A population-based epidemiological and health economic analysis of fracture-related infection.

Aims: The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI). Methods: This is a retrospective cohort study of operatively managed orthopaedic trauma patients from 1 January 2007 to 31 December 2016, performed in Queensland, Australia. Record linkage was used to develop a person-centric, population-based dataset incorporating routinely collected administrative, clinical, and health economic information. The FRI group consisted of patients with International Classification of Disease 10th Revision diagnosis codes for deep infection associated with an implanted device within two years following surgery, while all others were deemed not infected. Demographic and clinical variables, as well as healthcare utilization costs, were compared. Results: There were 111,402 patients operatively managed for orthopaedic trauma, with 2,775 of these (2.5%) complicated by FRI. The development of FRI had a statistically significant association with older age, male sex, residing in rural/remote areas, Aboriginal or Torres Strait Islander background, lower socioeconomic status, road traffic accident, work-related injuries, open fractures, anatomical region (lower limb, spine, pelvis), high injury severity, requiring soft-tissue coverage, and medical comorbidities (univariate analysis). Patients with FRI had an eight-times longer median inpatient length of stay (24 days vs 3 days), and a 2.8-times higher mean estimated inpatient hospitalization cost (AU$56,565 vs AU$19,773) compared with uninfected patients. The total estimated inpatient cost of the FRI cohort to the healthcare system was AU$156.9 million over the ten-year period. Conclusion: The results of this study advocate for improvements in trauma care and infection management, address social determinants of health, and highlight the upside potential to improve prevention and treatment strategies.

Comparative analysis of external locking plate and combined frame external fixator for open distal tibial fractures: a comprehensive assessment of clinical outcomes and financial implications.

BACKGROUND: Open distal tibial fractures pose significant challenges regarding treatment options and patient outcomes. This retrospective single-centre study aimed to compare the stability, clinical outcomes, complications, and financial implications of two surgical interventions, namely the external locking plate and the combined frame external fixator, to manage open distal tibial fractures. METHODS: Forty-four patients with distal open tibial (metaphyseal extraarticular) fractures treated between 2020 and 2022 were selected and formed into two main groups, Group A and Group B. Group A (19 patients) are patients that underwent treatment using the external locking plate technique, while Group B (25 patients) received the combined frame external fixator approach. Age, gender, inpatient stay, re-operation rates, complications, functional recovery (measured by the Johner-Wrush score), pain ratings (measured by the Visual Analogue Scale [VAS]), and cost analyses were evaluated for each group. Statistical analyses using SPSS were conducted to compare the outcomes between the two groups. RESULTS: The research found significant variations in clinical outcomes, complications, and cost consequences between Group A and Group B. Group A had fewer hospitalisation periods (23.687.74) than Group B (33.5619.47). Re-operation rates were also considerably lower in Group A (26.3%) than in Group B (48%), owing to a greater prevalence of pin-tract infections and subsequent pin loosening in the combination frame external fixator group. The estimated cost of both techniques was recorded and analysed with the locking average of 26,619.69 ± 9,602.352 and the combined frame average of 39,095.64 ± 20,070.077. CONCLUSION: This study suggests that although the two approaches effectively manage open distal tibia fractures, the locking compression plate approach (Group A) has an advantage in treating open distal tibia fractures. Shorter hospitalisation times, reduced re-operation rates, and fewer complications will benefit patients, healthcare systems, and budget allocation. Group A's functional recovery results demonstrate the locking plate technique's ability to improve recovery and patient quality of life. According to the cost analysis, the locking plate technique's economic viability and cost-effectiveness may optimise healthcare resources for open distal tibia fractures. These findings might improve patient outcomes and inform evidence-based orthopaedic surgery.

Locked Tension Band Wiring for Mayo IIA Olecranon Fractures: Modified Surgical Technique and Retrospective Comparative Study of Clinical Outcomes and Cost-effectiveness with Locking Plate.

Background: Tension band wiring (TBW) has traditionally been used for simple olecranon fractures, but due to its many complications, locking plate (LP) is increasingly being employed. To reduce the complications, we developed a modified technique for olecranon fracture repair, locked TBW (LTBW). The study aimed to compare (1) the frequency of complications and re-operations between LP and LTBW techniques, (2) clinical outcomes and the cost efficacy. Methods: We retrospectively evaluated data of 336 patients who underwent surgical treatment for simple and displaced olecranon fractures (Mayo Type ⅡA) in the hospitals of a trauma research group. We excluded open fractures and polytrauma. We investigated complication and re-operation rates as primary outcomes. As secondary outcomes, Mayo Elbow Performance Index (MEPI) and the total cost, including surgery, outpatients and re-operation, were examined between the two groups. Results: We identified 34 patients in the LP group and 29 patients in the LTBW group. The mean follow-up period was 14.2 ± 3.9 months. The complication rate in the LTBW group was comparable to that in the LP group (10.3% vs. 17.6%; p = 0.49). Re-operation and removal rates were not significantly different between the groups (6.9% vs. 8.8%; p = 1.000 and 41.4% vs. 58.8%; p = 1.00, respectively). Mean MEPI at 3 months was significantly lower in the LTBW group (69.7 vs. 82.6; p < 0.01), but mean MEPI at 6 and 12 months were not significantly different (90.6 vs. 85.2; p = 0.06, 93.9 vs. 95.2; p = 0.51, respectively). The mean cost/patient of the total cost in the LTBW group were significantly lower than those in the LP group ($5,249 vs. $6,138; p < 0.001). Conclusions: This study showed that LTBW achieved clinical outcomes equivalent to those of LP and was significantly more cost effective than LP in the retrospective cohort. Level of Evidence: Level III (Therapeutic).

Establishing a consensus on research priorities in orthopaedic trauma within South Africa.

BACKGROUND: Musculoskeletal (MSK) injuries are one of the leading causes of disability worldwide. Despite improvements in trauma-related morbidity and mortality in high-income countries over recent years, outcomes following MSK injuries in low- and middle-income countries, such as South Africa (SA), have not. Despite governmental recognition that this is required, funding and research into this significant health burden are limited within SA. This study aims to identify research priorities within MSK trauma care using a consensus-based approach amongst MSK healthcare practitioners within SA. METHOD: Members from the Orthopaedic Research Collaboration in Africa (ORCA), based in SA, collaborated using a two round modified Delphi technique to form a consensus on research priorities within orthopaedic trauma care. Members involved in the process were orthopaedic healthcare practitioners within SA. RESULTS: Participants from the ORCA network, working within SA, scored research priorities across two Delphi rounds from low to high priority. We have published the overall top 10 research priorities for this Delphi process. Questions were focused on two broad groups-clinical effectiveness in trauma care and general trauma public health care. Both groups were represented by the top two priorities, with the highest ranked question regarding the overall impact of trauma in SA and the second regarding the clinical treatment of open fractures. CONCLUSION: This study has defined research priorities within orthopaedic trauma in South Africa. Our vision is that by establishing consensus on these research priorities, policy and research funding will be directed into these areas. This should ultimately improve musculoskeletal trauma care across South Africa and its significant health and socioeconomic impacts.

State of the Union: Timeliness to Antibiotics in Open Fractures.

OBJECTIVE: In open fractures, early administration of systemic antibiotics has recently been recognized as a universal recommendation, with the current American College of Surgeons Trauma Center Verification recommendation for administration within 1 hour of facility arrival. We sought to quantify the baseline rate of timely antibiotic administration and the various factors associated with delay. METHODS: Data from the National Trauma Data Bank were obtained for all patients treated for open fractures in 2019. 65,552 patients were included. Univariate and multivariate analyses were performed, first for patient, prehospital, and hospital factors compared with rate of antibiotic administration within 1 hour of hospital arrival, then with a multivariate analysis of factors affecting these times. RESULTS: The overall rate of antibiotic administration within 1 hour of arrival was 47.6%. Patient factors associated with lower rates of timely antibiotics include increased age, Medicare status, and a higher number of comorbidities. Associated prehospital factors included non-work-related injuries, fixed-wing air or police transport, and walk-in arrival method. Patients with lower extremity open fractures were more likely to receive antibiotics within 1 hour of arrival than those with upper extremity open fractures. Traumatic amputations had a higher rate of timely administration (67.3%). ACS trauma Level II (52.5%) centers performed better than Level III (48.3%), Level I (45.5%), and Level IV (34.5%) centers. Multivariate analysis confirmed the findings of the univariate analysis. CONCLUSIONS: Despite current clinical standards, rates of adherence to rapid antibiotic administration are low. Certain patient, facility, and environmental factors are associated with delays in antibiotic administration and can be a focus for quality improvement processes. We plan to use these data to evaluate how focus on antibiotic administration as this quality standard changes practice over time. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Geographical Inequalities in Access to Bellwether Procedures in Brazil.

BACKGROUND: Brazil is a middle-income country that aims to provide universal health coverage, but its surgical system's efficiency has rarely been analyzed. In an effort to strengthen surgical national systems, the Lancet Commission on Global Surgery proposed bellwether procedures as quality indicators of surgical workforces. This study aims to evaluate regional inequalities in access to bellwether procedures and their associated mortality across the five Brazilian geographical regions. METHODS: Using DATASUS, Brazil's national healthcare database, data were collected on the total amount of performed bellwether procedures-cesarean section, laparotomy, and open fracture management-and their associated mortality, by geographical region. We evaluated the years 2018-2020, both in emergent and elective conditions. Statistical analysis was performed by one-way ANOVA test and Tukey's multiple comparisons test. RESULTS: During this period, DATASUS registered 2,687,179 cesarean sections, 1,036,841 laparotomies, and 648,961 open fracture treatments. The access and associated mortality related to these procedures were homogeneous between the regions in elective care. There were significant geographical inequalities in access and associated mortality in emergency care (p < 0.05, 95% CI) for all bellwether procedures. The Southeast, the most economically developed region of the country, was the region with the lowest amount of bellwether procedures per 100,000 inhabitants. CONCLUSION: Brazil's public surgical system is competent at promoting elective surgical care, but more effort is needed to fortify emergency care services. Public policies should encourage equity in the geographic allocation of the surgical workforce.

High-energy open-fracture model with initial experience of fluorescence-guided bone perfusion assessment.

High-energy orthopedic injuries cause severe damage to soft tissues and are prone to infection and healing complications, making them a challenge to manage. Further research is facilitated by a clinically relevant animal model with commensurate fracture severity and soft-tissue damage, allowing evaluation of novel treatment options and techniques. Here we report a reproducible, robust, and clinically relevant animal model of high-energy trauma with extensive soft-tissue damage, based on compressed air-driven membrane rupture as the blast wave source. As proof-of-principle showing the reproducibility of the injury, we evaluate changes in tissue and bone perfusion for a range of different tibia fracture severities, using dynamic contrast-enhanced fluorescence imaging and microcomputed tomography. We demonstrate that fluorescence tracer temporal profiles for skin, femoral vein, fractured bone, and paw reflect the increasing impact of more powerful blasts causing a range of Gustilo grade I-III injuries. The maximum fluorescence intensity of distal tibial bone following 0.1 mg/kg intravenous indocyanine green injection decreased by 35% (p < 0.01), 75% (p < 0.001), and 87% (p < 0.001), following grade I, II, and III injuries, respectively, compared to uninjured bone. Other kinetic parameters of bone and soft tissue perfusion extracted from series of fluorescence images for each animal also showed an association with severity of trauma. In addition, the time-intensity profile of fluorescence showed marked differences in wash-in and wash-out patterns for different injury severities and anatomical locations. This reliable and realistic high-energy trauma model opens new research avenues to better understand infection and treatment strategies. Level of evidence: Level III; Case-control.

The utility of air on computed tomography scans in the assessment of type 1 open fractures.

PURPOSE: The presence of air on computed tomography (CT) scans has been demonstrated to accurately diagnose occult traumatic arthrotomies. The purpose of this study was to determine if the presence of air on CT scans also has diagnostic utility for type 1 open fractures. METHODS: A retrospective review at a level 1 trauma center identified twenty-eight patients with Gustilo-Anderson Type 1 open fractures and preoperative CT scans. These patients were matched 2:1 with 56 closed fractures who also had CT scans. CT scans were reviewed to determine the presence of suprafascial and subfascial air. RESULTS: Air near the fracture site on CT scan was more common in open fractures then closed fractures (21 (75%) vs. 9 (16%) patients, proportional difference: 59% (37-75%), p < 0.0001). In the open fracture group, 18 (64.2%) patients had both supra- and subfascial air, 2 (7.1%) patients had isolated subfascial air, and 1 (3.5%) patient had isolated suprafascial air. In the closed fracture group, 3 (5.3%) patients had supra- and subfascial air, 4 (7.1%) had isolated subfascial air, and 2 (3.5%) had isolated suprafascial air. The sensitivity and specificity of air on CT for identifying a type 1 open fracture was 75 and 84%, respectively. CONCLUSIONS: This study found that the presence of air on CT scan was more likely in type 1 open versus closed fractures; however, the sensitivity or specificity was too low to be used reliably to identify occult open fractures in isolation. LEVEL OF EVIDENCE: Diagnostic Level III.

Synchronous circular frame stabilisation and microsurgical soft tissue reconstruction for open lower limb fractures-A cost analysis and description of the surgical technique.

INTRODUCTION: Current surgical paradigms for ortho-plastic management of IIIB open tibial fractures make compromises. Often, definitive circular frame stabilisation is delayed until the soft tissue envelope is secure to allow access for further soft tissue reconstruction if required. This delay has potential clinical and cost implications. A previous study showed acute circular frame stabilisation performed concurrently or before soft tissue reconstruction was feasible without additional soft tissue reconstruction problems. This study examines potential resource savings using this approach. METHODS: All open tibial fractures managed by circular fixator and microsurgical soft tissue reconstruction between April 2015 and June 2019 were identified from a prospectively maintained database. Those receiving circular frame stabilisation with synchronous microsurgical soft tissue reconstruction were considered cases; those in whom the frame stabilisation was delayed were controls. Cost data were derived from the Patient Level Information and Costing System. Salvage cases and those with incomplete treatment were excluded. RESULTS: Nine cases and 25 controls were evaluated. No statistically significant difference was observed between groups in terms of age, sex, injury severity score, time to debridement, time to coverage, length of follow up, or time to union. Median length of stay was 13.3 and 19.7 days for cases and controls respectively (p<0.01). Cases required fewer procedures (2.3) compared to controls (4.5) (p<0.001). The cost of care was less for cases (£25,527) than controls (£32,952) (p <0.05). No cases returned to theatre with flap failure or flap compromise. Complications were similar between groups. CONCLUSION: In suitable patients, synchronous circular frame stabilisation and microsurgical soft tissue reconstruction is a safe, clinically effective, and cost-saving option.

Antibiotic cement-coated intramedullary nail is cost-effective for the initial treatment of GAâ ¢ open tibia fractures.

OBJECTIVE: To evaluate the cost-effectiveness of antibiotic cement-coated intramedullary nails (IMN) in the initial management of Gustilo-Anderson type Ⅲ (GAIII) open tibia fractures. METHODS: A break-even equation was used to analyze the costs associated with antibiotic cement-coated IMN and postoperative infection following GAⅢ open tibia fractures. This equation produced a new infection rate, which defines what percentage the antibiotic coated IMN needs to decrease the initial infection rate for its prophylactic use to be cost-effective. The postoperative infection rate used for calculations was 30%, a value established in current literature for these fracture types (6-33%). The institutional costs associated with a single operative debridement and resultant inpatient stay and treatment were determined. A sensitivity analysis was conducted to demonstrate how various total costs of infection and different infection rates affected the break-even rate, the absolute risk reduction (ARR), and the number needed to treat (NNT). RESULTS: Financial review yielded an average institutional cost of treating a postoperative infection to be $13,282.85. This number was inclusive of all procedures during an inpatient stay. The added cost of the antibiotic coated implant to the hospital is $743.42. Utilizing the break-even formula with these costs and a 30% initial infection rate, antibiotic coated IMN was economically viable if it decreased infection rate by 0.056% (NNT = 1,785.714). CONCLUSION: This break-even analysis model suggests the initial use of an antibiotic coated IMN in the setting of GAⅢ open tibia fractures is cost-effective.

Assessment of Ethno-racial and Insurance-based Disparities in Pediatric Forearm and Tibial Fracture Care in the United States.

INTRODUCTION: Despite growing attention to healthcare disparities and interventions to improve inequalities, additional identification of disparities is needed, particularly in the pediatric population. We used state and nationwide databases to identify factors associated with the surgical treatment of pediatric forearm and tibial fractures. METHODS: The Healthcare Cost and Utilization Project State Inpatient, Emergency Department, and Ambulatory Surgery and Services Databases from four US states and the Nationwide Emergency Department Sample database were quarried using International Classification of Diseases codes to identify patients from 2006 to 2015. Multivariable regression models were used to determine factors associated with surgical treatment. RESULTS: State databases identified 130,006 forearm (1575 open) and 51,979 tibial fractures (1339 open). Surgical treatment was done in 2.6% of closed and 37.5% of open forearm fractures and 7.9% of closed and 60.5% of open tibial fractures. A national estimated total of 3,312,807 closed and 46,569 open forearm fractures were included, 59,024 (1.8%) of which were treated surgically. A total of 719,374 closed and 26,144 open tibial fractures were identified; 52,506 (7.0%) were treated surgically. Multivariable regression revealed that race and/or insurance status were independent predictors for the lower likelihood of surgery in 3 of 4 groups: Black patients were 43% and 35% less likely to have surgery after closed and open forearm fractures, respectively, and patients with Medicaid were less often treated surgically for open tibial fractures in state (17%) and nationwide (20%) databases. CONCLUSIONS: Disparities in pediatric forearm and tibial fracture care persist, especially for Black patients and those with Medicaid; identification of influencing factors and interventions to address them are important in improving equality and value of care.

[Clinical characteristics and cost-effectiveness of intramedullary nail and plate for the treatment of open tibial fractures].

OBJECTIVE: To analyze clinical characteristics and cost-effectiveness of different final surgical options for treating patients with open tibial fractures. METHODS: A retrospective analysis was conducted by enrolling 55 surgically treated patients with open tibial fractures from January 2018 to June 2019. All the patients were categorized in intramedullary nailing (IMN) group and locking compression plate(LCP) group according to the final fixation option. There were 35 cases in group IMN including 27 males and 8 females, aged from 25 to 69 years old with an average of (49.0±10.6) years old. Based on Gustilo-Anderson classification, there were 1 case of typeⅠ, 19 cases of typeⅡand 15 cases of type Ⅲ. There were 20 cases in group LCP including 15 males and 5 females, aged from 46 to 72 years old with an average age of (53.4±14.7) years old. Based on Gustilo-Anderson classification, there were 2 cases of typeⅠ, 11 cases of typeⅡand 7 cases of type Ⅲ. Preoperative waiting time, surgical debridement times, intraoperative bleeding loss, blood and albumin transfusion, operation time, bacterial cultures and complications, bone union time, Johner-Wruhs criteria at 1 year after operation and total cost within 1 year after surgery between two groups were compared. The variables recorded between two groups were statistically analyzed and compared respectively, then the factors affecting hospital costs were evaluated by univariate and multiple linear regression analysis respectively, finally the cost-effectiveness analysis was performed. RESULTS: Total 55 patients were enrolled with an average follow-up time of(16.4±7.1) months ranged from 14 to 27 months postoperatively. There were no significantly statistical differences of the demographic materials between the two groups. The intraoperative bleeding loss were(243.18±118.82) ml and (467.86±490.53) ml respectively in group IMN and LCP, the significantly statistical difference was discovered(P<0.05). The surgical duration were(247.50±57.94) min and(350.00±178.77) min respectively in group IMN and LCP, the significantly statistical difference was discovered(P<0.05). There were no significantly statistical differences of the average days before operation, surgical debridement times, received blood and albumin transfusion, wound cultures, complications and bone union time between the two groups(P>0.05). The univariate analysis of the factors affecting the hospital costs indicated that patients with smoke or alcohol (P=0.042), high energy damage (P=0.012), patients with comorbidity diseases(P=0.045), surgical debridement over 2 times (P=0.001), intraoperative bleeding loss over 400 ml (P<0.001), blood and albumin transfusion (P=0.027), wound cultures (P=0.000) and complications (P=0.035) were the factors. The multiple linear regression analysis demonstrated the smoke or alcohol using[ß=-0.256, t=-2.628, 95%CI(-29 667.09, -4 997.47), P=0.014] was the only factor affecting the total cost. The excellent and good rate were 80% and 85% respectively based on the Johner-Wruhs criteria. The average total cost within 1 year after surgery was (136 435.90±39 093.98) CNY in group IMN and (140 034.62±56 821.12) CNY in group LCP. The total surgical duration and total intraoperative bleeding loss were significant lower in group IMN than in group LCP. The average total costs of was significantly higher. The average cost for every 1% of excellent and good rate was 1 705.45 CNY in group IMN and 1 647.46 CNY in group LCP. Each 1% increasing of excellent and good rate cost 719.74 CNY more in group LCP compared with group IMN. CONCLUSION: Both IMN and LCP could provide a satisfactory outcome for open tibial fractures. Meanwhile considering the total cost, patients with smoke or alcohol history, traffic accident, comorbidity diseases, surgical debridement over 2 times, intraoperative bleeding loss over 400 ml, and complications should not be ignored.

Association between the Orthopaedic Trauma Society classification of open fractures and economic costs.

AIMS: The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs. METHODS: Resource use was measured during the six months that followed open fractures of the lower limb in 748 adults recruited as part of two large clinical trials within the UK Major Trauma Research Network. Resource inputs were valued using unit costs drawn from primary and secondary sources. Economic costs (GBP sterling, 2017 to 2018 prices), estimated from both a NHS and Personal Social Services (PSS) perspective, were related to the degree of complexity of the open fracture based on the OTS classification. RESULTS: Adjusted mean total NHS and PSS costs were £13,785 following treatment of complex fractures and £3,550 following treatment of simple fractures, where the open fracture wound is closed at the end of the first wound debridement, generating a mean difference of £10,235 (95% confidence interval £8,074 to £12,396). CONCLUSION: Following previous work correlating clinical outcomes with the OTS classification of open fractures, this study suggests that the new OTS classification also correlates with economic costs estimated from alternative study perspectives. Cite this article: Bone Joint J 2022;104-B(3):408-412.

Tibial Shaft and Pilon Fractures With Associated Syndesmotic Injury: A Matched Cohort Assessment.

OBJECTIVE: To determine the outcomes of pilon and tibial shaft fractures with syndesmotic injuries compared with similar fractures without syndesmotic injury. DESIGN: Retrospective case-control study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: All patients over a 5-year period (2012-2017) with tibial shaft or pilon fractures with a concomitant syndesmotic injury and a control group without a syndesmotic injury matched for age, OTA/AO fracture classification, and Gustilo-Anderson open fracture classification. INTERVENTION: Preoperative or intraoperative diagnosis of syndesmotic injury with reduction and fixation of both fracture and syndesmosis. MAIN OUTCOME MEASUREMENT: Rates of deep infection, nonunion, unplanned reoperation, and amputation in patients with a combined syndesmotic injury and tibial shaft or pilon fracture versus those without a syndesmotic injury. RESULTS: A total of 30 patients, including 15 tibial shaft and 15 pilon fractures, were found to have associated syndesmotic injuries. The matched control group comprised 60 patients. The incidence of syndesmotic injury in all tibial shaft fractures was 2.3% and in all pilon fractures was 3.4%. The syndesmotic injury group had more neurologic injuries (23.3% vs. 8.3% P = 0.02), more vascular injuries not requiring repair (30% vs. 15%, P = 0.13), and a higher rate compartment syndrome (6.7% vs. 0%, P = 0.063). Segmental fibula fracture was significantly more common in patients with a syndesmotic injury (36.7% vs. 13.3%, P = 0.04). Fifty percent of the syndesmotic injury group underwent an unplanned reoperation with significantly more unplanned reoperations (50% vs. 27.5%, P = 0.04). The syndesmotic group had a significantly higher deep infection rate (26.7% vs. 8.3% P = 0.047) and higher rate of amputation (26.7% vs. 3.3% P = 0.002) while the nonunion rate was similar (17.4% vs. 16.7% P = 0.85). CONCLUSIONS: Although syndesmotic injuries with tibial shaft or pilon fractures are rare, they are a marker of a potentially limb-threatening injury. Limbs with this combined injury are at increased risk of deep infection, unplanned reoperation, and amputation. The presence of a segmental fibula fracture should raise clinical suspicion to evaluate for syndesmotic injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Use of antibiotic coated intramedullary nails in open tibia fractures: A European medical resource use and cost-effectiveness analysis.

PURPOSE: In patients with open tibial fractures, bone and wound infections are associated with an increased hospital length of stay and higher costs. The infection risk increases with the use of implants. Innovations to reduce this risk include antibiotic-coated implants. This study models whether the use of a gentamicin-coated intramedullary tibial nail is cost-effective for trauma centers managing patients with a high risk of infection. EFFICACY: Absolute infection risk and relative risk reduction, by fracture grade, for antibiotic-coated nails compared to standard nails for patients with open tibial fractures were estimated based on the results of a meta-analysis, which assessed the additional benefit of locally-administered prophylactic antibiotics in open tibia fractures treated with implants. The observed efficacy of antibiotic-coated nails in reducing infections was applied in an economic model. METHODS: The model compared infection rates, inpatient days, theatre usage and costs in high risk patients, with a Gustilo-Anderson (GA) grade III open fracture, for two patient cohorts from a trauma center perspective, with a 1-year time horizon. In one cohort all GAIII patients received a gentamicin-coated nail whilst GAI and GAII patients received a standard nail. All patients in the comparator cohort received a standard nail. Four European trauma centers provided patient-level data (n=193) on inpatient days, procedures and related costs for patients with and without infections. RESULTS: Using the gentamicin-coated nail in patients at high risk of infection (GAIII) was associated with 75% lower rate of infection and cost savings (€477 - €3.263) for all included centers; the higher cost of the implant was offset by savings from fewer infections, inpatient days (-26%) and re-operations (-10%). This result was confirmed by extensive sensitivity analyses. CONCLUSIONS: Analyses demonstrated that infection rates and total costs for in-hospital treatment could be potentially reduced by 75% and up to 15% respectively, by using a gentamicin-coated nail in patients at high risk of infection. Fewer infections, reduced inpatient days and re-operations may be potentially associated with use of antibiotic-coated implants. Results are sensitive to the underlying infection risk, with greatest efficacy and cost-savings when the coated implant is used in high risk patients.

The economic burden of open tibia fractures: A systematic review.

BACKGROUND: Open tibia fractures are a common injury following road traffic collisions and place a large economic burden on patients and healthcare systems. Summarising their economic burden is key to inform policy and help prioritise treatment. METHODS: All studies were identified from a systematic search of Medline, Embase and the Cochrane Central Register of Controlled Trials. We included any human with a diagnosed open tibia fracture, following any intervention. The primary outcome was any costs reported or patient return to work status. Secondary outcomes included average length of stay, wage loss, absenteeism and complications such as infection, amputation and nonunion. Data was extracted and we performed a descriptive narrative summary. RESULTS: We reviewed 1,204 studies from our searches. A total of 34 studies were included from 14 different countries. The average age was 37.7 years old and 76% of the patients were male. 6.5% were Gustilo I, 12% Gustilo II and 82% Gustilo III. Initial direct hospitalisation costs were reported to be between £356 to £126,479 with an average length of stay of 56 days (3.1-244). 89% of participants were working pre-injury, 60% fully returned to work, 17% returned to work part time or changed profession and 22% did not return to work at one-year. The most common complications reported were 22% infection, 11% nonunion and 16% amputation. Mean follow-up duration for the studies was 25 months. CONCLUSION: The economic burden of open tibia fractures varies greatly, but it is costly for both hospitals and patients. The current evidence is predominantly from high-income countries (HICs), especially the USA. Further research is required to investigate the costs of open tibia fractures using validated costing tools, especially in low-income countries (LICs), to help inform and direct policy.

The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix.

PURPOSE: The aim of this study was to evaluate changes in both mechanism and diagnoses of injuries presenting to the orthopaedic department during this lockdown period, as well as to observe any changes in operative case-mix during this time. METHODS: A study period of twelve weeks following the introduction of the nationwide "lockdown period", March 23rd - June 14th, 2020 was identified and compared to the same time period in 2019 as a "baseline period". A retrospective analysis of all emergency orthopaedic referrals and surgical procedures performed during these time frames was undertaken. All data was collected and screened using the 'eTrauma' management platform (Open Medical, UK). The study included data from a five NHS Foundation Trusts within North West London. A total of 6695 referrals were included for analysis. RESULTS: The total number of referrals received during the lockdown period fell by 35.3% (n=2631) compared to the same period in 2019 (n=4064). Falls remained proportionally the most common mechanism of injury across all age groups in both time periods. The proportion sports related injuries compared to the overall number of injuries fell significantly during the lockdown period (p<0.001), however, the proportion of pushbike related accidents increased significantly (p<0.001). The total number of operations performed during the lockdown period fell by 38.8% (n=1046) during lockdown (n=1732). The proportion of patients undergoing operative intervention for Neck of Femur (NOF) and ankle fractures remained similar during both study periods. A more non-operative approach was seen in the management of wrist fractures, with 41.4% of injuries undergoing an operation during the lockdown period compared to 58.6% at baseline (p<0.001). CONCLUSION: In conclusion, the nationwide lockdown has led to a decrease in emergency orthopaedic referrals and procedure numbers. There has been a change in mechanism of injuries, with fewer sporting injuries, conversely, there has been an increase in the number of pushbike or scooter related injuries during the lockdown period. NOF fractures remained at similar levels to the previous year. There was a change in strategy for managing distal radius fractures with more fractures being treated non-operatively.

Negative-pressure wound therapy compared with standard dressings following surgical treatment of major trauma to the lower limb: the WHiST RCT.

BACKGROUND: Major trauma is the leading cause of death in people aged < 45 years. Patients with major trauma usually have lower-limb fractures. Surgery to fix the fractures is complicated and the risk of infection may be as high as 27%. The type of dressing applied after surgery could potentially reduce the risk of infection. OBJECTIVES: To assess the deep surgical site infection rate, disability, quality of life, patient assessment of the surgical scar and resource use in patients with surgical incisions associated with fractures following major trauma to the lower limbs treated with incisional negative-pressure wound therapy versus standard dressings. DESIGN: A pragmatic, multicentre, randomised controlled trial. SETTING: Twenty-four specialist trauma hospitals representing the UK Major Trauma Network. PARTICIPANTS: A total of 1548 adult patients were randomised from September 2016 to April 2018. Exclusion criteria included presentation > 72 hours after injury and inability to complete questionnaires. INTERVENTIONS: Incisional negative-pressure wound therapy (n = 785), in which a non-adherent absorbent dressing covered with a semipermeable membrane is connected to a pump to create a partial vacuum over the wound, versus standard dressings not involving negative pressure (n = 763). Trial participants and the treating surgeon could not be blinded to treatment allocation. MAIN OUTCOME MEASURES: Deep surgical site infection at 30 days was the primary outcome measure. Secondary outcomes were deep infection at 90 days, the results of the Disability Rating Index, health-related quality of life, the results of the Patient and Observer Scar Assessment Scale and resource use collected at 3 and 6 months post surgery. RESULTS: A total of 98% of participants provided primary outcome data. There was no evidence of a difference in the rate of deep surgical site infection at 30 days. The infection rate was 6.7% (50/749) in the standard dressing group and 5.8% (45/770) in the incisional negative-pressure wound therapy group (intention-to-treat odds ratio 0.87; 95% confidence interval 0.57 to 1.33; p = 0.52). There was no difference in the deep surgical site infection rate at 90 days: 13.2% in the standard dressing group and 11.4% in the incisional negative-pressure wound therapy group (odds ratio 0.84, 95% confidence interval 0.59 to 1.19; p = 0.32). There was no difference between the two groups in disability, quality of life or scar appearance at 3 or 6 months. Incisional negative-pressure wound therapy did not reduce the cost of treatment and was associated with a low probability of cost-effectiveness. LIMITATIONS: Owing to the emergency nature of the surgery, we anticipated that some patients who were randomised would subsequently be unable or unwilling to participate. However, the majority of the patients (85%) agreed to participate. Therefore, participants were representative of the population with lower-limb fractures associated with major trauma. CONCLUSIONS: The findings of this study do not support the use of negative-pressure wound therapy in patients having surgery for major trauma to the lower limbs. FUTURE WORK: Our work suggests that the use of incisional negative-pressure wound therapy dressings in other at-risk surgical wounds requires further investigation. Future research may also investigate different approaches to reduce postoperative infections, for example the use of topical antibiotic preparations in surgical wounds and the role of orthopaedic implants with antimicrobial coatings when fixing the associated fracture. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12702354 and UK Clinical Research Network Portfolio ID20416. FUNDING: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 38. See the NIHR Journals Library for further project information.

WHAT DID THE TRIAL FIND?: We found no evidence of a difference in the rate of surgical site infection between those patients randomised to negative-pressure wound therapy and those patients randomised to standard wound dressings. There was no difference in the rate of other wound healing complications or in the patients' self-report of disability, health-related quality of life or scar healing. Negative-pressure wound therapy is very unlikely to be cost-effective for the NHS. In conclusion, and contrary to previous reports, the findings of this study do not support the use of negative-pressure wound therapy in patients having surgery for major trauma to their legs.

Major trauma is the leading cause of death worldwide in people aged < 45 years and a significant cause of short- and long-term health problems. In 85% of major trauma patients, the injury involves broken bones. Surgery to fix broken bones in the lower limbs is complicated and has risks, one of the main ones being wound infection. In these patients, rates of wound infection have been reported to be as high as 27%. One factor that may affect the risk of infection is the type of dressing applied after surgery. In this trial, we compared standard wound dressings with a new treatment called incisional negative-pressure wound therapy. Negative-pressure wound therapy is a special type of dressing whereby gentle suction is applied to the surface of the wound. A total of 1548 patients from 24 specialist trauma hospitals in the UK agreed to take part and were assigned at random to receive either a standard wound dressing or negative-pressure wound therapy after their surgery. We reviewed the recovery of the patients for 6 months. We recorded how many had an infection in the surgical wound and asked the patients to rate the extent of their disability, their quality of life and the scar healing. We also collected information about the cost of treatment.

Bent Tibial Nail with Refracture: A Cost-Effective Removal Method: A Case Report.

CASE: A 45-year old man presented with a right open tibial fracture with a prominent, fixed deformity because of a retained right tibial intramedullary nail from a previous tibial fracture. After multiple futile intraoperative attempts to extract the bent nail, it was finally sectioned using an industrial drill bit that permitted its removal and revision tibial nailing. CONCLUSIONS: A tibial fracture resulting in a retained, bent nail presents unique challenges for nail extraction and subsequent exchange nailing. Failed implant removal can be limited by the equipment available in the operating theater. In this setting, the judicious use of inexpensive industrial materials and instruments may be effective in select cases.