Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 4.193
Filtrar
1.
JBJS Case Connect ; 13(1)2023 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-36706197

RESUMO

CASE: A 17-year-old boy presented with an open talus fracture complicated by soot contamination after a chimney-related accident. Standard irrigation and debridement (I&D) methods were used, but complete removal of soot was not possible. At the latest follow-up, there was no evidence of infection, hardware failure, or avascular necrosis. CONCLUSION: There is a lack of well-established guidelines regarding I&D of traumatic wounds contaminated with fine particulates. A review of potential debridement methods is discussed. Orthoapedic surgeons should be aware of hydrosurgical debridement as a potential treatment approach in these unique scenarios.


Assuntos
Fraturas do Tornozelo , Traumatismos do Tornozelo , Fraturas Expostas , Luxações Articulares , Tálus , Masculino , Humanos , Adolescente , Tálus/diagnóstico por imagem , Tálus/cirurgia , Traumatismos do Tornozelo/cirurgia , Fraturas do Tornozelo/diagnóstico por imagem , Fraturas do Tornozelo/cirurgia , Fixação de Fratura , Luxações Articulares/cirurgia , Fraturas Expostas/diagnóstico por imagem , Fraturas Expostas/cirurgia
2.
Plast Reconstr Surg ; 151(2): 308e-314e, 2023 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-36696332

RESUMO

BACKGROUND: The British Orthopaedic Association Standards for Orthopaedics and Trauma 4 (BOAST 4) inform the management of open lower-limb fractures. The authors conducted repeated reviews of performance against these standards over a 12-year period. This latest iteration has shown further improvements in outcomes concomitant with changes in service delivery. METHODS: Data on Gustilo-Anderson grade IIIB or IIIC open lower-limb fractures were collected from a prospectively constructed departmental database and analyzed using Excel. Outcomes assessed included time to stabilization, time to definitive soft-tissue coverage, and deep infection rates. RESULTS: A total of 69% of patients in our cohort received care that aligned with BOAST 4 guidelines. Median time to stabilization was 14.2 hours and to soft-tissue coverage was 47 hours, with 71% of cases compliant with BOAST 4 guidelines. The overall deep infection rate was 6.5% in our cohort. There was a significantly lower deep infection rate in BOAST 4-compliant cases (2%) versus noncompliant cases (16%), respectively (P = 0.05). A total of 41 of 61 patients had fixation and soft-tissue coverage in a single operation (fix and flap), eight had staged operations, and 12 required local flap closure. There was no significant difference in deep infection rates among these approaches. CONCLUSIONS: Compliance with the BOAST 4 guidelines and time to definitive soft-tissue coverage have improved at our center since the last review. Deep infection rates were significantly lower in BOAST 4-compliant cases, further validating this approach. The fix and flap technique was introduced during the study period and reduces operative burden for patients. These results support a joint orthoplastic approach as the optimal management for these complex injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Fraturas Expostas , Fraturas da Tíbia , Humanos , Fixação Interna de Fraturas/métodos , Fraturas da Tíbia/cirurgia , Fraturas Expostas/cirurgia , Estudos Retrospectivos , Retalhos Cirúrgicos , Resultado do Tratamento
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 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
5.
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
6.
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
7.
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
8.
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
9.
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
10.
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
11.
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
12.
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
14.
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
15.
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
16.
Injury ; 53(11): 3838-3842, 2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-36153252

RESUMO

AIMS: Open tibial fractures are often life-changing injuries and patient outcomes remain poor despite the introduction of national management guidelines. The longer-term impact to the patient can be considerable but this is often overlooked in the literature. This study aims to establish the functional, physical, and psychosocial impact of sustaining an open tibial fracture. METHODS: We reviewed 69 consecutive Gustilo-Anderson grade IIIB and IIIC open tibial fractures that presented to our Major Trauma Centre (MTC) between September 2012 and April 2018. Each participant was interviewed and sent patient-reported outcome questionnaires, a minimum of 12 months following injury. Our primary outcome was the Lower Extremity Functional Scale (LEFS). Secondary outcomes included the Short-Form 36 Healthy Survey (SF-36), Sickness Impact Profile 128 (SIP) and return to occupation. Subgroups were analysed according to age, Injury Severity Score (ISS) and limb amputation. RESULTS: The mean follow up was 43 months. 96% were grade IIIB and 4% grade IIIC. The response rate for our study was 72%. The mean LEFS was 42 (IQR 21.5-58.5). All total and sub-domain scores within both the SF-36 and SIP questionnaires were reduced when compared to normative population data. Only 48% of patients returned to full time employment. Subgroup analysis revealed significantly reduced LEFS, SIP and SF-36 subdomain scores for those with a presenting ISS >14 and those undergoing limb amputation. CONCLUSION: Patients are at significant risk of longer-term functional, physical and psychosocial harm after suffering an open tibial fracture. Those sustaining major polytrauma or amputation demonstrated to have the greatest risk of poor outcome. Early identification of these individuals likely to suffer most from their injury would help direct appropriate resources to those with greatest need at the earliest opportunity.


Assuntos
Fraturas Expostas , Fraturas da Tíbia , Humanos , Fraturas Expostas/cirurgia , Fraturas Expostas/psicologia , Medidas de Resultados Relatados pelo Paciente , Estudos Retrospectivos , Tíbia , Fraturas da Tíbia/epidemiologia , Resultado do Tratamento
17.
J Bone Joint Surg Am ; 104(12): 1061-1067, 2022 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-36149241

RESUMO

BACKGROUND: Modern external ring fixation has been hypothesized to reduce complications requiring hospital readmission compared with internal fixation when treating patients with high-energy open tibial shaft fractures. In this study, the 1-year probability of a major limb complication was compared between external and internal fixation of severe open tibial fractures. METHODS: This multicenter randomized clinical trial included patients 18 to 64 years of age with severe open tibial shaft fractures randomly assigned to either modern external ring fixation (n = 127) or internal fixation (n = 133). The primary outcome was a major limb complication within 365 days after randomization; these complications included amputation, infection, a soft-tissue problem, nonunion, malunion, and a loss of reduction/implant failure. RESULTS: Of 260 randomized patients, 254 were included in the final analysis. Their mean age (standard deviation) was 39 (13) years; 214 (84%) were men. The probability of at least 1 major limb complication was higher for external fixation (62.1% [95% confidence interval (CI): 53.4% to 70.8%]) than internal fixation (43.7% [95% CI: 35.5% to 52.9%]), with a risk difference of 18.4% (95% CI: 5.8% to 30.4%); p = 0.005). The most notable difference was in loss of reduction/implant failure, the rate of which was higher for external fixation (risk difference: 14.4% [95% CI: 7.0% to 21.6%]; p = 0.002). There was no appreciable difference in the probability of deep infection between external fixation (26.1%) and internal fixation (29.7%) (risk difference: -3.5% [95% CI: -14.8% to 7.8%]; p = 0.54). There were also no appreciable differences in the probabilities of amputation, nonunion, soft-tissue problems, malunion, or fracture healing between the groups. CONCLUSIONS: These results argue against routine use of modern external ring fixation for the treatment of these severe open tibial fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Fraturas Expostas , Fraturas da Tíbia , Adulto , Fixadores Externos , Feminino , Fixação de Fratura/efeitos adversos , Fixação de Fratura/métodos , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/métodos , Consolidação da Fratura , Fraturas Expostas/cirurgia , Humanos , Masculino , Estudos Retrospectivos , Fraturas da Tíbia/cirurgia , Resultado do Tratamento
18.
Trials ; 23(1): 772, 2022 Sep 12.
Artigo em Inglês | MEDLINE | ID: mdl-36096826

RESUMO

BACKGROUND: Approximately 1 in 10 patients with a surgically treated open fracture will develop a surgical site infection. The Aqueous-PREP trial will investigate the effect of 10% povidone-iodine versus 4% chlorhexidine in aqueous antiseptic solutions in reducing infections after open fracture surgery. The study protocol was published in April 2020. METHODS AND DESIGN: The Aqueous-PREP trial is a pragmatic, multicenter, open-label, randomized multiple period cluster crossover trial. Each participating cluster is randomly assigned in a 1:1 ratio to provide 1 of the 2 study interventions on all eligible patients during a study period. The intervention periods are 2 months in length. After completing a 2-month period, the participating cluster crosses over to the alternative intervention. We plan to enroll a minimum of 1540 patients at 14 sites. RESULTS: The primary outcome is surgical site infection guided by the Centers for Disease Control and Prevention's National Healthcare Safety Network reporting criteria (2017). All participants' surgical site infection surveillance period will end 30 days after definitive fracture management surgery for superficial infections and 90 days after definitive fracture management surgery for deep incisional or organ/space infections [1]. The secondary outcome is an unplanned fracture-related reoperation within 12 months of the fracture. CONCLUSION: This manuscript serves as the formal statistical analysis plan (version 1.0) for the Aqueous-PREP trial. The statistical analysis plan was completed on February 28, 2022.


Assuntos
Anti-Infecciosos Locais , Fraturas Expostas , Anti-Infecciosos Locais/efeitos adversos , Clorexidina/efeitos adversos , Fraturas Expostas/cirurgia , Humanos , Povidona-Iodo/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Estados Unidos , Água
19.
Artigo em Inglês | MEDLINE | ID: mdl-36155604

RESUMO

INTRODUCTION: Open tibial shaft fractures are high-risk injuries for developing acute infection. Prior research has focused on injury characteristics and treatment options associated with acute inpatient infection in these injuries without primary analysis of host factors. The purpose of this study was to determine the patient comorbidities associated with increased risk of acute infection after open tibial shaft fractures during initial hospitalization. METHODS: A total of 147,535 open tibial shaft fractures in the National Trauma Data Bank from 2007 to 2015 were identified that underwent débridement and stabilization. Infection was defined as a superficial surgical site infection or deep infection that required subsequent treatment. The International Classification of Diseases, ninth revision codes were used to determine patient comorbidities. Comparative statistical analyses including odds ratios (ORs) for patient groups who did develop infection and those who did not were conducted for each comorbidity. RESULTS: The rate of acute inpatient infection was 0.27% with 396 patients developing infection during hospital management of an open tibial shaft fracture. Alcohol use (OR, 2.26, 95% confidence interval [CI], 1.73-2.96, P < 0.0001), bleeding disorders (OR, 4.50, 95% CI, 3.13-6.48, P < 0.0001), congestive heart failure (OR, 3.25, 95% CI, 1.97-5.38, P < 0.0001), diabetes (OR, 1.73, 95% CI, 1.29-2.32, P = 0.0002), psychiatric illness (OR, 2.17, 95% CI, 1.30-3.63, P < 0.0001), hypertension (OR, 1.56, 95% CI, 1.23-1.95, P < 0.0001), obesity (OR, 3.05, 95% CI, 2.33-3.99, P < 0.0001), and chronic obstructive pulmonary disease (OR, 2.09, 95% CI, 1.51-2.91, P < 0.0001) were all associated with increased infection rates. Smoking (OR, 0.957, 95% CI, 0.728-1.26, P = 0.722) and drug use (OR, 1.11, 95% CI, 0.579-2.11, P = 0.7607) were not associated with any difference in infection rates. DISCUSSION: Patients with open tibial shaft fractures who have congestive heart failure, bleeding disorders, or obesity are three to 4.5 times more likely to develop an acute inpatient infection than patients without those comorbidities during their initial hospitalization. Patients with diabetes, psychiatric illness, hypertension, or chronic obstructive pulmonary disease are 1.5 to 2 times more likely to develop subsequent infection compared with patients without those comorbidities. Patients with these comorbidities should be counseled about the increased risks. Furthermore, risk models for the infectious complications after open tibial shaft fractures can be developed to account for this more at-risk patient population to serve as modifiers when evaluating surgeon/hospital performance. CONCLUSION: Patient comorbidities are associated with increased risk of acute inpatient infection of open tibial shaft fractures during hospitalization.


Assuntos
Fixação Intramedular de Fraturas , Fraturas Expostas , Insuficiência Cardíaca , Hipertensão , Doença Pulmonar Obstrutiva Crônica , Fraturas da Tíbia , Comorbidade , Fraturas Expostas/complicações , Fraturas Expostas/epidemiologia , Fraturas Expostas/cirurgia , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/epidemiologia , Humanos , Hipertensão/complicações , Hipertensão/epidemiologia , Obesidade/complicações , Obesidade/epidemiologia , Doença Pulmonar Obstrutiva Crônica/complicações , Estudos Retrospectivos , Fraturas da Tíbia/complicações , Fraturas da Tíbia/epidemiologia , Fraturas da Tíbia/cirurgia
20.
Bone Joint J ; 104-B(9): 1073-1080, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-36047016

RESUMO

AIMS: The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK. METHOD: Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded. RESULTS: Across 51 centres, 1,175 patients were analyzed. Antibiotics were given to 754 (69.0%) in the emergency department, 240 (22.0%) pre-hospital, and 99 (9.1%) as inpatients. Wounds were photographed in 848 (72.7%) cases. Median time to first surgery was 16 hrs 14 mins (interquartile range (IQR) 8 hrs 29 mins to 23 hrs 19 mins). Complex injuries were operated on sooner (median 12 hrs 51 mins (IQR 4 hrs 36 mins to 21 hrs 14 mins)). Of initial procedures, 1,053 (90.3%) occurred between 8am and 8pm. A consultant orthopaedic surgeon was present at 1,039 (89.2%) first procedures. In orthoplastic centres, a consultant plastic surgeon was present at 465 (45.1%) first procedures. Overall, 706 (60.8%) patients required a single operation. At primary debridement, 798 (65.0%) fractures were definitively fixed, while 734 (59.8%) fractures had fixation and coverage in one operation through direct closure or soft-tissue coverage. Negative pressure wound therapy was used in 235 (67.7%) staged procedures. Following wound closure or soft-tissue cover, 509 (47.0%) patients received antibiotics for a median of three days (IQR 1 to 7). CONCLUSION: OPEN provides an insight into care across the UK and different levels of hospital for open fractures. Patients are predominantly operated on promptly, in working hours, and at specialist centres. Areas for improvement include combined patient review and follow-up, scheduled operating, earlier definitive soft-tissue cover, and more robust antibiotic husbandry.Cite this article: Bone Joint J 2022;104-B(9):1073-1080.


Assuntos
Fraturas Expostas , Fraturas da Tíbia , Antibacterianos , Seguimentos , Fixação Interna de Fraturas/métodos , Fraturas Expostas/cirurgia , Humanos , Estudos Retrospectivos , Infecção da Ferida Cirúrgica , Fraturas da Tíbia/cirurgia , Resultado do Tratamento , Reino Unido
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...