Analyzing risk factors for treatment failure in fracture-related infection

INTRODUCTION

Fracture-related infection (FRI) represents a challenging clinical scenario. Limited evidence exists regarding treatment failure after initial management of FRI. The objective of our investigation was to determine incidence and risk factors for treatment failure in FRI.

MATERIALS AND METHODS

We conducted a retrospective review of patients treated for FRI between 2011 and 2015 at three level 1 trauma centers. One hundred and thirty-four patients treated for FRI were identified. Demographic and clinical variables were extracted from the medical record. Treatment failure was defined as the need for repeat debridement or surgical revision seven or more days after the presumed final procedure for infection treatment. Univariate comparisons were conducted between patients who experienced treatment failure and those who did not. Multivariable logistic regression was conducted to identify independent associations with treatment failure.

RESULTS

Of the 134 FRI patients, 51 (38.1%) experienced treatment failure. Patients who failed were more likely to have had an open injury (31% versus 17%; p = 0.05), to have undergone implant removal (p = 0.03), and additional index I&D procedures (3.3 versus 1.6; p < 0.001). Most culture results identified a single organism (62%), while 15% were culture negative. Treatment failure was more common in culture-negative infections (p = 0.08). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common organism associated with treatment failure (29%; p = 0.08). Multivariate regression demonstrated a statistically significant association between treatment failure and two or more irrigation and debridement (I&D) procedures (OR 13.22, 95% CI 4.77-36.62, p < 0.001) and culture-negative infection (OR 4.74, 95% CI 1.26-17.83, p = 0.02).

CONCLUSIONS

The rate of treatment failure following FRI continues to be high. Important risk factors associated with treatment failure include open fracture, implant removal, and multiple I&D procedures. While MRSA remains common, culture-negative infection represents a novel risk factor for failure, suggesting aggressive treatment of clinically diagnosed cases remains critical even without positive culture data.

LEVEL OF EVIDENCE

Retrospective cohort study; Level III.

Perspective on optical imaging for functional assessment in musculoskeletal extremity trauma surgery

SIGNIFICANCE

Extremity injury represents the leading cause of trauma hospitalizations among adults under the age of 65 years, and long-term impairments are often substantial. Restoring function depends, in large part, on bone and soft tissue healing. Thus, decisions around treatment strategy are based on assessment of the healing potential of injured bone and/or soft tissue. However, at the present, this assessment is based on subjective clinical clues and/or cadaveric studies without any objective measure. Optical imaging is an ideal method to solve several of these issues.

AIM

The aim is to highlight the current challenges in assessing bone and tissue perfusion/viability and the potentially high impact applications for optical imaging in orthopaedic surgery.

APPROACH

The prospective will review the current challenges faced by the orthopaedic surgeon and briefly discuss optical imaging tools that have been published. With this in mind, it will suggest key research areas that could be evolved to help make surgical assessments more objective and quantitative.

RESULTS

Orthopaedic surgical procedures should benefit from incorporation of methods to measure functional blood perfusion or tissue metabolism. The types of measurements though can vary in the depth of tissue sampled, with some being quite superficial and others sensing several millimeters into the tissue. Most of these intrasurgical imaging tools represent an ideal way to improve surgical treatment of orthopaedic injuries due to their inherent point-of-care use and their compatibility with real-time management.

CONCLUSION

While there are several optical measurements to directly measure bone function, the choice of tools can determine also the signal strength and depth of sampling. For orthopaedic surgery, real-time data regarding bone and tissue perfusion should lead to more effective patient-specific management of common orthopaedic conditions, requiring deeper penetrance commonly seen with indocyanine green imaging. This will lower morbidity and result in decreased variability associated with how these conditions are managed.

Selecting Residents for Predetermined Factors Identified and Thought to be Important for Work Performance and Satisfaction: A Methodology

OBJECTIVE

The medical profession seeks to hire and train individuals who consistently meet and/or exceed both job and cultural expectations. Resident selection is often not structured to meet this goal. The objective of this quality improvement project was to evaluate a classic unscripted interview process (OI) in conjunction with a structured, scripted interview process (SI) developed using an established hiring methodology from industry not yet utilized in health care. Qualitative questions we sought to answer: (1) Can SI be practically applied to the selection of residents? (2) Is there a significant difference in the relative position of applicants between the OI and SI rank lists? (3) Qualitatively, does SI help the evaluation/discussion of the affective domain?

METHODS

Design: Prospective qualitative comparison of OI versus SI.

SETTING

Dartmouth Hitchcock Medical Center, Lebanon, NH.

PARTICIPANTS

Applicants were assessed by OI and SI. SI factors were selected based on a job profile. Interview scripts were created from validated behavioral and attitudinal questions. Online assessments assessed 2 important attributes - adaptability and values. Rank lists were compared for relative rank position of applicants. Feedback from faculty was obtained.

RESULTS

Fifty-two applicants. Critical attributes were self-management, integrator-synthesizer, versatility, communication, and achievement. Absolute mean difference in rank/applicant was 9.8 (standard deviation 8.9, Range 0-36) positions. Comparing the top 20 candidates of each rank list, 40% of those applicants were only on one list. Faculty felt that applicants were given a greater opportunity to show "who they are."

CONCLUSIONS

In conjunction with OI, an industry proven methodology was practically applied to define and select for high performance for the authors' specific institution. Comparing OI and SI resulted in substantial differences in rank lists. This initiative seemed to provide a structure to evaluate values and motivations that are inherently difficult to assess. Faculty felt SI in conjunction with OI gave a greater chance for applicants to show "who they are."