Weight-based cefuroxime dosing provides comparable orthopedic target tissue concentrations between weight groups - a microdialysis porcine study.

Antibiotic prophylaxis is a key element in prevention of surgical site infections. For the majority of orthopedic procedures, antibiotic administration follows fixed dosing regimens irrespective of weight. However, this may result in insufficient antibiotic target tissue concentrations and higher risk of surgical site infections in obese individuals. The aim of this study was to investigate the effect of weight-based cefuroxime dosing on plasma and target tissue concentrations. Eighteen female pigs were allocated into three groups differentiated by weight: 53-57 kg, 73-77 kg, and 93-97 kg. Microdialysis catheters were placed for continuous sampling in bone, muscle, and subcutaneous tissue during an 8h sampling interval. Blood samples were collected as reference. Cefuroxime was administered intravenously as a bolus according to weight (20 mg/kg). The primary endpoint was the time above the cefuroxime minimal inhibitory concentration for Staphylococcus aureus (T > MIC (4 µg/mL)). Comparable target tissue T > MICs (4 µg/mL) were found between weight groups. Mean T > MIC ranged between 116-137 min for plasma, 118-154 min for bone, 109-146 min for the skeletal muscle, and 117-165 min for subcutaneous tissue across the groups. Weight-based cefuroxime (20 mg/kg) dosing approach provides comparable perioperative plasma and target tissue T > MIC (4 µg/mL) in animals between 50-100 kg body weight, and thus a comparable prophylaxis of surgical site infections.

Does UV Light as an Adjunct to Conventional Treatment Improve Healing and Reduce Infection in Wounds? A Systematic Review.

OBJECTIVE: To examine the effect of UV light on wound healing and infection in patients with skin ulcers or surgical incisions. Outcomes of interest included healing time, wound size and appearance, bacterial burden, and infection. DATA SOURCES: Ovid MEDLINE, Embase, Cochrane, PubMed, CINAHL, and Web of Science. STUDY SELECTION: Comparative and noncomparative clinical studies were considered, including observational cohort, retrospective, and randomized controlled studies. They addressed the research question: "Does the use of UV light as an adjunct to conventional treatment help improve healing and reduce infection in wounds?" Selection criteria included any English language study in adults who used UV light to improve wound healing and prevent or treat wound infection. DATA EXTRACTION: Authors extracted information pertaining to patient demographics, treatment protocols, and the following wound outcomes: appearance, healing time, infection, and bacterial burden. DATA SYNTHESIS: The search yielded 30,986 articles, and screening resulted in 11 studies that underwent final analysis. Of these (N = 27,833), seven (64%) demonstrated an improvement in healing outcomes with adjunctive UV therapy, and the results of four (36%) achieved statistical significance. CONCLUSIONS: There is limited research on the utility of adjunctive UV therapy to improve wound healing outcomes in humans. The majority of literature included in this review supported improved wound healing outcomes with adjuvant UV therapy. Future well-designed randomized controlled trials will be essential in further determining the benefit and utility of UV therapy in wound healing.

Usefulness of a Transumbilical Incision for Organ Removal in Laparoscopic Hepatectomy.

BACKGROUND/AIM: To evaluate the complication rates and risk factors associated with transumbilical wounds and investigate the usefulness of an incision for organ removal in laparoscopic hepatectomy (Lap-H). PATIENTS AND METHODS: We enrolled 42 patients who underwent Lap-H excluding a small partial resection in our hospital between 2013 and 2018. The occurrences of superficial surgical site infection (SSI) and transumbilical port-site incisional hernia were recorded. RESULTS: SSI was not observed, and hernia occurred in 3 patients (7.14%). Univariate analysis revealed that body mass index (BMI) (p=0.004) was significantly associated with the risk of hernia formation. CONCLUSION: High BMI is a risk factor for hernia formation in patients undergoing Lap-H with transumbilical incision; hence, wound closure should be performed carefully. The construction of the transumbilical wound for organ removal was feasible with rationality, with no need to create a new wound.

Bilateral-pectoral major muscle advancement flap combined with vacuum-assisted closure therapy for the treatment of deep sternal wound infections after cardiac surgery.

OBJECTIVES: The median sternotomy is the most common surgical approach for cardiac surgery. Deep sternal wound infection is a fatal complication after median sternotomy. The aim of this study was to evaluate the therapeutic effect of Bilateral-pectoral major muscle advancement flap combined with Vacuum-assisted closure therapy on rehabilitation for the treatment of deep sternal wound infection after cardiac surgery. METHODS: Between January 2016 to January 2018, 21 patients (10 males, 11 females) with deep sternal wound infection after cardiac surgery underwent Bilateral-pectoral major muscle advancement flap combined with Vacuum-assisted closure therapy. These patients were followed-up 12 months postoperative. The patient characteristics, duration of vacuum-assisted closure therapy, the mean hospital stay, postoperative complications, long-term survival of patients were retrospectively analyzed. RESULTS: Most patients undergone 1-3 times vacuum-assisted closure treatment sessions before closure. All patients were cured to discharge, the mean hospital stay was 21.1 days. Most patients' healing wounds were first-stage healing, only one patient's wound was second-stage healing, none was third-stage healing. One patient developed pulmonary infection and respiratory failure during the 12-month follow-up. None of the patients died during follow-up. CONCLUSIONS: Bilateral-pectoral major muscle advancement flap combined with Vacuum-assisted closure therapy for the treatment of deep sternal wound infections after cardiac surgery can shorten the hospital stays and few complications. However, this is a retrospective case series presentation with no comparison group, the number of inferences is limited, so further large-scale controlled studies are needed.

Safety of intraoperative hypothermia for patients: meta-analyses of randomized controlled trials and observational studies.

BACKGROUND: Previous studies have shown that intraoperative hypothermia was associated with higher risks of clinical adverse events, but we found otherwise from recent evidences. This study aims to synthesize the existing evidence evaluating safety of intraoperative hypothermia. METHODS: Articles, reviews, ongoing trials and grey literatures were retrieved from PubMed, The Cochrane Library, Clinical Trails and CNKI (a Chinese national database) till February 2nd, 2019. Both randomized controlled trials and observational studies compared incidences of all sorts of intra- and post-operative consequences between hypothermia and normothermia were included. Researches comparing different warming systems were excluded. We also examined risks of hypothermia using lowered standards (35.5 °C and 35 °C) from a Chinese trial (ChiCTR-IPR-17011099). RESULTS: A total of 9 RCT studies and 11 observational studies were included. RCT-synthesized results showed that intraoperative hypothermia was associated with higher risks of bleeding (MD = 131.90, 95%CI: 117.42, 146.38), surgical site infection (RD = 0.14, 95%CI: 0.06, 0.21) and shivering (RD = 0.32, 95%CI: 0.06, 0.58) but with no significant differences in duration of surgery, hospital stay or mortality. Observational study-synthesized evidences showed that intraoperative hypothermia did not result in higher risks in any of these adverse events. Results didn't change even if the standard of hypothermia was lowered by 0.5-1.0 °C. CONCLUSIONS: The study indicates that the synthesized risks resulted by intra-operative hypothermia might be overestimated and the eligibility of 36 °C to define hypothermia is not sensitive enough. Given body-temperature protection has not been popularized in China, it is still critical to normalize the hypothermia prevention at this stage.

Of Major Complication Types, Only Deep Infections After Spinal Fusion Are Associated With Worse Health-related Outcomes in Children With Cerebral Palsy.

STUDY DESIGN: Retrospective review. OBJECTIVE: The aim of this study was to determine whether major postoperative complications ("complications") are associated with 2-year improvements in Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) scores after scoliosis surgery, and whether complications and preoperative characteristics predict 2-year improvements in CPCHILD Total score. SUMMARY OF BACKGROUND DATA: Spinal arthrodesis can halt the progression of spinal deformity in patients with cerebral palsy (CP)-related scoliosis. However, these patients are prone to postoperative complications. METHODS: Using a multicenter CP registry, we identified 222 patients aged ≤21 years who underwent spinal fusion from 2008 to 2015 and had ≥2-year follow-up. We compared CPCHILD score improvement between 71 patients who had 1 or more complications ("complications group") versus 151 who did not ("no-complications group"). Complications were deep infections, thromboembolic events, and cardiopulmonary, gastrointestinal, and neurologic complications. Multiple linear regression was used to identify predictors of 2-year postoperative CPCHILD score improvement (alpha = 0.05). RESULTS: At 2-year follow-up, the complications group had similar mean improvement in CPCHILD score across all domains compared with the no-complications group (P > 0.05). When stratifying by complication type, deep infection was associated with less improvement in CPCHILD Comfort and Emotions (P = 0.02), Quality of Life (P < 0.01), and Total (P = 0.04) scores. When controlling for Gross Motor Function Classification System subcategory, age, and body mass index, only preoperative CPCHILD Total score and postoperative deep infection (F[4, 176] = 14; P < 0.0001; R = 0.24) predicted 2-year improvement in CPCHILD Total score. Higher preoperative Total score and postoperative deep infection independently predicted less improvement in Total score. CONCLUSION: Postoperative deep infection and higher preoperative CPCHILD Total score independently predicted less improvement in CPCHILD Total score. Other major postoperative complications were not associated with differences in 2-year postoperative improvements in CPCHILD scores across all domains. LEVEL OF EVIDENCE: 3.

The effectiveness of negative-pressure wound therapy for wound healing after stoma reversal: a randomised control study (SR-PICO study).

BACKGROUND: Although the wound-healing period for purse-string closure (PSC) after stoma reversal is longer than that required for the primary closure method, the rate of wound infection is reduced. The application of negative-pressure wound therapy (NPWT) can reduce the healing period for many types of wounds. Herein, we describe a planned trial to test the hypothesis that NPWT can reduce the healing period for PSC after stoma reversal. METHODS/DESIGN: Patients undergoing stoma reversal will be recruited and allocated into intervention and control groups, with 1:1 randomisation. Patients in the control group will receive standard postsurgical wound care; patients in the intervention group will receive NPWT using the PICO™ system. The target sample size will be 38 patients, as this will provide 80% power at the 5% level of significance to detect a 7-day reduction in the wound-healing period in the intervention group compared to that in the control group. The primary endpoint will be the duration to wound healing, defined as the time to nearly complete epithelisation of the wound, without any discharge or surgical site infection (SSI). Secondary endpoints will be the SSI rate, length of postoperative hospital stay, number of wound dressings and visits to the hospital for wound dressing after discharge, total cost of wound dressings, and patient and observer scar assessment scale scores. DISCUSSION: The results of this planned randomised controlled study will clarify the role of NPWT in patients undergoing stoma reversal and strengthen the rationale for choosing a dressing technique. TRIAL REGISTRATION: Clinical Research Information Service (CRIS), KCT0004063. Registered on 6 June 2019.

Reverse shoulder arthroplasty with a cementless short metaphyseal humeral prosthesis without a stem: survivorship, early to mid-term clinical and radiological outcomes in a prospective study from an independent centre.

INTRODUCTION: The use of reverse total shoulder arthroplasty has increased for the management of cuff-deficient glenohumeral joint arthritis and fractures. With bone preservation being a major target in reverse shoulder arthroplasty, metaphyseal humeral components without a stem were developed. The aim of this study is to present the survivorship, functional and radiological outcomes of a novel short metaphyseal prosthesis without a diaphyseal stem from an independent centre. METHODS: Clinical function and radiological features of patients undergoing stemless reverse shoulder arthroplasty were prospectively recorded. Patients' demographics, indications for surgery, complications, functional and radiological assessment at the final follow-up as well as survivorship with the end point of revision for any reason were recorded. RESULTS: Between 2009 and 2016, 36 patients received 37 reverse shoulder arthroplasties with the stemless Verso prosthesis. Mean age of the patients was 76.9 years. The most common indication for surgery was cuff tear arthropathy. Mean follow-up was 3 years (range 1-7 years). Oxford shoulder score improved from an average of 11 pre-operatively (range 2-19) to 44 post-operatively (range 29-48) (p < 0.0001). There was one case of a deep post-operative infection that needed washout, liner exchange with retention of the prosthesis. Radiographic analysis showed no lucencies, or stress shielding around the humeral or glenoid components. Constant score at the final follow-up was on average 63 (range 35-86). Activities of daily living with requirement for internal and external rotation score (ADLEIR) was on average 12 pre-operatively (range 0-27) and 31 post-operatively (range 18-36) (p < 0.0001). There was 100% survivorship of the prosthesis in this early to mid-term study. CONCLUSION: This early to mid-term prospective study demonstrates excellent survivorship and radiological results of the Verso reverse shoulder replacement. It needs a simple reproducible technique, and the results have been replicated at an independent centre. This study underlines its survivorship in the early to mid-term and confirms lower incidence of complications such as instability, notching, loosening and the need for revision surgery. Most importantly, it conserves the humeral bone stock for revision arthroplasties in the future. Our results are similar to those of the currently published literature.

Effects of intraoperative temperatures on postoperative infections in infants and neonates.

BACKGROUND: Perioperative hypothermia has been shown to increase surgical site infection (SSI) rates in adults. We sought to characterize whether intraoperative hypothermia or hyperthermia is associated with postoperative infections in infants. METHODS: We conducted a retrospective review of patients ≤6 months old who underwent surgical procedures from November 2013 to October 2015 at a Level I ACS Children's Surgical Center. The outcome was infections within 30 days after operation, with particular attention to SSI. Data obtained included weight and age at surgery, American Society of Anesthesiologists (ASA) physiologic status, wound class, case length, blood transfusion within 72 h of surgery, and administration of prophylactic antibiotics. Temperatures were classified as hypothermia (T < 36 °C), normothermia (T = 36.0 to 37.9 °C), and hyperthermia (T ≥ 38 °C). RESULTS: The 885 patients had 25 SSIs (2.8%) and 11 nonsurgical site infections (1.2%). On univariate analysis, weight at surgery, higher ASA, perioperative transfusions, and longer case length were associated with higher rate of SSI. Higher median Thigh, higher median T low, and any hyperthermia were associated with higher rate of SSI. On multivariable logistic regression adjusted analyses, hyperthermia at any time during the case was associated with SSI (OR 3.47, [95% CI 1.34, 9.04], p = 0.011). Transfusions were also associated with higher SSI rates (OR 3.60 [95% CI, 1.28, 10.3], p = 0.016). CONCLUSIONS: Intraoperative hyperthermia is associated with increased SSI rates in infants. LEVEL OF EVIDENCE: III.

Ileal Pouch Complications.

Complications after ileal pouch surgery can result in poor pouch function and can have a significant negative impact on a patient's quality of life. Timely diagnosis and appropriate management of complications allows for the best chance of pouch salvage. Many complications require a multimodal approach. As with any reoperative surgery, the success of surgical revision or redo of an ileal pouch is highly dependent on the skill, judgment, and experience of the surgeon and requires an extremely motivated patient.

Effectiveness and complications of primary C-clamp stabilization or external fixation for unstable pelvic fractures.

BACKGROUND AND PURPOSE: Unstable pelvic fractures frequently require emergency stabilization using a C-clamp or external (CC/EF) fixation. However, the effectiveness of this intervention and associated complications are still a matter of debate. PATIENTS AND METHODS: The analysis used data available from the German Pelvic Trauma Registry to study general complications, infections and mortality after primary stabilization using CC/EF in 5,499 patients (n = 957 with vs n = 4,542 without). Furthermore, the subgroups with secondary surgery (n = 713 vs n = 1,695), and ilio-sacral screw implantation following C-clamp stabilization were evaluated (n = 24 vs n = 219). Calculated odds ratios were adjusted for potential confounders. RESULTS: Patients treated by CC/EF were younger (45 ± 20 vs 62 ± 24 years), had more C-type fractures (65% vs 28%), higher ISS (≥25 63% vs 20%) and displacement (≥3 mm 81% vs 41%), and more complex fractures (32% vs 5%). These features were independent risk factors for complications (p < 0.001). While mortality was reduced after CC/EF stabilization by 32% (OR 0.68 95%CI 0.49-0.95), the risk for general complications was slightly increased (OR 1.25 95% CI 1.02-1.53). In patients undergoing secondary surgery, CC/EF fixation had no influence on mortality, general complications or infections. Related to preceding C-clamp stabilization (OR 4.67 95% CI 1.06-20.64), the risk for infection increased from 3.2% to 20.8% in ilio-sacral screw fixation. INTERPRETATION: Primary stabilization of unstable pelvic fractures with C-clamp or external fixation is associated with a decreased mortality and was not an independent risk factor for complications after secondary surgery. However, the risk for infection after ilio-sacral screw fixation increased almost 5-fold after C-clamp use.

Hyperglycemia as a risk factor for postoperative early wound infection after bicondylar tibial plateau fractures: Determining a predictive model based on four methods.

OBJECTIVES: Identify a glucose threshold that would put patients with isolated bicondylar tibial plateau fractures at risk of early wound infection (i.e. < 90 days). DESIGN: Retrospective review of medical records. SETTING: Academic American College of Surgeons (ACS) Level 1 trauma center. PATIENTS: Adult patients between 2010 and 2015 with an operatively treated isolated bicondylar tibial plateau fracture and at least three glucose measurements during their hospitalization. MAIN OUTCOME MEASUREMENT: To predict infection using four different methods: maximum preoperative blood glucose (PBG), maximum blood glucose (MGB), Hyperglycemic Index (HGI), and Time-Weighted Average Glucose (TWAG). RESULTS: 126/381 patients met our inclusion criteria. Fifteen (12%) patients had an open fracture and 30/126 (23%) developed an infection. Median glucose for each predictive method studied was 114 (IQR 101.2-137.8) mg/dL for PBG, 144 (IQR 119-169.8) mg/dL for MBG, 0.8 (IQR 0.20-1.60) mmol/L for HGI, and 120.4 (IQR 106.0-135.6) mg/dL for TWAG. As expected, infected patients had higher PBG, MGB, and TWAG. HGI was similar in both groups. None of these differences prove to be statistically significant (p > .05). Logistic regression models for all the methods showed that having an open fracture was the strongest predictor of infection. CONCLUSION: It is well known that stress-induced hyperglycemia increases the risk of infection, we present and compare four models that have been used in other medical fields. In our study, none of the methods presented identified a glucose threshold that would increase the risk of infection in patients with bicondylar tibial plateau fractures. LEVEL OF EVIDENCE: Retrospective review, Level III. See Instructions for Authors for a complete description of levels of evidence.

Atypical and Life-threatening Crohn's Disease Following Colectomy: A Case Report.

Although Crohn's Disease (CD) usually occurs between the second and third decade of life, it also may develop in older adults. Treating elderly patients may be challenging due to other comorbidities, including diverticular disease or intestinal ischemia. PURPOSE: The purpose of this case study was to describe successful treatment of atypical and life-threatening CD due to enterocutaneous fistulas with short-bowel syndrome and multiorgan failure after partial colectomy. CASE REPORT: After an urgent colectomy for an inflammatory colon tumor, a 64-year-old woman with a history of CD and multiple comorbidities developed acute small bowel ischemia. Following an extended bowel resection, she developed a severe surgical site infection, entero- and gastrocutaneous fistulas, multiorgan failure, and short bowel syndrome. Her care included intensive medical and nutritional treatment as well as negative pressure wound therapy (NPWT) using continuous negative pressure of -80 mm Hg. She not only survived, but she also achieved complete wound closure and restoration of digestive tract continuity and metabolic control. She was discharged with a central venous catheter on total parenteral nutrition. CONCLUSION: In this case study, a good outcome was observed using intensive medical treatment, nutritional therapy, and conservative surgical treatment that included NPWT for a patient with CD and major comorbidities who developed postoperative complications.

Development of a 'universal-reporter' outcome measure (UROM) for patient and healthcare professional completion: a mixed methods study demonstrating a novel concept for optimal questionnaire design.

OBJECTIVES: To describe the novel concept of, and methods for developing, a 'universal-reporter' outcome measure (UROM); a single questionnaire for completion by patients and/or healthcare professionals (HCPs) when views on the same subject are required. DESIGN: A mixed methods study with three phases-phase I: identification of relevant content domains from existing clinical tools, patient questionnaires and in-depth interviews with multistakeholders; phase II: item development using a novel approach that considered plain language in conjunction with medical terminology; and phase III: pretesting with multistakeholders using cognitive interviews. SETTING: A case study in surgical wound assessment undertaken in two UK hospital trusts and one university setting. PARTICIPANTS: Patients who had recently undergone general abdominal surgery and healthcare professionals involved in post-surgical wound care. RESULTS: Phase I: In the example case study, 19 relevant content domains were identified from two clinical tools, two patient questionnaires and 19 multistakeholder interviews (nine patients, 10 HCPs). Phase II: Domains were operationalised into items and subitems (secondary components to collect further information, if relevant). The version after pretesting had 16 items, five of which included further subitems. Plain language in conjunction with medical terminology was applicable in nine (27%) items/subitems. Phase III: Pretesting with 28 patients and 14 HCPs found that the UROM was acceptable to both respondent groups. An unanticipated secondary finding of the study was that the combined use of plain language and medical terminology during questionnaire development may be a useful, novel technique for evaluating item interpretation and thereby identifying items with inadequate content validity. CONCLUSION: UROMs are a novel approach to outcome assessment that are acceptable to both patients and HCPs. Combining plain language and medical terminology during item development is a recommended technique to improve accuracy of item interpretation and content validity during questionnaire design. More work is needed to further validate this novel approach and explore the application of UROMs to other settings.

Body mass index: Implications on disease severity and postoperative complications in patients with Crohn's disease undergoing abdominal surgery.

BACKGROUND: Obesity is increasing in prevalence among patients with Crohn's disease, but how body mass index affects disease severity and postoperative outcomes remains unknown. METHODS: A retrospective review of ileocolic resections for Crohn's disease performed at a single institution between January 2007 and December 2017 was conducted. On the day of surgery, patients were grouped by body mass index into underweight, normal weight, overweight, and obese categories. Intergroup comparisons and trend tests were performed on disease characteristics and postoperative outcomes. A multivariable model for superficial surgical site infection was constructed. RESULTS: A total of 758 patients were identified; 80 (11%) patients were underweight, 372 (49%) were normal weight, 178 (23%) were overweight, and 128 (17%) were obese. Both fistulizing Crohn's phenotype and preoperative immunosuppression occurred less frequently in obese patients compared with other body mass index groups (both P < 0.01). Conversion to open surgery and superficial surgical site infection were increased in obese patients, and obesity was an independent risk factor for superficial surgical site infection on multivariable analysis (odds ratio 3.0, 95% confidence interval: 1.6-5.6). CONCLUSION: Although obese patients had less severe Crohn's disease at the time of surgery, they experienced increased postoperative infectious complications. Preoperative weight loss and consideration of alternative wound closure methods may reduce these complications.

Infection after operative fixation of tibia plateau fractures. A risk factor analysis.

INTRODUCTION: Surgical fixation of tibial plateau fractures has been shown to improve long-term functional outcomes, but a major complication is that of postoperative infection which can be deleterious to long-term outcomes. This study aims to assess the impact of common comorbidities on the risk of postoperative infection. METHOD: A retrospective study of 210 consecutive operatively treated patients, treated at two Level 1 Trauma Centres over a 27-month period was performed. Records were analysed to assess the presence of the study factors; smoking, alcohol intake >13 units/week, diabetes, and BMI > 30. The impact of these factors on infection was assessed with univariate and multivariate analyses. RESULTS: 175 patients were included in the study, 56.6% male with a mean age of 46.9 years (± 18.2 years). Excessive alcohol consumption of >13 units/week was the only significant risk factor for postoperative infection (p = 0.05) on multivariate analysis. CONCLUSION: This study has identified excessive alcohol consumption as the only independent risk factor for postoperative infection in patients with all types of tibial plateau fracture treated with operative fixation. No relationship between smoking, diabetes nor obesity was found for postoperative infection.

ZnO-NPs embedded biodegradable thiolated bandage for postoperative surgical site infection: In vitro and in vivo evaluation.

Post-operative surgical site infections (SSI) present a serious threat and may lead to complications. Currently available dressings for SSI lack mucoadhesion, safety, efficacy and most importantly patient compliance. We aimed to address these concerns by developing a bioactive thiolated chitosan-alginate bandage embedded with zinc oxide nanoparticles (ZnO-NPs) for localized topical treatment of SSI. The FTIR, XRD, DSC and TGA of bandage confirmed the compatibility of ingredients and modifications made. The porosity, swelling index and lysozyme degradation showed good properties for wound healing and biodegradation. Moreover, in-vitro antibacterial activity showed higher bactericidal effect as compared to ZnO-NPs free bandage. In-vivo wound healing in murine model showed significant improved tissue generation and speedy wound healing as compared to positive and negative controls. Over all, thiolated bandage showed potential as an advanced therapeutic agent for treating surgical site infections, meeting the required features of an ideal surgical dressing.

Outcome Assessment of Z-shaped Osteotomy in the Management of Humeral Shaft Nonunion Secondary to Failed Plate Osteosynthesis.

Restoration of fracture alignment by osteotomy is crucial for the management of humeral nonunion. In the present study, we introduced a new way of osteotomy (Z-shaped) in treating humeral shaft nonunion secondary to failed plate osteosynthesis. Clinical data of 24 patients with humeral shaft nonunion following implant failure (from 2010 to 2014) were retrospectively evaluated. These patients underwent Z-shaped osteotomy in revision surgery after the initial surgery, plate osteosynthesis, was failed. Outcomes were evaluated using visual analogue scale (VAS) and Constant and Murley score. Repeated analysis of variance (ANOVA) was used for statistical analysis. Patients were followed up for a minimum of 24 months (26.83±4.33 months). The operative time was 102.33±10.16 min, and hospital stay averaged 9.75±2.13 days. All patients achieved clinical union at the latest follow-up. Complications included radial palsy (n=1) and superficial wound infection (n=1). The postoperative VAS scores decreased significantly compared to preoperative score (F=257.99, P<0.01). Constant and Murley score increased and reached 81.33±0.95 at 24 months' follow-up (F=247.35, P<0.01). Among all the cases, 15 cases were graded as "excellent", and 9 as "good". In conclusion, Z-shaped osteotomy was easy to perform, and it provided additional medial support with more bone contact areas. Revision surgery using locking plate and Z-shaped osteotomy achieved high union rate and improved functional outcome. It was a reasonable and safe option for treating humeral nonunion following implant failure.

Increased perioperative C-reactive protein and decreased postoperative albumin is associated with acute posttraumatic osteomyelitis in patients with high-energy tibial fractures.

BACKGROUND: Early diagnosis of acute posttraumatic osteomyelitis (POM) is of vital importance for avoiding devastating complications. Diagnosing POM is difficult due to the lack of a highly specific and sensitive test, such as in myocardial infarct, stroke and intracranial bleeding. Serum inflammatory markers, C-reactive protein (CRP), procalcitonin (PCT), white blood cells (WBC) can support clinical findings but they are not able to differentiate between inflammatory response to infection and the host response to non-infection insult with high specificity and sensitivity. AIM: The objectives of the study were to investigate whether the biochemical and immunoinflammatory patient profile could facilitate postoperative monitoring, guide the antibiotic treatment and timing of revision surgery. PATIENTS AND METHODS: This prospective nonrandomised cohort study included 86 patients after high-energy injury to the shin requiring primary surgical treatment (open or closed reduction and internal fixation of tibial fracture). Values of the biochemical and immunoinflammatory profile were measured on admission (ADD), first postoperative day (POD1) and fourth-postoperative day (POD4). RESULTS: We discovered on our sample that the development of POM is associated with increased CRP on ADD, POD1 and decreased albumins on POD4. Further studies are needed to prove that these differences can be useful in diagnosing the risk of infection. The assessment of other important risk factors such as: the extent of soft tissue damage, multiple fractures, transfusion rate, need for conversion primary external fixation to intramedullary (IM) nailing or locking plate fixation can empower our clinical judgment of POM. CONCLUSIONS: We can improve prediction of posttraumatic osteomyelitis by using the perioperative inflammatory biomarker CRP in combination with postoperative albumins levels and other associated independent risk factors.

Gross Motor Function Classification System Specific Growth Charts-Utility as a Risk Stratification Tool for Surgical Site Infection Following Spine Surgery.

BACKGROUND: There is currently minimal evidence that preoperative malnutrition increases surgical site infection (SSI) risk in children with cerebral palsy (CP) undergoing spinal deformity surgery. Growth charts specifically for patients with CP have been created to aid in the clinical interpretation of body mass index (BMI) as a marker of nutritional status, but to our knowledge these charts have never been used to risk stratify patients before orthopaedic surgery. We hypothesize that patients with CP who have BMI-for-age below the 10th percentile (BMI≤10) on CP-specific growth charts are at increased risk of surgical site infection following spinal deformity surgery compared with patients with BMI-for-age above the 10th percentile (BMI>10). METHODS: Single-center, retrospective review comparing the rate of SSI in patients with CP stratified by BMI-for-age percentiles on CP-specific growth charts who underwent spinal deformity surgery. Odds ratios with 95% confidence intervals and Pearson χ tests were used to analyze the association of the measured nutritional indicators with SSI. RESULTS: In total, 65 patients, who underwent 74 procedures, had complete follow-up data and were included in this analysis. Ten patients (15.4%) were GMFCS I-III and 55 (84.6%) were GMFCS IV-V; 39 (60%) were orally fed and 26 (40%) were tube-fed. The rate of SSI in this patient population was 13.5% with 10 SSIs reported within 90 days of surgery. There was a significant association between patients with a BMI below the 10th percentile on GMFCS-stratified growth charts and the development of SSI (OR, 13.6; 95% CI, 2.4-75.4; P=0.005). All SSIs occurred in patients that were GMFCS IV-V. There was no association between height, weight, feeding method, or pelvic instrumentation and development of SSI. CONCLUSIONS: CP-specific growth charts are useful tools for identifying patients at increased risk for SSI following spinal instrumentation procedures, whereas standard CDC growth charts are much less sensitive. There is a strong association between preoperative BMI percentile on GMFCS-stratified growth charts and SSI following spinal deformity surgery. LEVEL OF EVIDENCE: Level III-Retrospective Study.