Two patients required vascular repair. Soft tissue coverage was achieved within 72 hours in 26 patients (81%) and within a week in 30 patients (94%). The surgical techniques applied were: circular fine wire frame (19), monolateral external fixator (4) and open reduction internal fixation (8). Median follow up time was 18 (7-65) months. Paediatric quality of life scores were available in 30 patients (91%) with a median total score of 77.2 out of 100. The psychological trauma impact scores showed one in three patients was at risk of developing post-traumatic stress symptoms (PTSD). The GHISS scores ranged from 6-13. All fractures went on to unite over a median time of 3.8 (2-10) months. Three patients (9%) had major complications; two flap failures requiring revision, one femur non-union requiring revision fixation.

CONCLUSION

Limb salvage and timely fracture union is possible in children with complex lower limb trauma. Early intervention providing adequate debridement, skeletal stabilisation and early soft-tissue cover including the option of free microvascular reconstruction in small children when required, delivers acceptable outcomes. A multidisciplinary team approach including clinical psychologists to address the psychological impact of trauma provides optimal holistic care for these children and adolescents. Therefore, treatment for these patients should only be performed in paediatric major trauma centres.

Management of Gustilo-Anderson Type II and IIIA Open Long Bone Fractures in Children: Which Wounds Require a Second Washout?

INTRODUCTION

Timing of wound closure in pediatric Gustilo-Anderson grade II and IIIA open long bone fracture remain controversial. Our aims are (1) to determine the proportion of patients with these fractures whose wounds can be treated with early primary wound closure (EPWC); (2) to compare the complication rates between EPWC and delayed wound closure (DWC); and (3) to determine factors associated with higher likelihood of undergoing DWC.

PATIENTS AND METHODS

At a level-1 pediatric trauma center, 96 patients (younger than 18 y) who sustained Gustilo-Anderson grade II and IIIA open long bone fractures (humerus, radius, ulnar, femur, or tibia) within a 10-year period (2006-2016) were included for this study. Decision for EPWC versus DWC was at the discretion of the attending surgeon at time of initial surgery. Data collection was via retrospective review of charts and radiographs. Particular attention was paid to the incidence of return to operating room rate, nonunion, compartment syndrome, and infection. Median follow-up duration was 7.5 months (interquartile range: 3.6 to 25.3 mo). All patients were followed-up at least until bony union.

RESULTS

Overall, 81% of patients (78/96) underwent EPWC. Of the grade II fractures, 86% underwent EPWC. Four patients (5%) in the EPWC group and 1 patient (6%) in the DWC group had at least 1 complication. When controlling for mechanism of injury, Gustilo-Anderson fracture type and age, there was no difference in rate of complications between the EPWC and the DWC groups. Grade IIIA fractures and being involved in a motor vehicle accident were factors associated with a higher likelihood of undergoing DWC.

CONCLUSION

The majority of grade II and IIIA pediatric long bone fractures may be safely treatable with EPWC without additional washouts. Future prospective research is required to further define the subgroups that can benefit from DWC.

LEVEL OF EVIDENCE

Level IV-therapeutic, case cohort study.

Can surgical site infections be controlled through microbiological surveillance? A three-year laboratory-based surveillance at an orthopaedic unit, retrospective observatory study

OBJECTIVE

The aims of the study were to analyse the surgical site infections (SSIs) in patients operated at an orthopaedic ward and to describe the drug-resistance of the aetiology of those infections. Also, analyse the possibility of SSI control through microbiological surveillance. Additionally, we have studied the information inferred by aggregating cumulative antibiograms for the SSIs of the studied orthopaedic unit.

DESIGN

Cross-sectional studies carried out in 2013-2015.

SETTING AND PATIENTS

Orthopaedic and Trauma Surgery Unit in Sosnowiec, Poland; 5995 patients, 5239 operations.

METHODS

Retrospective laboratory-based data collection study of surgical site infections.

RESULTS

SSI incidence rate was 6.6%, in the implantations-hip prosthesis 5.8% and knee prosthesis 5.4%, about 6 times higher compared with European HAI-Net. SSIs were usually caused by Gram-positive bacteria (56%). The prevalence of MDR microorganisms was 22.6%, and mainly concerned the Gram-negative bacilli: 97.6% of Acinetobacter baumannii and 50.0% of Klebsiella pneumoniae were multidrug-resistant. On the basis of what the Formula for Rational Empiric Antimicrobial Therapy analysis has shown, the use of amikacin, imipenem and ciprofloxacin has been recommended as the most efficient in the empirical therapy of SSIs.

CONCLUSIONS

The infection control was a significant problem at the studied orthopaedic unit, as evidenced by the SSI incidence rate significantly higher than expected. We suggest implementing the infection control and prevention based on evidence-based medicine, and a unit-based surveillance. A cumulative unit-based antibiogram reflects the drug-susceptibility pattern for the strains from the infections acquired at the unit.

In vitro and in vivo accumulation of magnetic nanoporous silica nanoparticles on implant materials with different magnetic properties

Background

In orthopedic surgery, implant-associated infections are still a major problem. For the improvement of the selective therapy in the infection area, magnetic nanoparticles as drug carriers are promising when used in combination with magnetizable implants and an externally applied magnetic field. These implants principally increase the strength of the magnetic field resulting in an enhanced accumulation of the drug loaded particles in the target area and therewith a reduction of the needed amount and the risk of undesirable side effects. In the present study magnetic nanoporous silica core–shell nanoparticles, modified with fluorophores (fluorescein isothiocyanate/FITC or rhodamine B isothiocyanate/RITC) and poly(ethylene glycol) (PEG), were used in combination with metallic plates of different magnetic properties and with a magnetic field. In vitro and in vivo experiments were performed to investigate particle accumulation and retention and their biocompatibility.

Results

Spherical magnetic silica core–shell nanoparticles with reproducible superparamagnetic behavior and high porosity were synthesized. Based on in vitro proliferation and viability tests the modification with organic fluorophores and PEG led to highly biocompatible fluorescent particles, and good dispersibility. In a circular tube system martensitic steel 1.4112 showed superior accumulation and retention of the magnetic particles in comparison to ferritic steel 1.4521 and a Ti90Al6V4 control. In vivo tests in a mouse model where the nanoparticles were injected subcutaneously showed the good biocompatibility of the magnetic silica nanoparticles and their accumulation on the surface of a metallic plate, which had been implanted before, and in the surrounding tissue.

Conclusion

With their superparamagnetic properties and their high porosity, multifunctional magnetic nanoporous silica nanoparticles are ideal candidates as drug carriers. In combination with their good biocompatibility in vitro, they have ideal properties for an implant directed magnetic drug targeting. Missing adverse clinical and histological effects proved the good biocompatibility in vivo. Accumulation and retention of the nanoparticles could be influenced by the magnetic properties of the implanted plates; a remanent martensitic steel plate significantly improved both values in vitro. Therefore, the use of magnetizable implant materials in combination with the magnetic nanoparticles has promising potential for the selective treatment of implant-associated infections.

Electronic supplementary material

The online version of this article (10.1186/s12951-018-0422-6) contains supplementary material, which is available to authorized users.