RESUMO
BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).
Assuntos
Anti-Infecciosos Locais , Clorexidina , Fixação de Fratura , Fraturas Ósseas , Iodo , Infecção da Ferida Cirúrgica , Humanos , 2-Propanol/administração & dosagem , 2-Propanol/efeitos adversos , 2-Propanol/uso terapêutico , Anti-Infecciosos Locais/administração & dosagem , Anti-Infecciosos Locais/efeitos adversos , Anti-Infecciosos Locais/uso terapêutico , Antissepsia/métodos , Canadá , Clorexidina/administração & dosagem , Clorexidina/efeitos adversos , Clorexidina/uso terapêutico , Etanol , Extremidades/lesões , Extremidades/microbiologia , Extremidades/cirurgia , Iodo/administração & dosagem , Iodo/efeitos adversos , Iodo/uso terapêutico , Cuidados Pré-Operatórios/efeitos adversos , Cuidados Pré-Operatórios/métodos , Pele/microbiologia , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Fraturas Ósseas/cirurgia , Estudos Cross-Over , Estados UnidosRESUMO
This study's objective was to identify a difference in maximum temperature change during forward versus oscillating drilling of cadaveric bone. Paired femurs were dissected from the soft tissue of five cadavers. Each cadaver had one femur assigned to forward and the other to oscillation. The first drill hole was 2.5 cm distal to the lesser trochanter and the remaining 10 holes were evenly spaced 2 cm apart. A System 7 drill and 3.5 mm drill bit were attached to an Instron 5500R to provide a progressive force of 50 Newtons per minute for each drill hole. A thermal camera recorded each drilling. A new drill bit was used for each femur. Fifty bicortical drillings were analyzed in each group. The average time to complete forward drilling (45.0 seconds) was shorter compared to oscillation (55.5 s, p < 0.001). The average force required for forward drilling (27.7 N) was lower than for oscillation (44.3N, p < 0.001). The maximum change in temperature during the drilling process was similar (oscillating 100.2° F vs. forward 100.7° F, p = 0.871). The maximum change in temperature at the near cortex was lower for oscillation (78.1°F) compared to forward drilling (89.1°F, p = 0.011), while the maximum change at the far cortex was lower for forward drilling (89.3°F) compared to oscillation (95.8°F, p = 0.115) but not significantly. Overall, there is no difference in the thermal output between techniques. Oscillation may be beneficial in proximity to vital structures or to navigate narrow bony corridors, but it requires additional time and force. (Journal of Surgical Orthopaedic Advances 31(4):233-236, 2022).
Assuntos
Osso e Ossos , Procedimentos Ortopédicos , Humanos , Temperatura , Osso e Ossos/cirurgia , Fêmur/cirurgiaRESUMO
BACKGROUND: Prompt administration of antibiotics is a critical component of open fracture treatment. Traditional antibiotic recommendations have been a first-generation cephalosporin for Gustilo Type-I and Type-II open fractures, with the addition of an aminoglycoside for Type-III fractures and penicillin for soil contamination. However, concerns over changing bacterial patterns and the side effects of aminoglycosides have led to interest in other regimens. The purpose of the present study was to describe the adherence to current prophylactic antibiotic guidelines. METHODS: We evaluated the antibiotic-prescribing practices of 24 centers in the U.S. and Canada that were participating in 2 randomized controlled trials of skin-preparation solutions for open fractures. A total of 1,234 patients were evaluated. RESULTS: All patients received antibiotics on the day of admission. The most commonly prescribed antibiotic regimen was cefazolin monotherapy (53.6%). Among patients with Type-I and Type-II fractures, there was 61.1% compliance with cefazolin monotherapy. In contrast, only 17.2% of patients with Type-III fractures received the recommended cefazolin and aminoglycoside therapy, with an additional 6.7% receiving piperacillin/tazobactam. CONCLUSIONS: There is moderate adherence to the traditional antibiotic treatment guidelines for Gustilo Type-I and Type-II fractures and low adherence for Type-III fractures. Given the divergence between current practice patterns and prior recommendations, high-quality studies are needed to determine the most appropriate prophylactic protocol.
Assuntos
Antibacterianos/uso terapêutico , Antibioticoprofilaxia/estatística & dados numéricos , Fixação de Fratura/efeitos adversos , Fraturas Expostas/cirurgia , Fidelidade a Diretrizes/estatística & dados numéricos , Infecção da Ferida Cirúrgica/epidemiologia , Adulto , Antibioticoprofilaxia/normas , Cefazolina/uso terapêutico , Esquema de Medicação , Feminino , Fraturas Expostas/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Fatores de TempoRESUMO
CASE: An open obturator dislocation with associated pelvic ring injury and perineal wound underwent fixation and aggressive debridement. Despite this, the patient proceeded to infection requiring additional debridements and prolonged intravenous antibiotics. At 18 months postinjury, the patient developed avascular necrosis and significant heterotopic ossification; however, she was able to ambulate. CONCLUSIONS: Open obturator dislocations of the hip require a multidisciplinary team. Despite prompt antibiotic therapy and aggressive debridement, patients are at high risk of infection because of the microbial environment in this region. Open obturator hip dislocations are at significant risk of avascular necrosis despite timely reduction.
Assuntos
Fixação Intramedular de Fraturas , Fraturas Cominutivas/cirurgia , Luxação do Quadril/cirurgia , Ossos Pélvicos/lesões , Períneo/lesões , Acidentes de Trânsito , Adolescente , Feminino , Necrose da Cabeça do Fêmur/etiologia , Fraturas Cominutivas/complicações , Fraturas Cominutivas/diagnóstico por imagem , Luxação do Quadril/complicações , Luxação do Quadril/diagnóstico por imagem , Humanos , Osteomielite/etiologia , ReoperaçãoRESUMO
OBJECTIVES: To compare the efficiency, radiation exposure to surgeon and patient, and accuracy of C-arm versus O-arm with navigation in the placement of transiliac-transsacral and iliosacral screws by an orthopaedic trauma fellow, for a surgeon early in practice. METHODS: Twelve fresh frozen cadavers were obtained. Preoperative computed tomography scans were reviewed to assess for safe corridors in the S1 and S2 segments. Iliosacral screws were assigned to the S1 segment in dysmorphic pelvises. Screws were randomized to modality and laterality. An orthopaedic trauma fellow placed all screws. Time of procedure and radiation exposure to the cadaver and surgeon were recorded. Three fellowship-trained orthopaedic trauma surgeons rated the safety of each screw on postoperative computed tomography scan. RESULTS: Six normal and 6 dysmorphic pelvises were identified. Eighteen transiliac-transsacral screws and 6 iliosacral screws were distributed evenly between C-arm and O-arm. Average operative duration per screw was significantly shorter using C-arm compared with O-arm (15.7 minutes ± 6.1 vs. 23.7 ± 8.5, P = 0.014). Screw placement with C-arm exposed the surgeon to a significantly greater amount of radiation (3.87 × 10 rads vs. 0.32 × 10, P < 0.001) while O-arm exposed the cadaver to a significantly greater amount of radiation (0.03 vs. 2.76 rads, P < 0.001). Two S2 transiliac-transsacral screws (1 C-arm and 1 O-arm) were categorized as unsafe based on scoring. There was no difference in screw accuracy between modalities. CONCLUSIONS: A difference in accuracy between modalities could not be elucidated, whereas efficiency was improved with utilization of C-arm, with statistical significance. A statistically significant increase in radiation exposure to the surgeon using C-arm was found, which may be clinically significant over a career. The results of this study can be extrapolated to a fellow or surgeon early in practice. The decision between use of these modalities will vary depending on surgeon preference and hospital resources.
Assuntos
Exposição à Radiação , Cirurgiões , Cirurgia Assistida por Computador , Parafusos Ósseos , Cadáver , Humanos , Imageamento Tridimensional , Exposição à Radiação/prevenção & controle , Sacro/diagnóstico por imagem , Sacro/cirurgia , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVES: To report on our results using a proximal femoral locking plate for the treatment of peritrochanteric femur fractures. DESIGN: Retrospective study. SETTING: Level I Academic Medical Center. PATIENTS: Sixty-eight patients with 68 fractures. INTERVENTION: Demographics, fracture morphology, preoperative imaging, rationale against nailing, and outcomes were collected. MAIN OUTCOME MEASUREMENTS: Outcomes were grouped into no complication, minor complication, or major complication. Minor complications included healed fractures with implant failure or change in alignment from immediate postoperative radiographs, which did not require intervention or elective implant removal. Major complications included any case that required revision for nonunion or implant failure. RESULTS: Nine patients were lost to follow-up. Of the 59 fractures, 16 had complications (27%): 9 minor and 7 major. Active tobacco use (P = 0.020) and fractures with an associated intracapsular femoral neck component (P = 0.006) correlated with complications. CONCLUSIONS: Proximal femoral locking plates continue to be associated with a high complication rate. However, based on our experience, proximal femoral locking plates may be considered in highly selected cases when absolutely no other implant is deemed appropriate, based on the degree of comminution and the complexity of the fracture pattern. Patients must be informed about the possibility of revision surgery based on the inherent limitations of these devices. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Placas Ósseas , Fraturas do Fêmur/cirurgia , Fixação Interna de Fraturas/métodos , Consolidação da Fratura , Parafusos Ósseos , Fraturas do Fêmur/diagnóstico , Seguimentos , Humanos , Radiografia , Estudos RetrospectivosRESUMO
Fixation of young femoral neck fractures represents a challenge in the field of orthopaedic trauma surgery. Conventional methods, including cannulated screw and sliding hip screw constructs, have been studied and found to have similar results with regards to patient outcomes, which has made choosing an optimum fixation strategy difficult. In all of these cases, quality of reduction has been shown to be the most important factor when it comes to creating a favorable environment for fracture healing. Some of these patients, however, continue to have negative sequelae including nonunion, avascular necrosis, femoral head collapse, and poor hip function as a result. In this article, we review the 2 most commonly used constructs and present 2 novel fixation constructs for the fixation of femoral neck fractures in physiologically young patients, including the Smith & Nephew Conquest system and the Aesculap Targon system. We outline techniques for usage of these systems and proposed advantages to these systems compared with conventional fixation methods. We also discuss the results of previously published studies regarding conventional fixation methods and compare with some limited studies that have been published on these newer technologies.
Assuntos
Parafusos Ósseos , Fraturas do Colo Femoral/cirurgia , Cabeça do Fêmur/cirurgia , Fixação Interna de Fraturas/métodos , Consolidação da Fratura , Fraturas do Colo Femoral/diagnóstico , Cabeça do Fêmur/diagnóstico por imagem , Humanos , RadiografiaRESUMO
Percutaneous iliosacral screw (IS) fixation for pelvic ring injuries with the use of an O-arm imaging system has been associated with decreased procedure time and improved accuracy of IS screw placement compared with the use of fluoroscopic guidance. Specifically, patients with sacral dysmorphism require identification of safe bony sacral corridors, using specific anatomical measurements, to decrease the likelihood of complications such as screw perforation. Intraoperative computed tomography imaging and navigation can aid in safe and accurate IS screw fixation in patients with difficult anatomy.
Assuntos
Fixação Interna de Fraturas/métodos , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/cirurgia , Ossos Pélvicos/lesões , Sacro/anormalidades , Cirurgia Assistida por Computador/métodos , Parafusos Ósseos , Fixação Interna de Fraturas/instrumentação , Humanos , Ílio/cirurgia , Sacro/diagnóstico por imagem , Sacro/cirurgia , Cirurgia Assistida por Computador/instrumentação , Tomografia Computadorizada por Raios XRESUMO
Tibial plateau fractures are complex injuries that can affect both knee function and stability. In the past, surgeons have relied on radiographs, viewboxes, tracing paper, and scaled acetate templates to formulate a preoperative plan. With the advent of digital radiography, viewboxes, and standard radiographs are no longer routinely available. The availability of a digital format for preoperative planning has helped to address this, but fragment manipulation and implant templating are not features of most digital radiography systems. Digital surgical planning software allows for these functions thereby enabling the surgeon to formulate a preoperative plan for fracture reduction and fixation. Concomitant use of 3-dimensional (3D) imaging software permits unlimited inspection of the fracture by allowing for oblique or special views through manipulation of the software image as opposed to potentially painful positioning of the injured limb by the patient or radiograph personnel. This case report illustrates the advantages of these new software tools.