The clinical relevance of fixation failure after pubic symphysis plating for anterior pelvic ring injuries: an observational cohort study with long-term follow-up.

BACKGROUND: Open reduction and plate fixation is a standard procedure for treating traumatic symphyseal disruptions, but has a high incidence of implant failure. Several studies have attempted to identify predictors for implant failure and discussed its impact on functional outcome presenting conflicting results. Therefore, this study aimed to identify predictors of implant failure and to investigate the impact of implant failure on pain and functional outcome. METHODS: In a single-center, retrospective, observational non-controlled cohort study in a level-1 trauma center from January 1, 2006, to December 31, 2017, 42 patients with a plate fixation of a traumatic symphyseal disruption aged ≥ 18 years with a minimum follow-up of 12 months were included. The following parameters were examined in terms of effect on occurrence of implant failure: age, body mass index (BMI), injury severity score (ISS), polytrauma, time to definitive treatment, postoperative weight-bearing, the occurrence of a surgical site infection, fracture severity, type of posterior injury, anterior and posterior fixation. A total of 25/42 patients consented to attend the follow- up examination, where pain was assessed using the Numerical Rating Scale and functional outcome using the Majeed Pelvic Score. RESULTS: Sixteen patients had an anterior implant failure (16/42; 37%). None of the parameters studied were predictive for implant failure. The median follow-up time was six years and 8/25 patients had implant failure. There was no difference in the Numerical Rating Scale, but the work-adjusted Majeed Pelvic Score showed a better outcome for patients with implant failure. CONCLUSION: implant failure after symphyseal disruptions is not predictable, but appears to be clinically irrelevant. Therefore, an additional sacroiliac screw to prevent implant failure should be critically discussed and plate removal should be avoided in asymptomatic patients.

Thumb reconstruction after radical tumor resection using free osteocutaneous lateral arm flap with secondary humerus fracture-a case report.

INTRODUCTION: Malignant diseases with infiltration of bony structures in the area of the phalanges or metacarpals require either amputation or complex reconstruction. The decision for reconstruction means to restore length, mobility, sensibility, stability as well as aesthetics. METHODS: We present a case of complex first ray reconstruction of the left hand using a free osteocutaneous lateral arm flap from the ipsilateral side. The reconstruction was performed after radical resection of an exulcerated squamous cell carcinoma, including the first metacarpal bone, trapezium, partial trapezoid and distal scaphoid as well as partial resection of the extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus and flexor carpi radialis tendons. The osteosynthetic restoration was achieved distally by a double wire cerclage and a proximally by temporary K-wire suspension. Moreover, to reconstruct the extensor pollicis longus tendon the ipsilateral palmaris longus tendon was harvested and used. Postoperatively, a secondary humerus fracture occurred, which was initially attended by plate osteosynthesis. The fracture showed delayed healing, which was treated by re-plating and autologous cancellous bone. RESULTS: 12 months postoperatively, the patient showed an excellent outcome with length preservation and good range of motion, sensibility, stability and aesthetic of the thumb. Furthermore, the quarterly tumor aftercare showed no evidence of recurrence. CONCLUSION: This case report showed that the free osteocutaneous lateral arm flap is a reliable solution for the reconstruction of the first ray with a great functional and aesthetic outcome. To prevent a secondary humerus fracture, a preventive plate osteosynthesis simultaneous with the osteocutaneous flap elevation should be considered.

Pathogens and Shift of Resistance in Early Infections after Operative Fracture Fixation.

Background: Surgical site infections (SSIs) remain a challenge for the healthcare system. During the last 30 years, the literature has shown an increase of gram-negative bacterial strains in multiple infectious sites and that cephalosporins have replaced penicillin as the gold standard in peri-operative antibiotic prophylaxis. This study aims to examine the recent bacterial spectrum in orthopedic early SSIs and to compare it with a historical cohort. Patients and Methods: Patients in a level 1 trauma center with an SSI within six weeks after open fixation of a fracture were analyzed in two adjacent periods from 2007 to 2012 (data pool 1; DP1) and 2013 to 2017 (data pool 2; DP2), retrospectively. The detected microbiologic pathogens and the associated resistograms from both time periods were compared. Results: Six hundred eighty-one smear tests and respective pathogens from the wounds of 463 patients (mean age, 62.6 ± 20 years) with SSIs were analyzed. The following pathogens were found most frequent: Staphylococcus epidermidis (DP1, 20.6%; DP2, 26.3%), Staphylococcus aureus (DP1, 27.1%; DP2, 16.5%), Enterococcus faecalis (DP1, 13.7%; DP2, 11.1%), Bacillus sp. (DP1, 3.0%; DP2, 5.3%), Escherichia coli (DP1, 5.1%; DP2, 4.1%), Pseudomonas aeruginosa (DP1, 3.7%; DP2, 2.5%). In DP2, there were lower primary early infection rates with Staphylococcus aureus than in DP1 (p = 0.002). In DP2, Staphylococcus epidermidis showed an oxacillin resistance in 90.6% and an increased resistance (79.8%; p = 0.069) to several classes of antibiotic agents compared to DP1. Conclusions: No bacterial shift toward gram-negative species was observed in this investigation. However, Staphylococcus epidermidis showed an increased antibiotic resistance in the more recent patient cohort. The incidence of SSIs with Staphylococcus aureus decreased substantially.

[Fixation of displaced fifth metatarsal shaft and neck fractures]. / Osteosynthese dislozierter Metatarsale-V-Schaft- und -Halsfrakturen.

OBJECTIVE: Open reduction and internal fixation of grossly dislocated fifth metatarsal shaft and neck fractures aims at restoration of the anatomical structure of the forefoot. The goal is to restore length, axis, rotation and joint position, while observing the metatarsal index (Maestro curve). INDICATIONS: Grossly dislocated and/or open shaft/neck fractures of the fifth metatarsal; combined fractures of the forefoot involving the fifth metatarsal. CONTRAINDICATIONS: Lack of consent to surgery. Overall critical (life-threatening) general condition preventing surgery to the extremities. Contaminated or infected soft tissues. SURGICAL TECHNIQUE: Depending on the planned method of fixation, open reduction is usually conducted via a lateral approach centrally above the easily palpable metatarsal V shaft. The incision lies above the glabrous skin of the sole. For markedly shortened and multifragment subcapital and shaft fractures of the fifth metatarsal, open reduction and plate fixation is the method of choice. Interlocking plates with a screw diameter of 2.0-2.4 mm are preferred to avoid later soft tissue irritation. Anatomic reconstruction is carried out under longitudinal traction at the fifth toe using small reduction clamps and, if necessary, temporary K­wire fixation. If the fragments are large enough, one or more interfragmentary lag screws can be used for fracture compression. A straight or condylar plate is used for internal fixation. Long spiral fifth metatarsal shaft fractures may alternatively be fixed with screws. In the case of transverse or subcapital fractures, percutaneous antegrade or retrograde medullary wiring with two Kirschner wires should be considered. POSTOPERATIVE MANAGEMENT: Following surgical treatment, rest and elevation of the injured leg, and local cooling are indicated. Subsequently, mobilization with partial weight bearing (20 kg) in foot orthosis or cast shoe for 6 weeks. RESULTS: Even grossly displaced fractures of the fifth metatarsal shaft have a good to excellent prognosis following surgical treatment with high union rates and rare complications. Undisplaced and mildly displaced fractures can be successfully managed nonoperatively with 6 weeks of weight bearing as tolerated in a stable orthosis or cast shoes.