-A machine learning model to predict surgical site infection after surgery of lower extremity fractures.

PURPOSE: This study aimed to develop machine learning algorithms for identifying predictive factors associated with the risk of postoperative surgical site infection in patients with lower extremity fractures. METHODS: A machine learning analysis was conducted on a dataset comprising 1,579 patients who underwent surgical fixation for lower extremity fractures to create a predictive model for risk stratification of postoperative surgical site infection. We evaluated different clinical and demographic variables to train four machine learning models (neural networks, boosted generalised linear model, naïve bayes, and penalised discriminant analysis). Performance was measured by the area under the curve score, Youdon's index and Brier score. A multivariate adaptive regression splines (MARS) was used to optimise predictor selection. RESULTS: The final model consisted of five predictors. (1) Operating room time, (2) ankle region, (3) open injury, (4) body mass index, and (5) age. The best-performing machine learning algorithm demonstrated a promising predictive performance, with an area under the ROC curve, Youdon's index, and Brier score of 77.8%, 62.5%, and 5.1%-5.6%, respectively. CONCLUSION: The proposed predictive model not only assists surgeons in determining high-risk factors for surgical site infections but also empowers patients to closely monitor these factors and take proactive measures to prevent complications. Furthermore, by considering the identified predictors, this model can serve as a reference for implementing preventive measures and reducing postoperative complications, ultimately enhancing patient outcomes. However, further investigations involving larger datasets and external validations are required to confirm the reliability and applicability of our model.

Intact PCL is a potential predictor of ACL graft size in the skeletally immature knee and other anatomic considerations for ACL reconstruction.

PURPOSE: To develop a method for using an intact posterior cruciate ligament (PCL) as a predictor of anterior cruciate ligament (ACL) graft size and examine possible differences in tunnel length based on all-epiphyseal drilling method. METHODS: One hundred one patients 5-18 years of age with magnetic resonance imaging (MRI) of the knee at an outpatient pediatric orthopaedic clinic from 2008 to 2020 were included. ACL and PCL coronal, sagittal, and length measurements were made in all patients. Tunnel length measurements were made in patients with open physes. Statistical analyses were performed to evaluate potential associations in patient bony or ligamentous measurements. RESULTS: PCL sagittal width and PCL coronal width were statistically significant predictors of ACL sagittal width and ACL coronal width, respectively (p = 0.002, R = 0.304; p = 0.008, R = 0.264). The following equations were developed to calculate ACL coronal and sagittal width measurements from the corresponding measurement on an intact PCL; ACL Coronal Width (mm) = 6.23 + (0.16 x PCL Coronal Width); ACL Sagittal Width (mm) = 5.85 + (0.53 x PCL Sagittal Width). Mean tibial maximum oblique length (27.8 mm) was longer than mean tibial physeal sparing length (24.9 mm). Mean femoral maximum oblique length (36.9 mm) was comparable to mean femoral physeal sparing length (36.1 mm). Both were longer than mean femoral straight lateral length (32.7 mm). CONCLUSION: An intact PCL is a predictor of native ACL size. Tunnel length differs based on chosen drilling method in all-epiphyseal technique. LEVEL OF EVIDENCE: Diagnostic Level III.

Risk of Surgical Site Infections in OTA/AO Type C Tibial Plateau and Tibial Plafond Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVES: To analyze the current incidence of postoperative infection for OTA/AO type C fractures of the tibial plateau and tibial plafond. DATA SOURCES: Three medical databases: PubMed/MEDLINE, ScienceDirect, and the Cochrane Library, were used in our systematic literature search. Search results were restricted to articles transcribed in English/Spanish and publication date after January 1, 2000, to present day. STUDY SELECTION: Inclusion criteria were studies reporting postoperative infection data for OTA/AO type 41C, 43C, or equivalent fractures of skeletally mature individuals. A minimum of 6 total fractures of interest and a frequency of 75% overall were required. Studies reporting on pathologic fractures, stress fractures, or low-energy fracture types were excluded. DATA EXTRACTION: Two authors independently screened abstracts, evaluated full-text manuscripts, and extracted relevant data from included studies. Any instances of discrepancy were resolved within the study committee by consensus. DATA SYNTHESIS: Outcomes were expressed using direct proportions (PR) with a 95% confidence interval. The effects of comorbidities on infection rates were reported using odds ratios with a 95% confidence interval. All analyses used a DerSimonian-Laird estimate with a random-effects model based on heterogeneity. The presence of publication bias was evaluated using funnel plots and Egger's tests. CONCLUSIONS: Patients with these specific fractures develop infections at a notable frequency. The rates of deep infections were approximately 6% in tibial plateau fractures and 9% in tibial plafond fractures. These results may be useful as a reference for patient counseling and other future studies aimed at minimizing postoperative infection for these injuries. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Nutrition and Vitamin Deficiencies Are Common in Orthopaedic Trauma Patients.

Macro- and micronutrients play important roles in the biological wound-healing pathway. Although deficiencies may potentially affect orthopaedic trauma patient outcomes, data on nutritional deficiencies in orthopaedic trauma patients remain limited in the literature. The purpose of this study was to (1) evaluate the prevalence of macro- and micronutrient deficiencies in orthopaedic trauma patients with lower extremity fractures and (2) evaluate the impact of such deficiencies on surgical site complications. This retrospective study identified 867 patients with lower extremity fractures treated with surgical fixation from 2019 to 2020. Data recorded included albumin, prealbumin, protein, vitamins A/C/D, magnesium, phosphorus, transferrin and zinc, as well as wound complications. Nutritional deficiencies were found for prealbumin, albumin and transferrin at 50.5%, 23.4% and 48.5%, respectively. Furthermore, a high prevalence of micronutrient deficiencies (vitamin A, 35.4%; vitamin C, 54.4%; vitamin D, 75.4%; and zinc, 56.5%) was observed. We also recorded a statistically significant difference in wound complications in patients who were deficient in prealbumin (21.6% vs. 6.6%, p = 0.0142) and vitamin C (56.8% vs. 28.6%, p = 0.0236). Our study outlines the prevalence of nutritional deficiencies in an orthopaedic trauma population and identifies areas for possible targeted supplementation to decrease wound complications.

An Analysis of Traumatic Ankle Fracture Patients: Does Income Status Influence Access to Acute Orthopaedic Surgical Care?

PURPOSE: To evaluate if income status affects the timing of presentation to orthopaedic care, surgical treatment, or continuity of care following a closed ankle fracture. METHODS: Th is retrospective study identified 434 patients with closed ankle fractures treated with operative fixation from 2014 to 2016. Median income data were extracted using the patients' ZIP codes and data from the U.S. Census Bureau. RESULTS: Lower-income patients presented to the hospital and received surgical treatment significantly later than others. They were also more often uninsured and nonadherent with postoperative weightbearing precautions. Additionally, these patients less frequently sought care on the day of their injury, and they had both shorter inpatient stays and duration of overall follow-up in comparison with others. CONCLUSION: Socioeconomic status is a vital consideration for improving patient access to acute orthopaedic surgical care. Lower-income patients are more susceptible to multiple time-sensitive delays in their care, and these patients frequently encounter difficulties maintaining appropriate follow-up carex.

Surgical Site Complications in Open Pronation-Abduction Ankle Fracture-Dislocations With Medial Tension Failure Wounds.

OBJECTIVES: To examine the incidence of surgical site complications associated with pronation-abduction ankle fracture-dislocations with an open medial tension wound. DESIGN: Retrospective case series. SETTING: Accredited Level-1 trauma center. PATIENTS/PARTICIPANTS: Forty-eight open pronation-abduction ankle fracture-dislocations with medial tension failure wounds treated at our institution from 2014 to 2016. INTERVENTION: Immediate irrigation and debridement along with surgical stabilization of open ankle fracture-dislocation. MAIN OUTCOME MEASURES: The primary outcome measure was deep surgical site infection. Secondary outcome measures included other surgical site complications and adverse radiographic events. RESULTS: A total of 5 patients (10.4%) developed a deep surgical site infection requiring additional surgical debridement. One of the patients with a deep surgical site infection required a below-knee amputation as a result of sepsis. Adverse radiographic outcomes included 3 fibular nonunions (6.3%), 3 implant failures related to syndesmotic fixations (6.3%), one periimplant fracture (2.1%), and postoperative collapse of the tibial plafond in 3 patients (6.3%). CONCLUSIONS: Open pronation-abduction ankle fracture-dislocations with medial tension failure wounds remain a challenging and potentially devastating injury. Our study suggests that with appropriate surgical debridement, early stabilization, and primary wound closure, acceptable outcomes with a relatively low risk of surgical site complications can be achieved. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fate of the Uninsured Ankle Fracture: Significant Delays in Treatment Result in an Increased Risk of Surgical Site Infection.

OBJECTIVE: To examine the impact of insurance status on access to orthopaedic care and incidence of surgical site complications in patients with closed unstable ankle fractures. DESIGN: Retrospective chart review. SETTING: Certified Level-1 urban trauma center and county facility. PARTICIPANTS: Four hundred eighty-nine patients with closed unstable ankle fractures undergoing open reduction and internal fixation between 2014 and 2016. INTERVENTION: Open reduction and internal fixation of unstable ankle fracture. MAIN OUTCOME MEASURES: Time from injury to presentation, time from injury to surgery, rate of surgical site infections, and loss to follow-up. RESULTS: A total of 489 patients (70.5% uninsured vs. 29.5% insured) were enrolled. Uninsured patients were more likely to be present to an outside hospital first (P = 0.004). Time from injury to presentation at our hospital was significantly longer in uninsured patients (4.5 ± 7.6 days vs. 2.3 ± 5.5 days, P < 0.001). Time from injury to surgery was significantly longer in uninsured patient (9.4 ± 8.5 days vs. 7.3 ± 9.1 days, P < 0.001). Uninsured patients were more likely to be lost to postoperative follow-up care (P = 0.002). A logistic regression analysis demonstrated that delayed surgical timing was directly associated with an increased risk of postoperative surgical site infection (P = 0.002). CONCLUSIONS: Uninsured patients with ankle fractures requiring surgery experience significant barriers regarding access to health care. Delay of surgical management significantly increases the risk of surgical site infections in closed unstable ankle fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Skin closure with surgical staples in ankle fractures: a safe and reliable method.

PURPOSE: The purpose of this study is to examine the rates of surgical site complications of staple closure versus suture closure following open reduction and internal fixation of closed unstable ankle fractures. METHODS: Between 2014 and 2016, a total of 545 patients with closed ankle fractures were treated at our level-1 trauma centre by means of open reduction and internal fixation. A total of 360 patients matched the inclusion criteria and were included in the final analysis of this study. This included 119 patients undergoing wound closure using sutures and 241 patients using surgical staples. The demographics, clinical data, and injury characteristics were recorded. The primary outcome measure was the adverse event of any type of surgical site complication. RESULTS: The overall rate of patients with a surgical site complication was 15.6%. There was a trend towards a higher risk of surgical site complication in patients undergoing wound closure with sutures as compared with staples (20.2% versus 13.3%); however, this difference was not statistically significant (P = 0.0897). The rate of superficial surgical site infection also trended higher in patients undergoing wound closure with sutures versus staples without demonstrating statistical significance (10.1% versus 5%, P = 0.0678). The rate of deep surgical site infection was similar in both groups. CONCLUSION: The use of metal staples remains controversial in the setting of orthopedic surgery, particularly involving the foot and ankle. The current study supports that metal staples are a safe and reliable option in the closure of traumatic ankle fractures.

Outpatient surgery in patients with ankle fractures minimises hospital admissions and utilisation of healthcare resources.

PURPOSE: The recent outbreak of the novel coronavirus (SARS-CoV-2) has emphasised the need to minimise hospital admissions and utilisation of healthcare resources. The purpose of this study was to examine the outcomes of an outpatient surgery protocol for acute closed ankle fractures. METHODS: In this retrospective study, 262 patients underwent outpatient surgery for their closed ankle fractures at our level-1 trauma centre. A total of 196 patients met our inclusion criteria and were ultimately included in the final analysis. Our primary outcomes' measures included post-operative admission to the emergency department within 30 days after surgery and unplanned hospital readmission within 30 days after surgery. Our secondary outcome measure included the incidence of surgical site infection (SSI) within 12 weeks after surgery. RESULTS: Thirty-two patients (16.3%) had an unplanned emergency department visit within 30 days of fracture fixation and two patients (1.0%) required hospital readmission within 30 days of their surgery. Sixteen patients (8.2%) developed SSI, which included 11 (5.6%) superficial and five (2.6%) deep infections. CONCLUSION: Strategic outpatient management of acute closed ankle fractures is associated with acceptable rates of unplanned emergency department visits, hospital readmissions, and SSIs. In the context of the recent SARS-CoV-2 outbreak, outpatient management of these injuries may aide in the mitigation of nosocomial infections and the preservation of finite healthcare resources.