Reasons for Surgical Delay in Patients With Hip Fracture.

INTRODUCTION: 15% of patients with hip fracture older than 65 years in Israel have delayed surgery. The aim of this study was to determine which patient and/or organizational factors are associated with a delay of beyond 48 hours in hip fracture repair surgery. METHODS: A retrospective cohort study of 281 patients with hip fracture who underwent surgery during 2019-2020. Characteristics of patients with early surgery ( n = 40) and patients with delayed surgery ( n = 241) were compared. RESULTS: Presence of a cardiac disease (odds ratio [OR] = 1.38), pulmonary disease (OR = 1.21), or obesity (OR = 1.18) was identified as risk factors for surgical delay. Each additional comorbidity increased the risk. Most of the documented reasons for delay were medical, with antiplatelet therapy the most common ( n = 8, 20%). Unavailable operating rooms were another common reason for delays ( n = 8, 20%). In addition, a higher percentage of patients with delayed surgery were admitted in August and September (42.5%). CONCLUSIONS: It seems that most delays were for medical reasons. However, it is unclear whether allegedly clinically justified delays were indeed of benefit to the patients. Health care organizations should strive to minimize the impact of organizational factors on surgical delay.

Minimizing treatment complexity of combat-related soft tissue injuries using a dedicated tension relief system and negative pressure therapy augmented by high-dose in situ antibiotic therapy and oxygen delivery: a retrospective study.

BACKGROUND: Following combat-related, extensive soft tissue injury from gunshot wounds or blasts, prolonged duration from injury to full wound closure is associated with infection, increased morbidity and mortality, failure to mobilize, poor functional outcome and increased cost. The purpose of this study was to evaluate a novel treatment enabling early primary closure of combat wounds. METHODS: This was a retrospective study of 10 soldiers and civilians with extensive combat-related soft tissue limb injuries (5 gunshot wounds, 5 blasts) treated using the TopClosure® Tension Relief System (TRS) with simultaneous administration of regulated oxygen-enriched and irrigation negative pressure-assisted wound therapy (ROINPT) via the Vcare α® device. RESULTS: Nine patients were treated during the acute phase of injury and one was treated following removal of a flap due to deep infection 20 years after injury and flap reconstruction. Two patients had upper limb injury and the rest lower limb injury. With the aid of the TRS and/or ROINPT, immediate primary closure during reconstruction was achieved in 6 patients and delayed primary closure in three. Only one patient required a skin graft to close a small area of the wound after most of the wound had been closed by delayed primary closure. Wound closure was achieved within 0-37 days (median: 12.5 days, interquartile range: 2.75-19.75) from injury. CONCLUSIONS: The TRS is a novel device for effective, early skin stretching and secure wound closure through the application of stress relaxation and mechanical creep, achieving primary closure of large defects using a simplified surgical technique and reducing the need for closure using skin grafts and flaps and the use of tissue expanders. Delivering supplemental oxygen to the wound by ROINPT reverses the reduced oxygen levels inherent in conventional negative pressure-assisted wound therapy, mitigating anaerobic contamination and reducing infection. Irrigation may accelerate the evacuation of infectious material from the wound and provide a novel method for antibiotic administration. The combination of TRS and ROINPT devices allow for early primary closure with improved functionality of combat-related limb injuries.

Timing of antimicrobial initiation and reduced infection risk in open limb fractures: a cohort study.

To assess whether early administration of antimicrobials in open fractures of the limbs reduces infection risk. A historical cohort study included all adult patients admitted with an open fracture of the limbs, between January 1, 2012, and December 31, 2016. Epidemiological, clinical, and microbiological data was collected and analyzed. Microbiological infection was defined by positive wound cultures during the first 30 days, and clinical infection as defined by the treating physician. Of 167 patients, microbiological infection was identified in 12 (7%) patients, and clinical infection in 27 (16%) patients. All patients received the first dose of antimicrobials within 15 h of admission (median 1.29 h). Very early administration of the first dose did not reduce the risk of infection (median of 1.06 h and 1.31 h for patients that did vs. did not develop infection, respectively P = 0.58). In multivariate logistic regression, location of fracture in the lower limbs was associated with an increased risk of infection (OR 4.654, CI 1.407-15.398), and Gustilo-Anderson classification grade 1 or 2 was associated with a decreased risk of infection (OR 0.301, CI 0.104-0.872). Very early administration of antimicrobials did not reduce risk of infection in open limb fractures.