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Cheyrou-Lagreze A, Severyns M, Rongieras F, Germaneau A, Odri GA, Bertani A. Secondary intramedullary nailing for open tibial shaft fractures. Comparison of a one-stage versus two-stage surgical procedure. Orthop Traumatol Surg Res 2022; 108:103391. [PMID: 35944868 DOI: 10.1016/j.otsr.2022.103391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/13/2022] [Accepted: 05/05/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The objective of this study was to compare the rates of radiological and clinical complications after sequential treatment of a tibial shaft fracture by external fixation followed by secondary nailing with an early-stage conversion (C1S) versus a two-stage late conversion (C2S). The hypothesis of this work was that treatment with C1S does not increase the risk of surgical site infections compared to C2S, and allows faster healing with a lower malunion rate. MATERIAL AND METHODS We carried out a retrospective and comparative study based on the files of the traumatology department of the Édouard Herriot University Hospital in Lyon. We reviewed the records of patients who presented with a Gustilo grade 1, 2 or 3a open tibial fracture treated with external fixation with conversion by intramedullary nailing within 6 months from January 2010 to December 2020. We assessed the occurrence of Surgical Site Infections (SSI), consolidation time, time until resumption of weight bearing and the malunion rate. RESULTS Of the 55 patients included, a C1S procedure was performed in 25 cases (45.5%) versus 30 cases (54.5%) for C2S. No significant difference was found concerning the occurrence of SSI after intramedullary nailing between the two groups (p=0.81). A significant difference was observed in terms of bone healing (p=0.036) and the malunion rate (0.0013) in favor of nailing in one stage. DISCUSSION The strategy of converting an open leg fracture early, in one stage (C1S), after initial external fixator placement allows for faster healing and weight bearing, while ensuring a lower malunion rate compared to that of a late two-stage conversion. In the absence of a scar at the time of intramedullary nailing, C1S does not increase the risk of surgical site infections. While the choice of a late and sequential two-stage operation is likely related to the surgeon's apprehension around conversion of an open leg fracture by intramedullary nailing, this study could promote the use of C1S in a greater number of situations. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Adrien Cheyrou-Lagreze
- Service de chirurgie orthopédique et traumatologique Pavillon E, CHU Édouard Herriot, hospices civils de Lyon, Lyon, France
| | - Mathieu Severyns
- Service de chirurgie orthopédique, CHU La Meynard, Fort-de-France, Martinique; Institut Pprime Institut UP 3346, CNRS, Université de Poitiers, Poitiers, France.
| | - Frédéric Rongieras
- Service de chirurgie orthopédique et traumatologique Pavillon E, CHU Édouard Herriot, hospices civils de Lyon, Lyon, France
| | - Arnaud Germaneau
- Institut Pprime Institut UP 3346, CNRS, Université de Poitiers, Poitiers, France
| | | | - Antoine Bertani
- Service de chirurgie orthopédique et traumatologique Pavillon E, CHU Édouard Herriot, hospices civils de Lyon, Lyon, France
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Retrospective Analysis of Infection Factors in Secondary Internal Fixation after External Fixation for Open Fracture of a Long Bone: A Cohort of 117 Patients in a Two-Center Clinical Study. BIOMED RESEARCH INTERNATIONAL 2022; 2022:7284068. [PMID: 35813227 PMCID: PMC9262577 DOI: 10.1155/2022/7284068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/10/2022] [Indexed: 11/18/2022]
Abstract
Purpose To investigate infection risk factors after secondary internal fixation (IF) of open fracture of a long bone with removed fixation frame and explore the safe range of feasible operation for abnormal inflammatory indicators. Methods Clinical data of 117 cases of open fracture of a long bone that underwent temporary external fixation (EF) in one stage and IF in two stages were retrospectively analyzed. Collected data included age, sex, Gustilo type, multiple injuries, debridement time, duration of EF, needle infection, interval of conversion to IF after external fixator, preoperative white blood cell (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin (ALB), blood glucose, and prognosis. We selected these factors for univariate analysis of postoperative surgical site infection (SSI) and multivariate logistic regression analysis of statistically significant risk factors and created receiver operating characteristic (ROC) curves to compare the diagnostic efficiency of each index and determine the optimal screening point. Results We followed up 117 patients, with 130 limbs affected. Univariate analysis showed that ESR, CRP, ALB, WBC, EF time, and Gustilo fracture type were significantly associated with SSI. Multivariate logistic regression analysis showed that CRP, duration of EF, and Gustilo fracture type were independently associated with postoperative infection. Area under ROC curves for WBC, ESR, and CRP were 69.7%, 73.2%, and 81.2%. Conclusions We demonstrated the role of Gustilo classification of open fractures in predicting postoperative infection, especially for open fractures above type III. If the inflammatory indexes return to normal or show a downward trend, and the second-stage IF operation is performed within the cutoff values, postoperative recurrent infection was reduced.
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Ye Z, Zhao S, Zeng C, Luo Z, Yuan S, Li R. Study on the relationship between the timing of conversion from external fixation to internal fixation and infection in the treatment of open fractures of extremities. J Orthop Surg Res 2021; 16:662. [PMID: 34743751 PMCID: PMC8573926 DOI: 10.1186/s13018-021-02814-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 10/28/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To investigate the relationship between the infection rate and the timing of replacement of temporary external fixators with internal fixation, and the timing of immediate or delayed internal fixation after removal of temporary external fixation in the staging treatment modality of open fractures of extremities. Methods A retrospective analysis was performed on 122 cases of open fractures of extremities. External fixators were applied at the early stage and replaced with internal fixation when the condition of soft tissues improved and inflammatory indexes dropped to the normal range or showed a steady downward trend. Depending on the carrying time of external fixators after wound closure or healing, the patients were divided into three groups; the carrying time of groups A, B, and C was ≤ 14 days, 15–28 days, and > 28 days, respectively. Depending on the immediate or delayed internal fixation after removal of external fixator, patients were divided into group a (immediate internal fixation after removal of external fixator) and group b (delayed internal fixation after removal of external fixator, 5–7 days later). Results The infection rates of groups A, B, and C were 6.5%, 5.9%, and 23.3%, respectively. The differences among the three groups were statistically significant (P < 0.05). The infection rates of different Gustilo–Anderson fractures were as follows: no cases of infection out of 10 cases with type I fracture (0%); two cases of infection out of 35 cases with type II fracture (5.7%); three cases of infection out of 36 cases with IIIa fracture (8.3%); five cases of infection out of 28 cases with IIIB fracture (17.9%); and five cases of infection out of 13 cases with IIIC fracture (38.5%). The differences among the five groups were statistically significant. Conclusions The occurrence of infection of open fractures of extremities is associated with the fracture severity (Gustilo classification). For open fractures of Gustilo types I and II, the final internal fixation should be placed as soon as possible when the recovery of general and local conditions is good and the infection is controlled.
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Affiliation(s)
- Zelin Ye
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Shanwen Zhao
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510610, China.,Orthopaedic Hospital of Guangdong Province, Guangzhou, 510610, China.,Academy of Orthopaedics of Guangdong Province, Guangzhou, 510610, China.,Guangdong Provincial Key Laboratory of Bone and Joint Degenerative Diseases, Guangzhou, 510280, China
| | - Canjun Zeng
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510610, China.,Orthopaedic Hospital of Guangdong Province, Guangzhou, 510610, China.,Academy of Orthopaedics of Guangdong Province, Guangzhou, 510610, China.,Guangdong Provincial Key Laboratory of Bone and Joint Degenerative Diseases, Guangzhou, 510280, China
| | - Ziheng Luo
- Department of Joint and Orthopedic Surgery, Nanfang Hospital, Southern Medical Univeisity, Guangzhou, 510280, China
| | - Song Yuan
- Department of Orthopedics, Linzhi People's Hospital, Linzhi, 860000, China
| | - Runguang Li
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510610, China. .,Orthopaedic Hospital of Guangdong Province, Guangzhou, 510610, China. .,Academy of Orthopaedics of Guangdong Province, Guangzhou, 510610, China. .,Guangdong Provincial Key Laboratory of Bone and Joint Degenerative Diseases, Guangzhou, 510280, China. .,Department of Joint and Orthopedic Surgery, Nanfang Hospital, Southern Medical Univeisity, Guangzhou, 510280, China.
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Park KH, Park HW, Oh CW, Lee JH, Kim JW, Oh JK, Park IH, Ha SS. Conventional bicortical pin substitution with a novel unicortical pin in external fixation: A biomechanical study. Injury 2021; 52:1673-1678. [PMID: 33906742 DOI: 10.1016/j.injury.2021.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION As most patients with polytrauma or open fractures are converted from temporary external fixation to definite stabilization, the prevention of complications such as infection is especially important. To overcome the high risk of infection associated with the use of the conventional bicortical pin for temporary external fixation, the authors developed a novel unicortical pin and analyzed it in a biomechanical study. METHODS The unicortical pin consisted of an inner screw, purchasing the cortical bone, and an outer sleeve with 6 spikes. A bicortical pin was used for the purpose of comparison. A fracture gap model was stabilized using a monoplanar configuration. Both the unicortical pins (Uni group) and bicortical pins (Bi group) underwent axial compressive and torsional load testing using a servo-hydraulic testing machine. Stiffness, load to failure, and mode of failure were documented. RESULTS Stiffness and load to failure of the Uni group (average, 40.5 N/mm and 1098.4 N, respectively) were greater than that of the Bi group (average, 33.7 N/mm and 968.6 N, respectively) in the axial compressive load test (P = 0.008 and 0.032). Stiffness and load to failure of the Uni group (average, 1.2 Nm/degree and 1.7 Nm, respectively) were also significantly higher than those of the Bi group (average, 0.8 Nm/degree and 0.6 Nm, respectively) in the torsional load test (P = 0.008 and 0.016). All pins in the Bi group were bent at the pin-synthetic bone interface without synthetic bone failure. Contrarily, the Uni group did not show any pin bending or failure. However, in the axial compression test, partial cracks in the synthetic bone were found at the interface with spikes in the outer shell. In addition, in the torsion test, incomplete fractures were seen through the inner screws' holes. CONCLUSION Compared with the conventional bicortical pin, the newly designed unicortical pin significantly increased fracture stability under both axial compressive and torsional loads. The unicortical pin can be considered an alternative biomechanical solution to obtain adequate stability when performing external fixation of fractures.
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Affiliation(s)
- Kyeong-Hyeon Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| | - Ho-Won Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea.
| | - Jin-Han Lee
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| | - Joon-Woo Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, School of Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Il-Hyung Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| | - Sung-Soo Ha
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
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Tarng YW, Lin KC, Lin KJ, Yang YP, Chien Y, Wei HW. A novel low-profile external skeletal fixator for type IIIB open tibial fractures: A biomechanical and clinical pilot study. J Chin Med Assoc 2021; 84:528-535. [PMID: 33595994 DOI: 10.1097/jcma.0000000000000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although external fixator is standard for managing staged treatment of open tibial fracture, the main disadvantage of this device is too bulky to be tolerated by most patients for longtime use. The purposes of this pilot study were to compare the biomechanical properties of a novel low-profile external fixator (LP-ESF) with a traditional ESF and also to evaluate its performance in patients with Gustilo type IIIb tibial open fractures. METHODS A prospective clinical pilot study started from January 2015 to December 2017, and 18 patients with Gustilo type IIIb open tibial fractures underwent the fixation with a novel LP-ESF system. The biomechanical properties of the LP-ESF were compared with the Synthes External Fixation System according to the standard ASTM F1541-02. These patients were divided into two groups according to the size of bony defect. The postoperative clinical outcomes were subsequently collected. RESULTS The biomechanical properties of the LP-ESF were comparable with those of Synthes External Fixation System and had an improved the axial/torsional stiffness and ultimate strength. In the clinical study, all patients with LP-ESF had fracture union. The duration of application of LP-ESF was 3.5 to 18 months until fracture union. In 10 of 18 patients, their fractures were immobilized with the LP-ESF until bone union, and no pin tract infection and no chronic osteomyelitis were recorded. The 36-Item Short Form Health Survey life quality and health survey were good to excellent in these patients. Notably, the LP-ESF allowed a patient with severe bone and soft-tissue defects to preserve the leg and joints function. CONCLUSION In this study, we found that the novel LP-ESFs had improved clinical outcomes. The long-term LP-ESF application seems to be tolerable in our patients. This novel approach permits better controls in deep infection and faster healing of fractures, and thus may provide a viable alternative treatment for Gustilo type IIIb open tibial fractures.
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Affiliation(s)
- Yih-Wen Tarng
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Orthopaedics, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Kai-Cheng Lin
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Kun-Jhih Lin
- Department of Electrical Engineering, Chung Yuan Christian University, Taoyuan, Taiwan, ROC
- Technology Translation Center for Medical Device, Chung Yuan Christian University, Taoyuan, Taiwan, ROC
| | - Yi-Ping Yang
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yeuh Chien
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hung-Wen Wei
- Department of Electrical Engineering, Chung Yuan Christian University, Taoyuan, Taiwan, ROC
- Technology Translation Center for Medical Device, Chung Yuan Christian University, Taoyuan, Taiwan, ROC
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Santolini E, Stella M, Divano S, Ceccarelli M, Vicenti G, Bizzoca D, Santolini F. Optimum timing of conversion from DCO to definitive fixation in closed fractures of the lower limb: When and how? Injury 2020; 54 Suppl 1:S63-S69. [PMID: 32958344 DOI: 10.1016/j.injury.2020.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/18/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In damage control orthopaedics (DCO), fractures are initially stabilised with external fixation followed by delayed conversion to definitive internal fixation. The aim of this study is to determine whether the timing of the conversion influences the development of deep infection and fracture healing in a cohort of patients treated by DCO after a closed fracture of the lower limb. Furthermore, we wanted to evaluate whether the one-stage conversion procedure is always safe. MATERIALS AND METHODS A retrospective cohort study was conducted at a single level 1 trauma centre. Ninety-four cases of closed fractures of lower limb treated by DCO subsequently converted to internal fixation from 2012 to 2019 were included. Development of deep infection, superficial infection, non-union and time to union were recorded. Patients were then divided into three groups according to the timing of conversion: Group A (<7 days), Group B (7-13 days), Group C (> 14 days). Comparison between groups was performed to assess intergroup variabilty. RESULTS The mean number of days between DCO and conversion was 6.7±4.52 (range 1-22). We observed one case of deep infection (1.1%), one case of non-union (1.1%), four cases of superficial infection (4.3%) and mean time to union was ±1.38 months. Comparison between groups demonstrated no significant correlation between timing of conversion and development of superficial or deep infection and non-union, while it highlighted that complexity of the fracture and longer surgical time of conversion procedure were significantly higher in Group C. CONCLUSIONS One-stage conversion to definitive internal fixation within 22 days from DCO is a safe and feasible procedure, which does not influence the incidence of infection or non-union.
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Affiliation(s)
- Emmanuele Santolini
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10 - 16132, Genoa, Italy.
| | - Marco Stella
- Orthopedics and Trauma Unit, Ente Ospedaliero Ospedali Galliera, Mura delle Cappuccine 14 - 16148, Genoa, Italy
| | - Stefano Divano
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10 - 16132, Genoa, Italy
| | - Michele Ceccarelli
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10 - 16132, Genoa, Italy
| | - Giovanni Vicenti
- Department of Neuroscience and Sense Organs, Orthopaedics Section, University of Bari Aldo Moro, Bari, Italy
| | - Davide Bizzoca
- Department of Neuroscience and Sense Organs, Orthopaedics Section, University of Bari Aldo Moro, Bari, Italy
| | - Federico Santolini
- Orthopedics and Trauma Unit, Emergency Department, Ospedale Policlinico San Martino, Largo R. Benzi 10 - 16132, Genoa, Italy
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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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Potter JM, van der Vliet QMJ, Esposito JG, McTague MF, Weaver M, Heng M. Is the proximity of external fixator pins to eventual definitive fixation implants related to the risk of deep infection in the staged management of tibial pilon fractures? Injury 2019; 50:2103-2107. [PMID: 31530380 DOI: 10.1016/j.injury.2019.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/03/2019] [Accepted: 09/09/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In the staged management of tibial pilon fractures, overlap between definitive internal fixation and external fixation pin sites has been investigated as a risk factor for infection with equivocal conclusions. Our aim was to determine if overlap or proximity of definitive internal fixation to external fixation pin sites influences the risk of deep infection. PATIENTS AND METHODS We reviewed 280 AO/OTA 43B or 43C type distal tibia fractures in 277 patients at two level-one trauma centers. Patients underwent staged management using early temporizing external fixation followed by definitive open reduction and plate fixation. Primary outcome was the association between pin site overlap and the development of deep infection. Secondary outcome was the relationship between development of deep infection and the distance from pin site to definitive fixation. RESULTS The average duration between external fixation and definitive internal fixation was 14 days. 24% of fractures developed deep infection requiring surgical intervention. There was no association between pin site overlap and the development of deep infection (p = 0.18). There was no relationship between infection and the distance between proximal plate extent and pin site (p = 0.13). DISCUSSION We identified no association between pin site overlap and the development of deep infection. We suggest that temporizing external fixation pins should be placed so as to obtain optimal stability of the construct with lesser emphasis on aiming to be absolutely outside the zone of future fixation. LEVEL OF EVIDENCE Level III Therapeutic Retrospective Comparative study.
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Affiliation(s)
- Jeffrey M Potter
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Quirine M J van der Vliet
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, USA
| | - John G Esposito
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, USA
| | - Michael F McTague
- Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Weaver
- Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Marilyn Heng
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, USA.
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Li J, Zhang H, Qi B, Pan Z. Outcomes of Vacuum Sealing Drainage Treatment Combined with Skin Flap Transplantation and Antibiotic Bone Cement on Chronic Tibia Osteomyelitis: A Case Series Study. Med Sci Monit 2019; 25:5343-5349. [PMID: 31320603 PMCID: PMC6660807 DOI: 10.12659/msm.915921] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Chronic osteomyelitis is one of the currently refractory diseases. The aim of this study is to discuss the method and curative effects of vacuum sealing drainage (VSD) treatment combined with skin flap transplantation and antibiotic bone cement for chronic tibia osteomyelitis. MATERIAL AND METHODS For this study, 18 cases of open fracture secondary chronic tibia osteomyelitis were selected. After the granulation tissue of the wound surface became fresh and infection was controlled, the wound surface was repaired with a medial head of gastrocnemius transfer flap or a myofascial and cutaneous island pedicle flap with a collateral vessel nourished by the retrograde sural nerve. VSD combined with focus debridement and antibiotic bone cement filling was conducted. After inflammation was completely regulated, elective bone cement extraction, bone grafting, and internal fixation were performed. Within 2 to 3 years of follow-up post-surgery, the satisfaction and recurrence rates were evaluated. The patients' pre-operative and post-operative recovery of limb functions were compared according to the Enneking scoring system. RESULTS The patients did not suffer from osteomyelitis recurrence, with the exception of 1 case that manifested osteomyelitis recurrence and recovered through surgical treatment within the period of follow-up. The satisfaction and recurrence rates of these study cases post-surgery were 94.4% and 5.6%, respectively. The average functional recovery post-surgery was 81.5% of normal function. CONCLUSIONS Vacuum sealing drainage combined with skin flap transplantation and antibiotic bone cement is an effective treatment for chronic tibia osteomyelitis.
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Affiliation(s)
- Jingfeng Li
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Hao Zhang
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Baiwen Qi
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Zhenyu Pan
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
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Guerado E, Cano JR, Fernandez-Sanchez F. Pin tract infection prophylaxis and treatment. Injury 2019; 50 Suppl 1:S45-S49. [PMID: 31003703 DOI: 10.1016/j.injury.2019.03.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023]
Abstract
Pin tract infection in external fixation (ExFix) is a frequent finding which can eventually lead to loosening, osteomyelitis and loss of fixation. Its diagnosis is based on high empiricism and low validity, although it is possible to distinguish between minor and major infection. The first is limited to soft tissues, whereas the latter includes bone involvement. The rate of infection after conversion of external fixation to intramedullary nailing (IMN) is not well known. Unfortunately, papers referring to infection after the conversion of ExFix to intramedullary nailing (IMN) are of evidence level IV or V. It is suggested that conversion of ExFix to IMN should be carried out in a 2 step regimen. The time interval of 2 step regimen is uncertain although some authors have recommended to occur within 9 days. There is no consensus as to which prophylaxis protocol should be applied prior to conversion. In order to throw more light into this important issue, registries capturing important related parameters to the development of infection should be established.
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Affiliation(s)
- Enrique Guerado
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Costa del Sol, University of Malaga, Marbella (Malaga), Spain.
| | - Juan Ramon Cano
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Costa del Sol, University of Malaga, Marbella (Malaga), Spain
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Oliveira PR, Leonhardt MC, Carvalho VC, Kojima KE, Silva JS, Rossi F, Lima ALL. Incidence and risk factors associated with infection after intramedullary nailing of femoral and tibial diaphyseal fractures: Prospective study. Injury 2018; 49:1905-1911. [PMID: 30082109 DOI: 10.1016/j.injury.2018.07.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/12/2018] [Accepted: 07/26/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Diaphyseal fractures of femur and tibia are prominent due to its high incidence and high economic and social impact. Intramedullary nailing (IN) is the surgical procedure of choice. Surgical site infection (SSI) related to this procedure is considered a difficult to treat complication. AIMS Determine the incidence of SSI after IN of femoral and tibial diaphyseal fractures and evaluate possible risk factors. METHODS Prospective observational cohort study. SSI was defined according to CDC-NHSN criteria and surveillance period for the occurrence of infection was 12 months. Incidence of SSI was calculated as the ratio between the number of patients with SSI and total number of patients. Analysis of potential risk factors included patients-related factors (age, gender, body mass index, active foci of infection, immunosuppressive conditions, ASA score, alcohol or illicit drug abuse, smoking, polytrauma, etiology of fracture, type of fracture if closed or open, classification of fracture according to Müller AO, Tcherne classification for closed fractures, Gustilo-Anderson classification for open fractures, previous surgical manipulation, use of blood products); environmental and surgical-related factors (surgical wound classification, duration of surgery, hair removal, intraoperative contamination, antimicrobial use, presence of drains, hypothermia or hypoxia in the perioperative period, type of IN used, reaming, need for soft tissue reconstruction, use of negative pressure therapy) and microbiota-related factors (cultures of nasopharyngeal swabs forStaphylococcus aureus and axillary/inguinal/perineal swab for Acinetobacter baumannii). RESULTS 221 patients were included and completed the 12-month follow-up period. Incidence of SSI was 11.8%. In the initial analysis by unadjusted logistic regression, following factors were associated SSI: Müller AO classification of the fracture morphology groups 2 or 3, previous use of external fixator, presence of drains, use of negative pressure therapy and need for muscle or skin flap repair. In the multiple logistic regression-adjusted analysis, previous use of external fixator and need for muscle or skin flap repair remained associated with SSI. CONCLUSIONS Incidence of SSI associated with IN for femoral and tibial diaphyseal fractures was 11.8%. Previous use of external fixators and need for muscle or skin flap repair were factors associated with occurrence of infection.
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Affiliation(s)
- Priscila R Oliveira
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil.
| | - Marcos C Leonhardt
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Vladimir C Carvalho
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Kodi E Kojima
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Jorge S Silva
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Flavia Rossi
- Laboratorio de Microbiologia DLC, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Ana Lucia L Lima
- Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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Treatment of tibial nonunion with bone defect using a heterotopic ossification as autologous bone graft: literature overview and case report. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:741-746. [PMID: 29427092 DOI: 10.1007/s00590-018-2146-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/23/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Nonunion after open fracture of the lower leg is a frequent complication with a prevalence of up to 40%. In cases with major bone defects, revision of the osteosynthesis with bone grafting is commonly performed. Until today, there is no report on treatment of a tibial nonunion with transplantation of a heterotopic ossification. PRESENTATION OF CASE We present a case of a 27-year-old male patient, who suffered from a paragliding accident with major injuries. An open fracture of the lower leg (Gustilo-Anderson IIIB) was initially treated with external fixation and vacuum-assisted closure, followed by reamed intramedullary nailing. The tibia resulted in a bone defect situation with nonunion. It was successfully treated with revision, fibular osteotomy and transplantation of a heterotopic ossification, harvested from the ipsilateral hip. CONCLUSION In special cases, autologous transplantation of a mature heterotopic ossification is an attractive bone graft option in treating nonunion defects.
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Liu X, Cen S, Xiang Z, Zhong G, Yi M, Fang Y, Liu L, Huang F. [Safety evaluation of secondary conversion from external fixation to internal fixation for open tibia fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:665-669. [PMID: 29798646 DOI: 10.7507/1002-1892.201611127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To evaluate the safety of conversion from external fixation to internal fixation for open tibia fractures. Methods Between January 2010 and December 2014, 94 patients (98 limbs) with open tibia fractures were initially treated with external fixators at the first stage, and the clinical data were retrospectively analyzed. In 29 cases (31 limbs), the external fixators were changed to internal fixation for discomfort, pin tract response, Schantz pin loosening, delayed union or non-union after complete wound healing and normal or close to normal levels of erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and the leucocyte count as well as the neutrophil ratio (trial group); in 65 cases (67 limbs), the external fixators were used as the ultimate treatment in the control group. There was no significant difference in gender, age, side of the limbs, interval from injury to the first debridement, initial pathogenic bacteria, the limbs that skin grafting or flap transferring for skin and soft tissue defect between the two groups ( P>0.05). The incidence of Gustilo type III fractures in the control group was significantly higher than that in the trial group ( P=0.000). The overall incidence of infection was calculated respectively in the two groups. The incidence of infection according to different fracture types and whether skin grafting or flap transferring was compared between the two groups. The information of the pathogenic bacteria was recorded in the infected patients, and it was compared with the results of the initial culture. The incidence of infection in the patients of the trial group using different internal fixation instruments was recorded. Results The overall incidences of infection for the trial and control groups were 9.7% (3/31) and 9.0% (6/67) respectively, showing no significant difference ( χ2=0.013, P=0.909). No infection occurred in Gustilo type I and type II patients. The incidence of infection for Gustilo type IIIA patients in the trial group and the control group were 14.3% (1/7) and 6.3% (2/32) respectively, showing no significant difference ( χ2=0.509, P=0.476); the incidence of infection for type IIIB patients in the two groups were 50.0% (2/4) and 14.3% (2/14) respectively, showing no significant difference ( χ2=2.168, P=0.141); and the incidence of infection for type IIIC patients in the two groups were 0 and 16.7% (2/12) respectively, showing no significant difference ( χ2=0.361, P=0.548). Of all the infected limbs, only 1 limb in the trial group had the same Staphylococcus Aureus as the result of the initial culture. In the patients who underwent skin grafting or flap transferring, the incidence of infection in the trial and control groups were 33.3% (2/6) and 13.3% (2/15) respectively, showing no significant difference ( χ2=1.059, P=0.303). After conversion to internal fixation, no infection occurred in the cases that fixed with nails (11 limbs), and infection occurred in 4 of 20 limbs that fixed with plates, with an incidence of infection of 20%. Conclusion Conversion from external fixation to internal fixation for open tibia fractures is safe in most cases. However, for open tibia fractures with extensive and severe soft tissue injury, especially Gustilo type III patients who achieved wound heal after flap transfer or skin grafting, the choice of secondary conversion to internal fixation should carried out cautiously. Careful pre-operative evaluation of soft tissue status, cautious choice of fixation instrument and meticulous intra-operative soft tissue protection are essential for its safety.
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Affiliation(s)
- Xi Liu
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Shiqiang Cen
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
| | - Zhou Xiang
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Gang Zhong
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Min Yi
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yue Fang
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Lei Liu
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Fuguo Huang
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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Birt MC, Anderson DW, Toby EB, Wang J. Osteomyelitis: Recent advances in pathophysiology and therapeutic strategies. J Orthop 2017; 14:45-52. [PMID: 27822001 PMCID: PMC5090239 DOI: 10.1016/j.jor.2016.10.004] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/13/2016] [Indexed: 01/29/2023] Open
Abstract
This review article summarizes the recent advances in pathogenic mechanisms and novel therapeutic strategies for osteomyelitis, covering both periprosthetic joint infections and fracture-associated bone infections. A better understanding of the pathophysiology including the mechanisms for biofilm formation has led to new therapeutic strategies for this devastating disease. Research on novel local delivery materials with appropriate mechanical properties, lower exothermicity, controlled release of antibiotics, and absorbable scaffolding for bone regeneration is progressing rapidly. Emerging strategies for prevention, early diagnosis of low-grade infections, and innovative treatments of osteomyelitis such as biofilm disruptors and immunotherapy are highlighted in this review.
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Affiliation(s)
| | | | | | - Jinxi Wang
- Department of Orthopedic Surgery, University of Kansas Medical Center,
Kansas City, KS 66160, USA
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Bonnevialle P. Operative treatment of early infection after internal fixation of limb fractures (exclusive of severe open fractures). Orthop Traumatol Surg Res 2017; 103:S67-S73. [PMID: 28057476 DOI: 10.1016/j.otsr.2016.06.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 05/23/2016] [Accepted: 06/10/2016] [Indexed: 02/02/2023]
Abstract
Early infection after open reduction and internal fixation (ORIF) of a limb bone is defined as bacteriologically documented, deep and/or superficial surgical-site infection (SSI) diagnosed within 6months after the surgical procedure. This interval is arbitrarily considered sufficient to obtain fracture healing. The treatment of early infection after ORIF should be decided by a multidisciplinary team. The principles are the same as for revision arthroplasty. Superficial SSIs should be differentiated from deep SSIs, based on the results of bacteriological specimens collected using flawless technique. A turning point in the local microbial ecology occurs around the third or fourth week, when a biofilm develops around metallic implants. This biofilm protects the bacteria. The treatment relies on both non-operative and operative measures, which are selected based on the time to occurrence of the infection, condition of the soft tissues, and stage of bone healing. Both the surgical strategy and the antibiotic regimen should be determined during a multidisciplinary discussion. When treating superficial SSIs after ORIF, soft-tissue management is the main challenge. The treatment differs according to whether the hardware is covered or exposed. Defects in the skin and/or fascia can be managed using reliable reconstructive surgery techniques, either immediately or after a brief period of vacuum-assisted closure. In deep SSIs, deciding whether to leave or to remove the hardware is difficult. If the hardware is removed, the fracture site can be stabilised provisionally using either external fixation or a cement rod. Once infection control is achieved, several measures can be taken to stimulate bone healing before the end of the classical 6-month interval. If the hardware was removed, then internal fixation must be performed once the infection is eradicated.
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Affiliation(s)
- P Bonnevialle
- Département d'orthopédie traumatologie, CHU de Toulouse, hôpital P.P.-Riquet, place Baylac, 31052 Toulouse cedex, France.
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Nieto H, Baroan C. Limits of internal fixation in long-bone fracture. Orthop Traumatol Surg Res 2017; 103:S61-S66. [PMID: 28082050 DOI: 10.1016/j.otsr.2016.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 11/09/2016] [Accepted: 11/09/2016] [Indexed: 02/02/2023]
Abstract
Alternatives to internal fixation of long-bone fracture comprise, depending on location, external fixation or joint replacement. Limitations comprise risk of infection and functional outcome quality, which vary according to technique. The present study examines these limitations, based on comparative or large-scale studies from which certain significant results emerge. Four main questions are dealt with: (1) the present role of locking plates; (2) conditions for intramedullary nailing in Gustilo grade IIIb open fracture; (3) the limitations of conversion from external fixation to intramedullary nailing in open lower leg fracture; (4) and the limitations of definitive anterograde femoral nailing in multiple trauma. Locking plate fixation has yet to prove clinical superiority in any of the anatomic sites for which good-quality comparative analyses are available. Infection risk in Gustilo grade IIIb open lower leg fracture is equivalent when treated by intramedullary nailing or external fixation, if wound care and debridement are effective, antibiotherapy is initiated rapidly and skin cover is restored within 7days. Conversion from primary external fixation to intramedullary nailing is possible if the external fixator was fitted less than 28days previously and skin cover was restored within 7days. The pulmonary and systemic impact of peripheral lesions or definitive anterograde intramedullary nailing of femoral fracture in multiple trauma calls for caution and what is known as "damage-control orthopedics" (DCO), a term covering the general consequences of both the initial trauma and its treatment. Femoral intramedullary nailing is thus contraindicated in case of hemorrhagic shock (blood pressure<90mmHg), hypothermia (<33°C), coagulation disorder (platelet count<90,000) or peripheral lesions such as multiple long-bone fractures, crushed limb or primary pulmonary contusion. In such cases, external fixation or retrograde nailing with a small-diameter nail and without reaming are preferable.
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Affiliation(s)
- H Nieto
- Service de chirurgie orthopédique, centre hospitalier Georges-Renon, 40, avenue Charles-de-Gaulle, 79021 Niort cedex, France.
| | - C Baroan
- Service de chirurgie orthopédique, centre hospitalier Georges-Renon, 40, avenue Charles-de-Gaulle, 79021 Niort cedex, France
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Fang C, Wong TM, Lau TW, To KK, Wong SS, Leung F. Infection after fracture osteosynthesis - Part I. J Orthop Surg (Hong Kong) 2017; 25:2309499017692712. [PMID: 28215118 DOI: 10.1177/2309499017692712] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Bone and surgical site infections after osteosynthesis are notoriously difficult to manage and pose a tremendous burden in fracture management. In this article, we use the term osteosynthesis-associated infection (OAI) to refer to this clinical entity. While relatively few surgically treated fractures become infected, it is challenging to perform a rapid diagnosis. Optimal management strategies are complex and highly customized to each scenario and take into consideration the status of fracture union, the presence of hardware and the degree of mechanical stability. At present, a high level of relevant evidence is unavailable; most findings presented in the literature are based on laboratory work and non-randomized clinical studies. We present this overview of OAI in two parts: an examination of recent literature concerning OAI pathogenesis, diagnosis and classification and a review of treatment options.
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Affiliation(s)
- Christian Fang
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Tak-Man Wong
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China.,3 Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Tak-Wing Lau
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Kelvin Kw To
- 2 Department of Microbiology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Samson Sy Wong
- 2 Department of Microbiology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Frankie Leung
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China.,3 Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Uchiyama Y, Kobayashi Y, Ebihara G, Hamahashi K, Watanabe M. Retrospective comparison of postoperative infection and bone union between late and immediate intramedullary nailing of Gustilo grades I, II, and IIIA open tibial shaft fractures. Trauma Surg Acute Care Open 2016; 1:e000035. [PMID: 29766068 PMCID: PMC5891691 DOI: 10.1136/tsaco-2016-000035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/16/2016] [Accepted: 08/17/2016] [Indexed: 12/17/2022] Open
Abstract
Background The optimal method of skeletal stabilization is still controversial. Therefore, we examined the clinical outcomes associated with late (L) versus immediate intramedullary nailing (IMN). Methods This was a retrospective comparative study of trauma registry data from an emergency medical care center (university hospital). We examined 85 open tibial shaft fractures (85 patients) treated with L or immediate (I) IMN from January 2004 to December 2010. The L and I groups comprised 37 (33 men, 4 women) and 48 (44 men, 4 women) patients, respectively. The postoperative infection rate, time to bone union, and delayed union/non-union were evaluated. Results The mean ages at the time of trauma in the L and I groups were 41.8 (18-79) and 42.0 (18-71) years, respectively; the mean follow-up periods were 15.0 (6-39) and 18.3 (8-36) months, respectively. A higher rate of postoperative infection was found in the L group than in the I group (p=0.004). Superficial/deep infection developed at a higher rate in the L group than in the I group (p=0.042 and 0.045, respectively). Among patients with Gustilo grade IIIA fractures, postoperative infection occurred at a higher rate in the L group than in the I group (p=0.008). However, the delayed union rate, non-union rate, and time to bone union were not significantly different between the groups. Conclusions Gustilo grade IIIA fractures had a high infection rate, which is likely due to various factors, including pin-site infection after external fixation. We think that I IMN is safer than L IMN, and it should be the treatment of choice. Level of evidence Retrospective comparative study, level III.
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Affiliation(s)
- Yoshiyasu Uchiyama
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan
| | - Yuka Kobayashi
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan
| | - Gro Ebihara
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan
| | - Kosuke Hamahashi
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan
| | - Masahiko Watanabe
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan
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