Embolization of pelvic arterial injury is a risk factor for deep infection after acetabular fracture surgery

Postoperative Fever Following Pelvic and Acetabular Fixation: Incidence, Risk Factors, and Lack of Association With Surgical Site Infection

BACKGROUND

Despite numerous studies showing postoperative fever can be a common and benign occurrence, there is still a significant and costly workup when fevers occur after surgery, including for orthopedic patients with pelvic ring and acetabular injuries.

MATERIAL AND METHODS

A total of 204 patients undergoing pelvis and/or acetabular fixation were analyzed for fever, with positive fever defined as temperature >38° Celsius. Age, sex, substance use, smoking history, body mass index, diabetes, comorbidities, American Society of Anesthesiologists (ASA) score, fracture morphology, polytrauma, surgical treatment, transfusion requirements, operative time, estimated blood loss, use of vancomycin powder, and surgical site infection (SSI) were all recorded. Surgical site infection was defined as an infection at the surgical site requiring reoperation, with positive cultures at time of secondary surgery.

RESULTS

SSI was not associated with postoperative fever in patients undergoing pelvic and/or acetabular fixation. Higher ASA score, polytrauma, combined pelvic ring-acetabular fractures, open pelvic ring injuries, increased intraoperative blood loss, increased surgical time, and transfusions were associated with higher rates of fevers on univariate analysis. Multivariate analysis showed transfusions were the only independent risk factor for developing fever.

CONCLUSION

Surgeons and clinicians managing orthopedic patients should be aware that postoperative fever is common after pelvis and acetabular fixation and is rarely related to SSI. [Orthopedics. 202x;4x(x):xx-xx.].

Risk factors for surgical site infection following orthopaedic surgery for fracture by trauma: a nested case-control study

BACKGROUND

Surgical site infection (SSI) is associated with higher medical expenses and lower patient quality of life.

AIM

To identify specific modifiable risk factors for SSI after orthopaedic surgery for fractures caused by trauma.

METHODS

This nested case-control study used a nationwide trauma registry, the Japan Trauma Data Bank (JTDB) database. Patient data from 280 hospitals between January 2004 and May 2019 were retrieved from the JTDB. Patients with SSI and identified patients without SSI as control subjects were included, using propensity score matching adjusted for unmodifiable factors. Risk factors associated with SSI after orthopaedic trauma surgery were assessed using multi-level mixed-effects logistic regression models.

FINDINGS

In total, 15,910 patients were included in the analysis. Of these patients, 377 (2.4%) had SSI. After propensity score matching, 258 patients with SSI and 2580 matched patients without SSI were selected. In the multi-level mixed-effects logistic regression analysis, blood transfusion within 24 h (odds ratio (OR): 1.51; 95% confidence interval (CI): 1.06-2.13) was a significant risk factor for SSI following orthopaedic fracture surgery. The OR (95% CI) values for external fixation, transcatheter arterial embolization, and tourniquet for SSI following orthopaedic fracture surgery were 1.40 (0.96-2.03), 1.66 (0.81-3.38), and 2.99 (0.60-14.87), respectively.

CONCLUSION

These findings highlight the necessity of exercising caution when implementing blood transfusion within 24 h as a risk factor associated with SSI following orthopaedic trauma surgery.

Predictors of in-hospital surgical site infections in surgically managed acetabular fractures: A nationwide analysis

Background

A surgical site infection (SSI) rate of 4%-8% has been reported in patients who undergo open reduction and internal fixation (ORIF) for acetabular fractures. Studies have identified risk factors for SSI, but none have performed a nationwide analysis of SSI in surgically managed acetabular fracture patients.

Methods

The National Inpatient Sample (NIS) database was queried for patients who underwent ORIF for acetabular fractures from 2016 to 2019. Analysis was performed on all patients who underwent ORIF for acetabular fractures, as well as those who only underwent ORIF for isolated acetabular fractures. Clinical characteristics, hospital course, discharge disposition, and hospitalization costs were compared between groups. Multivariate regression analysis was conducted to assess predictors of SSI.

Results

41,725 patients undergoing acetabular fracture repair were identified, of which 490 (1.2%) developed SSI during hospitalization. Age (45.90 vs 49.90, p < 0.001) and Injury Severity Scale (5.99 vs 8.30, p < 0.001) were increased in patients who developed SSI. History of hypertension (HTN) (OR = 2.343, 95% CI 1.96-2.80, p < 0.001), longer hospital length of stay (30.27 days vs 10.00 days, p < 0.001) and total charges ($469,005 vs $193,032, p < 0.001) were associated with SSI. Lower rates of routine discharge were seen in SSI patients (OR = 0.333, 95% CI 0.260-0.426, p < 0.001). Higher rates of inpatient death were associated with SSI (OR = 2.210, 95% CI 1.172-4.17, p = 0.019). Multiple procedures in addition to acetabular fracture repair, iliac artery embolization, substance abuse, later time to internal fixation and HTN were predictive of SSI (p < 0.001).

Conclusions

Severity of injury, time to fixation, and factors associated with compromised cardiovascular integrity were predictors of SSI. Identifying patients at risk for SSI should lead to clinical maneuvers that may optimize outcome.

Advances in the Treatment of Implant-Associated Infections of the Pelvis: Eradication Rates, Recurrence of Infection, and Outcome

INTRODUCTION

Surgical site infections after operative stabilization of pelvic and acetabular fractures are rare but serious complications. The treatment of these infections involves additional surgical procedures, high health care costs, a prolonged stay, and often a worse outcome. In this study, we focused on the impact of the different causing bacteria, negative microbiological results with wound closure, and recurrence rates of patients with implant-associated infections after pelvic surgery.

MATERIAL AND METHODS

We retrospectively analyzed a study group of 43 patients with microbiologically proven surgical site infections (SSI) after surgery of the pelvic ring or the acetabulum treated in our clinic between 2009 and 2019. Epidemiological data, injury pattern, surgical approach, and microbiological data were analyzed and correlated with long-term follow-up and recurrence of infection.

RESULTS

Almost two thirds of the patients presented with polymicrobial infections, with staphylococci being the most common causing agents. An average of 5.7 (±5.4) surgical procedures were performed until definitive wound closure. Negative microbiological swabs at time of wound closure were only achieved in 9 patients (21%). Long-term follow-up revealed a recurrence of infection in only seven patients (16%) with an average interval between revision surgery and recurrence of 4.7 months. There was no significant difference of recurrence rate for the groups of patients with positive/negative microbiology in the last operative revision (71% vs. 78%). A positive trend for a correlation with recurrent infection was only found for patients with a Morel-Lavallée lesion due to run-over injuries (30% vs. 5%). Identified causing bacteria did not influence the outcome and rate of recurrence.

CONCLUSION

Recurrence rates after surgical revision of implant-associated infections of the pelvis and the acetabulum are low and neither the type of causing agent nor the microbiological status at the timepoint of wound closure has a significant impact on the recurrence rate.

Infection from an Iliosacral Screw 16 Years Postoperatively in Demolition Derby Umpire Crushed Between 2 Cars: A Case Report

CASE

A 47-year-old man crushed between 2 cars during a demolition derby, a nonracing North American motorsport, underwent open reduction and internal fixation, iliosacral screw fixation, arterial embolization, and multiple urologic procedures after massive pelvic ring injury, remarkably recovering nearly full function. Sixteen years after injury, he developed an abscess emanating from an iliosacral screw requiring irrigation, debridement, and hardware removal.

CONCLUSION

Deep surgical infections from iliosacral screws may present late, even more than 15 years after the original surgery. Obesity, preoperative embolization, diabetes, and urethral injuries are relevant risk factors. Similar patients should have a low threshold for infection workup when presenting with symptoms, even years after surgery.

Risk Factors for Deep Infection and Conversion Total Hip Arthroplasty After Operative Combined Pelvic Ring and Acetabular Fractures

OBJECTIVES

To determine risk factors for deep infection and conversion total hip arthroplasty (THA) after operative management of combined pelvic ring and acetabular injuries.

DESIGN

Retrospective case control study.

SETTING

Level 1 trauma center.

PATIENTS AND INTERVENTION

We reviewed 150 operative combined pelvic ring and acetabular injuries at our institution from 2010 to 2019, with an average follow-up of 690 (90-3282) days.

MAIN OUTCOME MEASUREMENTS

Deep infection and conversion THA.

RESULTS

Patients who developed deep infection (N = 17, 11.3%) had higher rates of hip dislocation ( P = 0.030), intraoperative transfusion ( P = 0.030), higher body mass index (BMI) ( P = 0.046), increased estimated blood loss ( P < 0.001), more intraoperative units transfused ( P = 0.004), and longer operative times ( P = 0.035). Of the 84 patients with 1-year follow-up, 24 (28.6%) required conversion to THA. Patients requiring conversion THA were older ( P = 0.022) and had higher rates of transverse posterior wall fracture pattern ( P = 0.034), posterior wall involvement ( P < 0.001), hip dislocation ( P = 0.031), wall comminution ( P = 0.002), and increased estimated blood loss ( P = 0.024). The order of the pelvic ring versus acetabular fixation did not affect rates of conversion to THA ( P = 0.109). Multiple logistic regression showed that an increased number of intraoperative units transfused [adjusted odds ratio (aOR) = 1.56, 95% confidence interval (CI) = 1.16-2.09, P = 0.003] and higher BMI (aOR = 1.10, 95% CI = 1.01-1.16, P = 0.024) were independently associated with an increased odds of deep infection. Posterior wall involvement was independently associated with an increased odds of conversion THA (aOR = 5.73, 95% CI = 1.17-27.04, P = 0.031).

CONCLUSIONS

Rates of deep infection and conversion THA after operative fixation of combined injuries were 11.3% and 28.6%, respectively. Higher average BMI and number of intraoperative units of blood transfused were independently associated with deep infection, whereas posterior wall involvement was independently associated with conversion to THA in these patients.

LEVEL OF EVIDENCE

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

Preoperative arterial embolization and wound complications after resection of malignant bone tumor in the pelvis: a nationwide database study

BACKGROUND

Massive intraoperative blood loss is common in pelvic malignant bone tumor surgery, and preoperative arterial embolization may be used in selected cases. Preoperative arterial embolization reportedly increases wound complications in pelvic fracture surgery, but little evidence is available regarding pelvic bone tumor surgery.

METHODS

Using a Japanese nationwide database (Diagnosis Procedure Combination database), we searched for patients who underwent pelvic malignant bone tumor surgery between July 2010 and March 2018. The primary endpoint was wound complications, defined as any wound requiring re-operation, negative pressure wound therapy or both. Univariate analyses (the chi-squared test for categorical variables, the unpaired t-test for continuous variables) and multivariate logistic regression analyses were performed to examine the association between preoperative arterial embolization and wound complications.

RESULTS

Among the 266 eligible patients, 43 (16%, 43/266) underwent embolization and 69 (26%, 69/266) developed wound complications. In the univariate analyses, preoperative arterial embolization (P < 0.001), duration of anesthesia (P < 0.001), the volume of blood transfusion (P < 0.001) and duration of indwelling drain tube (P < 0.001) were associated with wound complications. In the multivariate logistic regression analysis, preoperative arterial embolization was significantly associated with wound complications (odds ratio, 3.92; 95% confidence interval, 1.80-8.56; P = 0.001).

CONCLUSIONS

Preoperative arterial embolization may be associated with increased wound complications after pelvic malignant tumor surgery.

Pelvic Ring Resuscitation Pathways

A 35 year-old female is injured in a high-speed motor vehicle collision in which her car is struck on the driver's side by a distracted driver. The patient is unable to self-extricate from the vehicle and she is confused at the scene. She comes directly to the trauma bay via EMS and a binder is placed in transit for suspicion of a pelvic ring injury. Upon presentation she has a GCS of 14 due to confusion, and an initial pressure of 87/50. Workup does not disclose an associated head, chest or abdominal injury and the anteroposterior pelvis radiograph demonstrates a windswept pelvis injury pattern. Despite being transfused 4 units of whole blood, her hypotension does not improve. Please describe your institution's advanced resuscitation protocol and management of this scenario, and provide the rational and support for it.

Does transarterial pelvic embolization have a negative effect on perioperative outcomes in pelvic ring injury and acetabular fracture?

OBJECTIVE

The purpose of this study was to determine whether TAE negatively impacted perioperative outcomes in patients who underwent open surgery for pelvic trauma.

METHODS

We retrospectively reviewed the medical records and radiographs of patients who had open surgery for an acute pelvic trauma between February 2014 and May 2017. The patients were classified into two groups: those who underwent TAE and those who did not. We evaluated preoperative demographics and perioperative outcomes between the two groups. Injury type-specific comparisons were also performed.

RESULTS

A total of 136 patients (50 TAE and 86 non-TAE) were included in this study. There were significant differences in preoperative demographics including the type of injury, injury severity score, revised trauma score, surgical approach, initial blood pressure, and the amount of transfusion within 24 h between the two groups. However, no differences in perioperative outcomes were identified except for the amount of total transfusion. There were significant differences between the two groups in the injury type-specific comparisons, specifically in the amount of transfusion within 24 h in patients with pelvic ring injury and in the injury severity score in patients with acetabular fracture. However, there was no difference in perioperative outcomes between the groups for either injury type.

CONCLUSION

In the present study, we were unable to identify negative effects of TAE on perioperative outcomes. Therefore, when considering open surgery subsequent to TAE, there is no evidence of increased risk for negative perioperative outcomes, especially with respect to bone healing and deep infection.

Surgical Wound Complications After Percutaneous Posterior Pelvic Ring Fixation in Patients Who Undergo Pelvic Arterial Embolization

OBJECTIVE

To report on the incidence of surgical wound complications after percutaneous posterior pelvic ring fixation in patients who have also undergone pelvic arterial embolization (PAE) and determine whether the risks outweigh the benefits.

DESIGN

Retrospective cohort study.

SETTING

Academic level 1 trauma center.

PATIENTS

Two hundred one consecutive patients who underwent percutaneous posterior pelvic fixation at our institution were included in this study. Of these, 27 patients underwent pelvic arterial embolization.

INTERVENTION

Percutaneous posterior pelvic fixation and pelvic arterial embolization.

MAIN OUTCOME MEASUREMENTS

Charts were reviewed for posterior percutaneous surgical wound complications including infection, dehiscence, seroma, tissue necrosis, and return to OR for debridement in all patients.

RESULTS

Of the 27 patients who received PAE, none developed posterior surgical wound complications. Of those who did not receive PAE, there was one posterior surgical wound complication documented. There were no cases of wound infection in either group.

CONCLUSION

Pelvic arterial embolization can be a valuable intervention in treating hemodynamically unstable patients with pelvic ring injuries. Although even selective pelvic arterial embolization is not entirely benign, there seems to be minimal risk of wound complications when percutaneous posterior pelvic ring fixation is performed.

LEVEL OF EVIDENCE

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

Deep infection following reconstruction of pelvic fractures: prevalence, characteristics, and predisposing risk factors

Purpose

To identify the incidence, risk factors, and treatment course of patients who developed deep infection following fixation of pelvic fractures.

Methods

Over a period of 8 years patients who underwent pelvic reconstruction in our institution and developed postoperative infection were included. Exclusion criteria were pathological fractures and infections that were not secondary to post-traumatic reconstruction. The mean time of follow-up was 43.6 months (33–144). For comparison purposes, we randomly selected patients that underwent pelvic fracture fixation from our database (control group). A logistic regression was fitted to patient characteristics including age, sex, ISS, and diabetic status.

Results

Out of 858 patients, 18 (2.1%) (12 males), with a mean age of 41 (18–73) met the inclusion criteria. The control group consisted of 82 patients with a mean age of 41 years (18–72). The mean ISS was 27.7 and 17.6 in the infection and control group, respectively. The mean time from pelvic reconstruction to the diagnosis of infection was 20 days (7–80). The median number of trips to theatre was 3 (1–16). Methicillin-resistant Staphylococcus aureus (MRSA) was the most frequently isolated organism in the years prior to 2012. Eradication was achieved in 93% of the patients. The most important risk factors for deep infection were ISS (OR 1.08, 1.03–1.13), posterior sacral approach (OR 17.03, 1.49–194.40), and diabetes (OR 36.85, 3.54–383.70).

Conclusion

In this retrospective case–control study, deep infection following pelvic trauma was rare. A number of patient-, injury- and surgery-related factors have shown strong correlation with this serious complication.

Risk Factors for Surgical Site Infection after Operative Fixation of Acetabular Fractures: Is Psoas Density a Useful Metric?

BACKGROUND

Surgical site infection (SSI) occurs in 5% to 7% of patients undergoing operative fixation of acetabular fractures, with reported risk factors including longer operative duration, increased blood loss, pelvic artery embolization, and concurrent abdominal organ injury, among others. Psoas muscle density is a measure of muscle quality and, as a metric for sarcopenia and/or nutrition status, has been associated with poor outcomes such as mortality across multiple surgical specialties. To date, psoas muscle density has not been explored for its associations with SSI in acetabular fracture patients.Questions/purposes (1) Is decreased psoas muscle density, as measured by Hounsfield units, associated with an increased SSI risk after acetabular fracture fixation? (2) What patient, operative, and hospital variables are associated with an increased SSI risk after acetabular fracture fixation?

METHODS

Between 2012 to 2017, surgeons performed 684 acetabular ORIF procedures at one level I trauma center. Of those, 8% (56 of 684) did not meet inclusion criteria, leaving 92% (n = 628) for analysis in this study. The median (range) follow-up duration was 12 months (0.5-77). Patient demographics, comorbidities, operative and in-hospital variables, and psoas muscle density measured using preoperative pelvic CT images-acquired for all operative acetabular fracture patients-were analyzed. SSI was defined by positive culture results obtained during irrigation and débridement. Overall, 7% (42 of 628) of patients had an SSI. A multivariable regression analysis was performed to identify independent risk factors. Sensitivity analysis was performed with minimum follow-up set at 3 months and 6 months.

RESULTS

There was no difference in the mean psoas muscle density between patients with SSI (50.9 ± 10.2 Hounsfield units [HUs]) and those who did not have an SSI within 1 year of open reduction and internal fixation (51.4 ± 8.1 HUs) (mean difference: 0.5 [95% confidence interval -2.34 to 3.32]; p = 0.69). Four variables were independently associated with an increased risk of SSI: increased operative time (1.04 [95% CI 1.00 to 1.07]; p = 0.03), estimated blood loss (1.08 [95% CI 1.02 to 1.14]; p = 0.01), female sex (2.34 [95% CI 1.19 to 4.60]; p = 0.01), and intravenous drug use (3.95 [95% CI 1.51 to 10.33]; p = 0.01). Sensitivity analysis showed no change in results using either 3-month or 6-month minimum follow-up.

CONCLUSIONS

Risk factors for SSI after acetabular fixation include female sex, intravenous drug use, prolonged operative times, and increased intraoperative blood loss. Although the density of the psoas muscle may be a surrogate for nutritional markers, it was not associated with SSI in our patients with acetabular fractures. Thus, it is not useful for risk assessment of SSI in the general population with acetabular fracture; however, future studies with larger sample sizes of patients older than 60 years may re-investigate this marker for SSI risk. Contrary to the results of previous studies, pelvic artery embolization, intraoperative blood transfusion, and intensive care unit stay did not increase the risk of SSI; however, we may have been underpowered to detect differences in these secondary endpoints. Future large, multisite studies may be needed to address these conflicting results more definitively.

LEVEL OF EVIDENCE

Level III, therapeutic study.

High incidence of surgical site infection may be related to suboptimal case selection for non-selective arterial embolization during resuscitation of patients with pelvic fractures: a retrospective study

Background

In most institutions, arterial embolization (AE) remains a standard procedure to achieve hemostasis during the resuscitation of patients with pelvic fractures. However, the actual benefits of AE are controversial. In this study, we aimed to explore AE-related outcomes following resuscitation at our center and to assess the predictive value of contrast extravasation (CE) during computed tomography (CT) for patients with hemodynamically unstable closed pelvic fractures.

Methods

We retrospectively reviewed data from patients who were treated for closed pelvic fractures at a single center between 2014 and 2017. Data regarding the AE and clinical parameters were analyzed to determine whether poor outcomes could be predicted.

Results

During the study period, 545 patients were treated for closed pelvic fractures, including 131 patients who underwent angiography and 129 patients who underwent AE. Nonselective bilateral internal iliac artery embolization (nBIIAE) was the major AE strategy (74%). Relative to the non-AE group, the AE group had higher values for injury severity score, shock at hospital arrival, and unstable fracture patterns. The AE group was also more likely to require osteosynthesis and develop surgical site infections (SSIs). Fourteen patients (10.9%) experienced late complications following the AE intervention, including 3 men who had impotence at the 12-month follow-up visit and 11 patients who developed SSIs after undergoing AE and osteosynthesis (incidence of SSI: 11/75 patients, 14.7%). Nine of the 11 patients who developed SSI after AE had undergone nBIIAE. The positive predictive value of CE during CT was 29.6%, with a negative predictive value of 91.3%. Relative to patients with identifiable CE, patients without identifiable CE during CT had a higher mortality rate (30.0% vs. 11.0%, p = 0.03).

Conclusion

Performing AE for pelvic fracture-related hemorrhage may not be best practice for patients with no CE detected during CT or for unstable patients who do not respond to resuscitation after exclusion of other sources of hemorrhage. Given the high incidence of SSI following nBIIAE, this procedure should be selected with care. Given their high mortality rate, patients without CE during imaging might be considered for other hemostasis procedures, such as preperitoneal pelvic packing.

Complications After Pelvic Arteriography in Patients With Pelvic Ring Disruptions

INTRODUCTION

Pelvic angiography with transcatheter arterial embolization (TAE) is an established intervention for management of pelvic arterial hemorrhage. This study analyzes complication rates after angiography among patients with pelvic trauma treated in the context of a multidisciplinary institutional pelvic fracture protocol.

METHODS

Retrospective analysis of prospectively collected data was conducted. Demographics, fracture type, embolization (ie, unilateral versus bilateral and selective versus nonselective), and complications (ie, pseudoaneurysm, renal failure, soft-tissue necrosis/infection, and anaphylactic reactions) were noted.

RESULTS

Eighty-one patients with pelvic ring injuries underwent angiography from 2009 to 2013. Complications among 41 patients who underwent angiography with TAE were compared with a control group of 40 patients who underwent angiography without TAE. Eight of 41 patients with TAE had complications (19.5%) compared with 3 of 40 (7.5%) in the control group (P = 0.19). The overall complication rate was 13.6%.

CONCLUSION

The use of angiography with TAE as part of an institutional pelvic fracture protocol involves an acceptable rate of complications.

LEVEL OF EVIDENCE

III.

Bilateral Internal Iliac Artery Embolization Results in an Unacceptably High Rate of Complications in Patients Requiring Pelvic/Acetabular Surgery

OBJECTIVES

To assess complication rates in patients undergoing open reduction internal fixation (ORIF) of pelvic/acetabular fractures with and without pelvic angiography embolization (PAE).

DESIGN

Retrospective case series.

SETTING

Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

One hundred eleven patients with pelvic or acetabular fractures that required orthopaedic fixation.

INTERVENTION

Retrospective analysis of outcomes in patients who underwent ORIF of pelvic/acetabular fractures with and without PAE.

MAIN OUTCOME MEASUREMENTS

Comparison of surgical wound infections, necrosis, and/or fracture nonunions between the PAE group and a control group (no PAE).

RESULTS

Final study groups consisted of 50 patients in the PAE group and 61 patients in the control group. Ninety-six percent of patients underwent nonselective PAE. Significantly higher complications were noted in the PAE group than in the control group (20% compared with 4.9%; P = 0.020). In addition, posterior surgical approaches combined with internal iliac artery embolization represented the highest complication rate.

CONCLUSIONS

Patients requiring PAE and pelvic/acetabular ORIF should undergo a multidisciplinary treatment approach with the trauma surgeon, interventional radiologist, and orthopaedic surgeon before PAE being performed to decrease complications and avoid nonselective bilateral internal iliac artery embolization.

LEVEL OF EVIDENCE

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

Risk Factors for Early Reoperation After Operative Treatment of Acetabular Fractures

OBJECTIVES

To identify the risk factors for early reoperation after operative fixation of acetabular fractures.

DESIGN

Retrospective evaluation.

SETTING

Level I Trauma Center.

PATIENTS

Seven hundred ninety-one patients with displaced acetabular fractures treated with open reduction and internal fixation (ORIF) from 2006 to 2015. Average follow-up was 52 weeks.

MAIN OUTCOME MEASURES

Early reoperation after acetabular ORIF, defined as secondary procedure for infection or revision within 3 years of initial operation.

RESULTS

Fifty-six (7%) patients underwent irrigation and debridement for infection and wound complications. Four associated risk factors identified were length of stay in the intensive care unit, pelvic embolization, operative time, and time delay between injury and surgical fixation. Sixty-two (8%) patients underwent early revision, including 45 conversions to total hip arthroplasty, 10 revision ORIF, 6 fixation device removals because of concern for joint penetration (2 acutely and 4 > 6 months after surgery), and 1 stabilization procedure. Three risk factors associated with early revision were hip dislocation, articular comminution, and concomitant femoral head or neck injury. Combined injuries to the pelvic ring and acetabulum, fracture pattern, marginal impaction, and body mass index had no significant effect on early revision surgery.

CONCLUSIONS

Risk factors for early reoperation after operative fixation of acetabular fractures differed based on the reason for return to the operating room. Infection was more likely to occur in patients who had prolonged stays in the intensive care unit, had prolonged operative times, were embolized, or experienced delay in time to fixation. Revision was more likely with hip dislocation, articular comminution, femoral head or neck fracture, and advancing age.

LEVEL OF EVIDENCE

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

[Prevention of postoperative infections : Risk factors and the current WHO guidelines in musculoskeletal surgery]

BACKGROUND

Despite the many scientific and technological advances postoperative infection continues to be a large problem for trauma and orthopedic surgeons. Based on a review of the current literature, this study provides a comprehensive overview of the risk factors (RF) and possible preventive measures to control surgical site infections.

METHODS

Medline search and analysis from 1968-2017 (as of 01 March 2017). Selection of trauma and orthopedic relevant RFs and comparison with WHO recommendations (global guidelines for the prevention of surgical site infection, Nov. 2016).

RESULTS

Identification of 858 relevant articles from the last 50 years (1968-2017). Pooled postoperative rate of infection is 0.3% (hand surgery) and 19% (3rd degree open fractures). For open fractures, there is no clear tendency towards lower infection rates during the past five decades. Identification of 115 RF from three areas (patient-dependent RF, organizational and procedural RF, trauma- and surgery-dependent RF). The five most important RFs are body mass index over 35 kg/m², increased duration of surgery, diabetes mellitus, increased blood glucose levels in the perioperative period also in the case of nondiabetic patients, and errors in the perioperative antibiotic prophylaxis.

DISCUSSION

Inconsistent definition of "infection", interaction of the RF and the different follow-up duration limit the meaningfulness of the study.

CONCLUSION

In the future, considerable efforts must be made in order to achieve a noticeable reduction in the rate of infection, especially in the case of high-risk patients.

Does Pelvic Embolization Increase Infection Rates in Patients Who Undergo Open Treatment of Acetabular Fractures?

OBJECTIVE

Evaluate the impact of pelvic embolization on postoperative infection rate after acetabular fracture fixation.

DESIGN

Retrospective study of 3 separate cohorts.

SETTING

Level I Trauma Center.

PATIENTS/PARTICIPANTS

Identified patients who underwent angiography of the pelvis as well as required an open reduction internal fixation (ORIF) of an acetabular fracture. This group was compared to a control group of patients with an acetabular fracture, which did not undergo angiography, and underwent ORIF.

INTERVENTION

ORIF of an aectabular fracture with angiography ± embolization.

MAIN OUTCOME MEASUREMENTS

Deep infection rate.

RESULTS

Seventy-two patients remained for final analysis; 25 patients underwent embolization, 16 patients underwent angiography without embolization, and 31 patients did not undergo angiography. Two out of 25 (8%) patients developed infections in the embolization group, one deep infection and one superficial infection. Five out of 16 (31%) patients developed deep infections in the nonembolization group. Control group of patients who did not undergo angiography had a deep infection rate of 9.6%.

CONCLUSION

Despite previous reports of high infection rates after pelvic embolization, the deep infection rate was only 4% after embolization in our cohort. This suggests that concerns for higher rates of infection are not substantiated, and pelvic embolization should be performed when indicated.

LEVEL OF EVIDENCE

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

Infection after fracture osteosynthesis - Part I

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.

Novel Strategies for the Diagnosis of Posttraumatic Infections in Orthopaedic Trauma Patients

Orthopaedic infections that occur after trauma are common. Clinical examination, laboratory markers, imaging modalities, and culture and molecular technologies are used to aid the diagnosis of infection. Culture methods comprise the backbone of diagnostic systems used in hospital laboratory settings; however, several studies have questioned the ability of these techniques to adequately identify infections, particularly in cases where orthopaedic implants were used or when the presence of biofilm bacteria is suspected. Advances in imaging and molecular diagnostics can provide orthopaedic surgeons with an improved means of diagnosing and treating infections.

Combined acetabulum and pelvic ring injuries

Combined fractures of the acetabulum and pelvic ring are more common than previously believed, with an incidence as high as 15.7%. Recent series that include combined injuries indicate that the incidence of lateral compression and anteroposterior compression pelvic ring injuries is similar and that transverse and both-column acetabular fractures are the most common acetabular fracture patterns. Combined injuries most often are the result of high-energy mechanisms, and, compared with patients who present with isolated pelvic or acetabular injury, patients with combined injury typically have higher injury severity scores, higher transfusion requirements, and lower systolic blood pressure, with reported mortality rates of 1.5% to 13%. Treatment requires a multidisciplinary approach. The first priority is resuscitation following the Advanced Trauma Life Support protocols. Once the patient is stable, acetabular fractures and pelvic ring injuries should be assessed individually, and the most appropriate treatment for each should be outlined. These treatments should then be integrated to develop the most appropriate overall treatment strategy. Although outcomes data are available for isolated acetabulum and pelvic ring disruptions, no such data currently exist for combined injuries.

Acute complications of patients with pelvic fractures after pelvic angiographic embolization

BACKGROUND

Hemodynamically unstable patients with a pelvic fracture and arterial pelvic bleeding frequently are treated with pelvic angiographic embolization (PAE). PAE is reported to be a safe and effective method of controlling hemorrhage. However, the loss of blood supply and subsequent ischemia from embolization may lead to adverse consequences.

OBJECTIVES/PURPOSES

We sought to determine (1) the frequency and types of complications observed after PAE; (2) the mortality after PAE; and (3) the clinical factors associated with complications and mortality after PAE.

METHODS

We conducted a retrospective case series descriptive study at a Level I trauma center. Using our institution's trauma registry, we isolated patients with pelvic fractures treated with PAE admitted between June 1999 and December 2007. Complications attributed to PAE occurring in the initial hospital stay were recorded. We identified 98 patients with pelvic fractures treated by PAE with an average hospital stay of 25.3 days.

RESULTS

The complication rate was 11% and included six patients with gluteal muscle necrosis (6%), five with surgical wound breakdown (5%), four deep infections (4%), one superficial infection, two patients with of impotence (2%), and one with bladder necrosis. The mortality rate in the PAE group reached 20%. Bilateral embolization was performed in 100% of the patients with complications. Nonselective embolization was performed in 81% of patients with complications. All of the patients with gluteal necrosis had bilateral nonselective embolization.

CONCLUSIONS

Bilateral or nonselective PAE is associated with significant complications during the initial hospital stay. The value of PAE should be weighed against its possible adverse consequences. Selective unilateral arterial embolization should be considered whenever possible.