Fracture related infection in open tibial fractures.

Open tibia fractures frequently occur following high-energy trauma. Contamination of the fracture site combined with limited soft tissue coverage and blood supply means that these open fractures are associated with a high rate of complications, including fracture related infection (FRI). FRI is associated with lowered patient outcomes and requires early recognition and appropriate surgical and medical management. The current evidence on FRI after open tibial fractures largely is limited to case series, small retrospective cohort studies and expert opinion. Recent expert consensus has produced guidelines with the aim of standardising care for these patients. This review summarises the current management strategies employed in treating FRI following open tibial fractures and where possible the evidence behind them.

Osteocutaneous Turn-Up Fillet Flaps: A Spare-Parts Orthoplastic Surgery Option for a Functional Posttraumatic Below-Knee Amputation.

This article portrays the authors' experience with a complex lower limb bone and soft tissue defect, following chronic osteomyelitis and pathological fracture, which was managed by the multidisciplinary orthoplastic team. The decision for functional amputation versus limb salvage was deemed necessary, enhanced by the principles of "spare parts" in reconstructive microsurgery. This case describes the successful use of the osteocutaneous distal tibia turn-up fillet flap that allowed "lowering the level of the amputation" from a through knee to a below-knee amputation (BKA) to preserve the knee joint function. We comprehensibly review reports of turn-up flaps which effectively lower the level of amputation, also applying "spare-parts" surgery principles and explore how these concepts refine complex orthoplastic approaches when limb salvage is not possible to enhance function. The osteocutaneous distal tibia turn-up fillet flap is a robust technique for modified BKA reconstructions that provides sufficient bone length to achieve a tough, sensate stump and functional knee joint.

Microbiological Profile of Fracture Related Infection at a UK Major Trauma Centre.

Fracture Related Infection (FRI) represents one of the biggest challenges for Trauma and Orthopaedic surgery. A better understanding of the microbiological profile should assist with decision-making and optimising outcomes. Our primary aim was to report on the microbiological profile of FRI cases treated over a six-year period at one of Europe's busiest trauma centres. Secondarily, we sought to correlate our findings with existing anti-microbiological protocols and report on diagnostic techniques employed in our practice. All adult cases of FRI treated in our institution between 2016 and 2021 were identified, retrospectively. We recorded patient demographics, diagnostic strategies, causative organisms and antibiotic susceptibilities. There were 330 infection episodes in 294 patients. A total of 463 potentially pathogenic organisms (78 different species) were identified from cultures, of which 57.2% were gram-positive and 39.7% gram-negative. Polymicrobial cultures were found in 33.6% of cases and no causative organism was found in 17.5%. The most prevalent organisms were Staphylococcus aureus (24.4%), coagulase-negative Staphylococci (14%), Pseudomonas aeruginosa (8.2%), Enterobacter species (7.8%) and Escherichia coli (6.9%). Resistant gram-positive organisms (methicillin resistant Staphylococcus aureus or vancomycin-resistant Enterococci) were implicated in 3.3% of infection episodes and resistant gram-negatives (extended-spectrum beta-lactamase, ampC or carbapenemase-producing bacteria) in 13.6%. The organisms cultured in 96.3% of infection episodes would have been covered by our empirical systemic antibiotic choice of teicoplanin and meropenem. To our knowledge, this is the largest reported single-centre cohort of FRIs from a major trauma centre. Our results demonstrate patterns in microbiological profiles that should serve to inform the decision-making process regarding antibiotic choices for both prophylaxis and treatment.

Intramedullary application of local antibiotic bullets for the treatment of long bone fracture related infection.

PURPOSE: The optimal means of local antibiotic delivery for fracture related infection is unknown. Until now, intramedullary application of calcium sulphate based local antibiotics has been challenging. We report on the use of a newly available mode of preparation and delivery: the Stimulan Bullet Mat and Introducer (Biocomposites Ltd, Staffordshire, England). METHODS: A retrospective analysis of prospectively collected data for infection cases at two separate tertiary referral institutions was performed. We included cases of long bone FRI with a retained intramedullary nail, treated with a single stage protocol of metalwork removal, debridement, local antibiotic application using the novel mould and applicator, with additional bony stabilisation and soft tissue reconstruction where required. RESULTS: All 13 patients achieved infection remission rate with an average follow-up of 19.7 months (range 12-28). All 6 patients with infection around an unhealed fracture achieved union at an average 8 months (range 4-12) from debridement. No patients developed aseptic wound leak. CONCLUSIONS: Antibiotic impregnated calcium sulphate can be used safely as part of a single stage treatment protocol for the treatment of long bone fracture related infection following intramedullary nailing. We have demonstrated high rates of infection remission and union, using a newly available intramedullary applicator.

Complications after talus fractures: A trauma centre experience.

BACKGROUND: Talus fractures are anatomically complex, high-energy injuries that can be associated with poor outcomes and high complication rates. Complications include non-union, avascular necrosis (AVN) and post-traumatic osteoarthritis (OA). The aim of this study was to analyse the outcomes of these injuries in a large series. METHODS: We retrospectively collected data on 100 consecutive patients presenting to a single high volume major trauma centre with a talus fracture between March 2012 and March 2020. All patients were over the age of 18 with a minimum of 12 months follow up post injury. Retrospective review of case notes and imaging was conducted to collate demographic data and to classify fracture morphology. Whether patients were managed non-operatively or operatively was noted and where used, the type of operative fixation, outcomes and complications were recorded. RESULTS: The mean age was 35 years (range: 18-76 years). Open injuries accounted for 22% of patients. An isolated talar body fracture was the most frequent fracture (47%), followed by neck fractures (20%). The overall non-union rate was 2% with both cases occurring in patients with open fractures. The AVN rate was 6%, with the highest prevalence in talar neck fractures. Overall rates of post-traumatic OA of the tibio-talar, sub-talar and talo-navicular joints were 12%, 8%, and 6%, respectively. These were higher after a joint dislocation, and higher in neck or head fractures. The postoperative infection rate was 6%. The overall secondary surgery rate was 9%. There were 2% of patients who subsequently underwent a joint arthrodesis. CONCLUSION: Our study found that talar body fractures are more common than previously reported; however, talar neck fractures cause the highest rates of AVN and post-traumatic arthritis. Open fractures also carry a greater risk of complications. This information is useful during consenting and preoperatively when planning these cases to ensure adverse outcomes may be anticipated.

Functional Outcomes of Dorsal Bridge Plating for Lisfranc Injuries With Routine Implant Retention: A Major Trauma Center Experience.

OBJECTIVES: To assess medium-term functional outcomes and the complication profile for unstable Lisfranc injuries treated with dorsal bridge plate (DBP) fixation when implants are not routinely removed. DESIGN: Large single-center retrospective case series. SETTING: Level-1 Trauma Center, London, United Kingdom. PATIENTS: Consecutive cases of skeletally mature individuals with unstable Lisfranc injuries treated operatively between 2014 and 2019. INTERVENTION: Open reduction and DBP fixation with implants not routinely removed. MAIN OUTCOME MEASUREMENTS: Patient-reported outcome measures at final follow-up. The Manchester-Oxford Foot Questionnaire summary index was the primary outcome measure. The American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale, complications, and all-cause reoperation rates were secondary outcome measures. Logistic regression models were used to identify risk factors that influenced outcomes. RESULTS: Eighty-five patients were included. Mean follow-up was 40.8 months (24-72). The mean Manchester-Oxford Foot Questionnaire Summary Index was 27.0 (SD 7.1) and mean AOFAS score 72.6 (SD 11.6). The presence of an intra-articular fracture was associated with poorer outcomes, with worse MOXFQ and AOFAS scores (both P < 0.001). Eighteen patients (21%) required implants removal, with this more likely in female patients (OR 3.89, 95% confidence interval, 1.27 to 12.0, P = 0.02). Eight patients (9%) required secondary arthrodesis. CONCLUSIONS: This is the largest series of Lisfranc injuries treated with DBP fixation reported to-date and the only to routinely retain implants. Medium-term outcomes are comparable to existing literature in which implants are routinely removed. The presence of an intra-articular fracture is a poor prognostic indicator. Implant removal is more likely to be needed in female patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for authors for a complete description of levels of evidence.

Percutaneous subtalar joint screw fixation of comminuted calcaneal fractures: a salvage procedure.

INTRODUCTION: Malunited comminuted calcaneal fractures result in poor function due subtalar joint arthritis and altered biomechanics. We aimed to assess whether percutaneous subtalar joint screws after fracture reduction provide good outcomes for these difficult injuries. METHODS: We retrospectively analysed 15 comminuted calcaneal fractures (in 14 patients) treated with percutaneous subtalar screw fixation. All patients had a minimum of 12 months' follow-up. Six patients had open injuries. On the preoperative and the latest postoperative radiograph, Bohlers angle, Gissane angle, calcaneal inclination, width and length, absolute foot height, and posterior facet height were measured. Preoperative computed tomography scans were used to classify the fractures by Sanders classification. Clinical outcome scores were recorded postoperatively. RESULTS: Mean age was 34.2 ± 14.2 years. Minimum follow-up was 12 months (mean 17.2 ± 4.4 months). Nine patients had a Sanders 4, 3 had a Sanders 3AB, 2 had a Sanders 3BC, and 1 had a Sanders 3AC fracture. Eighty percent of patients had their angle of Gissane, absolute foot height, calcaneal length and inclination restored by this technique. Bohlers angle was restored back into the normal range in 54% of patients. Mean postoperative AOFAS score was 74 ± 11. AOFAS scores positively correlated with postoperative Bohlers angle (Pearson's correlation coefficient 0.85; p = 0.004). One patient (7%) had a wound breakdown postoperatively and three patients (20%) had heel pain from the screws, which improved after removal. CONCLUSION: Percutaneous subtalar screws offer a reliable option to restore calcaneal anatomy in comminuted calcaneal fractures, with low complication rates. Over 80% of patients had their angle of Gissane, calcaneal length and inclination restored, and over 50% of patients had all radiological parameters restored by this technique. It offers the benefits of percutaneous reduction and fixation and this procedure may be considered an effective first stage prior to definitive subtalar fusion. Further work is needed to review the longer-term outcomes and the conversion rate to arthrodesis. LEVEL OF EVIDENCE: IV (case series), Therapeutic.

A novel technique to assess rotational deformities in lower extremities using CT-based motion analysis.

Rotational deformities following intramedullary (IM) nailing of tibia has a reported incidence of as high as 20%. Common techniques to measure deformities following IM nailing of tibia are either based on clinical assessment, plain X-rays or Computed Tomography (CT) comparing the treated leg with the uninjured contralateral side. All these techniques are based on examiners manual calculation inherently subject to bias. Following our previous rigorous motion analysis and symmetry studies on hemi pelvises, femurs and orthopaedic implants, we aimed to introduce a novel fully digital technique to measure rotational deformities in the lower legs. Following formal institutional approval from the Imperial College, CT images of 10 pairs of human lower legs were retrieved. Images were anonymized and uploaded to a research server. Three dimensional CT images of the lower legs were bilaterally reconstructed. CT-based motion analysis (CTMA) was used and the mirrored images of the left side were merged with the right side proximally as stationary and distally as moving objects. Discrepancies in translation and rotation were automatically calculated. Our study population had a mean age of 54 ± 20 years. There were six males and four females. We observed a greater variation in translation (mm) of Centre of Mass (COM) in sagittal plane (95% CI - 2.959-.292) which was also presented as rotational difference alongside the antero-posterior direction or Y axis (95% CI .370-1.035). In other word the right lower legs in our study were more likely to be in varus compared to the left side. However, there were no statistically significant differences in coronal or axial planes. Using our proposed fully digital technique we found that lower legs of the human adults were symmetrical in axial and coronal plane. We found sagittal plane differences which need further addressing in future using bigger sample size. Our novel recommended technique is fully digital and commercially available. This new technique can be useful in clinical practice addressing rotational deformities following orthopaedic surgical intervention. This new technique can substitute the previously introduced techniques.

Impact of the COVID-19 pandemic on the management of open fractures in a major trauma centre.

INTRODUCTION: The Coronavrius-19 (COVID-19) pandemic has presented the biggest challenge that the National Health Service (NHS) has ever seen. As one of the worst affected regions, Orthopaedic service provision and delivery in London, changed dramatically. Our hypothesis is that these restrictions adversely impacted the care of open fractures in our major trauma unit in London. METHODS: This is a prospective case control study comparing the management of patients presenting pre-COVID, to those presenting during the height of the COVID pandemic in London. The pre-COVID, control cohort presented between the 1st October and the November 30, 2019. The COVID cohort presented between the April 1, 2020 and the May 31, 2020. Data was collected that related to the 11 clinical domains of the British Orthopaedic Association Standards of Trauma (BOAST) 4 guidance, as well as early complications. RESULTS: Of the 11 domains, 100 % compliance was achieved in 6 components, across both groups where applicable. During pre-COVID times, the timing to initial debridement was within 12 h for High energy trauma in 16/28 (57.1 %), dropping to 7/22 (31.8 %) during COVID, (p = 0.004). Definitive soft tissue closure within 72 h If not achievable at initial debridement dropped from 9/10 (90.0%) to 4/6 (66.7 %), (p = 0.006). There was no significant difference in early complication rates. CONCLUSION: Coronavirus has changed the landscape of healthcare worldwide and impacted open fracture care by increasing time to theatre. This had no effect on early complication rate but longer term effects remain to be seen.

Open tibial fractures: An overview.

Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. The close proximity of the tibia to the skin makes it prone to extensive soft tissue damage and subsequent detrimental complications, such as infection and non-union. Thus, they were historically associated with high rates of amputation, sepsis, or even death. The advancement of surgical instruments and techniques, along the emergence of evidence-based guidance, have resulted in a significant reduction in complications. Peculiarly though, modern management strategies have a strong foundation in practices described in the ancient times. Nevertheless, post-operative complications are still a challenge in the management of open tibial fractures. Efforts are actively being made to refine the surgical approaches used, while noteworthy is the emergence of the Orthoplastic approach. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.

The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis.

INTRODUCTION: Open tibial fractures are complex injuries with variable outcomes that significantly impact patients' lives. Surgical debridement is paramount in preventing detrimental complications such as infection and non-union; however, the exact timing of debridement remains a topic of great controversy. The aim of this study is to evaluate the association between timing of surgical debridement and outcomes such as infection and non-union in open tibial fractures. MATERIALS AND METHODS: We performed a systematic review and meta-analysis of the literature to capture studies evaluating the association between timing of initial surgical debridement and infection or non-union, or other reported outcomes. We searched the MEDLINE, PubMed Central, EMBASE, SCOPUS, Cochrane Central and Web of Science electronic databases. Our methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane handbook for systematic reviews of interventions. RESULTS: The systematic review included 20 studies with 10,032 open tibial fractures. The overall infection rate was 14.3% (314 out of 2193) and the overall non-union rate 14.2% (116 out of 817). We did not find any statistically significant association between delayed debridement and infection rate (OR = 0.87; 95% CI, 0.68 to 1.11; p = 0.23) or non-union rate (OR = 0.70; 95% CI, 0.42 to 1.15; p = 0.13). These findings did not change when we accounted for the effect of different time thresholds used for defining early and late debridement, nor with the Gustilo-Anderson classification or varying study characteristics. CONCLUSION: The findings of this meta-analysis support that delayed surgical debridement does not increase the infection or non-union rates in open tibial fracture injuries. Consequently, we propose that a reasonable delay in the initial debridement is acceptable to ensure that optimal management conditions are in place, such that the availability of surgical expertise, skilled staff and equipment are prioritised over getting to surgery rapidly. We recommend changing the standard guidance around timing for performing surgical debridement to 'as soon as reasonably possible, once appropriate personnel and equipment are available; ideally within 24-h'.

Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre.

AIMS: Ongoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation in ankle fractures in the setting of a major trauma centre. Our hypothesis is that posterior malleolus fixation leads to improved clinical outcomes. METHODS: A total of 320 patients were identified with operatively treated ankle fractures involving a posterior malleolus component, at our institution between January 2012 and January 2018, ensuring a minimum 2 year follow-up. Of these patients, 160 had the posterior malleolus fixed as part of their surgery and 160 did not. Patient demographics, surgical details and complications were assessed. The Manchester-Oxford Foot Questionnaire (MOXFQ) was the primary patient outcome measure. RESULTS: Fixation of the posterior malleolus was associated with a statistically significant improvement in patient outcomes. Mean MOXFQ score in the unfixed posterior malleolus group was 24.03 (0 - 62), compared to 20.10 (0 - 67) in the fixed posterior malleolus group (p = 0.04). Outcomes were worse with increasing size of posterior malleolar fragment. Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%)) and re-operation rate was double. CONCLUSION: This study demonstrates that in the practical setting of a major trauma unit, fixation of the posterior malleolar fracture leads to improved patient outcomes but with increased metalwork risks and reoperation rates.

A Novel Treatment of a 65-Year-Old Woman with a Neglected Type IIIB Open Fracture of the Tibia with Inadequate Soft Tissue Coverage and Periosteal Stripping Requiring an Ilizarov Approach to Bone and Soft Tissue Lengthening and Reconstruction: A Case Report and Review of the Literature.

BACKGROUND Type IIIB open bone fractures include loss of soft tissue with periosteal stripping and need rapid surgical repair. The Ilizarov method of bone lengthening and reconstruction offers limb salvage as an alternative to amputation. CASE REPORT We report a case of a neglected type IIIB open fracture of the tibia with inadequate soft tissue coverage and periosteal stripping requiring an Ilizarov approach for limb salvage in a 65-year-old woman. Surgical debridement resulted in a large bone deficit of 13 cm. Acute shortening facilitated wound closure, and the remaining skin defect was treated with skin grafting. Bone transport and limb lengthening techniques, in addition to skin expansion and support, were used to restore the length of the tibia. The regenerated bone had to be fused with the talus since the tibial plafond was excised during debridement. The external fixator was removed after 643 days of treatment. An external fixation index of 49.6 d/cm was estimated. Excellent bone and good functional results were obtained according to the criteria of the Association for the Study and Application of the Method of Ilizarov. Skin invagination, bone translocation, and pin tract infection were the major postoperative issues. CONCLUSIONS This case showed that a multidisciplinary approach may be required for the successful management of neglected open fractures of the tibia and that the Ilizarov approach to both bone and soft tissue lengthening and reconstruction should be considered to ensure limb salvage and improve the final cosmetic appearance.

Recycling of flap pedicle in complex lower extremity reconstruction: A proof of free muscle flap neovascularization.

This article portrays the authors' clinical experience of a complex case of lower extremity reconstruction using a recycled pedicle from 10 years old free latissimus dorsi musculocutaneous flap to supply a new free anterolateral thigh flap for proximal tibia wound defect reconstruction. It provides clinical evidence that muscle neovascularization occurs and supports the dogma peripheral tissue neovascularization. This case stipulates that recycling of pedicle is feasible, when used with appropriate strategy and safety and also provides evidence for the long-term survival of greater saphenous vein grafts in lower extremity reconstruction.

What Is the Best Method to Differentiate Acute Charcot Foot From Acute Infection?

RECOMMENDATION: Differentiation between acute Charcot neuroarthropathy (CN) and acute infection/osteomyelitis is complex and requires multiple (>1) diagnostic criteria. These criteria include an emphasis on the presence of neuropathy, history, and physical examination. The absence of skin wounds and resolution of swelling/erythema with elevation makes the likelihood of infection very low. In unclear cases, laboratory testing, histologic examination and culturing of bone specimens, scintigraphy, and imaging, especially magnetic resonance imaging (MRI), may be of benefit. LEVEL OF EVIDENCE: Moderate. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Does Revascularization Prior to Foot and Ankle Surgery Reduce the Incidence of Surgical Site Infection (SSI)?

RECOMMENDATION: Several studies support the effect of peripheral vascular disease (PVD) on wound healing and surgical site infection (SSI). Despite this, there have been no specific studies proving the beneficial effect of revascularization on SSI prior to operative intervention in the setting of traumatic or elective foot and ankle surgery. The majority of studies on revascularization are in the setting of diabetic foot infection or established ischemia. We recommend that in the presence of an inadequate vascularization in the foot and ankle, vascular optimization should be undertaken prior to elective surgery. LEVEL OF EVIDENCE: Limited. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Should Treatment of Diabetic Foot Osteomyelitis Be Based on Bone Biopsies?

RECOMMENDATION: Yes. Bone biopsies play both a crucial diagnostic and interventional role in the management of diabetic foot infection. Although bone biopsies are not required in every case of diabetic foot infection, their most important role is in guiding accurate antibiotic treatment, as they provide more accurate microbiological information than superficial soft tissue samples in patients with diabetic foot osteomyelitis. LEVEL OF EVIDENCE: Moderate. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Treating the Many Using a Few: A Novel Approach for the Application of External Fixators in Mass Casualties.

AIM: The aim of this is to allow the use of unsterile kit (clamps and rods) in situations where the demand for external limb fixators exceeds the available sterile equipment. BACKGROUND: In view of the recent rise in violence and terrorist activity, we have to be prepared for situations causing major incidences. These can place a large strain on our operating theaters and the available surgical kit due to the potential number of casualties. MATERIALS AND METHODS: We propose a sterile dressing technique during the application of an external limb fixator that provides an adequate seal around the pin sites and allows the use of simply decontaminated external fixator parts. CONCLUSION: This technique prevents the intraoperative contamination of the clamps and connecting rods, which allow for a sterile barrier to minimize pin site infections. HOW TO CITE THIS ARTICLE: Vris A, Al-Obaedi O, Vaghela KR, et al. Treating the Many Using a Few: A Novel Approach for the Application of External Fixators in Mass Casualties. Strategies Trauma Limb Reconstr 2019;14(2):92-93.

All Internal Bone Transport: Use of a Lengthening Nail and Double Plating for Management of Femoral Bone Loss.

BACKGROUND: Variety of techniques for management of segmental femoral bone loss have been described, each with different advantages and challenges during treatment. The development of motorized lengthening nails has provided a potential for all internal bone transport, avoiding some of the difficulties with external fixation in the femur. At present, there is limited published literature on experiences in this technique. AIM: The development of this technique aimed to overcome the difficulties previously reported for internal bone transport in the femur, particularly varus deformity and joint stiffness. TECHNIQUE: We describe the technique of double plating with bone transport utilizing a magnetic lengthening nail to manage segmental femoral bone loss. The benefits of the technique are discussed, along with specific challenges and lessons that have been learned through experience of internal bone transport. CONCLUSION: Use of a magnetic lengthening nail and double plating as a method of all internal bone transport provides an option for the management of massive femoral bone loss, while avoiding some of the challenges that have been reported with the existing techniques. CLINICAL SIGNIFICANCE: This technique provides an additional method in the armamentarium of the trauma or limb reconstruction surgeon treating massive femoral bone loss. HOW TO CITE THIS ARTICLE: Wright J, Bates P, Heidari N, et al. All Internal Bone Transport: Use of a Lengthening Nail and Double Plating for Management of Femoral Bone Loss. Strategies Trauma Limb Reconstr 2019;14(2):94-101.