Postoperative Deep Infection Research Articles

Examining the Influence of Psychiatric Comorbidities on Postoperative Outcomes in Total Ankle Arthroplasty

Category: Ankle; Ankle Arthritis Introduction/Purpose: Historically, a robust association between psychiatric conditions and perioperative complications following orthopaedic surgeries has been established. Within the past decade, the prevalence of total ankle arthroplasty (TAA) has risen by 136.1%. In a similar time frame, the United States has seen the prevalence of mental health disorders rise, a trend that was accentuated by the COVID-19 pandemic. This study aims to evaluate the effect of mental health disorders on the postoperative outcomes of patients undergoing primary TAA. Methods: The Nationwide Readmissions Database (NRD) was queried to identify 29,705 patients undergoing primary TAA from 2015 to 2020. Patients were then divided into cohorts based on concurrent mental health diagnosis (MHD) (MHD=6,041, no MHD=23,664). Further analysis was performed for common mental health diagnoses, including depression (n=3,553), anxiety (n=3,510), psychosis (n=592), bipolar disorder (BPD) (n=411), and post-traumatic stress disorder (PTSD) (n=235). A multivariate regression analysis was performed to control for confounding variables. Results: Patients with any MHD were significantly younger (p <.001), more likely to be female (p <.001), lower income (p <.001), and had a higher Charlson-Deyo Comorbidity Index (p <.001). These patients were also significantly more likely to have Medicaid insurance (p <.001) and be treated at an urban teaching hospital (p=.027). Patients with anxiety, depression, or psychosis experienced statistically significantly higher rates of complications. Similarly, patients with anxiety, psychosis, or PTSD experienced statistically significantly higher rates of postoperative deep infections. Multivariate regression analysis found any MHD to be predictive of increased risk of complication by 16% (OR=1.158; 95%CI=1.048-1.278; p=.004), adverse discharge by 70% (OR=1.678; 95%CI=1.57-1.793; p<.001), extended stay by 50% (OR=1.497; 95%CI=1.351-1.658; p<.001), and infection by 65% (OR=1.654; 95%CI=1.231-12.223; p<.001). Conclusion: Patients with MHD are at a statically significantly higher risk of complications, infections, protracted hospital stays, and adverse discharge outcomes following primary TAA. Careful appraisal and counseling are necessary in this patient demographic when considering patients selection for TAA.

The Open Abdomen After Intra-abdominal Contamination in Emergency General Surgery

IntroductionDelayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to compare the clinical outcomes of DFC versus immediate fascial closure (IFC) in EGS patients with intra-abdominal contamination. MethodsThis retrospective study was conducted using the 2013-2020 American College of Surgeons National Surgical Quality Improvement Program database. Adult EGS patients who underwent an exploratory laparotomy with intra-abdominal contamination [wound classification III (contaminated) or IV (dirty)] were included. Patients with agreed upon indications for DFC were excluded. A propensity-matched analysis was performed. The primary outcome was 30-d mortality. ResultsWe identified 36,974 eligible patients. 16.8% underwent DFC, of which 51.7% were female, and the median age was 64 y. After matching, there were 6213 pairs. DFC was associated with a higher risk of mortality (15.8% versus 14.2%, P = 0.016), pneumonia (11.7% versus 10.1%, P = 0.007), pulmonary embolism (1.9% versus 1.6%, P = 0.03), and longer hospital stay (11 versus 10 d, P < 0.001). No significant differences in postoperative sepsis and deep surgical site infection rates between the two groups were observed. Subgroup analyses by preoperative diagnosis (diverticulitis, perforation, and undifferentiated sepsis) showed that DFC was associated with longer hospital stay in all subgroups, with a higher mortality rate in patients with diverticulitis (8.1% versus 6.1%, P = 0.027). ConclusionsIn the presence of intra-abdominal contamination, DFC is associated with longer hospital stay and higher rates of mortality and morbidity. DFC was not associated with decreased risk of infectious complications. Further studies are needed to clearly define the indications of DFC.

Predominant Use of Bilateral Internal Mammary Arteries in Off-Pump Coronary Artery Bypass Surgery

Bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG) has been shown to provide long-term clinical benefits over single internal mammary artery (SIMA) grafting. Nevertheless, the perceived technical complexity of the procedure and concerns about potential early postoperative complications, particularly sternal wound infections have led to a utilization rate of BIMA grafting of less than 5% in the United States. We systematically compared early (30-day) post-operative outcomes between the BIMA and SIMA cohorts in patients with similar baseline characteristics. A retrospective single center study was conducted on matched patients, using stabilized inverse probability treatment weighting to mitigate bias between the two study cohorts. From 546 off-pump CABG patients initially identified, we examined 328 BIMA and 213 SIMA grafts from the matched samples. Despite utilizing 60.4% BIMA grafts, we observed similar rates of 30-day overall and cardiac mortality between the BIMA and SIMA groups. Rates of 30-day postoperative complications, including superficial and deep sternal wound infections, stroke, sepsis, acute kidney injury, and cardiac arrest, were similar between the two groups. Rates of 30-day overall and cardiac readmission were also similar. Additionally, median length of hospital stays, intensive care unit stay, and ventilation times were similar between the two groups. In conclusion, our data suggest that a BIMA utilization rate of 60.4% in off-pump CABG procedure is achievable without causing any significant increment in early post-operative complications, including deep sternal wound infection.

Definitive internal fracture fixation followed by staged free flap coverage (“fix followed by flap” protocol) for open Gustilo type IIIB fractures

BackgroundAlthough the concept of the “fix and flap” approach, in which definitive fracture fixation and flap coverage are completed in a single procedure at the earliest opportunity may seem ideal for the treatment of Gustilo type IIIB open fractures, the individual circumstances of patients, such as polytrauma or multiple fracture cases may not allow for the immediate fracture fixation and flap coverage (“fix and flap” approach). In our hospital, patients with Gustilo type IIIB open fractures are treated with definitive internal fixation of the fracture followed by staged flap coverage (“fix followed by flap” protocol) when the “fix and flap” approach was not feasible due to the patient's condition or difficulty in coordinating surgery schedules. The “fix followed by flap” protocol provides benefits in terms of flexibility in adjusting the surgical timetable, simplifying the planning of flap coverage following fracture fixation, and minimizing individual surgical invasion. MethodsWe reviewed 10 cases of severe open fractures treated with the “fix followed by flap” protocol and evaluated their outcomes. All surgical procedures, including wound debridement, fracture fixation, and flap coverage, were performed by orthoplastic surgeons specializing in both fracture surgery and microsurgery including soft tissue reconstruction. ResultsAll free flaps survived, and no partial necrosis was observed. None of the patients developed postoperative deep infection up to the last follow-up. Fracture union was achieved in all patients with or without autologous bone grafts. The median time for union was 9.4 months (range, 4–12 months). ConclusionsThis study presents favorable outcomes of treatment for Gustilo type IIIB open fractures with fracture fixation followed by staged flap coverage (“fix followed by flap” protocol). Despite a delay in flap coverage, the consistency of treatment provided by orthoplastic surgeons may have contributed to the favorable outcomes in this study.

Effect of unidirectional airflow ventilation on surgical site infection in cardiac surgery: environmental impact as a factor in the choice for turbulent mixed air flow

Surgical site infection (SSI) in the form of postoperative deep sternal wound infection (DSWI) after cardiac surgery is a rare, but potentially fatal, complication. In addressing this, the focus is on preventive measures, as most risk factors for SSI are not controllable. Therefore, operating rooms are equipped with heating, ventilation and air conditioning (HVAC) systems to prevent airborne contamination of the wound, either through turbulent mixed air flow (TMA) or unidirectional air flow (UDAF). To investigate if the risk for SSI after cardiac surgery was decreased after changing from TMA to UDAF. This observational retrospective single-centre cohort study collected data from 1288 patients who underwent open heart surgery over 2 years. During the two study periods, institutional SSI preventive measures remained the same, with the exception of the type of HVAC system that was used. Using multi-variable logistic regression analysis that considered confounding factors (diabetes, obesity, duration of surgery, and re-operation), the hypothesis that TMA is an independent risk factor for SSI was rejected (odds ratio 0.9, 95% confidence interval 0.4-1.8; P>0.05). It was not possible to demonstrate the preventive effect of UDAF on the incidence of SSI in patients undergoing open heart surgery when compared with TMA. Based on these results, the use of UDAF in open heart surgery should be weighed against its low cost-effectiveness and negative environmental impact due to highelectricity consumption. Reducing energy overuse by utilizing TMA for cardiac surgerycandiminish the carbon footprint of operating rooms, and their contribution to climate-related health hazards.

Removal of Spinal Instrumentation Is Not Required to Successfully Treat Postoperative Wound Infections in Most Cases.

Controversy exists regarding whether spinal implants need to be removed to treat postoperative deep wound infections (DWIs). This retrospective study aimed to determine whether the removal or retention of implants impacts the successful treatment of a DWIafter spine surgery. Postoperative spine surgery patients presenting with signs of infection who underwent irrigation and debridement (I&D) at Twin Cities Spine Surgeons at Abbott Northwestern Hospital, Minnesota, USA, were studied. First, the persistence of infection when implants were retained or removed was assessed. Second, we analyzed the persistence of infection with respect to the number of I&D, the use of vacuum-assisted closure (VAC) treatment, pseudoarthrosis status, and functional outcomes. One hundred thirty-five patients were included. Treatment of infection with retention of implants occurred in 64% (87/135); of these, 7% (6/87) had a persistent infection. Of patients with implant removal (36%, 48/135), 6% (3/48) had a persistent infection. Thus, we observed no difference between treatment with implants present compared to implants removed (p = 1.0). Fifty of the 135 patients (37%) received I&D and primary wound closure, and 85 (63%) patients received I&D and VACtreatment. There was no statistical difference between primary wound closure and VAC treatment (p = 0.15) with respect to persistence. Repeat I&D with VAC (three or more times) had a significantly lower rate of recurrence than those with two I&Ds. Pseudoarthrosis and persistent infection were unrelated. At minimum one-year follow-up, achieving a minimum clinically important difference in functional outcome was independent of persistent infection status. Persistent infection was unrelated to the retention of implants. When VAC treatment was deemed necessary, more than two I&Ds resulted in a significantly better cure for infection. Those with a persistent infection were no more likely to exhibit pseudoarthrosis than those with no persistent infection. All patients showed improvement in functional outcomes at minimum one-year follow-up.

Off-pump bilateral internal thoracic artery grafting in patients with left main coronary artery disease

BackgroundTo compare postoperative outcomes in patients with left main coronary artery disease who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA).MethodsAmong 1583 patients who underwent isolated coronary artery bypass grafting (CABG) in our hospital between 2002 and 2022, 604 patients with left main coronary artery disease underwent single (n = 169) or bilateral (n = 435) ITA grafting. We compared postoperative outcomes between the two groups after adjusting preoperative characteristics using inverse probability of treatment weighting.ResultsAfter adjustment using inverse probability of treatment weighting method, the sum of weights was 599.74 in BITA group and 621.64 in SITA group. There was no significant difference in postoperative deep sternal wound infection (p = 0.227) and 30-day mortality (p = 0.612). Follow-up was completed in 98.7% (596/604) of the patients, and the mean follow-up duration was 6.7 years. At 10 years, the overall survival following bilateral versus single ITA grafting was 71.2% and 60.6%, respectively (log-rank test, p = 0.040), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 63.3% and 46.3%, respectively (log-rank test, p = 0.008). In multivariate Cox proportional hazard models, bilateral ITA grafting was significantly associated with a lower risk of all-cause death (hazard ratio [HR]: 0.706, 95% confidence interval [CI]: 0.504–0.987; p = 0.042) and MACCE (HR: 0.671, 95% CI: 0.499–0.902; p = 0.008).ConclusionsBilateral skeletonized ITA grafting is associated with lower rates of all-cause death and MACCE than single ITA grafting in patients with left main coronary artery disease undergoing off-pump CABG.

Interim Use of Antibiotic-Loaded Cement Spacer for Patients with Infected Cervical Fusion

The management of postoperative deep infection after anterior cervical discectomy and fusion (ACDF) remains challenging for spine surgeons. Our institution uses handmade antibiotic-loaded cement spacers to treat these complex cases. This study aimed to determine the efficacy and feasibility of this treatment. This study included 4 patients with deep cervical spine infections after ACDF who underwent our treatment between March 2012 and January 2022. Patients' laboratory data, visual analog scale scores, comorbidities, complications, and neurological status were recorded. Their clinical conditions were also evaluated based on the Neck Disability Index, Japanese Orthopaedic Association score, and Odom criteria. Infection eradication was achieved in all patients after treatment. The average preoperative visual analog scale score was 7.5 (range: 7-8); this decreased to 1.25 (range: 1-2) at 1year postoperatively. None of the patients experienced severe complications, such as neurological deterioration or bone graft dislodgement. The Neck Disability Index improved from a preoperative value of 54% (range: 48-60%) to 6% (range: 4-8%) at 1year postoperatively. The Japanese Orthopaedic Association score improved from a preoperative score of 10.25 (range: 10-11)-14.75 (range: 14-16) at 1year postoperatively. All patients achieved excellent outcomes based on Odom criteria at 1year postoperatively. Good clinical outcomes were achieved in this study. Although 2-stage surgery is required, this technique could be an alternative for patients with postoperative deep infection after ACDF.

Identification of independent risk factors for postoperative deep wound infection after spine surgery in 2977 patients

Identification of independent risk factors for postoperative deep wound infection after spine surgery in 2977 patients

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 &lt; 0.05). There was no association between (antibiotic dosage or place of injury) with post-operative wound infection (p &gt; 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.

Patient Reported Outcomes with the Use of Fibular Nail Fixation, Retrospective Review of 41 Cases

Category: Trauma; Ankle Introduction/Purpose: Traditionally, open reduction and internal fixation of unstable lateral malleolus fractures with plate and screw constructs has been considered the gold standard treatment. More recently, the use of an intramedullary fibula nail has gained popularity as an alternative treatment method using a mini open incision to obtain anatomic reduction. The minimally invasive nature of this technique and the no profile load bearing/sharing implant is reported with very low complication rates and a much lower incidence of implant irritation and removal. We report our surgical and patient reported outcomes for a cohort of single surgeon consecutive fibula nails with proximal and distal locking fixation. Methods: We retrospectively reviewed prospectively collected data on 41 patients that were implanted with the Fibulock® Fibula Nail (Arthrex, Naples, Florida, USA). All nails were implanted by a single surgeon. Intraoperative reduction quality was recorded, and patients were followed post operatively with radiographs that were assessed for maintenance of reduction, healing, and complications. Patient reported outcome questionnaires (PROMs) were collected preoperatively and at 3, 6, 12, and 24 months postoperatively. The Foot and Ankle Ability Measure (FAAM) assessed the patient’s functional status in terms of activities of daily living and sports. The Visual Analogue Score (VAS) was also collected. Results: All 41 patients had one- to two- year follow-up (14.68 months ± 5.92). Demographics are listed on table 1. Forty of the patients were reduced via mini open incision and one was reduced closed. There were no conversions to a plate, no intraoperative complications, and no cases of loss of reduction postoperatively. No patient required revision surgeries, no cases of delayed union or nonunion, and zero superficial or deep postoperative infections. Statistical analysis revealed a significant difference between preoperative and postoperative FAAM scores overall (+67.52, p &lt; 0.001), within activities of daily living (+68.07, p &lt; 0.001), and sport (+65.95, p &lt; 0.001). Also, there was a significant difference between preoperative VAS and postoperative VAS (+4.73, p &lt; 0.001). Conclusion: Our results support existing literature that fixation of fibula fractures with an intramedullary nail with proximal and distal locking capabilities is an alternative option to a plate and screw construct, with a very low incidence of hardware related complications requiring removal, and favorable patient reported outcomes.

Cessation of Antibiotics for Complicated Appendicitis at Discharge Does Not Increase Risk of Post-operative Infection

PurposeThe utilization of home antibiotic therapy following surgery for complicated pediatric appendicitis is highly variable. In 2019, we stopped home antibiotic therapy in this cohort at our institution. We sought to evaluate our outcomes following this protocol change. MethodsWe queried our institutional NSQIP Pediatrics data for all children undergoing appendectomy for complicated appendicitis between January 2015 and May 2022. We identified two cohorts: those discharged with home antibiotics (1/1/15-4/30/19) and those discharged with no home antibiotics (5/1/19-4/30/22). Both groups were treated with response based parenteral antibiotics while hospitalized and discharged when clinically well. Our primary outcome was postoperative deep organ space infection requiring intervention (drainage, aspiration, reoperation, or antibiotics). Secondary outcomes included length of stay, superficial site infection, Clostridium difficile colitis, ER visits, post-operative CT imaging, and readmission. ResultsThere were 185 patients in the home antibiotic group (83% discharged with antibiotics) and 121 patients in the no home antibiotic group (8.3% discharged with antibiotics). There were no significant differences in deep organ space infection requiring intervention (7% vs. 7.4%, p = 1.0). Our length of stay was not different (4.5 days vs. 3.95 days, p = 0.32), nor were other secondary outcomes or patient characteristics. All patients had documented follow-up. ConclusionsWe did not identify differences in deep organ space infections, length of stay or other events after eliminating home antibiotic therapy in our complicated appendicitis cohort. The use of home antibiotics following surgery for complicated appendicitis should be reconsidered. Level of EvidenceIII.

The disc-endplate-bone-marrow complex classification: progress in our understanding of Modic vertebral endplate changes and their clinical relevance

Background contextThe disc, endplate (EP), and bone marrow region of the spine form a single anatomical and functional interdependent unit; isolated degeneration of any one structure is rare. Modic changes (MC), however, are restricted to the subchondral bone alone and based on only T1 and T2 sequences of MRI. This results in poor reliability in differentiating fat from edema and hence may give a false impression of disease inactivity. PurposeTo study the changes in disc, endplate, and bone marrow as a whole in degeneration and propose a classification based on the activity status of this complex with the addition of STIR MRI sequences. Study designObservational cohort. Patient samplePatients with isolated brain, cervical, or thoracic spine injury and patients with low back pain (LBP) who underwent MRI formed the control and study groups, respectively. Outcome measuresDemographic data, the prevalence of MC and disc-endplate-bone marrow classification (DEBC) changes, EPs undergoing reclassification based on DEBC, and comparison of the prevalence of MC, DEBC, H+modifier and DEBC with H+concordance between control and LBP group. The study determined the risk of LBP patients undergoing surgery as well as the incidence of postoperative infection based on DEBC changes. Significance was calculated by binomial test and chi-square test with the effect size of 0.3 to 0.5. Prevalence and association of outcome were calculated by Altman's odds ratio with the 95% CI and the scoring of z statistics. Logistic expression was plotted for independent variables associated with each class of both Modic and DEBC against dependent variables surgery and nonsurgery. MethodsLumbar segments in both groups were assessed for MC types. The DEBC classification was developed with the addition of STIR images and studying the interdependent complex as a whole: type-A: acute inflammation; type-B: chronic persistence; type-C: latent and type-D: inactive. Modifier H+ was added if there was disc herniation. The classification was compared with MC and correlated to clinical outcomes. ResultsA total of 3,560 EPs of 445 controls and 8,680 EPs in 1,085 patients with LBP were assessed. Four nonMC, 560 MC-II, and 22 MC-III EPs were found to have previously undetected edema in STIR (n=542) or hyperintensity in discs (n=44) needing reclassification. The formerly undescribed type-B of DEBC, representing a chronic persistent activity state was the most common (51.8%) type. The difference between the control and LBP of H+(12% vs 28.8%) and its co-occurrence with DEBC type 1.1% vs 23.3%) was significant (p<.0001). The odds ratio for the need for surgery was highest (OR=5.2) when H+ and DEBC type change co-occurred. Postoperative deep infection (as determined by CDC criteria) was 0.47% in nonDEBC, compared with 2.4% in patients with DEBC (p=.002), with maximum occurrence in type-B. ConclusionClassification based on the classic MC was found to need a reclassification in 586 EPs showing the shortcomings of results of previous studies. Considering the DEBC allowed better classification and better predictability for the need for surgical intervention and incidence of postoperative infection rate than MC.

Two Cases of Left Hip Heterotopic Ossification Treated with Surgery and their Outcomes Postoperatively

52-year-old woman was admitted to Trauma and Orthopedics department (TOD) due to septic arthritis (SA) in left hip joint (LHJ). Patient underwent three consecutive open debridement procedures. During the treatment, an intracerebral hematoma was discovered. Upon rehabilitation patient indicated severe pain in LHJ that impaired movement. Three months after admission CT showed heterotopic ossification (HO) in LHJ. Patient was recommended to complete treating postinfectious complications and refer to TOD for further evaluation and discussing treatment options. Five months after the first presentation, complete mechanical block could be seen in LHJ due to HO. Open left hip ossificate resection and LHJ redressation were performed. During procedure significant increase in range of motion (ROM) was obtained. Iatrogenic transection of the femoral nerve occurred and was treated surgically. After surgery, patient was subjected to early rehabilitation and later forwarded to rehabilitation department. Increase of active and passive ROM remained. 34-year-old man was admitted to TOD due to polytrauma, including multiple hip and acetabular fractures. Patient underwent three surgical interventions due to fractures. Month after admission, postoperative deep tissue infection in the fracture and Covid-19 were discovered and treated. Two years later, patient returned to TOD complaining about significant impairment of ROM in LHJ due to HO, which was surgically removed. Surgical treatment is rarely chosen for treatment of HO since alleviation of pain is not worth the risks, and HO can reoccur, preferring treatment with exercise and indomethacin, but when a significant increase of ROM is expected, surgical treatment is justified. These case reports show how surgical treatment of HO with mixed origin in patients with good expected outcomes and high involvement in their own rehabilitation should be at least considered. It is important to emphasize both pre and postoperative rehabilitation and prophylaxis.

Contemporary posterior surgical approach with standard cemented total hip arthroplasty for femoral neck fracture in patients of age 60 years and older: Still a safe option?

PurposeThe ideal operative treatment of displaced intracapsular femoral neck fractures in the active elderly is contentious. Recent literature favours a better outcome with the use of total hip arthroplasty (THA). Dislocation remains a major concern with THA, especially when a posterior approach is used. More recently, the concept of dual mobility cups is being promoted to avoid dislocations. The aim of the present study was to look at the outcomes of cemented THA utilising the posterior approach for these patients using a 28 ​mm (mm) femoral head. MethodsThis study retrospectively analysed the outcome of 108 primary cemented THA, performed by specialist hip surgeons, using a posterior approach with robust soft tissue repair in patients of age 60 years and older presenting with displaced intra capsular femoral neck fractures using a 28 ​mm head. ResultAt mean follow-up of 5.2 years (2.0–10.5 years), there were 2 dislocations (1.9%). One underwent manipulation under anaesthesia and the other had application of a posterior lip augmentation device. No other revisions were performed during the follow up period. The 30 day mortality was nil and no post-operative deep infections. Hundred patients (93%) at 1 year follow-up were independently mobilising. ConclusionsWith optimal patient selection, an excellent outcome can be achieved for patients with displaced femoral neck fractures using the standard cemented THA via the posterior approach with 28 ​mm head. A robust soft tissue repair and a specialist hip surgeon is recommended for this cohort of patients.

Systematic Review for Evaluation of Ilizarov External Fixator in Treatment of Open Fracture of Tibial Shaft

Background Tibial shaft fractures are one of the most common long bone fractures. Open fracture tibial shaft is common between those fracture. The Ilizarov external fixator (IEF) is a minimally invasive method that permits effective wound management, early weight-bearing, and bone lengthening. Aim of the Work We aim to systematically review the Ilizarov external fixator in the treatment of open fracture of the tibial shaft. Material and Methods Regarding the methodology of our study, we followed the PRISMA statement guidelines during this study preparation and performed all steps according to the Cochrane handbook of systematic reviews of intervention. We searched PubMed, Scopus, Cochrane, and Web of Science, Embase, and Science Direct in June 2021 and updated the search in July 2021 using relevant Keywords. Results We found a significant difference regarding the outcome of operation time. IEF consumed more time than the other different approaches. The analysis favored IEF over other different approach regarding the overall postoperative excellent to good improvement. No significant different was found between both IEF and other approaches regarding the union time (per months) as well as the risk of reoperation. The postoperative superficial infection was the at the same risk between IEF and other different approaches, However, there is no significant difference regarding risk in postoperative deep infection after IEF. The overall postoperative infection rate was increased after IEF. No significant difference was found regarding the risk of either non-union or malunion rate, postoperative healing, and deep venous thrombosis (DVT). Conclusion We concluded that the IEF can be considered reliable alternative techniques over other techniques. The analysis demonstrated that it is possible to successfully treat diaphyseal tibial fractures using the Ilizarov method, a minimally invasive technique allowing immediate weight-bearing.

A deep surgical site infection risk score for patients with open tibial shaft fractures treated with intramedullary nail

ObjectivesTo identify deep infection risk factors in patients with open tibial shaft fractures and to develop a scoring algorithm to predict the baseline deep infection risk in this patient population. MethodsA retrospective cohort study conducted at a single academic trauma center identified patients with open tibial shaft fractures treated with intramedullary nail fixation from December 2006 to October 2020. The primary outcome was a deep surgical site infection requiring surgical debridement. The outcome was identified by Current Procedural Terminology codes and confirmed with a medical chart review documenting evidence of a tibial draining wound or sinus tract. ResultsDeep surgical site infection occurred in 13% of patients (97/769). Factors that predicted deep surgical site infection were identified. Gustilo-Anderson type IIIB or IIIC was the strongest predictor with a 12-fold increase in the odds of deep infection (OR 11.8, p < 0.001). Additional factors included age >40 years (OR 1.7, p = 0.03), American Society of Anesthesiologists score ≥3 (OR 1.9, p < 0.01), Gustilo-Anderson type IIIA vs. type I or II (OR 2.8, p = 0.004), and gunshot wounds (OR 2.9, p = 0.02). The risk scoring model predicted patients who would develop an infection with an acceptable level of accuracy (AUC 0.79). The risk score categorized patients from a low probability of deep infection 2%–6% with <10 points to high risk (58%–69%) with >40 points. ConclusionsThis risk score model predicts deep postoperative infection in patients with open tibial shaft fractures treated with intramedullary nails. The ability to accurately estimate deep infection risk at the time of presentation might aid patient expectation management and allow clinicians to focus infection prevention strategies on the high-risk subset of this population.

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.

Low albumin-to-fibrinogen ratio predicts adverse clinical outcomes after primary total joint arthroplasty: A retrospective observational investigation.

Nutritional markers for adverse clinical outcomes following total joint arthroplasty (TJA) remain controversial. This study attempted to explore the validity of the albumin-to-fibrinogen ratio (AFR) in nutritional assessment and assess its predictive value for adverse postoperative outcomes in patients receiving TJA. 2137 patients who underwent primary TJA between January 2016 and June 2021 were screened. We performed receiver operating characteristic curves and area under the curve (AUC) to assess predictive value and establish optimal thresholds. Multivariate regression models were then used to assess potential associations between AFR and adverse postoperative outcomes. AFR might predict postoperative deep surgical site infections (AUC = 0.699, P = .023). The optimal threshold for wound complications, determined by the Youden index, was 12.96. Compared with patients with reduced AFR, patients with high AFR exhibited an enhanced risk of adverse postoperative outcomes (adjusted OR: 4.010-8.832, all P < .05). Using multivariate Cox regression analysis, we further confirmed a higher risk of adverse postoperative outcomes in patients with low AFR (adjusted HR: 3.733-7.335, all P < .05). Reduced preoperative AFR markedly enhanced adverse postoperative outcomes. Hence, AFR may serve as a potential biomarker for nutritional assessment, and may predict postoperative wound complications following primary TJA.

Local contamination is a major cause of early deep wound infections following open posterior lumbosacral fusions.

Postoperative surgical site infection in patients treated with lumbosacral fusion has usually been thought to be caused by perioperative contamination. With the proximity of these incisions to the perineum, this study sought to determine if contamination by gastrointestinal and/or urogenital flora should be considered as a major cause of this complication. We conducted a retrospective review of adults treated with open posterior lumbosacral fusions between 2014 and 2021 to identify common factors in deep postoperative infection and the nature of the infecting organisms. Cases of tumor, primary infection and minimally invasive surgery were excluded. 489 eligible patients were identified, 20 of which required debridement deep to the fascia (4.1%). Mean age, operative time, estimated blood loss and levels fused were similar between both groups. The infected group had a significantly higher BMI. The mean time from primary procedure to debridement was 40.8days. Four patients showed no growth, 3 showed Staphylococcus sp. infection (Perioperative Inside-Out) requiring debridement at 63.5days. Thirteen showed infection with intestinal or urogenital pathogens (Postoperative Outside-In) requiring debridement at 20.0days. Postoperative Outside-In infections led to debridement 80.3days earlier than Perioperative Inside-Out infections (p = 0.007). 65% of deep infections in patients undergoing open lumbosacral fusion were due to early contamination by pathogens associated with the gastrointestinal and/or urogenital tracts. These required earlier debridement than Staphylococcus sp. There should be renewed focus on keeping these pathogens away from the incision during the early stages of wound healing.