Increased risk for complications following removal of hardware in patients with liver disease, pilon or pelvic fractures: A regression analysis

Preoperative antibiotics reduce early surgical site infections after orthopaedic implant removal: a propensity-matched cohort study

BACKGROUND

Implant removal in orthopaedics after fracture consolidation is a very common procedure but is still associated with a high rate of surgical site infection (SSI). Antibiotic prophylaxis is not recommended but advocated by some.

AIM

To assess the efficacy of antibiotic prophylaxis in the prevention of early SSI following orthopaedic implant removal.

METHODS

A monocentric retrospective cohort study was conducted. Patients who underwent orthopaedic implant removal procedures performed from 2016 to 2021 were included. A 1:1 propensity score matching function was used to create a cohort with matched baseline characteristics and associated risk factors for SSI. Inter-cohort comparison of the occurrence of SSI (superficial or deep) and revision surgery for SSI, after propensity score matching, was performed using the odds ratio to determine the effect of preoperative antibiotic prophylaxis.

FINDINGS

In total, 965 distinct surgical procedures were included. Of these, 69 (7.15%) had an SSI, 24 (35.7%) of which required surgical revision; 214 procedures (22.18%) were performed under preoperative antibiotic prophylaxis. The propensity-matched cohort consisted of 396 procedures (198 with and without antibiotic prophylaxis). The SSI rates were 11.11% and 3.03%, respectively, in the control and antibiotic prophylaxis groups (odds ratio: 0.25; 95% confidence interval: 0.099; 0.63; P = 0.011). No difference was found for revision surgery.

CONCLUSION

Preoperative administration of antibiotic prophylaxis considerably reduces the risk of SSI during the removal of an orthopaedic implant without increasing the risk of side-effects.

Patients With Cirrhosis Who Have a Model for End-stage Liver Disease Sodium Score of 8 or Greater Are at Increased Risk of Poor Outcomes in Operatively Treated Tibia Fractures

The purpose of this study was to compare 30-day readmission rates for cirrhotic and non-cirrhotic patients after tibia fracture fixation by retrospectively identifying all surgically managed tibial plateau, tibial shaft, and pilon fractures from 2010 through 2018 in the National Surgical Quality Improvement Program database (N=14,028). The primary outcome measure was 30-day readmission rates. Secondary outcome measures included 30-day rates of reoperation, length of stay, pulmonary embolism, deep venous thrombosis, and wound complications, including deep or superficial infection. Cirrhotic patients (n=665) and non-cirrhotic patients (n=13,363) were identified using the aspartate aminotransferase to platelet ratio index test. Cirrhotic patients were more likely to have preoperative ascites, renal failure, bleeding disorders, and preoperative transfusions. No differences were reported between the two groups in readmission rate or any of the secondary outcome measures, except that cirrhotic patients' length of stay was longer by 0.5 day. Stratification of the cirrhotic cohort demonstrated that a Model for End-stage Liver Disease sodium (MELD-Na) score of 8 or greater was associated with a 4.1-fold increase in the rate of readmission (5.9% vs 1.5%; P<.01). No other differences were identified based on MELD-Na score stratification. Patients with advanced cirrhosis (MELD-Na score ≥8) have an increased risk of 30-day readmission after tibia fracture surgery. Cirrhosis associated with a lower MELD-Na score might not significantly increase the risk of 30-day complications in patients with tibia fractures. [Orthopedics. 2022;45(2):79-85.].

Complications of Hardware Removal

BACKGROUND

While hardware removal may improve patient function, the procedure carries risks of unexpected outcomes. Despite being among the most commonly performed orthopaedic procedures, scant attention has been given to its complication profile.

METHODS

We queried the American Board of Orthopaedic Surgery (ABOS) de-identified database of Part II surgical case lists from 2013 through 2019 for American Medical Association Current Procedural Terminology (CPT) implant-removal codes (20680, 20670, 22850, 22852, 22855, 26320). Hardware removal procedures that were performed without any other concurrent procedure ("HR-only procedures") were examined for associated complications.

RESULTS

In the 7 years analyzed, 13,089 HR-only procedures were performed, representing 2.1% (95% confidence interval [CI], 2.1% to 2.2%) of the total of 609,150 surgical procedures during that period. A complication was reported to have occurred in association with 1,256 procedures (9.6% [95% CI, 9.1% to 10.1%]), with surgical complications reported in association with 1,151 procedures (8.8% [95% CI, 8.3% to 9.3%]) and medical/anesthetic complications reported in association with 196 procedures (1.5% [95% CI, 1.3% to 1.7%]). Wound-healing delay/failure (2.1% [95% CI, 1.8% to 2.3%]) and infection (1.6% [95% CI, 1.4% to 1.8%]) were among the most commonly reported complications after HR-only procedures, but other serious events were reported as well, including unexpected reoperations (2.5% [95% CI, 2.2% to 2.7%]), unexpected readmissions (1.6% [95% CI, 1.4% to 1.8%]), continuing pain (95% CI, 1.2% [1.0% to 1.4%]), nerve injury (0.6% [95% CI, 0.4% to 0.7%]), bone fracture (0.5% [95% CI, 0.4% to 0.6%]), and life-threatening complications (0.4% [95% CI, 0.3% to 0.5%]).

CONCLUSIONS

Hardware removal is one of the most commonly performed orthopaedic procedures and was associated with an overall complication rate of 9.6% (95% CI, 9.1% to 10.1%) in a cohort of recently trained orthopaedic surgeons in the United States. Although specific complications such as infection, refractures, and nerve damage were reported to have relatively low rates of occurrence, and associated life-threatening complications occurred rarely, surgeons and patients should be aware that hardware removal carries a definite risk.

LEVEL OF EVIDENCE

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

Use of biomaterials in scaphoid fracture fixation, a systematic review

BACKGROUND

Scaphoid fractures account for 60-70% carpal injury. Due to limited vascular supply achieving adequate reduction and healing is important to avoid complications including avascular necrosis. Recent technological advances have led to renewed vigour in bioabsorbable material research to develop devices which could be used without the need for removal and complications including stress shielding and suboptimal imaging.

METHODS

A systematic search of databases including PubMed, Ovid Medline, and Google Scholar databases was made to identify studies related to the use of bioabsorbable materials in scaphoid fixation and postoperative patient outcomes. PRISMA guidelines were utilised for this review.

FINDINGS

Initial search results yielded 852 studies. 124 studies were screened, with 79 patients across 7 studies included in this review. Poly-L-Lactic acid derivatives were the most common biomaterial for scaphoid fixation, with magnesium and polyglycolide also used. Levels of evidence for studies ranged between III-IV. Analysis demonstrated mixed findings with generally comparable outcomes to conventional alloy-based screws.

INTERPRETATION

Development in bioabsorbable materials is ongoing, however there remains a dearth in data regarding their use in the scaphoid. Further research is needed to establish the efficacy and applicability of bioabsorbable devices in the scaphoid bone.

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

Pilon Fractures: Challenges and Solutions

Pilon fractures include a wide range of complexity. The timing and type of definitive fixation is dictated by the soft tissue injury and energy imparted to the fracture. One should have a low threshold for staged protocols and delayed definitive fixation to avoid complications. Proper radiographs and advanced imaging should be obtained for an exacting diagnosis and preoperative planning. Diligent management of the soft tissue and anatomic restoration of the articular surface, length, rotation, and axial alignment with stable fixation to the diaphysis should be obtained once feasible. Intramedullary implants with percutaneous articular fixation for simple or extra-articular patterns provide good results with little soft tissue insult in the zone of injury. Minimally invasive plate osteosynthesis techniques can help mitigate some concerns with soft tissue compromise while obtaining good articular alignment. Locking or conventional plating with lag screw fixation is used for complex articular injuries with or without fibular fixation. External fixators are generally used for temporizing measures but can be utilized as definitive fixation when indicated. There is a role for acute fusion in severely comminuted, osteoporotic, or arthritic fractures in patients with poor healing potential. This article outlines the diagnostic workup and treatment of these vexing injuries with solutions to challenges that arise.

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