ABSTRACT
OBJECTIVES: To examine the effect of local aqueous tobramycin injection adjunct to perioperative intravenous (IV) antibiotic prophylaxis in reducing fracture-related infections (FRIs) following reduction and internal fixation of open fractures. DESIGN: Retrospective cohort study. SETTING: Single academic Level I trauma center. PATIENTS SELECTION CRITERIA: Patients with open extremity fractures treated with reduction and internal fixation with (intervention group) or without (control group) 80 mg of local aqueous (2 mg/mL) tobramycin injected during closure at the time of definitive fixation were identified from December 2018 to August 2021 based on population-matched demographic and injury characteristics. OUTCOME MEASURES AND COMPARISONS: The primary outcome was FRI within 6 months of definitive fixation. Secondary outcomes consisted of fracture nonunion and bacterial speciation. Differences in outcomes between the 2 groups were assessed and logistic regression models were created to assess the difference in infection rates between groups, with and without controlling for potential confounding variables, such as sex, fracture location, and Gustilo-Anderson classification. RESULTS: An analysis of 157 patients was performed with 78 patients in the intervention group and 79 patients in the control group. In the intervention group, 30 (38.5%) patients were women with a mean age of 47.1 years. In the control group, 42 (53.2%) patients were women with a mean age of 46.4 years. The FRI rate was 11.5% in the intervention group compared with 25.3% in the control group ( P = 0.026). After controlling for sex, Gustilo-Anderson classification, and fracture location, the difference in FRI rates between groups remained significantly different ( P = 0.014). CONCLUSIONS: Local aqueous tobramycin injection at the time of definitive internal fixation of open extremity fractures was associated with a significant reduction in FRI rates when administered as an adjunct to intravenous antibiotics, even after controlling for potential confounding variables. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Subject(s)
Anti-Bacterial Agents , Antibiotic Prophylaxis , Fracture Fixation, Internal , Fractures, Open , Surgical Wound Infection , Tobramycin , Humans , Female , Male , Tobramycin/administration & dosage , Fractures, Open/surgery , Fractures, Open/complications , Middle Aged , Retrospective Studies , Anti-Bacterial Agents/administration & dosage , Surgical Wound Infection/prevention & control , Antibiotic Prophylaxis/methods , AdultABSTRACT
OBJECTIVES: To compare radiographic and clinical outcomes in nonoperative management of humeral shaft fractures treated initially with coaptation splinting (CS) followed by delayed functional bracing (FB) versus treatment with immediate FB. DESIGN: Retrospective cohort study. SETTING: Academic Level 1 Trauma Center. PATIENT SELECTION CRITERIA: Patients with closed humeral shaft fractures managed nonoperatively with initial CS followed by delayed FB or with immediate FB from 2016 to 2022. Patients younger than 18 years and/or with less than 3 months of follow-up were excluded. OUTCOME MEASURES AND COMPARISONS: The primary outcome was coronal and sagittal radiographic alignment assessed at the final follow-up. Secondary outcomes included rate of failure of nonoperative management (defined as surgical conversion and/or fracture nonunion), fracture union, and skin complications secondary to splint/brace wear. RESULTS: Ninety-seven patients were managed nonoperatively with delayed FB (n = 58) or immediate FB (n = 39). Overall, the mean age was 49.9 years (range 18-94 years), and 64 (66%) patients were female. The immediate FB group had less smokers ( P = 0.003) and lower incidence of radial nerve palsy ( P = 0.025), with more proximal third humeral shaft fractures ( P = 0.001). There were no other significant differences in demographic or clinical characteristics ( P > 0.05). There were no significant differences in coronal ( P = 0.144) or sagittal ( P = 0.763) radiographic alignment between the groups. In total, 33 (34.0%) humeral shaft fractures failed nonoperative management, with 11 (28.2%) in the immediate FB group and 22 (37.9%) in the delayed FB group ( P = 0.322). There were no significant differences in fracture union ( P = 0.074) or skin complications ( P = 0.259) between the groups. CONCLUSIONS: This study demonstrated that nonoperative treatment of humeral shaft fractures with immediate functional bracing did not result in significantly different radiographic or clinical outcomes compared to treatment with CS followed by delayed functional bracing. Future prospective studies assessing patient-reported outcomes will further guide clinical decision making. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Subject(s)
Braces , Humeral Fractures , Splints , Humans , Female , Retrospective Studies , Male , Middle Aged , Adult , Aged , Humeral Fractures/therapy , Adolescent , Aged, 80 and over , Young Adult , Treatment OutcomeABSTRACT
OBJECTIVES: To determine: 1) the natural incidence of sacral inlet angle differences between S1 and S2 and 2) implications for iliosacral screw placement with a technique to improve the accuracy of the intraoperative fluoroscopic inlet for S1 and S2. DESIGN: Combined retrospective and prospective cohort reviews. SETTING: Regional Level 1 trauma center. PATIENTS/PARTICIPANTS: After exclusion criteria, 300 patients with uninjured pelvic rings to determine the natural incidence of S1 - S2 angle differences and 33 patients treated with iliosacral screws over the study period. INTERVENTION: None in the retrospective cohort. In the prospective cohort all patients underwent fluoroscopically assisted iliosacral screw fixation. MAIN OUTCOME MEASUREMENTS: Radiographic determination of S1 - S2 angle differences above 10 degrees in a natural population for the retrospective cohort. In the prospective, operative cohort the outcome of interest was the safety of iliosacral screws in S1 and S2 as determined on intraoperative fluoroscopy and postoperative CT scan.Results: In the retrospective cohort, 180/300 (60.0%) had S1 - S2 inlet angle differences above 10 degrees. In the operative cohort, 19/33 (57.6%) had S1 - S2 inlet angle differences above 10 degrees. Of the iliosacral screws in S1 and S2 placed using the described imaging technique, all (69/69, 100%) were safe. CONCLUSIONS: A normal population determined that differences in the inlet angle between S1 and S2 are common. An operative cohort was treated using preoperative CT-based planning to define different intraoperative fluoroscopic inlet views for S1 and S2, if a larger difference existed. Using this technique, 69/69 (100%) of iliosacral screws were either intraosseous or juxtacortical and safe. LEVEL OF EVIDENCE: Level V. See Instructions for Authors for a complete description of levels of evidence.
ABSTRACT
Orthogeriatric hip fractures have high morbidity and mortality rates. Modern management focuses on multidisciplinary collaboration for prompt surgical stabilization, early mobilization with multimodal pain control to avoid opioid consumption, and an enhanced recovery pathway. Despite these advances, postoperative complications and mortality rates remain higher than age-matched control subjects. The authors of this article represent the orthopaedic, anesthesia, and hospitalist medicine members of a multidisciplinary team at a single, Level 1 trauma center. Our goal was to provide an up-to-date comprehensive review of orthogeriatric hip fracture perioperative management from a multidisciplinary perspective that every orthopaedic surgeon should know.
Subject(s)
Hip Fractures , Orthopedics , Humans , Aged , Hip Fractures/surgeryABSTRACT
INTRODUCTION: There are some situations where pelvic surgeons may want to place iliosacral screws with differing trajectories (Sacroiliac and Sacral styles) but may not be able to because of overlapping trajectories. HYPOTHESIS: Sacroiliac and Sacral style screws can be placed in S1 in select patients by using a preoperative planning technique off the 3D reconstructed surface rendered preoperative CT scan. MATERIALS/METHODS: Retrospective review of all patients receiving iliosacral screws using the described technique. RESULTS: Six patients received iliosacral screws using the described technique. When the preoperative planning technique demonstrated feasibility, all screws were able to be safely placed. DISCUSSION: Placing Sacroiliac and Sacral style screws within S1 may be ideal in some injury patterns. The described technique allows pelvic surgeons facile in iliosacral screw techniques to preoperatively plan for this construct. LEVEL OF EVIDENCE: VI; Retrospective case series.
Subject(s)
Fractures, Bone , Pelvic Bones , Humans , Fractures, Bone/diagnostic imaging , Fractures, Bone/surgery , Fracture Fixation, Internal/methods , Retrospective Studies , Bone Screws , Sacrum/diagnostic imaging , Sacrum/surgery , Sacrum/injuries , Pelvic Bones/diagnostic imaging , Pelvic Bones/surgery , Pelvic Bones/injuries , Ilium/diagnostic imaging , Ilium/surgery , Ilium/injuriesABSTRACT
OBJECTIVE: To quantify the posterior acetabular exposure achieved with the Kocher-Langenbeck (K-L) with gluteus minimus debridement and Gibson approaches. METHODS: A Kocher-Langenbeck approach and a subsequent Gibson approach on the contralateral hip were performed in the prone position on 9 fresh frozen cadavers. Calibrated digital images were obtained of the Kocher-Langenbeck exposure, Kocher-Langenbeck exposure after gluteus minimus debridement, and Gibson exposure. The surface area of the posterior hip and pelvis visualized with each approach was calculated and compared with the contralateral side to assess for the difference between exposures. RESULTS: In 5 of the 9 cadavers, the Kocher-Langenbeck exposure before gluteus minimus debridement yielded an increased exposure in comparison with the Gibson approach, and the exposure was equivocal in 3 specimens. An increase of greater than 10% was considered significant. The exposure increased anteriorly and cranially by an average of 13.1 cm 2 after debridement of the gluteus minimus caudal to the superior gluteal neurovascular bundle in the Kocher-Langenbeck approach. CONCLUSIONS: Debridement of the gluteus minimus caudal to the level of the superior gluteal neurovascular bundle can significantly increase anterior and cranial exposure in the Kocher-Langenbeck approach and provide similar areas of access when compared with that in the Gibson approach.
Subject(s)
Fractures, Bone , Acetabulum , Cadaver , Debridement , Fracture Fixation, Internal/methods , HumansABSTRACT
BACKGROUND: Early administration of antibiotics and wound coverage have been shown to decrease the deep infection risk in all patients with Type 3 open tibia fractures. However, it is unknown whether early antibiotic administration decreases infection risk in patients with Types 1, 2, and 3A open tibia fractures treated with primary wound closure. QUESTIONS/PURPOSES: (1) Does decreased time to administration of the first dose of antibiotics decrease the deep infection risk in all open tibia fractures with primary wound closure? (2) What patient demographic factors are associated with an increased deep infection risk in Types 1, 2, and 3A open tibia fractures with primary wound closure? METHODS: We identified 361 open tibia fractures over a 5-year period at a Level I regional trauma center that receives direct admissions and transfers from other hospitals which produces large variation in the timing of antibiotic administration. Patients were excluded if they were younger than 18 years, had associated plafond or plateau fractures, associated with compartment syndrome, had a delay of more than 24 hours from injury to the operating room, underwent repeat débridement procedures, had incomplete data, and were treated with negative-pressure dressings or other adjunct wound management strategies that would preclude primary closure. Primary closure was at the descretion of the treating surgeon. We included patients with a minimum follow-up of 6 weeks with assessment at 6 months and 12 months. One hundred forty-three patients with were included in the analysis. Our primary endpoint was deep infection as defined by the CDC criteria. We obtained chronological data, including the time to the first dose of antibiotics and time to surgical débridement from ambulance run sheets, transferring hospital records, and the electronic medical record to answer our first question. We considered demographics, American Society of Anesthesiologists classification, mechanism of injury, smoking status, presence of diabetes, and Injury Severity Score in our analysis of other factors. These were compared using one-way ANOVA, chi-square, or Fisher's exact tests. Binary regression was used to to ascertain whether any factors were associated with postoperative infection. Receiver operator characteristic curves were used to identify threshold values. RESULTS: Increased time to first administration of antibiotics was associated with an increased infection risk in patients who were treated with primary wound closure; the greatest inflection point on that analysis occurred at 150 minutes, when the increased infection risk was greatest (20% [8 of 41] versus 4% [3 of 86]; odds ratio 5.6 [95% CI 1.4 to 22.2]; p = 0.01). After controlling for potential confounding variables like age, diabetes and smoking status, none of the variables we evaluated were associated with an increased risk of deep infection in Type 1, 2, and 3A open tibia fractures in patients treated with primary wound closure. CONCLUSION: Our findings suggest that in open tibia fractures, which receive timely antibiotic administration, primary wound closure is associated with a decreased infection risk. We recognize that more definitive studies need to be performed to confirm these findings and confirm feasibility of early antibiotic administration, especially in the pre-hospital context. LEVEL OF EVIDENCE: Level III, therapeutic study.
Subject(s)
Anti-Bacterial Agents/administration & dosage , Antibiotic Prophylaxis/methods , Fractures, Open/surgery , Surgical Wound Infection/prevention & control , Tibial Fractures/surgery , Wound Closure Techniques , Adult , Female , Humans , Male , Negative-Pressure Wound Therapy , Open Fracture Reduction/adverse effects , Open Fracture Reduction/methods , Retrospective Studies , Risk Factors , Surgical Wound Infection/etiology , Tibia/surgery , Time Factors , Treatment OutcomeABSTRACT
OBJECTIVE: Fluoroscopy is used in many orthopaedic procedures. The C-Arm drape is known to be easily contaminated during orthogonal imaging. However, it is unknown if one area of the operative field is more prone to contamination than another. The purpose of this study was to determine if secondary transfer of contaminate from the undraped portion of the C-Arm occurs. METHODS: A C-Arm was utilized with standardized draping in a simulated operating room. We used a simulated contaminant: a fluorescent powder that phosphoresces under ultraviolet light. The powder was placed over nonsterile portions. A darkened room with a black light, and a camera was used. C-Arm movements were simulated by cycling through lateral to Anteroposterior imaging. Images were taken before (control) and after cycles of orthogonal imaging. The change in light intensity was quantified at each time point over each area as a percentage of change. RESULTS: Contamination of the surgical field was observed in all areas after 15 cycles, with the area adjacent to the C-Arm being most pronounced. A linear increase in intensity with increased cycles was observed (R = 0.297; P = 0.036), with the mean increase in intensity of 5% after 15 cycles (95% confidence interval, 1.97-7.86). The remaining areas (closest to surgeon and middle) showed an increase as well but were not significant (P > 0.05). CONCLUSIONS: Secondary contamination of the surgical field from the C-Arm occurs. The area most prone to contamination is the area immediately adjacent to the fluoroscopy unit, usually opposite the surgeon.
Subject(s)
Equipment Contamination/prevention & control , Femur/diagnostic imaging , Femur/surgery , Fluoroscopy/instrumentation , Orthopedic Procedures/instrumentation , Humans , Models, Anatomic , Models, BiologicalABSTRACT
OBJECTIVES: Determine if using different fluoroscopic views of the knee (Notch or Tangential) improves accuracy of screw lengths assessment compared to the standard posteroanterior (PA). PARTICIPANTS AND METHODS: Orthopaedic surgeons at three ACGME-accredited residency programs were asked via survey to assess screw lengths on PA, femoral notch, and tangential radiographic views. RESULTS: Responders correctly identified screw length using PA, femoral notch, and medial tangential views at rates of 46.75%, 52.27%, and 44.37% respectively. Respondents detected overall screw length discrepancies most accurately using the femoral notch view (Odds Ratio 1.26; 95% confidence interval: 1.07-1.47; P < 0.005). There was no statistical difference between the residents and faculty cohort in ability to detect screw length discrepancy. CONCLUSION: Differentiating distal interlocking screw lengths on traditional imaging (AP/Notch/Tangential) is poor. The femoral notch view significantly improves accuracy in radiographic determination of screw length. The femoral notch view should be used in conjunction with the traditional PA view to maximize sensitivity and specificity for detecting prominent screws.
Subject(s)
Bone Nails , Device Removal/methods , Fluoroscopy , Fracture Fixation, Intramedullary/instrumentation , Cadaver , HumansABSTRACT
Alzheimer disease is a neurologic disorder characterized by the progressive cognitive decline. As the population continues to age, orthopaedic surgeons need to become familiar with surgical and nonsurgical treatment considerations in this complex population. Despite the advances in geriatric and dementia care, surgical and postoperative management of both elective and emergent surgery remain complex and controversial in this patient population. Appropriate perioperative and postoperative management can optimize outcomes, and the management can significantly affect the quality of life of patient and caregiver and limit disease burden. Any treatment decision should be guided first and foremost by the goals of care as agreed between the surgeon, other providers, and family. Surgical management must be demand matched to the patient accounting for the severity of disease, life expectancy, and the social support system. The authors conducted a literature review of Alzheimer dementia care in orthopaedic patients via a Pubmed search of relevant articles published since 1980.
Subject(s)
Alzheimer Disease/complications , Fractures, Bone/surgery , Orthopedic Procedures , Perioperative Care , Postoperative Care , Accidental Falls/prevention & control , Aged , Aged, 80 and over , Cost of Illness , Female , Fractures, Bone/complications , Humans , Life Expectancy , Male , Psychosocial Support Systems , PubMed , Quality of Life , Severity of Illness Index , Treatment OutcomeABSTRACT
CASE: We present the case of a thirteen-year-old female who sustained a posterior wall acetabular fracture dislocation. She underwent urgent closed reduction and subsequent uncomplicated open reduction and internal fixation. Post reduction computed tomography demonstrated a concentrically reduced hip joint with no evidence of femoroacetabular impingement (FAI). She subsequently healed her fracture and returned to running activities; however, one year later presented with aching pain in her thigh. Radiographs demonstrated the development of a large osseous prominence on her anterolateral femoral neck consistent with femoroacetabular impingement. Based on these findings she was evaluated by a hip preservation specialist. She subsequently underwent successful hip arthroscopy for labral repair and femoral osteochondroplasty. She was eventually able to return to running sports with little pain. SUMMARY: We present a case of FAI presenting as a complication of acetabular fracture fixation. This should be discussed with patients presenting with traumatic hip dislocations as a possible complication of surgical fixation or possibly of the injury itself.