Treatment of Schatzker Type VI Tibia Fractures Using Circular External Fixation: State of the Art, Surgical Technique and Results.

BACKGROUND: Schatzker type VI tibia fractures are usually associated with infection and surgical wound-related problems. Circular external fixation (CEF) has been shown to minimize such complications. METHODS: We pose a retrospective study of patients with Schatzker type VI fractures treated with CEF. RESULTS: Twenty-two (22) patients were included (11M/11F) with a mean age of 60.1 ± 14.9 years. According to the AO/OTA classification, two fractures (9.1%) were A2, three (13.6%) were A3, and seventeen (77.3%) were C3. Three (13.6%) of them were open. The tissue damage observed in the nineteen (86.4%) closed fractures was classified according to Tscherne (four grade I, twelve grade II, and three grade III). The mean ex-fix time was 24.1 ± 5.1 weeks. None of the patients experienced deep infections, nonunion, or malunion. The mean ROM was 111.4 ± 17.8 degrees. Although stability was achieved in all cases, 50% of them suffered osteoarthritic degeneration. Four knees required TKR at a mean of 8.77 ± 5.58 years from trauma. The mean HHS knee score was 84.2 ± 10.3 points (excellent in fifteen (68.2%) cases, good in four (18.2%), and acceptable in three (13.6%)). The mean Rasmussen radiological score was 13.3 ± 3.5 (excellent in three (13.6%) cases, good in fifteen (68.2%), and acceptable in four (18.2%)). The mean SF-12 score was 35.1 ± 10.4 points on the physical scale and 53.0 ± 10.6 points on the mental scale. CONCLUSIONS: CEF has shown itself to be a valid treatment for patients with Schatzker type VI fractures, particularly for those where the fracture is comminuted, severely displaced, open, or associated with severe soft tissue damage.

Enterobacter cloacae Infection After Surgical Treatment of Ankle Fractures, a Multicenter Observational Study.

BACKGROUND: Infection is one of the challenging complications after open reduction and internal fixation for ankle fractures. Previously published case series conclude that Staphylococcus aureus is the most frequent causative microorganism. An unexpected increase in Enterobacter cloacae infections after this surgery was observed in a preliminary analysis of data at the promoting center of the study. In traumatology, its incidence has been reported in chronic osteomyelitis, prosthetic infections, septic osteoarthritis, open fractures in children and adults, and fractures other than the ankle. Because of this unexpected finding, we decided to perform this study to analyze the demographic and microbiological variables of acute osteosynthesis infection after ankle fracture and determine the distinctive features of the patients with E cloacae infection. METHODS: We performed a retrospective multicenter study including 4 university hospitals. All patients diagnosed with acute osteosynthesis infection after ankle fracture fixation between January 2015 and December 2018 were included. We analyzed demographic data, type of fracture, surgical technique, and microorganisms responsible for the infection. We performed a descriptive statistical analysis of the variables. Univariate and multivariate regression analysis were performed to compare patients with E cloacae infection to patients with infection caused by other microorganisms. RESULTS: A total of 65 patients were included. A predominance of polymicrobial infections (24.62%), followed by infections caused by S aureus (23.07%) and E cloacae (23.07%) was observed. When E cloacae isolated in polymicrobial infections were added, the incidence of E cloacae as a causative microorganism increased to 32.3%. Patients with E cloacae infection were older (64/53, P = .008) and had a higher requirement of negative-pressure therapy after surgical debridement (71%/40%, P = .017). CONCLUSION: A high incidence of E cloacae infections was observed. Patients with E cloacae infection were generally older and required a higher use of negative-pressure therapy after debridement. LEVEL OF EVIDENCE: Level V, mechanism-based reasoning.

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

INTRODUCTION: Acute 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 METHODS: A 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. RESULTS: We 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). CONCLUSIONS: Definitive 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.

Risk Factors of DAIR Failure and Validation of the KLIC Score: A Multicenter Study of Four Hundred Fifty-Five Patients.

Background: Debridement, antibiotic agents, and implant retention (DAIR) is a currently accepted approach for the treatment of early prosthetic joint infections (PJI). The success of a DAIR procedure has shown variable results throughout the published literature. Scoring systems such as the Kidney, Liver, Index surgery, Cemented prosthesis, and C-reactive protein value (KLIC) score for the selection of patients that are likely to benefit from DAIR have proved to be helpful in decision making. Our study aims to further validate the KLIC score using a large external multicentric cohort and to evaluate other risk factors for failure. Patients and Methods: A retrospective analysis of patients with an early acute PJI who were treated with DAIR and recorded in a database of eight Spanish university hospitals was performed. According to pre-operative variables of the KLIC study, patients were categorized into five groups: group A, ≤2 points; group B, 2.5-3.5 points; group C, 4-5 points; group D, 5.5-6.5 points; and group E, ≥7 points. Failure rates were compared between groups at 60 days and after 60 days of DAIR. Further variables for risk of failure were also analyzed. Results: A total of 455 patients with early acute PJI were included in the analyses. At 60 days, patients presenting with pre-operative elevated C-reactive protein serum levels, Staphylococcus aureus, and polymicrobial infections were associated with failure. Failure rates recorded were 12% for group A (n = 210), 18% for group B (n = 83), 26% for group C (n = 89), 24% for group D (n = 66), and 0% for group E (n = 7). Univariable analysis between consecutive groups of the KLIC score showed no differences for failure before 60 days of the DAIR procedure. Scheduled surgery and having the procedure performed by a specialized unit were also identified as important factors for DAIR success. Conclusions: Our results suggest the KLIC score was not useful for predicting failure in our cohort. Furthermore, our results indicate a specialized unit should conduct DAIR procedures.

Infected bone defects in the lower limb. Management by means of a two-stage distraction osteogenesis protocol.

INTRODUCTION: Although bone transport is generally accepted as the gold standard for the treatment of segmental septic bone defects, some aspects of its practical application are still open to debate. We present our results in this field and compare them with the series published so far. MATERIAL AND METHODS: We reviewed all our patients (2010-2018) that underwent a bone transport procedure in the lower limb due to a septic bone defect. We calculated the bone healing index (BHI), the external fixation index (EFI), the rate of complications and the clinical results. We statistically compared our results with 63 publications with a similar scope. RESULTS: Thirty-five patients (30 M/5F) with a mean age of 40 years and a mean follow-up of 45 months were included. Bone segment was 24 T/11F and mean defect was 8.4 cm (7.34 T/ 10.73F). Mean global BHI was 45.62 days/cm (48.16 T/40.09F). Mean EFI was 2.37 months/cm. Results were excellent in 9 patients, good in 23 and bad in 3. Bone graft was used in 60% of the cases. DISCUSSION: The size of our series is similar to previously published ones, although the mean age of our patients is higher and they present a larger bone defect. BHI of our series is similar to that of other series, although EFI is significantly higher. The number of complications is also in line with the existing literature. CONCLUSION: The use of a two-stage technique for managing segmental bone defects of septic origin in the lower extremity is a valid alternative. Our series shows results comparable to the current literature.