Objectives: To evaluate the current standard of care regarding empirical antimicrobial therapy in fracture-related infections (FRIs).
Methods:
Design: Retrospective cohort study.
Setting: Level I Trauma Center.
Patient selection criteria: Adult patients treated for FRI with surgical debridement and empirical antibiotics between September 1, 2014, and August 31, 2022. Patients were excluded if less than 5 tissue samples for culture were taken, culture results were negative, or there was an antibiotic-free window of less than 3 days before debridement.
Outcome measures and comparisons: FRI microbial etiology, antimicrobial resistance patterns (standardized antimicrobial panels were tested for each pathogen), the mismatch rate between empirical antimicrobial therapy and antibiotic resistance of causative microorganism(s), and mismatching risk factors.
Results: In total, 75 patients were included [79% (59/75) men, mean age 51 years]. The most prevalent microorganisms were Staphylococcus aureus (52%, 39/75) and Staphylococcus epidermidis (41%, 31/75). The most frequently used empirical antibiotic was clindamycin (59%, 44/75), followed by combinations of gram-positive and gram-negative covering antibiotics (15%, 11/75). The overall mismatch rate was 51% (38/75) [95% confidence interval (CI), 0.39-0.62] and did not differ between extremities [upper: 31% (4/13) (95% CI, 0.09-0.61), lower: 55% (33/60) (95% CI, 0.42-0.68, P = 0.11)]. Mismatching empirical therapy occurred mostly in infections caused by S. epidermidis and gram-negative bacteria. Combination therapy of vancomycin with ceftazidime produced the lowest theoretical mismatch rate (8%, 6/71). Polymicrobial infections were an independent risk factor for mismatching (OR: 8.38, 95% CI, 2.53-27.75, P < 0.001).
Conclusions: In patients with FRI, a mismatching of empirical antibiotic therapy occurred in half of patients, mainly due to lack of coverage for S. epidermidis , gram-negative bacteria, and polymicrobial infections. Empirical therapy with vancomycin and ceftazidime produced the lowest theoretical mismatch rates. This study showed the need for the consideration of gram-negative coverage in addition to standard broad gram-positive coverage. Future studies should investigate the effect of the proposed empirical therapy on long-term outcomes.
Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Objectives: To identify risk factors of reoperation to promote union or to address deep surgical-site infection (DSSI) in periprosthetic distal femur fractures treated with lateral distal femoral locking plates (LDFLPs).
Methods:
Design: Multicenter retrospective cohort study.
Setting: Ten level-I trauma centers.
Patient selection criteria: Patients with Orthopaedic Trauma Association/Association of Osteosynthesis (OTA/AO) 33A or 33C periprosthetic distal femur fractures who underwent surgical fixation between January 2012 and December 2019 exclusively using LDFLPs were eligible for inclusion. Patients with pathologic fractures or with follow-up less than 3 months without an outcome event (unplanned reoperation to promote union or for deep surgical infection) before this time point were excluded. Fracture fixation constructs used medial plates, intramedullary nails, or hybrid fixation constructs were excluded from analysis.
Outcome measures and comparisons: To examine the influence of patient demographics, injury characteristics, and features of the fracture fixation construct on the occurrence of unplanned reoperation to promote union or to address a DSSI.
Results: There was an 8.3% rate (19/228) of unplanned reoperation to promote union. Predictive factors for the need for reoperation to promote union included increasing body mass index (odds ratio [OR] = 1.09; 95% confidence interval [CI]: 1.02-1.16; P = 0.01), increasing number of screws in the distal fracture segment (OR = 1.73; 95% CI: 1.06-2.95; P = 0.03), and decreasing proportion of proximal segment screws that are locking (OR = 0.17; 95% CI: 0.03-0.70; P = 0.02) There was a 4.8% rate (11/228) of reoperation to address DSSI. There were no statistically significant predictive factors identified as risk factors of the need for reoperation to address DSSI ( P > 0.05).
Conclusions: 8.3% of periprosthetic distal femur fractures treated at 10 centers with LDFLPs underwent unplanned reoperation to promote union. Increasing patient body mass index and increasing number of screws in the distal fracture segment were found to be predictive factors, whereas increased locking screws in the proximal segment were found to be protective. 4.8% of patients in this cohort underwent reoperation to address DSSI.
Level of evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.
Objectives: Postoperative delirium is an acute neurocognitive complication that can have adverse effects on outcomes of geriatric patients after undergoing hip fracture surgery. The objective of this study was to examine the efficacy of preoperative steroids in preventing postoperative delirium after hip fracture surgery.
Methods:
Data sources: A systematic review and meta-analysis was performed using PubMed, SPORTDiscus, CINAHL, MEDLINE, and Web of Science from database inception until September 28, 2023.
Study selection: Inclusion criteria were randomized controlled trials of patients who underwent surgical intervention for hip fracture, were examined for postoperative delirium, and used preoperative steroids.
Data extraction: Data included the risk of postoperative delirium, postoperative all-cause infection, and postoperative hyperglycemia. Articles were graded via the Cochrane Collaboration's tool.
Data synthesis: Statistical analysis included a random-effects binary model with relative risk, 95% confidence intervals along with a defined "number needed to treat" threshold (number needed to treat).
Results: Four randomized controlled trials were included from 128 articles initially retrieved. Patients (n = 416; average age: 82.2 ± 2.2 years) underwent surgical intervention for hip fracture after receiving either preoperative steroids (n = 209) or control interventions (n = 207). There was a statistically significant decrease in the incidence of postoperative delirium among patients who received preoperative steroids (12.9%; 27 cases) as compared with patients who received control interventions (26.7%; 55 cases) after hip fracture surgery ( P < 0.001; RR: 0.84). The absolute risk difference was 13.8%, and the number needed to treat was 7.2 patients. There was no statistically significant difference in the risk of postoperative all-cause infection among patients who received preoperative steroids as compared with patients who received normal saline as placebo after hip fracture surgery ( P = 0.850; RR: 0.96).
Conclusions: The utilization of preoperative steroids seems to decrease the risk of postoperative delirium after hip fracture surgery in elderly adults. Furthermore, this decreased risk of postoperative delirium was not associated with a significant increase in postoperative infection, indicating possible safety of preoperative steroid administration.
Level of evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Objectives: To assess the relationship between patient smoking status and fracture-related infection (FRI) characteristics including patient symptoms at FRI presentation, bacterial species of FRI, and rates of fracture union.
Methods:
Design: Retrospective cohort study.
Setting: Urban level 1 trauma center.
Patient selection criteria: All patients undergoing reoperation for FRI from January 2013 to April 2021 were identified through manual review of an institutional database.
Outcome measures and comparisons: Data including patient demographics, fracture characteristics, infection presentation, and hospital course were collected through review of the electronic medical record. Patients were grouped based on current smoker versus nonsmoker status. Hospital course and postoperative outcomes of these groups were then compared. Risk factors of methicillin-resistant Staphylococcus aureus (MRSA) infection, Staphylococcus epidermidis infection, and sinus tract development were evaluated using multivariable logistic regression.
Results: A total of 301 patients, comprising 155 smokers (51%) and 146 nonsmokers (49%), undergoing FRI reoperation were included. Compared with nonsmokers, smokers were more likely male (69% vs. 56%, P = 0.024), were younger at the time of FRI reoperation (41.7 vs. 49.5 years, P < 0.001), and had lower mean body mass index (27.2 vs. 32.0, P < 0.001). Smokers also had lower prevalence of diabetes mellitus (13% vs. 25%, P = 0.008) and had higher Charlson Comorbidity Index 10-year estimated survival (93% vs. 81%, P < 0.001). Smokers had a lower proportion of S. epidermidis infections (11% vs. 20%, P = 0.037), higher risk of nonunion after index fracture surgery (74% vs. 61%, P = 0.018), and higher risk of sinus tracts at FRI presentation (38% vs. 23%, P = 0.004). On multivariable analysis, smoking was not found to be associated with increased odds of MRSA infection.
Conclusions: Among patients who develop a FRI, smokers seemed to have better baseline health regarding age, body mass index, diabetes mellitus, and Charlson Comorbidity Index 10-year estimated survival compared with nonsmokers. Smoking status was not significantly associated with odds of MRSA infection. However, smoking status was associated with increased risk of sinus tract development and nonunion and lower rates of S. epidermidis infection at the time of FRI reoperation.
Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Objectives: To evaluate patients with tarsometatarsal fractures and dislocations and describe complications and secondary operations.
Methods:
Design: Retrospective cohort study.
Setting: Level 1 trauma center.
Patient selection criteria: Consecutive adults treated acutely for Lisfranc injuries with reduction and fixation using standard techniques of rigid medial fixation and flexible lateral fixation.
Outcome measures and comparisons: Complications include infections, wound healing problems, nonunion, malunion, and posttraumatic arthrosis (PTA), and secondary unplanned procedures after a minimum of 2-year radiographic follow-up.
Results: Mean age of the included 118 patients was 40 years (range, 18-73 years) and 96 (74%) were male. Comorbidities included obesity (n = 32; 40%), diabetes mellitus (n = 12; 9%), and tobacco use (n = 67; 52%). Thirty (23%) were open injuries, and concomitant forefoot injuries were present in 47% and hindfoot injuries in 12%. Unplanned secondary procedures, including implant removals, were performed on 39 patients (33%), most often for removal of painful implants (26%) or infectious debridement (9%). Sixty-seven complications occurred, with PTA most frequent (37%). Deep infections occurred in 8%. On multivariate analysis, open injury ( P = 0.028, CI = 1.22-30.63, OR = 6.12) and concomitant forefoot injury ( P = 0.03, CI = 1.12-9.76, OR = 3.31) were independent risk factors for complication.
Conclusions: Open Lisfranc injuries were associated with complications, with deep infections occurring in 9%. Secondary procedures were most often performed for pain relief; the most common late complication was PTA, warranting counseling of patients about potential long-term sequelae of injury.
Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Objectives: To identify and compare characteristics of patients with hip fracture treated nonoperatively versus those treated operatively.
Methods:
Design: Retrospective cohort study.
Setting: Hip fracture population-based study.
Patient selection criteria: All adult patients with hip fractures (OTA/AO 31A and 31B) were included. Patients with pathological or periprosthetic hip fractures were excluded.
Outcome measures and comparisons: Patients were categorized according to the type of management (operative vs. nonoperative) and type of fracture (nondisplaced vs. other). Patient and fracture characteristics associated with nonoperative management (NOM) were analyzed.
Results: A total of 94,930 patients with hip fracture were included. Of these, 3.2% were treated nonoperatively. Patients receiving NOM were older [86 years (interquartile range, 79-91 years) vs. 81 years (interquartile range, 72-87 years); P < 0.001], more frequently institutionalized (42.4% vs. 17.6%), and were more dependent in activities of daily living (22.2% vs. 55.0%). Various clinical characteristics, including dementia [odds ratio (OR) 1.31 (95% confidence interval, CI, 1.18-1.45) P < 0.001], no functional mobility [OR 4.39 (95% CI, 3.14-3.68) P < 0.001], and activities of daily living (ADL) measured as KATZ-6-ADL [OR 1.17 (95% CI, 1.14-1.20) P < 0.001] were independently associated with NOM. Seven-day mortality was 37.6%, and 30-day mortality was 57.1% in patients treated nonoperatively.
Conclusions: The first step in understanding patients who potentially benefit from NOM is evaluating the current standard of care. This study provides insight into the current hip fracture population treated nonoperatively. These patients are older, have higher percentage of dementia, more dependent, and show higher short-term mortality rates.
Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Objectives: To assess if a suprapatellar (SP) approach, when compared with an infrapatellar (IP) approach, yielded less patient-reported anterior knee pain and higher patellofemoral joint function at 6 weeks and 12 months postoperatively, when treating tibial fractures with intramedullary nailing.
Methods:
Design: Prospective, parallel-group randomized control trial.
Setting: Tertiary level 1 trauma care center, Brisbane, Australia.
Patients selection criteria: Skeletally mature patients with an acute diaphyseal tibial fracture (AO/OTA 41A2/3, 42 A1-43A3) amenable to an intramedullary nailing were included. Exclusion criteria were periprosthetic fractures, nonunions, and presence of a contralateral injury that would restrict weight-bearing.
Outcome measures and comparisons: Anterior knee pain through the visual analog scale (VAS) and patellofemoral function using the Kujala scale at 6 weeks and 12 months were compared between those treated with a SP and IP approach.
Results: Ninety-five tibia fractures were included in the randomized trial, with complete follow-up data for 44 and 46 tibia fractures in the SP and IP groups, respectively. The SP cohort exhibited better patellofemoral knee function at both 6 weeks (Kajula 53.0 for SP vs. 43.2 for IP, P < 0.01) and 12 months (Kujala 92.0 for SP vs. 81.3 for IP, P < 0.01) postoperatively and a reduction in anterior knee pain at 12 months postoperatively (VAS 0.7 SP vs. 2.9 IP, P < 0.01).
Conclusions: This randomized trial demonstrated clinically meaningful differences in patellofemoral function, for a SP versus IP approach, with a greater than 10 point discrepancy in Kujala score at both 6 weeks and 12 months. In addition, there was a clinically important difference in VAS knee pain scores for patients at 12 months, but not at 6 weeks, postoperatively. These results contribute to the growing body of evidence demonstrating the functional and clinical benefits of the SP approach.
Level of evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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