跟骨骨折钢板内固定术后伤口并发症的处理

目的探讨跟骨骨折经外侧切口行钢板内固定术后伤口并发症的处理方法。方法回顾性分析2001年8月至2010年7月我科收治的28例跟骨骨折切开复位钢板内固定术后出现伤口并发症的患者,其中男26例,女2例;年龄25～66岁,平均47.6岁。结果在28例患者中,5例浅表坏死经保守治疗后伤口愈合,其余23例均行手术处理,经彻底清创,取出钢板,足部局部皮瓣转移4例,小腿远端蒂皮（筋膜）瓣转移修复19例。随访6个月～3年,所有伤口均愈合,无创面再坏死、裂开、感染等情况出现,恢复行走功能。结论根据创面的具体情况选择合适的方法治疗跟骨骨折钢板内固定术后伤口并发症,是取得满意疗效的关键。封闭负压吸引技术的应用大大提高了外科医生处理此类伤口并发症的能力。     

Postoperative Wound Infection After Implant and Removal of Osteosynthetic Material

Osteosynthetic material was implanted and removed in 972 consecutive operations in the upper and lower extremity. Early post-operative wound infection developed significantly more often after osteosynthesis than after removal of the implant; neither sex nor age influenced significantly the frequency of wound infection. The latter was higher when insertion or removal of material was performed in the lower extremity than in the upper extremity. The hip and ankle regions were involved most often. Staph, aureus and Staph, albus predominated among the Gram-positive infections; gram-negative infections, however, occurred remarkably frequently, E. coli being the most common organism isolated. To decimate exogenous and endogenous contamination of the wounds during operation, aseptic and antiseptic measures should he reinforced. In operation in a region proven to carry a higher post-operative infectious risk, i.e. the hip and ankle, it is suggested that antibiotics should be administered at the time of osteosynthesis.     

Comparison of the Conventional Surgery and the Surgery Assisted by 3d Printing Technology in the Treatment of Calcaneal Fractures

ABSTRACT

Purpose: This study was aimed to compare conventional surgery and surgery assisted by 3D printing technology in the treatment of calcaneal fractures. In addition, we also investigated the effect of 3D printing technology on the communication between doctors and patients. Methods: we enrolled 75 patients with calcaneal fracture from April 2014 to August 2016. They were divided randomly into two groups: 35 cases of 3D printing group, 40 cases of conventional group. The individual models were used to simulate the surgical procedures and carry out the surgery according to plan in 3D printing group. Operation duration, blood loss volume during the surgery, number of intraoperative fluoroscopy and fracture union time were recorded. The radiographic outcomes Böhler angle, Gissane angle, calcaneal width and calcaneal height and final functional outcomes including VAS and AOFAS score as well as the complications were also evaluated. Besides, we made a simple questionnaire to verify the effectiveness of the 3D-printed model for both doctors and patients. Results: The operation duration, blood loss volume and number of intraoperative fluoroscopy for 3D printing group was 71.4 ± 6.8 minutes, 226.1 ± 22.6 ml and 5.6 ± 1.9 times, and for conventional group was 91.3 ± 11.2 minutes, 288.7 ± 34.8 ml and 8.6 ± 2.7 times respectively. There was statistically significant difference between the conventional group and 3D printing group (p < 0.05). Additionally, 3D printing group achieved significantly better radiographic results than conventional group both postoperatively and at the final follow-up (p < 0.05). However, No significant difference was noted in the final functional outcomes between the two groups. As for complications, there was no significant difference between the two groups. Furthermore, the questionnaire showed that both doctors and patients exhibited high scores of overall satisfaction with the use of a 3D printing model. Conclusion: This study suggested the clinical feasibility of 3D printing technology in treatment of calcaneal fractures.     

植骨在手术治疗跟骨关节内骨折中的作用

目的通过前瞻性随机研究,观察植骨在切开复位内固定治疗关节内跟骨骨折中是否有益。方法2001年1月至2005年12月收治需要手术治疗的闭合性关节内跟骨骨折110例,随机分为植骨组和非植骨组。采用“L”形外侧延长切口,直视下显露整个跟骨外侧壁、距下关节后关节面及跟骰关节,给予跟骨骨折复位。对于植骨组采用自体髂骨植骨填充复位后的骨缺损,而非植骨组则不进行植骨。随后将塑形良好的跟骨解剖重建板放置于跟骨外侧壁以固定跟骨骨折。手术前后摄片测量Bohler角,术后采用美国矫形足踝协会踝后足评分标准进行患者的功能评价。结果手术前后植骨组和非植骨组的Bohler角增加没有统计学差异,术后6个月Bohler角的丢失也没有统计学差异,术后6个月、1年及2年的足功能评价也没有差异。结论在手术治疗关节内跟骨骨折中植骨并不具有优势。     

The Use of Cryotherapy for the Prevention of Wound Complications in the Treatment of Calcaneal Fractures

We analyzed the risk factors for skin infection and necrosis after calcaneal fracture surgery and evaluated the effect of cryotherapy in preventing postoperative skin infections and necrosis. We studied 129 calcaneal fracture patients (148 feet) who had undergone open reduction and internal fixation from January 2008 to December 2010. Three groups included were: control (44 patients; 49 feet), preoperative cryotherapy (43 patients; 48 feet), and perioperative cryotherapy (42 patients; 51 feet). The wound infection rate, Maryland foot score, and postoperative visual analog scale (VAS) score were compared. Risk factors for infection were analyzed using multinomial logistic regression. Both cryotherapy groups had lower infection rates, higher Maryland foot scores, lower VAS scores, and shorter hospitalizations than the control group (p?<?.05). The perioperative cryotherapy group had a lower infection rate, higher Maryland foot score, and shorter hospitalization (p?<?.05) but similar VAS score compared with the preoperative cryotherapy group (p?>?.05). Pre- and postoperative cryotherapy, postoperative drainage, surgical timing, smoking index, alcoholism, and suture method were risk factors for postoperative infection and necrosis. The risk of these can be largely reduced by patients not smoking and drinking alcohol and surgeons choosing the appropriate surgical timing, improving the suturing method, and performing postoperative drainage. Perioperative cryotherapy might be an effective method to decrease the postoperative infection rate, shorten the hospital stay, and reduce postoperative pain. Our findings require further validation in well-designed randomized controlled trials.     

Improved Interobserver Reliability of the Sanders Classification in Calcaneal Fractures Using Segmented Three-Dimensional Prints

We examined the added value of 3-dimensional (3D) prints in improving the interobserver reliability of the Sanders classification of displaced intraarticular calcaneal fractures. Twenty-four observers (radiologists, trainees, and foot surgeons) were asked to rate 2-dimensional (2D) computed tomography images and 3D prints of a series of 11 fractures, selected from cases treatment at our level I trauma center between 2014 and 2016. The interobserver reliability for the Sanders classification was assessed using kappa coefficients. Three versions of the Sanders classification were considered: Sanders classification with subclasses, Sanders classification without subclasses, and the combination of Sanders types III and IV because of the high incidence of comminution in both types. The reference standard for classification was the perioperative findings by a single surgeon. The 3D print always yielded higher values for agreement and chance-corrected agreement. The Brennan-Prediger–weighted kappa equaled 0.35 for the 2D views and 0.63 for the 3D prints for the Sanders classification with subclasses (p?=?.004), 0.55 (2D) and 0.76 (3D) for the classification without subclasses (p?=?.003), and 0.58 (2D) and 0.78 (3D) for the fusion of Sanders types III and IV (p?=?.027). Greater agreement was also found between the perioperative evaluation and the 3D prints (88% versus 65% for the 2D views; p?<?.0001). However, a greater percentage of Sanders type III-IV were classified with 2D than with 3D (56% versus 32%; p?<?.0001). The interobserver agreement for the evaluation of calcaneal fractures was improved with the use of 3D prints after “digital disarticulation.”     

髋臼骨折手术并发症的防治

目的探讨髋臼骨折手术并发症发生的原因及防治措施。方法总结我院1997年1月～2003年10月67例髋臼骨折手术治疗的病例，采用不同手术入路行手术切开复位内固定治疗，包括Kocher-Langenbeck入路44例，Ilio—inguinal入路12例，Extened Ilio—femoral入路5例，Ilio—femoral入路l例及联合入路5例。分析术后主要并发症的发生原因。结果平均随访36．4个月(6月～7年)，根据Matta临床标准和x线标准评定优良率分别为76．1％和73．1％。主要并发症为：坐骨神经损伤9例(13．4％)，异位骨化10例(14．9％)，股骨头缺血坏死3例(4．5％)，创伤性关节炎11例(16．4％)，经相应处理，疗效良好，无一例死亡，未再发生感染、血栓栓塞等并发症。结论髋臼骨折手术切开复位内固定疗效良好；术前正确判断骨折类型，选择最佳入路，术中减少手术创伤，良好复位和妥善固定，术后对症治疗可以减少并发症的发牛。     

撬拨复位外固定和切开复位内固定治疗跟骨骨折疗效分析

目的探讨经皮撬拨复位外固定和切开复位内固定治疗跟骨骨折的疗效。方法回顾分析我科自2006年5月至2011年7月治疗45例（50足）跟骨骨折的临床资料。结果所有患者均获得随访,时间为10～20个月,平均14.9个月。术后复查X线片显示跟距关节面基本恢复正常,撬拨复位外固定器固定组,Bo。hler角和Gissane角分别由术前的（9.56±6.23）°,（85.24±9.36）°恢复至术后的（32.43±7.61）°,（124.34±10.51）°;切开复位内固定组,Bo。hler角和Gissane角分别由术前的（8.29±7.47）°,（90.63±8.47）°恢复至术后的（30.49±8.06）°,（130.57±6.49）°,经统计两组之间差异无统计学意义（P〉0.05）。根据Maryland足部评分系统评价术后功能,撬拨复位外固定器固定组：优7足,良10足,中4足,差1足,优良率77.3%;切开复位内固定组：优10足,良13足,中3足,差2足,优良率82.1%,经统计两组优良率差异无统计学意义（P〉0.05）。结论这两种方法治疗跟骨骨折都是比较实用有效的选择,但应根据不同的骨折类型选择不同的治疗方法,实现治疗的个性化,才能取得良好的治疗效果,将骨折对患者术后的日常生活影响降到最低。     

Short-Term Outcomes of Open Reduction and Internal Fixation for Sanders Type III Calcaneal Fractures With and Without Bone Grafts

Calcaneal fractures, often caused by a fall from a height, are the most common injuries encountered by orthopedic surgeons. Currently, open anatomic reduction and internal fixation (ORIF) is considered a valuable treatment of displaced intraarticular fractures of the calcaneus; however, the need for bone grafting in the treatment is still controversial. Therefore, in the present study, we investigated the outcomes of 2 methods (with and without bone grafting) used for the surgical treatment of Sanders type III calcaneal fractures. From January 2013 to September 2015, 57 cases (55 patients) with displaced Sanders type III calcaneal fractures (53 unilateral and 2 bilateral) were enrolled. The patients were divided into 2 groups: group I was treated by ORIF with bone grafting (n = 28) and group II was treated by ORIF without bone grafting (n = 29). The radiologic evaluation included Böhler's angle, Gissane's angle, and the height and width of the calcaneum. In addition, the American Orthopaedic Foot and Ankle Society questionnaires and visual analog scale were completed by the patients. During the follow-up period, no differences were found in the outcome measures (Böhler's angle, p = .447; Gissane's angle, p = .599; calcaneal height, p = .065; calcaneal width p = .077; and American Orthopaedic Foot and Ankle Society questionnaires, p = .282) with or without bone grafting. The only difference between the 2 groups was the occurrence of postoperative pain (p = .024 and p = ≤ .05), which was greater in the patients who had undergone bone grafting. We have provided evidence that bone grafting with internal fixation in the treatment of intraarticular calcaneal fractures failed to improve the restoration of Böhler's angle or Gissane's angle. No statistically significant difference was found in the short-term outcomes between the 2 methods used for the surgical treatment of Sanders type III calcaneal fractures.     

Comparison of Early Adverse Events After Operative Treatment of Bimalleolar and Trimalleolar Fractures Versus Pilon Fractures

Ankle fractures requiring open reduction and internal fixation vary in severity from unimalleolar fractures to bimalleolar/trimalleolar (BT) fractures to pilon fractures. Consequently, the postoperative outcomes with these surgeries can vary. Most previous studies of these injuries had small sample sizes, studied a single risk factor or adverse event, or did not compare different injuries by severity. The purpose of the present study was to describe and compare the patient characteristics and postoperative outcomes of 2 high-energy ankle fractures: BT and pilon fractures. The relevant patients were identified from the American College of Surgeons National Surgical Quality Improvement Program database using the Current Procedural Terminology codes for BT and pilon fractures. Patient demographics, characteristics, comorbidities, and 30-day mortality and adverse events were recorded and compared between the 2 types of ankle fractures. More than 45% of patients with these fracture types were aged 40 to 65 years. Pilon fractures occurred more frequently in younger patients, were more likely to occur in men, required a longer hospital stay and operative time, were less likely to occur in patients with a body mass index of >30 kg/m², and conferred a greater risk of wound complications (odds ratio 1.76; p = .048) compared with BT fractures. The findings from the present study help us understand the differences in patient characteristics and potential early adverse events after open reduction and internal fixation of BT fractures versus pilon fractures.     

The Significance of the Intraoperative Repeated Dosing of Antimicrobials for Preventing Surgical Wound Infection in Colorectal Surgery

Purpose It is widely accepted that antimicrobial prophylaxis is useful for the prevention of surgical wound infection, especially in colorectal surgery. While many reports support the finding that the first dose should be administered immediately before surgery, there is less evidence concerning the ideal timing for the second dose. The purpose of this study is to examine the significance of intraoperative repeated dosing.Methods A surgical series of 131 patients with primary colorectal cancer was retrospectively analyzed for 14 parameters, including the protocols of antimicrobial administration to determine the clinical risk factors for surgical wound infection.Results The overall surgical wound infection rate of the 131 patients was 16.0% (21/131). When the operation finished within 4 h after the first dose (n = 29), wound infection was observed in only one patient (3.4%). In a prolonged operation exceeding 4 h after the first dose, the surgical wound infection rates were 8.5% and 26.5%, respectively, for those with (n = 47) and without (n = 49) intraoperative repeated dosing, which were significantly different based on both a univariate analysis (P = 0.031) and a multivariate analysis (P = 0.0079).Conclusion Intraoperative repeated antimicrobial dosing is therefore recommended to prevent the surgical wound infection for prolonged colorectal surgery.     

骨科手术后患者切口感染危险因素分析及创面修复处理对策

目的 总结骨科手术后患者切口感染的危险因素,探讨切口感染的创面修复处理对策。方法 选取2018年2月-2023年2月在我院骨科进行手术治疗的1480例患者为研究对象,采用统计方法收集术后 感染情况数据,运用Logistic回归分析法对手术切口感染的危险因素进行分析。结果 1480例骨科手术 患者中有23例发生切口感染,感染率为1.55%;单因素分析显示,不同年龄、手术切口类型、手术时 间、有无基础疾病、围术期用药、手术部位的切口感染发生率比较,差异有统计学意义（P＜0.05）; 多因素分析显示手术切口类型（OR=1.462）、年龄（OR=1.526）、手术时间（OR=1.812）、基础疾 病（OR=2.340）、围术期用药（OR=1.402）是骨科术后切口感染的影响因素（P＜0.05）。结论 导致 骨科手术患者术后切口感染的影响因素较多,包括手术切口类型、年龄、手术时间、基础疾病和围术期 用药。对此,应重点关于以上危险因素人群,并予以针对性干预,以期减少骨科手术后切口感染的发生 几率。     

Postoperative Reoperations and Complications in 32,307 Ankle Fractures With and Without Concurrent Ankle Arthroscopic Procedures in a 5-Year Period Based on a Large U.S. Healthcare Database

Residual symptoms often persist even after successful operative reduction and internal fixation (ORIF) of ankle fractures. Concurrent ankle arthroscopic procedures (CAAPs) have been proposed to improve clinical outcomes; however, a dearth of evidence is available supporting this practice. The purpose of the present study was to investigate the reoperation and complication rates after ORIF of ankle fractures with and without CAAPs. Reoperations and complications after ORIF of ankle fractures were identified using the PearlDiver database from January 2007 to December 2011. The CAAPs included bone marrow stimulation, debridement, synovectomy, and unspecified cartilage procedures. Reoperation procedures consisted of ankle fracture repeat fixation, arthroscopic procedures, osteochondral autograft transfers, and ankle arthrodesis. Of the 32,307 patients who underwent ankle fracture fixation, 248 received CAAP and 32,059 did not. No significant difference was found in the reoperation rate between the 2 groups (7.7% versus 8.6%; odds ratio 0.89; 95% confidence interval 0.55 to 1.42; p?=?.61). Of the 248 patients in the CAAP group, 19 (7.7%) underwent reoperation, of which 13 (68.4%) were arthroscopic debridement and 6 were either ankle refixation or osteochondral autograft transfer. For the non-CAAP group, 3021 reoperation procedures were performed, consisting of ankle refixation in 83.2%, arthroscopic procedures in 14.3%, and ankle arthrodesis in 2.5%. The complication rate in the non-CAAP group included wound dehiscence in 2.4%, wound surgery in 0.4%, deep vein thrombosis in 0.8%, and pulmonary embolism in 0.4%. No complications were detected in the CAAP group. Ankle fracture fixation with CAAPs did not increase the postoperative reoperation rate compared with ankle fracture fixation without CAAPs.     

Preoperative Risk Factors for Postoperative Urinary Tract Infection After Primary Total Hip and Knee Arthroplasties

BackgroundEstablishing clear risk factors for complications such as urinary tract infection (UTI) after arthroplasty procedures helps guide clinical practice and provides more information to both surgeons and patients. This study aims to assess selected preoperative patient characteristics as risk factors for postoperative UTI after primary total hip and knee arthroplasties (THA and TKA).MethodsThis was a retrospective analysis using current procedural terminology codes to investigate the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for patients who underwent THA or TKA from 2010 to 2017. Patients were classified for UTI by NSQIP guidelines. Patient samples with all possible covariates were included for multivariate logistic regression analysis and assessed for independent associations.ResultsIn a cohort of 983 identified patients (983 of 119,096; 0.83%): ages 57+ years, preoperative red blood cell (RBC) transfusion, perioperative RBC transfusion, bleeding disorders, operative time 110+ minutes, preoperative steroid use, diabetes, pulmonary comorbidities, body mass index 30+ kg/m² were independent risk factors for postoperative UTI after THA. In a cohort of 1503 identified patients (1503 of 189,327; 0.8%): ages 60+ years, preoperative RBC transfusion, perioperative RBC transfusion, anemia, platelets less than 150k, preoperative steroid use, diabetes, and body mass index 30+ kg/m² were independent risk factors for postoperative UTI after TKA. Male sex was associated with a decreased risk of UTI in both THA and TKA.ConclusionThis study provides novel evidence on risk factors associated with the development of UTI after THA or TKA. Clinicians should be aware of risk factors in the manifestation of postoperative UTI after primary THA or TKA procedures.     

Modified Dwyer Osteotomy with Rotation and Reinsertion of Autograft Bone Wedge for Residual Heel Deformity Despite Previous Delayed Subtalar Joint Arthrodesis After Calcaneal Fracture

Calcaneal fracture patterns vary widely, and many factors determine the type and timing of the treatment rendered. Severe calcaneus fractures involving joint damage, loss of heel height, and varus deformity of the tuberosity are ideally treated with open reduction and internal fixation to repair the joint surface and re-establish anatomic structure. This is not always possible owing to delayed presentation, soft tissue compromise, unrelated injuries, unstable medical condition, or lack of expertise by the treating physician. We present the case of a patient who had residual forefoot and rearfoot deformity despite undergoing delayed subtalar joint arthrodesis at an outside hospital 10 years before for a calcaneal fracture that was initially treated nonoperatively. At 4 years of follow-up after modified Dwyer calcaneal osteotomy with rotation and reinsertion of the autograft bone wedge and Cotton midfoot osteotomy, the postoperative gait was relatively normal, other than the expected lack of hindfoot mobility. The lateral column pain was resolved. The patient remained highly satisfied with the outcome at long-term follow-up of 48 months, with improved heel alignment, lack of a wide stance gait, a functional medial column, and a relatively normal gait. This case demonstrates the value of periarticular calcaneal osteotomies without the need to revise the subtalar joint arthrodesis for this challenging clinical situation.     

Postoperative Infection Risk in Total Joint Arthroplasty After Perioperative IV Corticosteroid Administration: A Systematic Review and Meta-Analysis of Comparative Studies

BackgroundPerioperative corticosteroid administration is associated with reduced postoperative nausea, pain, and enhanced recovery after surgery. However, potential complications including wound and periprosthetic joint infections remain a concern for surgeons after total joint arthroplasty (TJA).MethodsA systematic review of the search databases PubMed, Google Scholar, and EMBASE was made in January 2021 to identify comparative studies evaluating infection risk after perioperative corticosteroid administration in TJA. PRISMA guidelines were used for this review. Meta-analysis was used to assess infection risk in accordance with joint and corticosteroid dosing regimen used.Results201 studies were returned after initial search strategy, with 29 included for review after application of inclusion and exclusion criteria. Studies were categorized as using low- or high-dose corticosteroid with single or repeat dosing regimens. Single low-dose corticosteroid administration was not associated with an increased risk of infection (P = .4; CI = 0.00-0.00). Single high-dose corticosteroid was not associated with an increased infection risk (P = .3; CI = 0.00-0.01) nor did repeat low-dose regimens result in increased risk of infection (P = .8; CI = ?0.02-0.02). Studies assessing repeat high-dosing regimens reported no increased infection, with small numbers of participants included. No significant risk difference in infection risk was noted in hip (P = .59; CI = ?0.03-0.02) or knee (P = .2; CI = 0.00-0.01) arthroplasty. Heterogeneity in patient profiles included in studies to date was noted.ConclusionUse of perioperative corticosteroid in TJA does not appear to be associated with increased risk of postoperative infection in patients with limited comorbidities. Further research is warranted to evaluate postoperative complications after TJA in these at-risk patient populations.