Fracture-Related Complications:What You Can Do to Prevent Infection

Fracture-related infections (FRI) can occur when bacteria enter the wound during a traumatic injury. All efforts should be made to prevent FRI-associated complications due to the complexity of treatment at the time of onset and poor treatment outcomes. The risk factors for FRIs vary and several preoperative, perioperative, and postoperative measures can be implemented to prevent infections. Preoperative measures include blood sugar control, nutritional support, discontinuation of steroids and immunosuppressants, treatment of accompanying pre-existing infections, and decolonization of pathogens, specifically Staphylococcus aureus. The perioperative and postoperative measures include the use of prophylactic antibiotics, proper surgical site preparation (hair removal, preoperative washing, skin antisepsis), suitable surgical environment (operating room ventilation system, behavioral interventions in the operating room), correct surgical techniques (debridement, irrigation, wound closure, and negative pressure wound therapy). All medical staff should pay careful attention and ensure the implementation of the correct preventive measures.

Fibular Fixation in Same-Level Distal Third Tibiofibular Fractures: Is Fibular Fracture Regarded as a Secondary Importance?

Background@#Although most studies focused on the alignment or union of the tibia in same-level distal third tibiofibular fractures, the outcome of a concomitant fibular fracture is generally regarded as being of secondary importance in the literature. This study aimed to assess the outcomes of fibular fractures in same-level distal third tibiofibular fractures. @*Methods@#In this retrospective study, we enrolled 111 patients with same-level distal third tibiofibular fractures treated at our institute between January 2016 and August 2020. Tibial fractures were stabilized with intramedullary nailing, and the cases were divided into two groups based on whether they additionally underwent fibular fixation (group 1, 57 cases) or not (group 2, 54 cases). Clinical and radiographic outcomes were used for the evaluation of tibial and fibular alignments, union of the tibia and fibula, number of interlocking screws in the distal tibial fragment, range of motion of the ankle joint, and complications. @*Results@#No statistically significant differences in the tibial union rate or mean tibial alignment were observed between the two groups on either the immediate postoperative or final radiographs. The fibular union rate in group 1 was significantly higher than that in group 2 (fibular nonunion, 0 vs. 15; p < 0.001). Statistically significant differences in fibular displacement were observed on immediate postoperative radiographs between patients with fibular union and those without it. At the final follow-up, the mean range of ankle motion and lower extremity functional scale scores did not differ between the two groups. @*Conclusions@#Regardless of whether fibular fixation was performed, the overall tibial alignment with intramedullary nailing was well restored and the union rate of the tibia was comparable in the two groups. Fibular nonunion is not uncommon in unfixed fibula fractures. Displacement of the fibula as seen on immediate postoperative radiographs was related to fibular nonunion.

Bisphosphonate: An Invaluable Medication or Abandoned Acid?

Over the last two decades, bisphosphonate has widely been applied in the treatment of osteoporosis.We reviewed the various adverse effects, current trials involving diverse bone metabolic diseases, andthe future direction of bisphosphonate. Acute phase reaction, hypocalcemia, ocular inflammation, and gastrointestinal disturbances are the well-known short-term side-effects of bisphosphonate. Long term side-effects include osteonecrosis of the jaws and atypical femur fracture. In the modern clinical setting, bisphosphonate is widely used in treatments for osteoporosis, osteopenia, osteoarthritis, rheumatoid arthritis, and metastatic bone cancer. Further studies are underway for expanding the application as a bone-targeting agent in bone-related diseases. Bisphosphonate remains useful and invaluable as the 1st line medication for osteoporosis. Considering the numerous clinical situations, including time to medication after fracture, duration of drug usage, and individual drug holiday, an optimal and proper use of bisphosphonate needs to be achieved. In the current scenario, bisphosphonate will retain a strong position due to good efficacy and effectiveness for osteoporosis treatment, and the precise ap-plication to various bone diseases. We anticipate a key role of bisphosphonate for future applicationin the treatment of metabolic bone diseases. Further studies and advancement are highly anticipated, considering the high potential of bisphosphonate for various uses.

Bisphosphonate: An Invaluable Medication or Abandoned Acid?

Over the last two decades, bisphosphonate has widely been applied in the treatment of osteoporosis.We reviewed the various adverse effects, current trials involving diverse bone metabolic diseases, andthe future direction of bisphosphonate. Acute phase reaction, hypocalcemia, ocular inflammation, and gastrointestinal disturbances are the well-known short-term side-effects of bisphosphonate. Long term side-effects include osteonecrosis of the jaws and atypical femur fracture. In the modern clinical setting, bisphosphonate is widely used in treatments for osteoporosis, osteopenia, osteoarthritis, rheumatoid arthritis, and metastatic bone cancer. Further studies are underway for expanding the application as a bone-targeting agent in bone-related diseases. Bisphosphonate remains useful and invaluable as the 1st line medication for osteoporosis. Considering the numerous clinical situations, including time to medication after fracture, duration of drug usage, and individual drug holiday, an optimal and proper use of bisphosphonate needs to be achieved. In the current scenario, bisphosphonate will retain a strong position due to good efficacy and effectiveness for osteoporosis treatment, and the precise ap-plication to various bone diseases. We anticipate a key role of bisphosphonate for future applicationin the treatment of metabolic bone diseases. Further studies and advancement are highly anticipated, considering the high potential of bisphosphonate for various uses.

Risk Factors Affecting the Early Complications of Femoral Head Fractures

Purpose@#This study analyzed the prognostic factors in patients with femoral head fractures by comparing two groups with and without complications. @*Materials and Methods@#A retrospective study was performed on femoral head fracture patients who visited two different level-1 trauma centers from January 1, 2014 to June 30, 2018. Thirty-three patients with a follow-up period of more than one year were included. Early complications were defined as fair or poor in the Thompson–Epstein clinical evaluation criteria and grades 3 or 4 in the Kellgren– Lawrence classification within one year after the fracture. The patients were divided into two groups, with and without early complications. Statistical analysis was performed for the nominal variables with a Fisher’s exact test and continuous variables using a Mann–Whitney U test. @*Results@#Nine patients (27.3%) had early complications, and there were no significant differences according to age, sex, treatment method, combined fractures, Pipkin classification, and AO/OTA classification between the two groups. @*Conclusion@#The prognosis in femoral head fractures is difficult to predict. Therefore, the validation of existing classifications or a new classification is necessary.

Descriptive Study for Sonographic Morphology of the 1st Facet of Subscapularis Footprint / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to document the sonographic morphology of the subscapularis footprint, particularly the 1st facet, of the non-pathologic subscapularis tendon and footprint, and analyze the correlation between the size of the 1st facet and the demographic variables. MATERIALS AND METHODS: Between March 2015 and December 2017, retrospectively data analysis was performed for the ultrasound (US) scans of 115 consecutive shoulder (mean age 53.4 years, range 23–74 years) with non-pathologic subscapularis tendon and footprint. The sonographic findings of the 1st facet of the subscapularis footprint was a very unique, flat, broad, and plane angle in the upward direction, which were distinguished from the other facets. On US, the transverse (medio-lateral) and longitudinal (superior-inferior) length of the 1st facet on axis of the humerus shaft were recorded. The demographic variables, including age, site, body height, weight, body mass index (BMI), and arm length, were reviewed. RESULTS: On US, the mean transverse length of the 1st facet was 12.75 mm (range 10.54–14.50 mm, standard deviation [SD] 0.712) and the mean longitudinal length was 12.22 mm (range 9.20–13.30 mm, SD 0.888). The transverse and longitudinal length of the size of the 1st facet were significantly greater in males than in females (p<0.001, p=0.001). Of the demographic data (body height, weight, BMI, arm length) that showed a significant positive linear correlation, the correlation with body height (transverse r=0.749, p<0.001; longitudinal r=0.642, p<0.001) showed the strongest relationship, and the correlation with the BMI was weakly related. The relationships between the size of the 1st facet to site/age were not statistically significant or appeared to have no linear correlation. CONCLUSION: The structural and morphologic features of the 1st facet of the subscapularis footprint on the US were identified. This will provide anatomic knowledge of an US examination for subscapularis tendon pathology.

Results of Hook Plate Fixation of Unstable Distal Clavicle Fractures

PURPOSE: This study evaluated the clinical and radiological outcomes of unstable distal clavicular fractures treated with an AO Hook plate. MATERIALS AND METHODS: From March 2009 to October 2010, sixteen patients with distal clavicular fractures underwent open plating using an AO Hook plate. The clinical outcomes were assessed by measuring the UCLA scores and KSS sores, and the radiological outcomes were evaluated using simple radiographs at the final follow-up. RESULTS: Fracture union was obtained in all patients at an average of 13.9 weeks (range, 9~20 weeks). The UCLA scoring system showed excellent results in 9 cases and good results in 7. The average KSS scores of distal clavicular fractures were 95.5. At the final follow-up, subacromial osteolysis developed in 11 cases (68.7%) of whom 3 suffered from pain around the acromion. Other complications occurred in 4 patients: one had a fracture adjacent to the plate proximally, two had a stiff shoulder with subacromial impingement, and one had hypoesthesia around the surgical wound. CONCLUSION: Unstable distal clavicular fractures treated with a Hook plate provided rigid fixation and satisfactory outcomes considering the high union rate. Nevertheless, potential postoperative complications related to morphometric properties of the plate should be considered.

Cement Leakage into Disc after Kyphoplasty: Does It Increases the Risk of New Adjacent Vertebral Fractures?

PURPOSE: This study aims to investigate the relationship between cement leakage into the disc during percutaneous balloon kyphoplasty and subsequent compression fractures in adjacent vertebrae during treatment of osteoporotic vertebral compression fracture. MATERIALS AND METHODS: 103 patients (118 vertebrae) who have been treated with balloon kyphoplasty due to osteoporotic compression fracture from June 2007 to July 2010 were retrospectively analyzed. The group was composed of 13 males and 90 females. The mean age was 75 years (57~95 years). The mean follow-up period was 10 months (6~30 months). Patients were divided into two groups; one with cement leakage into the disc and the other without cement leakage into the disc. The study was performed to determine whether subsequent compression fractures in adjacent vertebrae were related to several factors. RESULTS: The cement leakages into the disc occurred in 16 of 118 vertebrae. Of the 16 vertebrae with cement leakage into the disc, 5 (31%) had subsequent adjacent vertebral compression fractures; however, of the 102 vertebrae in which cement leakage did not occur, only 11 (11%) had subsequent adjacent vertebral compression fractures (p<0.05). Of the 16 vertebrae with cement leakage into the disc, subsequent adjacent vertebral compression fractures occurred 1 vertebrae of 10 vertebrae with definite trauma history. Out of the 6 vertebrae with cement leakage and no definite trauma history, 4 vertebrae (67%) had subsequent adjacent vertebral compression fractures (p<0.05). CONCLUSION: The cement leakage into the disc significantly increases the incidence of subsequent adjacent vertebral compression fractures. Most of the subsequent fractures occurred in the early post-operative period. When cement leakage into the disc occurred in patients with no definite trauma history such as slip down, the incidence of subsequent adjacent vertebral compression fracture increased significantly.

Simultaneous Fractures of the Ipsilateral Distal and Proximal Clavicle: Double Clavicle Fracture: A Case Report

Clavicular fracture is common injury in the upper extremity, but ipsilateral proximal, distal or middle-third clavicular fractures which occur simultaneously are an extremely rare. Seven cases have been reported in the English and Japanese literatures, but it has never been reported in Korea. We report a case of ipsilateral proximal and distal clavicular fracture caused by fall from height and describe its presumed mechanism, diagnosis, treatment with a review of literatures.

Minimally Invasive Plate Osteosynthesis of Proximal, Middle and Distal Humerus Fractures / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to evaluate the clinical and radiological outcomes of proximal, middle and distal third humeral fractures treated with the minimally invasive plate osteosynthesis (MIPO). MATERIALS AND METHODS: Thirty-one patients with the proximal, middle or distal third humeral fractures underwent MIPO. There were 12 men and 19 women with an average age of 46.7 years. The radiological outcomes of bony union and anatomical reduction were evaluated. The clinical outcomes were assessed by measuring the range of shoulder and elbow motion, UCLA scores, KSS sores and the postoperative complications. RESULTS: Fracture union was obtained in all patients at an average of 18.4 weeks. According to the UCLA scores, 9 were excellent and 3 were good for the proximal humeral fractures. For the middle and distal third fractures, UCLA scoring system showed excellent results in 15 cases and good results in 4 cases. The average KSS scores of proximal and shaft fracture were 92.5 and 98.6, respectively. Complications developed in 3 patients: one had radial nerve palsy, one had a fracture adjacent to the plate distally, and one had a rotational deformity. CONCLUSION: MIPO for proximal, middle and distal third humeral fractures provided satisfactory clinical and radiological outcomes considering high union rate and minor complications.

Usefulness of Preoperative Autologous Blood Donation for Spinal Fusion / 대한수혈학회지

BACKGROUND: Major orthopedic surgical procedures, including spinal fusions, require 2 or 3 units of transfusion. In this study, we evaluated the usefulness of autologous transfusion by comparing the postoperative infections, the pre- and postoperative serological changes, the amount of transfusion during the operation and the segmented estimated blood loss of the patients who received spinal fusion surgery. METHODS: We analyzed 106 patients who were undergoing spinal fusion surgery and among them, 69 patients were operated on with using autologous transfusion, while 37 cases were operated on with using homologous transfusion. RESULTS: The segmental estimated blood loss was approximately 574.4+/-131.8 mL in group 1 and 635.3+/-250.1 mL in group 2. The mean number of transfused units in the autologous transfusion group was 2.1+/-0.3 units and this was 3.5+/-0.6 units in the homologous transfusion group. There was no significant statistical difference in the hemoglobin level or the complications between the two groups, yet the duration of fever in the group with homologous transfusion was 3.0+/-0.4 days, which was increased compared to that of group 1 (1.4+/-1.3 days). CONCLUSION: The total amount of transfusion and blood loss for the patients who were operated on using autologous transfusion were less, as compared to those for the patients who were operated on with homologous transfusion, and the patients with homologous transfusion showed a significantly decreased duration of fever. It seems that autologous transfusion is a way to shorten the duration of fever and increase the satisfaction of the patients.

Preoperative Risk Factors for Deep Infection Following Total Knee Replacements

PURPOSE: The aim of this study was to investigate the overall rate of deep infection and the risk factors for infection after primary total knee arhroplasties. MATERIALS AND METHODS: We conducted a retrospective case-control study of 229 patients (376 knees) who underwent total knee replacement (TKR) between January 2006 and June 2007 and who were followed up for more than one year. The risk factors for deep infection were determined via univariate analyses. RESULTS: The overall rate for developing infection was 1.9% (7 of 376). The risk factors were an operating theatre other than the main room (odds ratio=33.2, 95% confidence interval=1.9, 583.6) and a preoperative hemoglobin level lower than 12 mg% (odds ratio=4.3, 95% confidence interval=1.9, 9.4). CONCLUSION: The deep infection rates after TKRs might vary depending on the preoperative level of hemoglobin and the operating-room environment. Successful strategies to overcome the host and environmental risk factors are needed with the goal of preventing infection of the prosthesis.

Comparative Study of Intramedullary Nailing and Plate for Metaphyseal Fractures of the Distal Tibia

PURPOSE: To compare the radiological and clinical results between intramedullary nailing and plate fixation in the treatment of distal tibial fractures. MATERIALS AND METHODS: 19 cases of distal tibial metaphyseal fractures within 4 cm of the ankle joint line were enrolled. Ten patients were treated with interlocking intramedullary nail and the others with plate and screws. RESULTS: The mean union time was 14 weeks in nailing group and 16 weeks in plate group. The average angulation in AP view was 4.1 degrees in nailing group and 3.1 degrees in plate group. The average angulation in lateral view was 1.7 degrees in nailing group and 2.7 degrees in plate group. The rotational deformity was 2.8 degrees in nailing group and 1.7 degrees in plate group in average. There was no implant failure and soft tissue problem. CONCLUSION: There was no difference in clinical and radiological results between intramedullary nailing and plate in the treatment of the distal tibial fractures and, considering the preservation of the soft tissue, the intramedullary nails are a reliable method for managing distal metaphyseal fractures of the tibia.

Radiological Landmarks for the Assessment of the Alignment in the Use of the LCP-PLT (Locking Compression Plate-Proximal Lateral Tibia): An Anatomical and Radiological Study

PURPOSE: To evaluate the conformity of the anatomically pre-shaped LCP-PT to the tibias of the Korean adult and to identify radiological guidelines to assist intraoperative assessment of correct alignment. MATERIALS AND METHODS: 30 adult femur obtained from the Korean adult cadaver were used. A nine or eleven-hole LCP-DF was applied to the lateral surface of the tibia according to the contour. Then the distance from the inner surface of the plate to the lateral condyle was measured at the sites of mismatch. The angle between the most proximal screw and the articular surface was measured with the image intensifier. RESULTS: The LCP-PT showed good conformity to the tibia in general. The distance from the inner surface of the plate to the lateral condyle was 3.5mm in average (range 0~9). The angle between the most proximal locking screw and the joint line was 1.16 degrees in average (range 0~7 degree). CONCLUSION: The LCP-PT showed good conformity to the tibia in general. Malposition of the most proximal screw which is not paralleling to the joint line may herald a coronal plane malalignment.