Duration of antibiotic treatment and risk of recurrence after surgical management of orthopaedic device infections: a multicenter case-control study.

BACKGROUND: Device-related infections in orthopaedic and trauma surgery are a devastating complication with substantial impact on morbidity and mortality. Systemic suppressive antibiotic treatment is regarded an integral part of any surgical protocol intended to eradicate the infection. The optimal duration of antimicrobial treatment, however, remains unclear. In a multicenter case-control study, we aimed at analyzing the influence of the duration of antibiotic exposure on reinfection rates 1 year after curative surgery. METHODS: This investigation was part of a federally funded multidisciplinary network project aiming at reducing the spread of multi-resistant bacteria in the German Baltic region of Pomerania. We herein used hospital chart data from patients treated for infections of total joint arthroplasties or internal fracture fixation devices at three academic referral institutions. Subjects with recurrence of an implant-related infection within 1 year after the last surgical procedure were defined as case group, and patients without recurrence of an implant-related infection as control group. We placed a distinct focus on infection of open reduction and internal fixation (ORIF) constructs. Uni- and multivariate logistic regression analyses were employed for data modelling. RESULTS: Of 1279 potentially eligible patients, 269 were included in the overall analysis group, and 84 contributed to an extramedullary fracture-fixation-device sample. By multivariate analysis, male sex (odds ratio [OR] 2.06, 95% confidence interval [CI] 1.08 to 3.94, p = 0.029) and facture fixation device infections (OR 2.05, 95% CI 1.05 to 4.02, p = 0.036) remained independent predictors of reinfection. In the subgroup of infected ORIF constructs, univariate point estimates suggested a nearly 60% reduced odds of reinfection with systemic fluoroquinolones (OR 0.42, 95% CI 0.04 to 2.46) or rifampicin treatment (OR 0.41, 95% CI 0.08 to 2.12) for up to 31 days, although the width of confidence intervals prohibited robust statistical and clinical inferences. CONCLUSION: The optimal duration of systemic antibiotic treatment with surgical concepts of curing wound and device-related orthopaedic infections is still unclear. The risk of reinfection in case of infected extramedullary fracture-fxation devices may be reduced with up to 31 days of systemic fluoroquinolones and rifampicin, although scientific proof needs a randomized trial with about 1400 subjects per group. Concerted efforts are needed to determine which antibiotics must be applied for how long after radical surgical sanitation to guarantee sustainable treatment success.

Current management of open fractures: results from an online survey.

BACKGROUND: Open fractures are orthopaedic emergencies that carry a high risk for infection, non-union and soft tissue complications. Evidence-based treatment is impeded by the lack of high-quality evidence-based studies. The aim of this investigation was to elucidate the current practice of open fracture management in Germany and to determine major differences in treatment. METHODS: Surgeons were asked to complete an online questionnaire consisting of 45 items developed by an expert consensus. The first part covered questions on general principles of open fracture management. The second part included questions on soft tissue management, the preferred method of initial surgical stabilisation, microbiological testing, employment of pulsatile lavage and local antibiotics, antibiotic regimen, second-look operations, and blood testing. RESULTS: Of 653 respondents, 364 (65 %) completed the first part and 314 (48 %) completed the second part of the online survey. 55 % answered that a standard operating procedure for the diagnosis and treatment of patients with open fractures exists in their hospital. Only 25 % leave pre-hospitalisation applied dressings intact until arrival of the patient in the operating room, and 40 % make this decision depending on information provided by pre-hospitalisation emergency personnel. 84 % participants exclude the use of antibiotic-coated implants in the treatment of open fractures. The favoured stabilisation method in Gustilo type I fractures is definitive internal osteosynthesis and primary wound closure for 61 % of respondents. In Gustilo type II (74 %) and type III fractures (93 %), temporary external fixation is preferred. High-pressure pulsatile lavage is used by 22 % responding surgeons in Gustilo type I fractures, 53 % for type II fractures and 67 % for type III fractures. CONCLUSIONS: Open fracture management differs considerably among surgeons in Germany. Further studies are needed to deliver high-quality evidence concerning primary fracture stabilisation, soft tissue management and second-look operations. Existing evidence-based recommendations for general treatment, antibiotic prophylaxis and soft tissue management should be followed more strictly in clinical practice.

Single versus dual Kirschner wires for closed reduction and intramedullary nailing of displaced fractures of the fifth metacarpal neck (1-2 KiWi): a randomized controlled trial.

AIMS: The aim of this study was to investigate whether clinical and radiological outcomes after intramedullary nailing of displaced fractures of the fifth metacarpal neck using a single thick Kirschner wire (K-wire) are noninferior to those of technically more demanding fixation with two thinner dual wires. PATIENTS AND METHODS: This was a multicentre, parallel group, randomized controlled noninferiority trial conducted at 12 tertiary trauma centres in Germany. A total of 290 patients with acute displaced fractures of the fifth metacarpal neck were randomized to either intramedullary single-wire (n = 146) or dual-wire fixation (n = 144). The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire six months after surgery, with a third of the minimal clinically important difference (MCID) used as the noninferiority threshold. Secondary outcomes were pain, health-related quality of life (EuroQol five-dimensional questionnaire (EQ-5D)), radiological measures, functional deficits, and complications. RESULTS: Overall, 151/290 of patients (52%) completed the six months of follow-up, leaving 83 patients in the single-wire group and 68 patients in the dual-wire group. In the modified intention-to-treat analysis set, mean DASH scores six months after surgery were 3.8 (sd 7.0) and 4.4 (sd 9.4), respectively. With multiple imputation (n = 288), mean DASH scores were estimated at 6.3 (sd 8.7) and 7.0 (sd 10.0). Upper (1 - 2α)) confidence limits consistently remained below the noninferiority margin of 3.0 points in the DASH instrument. While there was a statistically nonsignificant trend towards a higher rate of shortening and rotational malalignment in the single wire group, no statistically significant differences were observed across groups in any secondary outcome measure. CONCLUSION: A single thick K-wire is sufficient for intramedullary fixation of acute displaced subcapital fractures of the fifth metacarpal neck. The less technically demanding single-wire technique produces noninferior clinical and radiological outcomes compared with the dual-wire approach. Cite this article: Bone Joint J 2019;101-B:1263-1271.

Urinary bladder volume measured in whole-body CT scans is a useful marker for alcohol intoxication.

PURPOSE: The aim of this study was to investigate whether urinary bladder volume (UBV) and blood alcohol concentration (BAC) correlate in a cohort of emergency trauma patients. Furthermore, the feasibility of semi-automated 3D-CT volumetry for urinary bladder volumetry calculations in whole-body CT examinations was elucidated. MATERIAL AND METHODS: Whole-body CT scans of 831 individuals treated in the emergency department with suspected multiple injuries were included. Manual 3D-CT volumetry of the urinary bladder was performed and the mechanism of injury, patient demographics, BAC, serum creatinine, and hematocrit were retrospectively analyzed. Semi-automated calculation of UBV was performed in 30 patients. Statistical analysis included ROC analysis to calculate cut-off values, sensitivity, and specificity. The Mann-Whitney test and Spearman's correlation coefficient were used to detect significant correlations between UBV and BAC. RESULTS: Manual 3D-CT volumetry showed maximum sensitivity and specificity with a cut-off value for urinary bladder volume of 416.3 mL (sensitivity 50.9%; specificity 76.3%; AUC 0.678). With a cut-off value of 4.2 mL/µmol for the creatinine quotient (quotient of serum creatinine and UBV), the sensitivity was 64.2% (specificity 67.0%; AUC 0.681). Semi-automated 3D-CT volumetry resulted in lower UBV values compared to those obtained with manual 3D-CT volumetry. CONCLUSION: Semi-automated 3D-CT volumetry is a reliable method to quantify UBV. UBV correlates with positive BAC results. A UBV above 416 mL seen on an initial whole-body CT must raise suspicion of alcohol intoxication. The creatinine quotient is an even more sensitive and specific parameter for the detection of alcohol intoxication.