Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Subtalar joint axis in patients with symptomatic peritalar subluxation compared to normal controls.

BACKGROUND: The etiology of peritalar subluxation (PTS) is poorly understood and likely mutifactorial. An anatomic predisposition for posterolateral subluxation of the hindfoot has not been previously described or investigated. The aim of the current study was to describe the morphology of the subtalar joint axis (STJA) in patients with symptomatic PTS compared to normal controls. METHODS: We identified patients with symptomatic PTS who had undergone operative correction from hospital records. The angle of the axis of the posterior facet of the subtalar joint was made on simulated weight-bearing CT (SWBCT) scans. A control group of patients who had no foot deformity on standing films was used for comparison. The STJA was defined as the angle between the superior talar dome and the posterior facet of the talus on coronal CT scan. The mean, maximum, and minimum STJAs were calculated for each cut from anterior to posterior across the posterior facet. The trend in progression across the posterior facet was also examined. RESULTS: After exclusions, 22 feet in 20 patients were included in the study group and compared to 20 control subjects. It was seen that patients with PTS had an increased valgus orientation of the subtalar joint. In patients with PTS the STJA began in valgus and progressed to even greater valgus from anterior to posterior across the posterior facet. The STJA in control subjects was seen instead to begin in slight varus and transition to valgus at the junction of the anterior and middle third and then increase in valgus as the joint progressed posteriorly. CONCLUSIONS: The valgus orientation of the coronal plane of the subtalar joint may represent an anatomic contribution to the etiology of PTS. LEVEL OF EVIDENCE: Level III, comparative series.

Anatomy of the varus foot and ankle.

In summary, varus deformity of the foot and ankle encompasses a spectrum of deformities from mild to severe. The cause of this deformity may be bone, muscle imbalance, or a combination of both. Surgical intervention should be planned only after the patient's anatomy is understood. Uncorrected symptomatic varus deformities may have significant consequences on gait kinematics and foot biomechanics.

Preference-based quality of life of end-stage ankle arthritis treated with arthroplasty or arthrodesis.

BACKGROUND: Health state values, or "utilities,'' are an important preference-based measure of quality of life used by health economists. This study describes the utilities reported by a multicenter cohort of subjects with end-stage ankle arthritis treated with ankle arthrodesis or total ankle arthroplasty. MATERIALS AND METHODS: Subjects with end-stage ankle arthritis were enrolled in a multicenter prospective cohort study. All subjects received either ankle arthrodesis or total ankle arthroplasty. Participants completed baseline SF-36 outcome evaluations preoperatively and at 1-year followup. Preference-based quality of life was assessed using health state values (HSVs) derived from the SF-36 (SF-6D transformation). RESULTS: 107 subjects were included. The mean baseline SF-6D health state value for the TAA group was 0.67 (95% CI 0.64 to 0.69) and 0.66 (95% CI 0.63 to 0.68) for the arthrodesis group. At 1-year followup, the mean reported health state value was 0.73 (95% CI 0.71 to 0.76) for the total ankle arthroplasty group and 0.73 (95% CI 0.70 to 0.76) for the ankle arthrodesis group. The 1-year followup results approach age- and gender-matched US population norms. Health state values poorly correlated with age, however, significant differences between genders were detected. CONCLUSION: These data demonstrate an improvement in preference-based quality of life following ankle arthroplasty or arthrodesis. The results also provide necessary data that can be used in future cost-effectiveness analyses.