Fixation Of Lower Extremity Fractures Research Articles

Primary Closure of External Fixator Pin Sites Is Safe After Orthopaedic Trauma Surgery.

To determine if rates of pin site infection and surgical site infection among patients managed with primary closure after external fixator removal were similar to those allowed to heal secondarily. Retrospective cohort. Urban/Suburban Academic Level I Trauma Center. Patients who had received a lower extremity external fixator for provisional management before definitive fixation of lower extremity fractures were included with pin site wounds closed primarily or allowed to heal by secondary intention. The rate of pin tract infection and surgical site infection following primary closure of external fixator pin sites relative to patients whose pin sites were allowed to heal through secondary intention. In total, 256 patients were evaluated: 143 patients (406 pin sites) in the primary closure group and 113 patients (340 in sites) in the secondary closure group. The average age was 49 ± 16 years. Sixty-five percent of included patients were male. There was no difference in pin tract infections between cohorts (primary = 0.5%, secondary = 1.5%, P = 0.26). External fixator duration in the primary closure group was 11.5 ± 8.4 days and 13.0 ± 8.1 days in the secondary closure group (P = 0.15). There was a greater rate of surgical site infections in the secondary intention cohort (15.9% vs. 7.7%, P = 0.047). There was no difference in pin site infection rate after primary pin site closure relative to patients who were allowed to heal through secondary intention. Furthermore, there was a lower rate of surgical site infection after primary closure. These results challenge the dogma of secondary closure for ex fix pin sites, suggesting that debridement and primary closure is a safe option for management of external fixator pin sites and may impart benefit in decreasing infection risk. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors Associated With Long-Term Quadriceps Muscle Function After Surgical Fixation of Lower Extremity Fractures.

The long-term performance of the quadriceps femoris muscle and physical function following surgical repair of a lower extremity fracture remains largely undefined. The purpose of this study was to investigate between-limb differences in quadriceps performance 12months after surgical fixation of a lower extremity fracture. It was hypothesized that the injured limb would be significantly weaker, have a lower rate of torque development (RTD), and that there would be a reduced step-down performance compared to the uninjured limb 12months after surgery. Additionally, this study sought to identify demographic, surgical, and psychological factors associated with poor quadriceps function 12months after surgery. Quadriceps performance was measured bilaterally in 95 participants (49 female), aged 42 (SD = 14.5) years, 12months after surgical fixation of a lower extremity fracture. Isometric quadriceps strength and RTD were quantified using isometric dynamometry, and a timed step-down test was used to evaluate quadriceps performance. Independent predictor variables from the time of surgery were extracted from participants' medical records. Kinesiophobia was screened at the time of testing. Wilcoxon signed-rank tests and linear regression analyses were used to assess between-limb differences in quadriceps performance and to determine factors associated with quadriceps performance 12months after surgery. Significant between-limb differences in each measure of quadriceps performance were identified (peak torque involved: 1.37 [0.71] Nm × kg-1; uninvolved: 1.87 [0.74] Nm × kg-1; RTD involved: 4.16 [2.75] Nm × kg-1 × s-1; uninvolved: 6.10 [3.02] Nm × kg-1 × × -1; and single-leg step-downs involved: 12.6 [5.0]; uninvolved: 21.7 [14.8]). Female biological sex, external fixation, and kinesiophobia at 12months were associated with reduced after-surgery quadriceps performance outcomes. Quadriceps performance is impaired 12months after surgical repair of a lower extremity fracture, particularly in female participants, in cases requiring external fixation, and in those with higher kinesiophobia 12months after surgery. Because long-term quadriceps weakness negatively impacts functional mobility, targeted strengthening should be emphasized after surgical repair of lower extremity fracture.

Does Lower Extremity Fracture Fixation Technique Influence Neurologic Outcomes in Patients with Traumatic Brain Injury? The EAST Brain vs. Bone Multicenter Trial.

To determine whether lower extremity (LE) fracture fixation technique & timing (≤ 24 vs > 24 hours) impact neurologic outcomes in TBI patients. A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age ≥ 18, head abbreviated injury scale (AIS) score > 2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN) or open reduction and internal fixation (ORIF). The analysis was conducted using ANOVA, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Score (RLAS-R). Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe LE injuries (AIS 4-5) compared to the IMN group (16% vs 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix 15 [8-24] vs. ORIF 26 [12-85] vs. IMN 31[12-70], p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of LE fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (OR 1.02, 95% CI 1.002-1.03 and OR 2.37, 95% CI 1.75-3.22) and a higher GCS motor score on admission (OR 0.84, 95% CI 0.73,0.97) was associated with higher RLAS-R score at discharge. Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of LE fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients. Level III (Prognostic/Epidemiological).

Clostridium difficile colitis portends poor outcomes in lower extremity orthopaedic trauma surgery

IntroductionClostridium difficile is the most common cause of healthcare-associated infectious diarrhea and colitis, and carries the potential for high morbidity, particularly in frail patient populations. The purpose of this study was to utilize a large nationally representative database in order to report 1.) the incidence of CDC in patients with operative lower extremity fractures, 2.) risk factors for the development of CDC, 3.) the association of CDC with length of stay (LOS), readmission, and 30-day mortality rates. MethodsThe ACS-NSQIP (2015–2019) was queried for patients who underwent surgical fixation of lower extremity fractures. A backward elimination multivariate regression model was used to identify risk factors for CDC. Chi squared and multivariate regression that controlled for preoperative variables and comorbidities were used to compare outcomes in patients with and without CDC. Results95,532 patients were included, 681 (0.71%) of whom developed CDC. Risk factors for CDC were advanced age, ASA class ≥ 3, smoking, dialysis, anemia, hypoalbuminemia, preoperative SIRS, preoperative wound infections, preoperative sepsis, and the use of spinal anesthesia or MAC/IV sedation. Patients with CDC had significantly increased 30-day mortality rates (10.6% vs 4.4%; OR 1.80, 95% CI 1.41–2.31), readmission (34.2% vs 7.5%; OR 5.13, 95% CI 4.36–6.05, and length of stay (7.5 days vs 5.3 days) compared to patients without CDC. ConclusionThe incidence of CDC in lower extremity orthopedic trauma patients was 0.71%. An occurrence of CDC was associated with approximately a 2.5 times increase in 30-day mortality, five times the readmission rate, and a longer hospital stay compared to patients without CDC. Mitigating the spread of c. diff through improved antibiotic stewardship and prompt treatment of CDC is paramount to decreasing the burden this infection imposes on orthopedic trauma patients and the healthcare system.

Factors associated with perioperative opioid demand in lower extremity fractures: Does consumption vary by anatomic location?

Perioperative opioid pain management protocols should reflect anticipated patient need. Fracture location and external fixation may be related to post-operative pain. The purpose of this study is to evaluate the impact of fracture location, articular injury, and pre-operative external fixation, and articular injury on perioperative opioid demand following definitive fixation. 1-month pre-operative to 1-year post-discharge opioid demand in oxycodone 5-mg equivalents in 23,441 patients undergoing fracture fixation of the femoral shaft through ankle between 2007 and 2017 was evaluated using a national database. Opioid demand was compiled over several timeframes: 1-month pre-op to 90-days post-discharge, 3 months post-discharge to 1-year post-discharge, and 1-month pre-op to 1-year post-discharge. Multivariable main effects linear and logistic regression models were constructed to evaluate the increased opioids filled, increased opioid prescriptions, and odds of refills in these timeframes with adjustment for fracture location, external fixator placement, and baseline patient and injury characteristics. Lower extremity anatomic location and pre-operative external fixation were significantly associated with increased 1-month pre-op to 1-year post-discharge opioid filling (17.6-54.7 additional oxycodone 5-mg equivalents, all p<0.05) and number of filled prescriptions (0.28-0.54 additional prescriptions, all p<0.05). Pilon fractures and pre-operative external fixation, specifically, were associated with increased odds of two or more opioid prescriptions within the 1-month pre-op to 1-year post-discharge time frame (1.25-1.32 odds ratio, all p<0.05). Fracture location and pre-operative external fixator placement predicted perioperative opioid demand. Articular zone (pilon, plateau, and distal femur) fracture fixation was associated with the largest increases in opioid demand after lower extremity fracture fixation. Patients with these injuries may be at highest risk of extensive opioid consumption.

Impact of Frailty and Malnutrition on Outcomes After Surgical Fixation of Lower Extremity Fractures in Young Patients.

Evaluate the relationship of nutrition parameters and the modified frailty index (mFI) on postsurgical complications within a young patient population sustaining lower extremity orthopaedic trauma. Retrospective observational cohort study. Urban, American College of Surgeons-Verified, Level-1, Trauma Center. Seventeen-thousand one hundred nine adult patients under the age of 65 sustaining lower extremity fractures undergoing operative intervention from 2006 to 2018. On admission, mFI and albumin levels were obtained, as well as complication data. Statistical analysis was used to analyze the association between frailty, malnutrition, and postoperative complications. Patients were stratified, healthy (mFI ≤1, albumin ≥3.5 g/dL), malnourished (mFI ≤1, albumin <3.5 g/dL), frail (mFI ≥2, albumin ≥3.5 g/dL), and frail and malnourished (mFI ≥2, albumin <3.5 g/dL). 60.4% of patients were healthy, 18.8% were malnourished, 11.7% were frail, and 9.0% were frail and malnourished. Frailty and/or malnourishment on admission predicted significantly higher odds of postoperative complications and mortality when compared with healthy patients. Frailty and malnourishment in conjunction predicted a significantly higher odds ratio of 1.46 (1.22-1.75) for developing postoperative complications when compared with the only malnourished. This was also observed when compared with the only frail (odd ratio: 1.61, P < 0.001); however, there was also a 2.72 (P < 0.001) increased odds of mortality. Frailty and malnutrition in conjunction predicts a subset of patients with a higher risk of postoperative complications beyond that of frailty or malnutrition in isolation. Identification of these physiological states on admission allows for interventional opportunities during hospitalization. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Incidence of Venous Thromboembolism Following Pelvic and Lower Extremity Trauma Despite Adherence to Modern Prophylactic Protocols.

Describe the incidence of venous thromboembolism (VTE) in patients with pelvic and lower extremity long bone trauma in the setting of modern prophylaxis. Retrospective health-system database study. Multi-center health care system. Database query from 2010 to 2017 identified 11,313 adult trauma patients who received open reduction internal fixation of pelvic, acetabular, femoral neck, or intertrochanteric fractures, or received intramedullary nailing (IMN) of the femoral or tibial shaft. Patients with incomplete prophylaxis, prior history of VTE, coagulopathy, or concomitant lower extremity fracture were excluded. Mechanical and chemical VTE prophylaxis following pelvic or lower extremity fracture fixation. VTE rates. The overall VTE rate was 0.82% [0.39% deep venous thromboses (DVT); 0.43% pulmonary emboli (PE)]. By procedure, pelvic open reduction and internal fixation (ORIF) and femoral IMN had the highest VTE rates 1.70% (0.98% DVT; 0.78% PE) and 1.33% (0.75% DVT; 0.58% PE), whereas tibial IMN had the lowest incidence of VTE 0.34% (0.17% DVT; 0.17% PE). Among hip fractures, femoral neck ORIF had a VTE rate of 0.98% (0.59% DVT; 0.39% PE), whereas intertrochanteric ORIF had lower rates of 0.59% (0.20% DVT; 0.39% PE). Despite adherence to modern VTEp protocols, nonpreventable VTE occur in 0.82% of pelvic and lower extremity orthopaedic trauma patients. Incidence ranged between 0.34% and 1.70% depending on injury/fixation method with the highest rate observed in pelvis ORIF followed by femoral IMN. In the era of pay for quality performance, it is important for health systems and auditing agencies to reconcile the difference between preventable and nonpreventable VTEs. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Titanium Alloy Intramedullary Nails and Plates Affect Serum Metal Ion Levels within the Fracture Healing Period.

Titanium alloy implants are the most used materials for the fixation of lower extremity fractures. Although these implants were thought to be inert materials in vitro, several studies have shown increased serum and remote tissue metal ion levels due to wear of implants and friction of the bone-implant interface in vivo. The aim of this study was to investigate the alteration of serum metal ion levels that are released from intramedullary nails and plates used for the fixation of lower extremity fractures, within the fracture healing period. The study included 20 adult patients, who were treated with intramedullary nail or plate osteosynthesis due to closed lower extremity fractures. Alterations of serum titanium, aluminum, molybdenum, and vanadium levels were evaluated at 6, 12, 18, and 24 weeks postoperatively. A statistically significant increase was determined in serum titanium, aluminum, molybdenum, and vanadium ion levels in the intramedullary nail and plate groups at the end of the follow-up period. Pairwise comparisons of metal ion levels between implant groups revealed no significant difference during a 24-week follow-up period. Compared to the control group, statistically significant increased levels of serum titanium, aluminum, vanadium, and molybdenum ions were determined in the implant groups used for the fixation of lower extremity fractures at the end of 24 weeks. In the current literature, the potential toxic effects of prolonged exposure to low levels of these metal ions are still unknown. It can be predicted that long-term metal ion exposure could result in vivo pathological processes in the future.

Utility of Routine Postoperative Radiographs After Fixation of Lower Extremity Fractures.

The goal of this study was to investigate the clinical utility of radiographs at all time points after internal fixation of lower extremity fractures. A retrospective chart review was conducted at a level I trauma center. Four hundred eighty-five patients with 586 fractures of the femur, tibia, and ankle were included. Data were analyzed to investigate the effect of radiographs on changes in management at all postoperative time points for each fracture type. Each fracture received, on average, 4.8 radiographs after fixation for a total cost of $938,469. The management of 31% (179 of 586) of fractures deviated from the expected postoperative course. Of the 179 fractures with a deviation, 93 (31%) resulted from radiographic findings alone and occurred (1) in the immediate postoperative period (2%) and (2) in the period from consideration of advancement to full weight bearing up until confirmation of fracture union (98%). Notable cost savings can be realized by using the findings to eliminate nonclinically indicated imaging at both the institutional and national levels. Routine radiographs in isolation contribute to changes in management (1) in the immediate postoperative period in select cases and (2) during the period when advancement to full weight bearing is being considered up until clinical fracture union. Level III.

Diabetes and Healing Outcomes in Lower Extremity Fractures: A Systematic Review

ObjectiveThe purpose of this study was to review the rates of adverse healing outcomes following surgical fixation of lower extremity fractures in diabetic patients and matched controls. Materials and MethodsSearches of PubMed, MEDLINE, CINAHL and Embase were performed for studies published between the date of database inception and July 6, 2015. Patient characteristics and the incidence of adverse healing outcomes (nonunion, malunion, delayed union, infection and reoperation) were extracted from each study. The occurrence of each fracture healing complication was pooled and analyzed for comparisons between diabetic and non-diabetic patients. An odds ratio with a 95% confidence interval for each healing outcome was calculated between the diabetic and non-diabetic groups. ResultsDiabetes was found to significantly increase rates of malunion, infection and reoperation in patients with surgically treated lower extremity fractures. In addition, when only peripheral lower extremity fractures (i.e. below the knee) were examined, diabetes significantly increased the rates of nonunion. ConclusionDiabetes substantially alters bone metabolism and soft tissue healing, posing a risk of adverse fracture healing and other complications. This systematic review provides evidence that the presence of diabetes significantly increases the risks of infection, malunion, nonunion and re-operation across a wide variety of surgically treated lower extremity fractures. This study provides prognostic information for clinicians and may aid in guiding treatment for this population.

Use of a “kickstand” modification for external fixation of lower extremity fractures in children

To evaluate and describe the kickstand modification and its use in children with lower extremity fractures. Retrospective review identified eight children in whom the kickstand technique was used during treatment of their lower extremity fractures. The seven boys and one girl had a mean age of 11.8years. All fractures were caused by high-energy trauma. Five of the eight tibial fractures were open fractures (one type 1, one type 2, and three type 3B), and five of the eight patients had multiple extremity fractures. Additional procedures were required in six of the eight children, four of whom had multiple lower extremity fractures. No additional pressure-relieving modalities were used in any patient. The kickstand did not affect the fracture reduction, prevent patient mobilization, or require operative adjustment in any patient, and none had any skin pressure-related complications on the heel of the affected extremity. In pediatric patients with lower extremity trauma, the addition of a kickstand to the external fixator provides a simple, inexpensive, lightweight, adjustable, and adaptable method for encouraging elevation of the injured extremity, which facilitates edema control; it also allows easy neurovascular monitoring and wound care.

Techniques for Assessing Limb Alignment During Closed Reduction and Internal Fixation of Lower Extremity Fractures

Techniques for Assessing Limb Alignment During Closed Reduction and Internal Fixation of Lower Extremity Fractures

Lower extremity fracture fixation in head-injured patients.

Compared with nonsurgical management or delayed repair, early fracture fixation can reduce the incidence of pulmonary complications in patients with long-bone fractures of the lower extremities. Blunt trauma victims often have multiple nonskeletal injuries that might influence the risk of pulmonary complications, and when head injuries are present it has been a common practice to delay nonemergent operations for several days to protect the injured brain. We conducted a retrospective review of 114 patients with multiple trauma whose injuries included head trauma and a fracture of the neck or shaft of the femur or shaft of the tibia to determine if delayed stabilization of lower extremity fractures increased the risk of pulmonary complications or reduced the risk of cerebral complications. Forty-six patients underwent surgical fixation of their fractures within 24 hours of injury (early fixation), 26 patients had their fractures repaired more than 24 hours after injury (late fixation), and 42 patients did not undergo surgical fracture fixation. The risk of pulmonary complications was not related to the timing of surgical fracture fixation but was strongly influenced by the severity of injuries to the head and to the chest (p less than 0.001). Furthermore, a delay in fracture fixation did not protect the injured brain; the risk of CNS events was determined by the severity of the head injury (p less than 0.0001). Early fracture fixation in patients with head injury may be appropriate because it simplifies patient care and does not seem to worsen the head injury, but it does not prevent pulmonary complications in these high-risk patients.

Genitoperineal Injury Induced by Orthopedic Fracture Table

AbstractReduction and fixation of lower extremity fractures commonly involve use of the orthopedic fracturetable, with incorporation of the perineal post for positioning and countertraction. Prolonged application of perineal pressure thereby is possible, with vulnerability to genitoperineal injury. Four examples are described.