Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury: 2022 Delphi Consensus Recommendations.

Our objective was to develop a clinical practice guideline (CPG) for the treatment of acute lower extremity fractures in persons with a chronic spinal cord injury (SCI). Methods: Information from a previous systematic review that addressed lower extremity fracture care in persons with an SCI as well as information from interviews of physical and occupational therapists, searches of the literature, and expert opinion were used to develop this CPG. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to determine the quality of evidence and the strength of the recommendations. An overall GRADE quality rating was applied to the evidence. Conclusions: Individuals with a chronic SCI who sustain an acute lower extremity fracture should be provided with education regarding the risks and benefits of operative and nonoperative management, and shared decision-making for acute fracture management should be used. Nonoperative management historically has been the default preference; however, with the advent of greater patient independence, improved surgical techniques, and advanced therapeutics and rehabilitation, increased use of surgical management should be considered. Physical therapists, kinesiotherapists, and/or occupational therapists should assess equipment needs, skills training, and caregiver assistance due to changes in mobility resulting from a lower extremity fracture. Therapists should be involved in fracture management as soon as possible following fracture identification. Pressure injuries, compartment syndrome, heterotopic ossification, nonunion, malunion, thromboembolism, pain, and autonomic dysreflexia are fracture-related complications that clinicians caring for patients who have an SCI and a lower extremity fracture may encounter. Strategies for their treatment are discussed. The underlying goal is to return the patient as closely as possible to their pre-fracture functional level with operative or nonoperative management.

Pathogenesis and management of fracture-related infection.

BACKGROUND: Both fracture-related infections (FRIs) and periprosthetic joint infections (PJIs) include orthopaedic implant-associated infections. However, key aspects of management differ due to the bone and soft tissue damage in FRIs and the option of removing the implant after fracture healing. In contrast to PJIs, research and guidelines for diagnosis and treatment in FRIs are scarce. OBJECTIVES: This narrative review aims to update clinical microbiologists, infectious disease specialists and surgeons on the management of FRIs. SOURCES: A computerized search of PubMed was performed to identify relevant studies. Search terms included 'Fracture' and 'Infection'. The reference lists of all retrieved articles were checked for additional relevant references. In addition, when scientific evidence was lacking, recommendations are based on expert opinion. CONTENT: Pathogenesis, prevention, diagnosis and treatment of FRIs are presented. Whenever available, specific data of patients with FRI are discussed. IMPLICATIONS: Management of patients with FRI should take into account FRI-specific features. Treatment pathways should implement a multidisciplinary approach to achieve a good outcome. Recently, international consensus guidelines were developed to improve the quality of care for patients suffering from this severe complication, which are highlighted in this review.

Insights into treatment and outcome of fracture-related infection: a systematic literature review.

INTRODUCTION: Standardized guidelines for treatment of fracture-related infection (FRI) are lacking. Worldwide many treatment protocols are used with variable success rates. Awareness on the need of standardized, evidence-based guidelines has increased in recent years. This systematic literature review gives an overview of available diagnostic criteria, classifications, treatment protocols, and related outcome measurements for surgically treated FRI patients. METHODS: A comprehensive search was performed in all scientific literature since 1990. Studies in English that described surgical patient series for treatment of FRI were included. Data were collected on diagnostic criteria for FRI, classifications used, surgical treatments, follow-up protocols, and overall outcome. A systematic review was performed according to the PRISMA statement. Proportions and weighted means were calculated. RESULTS: The search yielded 2051 studies. Ninety-three studies were suitable for inclusion, describing 3701 patients (3711 fractures) with complex FRI. The population consisted predominantly of male patients (77%), with the tibia being the most commonly affected bone (64%), and a mean of three previous operations per patient. Forty-three (46%) studies described FRI at one specific location. Only one study (1%) used a standardized definition for infection. A total of nine different classifications were used to guide treatment protocols, of which Cierny and Mader was used most often (36%). Eighteen (19%) studies used a one-stage, 50 (54%) a two-stage, and seven (8%) a three-stage surgical treatment protocol. Ten studies (11%) used mixed protocols. Antibiotic protocols varied widely between studies. A multidisciplinary approach was mentioned in only 12 (13%) studies. CONCLUSIONS: This extensive literature review shows a lack of standardized guidelines with respect to diagnosis and treatment of FRI, which mimics the situation for prosthetic joint infection identified many years ago. Internationally accepted guidelines are urgently required to improve the quality of care for patients suffering from this significant complication.

Body mass index predicts perioperative complications following orthopaedic trauma surgery: an ACS-NSQIP analysis.

PURPOSE: The impact of obesity on outcomes has been documented extensively in the elective orthopaedic literature, but little is known about the impact of obesity on outcomes following orthopaedic trauma surgery. Utilizing the ACS-NSQIP database, we sought to investigate the relationship between BMI and perioperative complications in orthopaedic trauma patients. METHODS: 53,219 orthopaedic trauma patients were identified using a CPT code search between 2005 and 2013 in the NSQIP database. Patient demographics, and perioperative complications (including minor, major, and total) were collected. Multivariate regression analysis was performed to control for baseline demographics and comorbidities. RESULTS: Compared with patients of normal weight, underweight patients had significantly greater odds of minor [OR 1.12, 95 % CI (1.0, 1.26), p = 0.04], major [OR 1.20, 95 % CI (1.1, 1.3), p = 0.0009], and total complications [OR 1.18, 95 % CI (1.1, 1.3), p = 0.0003]. Morbidly obese patients had significantly greater odds of major [OR 1.22, 95 % CI (1.0, 1.5), p = 0.023] and total complications [OR 1.18, 95 % CI (1.0, 1.4), p = 0.023] compared to normal weight patients. When wound-related complications were examined independently, obesity was associated with increased odds of superficial [OR 1.67, 95 % CI (1.3, 2.1), p < 0.0001] and deep wound infection [OR 1.52, 95 % CI (1.075, 2.144), p = 0.018], and morbid obesity was associated with increased odds of wound dehiscence [OR 2.29, 95 % CI (1.1, 4.9), p = 0.034] and deep infection [OR 2.51, 95 % CI (1.6, 3.9), p < 0.0001]. CONCLUSIONS: Morbidly obese patients have significantly greater odds of wound dehiscence, deep wound infection, major complications, and total complications compared to patients of normal weight. Additionally, BMI under 18.5 is associated with increased odds of minor, major, and total perioperative complications. Interventions aimed at decreasing complication rates should be targeted at these high-risk patient populations on both ends of the BMI spectrum.

Do orthopaedic trauma patients develop higher rates of cardiac complications? An analysis of 56,000 patients.

PURPOSE: Less than 5 % of orthopaedic patients develop postoperative cardiac complications; however, there are little data suggesting which orthopaedic patients are at greatest risk. In an era where emerging reimbursement models place an emphasis on quality, reducing complications through perioperative planning will be of paramount importance for orthopaedic surgeons. The purpose of this study was to determine whether orthopaedic trauma patients are at greater risk for postoperative cardiac complications and to reveal which factors are most predictive of these complications. METHODS: All orthopaedic patients were identified in the 2006-2013 ACS-NSQIP database. Cardiac complications were defined as cardiac arrests or myocardial infarctions within 30 days following surgery. Chi squared analysis determined differences in cardiac complication rates between trauma and non-trauma patients. Bivariate analysis incorporating over 40 patient/surgical characteristics determined significant associations between patient characteristics and cardiac complications. These factors were incorporated into a multivariate regression model to identify predictive risk factors for cardiac complications. RESULTS: The presence of a traumatic injury resulted in greater odds of developing cardiac complications (OR: 1.645, p < 0.001). The cardiac complication rate in the trauma group was 1.3 % compared to 0.3 % in the non-trauma group (p < 0.001). For trauma patients, ventilator use (OR: 27.354, p = 0.004), recent transfusion (OR: 19.780, p = 0.001), and history of coma (OR: 17.922, p = 0.020) were most predictive of cardiac complications. CONCLUSION: Orthopaedic trauma patients are more likely to develop cardiac complications than non-trauma patients. To reduce cardiac complications, orthopaedic traumatologists should be aware of patient risk factors including ventilator use, blood transfusion, and history of coma.

The Gustilo-Anderson classification system as predictor of nonunion and infection in open tibia fractures.

PURPOSE: We sought to conduct the largest retrospective study to date of open tibia fractures and describe the incidence of complications and evaluate the potential predictive risk factors for complications. METHODS: Patients with open tibia fractures treated with reamed intramedullary nail (IMN) across a 10-year period were evaluated. Patient charts were reviewed for demographics, type of open fracture (T), comorbidities, and postoperative complications. A multivariate model was conducted to determine the risk factors for each type of complication. RESULTS: Of the 486 patients with open tibia fractures, 13 % (n = 64) had infections, 12 % (n = 56) had nonunions, and 1 % (n = 7) had amputations. TIII fractures had much higher rates of each complication than TI and TII fractures. Fracture type was the only significant risk factor for both nonunion and infection. CONCLUSION: Our study found that the Gustilo grade of open tibia fracture is by far the greatest predictor of nonunion and infection.

Predictors of 30-day mortality following hip/pelvis fractures.

INTRODUCTION: With the cost of healthcare in the United States reaching $2.9 trillion in 2013 and expected to increase with a growing geriatric population, the Center for Medicare and Medicaid Services (CMS) and Hospital Quality Alliance (HQA) began publicly reporting 30-day mortality rates so that hospitals and physicians may begin to confront clinical problems and promote high-quality and patient-centered care. Though the 30-day mortality is considered a highly effective tool in measuring hospital performance, little data actually exists that explores the rate and risk factors for trauma-related hip and pelvis fractures. Therefore, in this study, we sought to explore the risk factors associated with 30-day mortality in trauma-related hip and pelvic fractures. MATERIALS AND METHODS: Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, 341,062 patients undergoing orthopaedic procedures from 2005 to 2013 were identified through a Current Procedural Terminology (CPT) code search. A second CPT code search identified 24,805 patients who sustained a hip/pelvis fracture. Patient demographics, preoperative comorbidities, operative characteristics and postoperative complications were collected and compared using Chi-squared test, Wilcoxon-Mann-Whitney test and multivariate logistic regression analysis. RESULTS: Preoperative and postoperative risk factors for 30-day mortality following a hip/pelvis fracture were found: ASA classification, ascites, disseminated cancer, dyspnea, functional status, history of congestive heart failure (CHF), history of chronic obstructive pulmonary disease (COPD), a recent blood transfusion, and the postoperative complications: pneumonia, myocardial infarction, stroke, and septic shock. DISCUSSION: Several preoperative patient risk factors and postoperative complications greatly increased the odds for patient mortality following 30-days after initial surgery. Orthopaedic surgeons can utilize these predictive risk factors to better improve patient care. LEVEL OF EVIDENCE: Retrospective study. Level IV.

13-Year experience in external fixation of the pelvis: complications, reduction and removal.

PURPOSE: To evaluate the complications associated with anterior pelvic external fixation and the success of this device in maintaining reduction when used in conjunction with sacroiliac screws. METHODS: Through a retrospective clinical study at an academic Level I Trauma Center, 129 patients fit the criteria for inclusion with a mean duration of anterior pelvic external fixation of 62 days and mean follow-up of 360 days. Charts were reviewed for complications postoperatively. The symphysis diastasis, vertical displacement and posterior displacement of each hemipelvis were quantified from pelvic radiographs. RESULTS: Of the 129 patients receiving anterior pelvic external fixation, 14 (10.9 %) presented to an emergency department for problems with their anterior pelvic external fixation. Of these 14 patients, 7 (5.4 %) required readmission, all for infectious concerns necessitating IV antibiotics. 6 (4.7 %) required formal operative debridement and device removal. 13 patients (10.1 %) had superficial pin site infections successfully treated with oral antibiotics. Reduction was maintained (rated as fair, good or excellent) in all patients with radiographic follow-up (n = 74, average radiographic follow-up of 216 days) following removal of their anterior pelvic external fixation. 38 patients (30.4 %) had their anterior pelvic external fixation removed in clinic, while 87 (69.6 %) had formal removal in the operating room. CONCLUSION: While previous data suggest high complication rates in definitive anterior pelvic external fixation, we present the largest cohort of patients receiving anterior pelvic external fixation and sacroiliac screws, demonstrating a low complication rate while maintaining reduction of the pelvic ring. In addition, we found that these devices could be reliably removed in a clinic setting.

Open distal tibial shaft fractures: a retrospective comparison of medial plate versus nail fixation.

PURPOSE: Studies comparing open reduction internal fixation (ORIF) vs. intramedullary nailing (IMN) for distal tibia shaft fractures focus upon closed injuries containing small patient series with open fractures. As such, complication rates for open fractures are unknown. To characterize complications associated with ORIF vs. IMN, we compared complications based on surgical approach in a large patient series of open distal tibia shaft fractures. METHODS: Through retrospective analysis at an urban level I trauma center, 180 IMN and 36 ORIF patients with open distal tibia fractures from 2002 to 2012 were evaluated. Patient charts were reviewed to identify patient demographics, fracture grade (G), patient comorbidities, and postoperative complications including nonunion, malunion, infection, hardware-related pain, and wound dehiscence. Fisher's exact tests compared complications between ORIF and IMN groups. Multivariate regression identified risk factors with statistical significance for the development of a postoperative complication. RESULTS: One hundred and eighty IMN (G1 22, G2 79, and G3 79) and 36 ORIF (G1 10, G2 16, and G3 10) patients were included for analysis. ORIF patients had a higher rate of nonunion (25.0 %, n = 9) compared with IMN patients (10.6 %, n = 20, p = 0.03). No additional complication had a significant statistical difference between groups. Multivariable analysis shows only surgical method influenced the development of complications: ORIF patients had 2.52 greater odds of developing complications compared with IMN patients (95 % CI 1.05-6.02; p = 0.04). CONCLUSIONS: ORIF leads to higher rates of nonunion and significantly increases the odds of developing a complication compared with IMN for open distal tibia fractures. This is the first study investigating complication rates based on surgical approach in a large cohort of patients with exclusively open distal tibia fractures.

Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures.

OBJECTIVES: To document the incidence of late pain and hardware removal after open reduction and internal fixation (ORIF) of ankle fractures. To test the hypothesis that late pain overlying the distal tibial and fibular hardware is associated with poorer functional outcomes. DESIGN: Retrospective review. SETTING: Level II trauma center. PATIENTS: One hundred twenty-six skeletally mature patients undergoing ORIF of unstable malleolar fractures who were followed up for at least six months from injury were included. MAIN OUTCOME MEASUREMENTS: Analog pain score, Short Form-36 Health Survey (SF-36), and Short Form Musculoskeletal Functional Assessment (SMFA). RESULTS: Thirty-nine (31 percent) of the 126 patients had lateral pain overlying their fracture hardware. Twenty-nine patients (23 percent) had had their hardware removed or desired to have it removed. Of the twenty-two patients with hardware-related pain who had undergone hardware removal, only eleven had improvement in their lateral ankle pain; the mean analog pain score decreased from 6 +/- 3.16 (mean +/- standard deviation) before hardware removal to 3 +/- 2.9 after hardware removal (p = 0.008). In general, SF-36 and SMFA scores at final follow-up were significantly lower for patients who had pain overlying their lateral hardware than for those who had no pain. For the group of patients who had lateral ankle pain, no significant difference was noted in SMFA or SF-36 scores for patients who had and who had not had their lateral hardware removed (p > 0.5). CONCLUSION: The incidence of late pain overlying the distal tibial and fibular plate or screws is not insignificant. Although pain is generally decreased after hardware removal, nearly half of patients continue to have pain even after hardware removal. Functional outcome scores are poorer for patients with pain overlying lateral ankle hardware than in those with no pain at this location; this poorer outcome seems to be independent of whether the hardware was removed. Although the results of this study do not support or condemn the routine removal of fracture hardware after healing of unstable ankle fractures, they give orthopaedic surgeons some information that may assist them in counseling patients as to the expected functional outcome after ORIF of ankle fractures and the likelihood of relief of pain after removal of fracture hardware from the distal tibia and fibula.

A comparison of transferred versus direct admission orthopedic trauma patients.

Trauma patients with orthopedic injuries transferred to Harborview Medical Center (HMC) were compared with all trauma patients directly admitted to HMC and with a set of matched controls regarding injury Severity Score (ISS) and age, if > or = 50 years old. Groups were compared on ISS, Revised Trauma Score (RTS), ICU stay, length of stay (LOS), total charges, reimbursement, payors, and outcome. Comparison of all transferred patients and directly admitted patients showed significant differences in ISS, LOS, ICU stay, and total charges. Despite a higher ISS, transferred patients had no differences in RTS or survival outcome. Comparison of matched transferred patients and directly admitted patients on ISS and age if > or = 50 years old showed a statistically significant increase in LOS, reimbursement, and charges. The survival rate of all transferred and directly admitted trauma patients was approximately 95% for both groups despite a slightly higher degree of injury in transferred patients. The reimbursement rate for both groups was low, 65% for transferred patients and 59% for directly admitted patients. The percentage of transfer patients on Medicaid was 34% and for direct admissions was 37% (p = 0.552). This is a large percentage of indigent care, since only 8.1% of Washington State residents are Medicaid dependent.

Fracture-dislocation of the shoulder in a child: case report.

This is a case of an 11-year old girl with a delayed diagnosis of a shoulder fracture-dislocation. Shoulder dislocations are rare, and proximal humerus fractures are uncommon. A fracture-dislocation in a child is, to our knowledge, as yet unrepresented in the English-language literature. The child's injury resolved without recurrence.