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1.
J Orthop Surg Res ; 18(1): 13, 2023 Jan 05.
Artigo em Inglês | MEDLINE | ID: mdl-36604668

RESUMO

BACKGROUND: External fixators (EFs) and intramedullary nailing (IMN) are two effective methods for open tibial fractures. However, both methods have advantages and disadvantages, and the optimal surgical approach remains controversial. Thus, we performed a meta-analysis of randomized controlled trials (RCTs) to compare EF with IMN to evaluate their efficacy and safety. METHODS: A systematic study of the literature was conducted in relevant studies published in PubMed, Embase, the Cochrane Library, Web of Science, CNKI, CBM, Wanfang and Weipu from database inception to April 2022. All eligible literature was critically appraised for methodological quality via the Cochrane's collaboration tool. The primary outcome measurements included postoperative superficial infection, postoperative deep infection, union time, delayed union, malunion, nonunion, and hardware failure. RESULTS: Nine RCTs involving 733 cases were included in the current meta-analysis. The pooled results suggested that cases in the IMN group had a significantly lower postoperative superficial infection rate [risk ratio (RR) = 2.84; 95% confidence interval (CI) = 1.83 to 4.39; P < 0.00001)] and malunion rate (RR = 3.05; 95% CI = 2.06 to 4.52; P < 0.00001) versus EF, but IMN had a significantly higher hardware failure occurrence versus EF (RR = 0.38; 95% CI = 0.17 to 0.83; P = 0.02). There were no significant differences in the postoperative deep infection rate, union time, delayed union rate or nonunion rate between the two groups (p > 0.05). CONCLUSIONS: Compared to EF, IMN had a significantly lower risk of postoperative superficial infection and malunion in patients with open tibial fractures. Meanwhile, IMN did not prolong the union time and increased the risk of the deep infection rate, delayed union rate and nonunion rate but had a higher hardware failure rate. The reanalysis of union time showed that it was significantly shorter in the IMN group than in the EF group after excluding the study with significant heterogeneity during sensitivity analysis. Therefore, IMN is recommended as a preferred method of fracture fixation for patients with open tibial fractures, but more attention should be given to the problem of hardware failure.


Assuntos
Fixação Intramedular de Fraturas , Fraturas Expostas , Fraturas da Tíbia , Humanos , Fixação Intramedular de Fraturas/efeitos adversos , Fixação Intramedular de Fraturas/métodos , Tíbia , Ensaios Clínicos Controlados Aleatórios como Assunto , Fixadores Externos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Fraturas da Tíbia/cirurgia , Fraturas Expostas/cirurgia , Resultado do Tratamento , Pinos Ortopédicos
2.
Med J (Ft Sam Houst Tex) ; (Per 23-1/2/3): 103-111, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36607307

RESUMO

BACKGROUND: Open fractures are at high risk for complications both in the military and civilian setting. Treatments to prevent fractures are limited in the Role 1 (prehospital, battalion aid station) setting. The goal of this study is to assess the efficacy of topical vancomycin powder, administered within 24 hours of an open fracture injury, in the prevention of infection and infection-related complications. METHODS: The POWDER study is a multicenter, prospective, randomized controlled clinical trial using a pragmatic open-label design. We will recruit 200 long bone open fracture patients from University Hospital at University of Texas Health at San Antonio (UTHSA) and the Brooke Army Medical Center (BAMC). We will screen and randomize patients in a 1:1 ratio to receive either usual care plus 2g topical vancomycin or usual care only. The primary objective of this study is to compare the proportion of infection and infection-related complications which occur in the 2 arms. An additional objective is to develop a risk-prediction model for open fracture wound complications. CONCLUSIONS: The infection rates seen in open fractures remain alarmingly high in both combat and civilian settings. Several orthopedic surgery studies suggest vancomycin powder is effective in reducing surgical site infections when applied topically at the time of wound closure. We expect to see a reduction in infections in open fracture injuries treated acutely with vancomycin powder. This study may provide important information regarding the use of local vancomycin powder during the acute treatment of open fractures. If shown to be efficacious, vancomycin powder could provide a simple, time- and cost-effective infection prophylaxis strategy for these injuries.


Assuntos
Antibacterianos , Fraturas Expostas , Humanos , Antibacterianos/uso terapêutico , Vancomicina/uso terapêutico , Fraturas Expostas/complicações , Fraturas Expostas/tratamento farmacológico , Fraturas Expostas/cirurgia , Pós , Estudos Prospectivos , Resultado do Tratamento , Serviço Hospitalar de Emergência
3.
JBJS Case Connect ; 13(1)2023 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-36638201

RESUMO

CASE: A 14-year-old adolescent girl sustained an open fracture of the foot after jumping off a building. Initial radiographs revealed large bone defect in the distal metaphysis of the comminuted tibia. The comminuted distal tibia was reconstructed by external fixation and internal fixation with bridge plating, followed by the Masquelet technique. After 12 months, the fracture healed without infection, and the patient could walk independently. CONCLUSION: In the case of a comminuted fracture of the contaminated distal tibia with a large bone defect, plate fixation and the Masquelet technique produced good outcomes.


Assuntos
Fraturas Cominutivas , Fraturas Expostas , Feminino , Adolescente , Humanos , Criança , Tíbia/diagnóstico por imagem , Tíbia/cirurgia , Tornozelo , Extremidade Inferior , Fixação Interna de Fraturas/métodos , Fraturas Expostas/diagnóstico por imagem , Fraturas Expostas/cirurgia , Fraturas Cominutivas/diagnóstico por imagem , Fraturas Cominutivas/cirurgia
4.
J Am Acad Orthop Surg ; 31(1): e1-e8, 2023 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-36548150

RESUMO

Prevention of Surgical Site Infections After Major Extremity Trauma Evidence-Based Clinical Practice Guideline is based on a systematic review of current scientific and clinical research. This clinical practice guideline (CPG) is designed to assist qualified physicians and clinicians when making treatment decisions for adults (18 years or older) who have sustained major extremity trauma. The CPG workgroup defined major extremity trauma as an open fracture, a major/high-energy closed fracture, a degloving injury, Morel-Lavallée lesions, a low-energy or high-energy gunshot injury, a crush injury, a blast injury, or any other moderate-energy to high-energy injury. This guideline contains 14 recommendations that evaluate preoperative, perioperative, and postoperative interventions to limit the risk of surgical site infections after major extremity trauma while also identifying and evaluating potential patient-specific risk factors to consider. Another six options formulated with either low-quality evidence, no evidence, or conflicting evidence are also presented and discussed in the CPG. These include the use of incisional negative-pressure wound therapy for high-risk surgical incisions, the implementation of an orthoplastic team, the possible role of hyperbaric O2, the value of various preoperative skin preparations, and select modifiable and administrative risk factors.


Assuntos
Fraturas Expostas , Tratamento de Ferimentos com Pressão Negativa , Adulto , Humanos , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Extremidades , Fatores de Risco
5.
Med J (Ft Sam Houst Tex) ; (Per 23-1/2/3): 103-111, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36580533

RESUMO

BACKGROUND: Open fractures are at high risk for complications both in the military and civilian setting. Treatments to prevent fractures are limited in the Role 1 (prehospital, battalion aid station) setting. The goal of this study is to assess the efficacy of topical vancomycin powder, administered within 24 hours of an open fracture injury, in the prevention of infection and infection-related complications. METHODS: The POWDER study is a multicenter, prospective, randomized controlled clinical trial using a pragmatic open-label design. We will recruit 200 long bone open fracture patients from University Hospital at University of Texas Health at San Antonio (UTHSA) and the Brooke Army Medical Center (BAMC). We will screen and randomize patients in a 1:1 ratio to receive either usual care plus 2g topical vancomycin or usual care only. The primary objective of this study is to compare the proportion of infection and infection-related complications which occur in the 2 arms. An additional objective is to develop a risk-prediction model for open fracture wound complications. CONCLUSIONS: The infection rates seen in open fractures remain alarmingly high in both combat and civilian settings. Several orthopedic surgery studies suggest vancomycin powder is effective in reducing surgical site infections when applied topically at the time of wound closure. We expect to see a reduction in infections in open fracture injuries treated acutely with vancomycin powder. This study may provide important information regarding the use of local vancomycin powder during the acute treatment of open fractures. If shown to be efficacious, vancomycin powder could provide a simple, time- and cost-effective infection prophylaxis strategy for these injuries.


Assuntos
Antibacterianos , Fraturas Expostas , Humanos , Antibacterianos/uso terapêutico , Vancomicina/uso terapêutico , Fraturas Expostas/complicações , Fraturas Expostas/tratamento farmacológico , Fraturas Expostas/cirurgia , Pós , Estudos Prospectivos , Resultado do Tratamento , Serviço Hospitalar de Emergência
6.
Trials ; 23(1): 968, 2022 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-36456987

RESUMO

BACKGROUND: Antimicrobial coatings of implants are of interest to reduce infection rate in orthopedic surgery. Demonstration of clinical effectiveness of such coated implants to obtain market approval is challenging. The objective of this article is to define a design for a randomized controlled trial to evaluate the clinical performance of a silver-coating for locking plates for fracture treatment. METHODS: The study design has to respect different criteria, such as feasibility, focus on overall complications, such as functional impairment, fracture healing, and particularly on infection rates. Distal tibia fractures were chosen due to the high prevalence of infections in this type of injuries, which warrants a particular benefit of antimicrobial prophylaxis and thus might allow to see a statistical trend in favor of the coated product. The study design was defined as a randomized, controlled, subject and observer-blinded, multi-center study in subjects with fractures of the distal tibia with a total of 226 patients. A number of 113 patients are planned for each of the two treatment arms with treatment of the fracture with a silver-coated device (first arm) or with an uncoated device (second arm). Inclusion criteria are closed fractures of the distal tibia according to the Tscherne-Oestern classification or open fractures of the distal tibia according to the Gustilo-Anderson classification in subjects older than 18 years. Primary outcome parameter is the Anticipated Adverse Device Effects (AADE) including all typical complications of this type of injury, such as functional impairment of the affected limb, non-union, and infections based on a non-inferiority study design. Also, silver-typical complications, such as argyria, are included. Secondary parameters are infection rates and fracture healing. Follow-up of patients includes five visits with clinical and X-ray evaluations with a follow-up time of 12 months. DISCUSSION: Demonstration of clinical effectiveness of antimicrobial coatings of fracture fixation devices remains a challenge. Definition of a prospective randomized pre-market trial design and recruitment of clinical sites for such a study is possible. A confirmative proof of the expected clinical benefit in terms of reduction of device-related infections will be addressed with a prospective post-market clinical follow-up study in a second step due to the large sample size required. TRIAL REGISTRATION: ClinicalTrials.gov NCT05260463. Registered on 02 March 2022.


Assuntos
Fraturas Expostas , Tíbia , Humanos , Tíbia/cirurgia , Prata , Estudos Prospectivos , Seguimentos , Antibacterianos
7.
BMC Musculoskelet Disord ; 23(1): 1110, 2022 Dec 20.
Artigo em Inglês | MEDLINE | ID: mdl-36539743

RESUMO

BACKGROUND: Traumatic brain injury (TBI) has been known to accelerate bone healing. Many cells and molecules have been investigated but the exact mechanism is still unknown. The neuroinflammatory state of TBI has been reported recently. We aimed to investigate the effect of TBI on fracture healing in patients with tibia fractures and assess whether the factors associated with hematoma formation changed more significantly in the laboratory tests in the fractures accompanied with TBI. METHODS: We retrospectively investigated patients who were surgically treated for tibia fractures and who showed secondary bone healing. Patients with and without TBI were divided for comparative analyses. Radiological parameters were time to callus formation and the largest callus ratio during follow-up. Preoperative levels of complete blood count and chemical battery on admission were measured in all patients. Subgroup division regarding age, gender, open fracture, concomitant fracture and severity of TBI were compared. RESULTS: We included 48 patients with a mean age of 44.9 (range, 17-78), of whom 35 patients (72.9%) were male. There were 12 patients with TBI (Group 1) and 36 patients without TBI (Group 2). Group 1 showed shorter time to callus formation (P <  0.001), thicker callus ratio (P = 0.015), leukocytosis and lymphocytosis (P ≤ 0.028), and lower red blood cell counts (RBCs), hemoglobin, and hematocrit (P <  0.001). Aging and severity of TBI were correlated with time to callus formation and callus ratio (P ≤ 0.003) while gender, open fracture, and concomitant fracture were unremarkable. CONCLUSION: Tibia fractures with TBI showed accelerated bone healing and superior measurements associated with hematoma formation (lymphocytes, RBCs, hemoglobin, hematocrit). Promoted fracture healing in TBI was correlated with the enhanced proinflammatory state. LEVEL OF EVIDENCE: III, case control study.


Assuntos
Lesões Encefálicas Traumáticas , Fraturas Expostas , Fraturas da Tíbia , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Feminino , Consolidação da Fratura , Estudos de Casos e Controles , Estudos Retrospectivos , Tíbia , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Calo Ósseo , Fraturas da Tíbia/complicações , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia
8.
J Orthop Surg (Hong Kong) ; 30(3): 10225536221119580, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36545907

RESUMO

Fracture related infections (FRIs) are a disabling condition causing significant concern within the orthopaedic community. FRIs have a huge societal and economic burden leading to prolonged recovery times and the potential for becoming chronic conditions or being life-threatening. Despite its importance in our field, the surgical community has just recently agreed on a definition which, added to the lack of surgical trials assessing preventive and treatment interventions have limited our understanding and precipitated wide variations in surgeons' practice. This article aims to review the current practices that can be supported with high-quality evidence. Currently, we have a limited body of high-quality evidence on FRI prevention and treatment. A handful of measures have proven effective, such as the use of prophylactic antibiotics, the use of saline and low pressure as the preferred irrigation solution and the safety of delaying initial surgical débridement more than 6 hours without impacting infection rates for open fracture wounds débridement. Future multicentre trials, properly powered, will shed light on current areas of controversy regarding the benefit of different preoperative and perioperative factors for the prevention and treatment of FRIs. Higher quality evidence is needed to guide surgeons to offer an evidence-based approach to prevent FRI occurrence and to treat patients suffering from them.


Assuntos
Fraturas Expostas , Ortopedia , Humanos , Fraturas Expostas/cirurgia
9.
Can J Surg ; 65(6): E792-E797, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36418064

RESUMO

BACKGROUND: Extensile lateral (ELA) and minimally invasive surgical (MIS) approaches are commonly used in the operative fixation of calcaneus fractures. The ELA has been the standard of care, but is associated with a high risk of wound complications. Minimally invasive surgical approaches have been developed to reduce these complications. METHODS: We completed a retrospective chart review of 201 patients with calcaneus fractures repaired by either ELA or MIS approaches between 2011 and 2018. We compared the incidence of soft tissue complications, including wound infections (requiring no surgical treatment) and deep infections (requiring surgical intervention), and performed multivariate regression analysis to determine independent risk factors associated with soft tissue complications and reoperation. RESULTS: The overall incidence of soft tissue complications was 8.1% in the MIS group compared with 28.8% in the ELA group (p = 0.0004). The incidence of patients with a deep infection requiring reoperation was 4.7% in the MIS group compared with 19.2% in the ELA group (p = 0.003). Risk factors of soft tissue complications included the presence of an open fracture (odds ratio [OR] 11.59, 95% confidence intervals [CI] 3.25-44.25) and use of ELA (OR 4.22, 95% CI 1.67-10.90). Risk factors for a deep infection requiring reoperation included the use of ELA (OR 4.43, 95% CI 1.51-13.64) and the presence of an open fracture (OR 4.00, 95% CI 0.91-15.3). CONCLUSION: The ELA is associated with an increased incidence of soft tissue complications and reoperation when compared with the MIS approach. The ELA and open fractures were found to be independent risk factors of soft tissue complications and reoperation. Surgeons treating calcaneus fractures should consider using a MIS technique, provided they are able to achieve the goals of surgical management without the ELA.


Assuntos
Calcâneo , Fraturas Expostas , Humanos , Calcâneo/cirurgia , Fraturas Expostas/etiologia , Estudos Retrospectivos , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos
10.
J Surg Orthop Adv ; 31(3): 181-186, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36413166

RESUMO

This study aimed to characterize postoperative infection rate among patients undergoing definitive fixation of both open and closed fractures during the same surgery. Outcomes between patients with open fractures (OF) treated first were compared to those with closed fractures (CF) treated first. We identified 303 adult patients with multiple (≥ 2) pelvis and extremity fractures who presented to our Level 1 Trauma hospital in 2017. Forty patients with at least one open and one closed fracture treated with operative fixation during the same surgery were included in analysis. Eight surgical site infections (SSI) developed in seven patients. There was no significant difference between treatment order groups (OF = 4 patients (5 fractures), CF = 3 patients (3 fractures); p > 0.99). This is the first study comparing different chronologies of operative fixation in coexisting open and closed fractures. Our study shows that the choice of treatment order does not influence SSI risk. (Journal of Surgical Orthopaedic Advances 31(3):181-186, 2022).


Assuntos
Fraturas Fechadas , Fraturas Expostas , Adulto , Humanos , Fraturas Expostas/cirurgia , Infecção da Ferida Cirúrgica/epidemiologia , Fraturas Fechadas/complicações , Fraturas Fechadas/cirurgia , Resultado do Tratamento , Estudos Retrospectivos
11.
Surg Infect (Larchmt) ; 23(9): 817-828, 2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-36350736

RESUMO

Background: Open fractures, defined as fractures communicating with the environment through a skin wound, cause substantial morbidity after traumatic injury. Current evidence supports administration of prophylactic systemic antibiotic agents to patients with open extremity fractures to decrease infectious complications. Methods: The Therapeutic and Guidelines Committee of The Surgical Infection Society convened to revise guidelines for antibiotic use in open fractures. PubMed was queried for pertinent studies. Evaluation of the published evidence was performed using the GRADE framework. All committee members voted to accept or reject each recommendation. Results: In type I or II open extremity fractures, we recommend against administration of extended-spectrum antibiotic coverage compared with gram-positive coverage alone to decrease infections complications, hospital length of stay or mortality. In type III open extremity fractures, we recommend antibiotic therapy for no more than 24 hrs after injury, in the absence of clinical signs of active infection, to decrease infectious complications, hospital length of stay or mortality, and we recommend against extended antimicrobial coverage beyond gram-positive organisms to decrease infectious complications, hospital length of stay or mortality. In type III open extremity fractures with associated bone loss, we recommend antibiotic therapy in addition to systemic therapy to decrease infectious complications. Conclusions: Although antibiotic agents remain a standard of care for infection prevention after open extremity fractures, our findings and surveys of clinical practice patterns clearly show that additional robust clinical trials are needed to provide stronger corroborating evidence.


Assuntos
Anti-Infecciosos , Fraturas Expostas , Humanos , Fraturas Expostas/complicações , Fraturas Expostas/tratamento farmacológico , Fraturas Expostas/cirurgia , Antibacterianos/uso terapêutico , Antibioticoprofilaxia , Anti-Infecciosos/uso terapêutico , Extremidades , Infecção da Ferida Cirúrgica/tratamento farmacológico , Infecção da Ferida Cirúrgica/prevenção & controle , Infecção da Ferida Cirúrgica/complicações , Estudos Retrospectivos
12.
Injury ; 53(12): 4104-4113, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-36424690

RESUMO

BACKGROUND: High energy open tibial fractures are complex injuries with no consensus on the optimal method of fixation. Treatment outcomes are often reported with union and re-operation rates, often without specific definitions being provided.  We sought to describe union, reoperation rates, and patient reported outcomes, using the validated EQ-VAS and Disability Rating Index (DRI) scores, following stabilisation with a Taylor Spatial Frame (TSF) and a combined orthoplastic approach for the management of soft tissues. A literature review is also provided. METHOD: A prospective cross-sectional follow up of open tibial fractures, treated at a level 1 major trauma centre, managed with a TSF using a one ring per segment technique between January 2014 and December 2019 were identified. Demographic, injury and operative data were recorded, along with Patient Reported Outcome Measures (PROM) scores, specifically the EQ-VAS and Disability Rating Index (DRI). Union rates, defined by radiographic union scale in tibia (RUST) scores, and re-operation rates were recorded. Appropriate statistical analyses were performed, with a p<0.05 considered statistically significant. RESULTS: Overall, 51 patients were included. Mean age was 51.2 ± 17.4 years, with a 4:1 male preponderance. Diaphyseal and distal fractures accounted for 76% of cases. Mean time in frame was 206.7 ± 149.4 days. Union was defined and was achieved in 41/51 (80.4%) patients. Deep infection occurred in 6/51 (11.8%) patients. Amputation was performed in 1 case (1.9%). Overall re-operation rate was 33%. Time to union were significantly longer if re-operation was required for any reason (uncomplicated 204±189 vs complicated 304±155 days; p = 0.0017) . EQ-VAS and DRI scores significantly deteriorated at 1 year follow-up (EQVAS 87.5 ± 11.7 vs 66.5 ± 20.4;p<0.0001 and DRI 11.9 ± 17.8 vs 39.3 ± 23.3;p<0.0001). At 1 year post op, 23/51(45.1%) required a walking aid, and 17/29 (58.6%) of those working pre-injury had returned to work. CONCLUSION: Open tibial fracture have significant morbidity and long recovery periods as determined by EQVAS and DRI outcome measures.  We report the largest series of open tibial feature treated primarily with a TSF construct, which has similar outcomes to other techniques, and should therefore be considered as a useful technique for managing these injuries.


Assuntos
Fraturas Expostas , Fraturas da Tíbia , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Idoso , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Estudos Transversais , Estudos Prospectivos , Medidas de Resultados Relatados pelo Paciente , Fraturas Expostas/cirurgia
13.
Acta Orthop Traumatol Turc ; 56(5): 316-320, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36250881

RESUMO

OBJECTIVE: The aim of this study was to evaluate the safety and results of one-stage surgery in Gustilo grade 1 and 2 open distal radius fractures with metadiaphyseal involvement. METHODS: This retrospective study included 54 patients with AO-2R3 and metadiaphyseal involvement according to the AO fracture classification. All fractures were treated with a long volar plate using the minimally invasive plate osteosynthesis (MIPO) technique. The patients were divided into two groups as open fracture group (25 patients) and closed fracture group (29 patients), and the groups were compared for their union time and complications and functional and radiological results. RESULTS: There was no statistically significant difference between the groups in terms of clinical and radiographic results (P > .05 for both). The mean union time was 12.77 (range, 8-20) weeks in the open fracture group and 12.75 (range, 8-18) weeks in the closed fracture group. There was no statistically significant difference between the groups in terms of union time (P > .05). Moreover, there was no statistically significant difference between the two groups in terms of major and minor complications. All fractures healed without the need for bone and/or soft tissue grafts. CONCLUSION: As a result of this study, using with long volar plate immediately minimally invasive plate osteosynthesis might be safely used as a single-stage definitive treatment for Gustilo grade 1 and 2 open distal radius fractures with metadiaphyseal involvement. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.


Assuntos
Fraturas Fechadas , Fraturas Expostas , Fraturas do Rádio , Humanos , Estudos Retrospectivos , Fraturas Expostas/cirurgia , Fraturas do Rádio/diagnóstico por imagem , Fraturas do Rádio/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Resultado do Tratamento , Placas Ósseas , Fixação Interna de Fraturas/métodos , Consolidação da Fratura
14.
Int Orthop ; 46(12): 2727-2734, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-36197460

RESUMO

OBJECTIVE: Infection and nonunion are the two most challenging issues for high-energy fractures. This study aimed to explore the clinical effect of benign inflammation-cultivated bone growth activity in the treatment of closed/small-sized open and high-energy fractures. METHODS: This study is a case series of closed/small-sized open and high-energy fractures of the lower limbs treated at our hospital from April 2009 to February 2017. All patients underwent debridement and external fixation in the early stage, followed by internal fixation in the second stage. After the operation, fracture healing was monitored by X-ray, and early-stage knee function training was initiated. Also, bone grafting was performed to stimulate the healing reaction, eliminating the atrophic nonunion factors. RESULTS: The operation in all 75 cases was carried out after the inflammatory responses completely subsided, leading to secondary wound healing. Bony union appeared in 71 patients who did not suffer from any pain and could stand up and walk without any restriction. Among them, 68 patients could flex their knee > 100°, and three patients had knee flexion ranging from 80 to 100°. No infections occurred after the second operation. CONCLUSION: This two-stage treatment for high-energy fractures could avoid the damage caused by excessive inflammatory responses that occurred following early-stage one-time internal fixation. This method protected benign inflammatory-callus reactions induced by the primary injury and utilized the advantages of closed reduction in AO fixation with open reduction, thereby avoiding potential infection and nonunion caused by one-time fixation during the early stage.


Assuntos
Fraturas Ósseas , Fraturas Expostas , Fraturas da Tíbia , Humanos , Resultado do Tratamento , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/cirurgia , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/métodos , Fixação de Fratura/efeitos adversos , Fixação de Fratura/métodos , Consolidação da Fratura , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Fraturas Expostas/cirurgia , Estudos Retrospectivos
15.
Oxid Med Cell Longev ; 2022: 8385456, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36193077

RESUMO

The study aimed to explore the feasibility of a nanodrug delivery system to treat open fractures with bone defects. We developed a cefazolin (Cef)/bone morphogenetic protein 2 (BMP-2)@mesoporous silica nanoparticle (MSN) delivery system; meanwhile, Cef/MBP-2@ poly(lactic-co-glycolic acid) (PLGA) was also developed as control. For the purpose of determining the osteogenic and anti-inflammatory actions of the nanodelivery system, we cultured bone marrow mesenchymal stem cells (BMSCs) and constructed a bone defect mouse model to evaluate its clinical efficacy. After physicochemical property testing, we determined that MSN had good stability and did not easily accumulate or precipitate and it could effectively prolong the Cef's half-life by nearly eight times. In BMSCs, we found that compared with the PLGA delivery system, MSNs better penetrated into the bone tissue, thus effectively increasing BMSCs' proliferation and migration ability to facilitate bone defect repair. Furthermore, the MSN delivery system could improve BMSCs' mineralization indexes (alkaline phosphatase [ALP], osteocalcin [OCN], and collagen I [Col I]) to effectively improve its osteogenic ability. Moreover, the MSN delivery system could inhibit inflammation in bone defect mice, which was mainly reflected in its ability to reduce the release of IL-1ß and IL-4 and increase IL-10 levels; it could also effectively reduce apoptosis of CD4+ and CD8+ T cells, thus improving their immune function. Furthermore, the percentage of new bones, bone mineral density, trabecular volume, and trabecular numbers in the fracture region were improved in mice treated with MSN, which allowed better repair of bone defects. Hence, Cef/BMP-2@MSN may be feasible for open fractures with bone defects.


Assuntos
Fraturas Expostas , Nanopartículas , Fosfatase Alcalina/metabolismo , Animais , Células da Medula Óssea/metabolismo , Proteína Morfogenética Óssea 2/metabolismo , Proteína Morfogenética Óssea 2/uso terapêutico , Linfócitos T CD8-Positivos/metabolismo , Cefazolina/farmacologia , Diferenciação Celular , Células Cultivadas , Colágeno/metabolismo , Interleucina-10/metabolismo , Interleucina-4/metabolismo , Camundongos , Nanopartículas/química , Osteocalcina , Osteogênese , Copolímero de Ácido Poliláctico e Ácido Poliglicólico/farmacologia , Dióxido de Silício/química
16.
Medicine (Baltimore) ; 101(39): e30891, 2022 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-36181018

RESUMO

RATIONALE: Floating-dislocated elbow is a severe and extremely rare injury in adults. Reviewing the literature, we found around 6 case reports regarding floating-dislocated elbow in adults. PATIENT CONCERNS AND DIAGNOSES: We report 2 cases of this unusual injury association. Both patients suffered a high energy trauma - fall from a height. Initial X-rays (radiography) revealed in both cases the fractures above and below the elbow (floating elbow) and associated elbow dislocation (floating-dislocated elbow). One case was a type IIIB Gustilo-Anderson open fracture-dislocation with an intra-articular component (olecranon fracture). INTERVENTIONS AND OUTCOMES: Each case had his own management problem regarding what to treat first: the dislocation or the associated fractures? Fractures were treated surgically by reduction and internal fixation, and after elbow dislocation reduction, the upper limb was immobilized in a long, well-padded plaster, with the elbow in 90° of flexion, for 3 weeks. Bone union was observed radiographically at 2 months after surgery in both cases. At the 2-year follow-up we recorded full upper limb recovery in terms of muscular trophism and elbow full range of motion. LESSONS: In addition to adding 2 new cases to a lower number of such lesion associations in adults, we also added a new variant of floating-dislocated elbow which has not been reported until now in the literature. Prompt management of these injuries, with stable fixation of the fractures allowed for early rehabilitation with excellent 2-years functional outcome.


Assuntos
Articulação do Cotovelo , Fraturas Expostas , Luxações Articulares , Fraturas da Ulna , Adulto , Cotovelo , Articulação do Cotovelo/diagnóstico por imagem , Articulação do Cotovelo/cirurgia , Fixação Interna de Fraturas , Humanos , Luxações Articulares/diagnóstico por imagem , Luxações Articulares/cirurgia , Amplitude de Movimento Articular , Estudos Retrospectivos , Resultado do Tratamento , Fraturas da Ulna/cirurgia
18.
Lancet ; 400(10360): 1334-1344, 2022 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-36244384

RESUMO

BACKGROUND: Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture. METHODS: We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304. FINDINGS: Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4). INTERPRETATION: For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds. FUNDING: US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.


Assuntos
Anti-Infecciosos Locais , Fraturas Expostas , Adulto , Anti-Infecciosos Locais/uso terapêutico , Antissepsia/métodos , Canadá/epidemiologia , Clorexidina/análogos & derivados , Clorexidina/uso terapêutico , Estudos Cross-Over , Feminino , Fraturas Expostas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Povidona-Iodo/uso terapêutico , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle
19.
Medicine (Baltimore) ; 101(35): e30460, 2022 Sep 02.
Artigo em Inglês | MEDLINE | ID: mdl-36107575

RESUMO

Upper extremity fractures (UEF) occurred in about 0.67% of males and females at some point in their lifetime. Surgical treatment has the advantage of good functional recovery, however, the occurrence of surgical site infection (SSI) affects the clinical outcome of operation. Currently, there are few studies focused on SSI of UEF. Consecutive patients with UEF and underwent surgeries from January 2010 to February 2021 were recruited. Demographic data, surgical related variables and laboratory test index of these patients were extracted and collected from the electronic medical records and picture archiving and communication system by well-trained investigators. Receiver operating characteristic (ROC) analysis was performed to detect the optimum cut-off value for continuous variables. Multivariate logistic regression analysis was performed to identify independent risk factors of SSI. In total, 286 patients with a mean age of 44.4 ±â€…16.6 years were identified for inclusion, 59.8% patients diagnosed with fracture of radius and ulna and 40.2% fractures located in the humerus, closed and open fractures were occurred in 252 and 34 adult patients respectively. 7.3% UEF patients were encountered with SSI, incidence of superficial and deep infection was 6.3% and 1.0%. Open fracture (OR, 8.33; P, .000), operation time longer than 122 minutes (OR, 3.12; P, .036), intraoperative blood loss more than 135 mL (OR, 3.98; P, .009) and albumin (ALB) lower than 40.8 g/L (OR, 3.60; P, .015) were demonstrated as independent risk factors of SSI. Adequate preoperative evaluation, careful intraoperative manipulation, and timely and appropriate postoperative interventions should be formulated to reduce the incidence of SSI in patients with the above perioperative high-risk factors.


Assuntos
Traumatismos do Braço , Fraturas Expostas , Adulto , Feminino , Fraturas Expostas/complicações , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/etiologia , Extremidade Superior/cirurgia
20.
J Plast Reconstr Aesthet Surg ; 75(11): 3970-3978, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-36163147

RESUMO

INTRODUCTION: Published standards for the management of open extremity fractures have improved limb salvage, fracture union, and deep infection rates, but the aesthetic and functional importance of our flap choices has been overlooked. Thin and superthin free flaps exhibit advantages over traditional free flaps in some situations but have seldom been reported in children. The aim of this paper is to present our experience of thin and superthin free flaps in pediatric extremity reconstruction. METHODS: Children (≤13 years) who underwent soft tissue reconstruction using a thin and superthin free flap following major extremity trauma are presented. RESULTS: Five patients (5 flaps) met the inclusion criteria. The median age was 9 (range 6-13). There were 3 Gustilo IIIB open fractures and 2 multiplanar degloving injuries. The median mangled extremity severity score (MESS) was 4 (range 2-6). The median time from injury to definitive soft tissue closure was 72 h (range 28-120 h). Four anterolateral thigh (ALT) flaps were raised as thin flaps, and 1 superficial circumflex iliac artery perforator (SCIP) was raised as a superthin flap. There was one re-exploration owing to venous congestion, and a second venous anastomosis was performed to enhance flap drainage. The same ALT flap exhibited necrosis at one margin, which was debrided and grafted before discharge. There were no other flap complications. No flap-related secondary surgeries were required. CONCLUSION: Thin and superthin free flaps are viable options in pediatric extremity reconstruction. They exhibit excellent aesthetic and functional contouring when a slender fasciocutaneous flap is needed, especially when body habitus renders traditional options unfavorable.


Assuntos
Fraturas Expostas , Retalhos de Tecido Biológico , Retalho Perfurante , Lesões dos Tecidos Moles , Humanos , Criança , Retalhos de Tecido Biológico/irrigação sanguínea , Coxa da Perna/cirurgia , Resultado do Tratamento , Lesões dos Tecidos Moles/cirurgia , Fraturas Expostas/cirurgia , Extremidade Inferior/cirurgia , Estudos Retrospectivos , Retalho Perfurante/irrigação sanguínea
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