Predicting Which Species of Bacteria Will Cause an Infection After Fracture Surgery.

The aim of this study was to develop and validate risk prediction models for deep surgical site infection (SSI) caused by specific bacterial pathogens after fracture fixation. A retrospective case-control study was conducted at a level I trauma center. Fifteen candidate predictors of the bacterial pathogens in deep SSI were evaluated to develop models of bacterial risk. The study included 441 patients with orthopedic trauma with deep SSI after fracture fixation and 576 control patients. The main outcome measurement was deep SSI cultures positive for methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), gram-negative rods (GNRs), anaerobes, or polymicrobial infection within 1 year of injury. Prognostic models were developed for five bacterial pathogen outcomes. Mean area under the curve ranged from 0.70 (GNRs) to 0.74 (polymicrobial). Strong predictors of MRSA were American Society of Anesthesiologists (ASA) classification of III or greater (odds ratio [OR], 3.4; 95% CI, 1.6-8.0) and time to fixation greater than 7 days (OR, 3.4; 95% CI, 1.9-5.9). Gustilo type III fracture was the strongest predictor of MSSA (OR, 2.5; 95% CI, 1.6-3.9) and GNRs (OR, 3.4; 95% CI, 2.3-5.0). ASA classification of III or greater was the strongest predictor of polymicrobial infection (OR, 5.9; 95% CI, 2.7-15.5) and was associated with increased odds of GNRs (OR, 2.7; 95% CI, 1.5-5.5). Our models predict the risk of MRSA, MSSA, GNR, anaerobe, and polymicrobial infections in patients with fractures. The models might allow for modification of preoperative antibiotic selection based on the particular pathogen posing greatest risk for this patient population. [Orthopedics. 2024;47(1):e19-e25.].

Coronal Plane Articular Shear Fractures of the Distal Humerus.

Coronal plane articular shear fractures of the distal humerus are a rare injury, comprising 6% of distal humerus fractures. The fracture can be easily missed on initial radiographs; therefore, a high index of suspicion is warranted. Radiographically obvious fractures are often more complex than initially appreciated, with plain radiographs often underestimating the extent of posterior comminution and trochlear involvement. Associated bony and ligamentous injuries are common. Anatomic reduction and internal fixation of displaced fractures is the standard of care because poor results have been described with nonsurgical treatment. However, the regional anatomy and the often-limited bone stock can make open reduction and internal fixation challenging. The lateral approach, with headless compression screws placed from anterior to posterior, is commonly used for simpler fracture patterns, but exposure and fixation of trochlea extension can be difficult. In the absence of posterior comminution, the anterolateral approach can enhance trochlea exposure and allow for a better trajectory for screw placement. Posterior comminution often requires locking plate fixation. Better results and lower complication rates have been reported for fractures with less fragmentation of the articular surface and those without posterior comminution. Contracture and symptomatic implants are the most common reasons for revision surgery.

Outcomes of Tibiotalocalcaneal Hindfoot Fusion Nails Used for Acute Lower Extremity Trauma in a High-Risk Patient Population.

OBJECTIVE: To determine the outcomes of high-risk patients treated with tibiotalocalcaneal hindfoot fusion nails. DESIGN: Retrospective case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Between January 2007 and December 2016, 50 patients with significant medical comorbidities treated with a tibiotalocalcaneal hindfoot fusion nail in the setting of acute distal tibia and ankle trauma considered to be limb-threatening. INTERVENTION: Tibiotalocalcaneal hindfoot fusion nail. MAIN OUTCOME MEASUREMENTS: Two-year cumulative incidence of unplanned reoperation and estimated survival with limb salvage at 2 years. RESULTS: Of the 50 patients, 20 (38%) had an unplanned reoperation (mean: 2.5 reoperations), including 19 for implant removal, 11 for irrigation and debridement and/or placement of an antibiotic delivery device, and 4 for revision fusion. Three patients required amputation and 3 patients died within 2 years of injury, resulting in an estimated survival with limb salvage at 2 years of 79% (95% confidence interval: 67%-91%). After accounting for the competing risk of death and incomplete follow-up, the 2-year cumulative incidence of unplanned reoperation was 64% (95% confidence interval: 62%-67%). CONCLUSIONS: Patients in this series experienced a high rate of return to the operating room but a relatively low rate of amputation. Because patients were indicated for this course of treatment on the basis of comorbidities felt to put them at high risk of loss of limb with traditional treatment, acute hindfoot fusion nailing might represent a viable option in select high-risk patients and injuries. Clinicians should be aware that complications are still common. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Are outcomes after fixation of distal humerus coronal shear fractures affected by surgical approach? A systematic review and meta-analysis.

Background: Surgical management of coronal shear fractures of the distal humerus is associated with a high rate of complications. Several surgical approaches have been described to address these fractures. The complication profiles associated with each approach have not previously been compared, and that is the aim of the present study. Methods: A systematic review of the literature was performed to identify all studies addressing coronal shear fractures of the distal humerus published between 2001 and January 2022. Of the 189 articles identified, 45 met the criteria for inclusion. Summaries of continuous data were calculated using the inverse variance method for pooling with random effects models. Fixed effects model estimates were reported unless significant heterogeneity was observed between studies. A subset of 6 studies reported the surgical approach and complications associated with the operative management of capitellar shear fractures without posterior comminution. The complication profiles of the extended lateral and anterolateral approaches were compared. Results: The 45 studies included yielded 899 patients. The average age was 44.9 years (95% confidence interval [CI]: 39.7 to 50.2). The fracture type was Dubberley A in 38% (n = 342), Dubberley B in 33% (n = 300), and not reported in the remainder. The reoperation rate was 13.8% (95% CI: 9.6% to 19.5%). Pooled complication rates included post-traumatic arthritis in 21.2% (95% CI: 18.0% to 24.9%), heterotopic ossification in 12.0% (95% CI: 9.2% to 15.6%), nerve injury in 7.8% (95% CI: 5.6% to 10.9%), and avascular necrosis in 7.4% (95% CI: 5.3% to 10.2%). The complication rate in noncomparative studies was 25.8% following the lateral approach and 16.7% following the anterolateral approach. Reported complications following the anterolateral approach were pain (9.5%) and nerve injury (7.1%). Reported complications following the lateral approach included arthritis (9.1%), heterotopic ossification (6.1%), avascular necrosis (4.5%), instability (3.0%), nerve injury (1.5%), and wound issues (1.5%). Discussion and Conclusion: Complications are common following operative management of capitellar shear fractures. In noncomparative studies, the complication rate was higher following the extended lateral compared to the anterolateral approach for Dubberley A fractures. Additionally, the reported complications following the extended lateral approach may impact long-term outcomes. Insufficient comparative evidence currently exists to recommend one approach over the other. High-quality comparative studies are needed.

Preoperative characteristics predictive of PROMIS Pain Interference two years after shoulder surgery.

INTRODUCTION: The objective of this study was to identify preoperative characteristics associated with worse Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) two years after shoulder surgery. METHODS: This was a retrospective analysis of prospectively collected data on 293 patients who underwent elective shoulder surgery. Survey questionnaires were collected within one week of surgery and then two years postoperatively. Bivariate analysis was used to identify associations and multivariable analysis was used to control for confounding variables. RESULTS: Worse two-year PROMIS PI was significantly correlated with older age, higher BMI, greater comorbidities, more prior surgeries, and multiple socio-demographic factors. Less improvement in PROMIS PI was significantly correlated with greater comorbidities, more previous surgeries, unemployment, prior orthopaedic surgery on the operative joint, and a higher American Society of Anesthesiologists (ASA) score. Better scores on all preoperative patient-reported outcome measures correlated with better two-year PROMIS PI. Multivariable analysis demonstrated that worse two-year PROMIS PI was independently predicted by the following preoperative factors: Workers' Compensation claim, opioid use, worse whole body Numeric Pain Score, and worse PROMIS PI. Less improvement in two-year PROMIS PI was predicted by the same preoperative factors. CONCLUSION: Worse PROMIS PI after shoulder surgery was associated with older age, greater comorbidities, mental health impairment, and lower socioeconomic status. Preoperative predictors of worse pain interference two years after shoulder surgery included Workers' Compensation, opioid use, worse whole body pain, and worse PROMIS PI. LEVEL OF EVIDENCE: III.