Quadrant通道下微创经椎间孔腰椎椎间融合术后手术部位感染的危险因素分析

目的 :探讨Quadrant通道下微创经椎间孔腰椎椎间融合术(minimally invasive transforaminal lumbar interbody fusion,MIS-TLIF)术后手术部位感染(surgical site infection,SSI)的危险因素。方法 :收集2015年1月～2018年12月在重庆市梁平区人民医院行Quadrant通道下MIS-TLIF治疗的患者资料,将术后发生SSI的患者纳入SSI组,于同期未发生SSI患者中按照1∶4比例随机抽取对照患者纳入无感染组。对文献报道常见的脊柱术后感染高危因素进行资料收集,包括两组患者的一般资料:年龄、性别、体重指数(BMI)、吸烟史、合并糖尿病和高血压病情况、腰椎疾病类型,术前血清学指标:糖化血红蛋白、血清白蛋白、血清球蛋白、红细胞、白细胞、血小板、血钾、血钙,手术相关指标:手术时间、术中出血量、手术节段、融合节段数。对上述资料进行组间单因素分析,筛选出具有统计学差异的指标纳入二分类Logistic回归,分析与SSI相关的危险因素,并选取OR值最高的因素进行受试者工作特征曲线(receiver operating characteristic curve,ROC)分析。结果:共纳入679例患者,其中25例发生SSI,发生率为3.68%(25/679),纳入SSI组。随机抽取同期100例未发生SSI的患者纳入无感染组。单因素分析结果显示两组患者年龄、BMI、吸烟史、合并糖尿病、糖化血红蛋白、血清白蛋白、手术时间、术中出血量、融合节段数有统计学差异(P0.05),而性别比、合并高血压病、腰椎疾病类型、血清球蛋白、红细胞、白细胞、血小板、血钾、血钙、手术节段无统计学差异(P0.05)。Logistic回归分析结果表明年龄(OR=1.077,95%CI 1.003～1.156,P=0.042)、BMI (OR=1.251,95%CI 1.004～1.559,P=0.046)、糖化血红蛋白(OR=2.368,95%CI 1.457～3.801,P0.001)、血清白蛋白(OR=0.877,95%CI 0.773～0.977,P=0.044)、手术时间(OR=1.026,95%CI 1.003～1.050,P=0.029)是MIS-TLIF术后SSI的相关危险因素,ROC曲线显示糖化血红蛋白的临界值为7.60%。结论:高龄、肥胖以及术前高糖化血红蛋白、低血清白蛋白、手术时间长会增加MIS-TLIF术后SSI发生的风险。     

腰椎骨折行椎弓根钉内固定术后并发手术部位感染的相关因素分析

目的探讨腰椎骨折行椎弓根钉内固定术后并发手术部位感染的情况,并进行相关因素分析。方法纳入2014年2月～2018年2月于本院行椎弓根钉内固定术治疗的256例腰椎骨折患者,调查其术后手术部位感染情况,将手术部位感染患者设为感染组,其余设为非感染组。调查两组患者性别、年龄等一般资料以及骨折节段、手术入路等手术资料,探讨术后并发手术部位感染的独立危险因素。结果 256例术后发生手术部位感染24例,感染率9. 38%;单因素分析显示,感染组与非感染组手术时间、吸烟史、住院时间、合并糖尿病、手术入路、术后引流时间、骨折至手术时间、手术出血量差异有统计学意义(P0. 05);多因素Logistic回归分析显示:手术时间(OR=2. 043)、吸烟史(OR=2. 221)、住院时间(OR=2. 543)、合并糖尿病(OR=2. 549)、手术入路(OR=3. 212)是术后并发手术部位感染的独立危险因素。结论腰椎骨折行椎弓根钉内固定术后手术部位感染率较高,手术时间、吸烟史、住院时间、合并糖尿病、手术入路可增加感染发生风险。     

胸腰椎骨折手术患者术后肺部感染率情况及多因素Logistic回归分析

目的探讨胸腰段骨折手术患者术后肺部感染情况,并进行相关因素的多因素Logistic回归分析。方法纳入2011年12月~2017年12月于本院治疗的584例胸腰椎骨折患者,均采用后路手术治疗,记录术后发生肺部感染人数,设为感染组,其余设为非感染组。调查两组性别、年龄、骨折情况等病历资料,经单因素及多因素Logistic回归分析探讨患者术后肺部感染的独立危险因素。结果 584例患者术后发生肺部感染40例,感染率6.85%。单因素分析显示,两组住院时间、吸烟史、合并慢性肺部疾病、卧床时间、麻醉方式、出血量、合并糖尿病、手术节段、手术时间、手术路径、合并脊髓神经损伤等差异均有统计学意义(P0.05);多因素Logistic回归分析显示,住院时间14 d(OR=3.133)、卧床时间7 d(OR=2.856)、合并慢性肺部疾病(OR=2.456)、吸烟史(OR=2.012)、全身麻醉(OR=2.656)是患者术后肺部感染率的独立危险因素。结论胸腰椎骨折手术患者术后肺部感染与住院时间14 d、卧床时间7 d、合并慢性肺部疾病、吸烟史、全身麻醉等多种因素有关,临床应制定相应措施以降低肺部感染率。     

不稳定踝关节骨折术后两种功能恢复方法的前瞻性评价

目的 探讨术后早期锻炼、负重与石膏固定6周两种方法 对不稳定踝关节骨折术后功能恢复是否存在差异.方法 采用前瞻性研究方法 ,选用2003年10月至2007年10月手术治疗的踝关节骨折患者为研究对象,入院后根椐床位单双号分为两组:早期活动组和石膏固定组,按照纳入标准两组均选择50例患者.入选的所有患者均根椐AO内固定原则对踝关节骨折采用切开复位内固定.术后根椐不同的分组进行相应的功能锻炼.并对患者进行随访,包括Olerud及Tegner评分、骨折后恢复日常生活及工作时间、完全负重时间、有无关节疼痛、骨折愈合时间等. 结果 早期活动组46例患者获平均20.3个月(14～27个月)随访.石膏固定组45例患者获平均21.4个月(13～27个月)随访.Olerud评分均达到"好",早期活动组评分平均为(87±21)分,略高于石膏固定组[(79±19)分],但差异无统计学意义(P=0.25).早期活动组和石膏固定组术后12个月Tegner评分分别为(8.4±2.3)、(8.1±2.4)分,差异无统计学意义(P=0.15).早期活动组完全负重时间平均为(7.7±1.8)周,而石膏固定组为(11.5±3.1)周,差异有统计学意义(P=0.01).早期活动组骨折均获得临床愈合,石膏固定组中有1例出现假关节.所有获得随访的患者均恢复日常生活及回到骨折前的工作岗位,早期活动组花费时间为(9.2±1.9)周,比石膏固定组[(10.4±1.7)周1提前约1周(P=0.47). 结论 术后达到坚强内固定且有较好依从性的不稳定踝关节骨折患者,可以采用早期活动及负重等功能锻炼来促进踝关节功能的康复.     

颈椎后路术后手术部位感染的术中危险因素分析

目的 :探讨颈椎后路术后手术部位感染(surgical site infection,SSI)的术中危险因素。方法:回顾性分析2007年1月~2016年12月在北京大学第三医院骨科颈椎组住院接受颈椎后路手术的患者,患者主要诊断包括脊髓型颈椎病、颈椎外伤、颈椎后纵韧带骨化症等。筛选出术后发生SSI的病例(SSI组)。再从未感染的患者中按1∶4的比例随机抽取对应数量的患者作为对照(非感染组)。收集两组患者的性别、年龄、术前改良JOA(m JOA)评分、术前诊断、手术方式、内科合并症情况、体质量指数(BMI)、吸烟史、术中出血量、术中放置引流管数量、术中回输血量、手术节段以及手术时间等指标进行单因素分析,根据单因素分析结果进行二因素Logistic回归分析,分析与SSI相关的术中危险因素,并进一步使用受试者工作曲线分析确定危险因素的临界值。结果:10年间共有3720例患者在我院骨科颈椎组接受颈椎后路手术,手术方式主要包括颈后路单开门椎管扩大成形术、颈后路单开门椎管扩大成形+侧块螺钉固定术、颈后路椎管后壁切除+侧块螺钉固定术。其中13例患者发生SSI,发生率为0.35%(13/3720),女3例,男10例,年龄为58.38±2.52岁。从未发生SSI的患者中随机抽取52例患者作为对照组(非感染组)。两组患者年龄、性别比、术前m JOA评分、术前诊断、手术方式、内科合并症情况、BMI、术中输血量等均无统计学差异(P0.05),吸烟、术中出血量、术中放置引流管数量、手术节段以及手术时间有统计学差异(P0.05)。将有统计学差异的五个因素纳入二因素Logistic回归分析,结果显示术中出血量和手术时间为颈椎后路术后SSI的独立术中危险因素;其临界值分别为180ml及84.5min。结论:术中出血量多、手术时间长,术后发生SSI的风险高。     

后路腰椎内固定术后手术部位感染的危险因素分析

目的:探讨后路腰椎内固定术后手术部位感染的危险因素,为降低手术部位感染的发生率提供参考依据。方法:回顾我科2016年1月1日～2018年12月31日实施后路腰椎内固定手术的1073例患者,男516例,女557例,年龄18～84岁(54.67±13.23岁),将术后手术部位感染的患者纳入感染组,其余患者纳入非感染组。收集两组患者的性别、年龄、诊断、体重指数(BMI)、合并糖尿病和高血压情况、手术时间、术中出血量、是否输血、吸烟史、术前美国麻醉医师协会(ASA)分级、术前使用激素情况、内固定节段数、是否固定至慨骨或骨盆、是否为翻修手术、手术开始时段等资料,进行单因素分析,对阳性结果进行多因素Logistic回归分析。结果:1073例患者中发生手术部位感染19例,感染发生率为1.77%,其中男11例,女8例,年龄18～77岁(54.89±16.67岁)。单因素分析显示两组肥胖(BMI≥28kg/m~2)、合并糖尿病、手术时间、手术开始时段等因素存在统计学差异(P0.05);性别、年龄、疾病种类、合并高血压、出血量、是否输血、吸烟史、术前ASA分级、术前使用激素、内固定节段数、是否固定至慨骨或骨盆、是否为翻修手术等因素无统计学差异(P0.05)。多因素Logistic回归结果显示肥胖(OR=6.704,P=0.005)、合并糖尿病(OR=4.071,P=0.008)、较长手术时间(OR=7.102,P=0.000)、手术开始时段为晚间(OR=3.981,P=0.018)是术后手术部位感染的独立危险因素。结论:肥胖、合并糖尿病、较长手术时间、手术开始时段为晚间的患者后路腰椎内固定术后发生手术部位感染的风险较高,应采取有针对性的预防措施,以期最大限度降低术后手术部位感染的发生。     

Pilon骨折术后发生手术部位感染的危险因素分析

目的探讨Pilon骨折术后发生手术部位感染的相关危险因素。 方法回顾性分析2015年1月至2020年6月行因Pilon骨折在扬州市江都人民医院行手术治疗的309例患者的临床资料，排除入院前有感染病史的患者，根据术后是否发生手术部位感染分为两组。比较两组患者之间性别、年龄、身体质量指数(BMI)、吸烟史、高血压、糖尿病病史、骨折类型、有无张力性水泡、是否合并关节脱位、骨折分型、受伤至手术时间、术后引流量、手术时间、手术入路、美国麻醉医师协会麻醉分级(ASA)、内固定钢板数量、是否临时使用外固定支架等相关因素对手术部位可能发生感染的影响。统计学分析包括独立样本t检验、卡方检验或Fisher精确检验，将有统计学意义的单因素为自变量行多因素logistic回归分析。 结果本研究共纳入研究对象309例，其中术后发生手术部位感染25例，感染发生率为8.1%(25/309)，22例患者切口分泌物培养阳性结果，阳性率为88%，最常见病原体是金黄色葡萄球菌(7/22, 31.8%)，大肠埃希菌(6/22, 27.3%)和表皮葡萄球菌(4/22, 18.2%)。单因素分析显示两组患者手术时间、高血压、国际内固定学会骨折分类系统(AO)分型、开放性骨折、吸烟史的差异有统计学意义(t＝2.629，χ²＝7.646、12.184、6.438、14.268，均为P<0.05)。而多因素logistic回归分析显示开放性骨折、吸烟为Pilon骨折术后感染的独立危险因素[比值比(OR)＝3.770、11.129，均为P<0.05]。 结论开放性骨折、吸烟是Pilon骨折切开复位内固定术后手术部位感染的独立危险因素。     

异体红细胞输注与胸腰椎骨折内固定术后感染的关系研究

目的 调查异体红细胞输注与胸腰椎骨折内固定术后感染的关系.方法 选择2017年1月～2021年6月本院收治的560例胸腰椎骨折患者,均采用以椎弓根螺钉内固定手术治疗,比较是否输注异体红细胞患者的术后手术部位感染(surgery site infection,SSI)情况,并调查年龄、合并疾病等病历资料,采用单因素及多因素Logistic回归分析调查术后SSI的危险因素.结果 异体红细胞输注组的SSI发生率显著高于未输注组(P<0.05);不同年龄、引流时间、骨折椎体数量、术前白蛋白(albumin,ALB)、手术时间、出血量的患者SSI发生率差异有统计学意义(P<0.05);Logistic回归分析显示,异体红细胞输注、术前ALB<35 g/L、合并糖尿病、引流时间>3 d,均是胸腰椎骨折内固定术后SSI的危险因素.结论 异体红细胞输注会增加胸腰椎骨折内固定术后SSI的发生风险,应严格把握异体红细胞输注的适应证,并结合相关危险因素,采取针对性措施降低SSI的发生率.     

异体红细胞输注与胸腰椎骨折内固定术后感染的关系研究

目的 调查异体红细胞输注与胸腰椎骨折内固定术后感染的关系.方法 选择2017年1月～2021年6月本院收治的560例胸腰椎骨折患者,均采用以椎弓根螺钉内固定手术治疗,比较是否输注异体红细胞患者的术后手术部位感染(surgery site infection,SSI)情况,并调查年龄、合并疾病等病历资料,采用单因素及多因素Logistic回归分析调查术后SSI的危险因素.结果 异体红细胞输注组的SSI发生率显著高于未输注组(P<0.05);不同年龄、引流时间、骨折椎体数量、术前白蛋白(albumin,ALB)、手术时间、出血量的患者SSI发生率差异有统计学意义(P<0.05);Logistic回归分析显示,异体红细胞输注、术前ALB<35 g/L、合并糖尿病、引流时间>3 d,均是胸腰椎骨折内固定术后SSI的危险因素.结论 异体红细胞输注会增加胸腰椎骨折内固定术后SSI的发生风险,应严格把握异体红细胞输注的适应证,并结合相关危险因素,采取针对性措施降低SSI的发生率.     

下肢骨折外固定器固定术后发生针孔感染的危险因素分析

目的 :探讨下肢骨折外固定器固定术后发生针孔感染的危险因素。方法 :回顾性分析2009年5月至2014年5月,在我院行外固定器固定术的272例下肢骨折患者的临床资料,按照术后针孔感染的发生情况,分为两组。感染组29例,男23例,女6例;年龄25~77岁,平均(53.41±12.77)岁。对照组243例,男217例,女26例;年龄27~78岁,平均(48.71±11.87)岁。将年龄、性别、外固定器固定时间、下肢骨折严重程度、糖尿病、卧床时间、吸烟、其他部位手术情况和其他部位感染情况作为危险因素纳入研究。结果:两组的年龄(χ2=15.708,P0.001),外固定器固定时间(χ2=11.940,P0.001),下肢损伤严重程度(χ2=15.438,P0.001),糖尿病(χ2=8.519,P=0.004)以及卧床时间(χ2=7.165,P=0.007)比较差异有统计学意义。多因素Logistic回归分析提示:年龄(OR=8.327,P0.001),外固定器固定时间(OR=6.795,P0.001),糖尿病(OR=4.965,P=0.001)和卧床时间(OR=4.864,P=0.008)是下肢骨折外固定器固定术后的危险因素。结论:高龄患者、外固定时间长、患有糖尿病以及长时间卧床使下肢骨折外固定器固定术后发生针孔感染的风险增加。     

2种内固定方法治疗98例踝关节骨折的疗效比较

目的比较闭合复位经皮空心螺钉内固定与传统切开复位内固定治疗踝关节骨折的疗效。方法 2004年3月～2009年8月收治的98例非粉碎型内外踝双骨折根据内固定方法不同分为闭合复位经皮空心螺钉内固定(闭合复位组)和传统切开复位内固定(切开复位组),比较2组患者的手术时间、术中出血量、骨折愈合时间、骨折愈合后外踝有无疼痛及术后1年AOFAS足踝评分。结果闭合复位组术中出血量、术后切口感染发生率及骨折愈合后外踝出现疼痛发生率明显优于切开复位组(P<0.05)。闭合复位组51例术后随访16～81个月,平均29.7月,骨折全部愈合;切开复位组42例随访17～80个月,平均28.3月,4例出现切口红肿、皮缘坏死,经换药后切口愈合,无深部感染发生,1例出现骨折不愈合。结论与传统切开复位内固定比较,闭合复位经皮空心螺钉内固定治疗踝关节骨折具有出血少、术后切口并发症发生率低、骨折愈合后外踝疼痛发生率低的优点,并能获得与切开复位内固定等同的踝关节功能。     

The treatment of unstable ankle fractures in patients over eighty years of age

BACKGROUND: The current study examined the outcomes of operative treatment of unstable ankle fractures in patients at least 80 years old at the time of injury. METHODS: Of 2,682 patients who presented for treatment of ankle fractures, 17 patients met the study criteria. These patients had open reduction and internal fixation after sustaining 15 closed and two open unstable ankle fractures. There were 11 type B fractures and six type C fractures by the Danis-Weber classification, and 12 supination-external rotation and five pronation-external rotation fractures by the Laugen-Hansen classification systems. RESULTS: When noncompliant patients who developed complications were removed from analysis, the fixation failure and deep infection rates were 0% each. CONCLUSIONS: These results highlight the importance of patient compliance and non-weightbearing status in the treatment of ankle fractures in patients over 80 years.     

The influence of the timing of surgery on soft tissue complications and hospital stay. A review of 84 closed ankle fractures

BACKGROUND AND AIMS: Open reduction and internal fixation of an extensively swollen ankle may lead to wound closure problems, blistering, wound edge necrosis and infection. Accordingly, internal fixation should be accomplished either before or after the period of critical soft tissue swelling. The object of the study was to investigate if the timing of surgery had any influence upon soft tissue complications and hospital stay. PATIENTS AND METHODS: The clinical course of the first 6 postoperative weeks of 84 closed ankle fractures treated by open reduction and internal fixation were reviewed. Seventeen patients were not operated on early due to lack of operative capacity and were thus operated on after 5 days or more. These patients were compared to the patients operated on within 8 hours (n = 67). The groups were comparable with respect to age, gender and fracture types. RESULTS: Despite a higher incidence of primary soft tissue injuries in the early group, the patients operated on delayed had a higher incidence of wound infections (17.6% vs. 3.0%) and hospital stay was prolonged with 12.4 days compared to early surgery. All wound infections were found in grossly displaced fractures despite adequate closed reduction immediately after arrival in the hospital. CONCLUSIONS: Delayed surgery of closed ankle fractures increases the risk of soft tissue complications and prolongs hospital stay. Immediate surgery is particularly indicated in the severely displaced ankle fracture, and if not achievable, temporary reduction and immobilization is recommended.     

Multiple preoperative biomarkers are associated with incidence of surgical site infection following surgeries of ankle fractures

The aim of the study was to investigate the epidemiologic characteristics of surgical site infection (SSI) following surgeries of ankle fractures. This was a retrospective study. Patients who underwent surgeries for ankle fractures in our hospital between January 2016 and June 2019 were included. Inpatient medical records were inquired for data collection, including demographics, comorbidities, injury‐related data, laboratory biomarkers, and confirmation of the SSI cases. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors. Among the 1532 patients, 45 had a postoperative SSI, indicating the incidence rate of 2.9%. About 18% of SSIs were identified after discharge. Twenty percent of SSIs were caused by mixed bacteria, and 39% were caused by drug‐resistant bacteria. In the final multivariate model, 7 factors including 5 biomarkers were identified to be independently associated with SSI: gender (male vs female, OR, 2.69; 95% CI, 1.33‐4.76), perioperative blood transfusion (OR. 3.02; 95% CI, 1.30‐7.04), albumin <35 g/L (OR, 2.87; 95% CI, 1.31‐6.31), lower high‐density lipoprotein cholesterol (HDL‐C) (OR, 2.34; 95% CI, 1.19‐4.60), haemoglobin (OR, 2.16; 95% CI, 1.03‐4.67), elevated alanine aminotransferase (OR, 2.09; 95% CI, 1.10‐3.95) and neutrophile/lymphocyte rate (NLR, OR, 3.45; 95% CI, 1.33‐6.74). These epidemiologic data on SSI may help counsel patients about the risk of SSI, individualised assessment of the risk factors, and accordingly the risk stratification.     

胫骨pilon骨折治疗中踝关节外侧结构损伤恢复的重要性

目的 探讨踝关节外侧结构稳定性在胫骨pilon骨折治疗中的意义.方法 从2005年7月至2008年1月共收治18例胫骨pilon骨折伴踝关节外侧结构损伤患者,其中男13例,女5例,平均年龄41.3岁.闭合性骨折16例,开放性骨折2例.AO分型:B1型3例,B2型5例;C1型3例,C2型7例.对于12例闭合性胫骨pilon骨折患者,首先采用后外侧切口进行腓骨复位和内固定,接着采用改良前内侧切口进行胫骨Chaput结节的复位和固定,中间关节面以及内侧骨块参照Chaput结节进行复位.对于2例开放性骨折和4例伴有严重软组织损伤或多发伤的闭合性胫骨pilon骨折患者,采用分期手术治疗,一期腓骨切开复位钢板内固定结合内侧胫骨跨踝关节外固定支架固定,对内侧结构只做克氏针或螺钉临时复位固定,二期(平均14 d后)拆除胫骨外固定支架或行胫骨切开复位钢板内固定. 结果 14例患者术后获8～30个月(平均18.4个月)随访,4例失访.14例骨折均获骨性愈合,平均愈合时间为5.4个月.关节面复位评价:解剖复位9例,一般4例,差1例.临床功能评价:优6例,良3例,可4例,差1例.1例开放性胫骨pilon骨折外固定后出现感染,在抗感染治疗后7周更换内固定,同时放置庆大霉素珠链,术后30周骨折愈合. 结论踝关节外侧结构稳定性的恢复在胫骨pilon骨折治疗中极其重要.     

Can Locked Fibula Nail Replace Plate Fixation for Treatment of Acute Ankle Fracture? A Systematic Review and Meta-Analysis

The standard surgical treatment for unstable ankle fractures involves open reduction and internal fixation (ORIF) with plates. However, ORIF has been associated with several complications, such as soft tissue irritation, wound infection, and nerve injury. Previous studies have shown that closed reduction and internal fixation with locked intramedullary nails (LIMNs) yields satisfactory efficacy in the treatment of ankle fractures and is associated with low complication rates. Therefore, a systematic review and meta-analysis of randomized controlled trials is imperative to provide evidence on whether or not LIMN fixation is comparable to or superior than traditional ORIF. We conducted a comprehensive literature search in the PubMed, Cochrane Library and EMBASE databases. A total of 4 randomized controlled trials involving 359 participants who suffered ankle fractures were included in this systematic review and meta-analysis. The results showed that the LIMN fixation group was statistically significant in terms of functional outcomes at the 3-month follow-up and wound-related complications. There was no statistical advantage for patients in the LIMN fixation group in terms of nonwound-related complications, total complications, or mid-term follow-up functional outcomes. There was no statistical difference between the LIMN and ORIF groups regarding operation time and quality of reduction. We believe LIMN fixation is a viable option for the treatment of unstable ankle fractures in both young and elderly individuals.     

Surgical options for the treatment of severe tibial pilon fractures: a study of three techniques

OBJECTIVE: To determine whether long-term results of one of three different management protocols for severe tibial pilon fractures offer advantages over the other two. DESIGN: In a retrospective study, patients were examined clinically and radiologically after internal fixation of severe tibial plafond fractures (i.e., 92 percent Type C fractures according to the AO-ASIF classification). SETTING: Department of Traumatology, Hanover Medical School. Level I trauma center. PATIENTS: Fifty-one of seventy-seven patients treated between 1982 and 1992 were examined clinically and radiologically at an average of sixty-eight months (range 13 to 130 months) after injury. INTERVENTIONS: The patients were treated in three different ways: primary internal fixation with a plate following the AO-ASIF principles (n = 15), which was reserved for patients with closed fractures without severe soft tissue trauma; one-stage minimally invasive osteosynthesis for reconstruction of the articular surface with long-term transarticular external fixation of the ankle for at least four weeks (n = 28); and a two-stage procedure entailing primary reduction and reconstruction of the articular surface with minimally invasive osteosynthesis and short-term transarticular external fixation of the ankle joint followed by secondary medial stabilization with a plate using a technique requiring only limited skin incisions (a reduced invasive technique) (n = 8). MAIN OUTCOME MEASUREMENTS: Objective evaluation criteria were infection rate, amount of posttraumatic arthritis, range of ankle movement, and number of arthrodeses. Subjective criteria were pain, swelling, and restriction of work or leisure activities. RESULTS: Because only closed fractures were treated by primary internal fixation with a plate, there was a statistically significant difference (p < 0.005) in the distribution of open fractures between the three treatment groups. Fracture classification in these groups were not significantly different. All but four fractures were classified as Type C lesions according to the AO-ASIF system. The soft tissue was closed in 63 percent (n = 32) and open in 37 percent (n = 19). No significant relationship could be found between the soft tissue damage and degree of arthritis or between the type of surgical treatment and extent of posttraumatic arthritis. However, none of the patients who required secondary arthrodesis (23 percent of all cases) were in the group who had undergone two-step surgery (p < 0.05). The range of ankle movement was much greater in the two-step group than in the others; these patients also had less pain, more frequently continued working in their previous profession, and had fewer limitations in their leisure activities. These differences did not reach statistical significance. The incidence of wound infection did not differ significantly among the three groups. CONCLUSIONS: On the basis of our results, we now prefer a two-step procedure for the treatment of severe tibial pilon fractures with extensive soft tissue damage. In the first stage, primary reduction and internal fixation of the articular surface is performed using stab incisions, screws, and K-wires. Temporary external fixation is applied across the ankle joint. After recovery of the soft tissues, the second stage entails internal fixation with a medial plate using a reduced invasive technique.     

Risk factors for ankle fracture requiring operative fixation

BACKGROUND: Ankle fractures are common and expensive injuries, particularly the injuries that require operative intervention. However, epidemiological research on the causative factors is sparse. This study aims to identify the groups at risk of ankle fracture requiring operative fixation, and to suggest directions for further study. METHODS: The clinical data on 336 patients with ankle fractures admitted to an urban hospital in New Zealand in 1994 were reviewed. Statistical analysis was carried out on the 252 patients with ankle fractures requiring operative fixation. RESULTS: Those at highest risk of ankle fracture are young male rugby players and middle-aged women who sustain injury while walking. Young males have a similar incidence of AO Type B and C fractures, while Type B fractures predominate strongly in older women. CONCLUSIONS: The groups at risk of ankle fracture requiring operative fixation, and the activities predisposing these groups to injury have been identified. More work is required to define the specific risk factors and biomechanical mechanisms that lead to these debilitating injuries.     

Results after immediate operations of closed ankle fractures in patients with preoperatively neglected type 2 diabetes

Many studies suggest diabetes influences ankle fracture surgical outcomes, but results after immediate surgical treatment of closed ankle fractures (CAFs) in patients with preoperatively neglected type 2 diabetes (PND2) have not been documented. We contrasted the results of the immediate operation on CAF in 36 PND2 patients with those of a matched group of non-diabetic patients, using a case-controlled study. Outcomes were complications and ankle scores during the first 12 months of treatment. Compared with non-diabetic patients, immediate surgical fixation of the CAF in PND2 patients showed similar ankle scores. Immediate surgery in PND2 patient with CAF may increase the risk of postoperative infection compared to non-diabetic controls, but the difference was not statistically significant and did not worsen the final prognosis. These findings suggest that immediate surgical intervention is appropriate in CAF patients with type 2 diabetes.     

Are deep infections that present before and after 90 days from orthopaedic trauma different? An analysis of the validity of the recent change in CDC criteria for infections

BackgroundIn 2016, the Centers for Disease Control and Prevention (CDC) changed the time frame for their definition of deep surgical site infection (SSI) from within 1 year to within 90 days of surgery. We hypothesized that a substantial number of infections in patients who have undergone fracture fixation present beyond 90 days and that there are patient or injury factors that can predict who is more likely to present with SSI after 90 days.MethodsA retrospective review yielded 452 deep SSI after fracture fixation. These patients were divided into two groups—those infected within 90 days of surgery and those infected beyond 90 days . Data were collected on risk factors for infection. Univariate and multiple logistic regression analyses were performed to compare the two groups. A randomly selected control group was used to build infection prediction models for both outcomes. The two outcomes were then modelled against each other to determine whether differences in predictors for early versus late infection exist.ResultsOf the 452 infections, 144 occurred beyond 90 days (32% [95% CI, 28%–36%]). No statistically significant patient factors were found in multivariable analysis between the early and late infection groups. The need for flap coverage was the only injury characteristic that differed significantly between groups, with patients in the late infection group more likely to have needed a flap. When modelled against the control group and directly comparing the two models, predictors for early infection include male sex and fractures of the pelvis, acetabulum, or hip, whereas predictors of late infection include hepatitis C and/or human immunodeficiency virus (HIV) and admission to the intensive care unit (ICU).ConclusionUse of the recent CDC definition will underestimate the rate of actual postoperative infections when applied to orthopaedic trauma patients. Hepatitis C and/or HIV and ICU admission are predictors of late infection, whereas male sex and pelvis, acetabulum, or hip fractures are predictors of early infection. Patients who receive flap coverage may be more likely to present with late infection.