Fracture-related Infection Research Articles

Microbiology of fracture related infections.

Fracture related infection remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families, treating physicians and healthcare systems. Even current curative approaches (radical debridement, revision surgery and long-term antibiotics) often result in significant socioeconomic costs and the risk of life-long functional impairment to the patient. The prevalence of osteomyelitis due to trauma and surgical complications does not seem to be diminishing in our society and the emergence of antimicrobial resistance is a major health related concern with global relevance. Despite multi-drug resistant bacteria being on the rise universally, perioperative antibiotic prophylaxis in orthopaedic trauma care has only slightly changed in the last 25years. Staphylococcus infections remain an increasing global concern, partially due to the resistance mechanisms developed by staphylococci to evade the host immune system and antibiotic treatment, and as such antibiotics are becoming increasingly ineffective. This paper will address fracture related infections in trauma patients, looking at the bacteriology of these infections, its clinical implications and evolving nature.

Clinical value of bacterial culture in sinus tract in the diagnosis of fracture-related infection

Objectives: This study compared the results of bacterial culture from operation versus sinus tract samples in patients with fracture-related infection (FRI), and examined the ability of bacterial culture in sinus tract to identify pathogenic bacteria. Methods: A retrospective analysis of 53 patients with FRI from June 2016 to June 2021 was done. Common infection sites were femur, tibiofibular, hip joint, and ankle. Samples collected in sinus tract and during the operation were sent for bacterial culture. Results were summarized and compared, respectively, with pathogenic bacteria. Results: In sinus tract bacterial culture, bacteria were found in 75.6% of culture samples. The top 3 bacteria presented were: Staphylococcus aureus (32.26%), Staphylococcus epidermis (12.90%), and Pseudomonas aeruginosa (8.06%). Bacterial culture from the sinus tract matched the result of intraoperative samples 67.30% of the time, while 51.50% matched the pathogenic bacteria. Conclusion: Bacterial culture of sinus tract samples is not recommended as the basis for identifying pathogenic bacteria. Stopping antibiotic 2 weeks before operation, taking multiple samples at different sites, and sending multiple samples for bacterial culture are good ways to improve pathogen detection rate.

Antibiotic coated nails: Rationale, development, indications and outcomes.

The concept of antibiotic-coated implants, mainly coated intramedullary nails, has become increasingly used for the treatment of fracture related infections. After a long period of hand-made implants, commercially fabricated implants combine several benefits. Antibiotic-coated nails constitute a solid treatment option for unstable diaphyseal infections with fractures or non-unions. They release high concentrations of antibiotics locally, while retaining reduction and providing axial stability. This review aims to provide an overview about the background, the development, the indications, the treatment strategies and the outcomes of antibiotic-coated intramedullary nails.

Complex limb salvage with an orthoplastic approach: a case report

Lower extremity trauma is an important cause of patient morbidity and disability-adjusted life years (DALYs). It also presents a significant reconstructive challenge for surgeons. Mangled extremity injuries can result in an amputation when limb salvage procedures are unsuccessful. Identifying strategies to optimize limb salvage attempts is necessary to improve postoperative outcomes. Establishing a constructive relationship between orthopaedic and plastic surgeons has been shown to be beneficial and subject to a growing interest in the trauma literature. We present the case of a 42-year-old male referred to our institution for limb salvage after sustaining severe bilateral lower extremity injuries. These included a right open Gustilo 3B tibia shaft fracture with a critical bone defect combined with a left floating knee (closed femur fracture and open Gustilo 3C tibia fracture). Bilateral tibia fracture-related infections were treated in conjunction with successful flap coverage. Following eradication of the infections, adequate soft tissue coverage and stable bony fixation, the tibia critical bone defect of close to 8 cm was treated with bone transport. Limb salvage was successful; amputation was avoided, and good function of both limbs was achieved. This manuscript shares a great clinical success in the extensive collaboration between two surgical subspecialties. • Successful complex lower limb salvage. • Orthopedic and plastic surgery collaboration can avoid the need for amputation. • Tertiary care centres are best equipped to manage Orthoplastic trauma. • Tertiary care centres are best equipped to manage Orthoplastic trauma.

The State of Research in Fracture-Related Infection-A Bibliometric Analysis.

Background and Objectives: Fracture-related infection (FRI) is a challenging complication in trauma surgery. A consensus definition of FRI has only recently been published. Therefore, the purpose of this study was to evaluate the state of research related to FRI. Material and Methods: A systemic literature review was conducted on research on FRI published between 2017 and 2020. The Web of Science database was used, and a bibliometric analysis was performed. To provide robust evidence regarding the impact of publications, the behavior of publications in non-traditional dissemination channels was analyzed. For this, the Research Interest Score and the Altmetric Score were combined. The Research Interest Score was calculated from information extracted from ResearchGate, while Altmetric Score includes information from different websites and apps with a significant volume of traffic, such as Twitter. Results: A total of 131 published papers were identified. The most significant contribution came from the United States and European countries. The most relevant articles were published by the journal Injury—International Journal of the Care of the Injured. A positive correlation was observed between the number of citations and Research Interest Scores, whereas the number of citations and Altmetric Score showed no correlation. The social media platform most used by FRI researchers was Twitter. Conclusions: By evaluating the status of publications for FRI between 2017 and 2020, an upward trend in the number of publications was evident. This could be related to the increasing acceptance of the long-needed definition for FRI and the implications it carries for daily clinical practice.

Evaluation of Comorbidities as Risk Factors for Fracture-Related Infection and Periprosthetic Joint Infection in Germany.

Introduction: Fracture-related infections (FRI) and periprosthetic joint infections (PJI) represent a major challenge in orthopedic surgery. Incidence of both entities is annually growing. Comorbidities play an important role as an influencing factor for infection and thus, for prevention and treatment strategies. The aims of this study were (1) to analyze the frequency of comorbidities in FRI and PJI patients and (2) to evaluate comorbidities as causative risk factor for PJI and FRI. Methods: This retrospective cohort study analysed all ICD-10 codes, which were coded as secondary diagnosis in all in hospital-treated FRI and PJI in the year 2019 in Germany provided by the Federal Statistical Office of Germany (Destatis). Prevalence of comorbidities was compared with the prevalence in the general population. Results: In the year 2019, 7158 FRIs and 16,174 PJIs were registered in Germany, with 68,304 comorbidities in FRI (mean: 9.5 per case) and 188,684 in PJI (mean: 11.7 per case). Major localization for FRI were infections in the lower leg (55.4%) and forearm (9.2%), while PJI were located mostly at hip (47.4%) and knee joints (45.5%). Mainly arterial hypertension (FRI: n = 3645; 50.9%—PJI: n = 11360; 70.2%), diabetes mellitus type II (FRI: n = 1483; 20.7%—PJI: n = 3999; 24.7%), obesity (FRI: n = 749; 10.5%—PJI: n = 3434; 21.2%) and chronic kidney failure (FRI: n = 877; 12.3%—PJI: n = 3341; 20.7%) were documented. Compared with the general population, an increased risk for PJI and FRI was reported in patients with diabetes mellitus (PJI: 2.988; FRI: 2.339), arterial hypertension (PJI: 5.059; FRI: 2.116) and heart failure (PJI: 6.513; FRI: 3.801). Conclusion: Patients with endocrinological and cardiovascular diseases, in particular associated with the metabolic syndrome, demonstrate an increased risk for orthopedic implant related infections. Based on the present results, further infection prevention and treatment strategies should be evaluated.

Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients

BackgroundTibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds. MethodsA retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure. ResultsOf the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39). ConclusionData from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation.

Outcomes of two circular external fixation systems in the definitive treatment of acute tibial fracture related infections

IntroductionAcute tibial fracture-related infection (FRI) is one of the most feared and challenging complications after a tibial fracture. The most appropriate treatment in this scenario is far from a resolved topic. Circular external fixators (CEFs) offer multiplanar control and minimize soft tissue injury using temporary implants far from the infected area. This study aimed to investigate the outcomes of two different types of CEFs (Ilizarov and hexapod) in the treatment of a series of acute tibial FRIs. Material and MethodsA retrospective study at two specialized limb reconstruction centres identified all patients with an acute tibial FRI (≤4 weeks after index procedure) definitively treated with a CEF from January 2015 to December 2020. Primary outcomes: fracture healing and infection eradication rate with a minimum FU of 12 months after frame removal. Secondary outcomes: to investigate the differences between the two types of circular frames regarding final post-treatment deformity magnitude. ResultsWe included 31 patients with acute tibial FRIs: 18 treated with hexapod-type and 13 with Ilizarov-type CEFs. Average age was 45.5±16.56 years. Fracture healing and infection eradication were achieved in all patients (31/31) after a mean follow-up of 24.7 months (range 12.1-55.3). Patients treated with an Ilizarov-type fixator presented shorter time to fracture union (5.5±2.2 months vs. 9.2±6.0 months; p-value 0.021) and shorter duration of external fixation (p-value 0.001). Regarding residual post-treatment deformity, the hexapod system presented significantly less residual coronal translation deformity (p-value 0.034) and better callus quality. Fixator-related complications were similar when comparing the two groups. No significant differences were seen in pain (p-value 0.25), RTW rate (35% vs. 45%; p-value 0.7) or functionality (p-value 0.4). ConclusionsDefinitive circular external fixation is an excellent treatment for acute tibial FRI. Both Ilizarov and hexapod systems offer a very high rate of fracture healing and infection eradication. Although both presented very low radiological post-operative residual deformity, the hexapod system showed less residual coronal translation deformity and better callus quality.

Quality of life after fracture-related infection of the foot

BackgroundFracture related infection (FRI) of the foot is a serious hazard. Despite successful therapy, the physiological and psychological involvement seems to be high. Therefore, we aim to analyze the impact of an FRI of the foot on the quality of life after successful surgical therapy and infect eradication. MethodsIn total, 25 patients from two German hospitals treated for FRI of the foot between March 2011 to January 2020 were retrospectively included. Quality of life was assessed by the German Short Form 36 (SF-36) and the EuroQol five-dimension three-level questionnaire (EQ-5D) as well as the ICD-10 based psychological symptom rating (ISR), and compared to a norm obtained from the general population of Germany. Results3.0 years (range 0.7–7.9 years) following final surgery after fracture-related infection of the foot, the mean physical health component score (PCS) of the SF-36 was 35.6 ± 12.3, and the mean mental health component score (MCS) of the SF-36 reached a value of 41.3 ± 12.9. Both values were significantly lower than in the general population of Germany (p< .019). The mean scores of the ISR of the cohort crossed the threshold of mild symptom burden in total, as well as for the subscales depression and somatization. The mean EQ-5D VAS rating (62.1 ± 18.6) and the EQ-5D index value (0.66 ± 0.27) were significantly lower in comparison to a score of 72.9 ± 1.0 and 0.88 obtained from an age-matched reference population (p < .01). ConclusionFRI of the foot represents a major burden for the patient. Physical and mental well-being of affected patients is restricted albeit successful treatment in terms of infect eradication and bone union has been achieved after a mean follow-up of 3.0 years. A patient-centered treatment approach focusing on improvement of quality of life during and after treatment is therefore warranted.

Combined Orthoplastic Approach in Fracture-Related Infections of the Distal Tibia.

This series reports on the treatment of distal tibia (DT) fracture-related infections (FRI) with a combined orthoplastic approach. Thirteen patients were included. In eight patients with extensive bone involvement and in those with a non-healed fracture, the DT was resected (“staged approach”). In five cases, the DT was preserved (“single-stage approach”). A wide debridement was performed, and the cavity was filled with antibiotic-loaded PerOssal beads. All patients had a soft-tissue defect covered by a free vascularized flap (anterolateral thigh perforator flap in eight cases, latissimus dorsi flap in five). At the final follow-up (mean 25 months, range, 13–37), no infection recurrence was observed. In one patient, the persistence of infection was observed, and the patient underwent a repeated debridement. In two cases, a voluminous hematoma was observed. However, none of these complications impacted the final outcome. The successful treatment of FRI depends on proper debridement and obliteration of dead spaces with a flap. Therefore, when dealing with DT FRI, debridement of infected bone and soft tissues must be as radical as required, with no fear of the need for massive reconstructions.

A major trauma centre experience with gentamicin-coated tibial intramedullary nails (ETN PROtect™) in acute primary open fracture fixation and complex revision surgery.

Fracture-related infections (FRI) following intramedullary nailing for tibial shaft fractures remain challenging to treat with associated high patient morbidity and health care costs. Recently, antibiotic-coated nails have been introduced as a strategy to reduce implant related infection rates in high-risk patients. We present the largest single-centre case series on ETN PROtect® outcomes reporting on fracture union, infection rates and treatment complications. Fifty-six adult patients underwent surgery with ETN PROtect® between 01/09/17 and 31/12/20. Indications consisted of acute open fractures and complex revision cases (previous FRI, non-union surgery and re-fracture) with a mean of three prior surgical interventions. We report on patient demographics, union rates and deep infection. Minimum follow-up was one year. One (1.8%) patient developed a deep surgical infection and associated non-union requiring further surgery. In addition, we identified three cases (5.4%) of aseptic non-union following facture treatment with ETN PROtect®. Of the five patients who underwent staged complex revision surgery for established FRI with ETN PROtect®, all had treatment failure with ongoing symptoms of deep infection requiring implant removal and further treatment. Use of the ETN PROtect® nail in high-risk patients (open fractures and those initially treated with external fixation) and in those patients with aseptic non-unions, demonstrates promising outcomes in the prevention of implant-related infection. In our limited series we have failed to observe any benefit over uncoated nails, when used in treating cases of previously established FRI/osteomyelitis and would therefore advise caution in their use, especially in view of the high cost.

Risk Factors for Wound Complications Following Conversion TKA after Tibial Plateau Fracture.

The purpose is to investigate the incidence of wound complications for total knee arthroplasty (TKA) following tibial plateau open reduction and internal fixation (ORIF). A prospective arthroplasty registry was queried for patients with CPT codes for primary TKA, tibial plateau ORIF, removal of hardware (ROH), and diagnosis of post-traumatic arthritis. Patients were included if they had undergone tibial plateau ORIF and subsequent TKA. Chart review was performed to obtain demographic, clinical and post-operative information. Twenty-one patients were identified, with average age of 56.23 ± 13.2years at time of tibial plateau ORIF and 62.91 ± 10.8years at time of TKA. Seven (33.3%) patients had a tibial plateau fracture-related infection (FRI). Eight (38.1%) patients underwent ROH prior to TKA. Seven (33.3%) patients' TKA incision incorporated the prior plateau incisions. Eight (36.4%) patients developed wound complications following TKA and 5 (23.8%) developed an acute periprosthetic joint infection (PJI) following TKA and had the plateau incision incorporated into the TKA incision. FRI history did not increase the rate of wound complications but did increase the rate of ROH prior to TKA. Previous FRI involving tibial plateau repair surgery doesn't correlate with PJI after conversion TKA for post traumatic OA. Surgeon-controlled factors such as staged ROH and incision placement can help reduce the rate of wound complications following TKA performed after tibial plateau ORIF. Prognostic Level IV. The online version contains supplementary material available at 10.1007/s43465-022-00709-1.

Risk Factors for Infection and Subsequent Adverse Clinical Results in the Setting of Operatively Treated Pilon Fractures.

To determine patient-specific and injury-specific factors that may predict infection and other adverse clinical results in the setting of tibial pilon fractures. Retrospective chart review. Level 1 academic trauma center. Two hundred forty-eight patients who underwent operative treatment for tibial pilon fractures between 2010 and 2020. External fixation and/or open reduction and internal fixation. Fracture-related infection rates and specific bacteriology, risk factors associated with development of a fracture-related infection, and predictors of adverse clinical results. Two hundred forty-eight patients were enrolled. There was an infection rate of 21%. The 3 most common pathogens cultured were methicillin-resistant Staphylococcus aureus (20.3%), Enterobacter cloacae (16.7%), and methicillin-resistant Staphylococcus aureus (15.5%). There was no significant difference in age, sex, race, body mass index, or smoking status between those who developed an infection and those who did not. Patients with diabetes mellitus ( P = 0.0001), open fractures ( P = 0.0043), and comminuted fractures (OTA/AO 43C2 and 43C3) ( P = 0.0065) were more likely to develop a fracture-related infection. The presence of a polymicrobial infection was positively associated with adverse clinical results ( P = 0.006). History of diabetes was also positively associated with adverse results ( P = 0.019). History of diabetes and severe fractures, such as those that were open or comminuted fractures, were positively associated with developing a fracture-related infection after the operative fixation of tibial pilon fractures. History of diabetes and presence of a polymicrobial infection were independently associated with adverse clinical results. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Molecular biology: a guide for orthopaedic surgeons

Fracture non-union, prosthetic joint infection and fracture-related infections are complications frequently encountered by the trauma and orthopaedic surgeon. Moreover, they pose a significant socioeconomic and healthcare burden to the society. A clear understanding of the molecular biology surrounding fracture healing, as well as the pathophysiology of orthopaedic-related infections, is of paramount importance to their successful management. The first section of this article aims to explain the basic science critical to the understanding of DNA, RNA, gene and protein expression, and the molecular techniques most commonly deployed in the diagnostic and research fields of trauma and orthopaedics. The second section provides a general overview of the molecular physiology of fracture healing and biofilm, the molecular characteristics and genetic predisposition of fracture non-union, followed by discussing recent advances in molecular techniques used in the diagnosis and treatment of fracture non-union, prosthetic joint infection and fracture-related infections.

Causative Pathogens Do Not Differ between Early, Delayed or Late Fracture-Related Infections.

Fracture-related infections (FRIs) are classically considered to be early (0–2 weeks), delayed (3–10 weeks) or late (>10 weeks) based on hypothesized differences in causative pathogens and biofilm formation. Treatment strategies often reflect this classification, with debridement, antimicrobial therapy and implant retention (DAIR) preferentially reserved for early FRI. This study examined pathogens isolated from FRI to confirm or refute these hypothesized differences in causative pathogens over time. Cases of FRI managed surgically at three centres between 2015–2019 and followed up for at least one year were included. Data were analysed regarding patient demographics, time from injury and pathogens isolated. Patients who underwent DAIR were also analysed separately. In total, 433 FRIs were studied, including 51 early cases (median time from injury of 2 weeks, interquartile range (IQR) of 1–2 weeks), 82 delayed cases (median time from injury of 5 weeks, IQR of 4–8 weeks) and 300 late cases (median time from injury of 112 weeks, IQR of 40–737 weeks). The type of infection was associated with time since injury; early or delayed FRI are most likely to be polymicrobial, whereas late FRIs are more likely to be culture-negative, or monomicrobial. Staphylococcus aureus was the most commonly isolated pathogen at all time points; however, we found no evidence that the type of pathogens isolated in early, delayed or late infections were different (p = 0.2). More specifically, we found no evidence for more virulent pathogens (S. aureus, Gram-negative aerobic bacilli) in early infections and less virulent pathogens (such as coagulase negative staphylococci) in late infections. In summary, decisions on FRI treatment should not assume microbiological differences related to time since injury. From a microbiological perspective, the relevance of classifying FRI by time since injury remains unclear.

What Factors Affect Outcome in the Treatment of Fracture-Related Infection?

This international, multi-center study investigated the effect of individual components of surgery on the clinical outcomes of patients treated for fracture-related infection (FRI). All patients with surgically treated FRIs, confirmed by the FRI consensus definition, were included. Data were collected on demographics, time from injury to FRI surgery, soft tissue reconstruction, stabilization and systemic and local anti-microbial therapy. Patients were followed up for a minimum of one year. In total, 433 patients were treated with a mean age of 49.7 years (17–84). The mean follow-up time was 26 months (range 12–72). The eradication of infection was successful in 86.4% of all cases and 86.0% of unhealed infected fractures were healed at the final review. In total, 3.3% required amputation. The outcome was not dependent on age, BMI, the presence of metalwork or time from injury (recurrence rate 16.5% in FRI treated at 1–10 weeks after injury; 13.1% at 11–52 weeks; 12.1% at >52 weeks: p = 0.52). The debridement and retention of a stable implant (DAIR) had a failure rate of 21.4%; implant exchange to a new internal fixation had a failure rate of 12.5%; and conversion to external fixation had a failure rate of 10.3% (adjusted hazard ratio (aHR) DAIR vs. Ext Fix 2.377; 95% C.I. 0.96–5.731). Tibial FRI treated with a free flap was successful in 92.1% of cases and in 80.4% of cases without a free flap (HR 0.38; 95% C.I. 0.14–1.0), while the use of NPWT was associated with higher recurrence rates (HR 3.473; 95% C.I. 1.852–6.512). The implantation of local antibiotics reduced the recurrence from 18.7% to 10.0% (HR 0.48; 95% C.I. 0.29–0.81). The successful treatment of FRI was multi-factorial. These data suggested that treatment decisions should not be based on time from injury alone, as other factors also affected the outcome. Further work to determine the best indications for DAIR, free flap reconstruction and local antibiotics is warranted.

Epidemiology and Drug Resistance of Fracture-Related Infection of the Long Bones of the Extremities: A Retrospective Study at the Largest Trauma Center in Southwest China.

ObjectiveTo describe the demographic characteristics, risk factors, and bacterial resistance of fracture-related infection (FRI) of the long bones of the extremities.Materials and MethodsThis single-center study retrospectively evaluated patients with FRI of the long bones of the extremities at West China Hospital between January 2012 and December 2017, and analyzed the demographic characteristics, risk factors, distribution of pathogenic bacteria, and bacterial drug resistance.ResultsAmong 9,900 patients, 535 patients (5.4%) were diagnosed with FRI. The most common site of FRI was tibiofibular (298, 55.7%), with 424 cases (79.2%) of open fractures, and 282 cases (52.7%) due to traffic injuries. The 41–50 years age group had the highest incidence of FRI with 157 (29.3%) cases. Overall, 546 strains of 52 types of bacteria were detected in FRI patients, with 105 strains of multidrug-resistant (MDR) bacteria. Methicillin-resistant Staphylococcus aureus (48, 8.8%) and extended-spectrum-β-lactamase Escherichia coli (32, 5.8%) accounted for the largest proportion. Multivariate logistic regression analysis showed that sex (odds ratio [OR] 1.813; 95% confidence interval [CI], 1.071∼3.070; P = 0.027) and fracture type (OR 3.128; 95% CI, 1.683∼5.815; P < 0.001) were independent risk factors for monomicrobial infection (MI). Female sex (OR 4.190; 95% CI, 1.212∼14.486; P = 0.024) was an independent risk factor for polymicrobial infection (PI).ConclusionThis study clarified the infection rates, changes in the bacterial spectrum, and drug resistance characteristics, and risk factors of FRI of the long bones of the extremities in the largest trauma center in southwest China.

Civilian Ballistic Femoral Shaft Fractures Compared With Blunt Femur Shaft Fractures.

To assess ballistic femoral shaft fracture outcomes in comparison with closed and open femoral shaft fractures sustained by blunt mechanisms. We hypothesized that ballistic femoral shaft fractures would have similar outcomes to blunt open fractures. Retrospective cohort study. Academic Level I trauma center. Patients 16 years and older presenting with ballistic (140), blunt closed (317), or blunt open (71) femoral shaft fractures. Unplanned return to operating room, fracture-related infection, soft tissue reconstruction, nonunion, implant failure, length of stay, Injury Severity Scores, hospital charges, and compartment syndrome. A total of 528 femoral shaft fractures were identified. A group of 140 ballistic fractures and comparison groups of all femoral shaft fractures sustained by blunt mechanisms and treated with intramedullary nailing were included in the analysis. Among the 2 subgroups of nonballistic injuries, 317 were blunt closed fractures and 71 were blunt open fractures. The ballistic group was associated with a 3-fold increase in overall complications (30%) compared with the blunt closed group (10%, P < 0.001), had a higher occurrence of thigh compartment syndrome (P < 0.001), and required more soft tissue reconstruction (P < 0.001) than either of the blunt fracture groups. Ballistic femoral shaft fractures do not perfectly fit with blunt closed or open femoral fractures. A high index of suspicion for the development of thigh compartment syndrome should be maintained in ballistic femoral shaft fractures. The overall rates of nonunion and infection were comparable between all groups, but the all-cause complication rate was significantly higher in the ballistic group compared with the blunt closed group. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

CORR Insights®: Isothermal Microcalorimetry Improves the Time to Diagnosis of Fracture-related Infection Compared With Conventional Tissue Cultures.

CORR Insights®: Isothermal Microcalorimetry Improves the Time to Diagnosis of Fracture-related Infection Compared With Conventional Tissue Cultures.

Subtrochanteric femoral fractures and intramedullary nailing complications: a comparison of two implants

IntroductionIntramedullary (IM) nails are considered the ‘gold’ standard treatment for subtrochanteric femoral fractures. The incidence and risk factors for re-operation in subtrochanteric fractures remain unclear. Furthermore, no studies have compared the outcomes of different nailing systems used to treat subtrochanteric fractures in the same study population.Aims/objectivesOur study aimed to (i) investigate the cumulative incidence and factors associated with an increased risk of re-operation in subtrochanteric fractures treated with a long intramedullary (IM) nail, (ii) compare the outcomes of subtrochanteric fractures treated with long Affixus and Gamma nails, and (iii) establish whether the addition of a proximal anti-rotation screw in the Affixus nail confers any clinical benefit.MethodsA retrospective review of all adult patients admitted to a level 1 trauma centre with a subtrochanteric femur fracture treated with a long cephalomedullary IM nail over an 8-year period was conducted. Exclusion criteria were primary surgery performed at another institution, prophylactic nailing because of tumours, incomplete fractures, and patients who were lost to follow-up or died before fracture healing. Data variables were assessed for normality prior to determining the use of either parametric or non-parametric tests. Logistic regression analysis was performed to identify potential factors associated with re-operation. For the comparison between the two nail types, patients were matched into two groups of 119 each by age (10-year intervals), gender and mechanism of injury (low energy, high energy and pathological fractures). A p-value < 0.05 was considered significant. The Kaplan–Meier nail survival curve was used to demonstrate the survival of each nail. Data were analysed using the statistical package R (R version 3.6.0).ResultsA total of 309 subtrochanteric fractures were treated with a distally locked long IM nail (re-operation rate: 22.33%) over an 8-year period. Logistic regression identified six factors associated with an increased risk of re-operation, including age < 75 years old, use of a long Gamma nail, pre-injury coxa-vara femoral neck shaft angles, an immediate post-operative reduction angle of > 10° varus, deep wound infection and non-union.Following matching, we compared the two long cephalomedullary nailing systems used (Gamma versus Affixus nail). The only differences identified from the unadjusted analysis were a higher overall incidence of nail failure in Gamma nails due to any cause, re-operation, and impingement of the nail tip distally against the anterior femoral cortex. When we corrected for covariates, no significant differences remained evident between the two nails. From the Kaplan–Meier nail survival curves, however, the Affixus nail demonstrated better survivorship up to 5 years post-implantation in terms of nail failure and re-operation for all causes. Finally, the addition of a proximal anti-rotation screw in the Affixus nail did not seem to confer any benefit.ConclusionWe reported a 22.3% re-operation rate in our cohort of subtrochanteric fractures treated with a long IM nail. We have identified six risk factors associated with re-operation: age < 75 years old, pre-injury femoral neck shaft angle, choice of nail, varus reduction angle, fracture-related infection and non-union. The addition of a proximal anti-rotation screw in the Affixus nail did not confer any benefit.