Deep Infection Rate Research Articles

Clinical and radiological outcomes of gunshot-induced femur fractures: a comparative study of monolateral external fixators and hybrid advanced ilizarov method

Aims: Clinical and radiological outcomes, complication rates, and 10-year follow-up results of comminuted femoral open fractures resulting from firearm injuries were evaluated by comparing the Hybrid Advanced Ilizarov method (HAIM) and monolateral external fixator (MEF) of the limb reconstruction system (LRS) for treatment.
 Methods: Nineteen patients (18 males, 1 female) treated with HAIM and 14 male patients treated with MEF-LRS for femoral comminuted open fractures due to firearm injuries were retrospectively analyzed. Complication rates, pin tract and deep infection rates, time to union, and the need for secondary surgeries were assessed. The Tegner activity score and Short Form-36 (SF-36) were used for comparative evaluation of functional and radiological outcomes and comfort levels with the fixator.
 Results: There were no significant differences between the groups in terms of age, gender, follow-up duration, time to union, union rate, delayed union, or deep infection. No infections were detected in either group that required a change in the fixation method. There were no significant differences in radiological and functional outcomes between the groups. Significant differences were observed in terms of pin tract infections between the groups. The comfort level of MEF-LRS patients was significantly higher than that of HAIM patients.
 Conclusion: In the treatment of femoral fractures due to firearm injuries in early and long-term follow-ups, similar complication rates and functional outcomes were achieved for both MEF-LRS and HAIM methods. When considering external fixator preference, MEF-LRS is a better alternative, with a lower rate of pin tract infections and higher patient comfort level.

Enhanced recovery for acute open lower limb fracture ‘fix and flap’

IntroductionEnhanced recovery (ER) aims to achieve earlier recovery, reduced hospital length of stay (LoS) whilst improving outcomes. Our ER protocol for acute lower-limb open fracture (ALLOFs) includes dangling at day 3 and mobilising fully weight-bearing from day 5. Our aims were to evaluate the outcomes of ALLOFs using our ER protocol for limb salvage, LoS following ‘fix & flap’, return to theatre, rate of successful flap salvage, flap failure and deep infection rates. MethodsAn observational study of a prospectively maintained lower limb flap database from September 2020 to January 2023 was undertaken. Search criteria encompassed patients with a Gustilo IIIB/C injury and a free flap reconstruction. Exclusions were for local/perforator flaps, soft tissue injury only, fracture related/prosthetic joint infections, or chronic osteomyelitis cases. Results161 patients were available for analysis, 126 male (78 %) and 35 female (22 %) with a median age of 40 years (12-79, interquartile range 30.0). 81 % of cases were high-energy injuries. For all patients, the median time to definitive fixation and soft tissue coverage from injury was 4 days (0-30, interquartile range 2). 18 cases (11.2 %) required return to theatre for flap exploration; 11 cases were successfully salvaged (61 %). Nine free flaps failed (5.4 %). The median total LoS from admission was 10 days (6 to 46, interquartile range 5), with a median LoS following definitive fixation and soft tissue coverage of 7 days (4 to 20, interquartile range 3). The median follow-up period was 18 months (12 to 38.2, interquartile range 9), with a deep infection rate of 6.5 %. ConclusionIn isolated ALLOFs, our ER protocol is safe and effective in shortening the LoS. Our outcomes sit comfortably within acceptable ranges of contemporary literature for return to theatre, flap salvage/failure and deep infection. Our ER protocol actively involves our allied health professional colleagues early to facilitate discharge.

Does Alexis Wound Protector/Retractor Reduce the Risk of Surgical Site Infections After Open Radical Cystectomy for Bladder Cancer? Results From a Single Center, Comparative Study

To assess if Alexis dual-ring wound protector/retractor reduced the incidence of superficial and deep incisional infection following open radical cystectomy (ORC). Since January 2020, all procedures were performed using the Alexis retractor. We retrospectively reviewed our ORC database and compared patients who were operated on with Alexis with the same number of consecutive patients operated with a stainless steel retractor in the previous period. Data are presented as median and (interquartile range). Seventy-four patients underwent RC with Alexis (group 1) and 74 with stainless steel retractor (group 2). Median age was 73.0(13) in group 1, 73.5(14) in group 2 (P = .338). There were 59(79.7%) men in both groups. The groups were comparable in terms of comorbidities, body mass index, American Society of Anesthesiology score, and neoadjuvant chemotherapy rate. There was no statistically significant difference in type of lymph node dissection and urinary diversion, total surgical time. Postoperative stay was shorter in group 1 [8(4) days vs 9(4) in group 2, P = .012]. Group 2 had a significantly higher rate of both superficial (8.1% vs 18.9%, P = .045) and deep incisional infection (2.7% vs 14.9%, P = .009). At multivariable analysis, body mass index (OR 1.129 95% CI 1.162-1.283, P = .043) was significantly associated with higher odds of superficial incisional infection. The use of Alexis was significantly associated with lower odds of having both superficial (OR 0.274 95%CI 0.033-0.781, P = .023) and deep incisional infection (OR 0.159 95% CI 0.034-0.745, P = .020). The use of Alexis significantly reduces the rate of superficial and deep incisional infection following ORC.

THE ROLE OF PROPHYLACTIC ANTIBIOTICS IN ZONE II AND ZONE V ACUTE FLEXOR TENDON INJURIES

Our study sought to establish the necessity of prolonged pre-operative antibiotic prophylaxis in patients presenting with zone II and zone V acute flexor tendon injuries (FTI). We hypothesized that a single dose of prophylactic antibiotic was adequate in prevention of post-operative wound infection in acute zone II and V FTI.This was a prospective study of 116 patients who presented with zone II and zone V acute FTI. The study included patients who were 18 years and older. Those with macroscopic contamination, immunocompromised, open fractures, bite injuries, and crush injuries were excluded. Patients were randomised into a group receiving a single dose of prophylactic antibiotic and another group receiving a continuous 8 hourly antibiotic doses until the day of surgery. Each group was subdivided into occupational and non-occupational injuries. Their post-operative wound outcomes were documented 10 – 14 days after surgery. The wound outcome was reported as no infection, superficial infection (treated with wound dressings), and deep infection (requiring surgical debridement).There was 0.9% rate of deep post-operative wound infections, which was a single zone V acute FTI case in a single dose prophylactic antibiotic group. There was a 7.8% superficial post-operative wound infection rate, which was mainly zone II acute FTI in both antibiotic groups. There was a strong association between zone II acute FTI and post-operative wound infection (p < 0.05). There was no association between (antibiotic dosage or place of injury) with post-operative wound infection (p > 0.05).There is no benefit in prescribing prolonged pre-operative antibiotic in patients with acute, simple lacerations to zone II and zone V FTI if there is no macroscopic wound contamination.

DEEP INFECTION RATE RESULTING IN REOPERATION FOR SEPSIS FOLLOWING MINOR HAND SURGERY WITH WIDE-AWAKE LOCAL ANAESTHESIA, NO TOURNIQUET (WALANT), AND FIELD STERILITY IN AN OUTPATIENT SETTING

This study aims to determine the incidence of surgical site infection leading to reoperation for sepsis following minor hand procedures performed outside the main operating room using field sterility in the South African setting.The investigators retrospectively reviewed the records of 485 patients who had WALANT-assisted minor hand surgery outside a main operating theatre, a field sterility setting between March 2019 and April 2023. The primary outcome was the presence or absence of deep surgical site infection that required reoperation within four weeks. Cases included where elective WALANT minor hand procedures, a minimum age of 18 with complete clinical records.The patients were mostly female (54.8%), with a mean age of 56.35 years. The majority of cases were trigger finger and carpal tunnel release. An overall 485 cases were reviewed, the deep surgical site infection rate resulting in reoperation within 4 weeks post-operatively was 1.24% ((95% Confidence Interval (CI) 0.0034 to 0.0237); p = 0.009).Minor hand procedures performed under field sterility using WALANT have a low surgical site infection rate. The current study's infection rates are comparable to international surgical site infection rates for similar surgeries performed in main operating rooms using standard sterilisation procedures. Field sterility is a safe and acceptable clinical practice that may improve work efficiency in public sector.

Effectiveness of antibiotic-coated intramedullary nails for open tibia fracture infection prevention. A systematic review and meta-analysis

IntroductionOpen Tibia fractures are associated with high rates of Fracture Related Infection (FRI). Given the negative outcomes and increased costs related to the latter, several prophylactic local antibiotic delivery methods have been proposed, aiming to decrease the FRI rate. Our objective with this study was to determine the effectiveness of antibiotic-coated intramedullary nails for open tibia FRI prevention. Patients and MethodsWe conducted a PRISMA compliant systematic review and meta-analysis. Queries were performed on Embase, PubMed, Lilacs and Cochrane data libraries. Seventeen studies were included for qualitative analysis and 2 studies were amenable for meta-analysis. ResultsGlobal infection, deep infection and non-union rates were 8.4%, 5.4% and 3.7% in the antibiotic-coated nail group and 22%, 14% and 14% in the non-antibiotic-coated nail group respectively. The meta-analysis showed a protective trend that favored the antibiotic-coated nail group although it didn't achieve statistical significance: deep infection Relative Risk (RR) (RR = 0.17 CI95% [0.02 – 1.31]); global infection RR = 0.36 CI95% [0.10 – 1.35]) and non-union (RR = 0.14 CI95% [0.02 – 1.22]), ConclusionsOur findings suggest a favorable trend towards antibiotic-coated nail, with decreased risk of global infection, deep infection and non-union as compared to non-antibiotic-coated nail in patients with open tibia fractures. Nonetheless, higher level evidence studies are required to confirm our findings.

The effect of epidural steroid injection during surgery on surgical site infections following lumbar fusion.

Intraoperative epidural steroid injections (ESIs) have been suggested to limit pain following lumbar fusions. However, the frequency of resultant surgical site infections has not been fully investigated. We retrospectively followed two groups of patients; 23 patients were the control group, while the other 23 patients received, in addition to the spinal fusions, intraoperative ESI. Patients in the latter ESI/fusion treatment group had significantly increased rates of superficial and deep infections (i.e., superficial infections 17.4% and 4.3% deep infections) versus control patients (i.e., 8.6% superficial and 0% deep) undergoing fusions alone. We observed an increased risk of postoperative surgical site infections among patients who underwent intraoperative ESI in addition to their lumbar fusions.

Systematic Review of Complications Associated With Proximal Hamstring Tendon Repair.

Although several complications of proximal hamstring tendon ruptures have been reported in the literature, few studies have comprehensively analyzed the complication profile of proximal hamstring tendon repair. To identify the overall rate of complications following proximal hamstring tendon repair and to differentiate these complications into categories. Systematic review; Level of evidence, 4. Included in this review were studies that examined surgical repair of proximal hamstring tendon ruptures; all studies were in English and had an evidence level of 4 or higher. No restrictions were made regarding publication date or methodological quality. Data regarding complications were extracted to calculate the overall complication rate as well as the rate of major and minor complications. A quantitative data synthesis was conducted using the chi-square test to compare the proportion of patients who experienced complications with the endoscopic versus open approach. A total of 43 articles including 2833 proximal hamstring tendon repairs were identified. The overall postoperative complication rate was 15.3% (n = 433). The rate of major complications was 4.6%, including a 1.7% rate of sciatic nerve injury, 0.8% rate of venous thromboembolism, 0.8% reoperation rate, 0.8% rerupture rate, and 0.4% rate of deep infection. Minor complications included a 2.4% rate of posterior femoral cutaneous nerve injury, 2.3% rate of persistent hamstring myopathy, 2.2% rate of persistent sitting pain, 1.8% rate of peri-incisional numbness, 1.1% rate of superficial infection, and 0.8% rate of hematoma/seroma. Proximal hamstring tendon repair is associated with an overall complication rate of 15.3%, including a 4.6% rate of major complications.

535 A Case Report of a Rare Post Traumatic Infected Regenerate Following Corticotomy for Lengthening Following a Frame Ankle Fusion

Abstract Introduction We present a case of a 49-year-old patient who initially presented in May 2020 with an open pilon fracture. Managed with initial debridement, fixation, and flap - who subsequently underwent circular frame application for failure of fixation, requiring a transport to fusion frame who developed beta-haemolytic streptococcus A within the site of the proximal corticotomy. Method A systematic review of the literature was conducted searching EMBASE, MEDLINE and Cochrane library for all articles discussing infected bone regenerate- a paucity of information was found. Abstracts were independently reviewed by 2 authors (LH and LT). In total, there were 16 papers, and then subsequently analysed we identified two case reports regarding infected regenerate. Results Developing an infection in a regenerate is highly rare with very few reported cases within the published literature. The literature identified risk factors for an infected regenerate, with open fracture and smoking being the two consistent factors. The open fracture deep infection rate is cited at 10% in most publications, this is at the site of the open fracture and not within the regenerate. Conclusions Infection within the regenerate during distraction osteogenesis is highly unusual, with only two other published papers in the literature to the best of our knowledge. This should be borne in mind when managing patients with infection of unknown sources in cases of distraction osteogenesis.

Comparison of suprapatellar intramedullary nailing versus minimal invasive locked plating for proximal tibia fractures.

To compare the radiological alignment, union time, union rate, and complication rate between suprapatellar intramedullary nails and minimally invasive locking plate fixation in the treatment of proximal tibial fractures. We retrospectively analyzed 103 patients who underwent plate fixation (n = 50) or suprapatellar intramedullary nailing (n = 53) for proximal tibial fractures involving the meta-diaphyseal junction between November 2015 and October 2020 at our institution. The union rate, union time, radiologic alignments, and complications, such as malalignment, nonunion, and deep infection, were investigated. The demographic data did not differ between the plate and suprapatellar intramedullary nail groups. The alignment of the coronal plane was 0.24 ± 3.19 in the plate group and - 0.49 ± 2.22 in the intramedullary nail group (p = 0.196). Sagittal plane alignment was - 0.29 ± 4.97 in the plate group and 0.24 ± 4.12 in the intramedullary nail group (p = 0.571), and coronal malalignment (p = 0.196), sagittal malalignment (p = 0.57), deep infection (p = 0.264), nonunion (p = 0.695), union time (p = 0.329), and final union rate (p = 0.699) were not significantly different between groups. Compared with the minimally invasive locking compression plate group, the suprapatellar intramedullary nail group yielded comparable results in terms of radiological alignment and complications. Considering that proximal tibial fractures are associated with high-energy trauma and severe soft tissue damage, we believe that a suprapatellar intramedullary nail may be a good alternative. Level III.

Updated Meta-Analysis of Randomized Controlled Trials Comparing External Fixation to Intramedullary Nailing in the Treatment of Open Tibial Fractures.

Background: The purpose of this study was to collect all available randomized controlled trials (RCT) on the treatment of open tibial fractures with an external fixator (EF) and intramedullary nailing (IMN) for meta-analysis to provide reliable evidence-based data for clinical decision-making. Material and methods: The systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and AMSTAR (Assessing the Methodological Quality of Systematic Review). An electronic search of PubMed, Cochrane Library, and Web of Science was performed until 1 March 2023 to identify RCTs which compared either IMN or EF to fix the open tibial fracture. Outcome measures were: postoperative superficial and deep infection, time to union, delayed union, malunion, nonunion and hardware failure. In addition, pain and health-related quality of life were evaluated after 3 and 12 months of follow-up. Results: Sixteen publications comprising 1011 patients were included in the meta-analysis. The pooled results suggested that the IMN technique had a lower postoperative superficial infection and malunion rate (RR = 3.56, 95%CI = 2.56-4.95 and RR = 1.96, 95%CI = 1.12-3.44, respectively), but higher hardware failure occurrence in contrast to EF (RR = 0.30; 95%CI = 0.13-0.69). No significant differences were found in the union time, delayed union or nonunion rate, and postoperative deep infection rate between the treatments. Lower levels of pain were found in the EF group (RR = 0.05, 95%CI = 0.02-0.17, p < 0.001). A difference in quality of life favoring IMN after 3 months was found (RR = -0.04, 95%CI = -0.05-0.03, p < 0.001), however, no statistical difference was found after 12 months (RR = 0.03, 95%CI = -0.05-0.11, p = 0.44). Conclusions: Meta-analysis presented reduced incidence rates of superficial infection, malunion, and health-related quality of life 3 months after treatment in IMN. However, EF led to a significant reduction in pain and incidence rate of hardware failure. Postoperative deep infection, delayed union, nonunion and health-related quality of life 12 months following therapy were similar between groups. More high-quality RCTs should be conducted to provide reliable evidence-based data for clinical decision-making.

Rate of Infection and Causative Organisms in a Lateral Approach Total Ankle Replacement.

Although the rate of both superficial and deep infection in total ankle replacement (TAR) can reach up to 13% as reported in the literature, there is little information on the causative organisms, especially in laterally implanted prosthesis. This study aims to identify organisms causing infections to ultimately guide to better antibiotic prophylaxis. Between September 2016 and April 2021, we retrospectively reviewed patients who had an infection after a lateral TAR. Cause of the infection, causative organisms, and implant survival were recorded. Out of 130 patients, 10 of 130 patients (7.6%) had a superficial infection whereas 3 of 130 patients (2.3%) had a deep infection. Staphylococcus and Pseudomonas species were found to be the most common. No significant difference was found between the type of plate used for fibula fixation regarding wound dehiscence. Infection after lateral TAR is generally polymicrobial in nature with Staphylococcus and Pseudomonas species being the most common. Level IV Case Series.

Early Postoperative Complications and Associated Variables After High Tibial Osteotomy and Distal Femoral Osteotomy: A 15-Year Experience From a Single Academic Institution

Background: High tibial osteotomy (HTO) and distal femoral osteotomy (DFO) are well-recognized treatments to address varus and valgus malalignment, respectively, in the setting of symptomatic unicompartmental arthritis of the tibiofemoral joint. The existing literature is limited in its ability to characterize complications after HTO or DFO procedures. Purpose: The objective of this study was to determine the rate of early (≤90 days) postoperative complications and associated variables from the 15-year experience of a single academic institution. Study Design: Case series; Level of evidence, 4. Methods: Patients treated at a single academic institution between 2008 and 2022 who underwent HTO or DFO procedures were identified. All patients with minimum 90-day follow-up were considered for inclusion in the study. Exclusion criteria were inadequate follow-up, unavailable medical records, age <14 years, and revision osteotomy. Patient demographic characteristics, surgical history, and concomitant procedures were identified, and risk factor analysis was performed to identify variables associated with early postoperative complications. All intraoperative complications were recorded. Results: A total of 243 knees in 232 patients met eligibility and were included in the final analysis. Three intraoperative complications (1.2%) involving fracture extension of the osteotomy occurred. There were 127 early postoperative complications (121 surgical, 6 medical) in 102 knees (68 with HTO and 34 with DFO). Medical complications included pulmonary embolus in 3 patients (1.2%), urinary tract infection in 2 patients (0.8%), and postoperative ileus requiring prolonged hospitalization in 1 patient (0.4%). The most common complications were stiffness requiring a non–standard of care intervention (17.7%), superficial wound infection or wound dehiscence (13.2%), and hemarthrosis or effusion requiring aspiration (6.6%). The rate of deep infection requiring irrigation and debridement was 4.1%. Variables associated with early postoperative complications included smoking (odds ratio [OR], 3.05; 95% CI, 1.34-6.94; P = .008), concomitant chondroplasty and/or loose body removal (OR, 2.55; 95% CI, 1.50-4.33; P = .001), and concomitant ligament reconstruction (OR, 3.97; 95% CI, 1.37-11.53; P = .011). Conclusion: These 15-year data revealed a low rate of intraoperative complications (1.2%) and a relatively high rate of early (≤90 days) postoperative complications (42.0%) after an HTO or DFO procedure. Surgeons should be aware of the increased postoperative complications associated with smoking, concomitant chondroplasty, and concomitant ligament reconstruction and should use this information to counsel patients regarding appropriate expectations in the postoperative period.

Poster 224: Complications Associated with Proximal Hamstring Tendon Repair: A Systematic Review

Objectives: Proximal hamstring tendon ruptures typically occur as a result of simultaneous hip flexion and knee extension, leading to avulsion of the conjoint and/or semimembranosus tendons from their origin at the ischial tuberosity. Surgical repair of proximal hamstring tendon ruptures has been shown in multiple clinical outcome studies to be superior to nonoperative management, with improved functional scores and ability to return to sport postoperatively. Although several potential complications have been reported in the literature, few studies have comprehensively analyzed the complication profile of proximal hamstring tendon repair. The purpose of this systematic review was to identify the overall rate of complications following proximal hamstring tendon repair, to differentiate these complications into categories, and to compare the complication rates of open versus endoscopic repair. Methods: A systematic review of original research articles was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. To qualify for study inclusion, included articles were required to be published in English, Level 4 evidence or higher, and had to examine surgical repair of proximal hamstring tendon ruptures. No restrictions were made regarding publication date and methodological quality. Data regarding complications were extracted to calculate the overall complication rate as well as the rate of major and minor complications. A quantitative data synthesis was conducted using Chi-square tests to compare the proportion of patients who experienced complications with endoscopic and open approaches. Results: Forty-three articles including 2,823 proximal hamstring tendon repairs were identified. The overall postoperative complication rate was 15.4% (n = 436). The rate of major complications was 4.6%, including a 0.8% re-rupture rate, 0.8% re-operation rate, 1.7% rate of sciatic nerve injury, 0.9% rate of venous thromboembolism (VTE), and 0.4% rate of deep infection. Minor complications included posterior femoral cutaneous nerve injury (2.4%), persistent sitting pain (2.3%), persistent hamstring myopathy (2.3%), hematoma/seroma (0.8%), peri-incisional numbness (1.8%), and superficial infection (1.1%). Endoscopic proximal hamstring tendon repair was associated with a higher rate of overall complications (p = 0.012), major complications (p = 0.048), and minor complications (p &lt; 0.001) compared to open repair. Conclusions: Proximal hamstring tendon repair is associated with an overall complication rate of 15.4%, including a 4.6% rate of major complications. There was a statistically significant increase in complications for patients treated endoscopically compared to those who underwent an open surgical repair.

High-dose dual-antibiotic loaded cement for hip hemiarthroplasty in the UK (WHiTE 8): a randomised controlled trial

Hip fracture is the most common injury requiring treatment in hospital. Controversy exists regarding the use of antibiotic loaded bone cement in hip fractures treated with hemiarthroplasty. We aimed to compare the rate of deep surgical site infection in patients receiving high-dose dual-antibiotic loaded cement versus standard care single-antibiotic loaded cement. We included people aged 60 years and older with a hip fracture attending 26 UK hospitals in this randomised superiority trial. Participants undergoing cemented hemiarthroplasty were randomly allocated in a 1:1 ratio to either a standard care single-antibiotic loaded cement or high-dose dual-antibiotic loaded cement. Participants and outcome assessors were masked to the treatment allocation. The primary outcome was deep surgical site infection at 90 days post-randomisation as defined by the US Centers for Disease Control and Prevention in an as-randomised population of consenting participants with available data at 120 days. Secondary outcomes were quality of life, mortality, antibiotic use, mobility, and residential status at day 120. The trial is registered with ISRCTN15606075. Between Aug 17, 2018, and Aug 5, 2021, 4936 participants were randomly assigned to either standard care single-antibiotic loaded cement (2453 participants) or high-dose dual-antibiotic loaded cement (2483 participants). 38 (1·7%) of 2183 participants with follow-up data in the single-antibiotic loaded cement group had a deep surgical site infection by 90 days post-randomisation, as did 27 (1·2%) of 2214 participants in the high-dose dual-antibiotic loaded cement group (adjusted odds ratio 1·43; 95% CI 0·87-2·35; p=0·16). In this trial, the use of high-dose dual-antibiotic loaded cement did not reduce the rate of deep surgical site deep infection among people aged 60 years or older receiving a hemiarthroplasty for intracapsular fracture of the hip. Heraeus Medical. Supported by the UK National Institute for Health and Care Research Oxford Biomedical Research Centre.

High-dose dual-antibiotic loaded bone cement in patients undergoing hemiarthroplasty

Hip fractures continue to be a major cause of morbidity and mortality in the older population. 1 Moran CG Wenn RT Sikand M Taylor AM Early mortality after hip fracture: is delay before surgery important?. J Bone Joint Surg Am. 2005; 87: 483-489 Crossref PubMed Scopus (546) Google Scholar Furthermore, due to substantial improvements in life expectancy worldwide, the annual number of patients with hip fracture is expected to reach an all-time high over the course of the next two decades. 2 Cooper C Campion G Melton 3rd, LJ Hip fractures in the elderly: a world-wide projection. Osteoporos Int. 1992; 2: 285-289 Crossref PubMed Scopus (2406) Google Scholar Although there is currently no gold standard for the surgical management of patients with hip fractures, hemiarthroplasty continues to be one of the more popular treatment options in these patients. 3 Bhandari M Einhorn T A Guyatt G et al. Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med. 2019; 381: 2199-2208 Crossref PubMed Scopus (178) Google Scholar Concurrently, surgical site infection (SSI) is a devastating complication following hemiarthroplasty, and one of the leading causes of mortality and morbidity in these patients. 4 Gupta A Shin J Oliver D Vives M Lin S Incidence and risk factors for surgical site infection (SSI) after primary hip hemiarthroplasty: an analysis of the ACS-NSQIP hip fracture procedure targeted database. Arthroplasty. 2023; 5: 1-7 Crossref PubMed Scopus (0) Google Scholar High-dose dual-antibiotic loaded cement for hip hemiarthroplasty in the UK (WHiTE 8): a randomised controlled trialIn this trial, the use of high-dose dual-antibiotic loaded cement did not reduce the rate of deep surgical site deep infection among people aged 60 years or older receiving a hemiarthroplasty for intracapsular fracture of the hip. Full-Text PDF Open Access

WHEN SHOULD A DEEP INFECTION IN TOTAL HIP ARTHROPLASTY BE CLASSIFIED AS THEATRE-ACQUIRED? NEW INSIGHTS FROM OLD DATA

The documentation of deep infection rates in joint replacement is fraught with multiple difficulties. Deep infections acquired in theatre may present late, but some later presenting deep infections are clearly haematogenous, and not related to surgical management. The effect of Ultra Clean Air on infection rates was published by Charnley in 1972 (CORR,87:167–187). The data is valuable because large numbers of THRs were performed in standard and Ultra Clean theatres, and detailed microbiology of the air was also recorded. No IV antibiotics were used, so only the effect of air quality was studied.We extracted the data on theatre type and numbers from Table 3, and numbers and intervals from surgery of deep infections from Table 7. Theatre types with 300 air changes per hour and 3.5 CFU/M3 were classified as Ultra Clean. A logistic regression model was used to examine the effect of theatre type and time elapsed after procedure on the probability of becoming infected.The model suggests that, controlling for time period, Ultra Clean Air is associated with a significantly lower probability of infection, with an OR of 0.30, p = 2.74 × 10−6. The effect is larger earlier post-surgery, but it does persist. The results are best reviewed as a graphic, which shows that Ultra Clean Air clearly affects the deep infection rate for up to four years post-surgery.Ultra Clean Air reduces infection rates for up to four years post-surgery, so it is safe to assume that infections presenting after this are haematogenous. Ultra Clean Air does not eliminate early deep infection, so some early infections are not related to air quality. It is not practical to undertake widespread detailed retrospective analyses of cases. When monitoring infection rates there needs to be a balance between failing to record infections related to surgical technique and waiting many years to record low numbers of very late presenting problems. We suggest that registries should regard infections documented within three years of surgery as treatment complications.For any figures or tables, please contact the authors directly.

MID- TO LONG-TERM OUTCOME OF OPEN TIBIAL FRACTURES DEFINITIVELY MANAGED WITH A CIRCULAR FRAME

IntroductionOpen tibial fractures typically occur as a consequence of high energy trauma in patients of working age resulting in high rates of deep infection and poor functional outcome. Whilst improved rates of limb salvage, avoidance of infection and better ultimate function have been attributed to improved centralisation of care in orthoplastic units, there remains no universally accepted method of definitive management of these injuries. The aim of this study is to the report the experience of a major trauma centre utilising circular frames as definitive fixation in patients sustaining Gustilo-Anderson (GA) 3B open fracturesMaterials &amp; MethodsA prospectively maintained database was interrogated to identify all patients. Case notes and radiographs were reviewed to collate patient demographics and injury factors . The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventionsResults247 open tibial fractures with a soft tissue manipulation in order to achieve skin cover, of which 203 had a minimum follow up of 2 years. Mean age was 43.2 years old, with 72% males, 34% smokers and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Nine (4.4%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-five (37%) of patients had a secondary intervention of which; 8 comprised debridement of deep infection, 1 amputation for deep infection and the remainder adjustments of frames.ConclusionsOrthoplastic care including circular frame fixation for GA 3B fractures of the tibia results in a low rate of deep infection, around a quarter of contemporary literature for internal fixation.

Outcomes following acute versus staged fixation of complete articular tibial plafond fractures.

To determine outcomes following acute versus staged fixation of complete articular tibial plafond fractures. Retrospective cohort study. Single Level 1 Trauma center. 98 skeletally mature patients with OTA/AO 43C type fractures who underwent definitive fixation with plate and screw constructs and had minimum 6 month follow up. Acute (aORIF) versus staged (sORIF) definitive fixation. Rates of wound dehiscence/necrosis and deep infection. Acute (N=40) versus staged (N=58) ORIF groups had comparable rates of vascular disease, renal disease, and substance/nicotine use, but aORIF patients had higher rates of diabetes mellitus (10% vs 0%, p<0.001), which correlated with higher ASA scores (>ASA 3: 37.5% vs 13.8%, p=0.02). Both groups achieved anatomic/good reductions, as determined by post-operative CT scans, at rates greater than 90%; however, the sORIF group required modestly longer operative times to achieve this outcome (aORIF vs sORIF: 121 vs 146 minutes, p=0.02). Post-operatively, both groups had similar rates of wound dehiscence (2.5% vs 6.9%, p=0.65), superficial (10% vs 17.2%, p=0.39), and deep (10% vs 8.6%, p=0.99) infections. While the injury pattern itself required free flap coverage in 1 patient in each group, unplanned free flap coverage occurred in 10.0% and 10.3% of aORIF and sORIF groups, respectively. Overall, rates of unplanned reoperations, excluding ankle arthrodesis, did not differ between groups (aORIF vs sORIF:12.5% vs 25.9%, p=0.13). In select patients managed by fellowship trained Orthopaedic traumatologists, acute definitive pilon fixation can produce acceptable outcomes.

A CASE REPORT OF A RARE POST-TRAUMATIC INFECTED REGENERATE CORTICOTOMY FOR LENGTHENING FOLLOWING A FRAME ANKLE FUSION

IntroductionWe present a case of a 49-year-old patient who initially presented in May 2020 with an open pilon fracture. Managed with initial debridement, fixation and flap - who subsequently underwent circular frame application for failure of fixation, requiring a transport to fusion frame who developed beta-haemolytic streptococcus A within the site of the proximal corticotomy.Materials &amp; MethodsA systematic review of the literature was conducted searching EMBASE, MEDLINE and Cochrane library for all articles discussing infected bone regenerate- a paucity of information was found. Abstracts were independently reviewed by 2 authors (LH and LT). In total, there were 16 papers, and then subsequently analysed we identified two case reports regarding infected regenerate.ResultsDeveloping an infection in a regenerate is highly rare with very few reported cases within the published literature. The literature identified risk factors for an infected regenerate, with open fracture and smoking being the two consistent factors. The open fracture deep infection rate is cited at 10% in most publications, this is at the site of the open fracture and not within the regenerate.ConclusionsInfection within the regenerate during distraction osteogenesis is highly unusual, with only two other published papers in the literature to the best of our knowledge. This should be borne in mind when managing patients with infection of unknown sources in cases of distraction osteogenesis.