Soft-tissue reconstruction in lower-leg fracture-related infections: An orthoplastic outcome and risk factor analysis.

Introduction Fracture-related infection (FRI) is a severe post-traumatic complication which is occasionally accompanied by a deficient or even avital soft-tissue envelope. In these cases, a thoroughly planned orthoplastic approach is imperative as a vital and intact soft-tissue envelope is mandatory to achieve fracture union and infection eradication. The aim of this study was, to analyse if soft-tissue reconstruction (STR) without complications is associated with a better long-term outcome compared to FRI patients with STR complications. In particular, it was investigated if primary flap failure represented a risk factor for compromised fracture union and recurrence of infection. Patients and Methods Patients with a lower leg FRI requiring STR (local, pedicled and free flaps) who were treated from 2010-18 at the University Hospital Basel were included in this retrospective analysis. The main outcome measure was the success rate of STR, further outcome measures were fracture nonunion and recurrence of infection. Results Overall, 145 patients with lower leg FRI were identified, of whom 58 (40%) received STR (muscle flaps: n = 38, fascio-cutaneous flaps: n=19; composite osteo-cutaneous flap: n = 1). In total seven patients required secondary STR due to primary flap failure. All failures and flap-related complications occurred within the first three weeks after surgery. Secondary STR was successful in all cases. A high Charlson Comorbidity Index Score was a significant risk factor for flap failure (p = 0.011). Out of the 43 patients who completed the 9-month follow-up, 11 patients presented with fracture nonunion and 12 patients with a recurrent infection. Polymicrobial infection was a significant risk factor for fracture nonunion (p = 0.002). Primary flap failure was neither a risk factor for compromised fracture consolidation (p = 0.590) nor for recurrence of infection (p = 0.508). Conclusion: A considerable number of patients with lower-leg FRI required STR. This patient subgroup is complex and rich in complications and the long-term composite outcome demonstrated a high rate of compromised fracture consolidation and recurrent infections. It appears that secondary STR should be performed, as primary flap failure was neither a risk factor for compromised fracture consolidation nor for recurrence of infection. We propose to monitor these patients closely for three weeks after STR.

Outcomes of Hospitalized Patients with Glucocorticoid-Induced Hyperglycemia-A Retrospective Analysis.

BACKGROUND: Glucocorticoid (GC)-induced hyperglycemia is a frequent side effect in hospitalized patients. Guidelines recommend treat-to-target treatment between 6-10 mmol/L (108-180 mg/dL) with insulin, but data on outcome is scarce. We investigated the 30-day outcome in hospitalized patients receiving GCs. METHODS: All patient records of hospitalized patients between January 2014 and April 2018 were screened for GC administration and consecutive hyperglycemia. The primary combined endpoint consisted of death, cardiovascular events, and infections until 30 days after admission. Hypoglycemia was a secondary outcome. RESULTS: Of the 2424 hospitalized patients (9.6% of all hospitalized patients) who received systemic GCs and met inclusion criteria, the overall incidence for GC-induced hyperglycemia was 812 (33.5%), and 89 (3.7%) had at least one documented hypoglycemia during their hospital stay. Compared to patients with normoglycemia, GC-induced hyperglycemia had an adjusted-odds ratio of 1.68 (95% CI 1.25-2.26) for the combined primary endpoint. Hypoglycemia even had an odds ratio of 1.95 (95% CI 1.2-3.17). CONCLUSIONS: Mortality, cardiovascular events, and rate of infections were markedly higher in patients with GC-induced hyperglycemia as compared to patients with normoglycemia. Importantly, hypoglycemia was associated with a doubled risk for adverse outcome. Future studies should evaluate whether optimized glucose control by minimizing the risk for hypoglycemia has a beneficial effect on clinical outcomes in patients with GC-induced hyperglycemia.