1
|
O’Hara NN, Frey KP, Stein DM, Levy JF, Slobogean GP, Castillo R, Firoozabadi R, Karunakar MA, Gary JL, Obremskey WT, Seymour RB, Cuschieri J, Mullins CD, O’Toole RV. Effect of Aspirin Versus Low-Molecular-Weight Heparin Thromboprophylaxis on Medication Satisfaction and Out-of-Pocket Costs: A Secondary Analysis of a Randomized Clinical Trial. J Bone Joint Surg Am 2024; 106:590-599. [PMID: 38381842 PMCID: PMC10980176 DOI: 10.2106/jbjs.23.00824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Current guidelines recommend low-molecular-weight heparin for thromboprophylaxis after orthopaedic trauma. However, recent evidence suggests that aspirin is similar in efficacy and safety. To understand patients' experiences with these medications, we compared patients' satisfaction and out-of-pocket costs after thromboprophylaxis with aspirin versus low-molecular-weight heparin. METHODS This study was a secondary analysis of the PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT) trial, conducted at 21 trauma centers in the U.S. and Canada. We included adult patients with an operatively treated extremity fracture or a pelvic or acetabular fracture. Patients were randomly assigned to receive 30 mg of low-molecular-weight heparin (enoxaparin) twice daily or 81 mg of aspirin twice daily for thromboprophylaxis. The duration of the thromboprophylaxis, including post-discharge prescription, was based on hospital protocols. The study outcomes included patient satisfaction with and out-of-pocket costs for their thromboprophylactic medication measured on ordinal scales. RESULTS The trial enrolled 12,211 patients (mean age and standard deviation [SD], 45 ± 18 years; 62% male), 9725 of whom completed the question regarding their satisfaction with the medication and 6723 of whom reported their out-of-pocket costs. The odds of greater satisfaction were 2.6 times higher for patients assigned to aspirin than those assigned to low-molecular-weight heparin (odds ratio [OR]: 2.59; 95% confidence interval [CI]: 2.39 to 2.80; p < 0.001). Overall, the odds of incurring any out-of-pocket costs for thromboprophylaxis medication were 51% higher for patients assigned to aspirin compared with low-molecular-weight heparin (OR: 1.51; 95% CI: 1.37 to 1.66; p < 0.001). However, patients assigned to aspirin had substantially lower odds of out-of-pocket costs of at least $25 (OR: 0.15; 95% CI: 0.12 to 0.18; p < 0.001). CONCLUSIONS Use of aspirin substantially improved patients' satisfaction with their medication after orthopaedic trauma. While aspirin use increased the odds of incurring any out-of-pocket costs, it protected against costs of ≥$25, potentially improving health equity for thromboprophylaxis. LEVEL OF EVIDENCE Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Nathan N. O’Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Katherine P. Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Deborah M. Stein
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph F. Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gerard P. Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Renan Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Madhav A. Karunakar
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Joshua L. Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - William T. Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachel B. Seymour
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Joseph Cuschieri
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - C. Daniel Mullins
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Robert V. O’Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
2
|
Joshi M, O'Toole RV, Carlini AR, Gary JL, Obremskey WT, Murray CK, Gaski G, Reid JS, Degani Y, Taylor TJ, Collins SC, Huang Y, Whiting PS, Patterson JT, Lee OC, Castillo RC. Does Topical Vancomycin Powder Use in Fracture Surgery Change Bacteriology and Antibiotic Susceptibilities? An Analysis of the VANCO Trial. J Orthop Trauma 2024; 38:183-189. [PMID: 38206761 DOI: 10.1097/bot.0000000000002767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/05/2024] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To determine whether intrawound vancomycin changes the bacteriology of surgical site infection pathogens and investigate the emergence of antibiotic-resistant pathogens. METHODS DESIGN Secondary analysis of phase III, prospective, randomized clinical trial. SETTING Thirty-six US trauma centers. PATIENT SELECTION CRITERIA Patients who became infected after fixation of tibial plateau or pilon fracture. OUTCOME MEASURES AND COMPARISONS Pathogen types and bacterial susceptibilities as determined from routine clinical culture in the operating room. RESULTS Seventy-four patients were studied who were 67.5% male with a mean age of 48.6 years. A lower proportion of gram-positive cocci was observed in the vancomycin powder compared with the standard-of-care group (3.7% vs. 8.0%, P = 0.01). Methicillin-resistant Staphylococcus aureus infection incidence was comparable in both the vancomycin powder and the standard-of-care groups, but rates of methicillin-susceptible S. aureus infections were lower in the treatment group (1.4% vs. 4.8%, P = 0.01). The incidence of coagulase-negative Staphylococci and gram-negative rod infections were similar in both groups. There was no significant difference in susceptibilities between groups in rates of vancomycin-resistant enterococcus. CONCLUSIONS Topical vancomycin powder decreases the likelihood of gram-positive infections consistent with the biologic activity of vancomycin. Fewer methicillin-susceptible S. aureus and coagulase-negative Staphylococci infections were observed in the group treated with vancomycin powder. An effect of vancomycin powder on methicillin-resistant S. aureus infection risk was not detected given the low incidence in both the intrawound vancomycin and the standard-of-care groups. There was no emergence of gram-negative rod infections or increased resistance patterns observed. Use of topical vancomycin powder does not seem to produce infections in these patients with greater antibiotic resistance than would have occurred without its use. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Manjari Joshi
- Division of Infectious Disease, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Anthony R Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Yasmin Degani
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Tara J Taylor
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Susan C Collins
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yanjie Huang
- University of Michigan School of Dentistry, Ann Arbor, MI
| | - Paul S Whiting
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI; and
| | - Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Olivia C Lee
- Department of Orthopaedics, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| |
Collapse
|
3
|
Flagstad I, Albright P, Pedri T, Kleinsmith RM, Schmidt A, Alley M, Westberg JR, Moreno AF, Henry G, Tatman LM, Obremskey WT, Tornetta P, Cunningham BP. Early Versus Delayed Definitive Fixation Relative to Fasciotomy Closure in High-Energy Tibial Plateau Fractures with Compartment Syndrome. J Orthop Trauma 2024:00005131-990000000-00349. [PMID: 38466820 DOI: 10.1097/bot.0000000000002802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
OBJECTIVES To evaluate the timing of definitive fixation of tibial plateau fractures relative to fasciotomy closure with regards to alignment and articular reduction. METHODS Design: Retrospective Case Series. SETTING Four Level I trauma centers. PATIENT SELECTION CRITERIA Patients with tibial plateau fractures with ipsilateral compartment syndrome treated with fasciotomy between 2006-2018 met inclusion criteria. Open fractures, patients under the age of 18, patients with missed or delayed treatment of compartment syndrome, patients with diagnosis of compartment syndrome after surgical fixation, and patients whose plateau fracture was not treated with open reduction and internal fixation (ORIF) were excluded. Patients were divided into two groups depending on the relative timing of fixation to fasciotomy closure: early fixation (EF) was defined as fixation before or at the time of fasciotomy closure and delayed fixation (DF) was defined as fixation after fasciotomy closure. OUTCOME MEASURES AND COMPARISONS Radiographic limb alignment (categorized as anatomic alignment (no varus/valgus), ≤ 5° varus/valgus, or > 5° varus/valgus) and articular reduction (categorized as anatomical alignment with no residual gap or step off, <2mm, 2-5mm, and >5mm of articular surface step off) was compared between early and delayed fixation groups. Additionally, superficial and deep infection rates were compared between those in the EF and DF cohorts. Subgroup analysis within the EF cohort was performed to compare baseline characteristics and outcomes between those that received fixation prior to closure and those that underwent concurrent fixation and closure within one operative episode. RESULTS A total of 131 patients met inclusion criteria for this study. Sixty-four patients (48.9%) were stratified into the delayed fixation group and 67 patients (51.1%) were stratified into early fixation. In the EF cohort, 57 (85.1%) were male with an average age of 45.3 ± 13.6 years and an average BMI of 31.0 ± 5.9. The DF cohort was primarily male (44, 68.8%), with an average age of 46.6 ±13.9 and an average BMI of 28.4 ± 7.9. Fracture pattern distribution did not differ significantly between the early and delayed fixation cohorts (p = 0.754 for Schatzker classification and p = 0.569 for AO/OTA classification). The relative risk of infection for the DF cohort was 2.17 [95%CI = 1.04, 4.54] compared to the EF cohort. . Patients in the early fixation cohort were significantly more likely to have anatomic articular reduction compared to their delayed fixation counterparts (37.5% vs. 52.2%; p < 0.001). CONCLUSIONS This study demonstrated higher rates of anatomic articular reduction in patients that underwent fixation of tibial plateau fractures prior to or at the time of fasciotomy closure for acute compartment syndrome compared to their counterparts that underwent definitive fixation for tibial plateau fracture after fasciotomy closure. The relative risk of overall infection in the for those that underwent fasciotomy closure after definitive fixation for tibial plateau fracture was 2.17 compared to the cohort that underwent closure before or concomitantly with definitive fixation. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Ilexa Flagstad
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Patrick Albright
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Tony Pedri
- Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Rebekah M Kleinsmith
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA
- Department of Orthopaedic Surgery, Methodist Hospital, St. Louis Park, MN, USA
| | - Andrew Schmidt
- Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Maxwell Alley
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jerald R Westberg
- Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Andres Fidel Moreno
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA, USA
| | - Greer Henry
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA, USA
| | - Lauren M Tatman
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA, USA
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA
- Department of Orthopaedic Surgery, Methodist Hospital, St. Louis Park, MN, USA
| |
Collapse
|
4
|
Davis ME, Ishmael C, Fram B, Light JJ, Obremskey WT, Cannada LK. Finding Your Job in Orthopaedic Trauma: A Survey Revealing the Cold Hard Facts. J Orthop Trauma 2024; 38:e120-e125. [PMID: 38117574 DOI: 10.1097/bot.0000000000002744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVES Finding a first job after fellowship can be stressful due to the uncertainty about which resources to use, including fellowship program directors, residency faculty, and other sources. There are more than 90 orthopaedic trauma fellows seeking jobs annually. We surveyed orthopaedic trauma fellows to determine the job search process. METHODS DESIGN An anonymous 37-question survey. SETTING Online Survey. PATIENT SELECTION CRITERIA Orthopaedic trauma fellows from the 5 fellowship-cycle years of 2016-2021. OUTCOME MEASURES AND COMPARISONS The primary questions were related to the job search process, current job, and work details. The secondary questions addressed job satisfaction. Data analysis was performed using STATA 17. RESULTS There were 159 responses (40%). Most of the respondents completed a fellowship at an academic program (84%). Many (50%) took an academic job and 24% were hospital employed. Sixteen percent had a job secured before fellowship and 49% went on 2-3 interviews. Word of mouth was the top resource for finding a job (53%) compared with fellowship program director (46%) and residency faculty (33%). While 82% reported ending up in their first-choice job, 34% of respondents felt they "settled." The number of trauma cases was important (62%), ranked above compensation (52%) as a factor affecting job choice. Surgeons who needed to supplement their practice (46%) did so with primary and revision total joints (37%). CONCLUSIONS Jobs were most often found by word of mouth. Most fellows landed their first job choice, but still a third of respondents reporting settling on a job. Case volume played a significant role in factors affecting job choice.
Collapse
Affiliation(s)
- Max E Davis
- Texas Tech University Health Sciences Center, Lubbock, TX
| | - Chad Ishmael
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Brianna Fram
- Department of Orthopaedics & Rehabilitation, Orthotrauma, Yale School of Medicine, New Haven, CT
| | - Jonathan J Light
- Eastern Virginia Medical School, School of Medicine, Norfolk, VA
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University, Nashville, TN; and
| | - Lisa K Cannada
- Novant Health Orthopaedic Fracture Clinic, University of North Carolina School of Medicine, Charlotte Campus, Charlotte, NC
| |
Collapse
|
5
|
Allen L, O'Toole RV, Bosse MJ, Obremskey WT, Archer KR, Cannada LK, Shores J, Reider LM, Frey KP, Carlini AR, Staguhn ED, Castillo RC. How many sites should an orthopedic trauma prospective multicenter trial have? A marginal analysis of the Major Extremity Trauma Research Consortium completed trials. Trials 2024; 25:107. [PMID: 38317256 PMCID: PMC10840249 DOI: 10.1186/s13063-024-07917-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/09/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Multicenter trials in orthopedic trauma are costly, yet crucial to advance the science behind clinical care. The number of sites is a key cost determinant. Each site has a fixed overhead cost, so more sites cost more to the study. However, more sites can reduce total costs by shortening the study duration. We propose to determine the optimal number of sites based on known costs and predictable site enrollment. METHODS This retrospective marginal analysis utilized administrative and financial data from 12 trials completed by the Major Extremity Trauma Research Consortium. The studies varied in size, design, and clinical focus. Enrollment across the studies ranged from 1054 to 33 patients. Design ranged from an observational study with light data collection to a placebo-controlled, double-blinded, randomized controlled trial. Initial modeling identified the optimal number of sites for each study and sensitivity analyses determined the sensitivity of the model to variation in fixed overhead costs. RESULTS No study was optimized in terms of the number of participating sites. Excess sites ranged from 2 to 39. Excess costs associated with extra sites ranged from $17K to $330K with a median excess cost of $96K. Excess costs were, on average, 7% of the total study budget. Sensitivity analyses demonstrated that studies with higher overhead costs require more sites to complete the study as quickly as possible. CONCLUSIONS Our data support that this model may be used by clinical researchers to achieve future study goals in a more cost-effective manner. TRIAL REGISTRATION Please see Table 1 for individual trial registration numbers and dates of registration.
Collapse
Affiliation(s)
- Lauren Allen
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, 415 North Washington Street, Baltimore, MD, 21205, USA.
| | - Robert V O'Toole
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Michael J Bosse
- Atrium Health Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Kristin R Archer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Lisa K Cannada
- Novant Health Orthopedic Fracture Clinic, Charlotte, NC, 28211, USA
| | - Jaimie Shores
- School of Medicine, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Lisa M Reider
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, 415 North Washington Street, Baltimore, MD, 21205, USA
| | - Katherine P Frey
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, 415 North Washington Street, Baltimore, MD, 21205, USA
| | - Anthony R Carlini
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, 415 North Washington Street, Baltimore, MD, 21205, USA
| | - Elena D Staguhn
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, 415 North Washington Street, Baltimore, MD, 21205, USA
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, 415 North Washington Street, Baltimore, MD, 21205, USA
| |
Collapse
|
6
|
Marais LC, Hungerer S, Eckardt H, Zalavras C, Obremskey WT, Ramsden A, McNally MA, Morgenstern M, Metsemakers WJ. Key aspects of soft tissue management in fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg 2024; 144:259-268. [PMID: 37921993 PMCID: PMC10774153 DOI: 10.1007/s00402-023-05073-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/11/2023] [Indexed: 11/05/2023]
Abstract
A judicious, well-planned bone and soft tissue debridement remains one of the cornerstones of state-of-the-art treatment of fracture-related infection (FRI). Meticulous surgical excision of all non-viable tissue can, however, lead to the creation of large soft tissue defects. The management of these defects is complex and numerous factors need to be considered when selecting the most appropriate approach. This narrative review summarizes the current evidence with respect to soft tissue management in patients diagnosed with FRI. Specifically we discuss the optimal timing for tissue closure following debridement in cases of FRI, the need for negative microbiological culture results from the surgical site as a prerequisite for definitive wound closure, the optimal type of flap in case of large soft tissue defects caused by FRI and the role of negative pressure wound therapy (NPWT) in FRI. Finally, recommendations are made with regard to soft tissue management in FRI that should be useful for clinicians in daily clinical practice.Level of evidence Level V.
Collapse
Affiliation(s)
- Leonard C Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Sven Hungerer
- Department of Joint Surgery and Arthroplasty, Trauma Center Murnau, Murnau Germany and Paracelsus Medical University (PMU) Salzburg, Salzburg, Austria
| | - Henrik Eckardt
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alex Ramsden
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | | |
Collapse
|
7
|
Patterson JT, Slobogean GP, Gary JL, Castillo RC, Firoozabadi R, Carlini AR, Joshi M, Allen LE, Huang Y, Bosse MJ, Obremskey WT, McKinley TO, Reid JS, O'Toole RV, O'Hara NN. The VANCO Trial Findings Are Generalizable to a North American Trauma Registry. J Orthop Trauma 2024; 38:10-17. [PMID: 38093438 DOI: 10.1097/bot.0000000000002704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 12/18/2023]
Abstract
OBJECTIVES To estimate the generalizability of treatment effects observed in the VANCO trial to a broader population of patients with tibial plateau or pilon fractures. METHODS Design and Setting: Clinical trial data from 36 United States trauma centers and Trauma Quality Programs registry data from more than 875 Level I-III trauma centers in the United States and Canada.Patient Selection Criteria: Patients enrolled in the VANCO trial treated with intrawound vancomycin powder from January 2015 to June 2017 and 31,924 VANCO-eligible TQP patients admitted in 2019 with tibial plateau and pilon fractures.Outcome Measure and Comparisons: Deep surgical site infection and gram-positive deep surgical site infection estimated in the TQP sample weighed by the inverse probability of trial participation. RESULTS The 980 patients in the VANCO trial were highly representative of 31,924 TQP VANCO-eligible patients (Tipton generalizability index 0.96). It was estimated that intrawound vancomycin powder reduced the odds of deep surgical infection by odds ratio (OR) = 0.46 (95% confidence interval [CI] 0.25-0.86) and gram-positive deep surgical infection by OR = 0.39 (95% CI, 0.18-0.84) within the TQP sample of VANCO-eligible patients. For reference, the trial average treatment effects for deep surgical infection and gram-positive deep surgical infection were OR = 0.60 (95% CI, 0.37-0.98) and OR = 0.44 (95% CI, 0.23-0.80), respectively. CONCLUSIONS This generalizability analysis found that the inferences of the VANCO trial generalize and might even underestimate the effects of intrawound vancomycin powder when observed in a wider population of patients with tibial plateau and pilon fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, CA
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, CA
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Reza Firoozabadi
- Department of Orthopedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA
| | - Anthony R Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Manjari Joshi
- Department of Medicine, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Lauren E Allen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yanjie Huang
- University of Michigan School of Dentistry, Ann Arbor, MI
| | - Michael J Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, NC
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Todd O McKinley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN; and
| | - J Spence Reid
- Department of Orthopaedic Surgery, Penn State College of Medicine, Hershey, PA
| | - Robert V O'Toole
- Department of Orthopaedics, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD
| |
Collapse
|
8
|
Metsemakers WJ, Moriarty TF, Morgenstern M, Marais L, Onsea J, O'Toole RV, Depypere M, Obremskey WT, Verhofstad MHJ, McNally M, Morshed S, Wouthuyzen-Bakker M, Zalavras C. The global burden of fracture-related infection: can we do better? Lancet Infect Dis 2023:S1473-3099(23)00503-0. [PMID: 38042164 DOI: 10.1016/s1473-3099(23)00503-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 12/04/2023]
Abstract
Fracture-related infection is a major complication related to musculoskeletal injuries that not only has important clinical consequences, but also a substantial socioeconomic impact. Although fracture-related infection is one of the oldest disease entities known to mankind, it has only recently been defined and, therefore, its global burden is still largely unknown. In this Personal View, we describe the origin of the term fracture-related infection, present the available data on its global impact, and discuss important aspects regarding its prevention and management that could lead to improved outcomes in both high-resource and low-resource settings. We also highlight the need for health-care systems to be adequately compensated for the high cost of human resources (trained staff) and well-equipped facilities required to adequately care for these complex patients. Our aim is to increase awareness among clinicians and policy makers that fracture-related infection is a disease entity that deserves prioritisation in terms of research, with the goal to standardise treatment and improve patient outcomes on a global scale.
Collapse
Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - T Fintan Moriarty
- AO Research Institute Davos, Davos, Switzerland; Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Leonard Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Martin McNally
- The Bone Infection Unit, Oxford University Hospitals, Oxford, UK
| | - Saam Morshed
- Department of Orthopaedic Surgery and Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
9
|
Bouklouch Y, Bernstein M, Bosse M, Cota A, Duckworth AD, Dunbar RP, Gamulin A, Guy P, Hak DJ, Haller JM, Hayda R, Jarragh A, Johnstone AJ, Karunakar M, Lawendy AR, Leighton R, Mavrogenis AF, Mauffrey C, Miclau T, Obremskey WT, Renninger C, Sanders DW, Schmidt AH, Schneider P, Sen MK, Taitsman L, Van Lancker H, Harvey EJ. Postfasciotomy Classification System for Acute Compartment Syndrome of the Leg. J Orthop Trauma 2023; 37:581-585. [PMID: 37491711 DOI: 10.1097/bot.0000000000002663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy. METHODS Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses. RESULTS The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency. CONCLUSION This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.
Collapse
Affiliation(s)
| | | | - Michael Bosse
- Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Adam Cota
- St Mary's Medical Center-Intermountain Health, Grand Junction, CO
| | | | - Robert P Dunbar
- Harborview Medical Center/University of Washington, Seattle, WA
| | - Axel Gamulin
- University Hospitals of Geneva, Geneva, Switzerland
| | - Pierre Guy
- University of British Columbia, Vancouver, BC, Canada
| | - David J Hak
- Hughston Clinic/University of Central Florida, Orlando, FL
| | | | | | - Ali Jarragh
- Kuwait University, Dar Al Shifa Hospital, Kuwait City, Kuwait
| | | | | | | | | | | | | | | | | | | | | | | | - Prism Schneider
- Foothills Orthopaedic Trauma Service, University of Calgary, Calgary, AB, Canada
| | - Milan K Sen
- NYC Health+Hospitals/Jacobi, New York, NY; and
| | - Lisa Taitsman
- Harborview Medical Center/University of Washington, Seattle, WA
| | | | | |
Collapse
|
10
|
Mihas AK, Prather JC, Alexander BK, Boateng IB, Moran TE, Turnbull LM, Allen A, Vise H, Kammire MS, Moreno AF, McGwin G, Chen AT, Talerico MT, Obremskey WT, Weiss DB, Bergin PF, Spitler CA. Use of Computed Tomography Angiography to Predict Complications in Tibia Fractures: A Multicenter Retrospective Analysis. J Orthop Trauma 2023; 37:456-461. [PMID: 37074790 DOI: 10.1097/bot.0000000000002618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVES To assess the ability of computed tomography angiography identified infrapopliteal vascular injury to predict complications in tibia fractures that do not require vascular surgical intervention. DESIGN Multicenter retrospective review. SETTING Six Level I trauma centers. PATIENTS AND INTERVENTION Two hundred seventy-four patients with tibia fractures (OTA/AO 42 or 43) who underwent computed tomography angiography maintained a clinically perfused foot not requiring vascular surgical intervention and were treated with an intramedullary nail. Patients were grouped by the number of vessels below the trifurcation that were injured. MAIN OUTCOME MEASUREMENTS Rates of superficial and deep infection, amputation, unplanned reoperation to promote bone healing (nonunion), and any unplanned reoperation. RESULTS There were 142 fractures in the control (no-injury) group, 87 in the one-vessel injury group, and 45 in the two-vessel injury group. Average follow-up was 2 years. Significantly higher rates of nerve injury and flap coverage after wound breakdown were observed in the two-vessel injury group. The two-vessel injury group had higher rates of deep infection (35.6% vs. 16.9%, P = 0.030) and unplanned reoperation to promote bone healing (44.4% vs. 23.9%, P = 0.019) compared with controls, as well as increased rates of any unplanned reoperation compared with control and one-vessel injury groups (71.1% vs. 39.4% and 51.7%, P < 0.001), respectively. There were no significant differences in rates of superficial infection or amputation. CONCLUSIONS Tibia fractures with two-vessel injuries were associated with higher rates of deep infection and unplanned reoperation to promote bone healing compared with those without vascular injury, as well as increased rates of any unplanned reoperation compared with controls and fractures with one-vessel injury. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Alexander K Mihas
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - John C Prather
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Bradley K Alexander
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS
| | - Isaac B Boateng
- Department of Orthopaedic Surgery, Vanderbilt Medical Center, Nashville, TN
| | - Thomas E Moran
- Department of Orthopaedic Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Lacie M Turnbull
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida-Gainesville, Gainesville, FL; and
| | - Andrew Allen
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Healy Vise
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS
| | - Maria S Kammire
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Andres F Moreno
- Department of Orthopaedic Surgery, Vanderbilt Medical Center, Nashville, TN
| | - Gerald McGwin
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Andrew T Chen
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Michael T Talerico
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida-Gainesville, Gainesville, FL; and
| | | | - David B Weiss
- Department of Orthopaedic Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Patrick F Bergin
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
11
|
Labrum JT, Moreno Diaz AF, Davis ME, Yong TM, Obremskey WT. Dorsal Impaction Injuries of the Distal Radius: Operative Technique Through Dorsal Approach to the Wrist. J Orthop Trauma 2023; 37:S1-S2. [PMID: 37443433 DOI: 10.1097/bot.0000000000002631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 07/15/2023]
Abstract
SUMMARY Distal radius fractures vary widely in fracture pattern and displacement. Impaction injuries involving the dorsal articular surface of the distal radius can present challenges when anatomic reduction and fixation is attempted through a standard volar approach. Dorsal approach to the distal radius can provide direct visualization of these fracture patterns, greatly facilitating anatomic reduction and stabilization. In this technique video, surgical approach, fracture reduction, and operative fixation of a dorsally impacted, intra-articular distal radius fracture through a dorsal approach is presented. Low-profile dorsal plating can be a safe and effective technique in treating amenable distal radius fractures, with satisfactory radiographic and clinical outcomes. Although this technique provides excellent exposure and facilitates anatomic reduction, surgeons should be aware of associated risks of wrist stiffness and extensor tendon irritation and select low-profile constructs to mitigate these risks.
Collapse
Affiliation(s)
- Joseph T Labrum
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester MN; and
| | | | - Max E Davis
- Department of Orthopaedic Surgery, Vanderbilt Medical Center, Nashville, TN
| | - Taylor M Yong
- Department of Orthopaedic Surgery, Vanderbilt Medical Center, Nashville, TN
| | | |
Collapse
|
12
|
Yong TM, Davis ME, Moreno-Diaz AF, Obremskey WT. Single-Incision, Four-Compartment Fasciotomy and Application of Negative Pressure Dressing for Compartment Syndrome of the Leg. J Orthop Trauma 2023; 37:S7-S8. [PMID: 37443436 DOI: 10.1097/bot.0000000000002630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 07/15/2023]
Abstract
SUMMARY The video described by this article presents a safe and effective technique for single-incision, 4-compartment fasciotomy of the leg in a patient with a tibial plateau fracture and clinically diagnosed compartment syndrome. We also demonstrate a technique for the application of a negative pressure wound dressing when delayed closure or coverage is planned.
Collapse
Affiliation(s)
- Taylor M Yong
- Department of Orthopaedic Surgery & Rehabilitation, Texas Tech University Health Science Center El Paso; El Paso, TX
| | - Max E Davis
- Department of Orthopaedic Surgery, Texas Tech University Health Science Center; Lubbock, TX; and
| | - Andres F Moreno-Diaz
- Department of Orthopaedic Surgery & Rehabilitation, Vanderbilt University Medical Center; Nashville, TN
| | - William T Obremskey
- Department of Orthopaedic Surgery & Rehabilitation, Vanderbilt University Medical Center; Nashville, TN
| |
Collapse
|
13
|
Quacinella MA, Yong TM, Obremskey WT, Stinner DJ. Negative pressure wound therapy: Where are we in 2022? OTA Int 2023; 6:e247. [PMID: 37448565 PMCID: PMC10337842 DOI: 10.1097/oi9.0000000000000247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 12/22/2022] [Indexed: 07/15/2023]
Abstract
The use of negative pressure wound therapy (NPWT) continues to be an important tool for surgeons. As the use and general acceptance of NPWT have grown, so have the indications for its use. These indications have expanded to include soft tissue defects in trauma, infection, surgical wound management, and soft tissue grafting procedures. Many adjuvants have been engineered into newer generations of NPWT devices such as wound instillation of fluid or antibiotics allowing surgeons to further optimize the wound healing environment or aid in the eradication of infection. This review discusses the recent relevant literature on the proposed mechanisms of action, available adjuvants, and the required components needed to safely apply NPWT. The supporting evidence for the use of NPWT in traumatic extremity injuries, infection control, and wound care is also reviewed. Although NPWT has a low rate of complication, the surgeon should be aware of the potential risks associated with its use. Furthermore, the expanding indications for the use of NPWT are explored, and areas for future innovation and research are discussed.
Collapse
|
14
|
Rickert MM, McKeithan LJ, Volkmar AJ, Henderson K, Coronado RA, Mitchell PM, Gallagher B, Obremskey WT. Comparing Calcaneus Fracture Radiographic Outcomes and Complications after Percutaneous Pin versus Screw Fixation. J Foot Ankle Surg 2023; 62:365-370. [PMID: 36328917 PMCID: PMC11057190 DOI: 10.1053/j.jfas.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 09/09/2022] [Accepted: 09/19/2022] [Indexed: 02/03/2023]
Abstract
Calcaneus fracture fixation is associated with high rates of morbidity and disability from wound complications, infection, subtalar arthritis, and malunion. Percutaneous fixation with Kirshner wires (K-wires) or screws may be implemented when soft tissue injury precludes an open approach. Although screws are thought to provide greater stability, limited data exists directly comparing fixation success of these implants. Medical record data from 53 patients (62 total fractures) surgically treated with percutaneous screws (28 fractures) or K-wires (34 fractures) for joint-depression calcaneus fractures at a large tertiary hospital were retrospectively reviewed. Bohler's angle and calcaneal varus were assessed from available radiographs at time of injury, postoperatively, and at final follow-up, and joint congruity was assessed postoperatively and at final follow-up. Complications were also extracted. There were no statistical differences in patient characteristics between surgical groups although a higher proportion of patients treated with K-wires compared to screws had other associated injuries (79% vs 42%, p = .01). A higher proportion of fractures treated with screws compared to K-wires maintained joint congruity at the final follow-up (69% vs 32%, p = .005). However, there were no statistically detectable differences in other postoperative radiographic metrics (p > .05). In conclusion, joint congruity was more often maintained with screw fixation although there was no statistical difference in restoration and maintenance of Bohler's angle or varus alignment. The difference in radiographic metrics was not correlated with secondary procedures, namely subtalar arthrodesis, and may not be clinically significant. Neither group was completely effective in attaining and maintaining reduction, and additional fixation strategies should be considered if feasible based on patient, injury, and soft tissue characteristics.
Collapse
Affiliation(s)
- Mariel M Rickert
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Lydia J McKeithan
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Alexander J Volkmar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Rogelio A Coronado
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Phillip M Mitchell
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Bethany Gallagher
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
15
|
Johnson SR, Benvenuti T, Nian H, Thomson IP, Baldwin K, Obremskey WT, Schoenecker JG, Moore-Lotridge SN. Measures of Admission Immunocoagulopathy as an Indicator for In-Hospital Mortality in Patients with Necrotizing Fasciitis: A Retrospective Study. JB JS Open Access 2023; 8:JBJSOA-D-22-00106. [PMID: 36864907 PMCID: PMC9974085 DOI: 10.2106/jbjs.oa.22.00106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
Necrotizing fasciitis is a rapidly progressive infection with a high mortality rate. Pathogens evade the host containment and bactericidal mechanisms by hijacking the coagulation and inflammation signaling pathways, leading to their rapid dissemination, thrombosis, organ dysfunction, and death. This study examines the hypothesis that measures of immunocoagulopathy upon admission could aid in the identification of patients with necrotizing fasciitis at high risk for in-hospital mortality. Methods Demographic data, infection characteristics, and laboratory values from 389 confirmed necrotizing fasciitis cases from a single institution were analyzed. A multivariable logistic regression model was built on admission immunocoagulopathy measures (absolute neutrophil, absolute lymphocyte, and platelet counts) and patient age to predict in-hospital mortality. Results The overall in-hospital mortality rate was 19.8% for the 389 cases and 14.6% for the 261 cases with complete measures of immunocoagulopathy on admission. A multivariable logistic regression model indicated that platelet count was the most important predictor of mortality, followed by age and absolute neutrophil count. Greater age, higher neutrophil count, and lower platelet count led to significantly higher risk of mortality. The model discriminated well between survivors and non-survivors, with an overfitting-corrected C-index of 0.806. Conclusions This study determined that measures of immunocoagulopathy and patient age at admission effectively prognosticated the in-hospital mortality risk of patients with necrotizing fasciitis. Given the accessibility of neutrophil-to-lymphocyte ratio and platelet count measurements determined from a simple complete blood-cell count with differential, future prospective studies examining the utility of these measures are warranted. Level of Evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
| | - Teresa Benvenuti
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hui Nian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Isaac P. Thomson
- Division of Infectious Disease, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Keith Baldwin
- Department of Orthopaedics, The Children’s Hospital of Pennsylvania, Philadelphia, Pennsylvania
| | - William T. Obremskey
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan G. Schoenecker
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee,Division of Pediatric Orthopaedics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,Center for Bone Biology, Vanderbilt University Medical Center, Nashville, Tennessee,Email for corresponding author:
| | - Stephanie N. Moore-Lotridge
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee,Division of Pediatric Orthopaedics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee,Center for Bone Biology, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
16
|
Murphy PB, Kasotakis G, Haut ER, Miller A, Harvey E, Hasenboehler E, Higgins T, Hoegler J, Mir H, Cantrell S, Obremskey WT, Wally M, Attum B, Seymour R, Patel N, Ricci W, Freeman JJ, Haines KL, Yorkgitis BK, Padilla-Jones BB. Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association. Trauma Surg Acute Care Open 2023; 8:e001056. [PMID: 36844371 PMCID: PMC9945020 DOI: 10.1136/tsaco-2022-001056] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/09/2023] [Indexed: 02/25/2023] Open
Abstract
Objectives Fracture is a common injury after a traumatic event. The efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) to treat acute pain related to fractures is not well established. Methods Clinically relevant questions were determined regarding NSAID use in the setting of trauma-induced fractures with clearly defined patient populations, interventions, comparisons and appropriately selected outcomes (PICO). These questions centered around efficacy (pain control, reduction in opioid use) and safety (non-union, kidney injury). A systematic review including literature search and meta-analysis was performed, and the quality of evidence was graded per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The working group reached consensus on the final evidence-based recommendations. Results A total of 19 studies were identified for analysis. Not all outcomes identified as critically important were reported in all studies, and the outcome of pain control was too heterogenous to perform a meta-analysis. Nine studies reported on non-union (three randomized control trials), six of which reported no association with NSAIDs. The overall incidence of non-union in patients receiving NSAIDs compared with patients not receiving NSAIDs was 2.99% and 2.19% (p=0.04), respectively. Of studies reporting on pain control and reduction of opioids, the use of NSAIDs reduced pain and the need for opioids after traumatic fracture. One study reported on the outcome of acute kidney injury and found no association with NSAID use. Conclusions In patients with traumatic fractures, NSAIDs appear to reduce post-trauma pain, reduce the need for opioids and have a small effect on non-union. We conditionally recommend the use of NSAIDs in patients suffering from traumatic fractures as the benefit appears to outweigh the small potential risks.
Collapse
Affiliation(s)
- Patrick B Murphy
- Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - George Kasotakis
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins Univ, Baltimore, Maryland, USA
| | - Anna Miller
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Edward Harvey
- Department of Surgery, McGill University, Montreal, Québec, Canada
| | - Eric Hasenboehler
- Holy Spirit Hospital Penn State Health, Camp Hill, Pennsylvania, USA
| | - Thomas Higgins
- Department of Orthopaedics, University of Utah Health, Salt Lake City, Utah, USA
| | - Joseph Hoegler
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Hassan Mir
- Department of Orthopaedic Surgery, University of South Florida, Tampa, Florida, USA
| | - Sarah Cantrell
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - William T Obremskey
- The Vanderbilt Orthopaedic Institute Center for Health Policy, Nashville, Tennessee, USA
| | - Meghan Wally
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Basem Attum
- Institute Center for Health Policy, Nashville, Tennessee, USA
| | - Rachel Seymour
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nimitt Patel
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - William Ricci
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Jennifer J Freeman
- Department of Surgery, TCU and UNTHSC School of Medicine, Fort Worth, Texas, USA
| | - Krista L Haines
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Brian K Yorkgitis
- Department of Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - Brandy B Padilla-Jones
- Department of General Surgery, Sunrise Hospital and Medical Center, Las Vegas, Nevada, USA
| |
Collapse
|
17
|
Lawendy AR, Kapilow J, Schaffer NE, Obremskey WT, Patel M, Schemitsch GW, McKee MD, Schemitsch EH. Compartment Syndrome: The Issues and Solutions You Need to Know About. Instr Course Lect 2023; 72:343-356. [PMID: 36534866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The diagnosis and management of compartment syndrome remains challenging and controversial. There continues to be a significant burden of disease and substantial resource implications associated with fractures complicated by compartment syndrome. Achieving consensus opinions regarding the diagnosis and treatment of this problem has important implications given the profound effect on patient outcomes.
Collapse
|
18
|
Streeter SS, Ray GS, Bateman LM, Hebert KA, Bushee FE, Rodi SW, Gitajn IL, Ahn J, Singhal S, Martin ND, Bernthal NM, Lee C, Obremskey WT, Schoenecker JG, Elliott JT, Henderson ER. Early identification of life-threatening soft-tissue infection using dynamic fluorescence imaging: first-in-kind clinical study of first-pass kinetics. Proc SPIE Int Soc Opt Eng 2023; 12361:123610B. [PMID: 37034555 PMCID: PMC10078977 DOI: 10.1117/12.2648408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
Necrotizing soft-tissue infections (NSTIs) are aggressive and deadly. Immediate surgical debridement is standard-of-care, but patients often present with non-specific symptoms, thereby delaying treatment. Because NSTIs cause microvascular thrombosis, we hypothesized that perfusion imaging using indocyanine green (ICG) would show diminished fluorescence signal in NSTI-affected tissues, particularly compared to non-necrotizing, superficial infections. Through a first-in-kind clinical study, we performed first-pass ICG fluorescence perfusion imaging of patients with suspected NSTIs. Early results support our hypothesis that ICG signal voids occur in NSTI-affected tissues and that dynamic contrast-enhanced fluorescence parameters reveal tissue kinetics that may be related to disease progression and extent.
Collapse
Affiliation(s)
- Samuel S. Streeter
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH 03756
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755
| | - Gabrielle S. Ray
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH 03756
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755
| | - Logan M. Bateman
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755
| | - Kendra A. Hebert
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755
| | | | - Scott W. Rodi
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755
| | - I. Leah Gitajn
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH 03756
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755
| | - Jaimo Ahn
- Michigan Medicine, U. of Michigan, Ann Arbor, MI 48109
| | - Sunil Singhal
- Perelman School of Medicine, U. of Pennsylvania, Philadelphia, PA 19104
| | - Niels D. Martin
- Perelman School of Medicine, U. of Pennsylvania, Philadelphia, PA 19104
| | - Nicholas M. Bernthal
- David Geffen School of Medicine, U. of California Los Angeles, Santa Monica, CA 90404
| | - Christopher Lee
- David Geffen School of Medicine, U. of California Los Angeles, Santa Monica, CA 90404
| | | | | | - Jonathan Thomas Elliott
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH 03756
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755
| | - Eric R. Henderson
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH 03756
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755
| |
Collapse
|
19
|
O'Hara NN, Castillo RC, Carlini AR, Joshi M, Murray CK, Allen LE, Huang Y, Gary JL, Bosse MJ, Obremskey WT, McKinley TO, Schmidt AH, O'Toole RV. Application of Bayesian Methods to Help Interpret the VANCO Trial Results. J Orthop Trauma 2023; 37:1-7. [PMID: 35830572 DOI: 10.1097/bot.0000000000002458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether a Bayesian analysis changes the results of the VANCO trial. DESIGN A secondary analysis of a randomized clinical trial using Bayesian methods. SETTING Thirty-six US trauma centers. PATIENTS Patients ages 18-80 years with a tibial plateau or pilon fracture deemed high risk of infection and definitively treated with plate and screw fixation. INTERVENTION Patients were randomly allocated to receive 1000 mg of intrawound vancomycin powder at their definitive fixation or to a control group that received no topical antibiotics. MAIN OUTCOME MEASUREMENTS A deep surgical site infection requiring operative treatment within 6 months of definitive fixation. Secondary outcomes included gram-positive and gram-negative-only deep surgical site infections. RESULTS Of the 980 patients randomized, 874 (89%) had at least 140 days of follow-up and were included in this Bayesian analysis. The estimated probability that intrawound vancomycin powder reduces the risk of a deep surgical site infection is >98% [relative risk (RR), 0.66; 95% credible interval (CrI), 0.46-0.98]. There is a >99% chance intrawound vancomycin powder reduces gram-positive infections and an 80% chance the magnitude of this risk reduction exceeds 35% (RR, 0.52; 95% CrI, 0.33-0.84) exists. It is unlikely (44%) that intrawound vancomycin powder prevents gram-negative surgical site infections (RR, 1.06; 95% CrI, 0.48-2.45). CONCLUSIONS There is a high probability (>98%) that intrawound vancomycin powder reduces deep surgical site infections in patients with tibial plateau or pilon fractures at high risk of infection and even more likely it reduces deep infections with gram-positive pathogens (>99%). LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Nathan N O'Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Renan C Castillo
- METRC Coordinating Center at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Anthony R Carlini
- METRC Coordinating Center at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Manjari Joshi
- Department of Infectious Diseases, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Clinton K Murray
- Department of Orthopaedic Surgery, Infectious Disease Service, Brooke Army Medical Center, San Antonio, TX
| | - Lauren E Allen
- METRC Coordinating Center at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yanjie Huang
- METRC Coordinating Center at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Joshua L Gary
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Michael J Bosse
- Atrium Health Musculoskeletal Institute-Carolinas Medical Center, Charlotte, NC
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Todd O McKinley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN; and
| | - Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin Healthcare, Minneapolis, MN
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
20
|
Slobogean GP, Sprague S, Wells JL, Bhandari M, Harris AD, Mullins CD, Thabane L, Wood A, Della Rocca GJ, Hebden JN, Jeray KJ, Marchand LS, O'Hara LM, Zura RD, Lee C, Patterson JT, Gardner MJ, Blasman J, Davies J, Liang S, Taljaard M, Devereaux PJ, Guyatt G, Heels-Ansdell D, Marvel D, Palmer JE, Friedrich J, O'Hara NN, Grissom F, Gitajn IL, Morshed S, O'Toole RV, Petrisor B, Mossuto F, Joshi MG, D'Alleyrand JCG, Fowler J, Rivera JC, Talbot M, Pogorzelski D, Dodds S, Li S, Del Fabbro G, Szasz OP, Bzovsky S, McKay P, Minea A, Murphy K, Howe AL, Demyanovich HK, Hoskins W, Medeiros M, Polk G, Kettering E, Mahal N, Eglseder A, Johnson A, Langhammer C, Lebrun C, Nascone J, Pensy R, Pollak A, Sciadini M, Degani Y, Phipps H, Hempen E, Johal H, Ristevski B, Williams D, Denkers M, Rajaratnam K, Al-Asiri J, Gallant JL, Pusztai K, MacRae S, Renaud S, Adams JD, Beckish ML, Bray CC, Brown TR, Cross AW, Dew T, Faucher GK, Gurich Jr RW, Lazarus DE, Millon SJ, Moody MC, Palmer MJ, Porter SE, Schaller TM, Sridhar MS, Sanders JL, Rudisill Jr LE, Garitty MJ, Poole AS, Sims ML, Walker CM, Carlisle R, Hofer EA, Huggins B, Hunter M, Marshall W, Ray SB, Smith C, Altman KM, Pichiotino ER, Quirion JC, Loeffler MF, Cole AA, Maltz EJ, Parker W, Ramsey TB, Burnikel A, Colello M, Stewart R, Wise J, Anderson M, Eskew J, Judkins B, Miller JM, Tanner SL, Snider RG, Townsend CE, Pham KH, Martin A, Robertson E, Bray E, Sykes JW, Yoder K, Conner K, Abbott H, Natoli RM, McKinley TO, Virkus WW, Sorkin AT, Szatkowski JP, Mullis BH, Jang Y, Lopas LA, Hill LC, Fentz CL, Diaz MM, Brown K, Garst KM, Denari EW, Osborn P, Pierrie SN, Kessler B, Herrera M, Miclau T, Marmor MT, Matityahu A, McClellan RT, Shearer D, Toogood P, Ding A, Murali J, El Naga A, Tangtiphaiboontana J, Belaye T, Berhaneselase E, Pokhvashchev D, Obremskey WT, Jahangir AA, Sethi M, Boyce R, Stinner DJ, Mitchell PP, Trochez K, Rodriguez E, Pritchett C, Hogan N, Fidel Moreno A, Hagen JE, Patrick M, Vlasak R, Krupko T, Talerico M, Horodyski M, Pazik M, Lossada-Soto E, Gary JL, Warner SJ, Munz JW, Choo AM, Achor TS, Routt ML“C, Kutzler M, Boutte S, Warth RJ, Prayson MJ, Venkatarayappa I, Horne B, Jerele J, Clark L, Boulton C, Lowe J, Ruth JT, Askam B, Seach A, Cruz A, Featherston B, Carlson R, Romero I, Zarif I, Dehghan N, McKee M, Jones CB, Sietsema DL, Williams A, Dykes T, Guerra-Farfan E, Tomas-Hernandez J, Teixidor-Serra J, Molero-Garcia V, Selga-Marsa J, Porcel-Vazquez JA, Andres-Peiro JV, Esteban-Feliu I, Vidal-Tarrason N, Serracanta J, Nuñez-Camarena J, del Mar Villar-Casares M, Mestre-Torres J, Lalueza-Broto P, Moreira-Borim F, Garcia-Sanchez Y, Marcano-Fernández F, Martínez-Carreres L, Martí-Garín D, Serrano-Sanz J, Sánchez-Fernández J, Sanz-Molero M, Carballo A, Pelfort X, Acerboni-Flores F, Alavedra-Massana A, Anglada-Torres N, Berenguer A, Cámara-Cabrera J, Caparros-García A, Fillat-Gomà F, Fuentes-López R, Garcia-Rodriguez R, Gimeno-Calavia N, Martínez-Álvarez M, Martínez-Grau P, Pellejero-García R, Ràfols-Perramon O, Peñalver JM, Salomó Domènech M, Soler-Cano A, Velasco-Barrera A, Yela-Verdú C, Bueno-Ruiz M, Sánchez-Palomino E, Andriola V, Molina-Corbacho M, Maldonado-Sotoca Y, Gasset-Teixidor A, Blasco-Moreu J, Fernández-Poch N, Rodoreda-Puigdemasa J, Verdaguer-Figuerola A, Cueva-Sevieri HE, Garcia-Gimenez S, Viskontas DG, Apostle KL, Boyer DS, Moola FO, Perey BH, Stone TB, Lemke HM, Spicer E, Payne K, Hymes RA, Schwartzbach CC, Schulman JE, Malekzadeh AS, Holzman MA, Gaski GE, Wills J, Pilson H, Carroll EA, Halvorson JJ, Babcock S, Goodman JB, Holden MB, Williams W, Hill T, Brotherton A, Romeo NM, Vallier HA, Vergon A, Higgins TF, Haller JM, Rothberg DL, Olsen ZM, McGowan AV, Hill S, Dauk MK, Bergin PF, Russell GV, Graves ML, Morellato J, McGee SL, Bhanat EL, Yener U, Khanna R, Nehete P, Potter D, VanDemark III R, Seabold K, Staudenmier N, Coe M, Dwyer K, Mullin DS, Chockbengboun TA, DePalo Sr. PA, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Mayfield A, Sweeney J, Jaeblon T, Beer R, Bauer B, Meredith S, Talwar S, Domes CM, Gage MJ, Reilly RM, Paniagua A, Dupree J, Weaver MJ, von Keudell AG, Sagona AE, Mehta S, Donegan D, Horan A, Dooley M, Heng M, Harris MB, Lhowe DW, Esposito JG, Alnasser A, Shannon SF, Scott AN, Clinch B, Weber B, Beltran MJ, Archdeacon MT, Sagi HC, Wyrick JD, Le TT, Laughlin RT, Thomson CG, Hasselfeld K, Lin CA, Vrahas MS, Moon CN, Little MT, Marecek GS, Dubuclet DM, Scolaro JA, Learned JR, Lim PK, Demas S, Amirhekmat A, Dela Cruz YM. Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial. Lancet 2022; 400:1334-1344. [PMID: 36244384 DOI: 10.1016/s0140-6736(22)01652-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture. METHODS We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304. FINDINGS Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4). INTERPRETATION For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds. FUNDING US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.
Collapse
|
21
|
Shapiro JA, Stillwagon MR, Tornetta P, Seaver TM, Gage M, O’Donnell J, Whitlock K, Yarboro SR, Jeray KJ, Obremskey WT, Rodriguez-Buitrago A, Matuszewski P, Lin FC, Ostrum RF. Serology and Comorbidities in Patients With Fracture Nonunion: A Multicenter Evaluation of 640 Patients. J Am Acad Orthop Surg 2022; 30:e1179-e1187. [PMID: 36166389 PMCID: PMC9521813 DOI: 10.5435/jaaos-d-21-00366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/20/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION This multicenter cohort study investigated the association of serology and comorbid conditions with septic and aseptic nonunion. METHODS From January 1, 2011, to December 31, 2017, consecutive individuals surgically treated for nonunion were identified from seven centers. Nonunion-type, comorbid conditions and serology were assessed. RESULTS A total of 640 individuals were included. 57% were male with a mean age of 49 years. Nonunion sites included tibia (35.2%), femur (25.6%), humerus (20.3%), and other less frequent bones (18.9%). The type of nonunion included septic (17.7%) and aseptic (82.3%). Within aseptic, nonvascular (86.5%) and vascular (13.5%) nonunion were seen. Rates of smoking, alcohol abuse, and diabetes mellitus were higher in our nonunion cohort compared with population norms. Coronary artery disease and tobacco use were associated with septic nonunion (P < 0.05). Diphosphonates were associated with vascular nonunion (P < 0.05). Serologically, increased erythrocyte sedimentation rate, C-reactive protein, parathyroid hormone, red cell distribution width, mean platelet volume (MPV), and platelets and decreased absolute lymphocyte count, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and albumin were associated with septic nonunion while lower calcium was associated with nonvascular nonunion (P < 0.05). The presence of four or more of increased erythrocyte sedimentation rate, C-reactive protein, or red cell distribution width; decreased albumin; and age younger than 65 years carried an 89% positive predictive value for infection. Hypovitaminosis D was seen less frequently than reported in the general population, whereas anemia was more common. However, aside from hematologic and inflammatory indices, no other serology was abnormal more than 25% of the time. DISCUSSION Abnormal serology and comorbid conditions, including smoking, alcohol abuse, and diabetes mellitus, are seen in nonunion; however, serologic abnormalities may be less common than previously thought. Septic nonunion is associated with inflammation, younger age, and malnourishment. Based on the observed frequency of abnormality, routine laboratory work is not recommended for nonunion assessment; however, specific focused serology may help determine the presence of septic nonunion.
Collapse
Affiliation(s)
| | | | | | | | - Mark Gage
- Duke University Department of Orthopaedic Surgery
| | | | | | | | - Kyle J. Jeray
- Greenville Health System Department of Orthopaedic Surgery
| | | | | | - Paul Matuszewski
- University of Kentucky Department of Orthopaedic Surgery and Sports Medicine
| | | | | |
Collapse
|
22
|
Bouklouch Y, Schmidt AH, Obremskey WT, Bernstein M, Gamburg N, Harvey EJ. Big data insights into predictors of acute compartment syndrome. Injury 2022; 53:2557-2561. [PMID: 35249740 DOI: 10.1016/j.injury.2022.02.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/16/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND There remain gaps in knowledge regarding the pathophysiology, initial diagnosis, treatment, and outcome of acute compartment syndrome (ACS). Most reported clinical outcomes are from smaller studies of heterogeneous patients. For a disease associated with a financial burden to society that represents billions of dollars worldwide the literature does not currently establish baseline diagnostic parameters and risk factors that may serve to predict treatment and outcomes. METHODS This study looks at a very large cohort of trauma patients obtained from four recent years of the Trauma Quality Programs data from the American College of Surgeons. From 3,924,127 trauma cases - 203,500 patients with tibial fractures were identified and their records examined for demographic information, potential risk factors for compartment syndrome, an associated coded diagnosis of muscle necrosis, and presence of other outcomes associated with compartment syndrome. A recurrent multiple logistic regression model was used to identify factors predictive of fasciotomy. The results were compared to the reported results from the literature to validate the findings. RESULTS The rate of fasciotomy treatment for ACS was 4.3% in the cohort of identified patients. The analysis identified several clinical predictors of fasciotomy. Proximal and midshaft tibial fractures (P <0.0001) showed highest increases in the likelihood of ACS. Open fractures were twice (O.R [2.20-2.42]) as likely to have ACS. Having a complex fracture (P<0.0001), substance abuse disorder (P<0.0002), cirrhosis (P = 0.002) or smoking (P<0.0051) all increased the likelihood of ACS. Age decreased the likelihood by 1% per year (OR= [0.99-0.993]). Crush and penetrating injuries showed an important increase in the likelihood of ACS (O.R of 1.83 and 1.37 respectively). Additionally, sex, BMI, cirrhosis, tobacco smoking and fracture pattern as defined by OTA group and OTA subgroup had predictive value on actual myonecrosis. Fasciotomies for open tibial fractures were more likely to uncover significant muscle necrosis compared to closed fractures. Amputation resulted after 5.4% of fasciotomies. CONCLUSION This big data approach shows us that ACS is primarily linked to the extent of soft tissue damage. However, newfound effect of some comorbidities like cirrhosis and hypertension on the risk of ACS imply other mechanisms.
Collapse
Affiliation(s)
| | | | - William T Obremskey
- Department of Orthopaedic Surgery Vanderbilt Medical Center, Vanderbilt Center for Musculoskeletal Research
| | - Mitchell Bernstein
- McGill University Health Center - Research Institute; McGill University Department of Surgery, Division of Orthopaedic Surgery
| | | | - Edward J Harvey
- McGill University Health Center - Research Institute; McGill University Department of Surgery, Division of Orthopaedic Surgery.
| |
Collapse
|
23
|
Obremskey WT, Rodriguez-Baron EB, Tatman LM, Pesantez RF. Acute Dislocations of the Sternoclavicular Joint: A Review Article. J Am Acad Orthop Surg 2022; 30:148-154. [PMID: 34898528 DOI: 10.5435/jaaos-d-20-01239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 11/01/2021] [Indexed: 02/01/2023] Open
Abstract
Acute dislocations of the sternoclavicular joint are uncommon injuries, and it is difficult for physicians to develop expertise in treating these injuries because of their infrequent nature. No level I evidence currently exists for these injuries, but several retrospective studies and surgical techniques have been described. For acute injuries, current recommendations include early treatment with closed reduction. If unable to attain or maintain reduction after a closed attempt, open management should be considered. Previous reviews have outlined relevant anatomy, physical examination findings, and imaging for these injuries. This article aims to review updated information from the past decade regarding techniques for reduction, outcomes, and complications related to the injury and surgical management.
Collapse
Affiliation(s)
- William T Obremskey
- From the Division of Orthopaedic Trauma, Vanderbilt University Medical center (Obremskey and Baron), Division of Orthopaedic Trauma, Fundacion Santa Fe de Bogota University Hospital, Bogotá D.C., Colombia (Pesantez); Division of Orthopaedic Trauma, Washington University, St. Louis, MO (Tatman)
| | | | | | | |
Collapse
|
24
|
Cereijo C, Johnson SR, Schoenecker JG, Collinge CA, Obremskey WT, Moore-Lotridge SN. Quantitative Analysis of Growth Factors From Cancellous Bone Graft Collected With a Reamer-Irrigator-Aspirator System From Native Long Bones Versus Previously Reamed Long Bones. J Orthop Trauma 2022; 36:S23-S27. [PMID: 35061647 DOI: 10.1097/bot.0000000000002309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Collection of bone graft with the Reamer-Irrigator-Aspirator (RIA) system has become common practice across the field of orthopaedic surgery. While RIA bone graft is typically obtained from native long bones, grafting material can likewise be harvested from long bones that have previously undergone the placement and removal of an intramedullary nail, a process termed re-reamed RIA (RRR). The purpose of this study was to evaluate the total protein and growth factor concentrations present in native-RIA (NR) compared with RRR samples. METHODS NR and RRR bone grafts were collected intraoperatively with the RIA system and processed to evaluate both the aqueous and the hard tissue components. Total protein concentration and specific growth factors were analyzed using standard bicinchoninic acid and multiplex assays, respectively. Analyte levels were then normalized to the total amount of protein detected. RESULTS Total protein levels were comparable between NR and RRR samples for both the aqueous filtrate and the hard tissue samples. When normalized, while levels of bone morphogenic protein-2 and vascular endothelial growth factor were comparable in the hard tissue component, the aqueous filtrate from the RRR sample was found to have elevated levels of growth factors, with bone morphogenic protein-2 reaching statistical significance. CONCLUSIONS This study demonstrates that ample protein is found within both NR and RRR samples, with comparable or elevated levels of osteogenic growth factors found within RRR samples. Future, larger, prospective studies will be required to evaluate the osteogenic potential and clinical efficacy of NR and RRR cancellous bone grafts to validate their equivalency.
Collapse
Affiliation(s)
- Cesar Cereijo
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN
- Division of Orthopaedic Trauma, Vanderbilt University Medical Center, Nashville, TN
| | | | - Jonathan G Schoenecker
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN
- Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
- Department of Pharmacology, Vanderbilt University, Nashville, TN ; and
| | - Cory A Collinge
- Fort Worth Orthopaedic Trauma Specialists, Harris Methodist Hospital Fort Worth, Fort Worth, TX
| | - William T Obremskey
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN
- Division of Orthopaedic Trauma, Vanderbilt University Medical Center, Nashville, TN
| | - Stephanie N Moore-Lotridge
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN
- Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
25
|
Obremskey WT, Rickert MM, Miller AN, Schemitsch GW, Nauth A, Crist BD, Gardner MJ, Watson JT, Schemitsch EH. Augmentation of Fracture Repair: Is Anything Ready for Prime Time? Instr Course Lect 2022; 71:329-344. [PMID: 35254792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
There continues to be a significant burden of disease associated with the delayed healing of common fractures. Despite a number of trials focused on the augmentation of fracture repair, management remains controversial and evidence regarding cost-effectiveness is lacking. The recent evidence that has challenged traditional thinking regarding management of fracture healing problems will be evaluated.
Collapse
|
26
|
Leroux A, Frey KP, Crainiceanu CM, Obremskey WT, Stinner DJ, Bosse MJ, Karunakar MA, O'Toole RV, Carroll EA, Hak DJ, Hayda R, Alkhoury D, Schmidt AH. Defining Incidence of Acute Compartment Syndrome in the Research Setting: A Proposed Method From the PACS Study. J Orthop Trauma 2022; 36:S26-S32. [PMID: 34924516 DOI: 10.1097/bot.0000000000002284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the retrospective decision of an expert panel who assessed likelihood of acute compartment syndrome (ACS) in a patient with a high-risk tibia fracture with decision to perform fasciotomy. DESIGN Prospective observational study. SETTING Seven Level 1 trauma centers. PATIENTS/PARTICIPANTS One hundred eighty-two adults with severe tibia fractures. MAIN OUTCOME MEASUREMENTS Diagnostic performance (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver-operator curve) of an expert panel's assessment of likelihood ACS compared with fasciotomy as the reference diagnostic standard. SECONDARY OUTCOMES The interrater reliability of the expert panel as measured by the Krippendorff alpha. Expert panel consensus was determined using the percent of panelists in the majority group of low (expert panel likelihood of ≤0.3), uncertain (0.3-0.7), or high (>0.7) likelihood of ACS. RESULTS Comparing fasciotomy (the diagnostic standard) and the expert panel's assessment as the diagnostic classification (test), the expert panel's determination of uncertain or high likelihood of ACS (threshold >0.3) had a sensitivity of 0.90 (0.70, 0.99), specificity of 0.95 (0.90, 0.98), PPV of 0.70 (0.50, 0.86), and NPV of 0.99 (0.95, 1.00). When a threshold of >0.7 was set as a positive diagnosis, the expert panel assessment had a sensitivity of 0.67 (0.43, 0.85), specificity of 0.98 (0.95, 1.00), PPV of 0.82 (0.57, 0.96), and NPV of 0.96 (0.91, 0.98). CONCLUSION In our study, the retrospective assessment of an expert panel of the likelihood of ACS has good specificity and excellent NPV for fasciotomy, but only low-to-moderate sensitivity and PPV. The discordance between the expert panel-assessed likelihood of ACS and the decision to perform fasciotomy suggests that concern regarding potential diagnostic bias in studies of ACS is warranted. LEVEL OF EVIDENCE Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Andrew Leroux
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Katherine P Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ciprian M Crainiceanu
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Daniel J Stinner
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Michael J Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Madhav A Karunakar
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Eben A Carroll
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, NC
| | - David J Hak
- Department of Orthopedics, Denver Health and Hospital Authority, Denver, CO (now at Department of Orthopedic Trauma, Hughston Clinic, Sanford, FL)
| | - Roman Hayda
- Department of Orthopaedic Surgery, Rhode Island Hospital at Brown University, Providence, RI; and
| | - Dana Alkhoury
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrew H Schmidt
- Department of Orthopedic Surgery, Hennepin Healthcare, Minneapolis, MN
| |
Collapse
|
27
|
Nauth A, Schemitsch GW, Patel M, Yong T, Obremskey WT, Davis ME, McKee MD, Schemitsch EH. Elbow Trauma: An Evidence-Based Approach to Improving Outcomes. Instr Course Lect 2022; 71:313-328. [PMID: 35254791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The management of elbow fractures remains difficult and controversial. The failure rate of surgical intervention in elbow fractures remains higher than that seen with other fractures, and there remains significant room for improvement in the care of these injuries. Evidence-based management strategies for elbow fractures and how to prevent and manage complications following elbow fracture surgery have been described.
Collapse
|
28
|
Carlini AR, Collins SC, Staguhn ED, Frey KP, O’Toole RV, Archer KR, Obremskey WT, Agel J, Kleweno CP, Morshed S, Weaver MJ, Higgins TF, Bosse MJ, Levy JF, Wu AW, Castillo RC. Streamlining Trauma Research Evaluation With Advanced Measurement (STREAM) Study: Implementation of the PROMIS Toolbox Within an Orthopaedic Trauma Clinical Trials Consortium. J Orthop Trauma 2022; 36:S33-S39. [PMID: 34924517 PMCID: PMC8694658 DOI: 10.1097/bot.0000000000002291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 02/02/2023]
Abstract
LEVEL OF EVIDENCE Prognostic Level II.
Collapse
Affiliation(s)
- Anthony R. Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Susan C. Collins
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elena D. Staguhn
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Katherine P. Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Robert V. O’Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Kristin R. Archer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Center for Musculoskeletal Research and Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Nashville, TN
| | - William T. Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Julie Agel
- Department of Orthopaedics and Sports Medicine, University of Washington Harborview Medical Center, Seattle, WA
| | - Conor P. Kleweno
- Department of Orthopaedics and Sports Medicine, University of Washington Harborview Medical Center, Seattle, WA
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael J. Weaver
- Department of Orthopedic Surgery, Harvard Orthopaedic Trauma Service, Boston, MA
| | - Thomas F. Higgins
- Department of Orthopaedic Surgery, The University of Utah; Salt Lake City, UT
| | - Michael J. Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Joseph F. Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Albert W. Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Renan C. Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | |
Collapse
|
29
|
Archer KR, Davidson CA, Alkhoury D, Vanston SW, Moore TL, Deluca A, Betz JF, Thompson RE, Obremskey WT, Slobogean GP, Melton DH, Wilken JM, Karunakar MA, Rivera JC, Mir HR, McKinley TO, Frey KP, Castillo RC, Wegener ST. Cognitive-Behavioral-Based Physical Therapy for Improving Recovery After Traumatic Orthopaedic Lower Extremity Injury (CBPT-Trauma). J Orthop Trauma 2022; 36:S1-S7. [PMID: 34924512 DOI: 10.1097/bot.0000000000002283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY Physical and psychological impairment resulting from traumatic injuries is often significant and affects employment and functional independence. Extremity trauma has been shown to negatively affect long-term self-reported physical function, the ability to work, and participation in recreational activities and contributes to increased rates of anxiety and/or depression. High pain levels early in the recovery process and psychosocial factors play a prominent role in recovery after traumatic lower extremity injury. Cognitive-behavioral therapy pain programs have been shown to mitigate these effects. However, patient access issues related to financial and transportation constraints and the competing demands of treatment focused on the physical sequelae of traumatic injury limit patient participation in this treatment modality. This article describes a telephone-delivered cognitive-behavioral-based physical therapy (CBPT-Trauma) program and design of a multicenter trial to determine its effectiveness after lower extremity trauma. Three hundred twenty-five patients from 7 Level 1 trauma centers were randomized to CBPT-Trauma or an education program after hospital discharge. The primary hypothesis is that compared with patients who receive an education program, patients who receive the CBPT-Trauma program will have improved physical function, pain, and physical and mental health at 12 months after hospital discharge.
Collapse
Affiliation(s)
- Kristin R Archer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Center for Musculoskeletal Research and Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Nashville, TN
| | - Claudia A Davidson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Dana Alkhoury
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Susan W Vanston
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Tanisha L Moore
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Andrea Deluca
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Joshua F Betz
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Gerard P Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Danielle H Melton
- Department of Orthopedic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
| | - Jason M Wilken
- Department of Physical Therapy and Rehabilitation Science, the University of Iowa, Iowa City, IA
| | - Madhav A Karunakar
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Jessica C Rivera
- U.S. Army Institute for Surgical Research, Brooke Army Medical Center, San Antonio, TX. Dr. Rivera is now with the Department of Orthopaedic Surgery, Louisiana State University Medical Center, New Orleans, LA
| | - Hassan R Mir
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, Tampa, FL
| | - Todd O McKinley
- Department of Orthopaedic Surgery, Indiana University Health Methodist Hospital, Indianapolis, IN; and
| | - Katherine P Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Stephen T Wegener
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD
| |
Collapse
|
30
|
Onsea J, Post V, Buchholz T, Schwegler H, Zeiter S, Wagemans J, Pirnay JP, Merabishvili M, D’Este M, Rotman SG, Trampuz A, Verhofstad MHJ, Obremskey WT, Lavigne R, Richards RG, Moriarty TF, Metsemakers WJ. Bacteriophage Therapy for the Prevention and Treatment of Fracture-Related Infection Caused by Staphylococcus aureus: a Preclinical Study. Microbiol Spectr 2021; 9:e0173621. [PMID: 34908439 PMCID: PMC8672900 DOI: 10.1128/spectrum.01736-21] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 11/09/2021] [Indexed: 12/23/2022] Open
Abstract
Although several studies have shown promising clinical outcomes of phage therapy in patients with orthopedic device-related infections, questions remain regarding the optimal application protocol, systemic effects, and the impact of the immune response. This study provides a proof-of-concept of phage therapy in a clinically relevant rabbit model of fracture-related infection (FRI) caused by Staphylococcus aureus. In a prevention setting, phage in saline (without any biomaterial-based carrier) was highly effective in the prevention of FRI, compared to systemic antibiotic prophylaxis alone. In the subsequent study involving treatment of established infection, daily administration of phage in saline through a subcutaneous access tube was compared to a single intraoperative application of a phage-loaded hydrogel and a control group receiving antibiotics only. In this setting, although a possible trend of bacterial load reduction on the implant was observed with the phage-loaded hydrogel, no superior effect of phage therapy was found compared to antibiotic treatment alone. The application of phage in saline through a subcutaneous access tube was, however, complicated by superinfection and the development of neutralizing antibodies. The latter was not found in the animals that received the phage-loaded hydrogel, which may indicate that encapsulation of phages into a carrier such as a hydrogel limits their exposure to the adaptive immune system. These studies show phage therapy can be useful in targeting orthopedic device-related infection, however, further research and improvements of these application methods are required for this complex clinical setting. IMPORTANCE Because of the growing spread of antimicrobial resistance, the use of alternative prevention and treatment strategies is gaining interest. Although the therapeutic potential of bacteriophages has been demonstrated in a number of case reports and series over the past decade, many unanswered questions remain regarding the optimal application protocol. Furthermore, a major concern during phage therapy is the induction of phage neutralizing antibodies. This study aimed at providing a proof-of-concept of phage therapy in a clinically relevant rabbit model of fracture-related infection caused by Staphylococcus aureus. Phage therapy was applied as prophylaxis in a first phase, and as treatment of an established infection in a second phase. The development of phage neutralizing antibodies was evaluated in the treatment study. This study demonstrates that phage therapy can be useful in targeting orthopedic device-related infection, especially as prophylaxis; however, further research and improvements of these application methods are required.
Collapse
Affiliation(s)
- Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | | | | | | | | | - Jean-Paul Pirnay
- Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, Brussels, Belgium
| | - Maya Merabishvili
- Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, Brussels, Belgium
| | | | | | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Michael H. J. Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rob Lavigne
- Laboratory of Gene Technology, KU Leuven, Leuven, Belgium
| | | | | | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| |
Collapse
|
31
|
Patterson JT, Ishii K, Tornetta P, Leighton RK, Friess DM, Jones CB, Levine A, Maclean JJ, Miclau T, Mullis BH, Obremskey WT, Ostrum RF, Reid JS, Ruder JA, Saleh A, Schmidt AH, Teague DC, Tsismenakis A, Westberg JR, Morshed S. Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture. J Orthop Trauma 2021; 35:517-522. [PMID: 34510125 DOI: 10.1097/bot.0000000000002068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches. DESIGN Retrospective cohort study. SETTING Twelve Level 1 North American trauma centers. PATIENTS Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation. INTERVENTION Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006). CONCLUSIONS No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Keisuke Ishii
- Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA
| | - Ross K Leighton
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR
| | - Darin M Friess
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, NS
| | - Clifford B Jones
- Division of Orthopaedic Surgery, Dignity Health Arizona, Creighton Medical School, Phoenix, AZ
| | - Ari Levine
- Department of Orthopaedics, MetroHealth Medical Center, Cleveland, OH
| | - Jeffrey J Maclean
- Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Theodore Miclau
- Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Brian H Mullis
- Department of Orthopaedic Surgery, Indiana University, Indianapolis, IN
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University, Nashville, TN
| | - Robert F Ostrum
- Department of Orthopaedic Surgery, University of North Carolina, Charlotte, NC
| | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Penn State University, Hersey Medical Center, Hersey, PA
| | - John A Ruder
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, NC
| | - Anas Saleh
- Department of Orthopaedics, MetroHealth Medical Center, Cleveland, OH
| | - Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin Healthcare, Minneapolis, MN; and
| | - David C Teague
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City, OK
| | | | - Jerald R Westberg
- Department of Orthopaedic Surgery, Hennepin Healthcare, Minneapolis, MN; and
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| |
Collapse
|
32
|
Flagstad IR, Tatman LM, Heare A, Parikh HR, Albersheim M, Atchison J, Breslin M, Davis P, Feinstein S, Hak DJ, Labrum JT, Lufrano RC, Lund EA, Connelly D, Matar RN, Nadeau J, Ries de Chaffin D, Rodriguez-Buitrago AF, Schmidt T, Shaw N, Simske N, Siy AB, Titter J, Vang S, Wagstrom E, Westberg JR, Hahn J, Mauffrey C, Mir HR, O'Toole RV, Obremskey WT, Sanders RW, Schmidt AH, Vallier HA, Whiting PS, Cunningham BP. Single-Stage Versus 2-Stage Bilateral Intramedullary Nail Fixation in Patients With Bilateral Femur Fractures: A Multicenter Retrospective Review. J Orthop Trauma 2021; 35:499-504. [PMID: 33512861 DOI: 10.1097/bot.0000000000002055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate rates of complications in patients with bilateral femur fractures treated with intramedullary nailing (IMN) during either 1 single procedure or 2 separate procedures. DESIGN A multicenter retrospective review of patients sustaining bilateral femur fractures, treated with IMN in single or 2-stage procedure, from 1998 to 2018 was performed at 10 Level-1 trauma centers. SETTING Ten Level-1 trauma centers. PATIENTS/PARTICIPANTS Two hundred forty-six patients with bilateral femur fractures. INTERVENTIONS Intramedullary nailing. MAIN OUTCOME MEASURES Incidence of complications. RESULTS A total of 246 patients were included, with 188 single-stage and 58 two-stage patients. Gender, age, injury severity score, abbreviated injury score, secondary injuries, Glasgow coma scale, and proportion of open fractures were similar between both groups. Acute respiratory distress syndrome (ARDS) occurred at higher rates in the 2-stage group (13.8% vs. 5.9%; P value = 0.05). When further adjusted for age, gender, injury severity score, abbreviated injury score, Glasgow coma scale, and admission lactate, the single-stage group had a 78% reduced risk for ARDS. In-hospital mortality was higher in the single-stage cohort (2.7% compared with 0%), although this did not meet statistical significance (P = 0.22). CONCLUSIONS This is the largest multicenter study to date evaluating the outcomes between single- and 2-stage IMN fixation for bilateral femoral shaft fractures. Single-stage bilateral femur IMN may decrease rates of ARDS in polytrauma patients who are able to undergo simultaneous definitive fixation. However, a future prospective study with standardized protocols in place will be required to discern whether single- versus 2-stage fixation has an effect on mortality and to identify those individuals at risk. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Ilexa R Flagstad
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Lauren M Tatman
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Austin Heare
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
- Department of Orthopaedics, University of Miami Miller School of Medicine, Miami, FL
| | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Melissa Albersheim
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Jared Atchison
- Department of Orthopaedics, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Mary Breslin
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Patrick Davis
- Department of Orthopaedics, Florida Orthopaedic Institute, Tampa, FL
| | - Shawn Feinstein
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - David J Hak
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
| | - Joseph T Labrum
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Reuben C Lufrano
- Department of Orthopaedics and Rehabilitation, University of Wisconsin, Madison, WI
| | - Erik A Lund
- Department of Orthopaedics, Florida Orthopaedic Institute, Tampa, FL
| | - Daniel Connelly
- Department of Orthopaedics, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Robert N Matar
- Department of Orthopaedic Surgery, University of Cincinnati, Cincinnati, OH
| | - Jason Nadeau
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
| | | | | | - Tegan Schmidt
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Nichole Shaw
- Department of Orthopaedics, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Natasha Simske
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Alexander B Siy
- Department of Orthopaedics and Rehabilitation, University of Wisconsin, Madison, WI
| | - Julie Titter
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Sandy Vang
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Emily Wagstrom
- Department of Orthopaedics, Hennepin County Medical Center, Minneapolis, MN
| | - Jerald R Westberg
- Department of Orthopaedics, Hennepin County Medical Center, Minneapolis, MN
| | - Jesse Hahn
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
| | - Hassan R Mir
- Department of Orthopaedics, Florida Orthopaedic Institute, Tampa, FL
| | - Robert V O'Toole
- Department of Orthopaedics, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Roy W Sanders
- Department of Orthopaedics, Florida Orthopaedic Institute, Tampa, FL
| | - Andrew H Schmidt
- Department of Orthopaedics, Hennepin County Medical Center, Minneapolis, MN
| | - Heather A Vallier
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
| | - Paul S Whiting
- Department of Orthopaedics and Rehabilitation, University of Wisconsin, Madison, WI
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orhopaedics, TRIA Orthopaedics Center, Bloomington, MN; and
- Department of Orthopaedic Surgery, Methodist Hospital, St. Louis Park, MN
| |
Collapse
|
33
|
Flagstad IR, Tatman LM, Albersheim M, Heare A, Parikh HR, Vang S, Westberg JR, de Chaffin DR, Schmidt T, Breslin M, Simske N, Siy AB, Lufrano RC, Rodriguez-Buitrago AF, Labrum JT, Shaw N, Only AJ, Nadeau J, Davis P, Steverson B, Lund EA, Connelly D, Atchison J, Mauffrey C, Hak DJ, Titter J, Feinstein S, Hahn J, Sagi C, Whiting PS, Mir HR, Schmidt AH, Wagstrom E, Obremskey WT, O'Toole RV, Vallier HA, Cunningham B. Factors influencing management of bilateral femur fractures: A multicenter retrospective cohort of early versus delayed definitive Fixation. Injury 2021; 52:2395-2402. [PMID: 33712297 DOI: 10.1016/j.injury.2021.02.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/16/2021] [Accepted: 02/28/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of our study was to evaluate the factors that influence the timing of definitive fixation in the management of bilateral femoral shaft fractures and the outcomes for patients with these injuries. METHODS Patients with bilateral femur fractures treated between 1998 to 2019 at ten level-1 trauma centers were retrospectively reviewed. Patients were grouped into early or delayed fixation, which was defined as definitive fixation of both femurs within or greater than 24 hours from injury, respectively. Statistical analysis included reversed logistic odds regression to predict which variable(s) was most likely to determine timing to definitive fixation. The outcomes included age, sex, high-volume institution, ISS, GCS, admission lactate, and admission base deficit. RESULTS Three hundred twenty-eight patients were included; 164 patients were included in the early fixation group and 164 patients in the delayed fixation group. Patients managed with delayed fixation had a higher Injury Severity Score (26.8 vs 22.4; p<0.01), higher admission lactate (4.4 and 3.0; p<0.01), and a lower Glasgow Coma Scale (10.7 vs 13; p<0.01). High-volume institution was the most reliable influencer for time to definitive fixation, successfully determining 78.6% of patients, followed by admission lactate, 64.4%. When all variables were evaluated in conjunction, high-volume institution remained the strongest contributor (X2 statistic: institution: 45.6, ISS: 8.83, lactate: 6.77, GCS: 0.94). CONCLUSION In this study, high-volume institution was the strongest predictor of timing to definitive fixation in patients with bilateral femur fractures. This study demonstrates an opportunity to create a standardized care pathway for patients with these injuries. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Ilexa R Flagstad
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street R200, Minneapolis, MN 55455, USA
| | - Lauren M Tatman
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street R200, Minneapolis, MN 55455, USA
| | - Melissa Albersheim
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street R200, Minneapolis, MN 55455, USA
| | - Austin Heare
- Department of Orthopaedic Surgery, University of Miami Hospital Ortho Clinic, 1400 N.W. 12th Avenue, Suite 2, Miami, FL 33136, USA
| | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street R200, Minneapolis, MN 55455, USA
| | - Sandy Vang
- Department of Orthopaedic Surgery, Regions Hospital, 640 Jackson Street, Saint Paul, MN 55101, USA
| | - Jerald R Westberg
- Department of Orthopaedic Surgery, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN 55415, USA
| | - Danielle Ries de Chaffin
- Department of Orthopaedic Surgery, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN 55415, USA
| | - Tegan Schmidt
- Department of Orthopaedic Surgery, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Mary Breslin
- Department of Orthopaedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Natasha Simske
- Department of Orthopaedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Alexander B Siy
- Department of Orthopaedic Surgery, University of Wisconsin Hospital and Clinic, 1685 Highland Ave, Madison, WI 53705, USA
| | - Reuben C Lufrano
- Department of Orthopaedic Surgery, University of Wisconsin Hospital and Clinic, 1685 Highland Ave, Madison, WI 53705, USA
| | - Andres F Rodriguez-Buitrago
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South MCE South Tower, Suite 4200, Nashville, TN 37232, USA
| | - Joseph T Labrum
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South MCE South Tower, Suite 4200, Nashville, TN 37232, USA
| | - Nichole Shaw
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Arthur J Only
- Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, St. Louis Park, MN 55426, USA
| | - Jason Nadeau
- Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA
| | - Patrick Davis
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 909 North Dale Mabry Highway, Tampa, FL 33609, USA
| | - Barbara Steverson
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 909 North Dale Mabry Highway, Tampa, FL 33609, USA
| | - Erik A Lund
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 909 North Dale Mabry Highway, Tampa, FL 33609, USA
| | - Daniel Connelly
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Jared Atchison
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Cyril Mauffrey
- Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA
| | - David J Hak
- Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA
| | - Julie Titter
- Department of Orthopaedic Surgery, University of North Carolina, 130 Mason Farm Road CB# 7055 UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - Shawn Feinstein
- Department of Orthopaedic Surgery, University of North Carolina, 130 Mason Farm Road CB# 7055 UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - Jesse Hahn
- Department of Orthopaedic Surgery, University of North Carolina, 130 Mason Farm Road CB# 7055 UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - Claude Sagi
- Department of Orthopaedic Surgery, University of Cincinnati, Medical Sciences Building Room 3109 231 Albert Sabin Way, PO Box 670531, Cincinnati, OH 45267, USA
| | - Paul S Whiting
- Department of Orthopaedic Surgery, University of Wisconsin Hospital and Clinic, 1685 Highland Ave, Madison, WI 53705, USA
| | - Hassan R Mir
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 909 North Dale Mabry Highway, Tampa, FL 33609, USA
| | - Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN 55415, USA
| | - Emily Wagstrom
- Department of Orthopaedic Surgery, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN 55415, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South MCE South Tower, Suite 4200, Nashville, TN 37232, USA
| | - Robert V O'Toole
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Heather A Vallier
- Department of Orthopaedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Brian Cunningham
- Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, St. Louis Park, MN 55426, USA.
| |
Collapse
|
34
|
O'Toole RV, Joshi M, Carlini AR, Murray CK, Allen LE, Huang Y, Scharfstein DO, O'Hara NN, Gary JL, Bosse MJ, Castillo RC, Bishop JA, Weaver MJ, Firoozabadi R, Hsu JR, Karunakar MA, Seymour RB, Sims SH, Churchill C, Brennan ML, Gonzales G, Reilly RM, Zura RD, Howes CR, Mir HR, Wagstrom EA, Westberg J, Gaski GE, Kempton LB, Natoli RM, Sorkin AT, Virkus WW, Hill LC, Hymes RA, Holzman M, Malekzadeh AS, Schulman JE, Ramsey L, Cuff JAN, Haaser S, Osgood GM, Shafiq B, Laljani V, Lee OC, Krause PC, Rowe CJ, Hilliard CL, Morandi MM, Mullins A, Achor TS, Choo AM, Munz JW, Boutte SJ, Vallier HA, Breslin MA, Frisch HM, Kaufman AM, Large TM, LeCroy CM, Riggsbee C, Smith CS, Crickard CV, Phieffer LS, Sheridan E, Jones CB, Sietsema DL, Reid JS, Ringenbach K, Hayda R, Evans AR, Crisco MJ, Rivera JC, Osborn PM, Kimmel J, Stawicki SP, Nwachuku CO, Wojda TR, Rehman S, Donnelly JM, Caroom C, Jenkins MD, Boulton CL, Costales TG, LeBrun CT, Manson TT, Mascarenhas DC, Nascone JW, Pollak AN, Sciadini MF, Slobogean GP, Berger PZ, Connelly DW, Degani Y, Howe AL, Marinos DP, Montalvo RN, Reahl GB, Schoonover CD, Schroder LK, Vang S, Bergin PF, Graves ML, Russell GV, Spitler CA, Hydrick JM, Teague D, Ertl W, Hickerson LE, Moloney GB, Weinlein JC, Zelle BA, Agarwal A, Karia RA, Sathy AK, Au B, Maroto M, Sanders D, Higgins TF, Haller JM, Rothberg DL, Weiss DB, Yarboro SR, McVey ED, Lester-Ballard V, Goodspeed D, Lang GJ, Whiting PS, Siy AB, Obremskey WT, Jahangir AA, Attum B, Burgos EJ, Molina CS, Rodriguez-Buitrago A, Gajari V, Trochez KM, Halvorson JJ, Miller AN, Goodman JB, Holden MB, McAndrew CM, Gardner MJ, Ricci WM, Spraggs-Hughes A, Collins SC, Taylor TJ, Zadnik M. Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial. JAMA Surg 2021; 156:e207259. [PMID: 33760010 DOI: 10.1001/jamasurg.2020.7259] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Importance Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. Objective To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. Design, Setting, and Participants This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. Interventions A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. Main Outcomes and Measures The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. Results The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. Conclusions and Relevance Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. Trial Registration ClinicalTrials.gov Identifier: NCT02227446.
Collapse
Affiliation(s)
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Manjari Joshi
- Department of Infectious Diseases, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Anthony R Carlini
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Clinton K Murray
- Department of Medicine, San Antonio Military Medical Center, San Antonio, Texas
| | - Lauren E Allen
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yanjie Huang
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Daniel O Scharfstein
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nathan N O'Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Joshua L Gary
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Michael J Bosse
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Renan C Castillo
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center/University of Washington, Seattle
| | - Joseph R Hsu
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Madhav A Karunakar
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Rachel B Seymour
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Stephen H Sims
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Christine Churchill
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael L Brennan
- Department of Orthopaedic Surgery, Baylor Scott and White Memorial Center, Temple, Texas
| | - Gabriela Gonzales
- Department of Orthopaedic Surgery, Baylor Scott and White Memorial Center, Temple, Texas
| | - Rachel M Reilly
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Robert D Zura
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Cameron R Howes
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Hassan R Mir
- Florida Orthopaedic Institute/Tampa General Hospital, Tampa
| | - Emily A Wagstrom
- Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Jerald Westberg
- Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Greg E Gaski
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Laurence B Kempton
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Anthony T Sorkin
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Walter W Virkus
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Lauren C Hill
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Robert A Hymes
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Michael Holzman
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - A Stephen Malekzadeh
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Jeff E Schulman
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Lolita Ramsey
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Jaslynn A N Cuff
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Sharon Haaser
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Greg M Osgood
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Vaishali Laljani
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Olivia C Lee
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Peter C Krause
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Cara J Rowe
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Colette L Hilliard
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Massimo Max Morandi
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, Shreveport
| | - Angela Mullins
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, Shreveport
| | - Timothy S Achor
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Andrew M Choo
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - John W Munz
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Sterling J Boutte
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | | | - Mary A Breslin
- Department of Orthopaedics, MetroHealth, Cleveland, Ohio
| | - H Michael Frisch
- Orthopaedic Trauma Service, Mission Health, Asheville, North Carolina
| | - Adam M Kaufman
- Orthopaedic Trauma Service, Mission Health, Asheville, North Carolina
| | - Thomas M Large
- Orthopaedic Trauma Service, Mission Health, Asheville, North Carolina
| | - C Michael LeCroy
- Orthopaedic Trauma Service, Mission Health, Asheville, North Carolina
| | | | - Christopher S Smith
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Colin V Crickard
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Laura S Phieffer
- Department of Orthopaedics, Ohio State University, Wexner Medical Center, Columbus
| | - Elizabeth Sheridan
- Department of Orthopaedics, Ohio State University, Wexner Medical Center, Columbus
| | | | | | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Penn State Health, Hershey, Pennsylvania
| | - Kathy Ringenbach
- Department of Orthopaedics and Rehabilitation, Penn State Health, Hershey, Pennsylvania
| | - Roman Hayda
- Department of Orthopedic Surgery, Brown University/Rhode Island Hospital, Providence
| | - Andrew R Evans
- Department of Orthopedic Surgery, Brown University/Rhode Island Hospital, Providence
| | - M J Crisco
- Department of Orthopedic Surgery, Brown University/Rhode Island Hospital, Providence
| | - Jessica C Rivera
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Patrick M Osborn
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Joseph Kimmel
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Stanislaw P Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Chinenye O Nwachuku
- Department of Orthopedic Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Thomas R Wojda
- Department of Family Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Saqib Rehman
- Department of Orthopaedic Surgery and Sports Medicine, Temple University, Philadelphia, Pennsylvania
| | - Joanne M Donnelly
- Department of Orthopaedic Surgery and Sports Medicine, Temple University, Philadelphia, Pennsylvania
| | - Cyrus Caroom
- Department of Orthopaedics, Texas Tech University Health Sciences Center, Lubbock
| | - Mark D Jenkins
- Department of Orthopaedics, Texas Tech University Health Sciences Center, Lubbock
| | - Christina L Boulton
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Timothy G Costales
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Christopher T LeBrun
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Theodore T Manson
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Daniel C Mascarenhas
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Jason W Nascone
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Andrew N Pollak
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Marcus F Sciadini
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Gerard P Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Peter Z Berger
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Daniel W Connelly
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Yasmin Degani
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Andrea L Howe
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Dimitrius P Marinos
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Ryan N Montalvo
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - G Bradley Reahl
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Carrie D Schoonover
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Lisa K Schroder
- Department of Orthopaedic Surgery, University of Minnesota-Regions Hospital, St Paul
| | - Sandy Vang
- Department of Orthopaedic Surgery, University of Minnesota-Regions Hospital, St Paul
| | - Patrick F Bergin
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - Matt L Graves
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - George V Russell
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - Josie M Hydrick
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - David Teague
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City
| | - William Ertl
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City
| | - Lindsay E Hickerson
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City
| | - Gele B Moloney
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John C Weinlein
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, Memphis
| | - Boris A Zelle
- Department of Orthopaedics, University of Texas Health at San Antonio, San Antonio
| | - Animesh Agarwal
- Department of Orthopaedics, University of Texas Health at San Antonio, San Antonio
| | - Ravi A Karia
- Department of Orthopaedics, University of Texas Health at San Antonio, San Antonio
| | - Ashoke K Sathy
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Brigham Au
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Medardo Maroto
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Drew Sanders
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas
| | | | - Justin M Haller
- Department of Orthopaedics, University of Utah, Salt Lake City
| | | | - David B Weiss
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville
| | - Seth R Yarboro
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville
| | - Eric D McVey
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville
| | - Veronica Lester-Ballard
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville
| | - David Goodspeed
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison
| | - Gerald J Lang
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison
| | - Paul S Whiting
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison
| | - Alexander B Siy
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - A Alex Jahangir
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Basem Attum
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eduardo J Burgos
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cesar S Molina
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Vamshi Gajari
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karen M Trochez
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jason J Halvorson
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest Baptist University Medical Center, Winston-Salem, North Carolina
| | - Anna N Miller
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest Baptist University Medical Center, Winston-Salem, North Carolina
| | - James Brett Goodman
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest Baptist University Medical Center, Winston-Salem, North Carolina
| | - Martha B Holden
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest Baptist University Medical Center, Winston-Salem, North Carolina
| | - Christopher M McAndrew
- Department of Orthopedic Surgery, Washington University in St Louis/Barnes Jewish Hospital, St Louis, Missouri
| | - Michael J Gardner
- Department of Orthopedic Surgery, Washington University in St Louis/Barnes Jewish Hospital, St Louis, Missouri
| | - William M Ricci
- Department of Orthopedic Surgery, Washington University in St Louis/Barnes Jewish Hospital, St Louis, Missouri
| | - Amanda Spraggs-Hughes
- Department of Orthopedic Surgery, Washington University in St Louis/Barnes Jewish Hospital, St Louis, Missouri
| | - Susan C Collins
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Tara J Taylor
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mary Zadnik
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| |
Collapse
|
35
|
Morgenstern M, Kuehl R, Zalavras CG, McNally M, Zimmerli W, Burch MA, Vandendriessche T, Obremskey WT, Verhofstad MHJ, Metsemakers WJ. The influence of duration of infection on outcome of debridement and implant retention in fracture-related infection. Bone Joint J 2021; 103-B:213-221. [PMID: 33517743 DOI: 10.1302/0301-620x.103b2.bjj-2020-1010.r1] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIMS The principle strategies of fracture-related infection (FRI) treatment are debridement, antimicrobial therapy, and implant retention (DAIR) or debridement, antimicrobial therapy, and implant removal/exchange. Increasing the period between fracture fixation and FRI revision surgery is believed to be associated with higher failure rates after DAIR. However, a clear time-related cut-off has never been scientifically defined. This systematic review analyzed the influence of the interval between fracture fixation and FRI revision surgery on success rates after DAIR. METHODS A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, in PubMed (including MEDLINE), Embase, and Web of Science Core Collection, investigating the outcome after DAIR procedures of long bone FRIs in clinical studies published until January 2020. RESULTS Six studies, comprising 276 patients, met the inclusion criteria. Data from this review showed that with a short duration of infection (up to three weeks) and under strict preconditions, retention of the implant is associated with high success rates of 86% to 100%. In delayed infections with a fracture fixation-FRI revision surgery interval of three to ten weeks, absence of recurrent infection was reported in 82% to 89%. Data on late FRIs, with a fracture fixation-FRI revision surgery interval of more than ten weeks, are scarce and a success rate of 67% was reported. CONCLUSION Acute/early FRI, with a short duration of infection, can successfully be treated with DAIR up to ten weeks after osteosynthesis. The limited available data suggest that chronic/late onset FRI treated with DAIR may be associated with a higher rate of recurrence. Successful outcome is dependent on managing all aspects of the infection. Thus, time from fracture fixation is not the only factor that should be considered in treatment planning of FRI. Due to the heterogeneity of the available data, these conclusions have to be interpreted with caution. Cite this article: Bone Joint J 2021;103-B(2):213-221.
Collapse
Affiliation(s)
- Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Richard Kuehl
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Charalampos G Zalavras
- Keck School of Medicine, University of Southern California, LAC+USC Medical Center, Los Angeles, California, USA
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Werner Zimmerli
- Interdisciplinary Unit for Orthopaedic Infections, Kantonsspital Baselland, Liestal, Switzerland
| | - Marc Antoine Burch
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | | | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | | |
Collapse
|
36
|
Onsea J, Pallay J, Depypere M, Moriarty TF, Van Lieshout EMM, Obremskey WT, Sermon A, Hoekstra H, Verhofstad MHJ, Nijs S, Metsemakers WJ. Intramedullary tissue cultures from the Reamer-Irrigator-Aspirator system for diagnosing fracture-related infection. J Orthop Res 2021; 39:281-290. [PMID: 32735351 DOI: 10.1002/jor.24816] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 02/04/2023]
Abstract
Fracture-related infection (FRI) is a serious complication following musculoskeletal trauma. Accurate diagnosis and appropriate treatment depend on retrieving adequate deep tissue biopsies for bacterial culture. The aim of this cohort study was to compare intraoperative tissue cultures obtained by the Reamer-Irrigator-Aspirator system (RIA)-system against standard tissue cultures obtained during the same surgical procedure. All patients had long bone fractures of the lower limbs and were assigned to the FRI or Control group based on the FRI consensus definition. The FRI group consisted of 24 patients with confirmed FRI and the Control group consisted of 21 patients with aseptic nonunion or chronic pain (in the absence of other suggestive/confirmatory criteria). Standard tissue cultures and cultures harvested by the RIA-system showed similar results. In the FRI group, standard tissue cultures and RIA cultures revealed relevant pathogens in 67% and 71% of patients, respectively. Furthermore, in four FRI patients, cultures obtained by the RIA-system revealed additional relevant pathogens that were not found by standard tissue culturing, which contributed to the optimization of the treatment plan. In the Control group, there were no false-positive RIA culture results. As a proof-of-concept, this cohort study showed that the RIA-system could have a role in the diagnosis of FRI as an adjunct to standard tissue cultures. Since scientific evidence on the added value of the RIA-system in the management of FRI is currently limited, further research on this topic is required before its routine application in clinical practice.
Collapse
Affiliation(s)
- Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Jan Pallay
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - An Sermon
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| |
Collapse
|
37
|
Metsemakers WJ, Kortram K, Ferreira N, Morgenstern M, Joeris A, Pape HC, Kammerlander C, Konda S, Oh JK, Giannoudis PV, Egol KA, Obremskey WT, Verhofstad MHJ, Raschke M. Fracture-related outcome study for operatively treated tibia shaft fractures (F.R.O.S.T.): registry rationale and design. BMC Musculoskelet Disord 2021; 22:57. [PMID: 33422025 PMCID: PMC7797092 DOI: 10.1186/s12891-020-03930-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/28/2020] [Indexed: 01/12/2023] Open
Abstract
Background Tibial shaft fractures (TSFs) are among the most common long bone injuries often resulting from high-energy trauma. To date, musculoskeletal complications such as fracture-related infection (FRI) and compromised fracture healing following fracture fixation of these injuries are still prevalent. The relatively high complication rates prove that, despite advances in modern fracture care, the management of TSFs remains a challenge even in the hands of experienced surgeons. Therefore, the Fracture-Related Outcome Study for operatively treated Tibia shaft fractures (F.R.O.S.T.) aims at creating a registry that enables data mining to gather detailed information to support future clinical decision-making regarding the management of TSF’s. Methods This prospective, international, multicenter, observational registry for TSFs was recently developed. Recruitment started in 2019 and is planned to take 36 months, seeking to enroll a minimum of 1000 patients. The study protocol does not influence the clinical decision-making procedure, implant choice, or surgical/imaging techniques; these are being performed as per local hospital standard of care. Data collected in this registry include injury specifics, treatment details, clinical outcomes (e.g., FRI), patient-reported outcomes, and procedure- or implant-related adverse events. The minimum follow up is 12 months. Discussion Although over the past decades, multiple high-quality studies have addressed individual research questions related to the outcome of TSFs, knowledge gaps remain. The scarcity of data calls for an international high-quality, population-based registry. Creating such a database could optimize strategies intended to prevent severe musculoskeletal complications. The main purpose of the F.R.O.S.T registry is to evaluate the association between different treatment strategies and patient outcomes. It will address not only operative techniques and implant materials but also perioperative preventive measures. For the first time, data concerning systemic perioperative antibiotic prophylaxis, the influence of local antimicrobials, and timing of soft-tissue coverage will be collected at an international level and correlated with standardized outcome measures in a large prospective, multicenter, observational registry for global accessibility. Trial registration ClinicalTrials.gov: NCT03598530. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-020-03930-x.
Collapse
Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium. .,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - Kirsten Kortram
- Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nando Ferreira
- Division of Orthopaedics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Alexander Joeris
- AO Innovation Translation Center, AO Foundation, Dübendorf, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, UniversitätsSpital Zürich, University of Zurich, Raemistrasse, Zurich, Switzerland
| | - Christian Kammerlander
- Department of General Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Sanjit Konda
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital and Jamaica Hospital Medical Center, New York, NY, USA
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, Guro-gu, Seoul, Republic of Korea
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michael Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany
| | | |
Collapse
|
38
|
Richards JE, Medvecz AJ, O'Hara NN, Guillamondegui OD, O'Toole RV, Obremskey WT, Galvagno SM, Scalea TM. Musculoskeletal Trauma in Critically Injured Patients: Factors Leading to Delayed Operative Fixation and Multiple Organ Failure. Anesth Analg 2020; 131:1781-1788. [PMID: 33186164 DOI: 10.1213/ane.0000000000005252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Musculoskeletal injuries are common following trauma and variables that are associated with late femur fracture fixation are important to perioperative management. Furthermore, the association of late fracture fixation and multiple organ failure (MOF) is not well defined. METHODS We performed a retrospective cohort investigation from 2 academic trauma centers. INCLUSION CRITERIA age 18-89 years, injury severity score (ISS) >15, femoral shaft fracture requiring operative fixation, and admission to the intensive care unit >2 days. Admission physiology variables and abbreviated injury scale (AIS) scores were obtained. Lactate was collected as a marker of shock and was described as admission lactate (LacAdm) and as 24-hour time-weighted lactate (LacTW24h), which reflects an area under the curve and is considered a marker for the overall depth of shock. The primary aim was to evaluate clinical variables associated with late femur fracture fixation (defined as ≥24 hours after admission). A multivariable logistic regression model tested variables associated with late fixation and is reported by odds ratio (OR) with 95% confidence interval (CI). The secondary aim evaluated the association between late fixation and MOF, defined by the Denver MOF score. The summation of scores (on a scale from 0 to 3) from the cardiac, pulmonary, hepatic, and renal systems was calculated and MOF was confirmed if the total daily sum of the worst scores from each organ system was >3. We assessed the association between late fixation and MOF using a Cox proportional hazards model adjusted for confounding variables by inverse probability weighting (a propensity score method). A P value <.05 was considered statistically significant. RESULTS One hundred sixty of 279 (57.3%) patients received early fixation and 119 of 279 (42.7%) received late fixation. LacTW24h (OR = 1.66 per 1 mmol/L increase, 95% CI, 1.24-2.21; P < .001) and ISS (OR = 1.07 per 1-point increase, 95% CI, 1.03-1.10; P < .001) were associated with higher odds of late fixation. Late fixation was associated with a 3-fold increase in the odds of MOF (hazard ratio [HR] = 3.21, 95% CI, 1.48-7.00; P < .01). CONCLUSIONS In a cohort of multisystem trauma patients with femur fractures, greater injury severity and depth of shock, as measured by LacTW24h, were associated with late operative fixation. Late fixation was also associated with MOF. Strategies to reduce the burden of MOF in this population require further investigation.
Collapse
Affiliation(s)
- Justin E Richards
- From the Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Andrew J Medvecz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nathan N O'Hara
- Division of Orthopedic Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Oscar D Guillamondegui
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert V O'Toole
- Division of Orthopedic Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - William T Obremskey
- Division of Orthopedic Trauma, Vanderbilt Orthopedic Institute, Nashville, Tennessee
| | - Samuel M Galvagno
- From the Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Thomas M Scalea
- Division of Trauma Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| |
Collapse
|
39
|
Metsemakers WJ, Morgenstern M, Senneville E, Borens O, Govaert GAM, Onsea J, Depypere M, Richards RG, Trampuz A, Verhofstad MHJ, Kates SL, Raschke M, McNally MA, Obremskey WT. General treatment principles for fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg 2020; 140:1013-1027. [PMID: 31659475 PMCID: PMC7351827 DOI: 10.1007/s00402-019-03287-4] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Indexed: 12/15/2022]
Abstract
Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients' short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group.Level of evidence: Level V.
Collapse
Affiliation(s)
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Eric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, University of Lille, Lille, France
| | - Olivier Borens
- Orthopedic Department of Septic Surgery, Orthopaedic-Trauma Unit, Department for the Musculoskeletal System, CHUV, Lausanne, Switzerland
| | - Geertje A M Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael H J Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, USA
| | - Michael Raschke
- Department of Trauma Surgery, University Hospital of Münster, Münster, Germany
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
40
|
Huang D, Weaver F, Obremskey WT, Ahn J, Peterson K, Anderson J, Veazie S, Carbone LD. Treatment of Lower Extremity Fractures in Chronic Spinal Cord Injury: A Systematic Review of the Literature. PM R 2020; 13:510-527. [PMID: 32500657 DOI: 10.1002/pmrj.12428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To review the literature regarding outcomes of surgical and nonsurgical management of lower extremity (LE) fractures in chronic spinal cord injury (SCI). TYPE: Systematic review. LITERATURE SURVEY Medline (PubMed), Embase, Cochrane Database of Systemic Reviews, Cochrane Central, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, International Clinical Trials Registry Platform, and International Standard Randomized Controlled Trials were searched from January 1, 1966, to March 1, 2019. METHODOLOGY Search was restricted to English language and adults (age ≥ 18 yr). Titles and abstracts were reviewed for relevance to study topics for inclusion. Case reports, reviews, non-SCI population studies, and studies examining fractures at the time of acute SCI were excluded. References of included articles from the original search and task force and external submissions yielded two additional articles that were included in the review after voting by task force members. Data extraction was performed by four task force members using a data extraction form, glossary, and instructions created in Microsoft Excel. Quality assessment was performed by three methodologists using prespecified criteria. SYNTHESIS Twenty-three articles were included. Use of surgery to treat LE fractures in chronic SCI has increased, though nonoperative management was still more frequently reported. Regardless of type of management, amputations, nonunion/malunion, and pressure injuries were among the most commonly reported complications. Functional and quality of life outcomes were less frequently reported. CONCLUSIONS There is insufficient evidence to support operative versus nonoperative management as best practice for management of LE fracture of SCI. Existing literature was limited by small sample sizes, lack of randomization or matched study designs, significant heterogeneity in populations and treatment strategies studied, and variability in defining and reporting outcomes of interest. The field would benefit from future research to address study design issues and standardization of outcome reporting to facilitate comparison of outcomes of operative versus nonoperative management.
Collapse
Affiliation(s)
- Donna Huang
- Spinal Cord Injury Care Line, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Frances Weaver
- Health Services Research and Development, Department of Veterans' Affairs, Hines VA Hospital, Center of Innovation for Complex Chronic Healthcare, Hines, IL, USA.,Department of Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, IL, USA
| | - William T Obremskey
- Division of Orthopedic Trauma Research, Center for Musculoskeletal Research, Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jaimo Ahn
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kimberly Peterson
- Veterans' Affairs Evidence-Based Synthesis Program, Portland VA Healthcare System, Portland, OR, USA
| | - Johanna Anderson
- Veterans' Affairs Evidence-Based Synthesis Program, Portland VA Healthcare System, Portland, OR, USA
| | - Stephanie Veazie
- Veterans' Affairs Evidence-Based Synthesis Program, Portland VA Healthcare System, Portland, OR, USA
| | - Laura D Carbone
- Charlie Norwood VA Medical Center, Augusta, GA, USA.,Division of Rheumatology, Department of Internal Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
| |
Collapse
|
41
|
Obremskey WT, Metsemakers WJ, Schlatterer DR, Tetsworth K, Egol K, Kates S, McNally M. Musculoskeletal Infection in Orthopaedic Trauma: Assessment of the 2018 International Consensus Meeting on Musculoskeletal Infection. J Bone Joint Surg Am 2020; 102:e44. [PMID: 32118653 DOI: 10.2106/jbjs.19.01070] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fracture-related infections (FRIs) are among the most common complications following fracture fixation, and they have a huge economic and functional impact on patients. Because consensus guidelines with respect to prevention, diagnosis, and treatment of this major complication are scarce, delegates from different countries gathered in Philadelphia in July 2018 as part of the Second International Consensus Meeting (ICM) on Musculoskeletal Infection. This paper summarizes the discussion and recommendations from that consensus meeting, using the Delphi technique, with a focus on FRIs. A standardized definition that was based on diagnostic criteria was endorsed, which will hopefully improve reporting and research on FRIs in the future. Furthermore, this paper provides a grade of evidence (strong, moderate, limited, or consensus) for strategies and practices that prevent and treat infection. The grade of evidence is based on the quality of evidence as utilized by the American Academy of Orthopaedic Surgeons. The guidelines presented herein focus not only on the appropriate use of antibiotics, but also on practices for the timing of fracture fixation, soft-tissue coverage, and bone defect and hardware management. We hope that this summary as well as the full document by the International Consensus Group are utilized by those who are charged with musculoskeletal care internationally to optimize their management strategies for the prevention and treatment of FRIs.
Collapse
Affiliation(s)
- William T Obremskey
- Department of Orthopaedic Trauma, Vanderbilt Medical Center, Nashville, Tennessee
| | | | | | - Kevin Tetsworth
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Orthopaedic Research Centre of Australia, Brisbane, Queensland, Australia.,Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Kenneth Egol
- Department of Orthopedic Surgery, NYU School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Stephen Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Martin McNally
- Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | | | | |
Collapse
|
42
|
Affiliation(s)
- William T Obremskey
- Vanderbilt Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | |
Collapse
|
43
|
Hysong AA, Posey SL, Blum DM, Benvenuti MA, Benvenuti TA, Johnson SR, An TJ, Devin JK, Obremskey WT, Martus JE, Moore-Lotridge SN, Schoenecker JG. Necrotizing Fasciitis: Pillaging the Acute Phase Response. J Bone Joint Surg Am 2020; 102:526-537. [PMID: 31977818 PMCID: PMC8590823 DOI: 10.2106/jbjs.19.00591] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Samuel L Posey
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Deke M Blum
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Michael A Benvenuti
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Teresa A Benvenuti
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samuel R Johnson
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas J An
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jessica K Devin
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - William T Obremskey
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey E Martus
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephanie N Moore-Lotridge
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan G Schoenecker
- Department of Orthopaedics and Rehabilitation (M.A.B., T.A.B., S.R.J., T.J.A., W.T.O., J.E.M., S.N.M.-L., and J.G.S.), Division of Diabetes, Endocrinology, and Metabolism (J.K.D.), and Departments of Pediatrics (J.E.M and J.G.S.), Pathology, Microbiology, and Immunology (J.G.S.), and Pharmacology (J.G.S.), Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
44
|
Depypere M, Morgenstern M, Kuehl R, Senneville E, Moriarty TF, Obremskey WT, Zimmerli W, Trampuz A, Lagrou K, Metsemakers WJ. 'Pathogenesis and management of fracture-related infection' - Author's reply. Clin Microbiol Infect 2020; 26:652-653. [PMID: 32087322 DOI: 10.1016/j.cmi.2020.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/09/2020] [Indexed: 01/22/2023]
Affiliation(s)
- M Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Belgium
| | - M Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - R Kuehl
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland
| | - E Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, University of Lille, F-59000 Lille, France
| | | | - W T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - W Zimmerli
- Interdisciplinary Unit for Orthopaedic Infections, Kantonsspital Baselland, Rheinstrasse 26, 4410, Liestal, Switzerland
| | - A Trampuz
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - K Lagrou
- Department of Laboratory Medicine, University Hospitals Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - W-J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Belgium.
| |
Collapse
|
45
|
Govaert GAM, Kuehl R, Atkins BL, Trampuz A, Morgenstern M, Obremskey WT, Verhofstad MHJ, McNally MA, Metsemakers WJ. Diagnosing Fracture-Related Infection: Current Concepts and Recommendations. J Orthop Trauma 2020; 34:8-17. [PMID: 31855973 PMCID: PMC6903359 DOI: 10.1097/bot.0000000000001614] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 02/02/2023]
Abstract
Fracture-related infection (FRI) is a severe complication after bone injury and can pose a serious diagnostic challenge. Overall, there is a limited amount of scientific evidence regarding diagnostic criteria for FRI. For this reason, the AO Foundation and the European Bone and Joint Infection Society proposed a consensus definition for FRI to standardize the diagnostic criteria and improve the quality of patient care and applicability of future studies regarding this condition. The aim of this article was to summarize the available evidence and provide recommendations for the diagnosis of FRI. For this purpose, the FRI consensus definition will be discussed together with a proposal for an update based on the available evidence relating to the diagnostic value of clinical parameters, serum inflammatory markers, imaging modalities, tissue and sonication fluid sampling, molecular biology techniques, and histopathological examination. Second, recommendations on microbiology specimen sampling and laboratory operating procedures relevant to FRI will be provided. LEVEL OF EVIDENCE:: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Geertje A. M. Govaert
- Department of Trauma Surgery, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Richard Kuehl
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | - Bridget L. Atkins
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Michael H. J. Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; and
| | - Martin A. McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | | |
Collapse
|
46
|
Depypere M, Kuehl R, Metsemakers WJ, Senneville E, McNally MA, Obremskey WT, Zimmerli W, Atkins BL, Trampuz A. Recommendations for Systemic Antimicrobial Therapy in Fracture-Related Infection: A Consensus From an International Expert Group. J Orthop Trauma 2020; 34:30-41. [PMID: 31567902 PMCID: PMC6903362 DOI: 10.1097/bot.0000000000001626] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 02/02/2023]
Abstract
Fracture-related infection (FRI) is a major complication in musculoskeletal trauma and one of the leading causes of morbidity. Standardization of general treatment strategies for FRI has been poor. One of the reasons is the heterogeneity in this patient population, including various anatomical locations, multiple fracture patterns, different degrees of soft-tissue injury, and different patient conditions. This variability makes treatment complex and hard to standardize. As these infections are biofilm-related, surgery remains the cornerstone of treatment, and this entails multiple key aspects (eg, fracture fixation, tissue sampling, debridement, and soft-tissue management). Another important aspect, which is sometimes less familiar to the orthopaedic trauma surgeon, is systemic antimicrobial therapy. The aim of this article is to summarize the available evidence and provide recommendations for systemic antimicrobial therapy with respect to FRI, based on the most recent literature combined with expert opinion. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Richard Kuehl
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | | | - Eric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, University of Lille, Lille, France
| | - Martin A. McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Werner Zimmerli
- Kantonsspital Baselland, Interdisciplinary Unit for Orthopedic Infections, Liestal, Switzerland; and
| | - Bridget L. Atkins
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| |
Collapse
|
47
|
Mir HR, Miller AN, Obremskey WT, Jahangir AA, Hsu JR. Confronting the Opioid Crisis: Practical Pain Management and Strategies: AOA 2018 Critical Issues Symposium. J Bone Joint Surg Am 2019; 101:e126. [PMID: 31800430 DOI: 10.2106/jbjs.19.00285] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The United States is in the midst of an opioid crisis. Clinicians have been part of the problem because of overprescribing of narcotics for perioperative pain management. Clinicians need to understand the pathophysiology and science of addiction to improve perioperative management of pain for their patients. Multiple modalities for pain management exist that decrease the use of narcotics. Physical strategies, cognitive strategies, and multimodal medication can all provide improved pain relief and decrease the use of narcotics. National medical societies are developing clinical practice guidelines for pain management that incorporate multimodal strategies and multimodal medication. Changes to policy that improve provider education, access to naloxone, and treatment for addiction can decrease narcotic misuse and the risk of addiction.
Collapse
Affiliation(s)
- Hassan R Mir
- Department of Orthopaedic Surgery, University of South Florida, Florida Orthopedic Institute, Tampa, Florida
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - A Alex Jahangir
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joseph R Hsu
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| |
Collapse
|
48
|
Nauth A, Wasserstein D, Tornetta P, Cole PA, Obremskey WT, Attum B, Slobogean GP. Patient Outcomes in Orthopaedic Trauma: How to Evaluate if Your Treatment Is Really Working? J Orthop Trauma 2019; 33 Suppl 6:S20-S24. [PMID: 31083144 DOI: 10.1097/bot.0000000000001470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Outcomes are critical to gauge the success of our treatments and, in particular, surgical interventions in orthopaedic trauma. Patient-reported outcomes have evolved to become the primary measurement of success in surgery. This article reviews the concepts relevant to understanding these outcomes including general health outcomes, extremity- and disease-specific outcomes, minimum clinically important difference, economic analysis of treatment cost/benefit, and the impact of psychosocial factors on outcomes. An understanding of these concepts is important to allow for effective interpretation and critical analysis of the literature as well as to facilitate the practice of evidence-based medicine.
Collapse
Affiliation(s)
- Aaron Nauth
- Orthopaedic Division, Department of Surgery, St. Michael's Hospital, Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | | | | | - Peter A Cole
- HealthPartners Medical Group, Bloomington, MN.,Orthopaedic Department, Regions Hospital, St. Paul, MN.,University of Minnesota, Minneapolis, MN
| | | | - Basem Attum
- Vanderbilt University Medical Center, Nashville, TN.,Department of Orthopedic Surgery, UCSD, San Diego, CA
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
49
|
Schwarz EM, Parvizi J, Gehrke T, Aiyer A, Battenberg A, Brown SA, Callaghan JJ, Citak M, Egol K, Garrigues GE, Ghert M, Goswami K, Green A, Hammound S, Kates SL, McLaren AC, Mont MA, Namdari S, Obremskey WT, O'Toole R, Raikin S, Restrepo C, Ricciardi B, Saeed K, Sanchez-Sotelo J, Shohat N, Tan T, Thirukumaran CP, Winters B. 2018 International Consensus Meeting on Musculoskeletal Infection: Research Priorities from the General Assembly Questions. J Orthop Res 2019; 37:997-1006. [PMID: 30977537 DOI: 10.1002/jor.24293] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 02/22/2019] [Accepted: 03/19/2019] [Indexed: 02/04/2023]
Abstract
Musculoskeletal infections (MSKI) remain the bane of orthopedic surgery, and result in grievous illness and inordinate costs that threaten healthcare systems. As prevention, diagnosis, and treatment has remained largely unchanged over the last 50 years, a 2nd International Consensus Meeting on Musculoskeletal Infection (ICM 2018, https://icmphilly.com) was completed. Questions pertaining to all areas of MSKI were extensively researched to prepare recommendations, which were discussed and voted on by the delegates using the Delphi methodology. The questions, including the General Assembly (GA) results, have been published (GA questions). However, as critical outcomes include: (i) incidence and cost data that substantiate the problems, and (ii) establishment of research priorities; an ICM 2018 research workgroup (RW) was assembled to accomplish these tasks. Here, we present the result of the RW consensus on the current and projected incidence of infection, and the costs per patient, for all orthopedic subspecialties, which range from 0.1% to 30%, and $17,000 to $150,000. The RW also identified the most important research questions. The Delphi methodology was utilized to initially derive four objective criteria to define a subset of the 164 GA questions that are high priority for future research. Thirty-eight questions (23% of all GA questions) achieved the requisite > 70% agreement vote, and are highlighted in this Consensus article within six thematic categories: acute versus chronic infection, host immunity, antibiotics, diagnosis, research caveats, and modifiable factors. Finally, the RW emphasizes that without appropriate funding to address these high priority research questions, a 3rd ICM on MSKI to address similar issues at greater cost is inevitable.
Collapse
Affiliation(s)
- Edward M Schwarz
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Javad Parvizi
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios Endo Klinik Hamburg, Hamburg, Germany
| | - Amiethab Aiyer
- Department of Orthopaedic Surgery, University of Miami/Miller School of Medicine, Miami, Florida
| | - Andrew Battenberg
- Department of Orthopaedics, Kaiser Permanente Vacaville Medical Center, Vacaville, California
| | - Scot A Brown
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - John J Callaghan
- Deparment of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios Endo Klinik Hamburg, Hamburg, Germany
| | - Kenneth Egol
- Department of Orthopedic Surgery, New York University, New York, New York
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michelle Ghert
- Department of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Karan Goswami
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Andrew Green
- Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
| | - Sommer Hammound
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Alex C McLaren
- Department of Orthopaedic Surgery, College of Medicine-Phoenix, University of Arizona, Phoenix, Arizona
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Surena Namdari
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - William T Obremskey
- Department of Orthopedic Surgery, Vanderbilt Medical Center, Nashville, Tennessee
| | - Robert O'Toole
- Department of Orthopaedics, University of Maryland, Baltimore, Maryland
| | - Steven Raikin
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Camilo Restrepo
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Benjamin Ricciardi
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Kordo Saeed
- Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, United Kingdom
- Department of Microbiology, School of Medicine, University of Southampton, Southampton, United Kingdom
| | | | - Noam Shohat
- Department of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Timothy Tan
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Caroline P Thirukumaran
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Brian Winters
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| |
Collapse
|
50
|
Abstract
Hemiarthroplasty is a common treatment for femoral neck fractures in the elderly population. The main complications are periprosthetic dislocation and infection, which potentially impact morbidity and quality of life and may contribute to mortality. This procedure can be technically demanding, and adequate closure of the capsule and soft tissue cannot be emphasized enough. One advantage of a bipolar prosthesis is that it can be easily converted to a total hip arthroplasty without replacing the femoral component and with approximately the same complication rates as a revision total hip arthroplasty. Cement should be used when the patient is osteoporotic or has a Dorr type-C canal because there is a significant reduction in risk of fracture. The addition of a collared stem is helpful if there is a crack in the calcar extending from the fracture. The procedure is as follows. (1) The patient is placed in the lateral decubitus position. (2) The surgical site is prepared and draped to above the iliac crest and mid-sacrum. (3) A posterior approach is utilized. (4) The hip is dislocated. (5) A cut is made at the femoral neck. (6) The implant is templated with the femoral head. (7) The femur is broached. (8) The trial implant is placed. (9) The femur is cemented. (10) Trial implants are removed and cement is placed. (11) The final stem implant is placed in 5° to 10° of anteversion. (12) The final head and neck implants are trialed and then placed. (13) Implant position and range of motion are tested. (14) The surgical wound is irrigated. (15) Short external rotators are repaired. The posterior approach, which is often used, is known for increased rates of dislocation. The rate of dislocation can be minimized with repair of the posterior capsule and posterior soft tissue. Proper placement of the implants is of the utmost importance to minimize complications. Other contributing factors that lead to dislocation are implant malpositioning and patient factors.
Collapse
Affiliation(s)
| | - Basem Attum
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cesar Cereijo
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kurt Yusi
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | |
Collapse
|