Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique

OBJECTIVES: Single incision open reduction and double plate fixation of complex tibial plateau fractures has been associated with high wound complication rates. Minimally invasive methods have been recommended to decrease the wound complication rates as compared with open techniques. Additionally, laterally applied fixed-angle devices appear to minimize late varus deformity without the need for additional medial stabilization. Accurate reduction of comminuted lateral and/or medial articular surfaces, however, often requires visualization through an open reduction. This study reports the complications, infection rate, and radiographic assessment of reduction associated with double plating complex AO/OTA 41-C3 tibial plateau fractures utilizing 2 incisions. DESIGN: Retrospective clinical review. SETTING: Urban level 1 university trauma center. PATIENTS: Over a 77-month period, 83 patients were treated for a complex bicondylar tibial plateau fracture at our institution utilizing a 2-incision technique. INTERVENTION: Dual plating using anterolateral and posteromedial incisions. MAIN OUTCOME MEASURE: Type and incidence of septic and non-septic complications and radiographic assessment of articular reduction and axial alignment. RESULTS: Eleven fractures were open (13.3%) and classified according to Gustilo as type II (1 patient), type III-A (7 patients), type III-B (2 patients), and type III-C (1 patient). Compartment syndrome was diagnosed and treated with fasciotomies in 12 patients (14.5%). The average time interval from injury to definitive surgical treatment was 9 days. Seven patients developed deep wound infections (8.4%). Three of these had an associated septic arthritis (3.6%). Clinical resolution of infection occurred after an average of 3.3 additional procedures. The presence of a dysvascular limb requiring vascular reconstruction was statistically associated with a deep wound infection (P = 0.006). Secondary procedures for complications included 13 patients who required removal of implants secondary to local discomfort, 5 patients who required a knee manipulation, 2 patients that were managed with excision of heterotopic ossification to improve knee motion, 1 patient that required an equinus contracture release, and 1 patient treated for a metadiaphyseal nonunion. Sixteen patients (19.3%) incurred deep venous thromboses. No patient was diagnosed with pulmonary embolism. Sixty-two percent of patients demonstrated satisfactory articular reductions, 91% demonstrated satisfactory coronal alignment, 72% demonstrated satisfactory sagittal alignment, and 98% demonstrated satisfactory condylar width. CONCLUSIONS: Comminuted bicondylar tibial plateau fractures can be successfully treated with open reduction and medial and lateral plate fixation using 2 incisions. Dysvascular limbs requiring vascular repair are at increased risk for deep sepsis. The use of 2 incisions, temporary spanning external fixation, and proper soft-tissue handling may contribute to a lower wound complication rate than previously reported.     

Prospective cohort study of neoadjuvant treatment in conservative surgery of soft tissue sarcomas

Background: 1994 marked a decade since the inception of a prospective population-based study on the value of a neoadjuvant approach for soft tissue sarcomas of head, neck, and limbs at the Tom Baker Cancer Centre, Calgary, Alberta. To date, 42 patients have been followed for a minimum of 5 years or until death. Methods: Each patient received a protocol of 60 mg to 90 mg of Adriamycin infused intraarterially or intravenously over 3 days into a vessel feeding the involved area, 30 Gy of radiotherapy given over 10 days, and complete resection of the sarcoma 4 to 6 weeks later. The lower dose was used empirically for smaller limbs (e.g., arm). Results: Two of the 42 patients were immediate failures of protocol, with one requiring amputation and one requiring later reexcision. In the 38 appendicular lesions, the ultimate limb salvage rate was 97.5%. All tumors were associated with a high risk of local recurrence, with 15 being previous local failures. The rest were deep and grade 2 or 3 lesions. Serious local complications were seen in one patient (2.5%) who had wound necrosis requiring reoperation. Minor wound complications were seen in five patients (12.5%) (one wound infection, one resolved edema, three long-term drainage). There was one local recurrence; thus 5-year local control was 97%. No patient had long-term morbidity related to the treatment. No effect on systemic control was suggested. Conclusion: Our report demonstrates that this combined modality approach provides superior local control of soft tissue sarcomas with low postoperative morbidity.     

The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial

Open fractures of the distal phalanx commonly present to the Accident and Emergency Department. Controversy surrounds the use of prophylactic antibiotics in treating this injury. A double-blind, prospective, randomized placebo-controlled study was undertaken comparing the use of prophylactic flucloxacillin to placebo in addition to meticulous wound toilet. One hundred and ninety-three adult patients with an open fracture of the distal phalanx were studied. Seven patients developed superficial infections, an overall infection rate of 4%. No patient developed osteitis or a deep wound infection. There were three cases of infection in the 98 patients (3%) in the antibiotic group and four cases of infection in the 95 patients (4%) in the placebo group. A difference of proportion test confirmed no significant difference. It is concluded that the addition of prophylactic flucloxacillin to thorough wound toilet and careful soft-tissue repair of open fracture of the distal phalanx confers no benefit.     

Flexible intramedullary nailing of subtrochanteric fractures of the femur. A multicenter analysis

In a retrospective, multicenter analysis, 79 subtrochanteric fractures of the femur were treated with flexible intramedullary nails. Seventy fractures were traumatic in origin, three were pathologic, and six occurred in spinal cord patients. All of the fractures healed, and there were no fixation failures. Thirteen patients (16%) required adjunctive internal fixation, bone grafts, or postoperative traction. Shortening greater than 1 cm occurred in four patients (5%). Reoperation with one week of surgery was necessary in eight patients (10%). The single greatest complication was knee complaints, which occurred in 17 patients (21.5%). However, only six of these patients required revision prior to fracture union. In one patient a deep wound infection developed, which eventually healed without evidence of osteomyelitis. All patients who were ambulatory before their fracture were able to bear weight.     

Early complications of hip resurfacing

There has been a rapid increase in the number of hip resurfacing procedures for the treatment of symptomatic osteoarthritis over the last decade. We examine our early complications associated with this procedure. Eight hundred forty consecutive hip resurfacing procedures by 1 surgeon using 1 prosthesis were assessed. The complications seen within the first 12-month postoperative period were analyzed. Specific patient selection criteria were used. Complications such as loosening, femoral neck notching, femoral neck fracture, deep vein thrombosis, stress fracture, nerve palsy, and infection were noted. Complications linked with loosening were categorized to either the femoral or acetabular component. A total of 86 early complications were observed in the 840 resurfacings. Twenty-three (2.7%) required operative intervention, and 10 (1.2%) were converted to stemmed hip arthroplasties. Of these 86 complications, the most common complication was deep vein thrombosis, 19 instances (2.26% occurrence in 840), followed by femoral neck fracture, 11 (1.31%); infection, 10 (1.19%); femoral notching, 10 (1.19%); transient nerve palsy, 8 (0.95%); acetabular loosening, 6 (0.71%); hematoma, 5 (0.60%); and stress fracture, 4 (0.48%). The fractures occurred mostly in patients older than 60 years.     

VSD结合外固定支架在西藏高原地区胫腓骨开放性骨折分期治疗中应用

目的：探讨负压吸引敷料结合外固定支架技术在西藏高原地区胫腓骨开放性骨折分期治疗中的应用及临床疗效。方法2014年8月-2015年8月收治16胫腓骨开放性骨折患者,其中男性12例,女性4例,年龄19~66岁,平均年龄39.4岁(19~66岁);胫腓骨中上段骨折4例,下段骨折12例。待患者病情稳定后患者生命体征稳定后,无继发性损伤,予行清创、外固定支架固定骨折端,并采用负压吸引敷料覆盖创面或创腔。7 d后更换VSD或予行二期缝合或软组织覆盖。 X线检查明确骨折愈合时间并记录相关并发症。结果本组16例创面均二期愈合,未见感染、皮肤或皮瓣坏死等软组织并发症。本组共随访患者12例(电话通知来院复诊),4例失访,平均随访18个月(12~24个月)。影像学检查明确平均骨折愈合时间为5.5个月(3~7个月),其中骨折一期临床愈合9例(75%),延迟愈合3例(25%)。随访期间除2例出现钉道感染,经保守治疗后治愈,余患者未见深部感染、植皮或皮瓣坏死、畸形愈合、骨不连或骨髓炎发生。结论负压吸引敷料结合外固定支架治疗西藏高原地区胫腓骨开放性骨折,在迅速有效地稳定骨折的同时,能安全有效地封闭创面,缩短二期创面修复时间,促进骨折愈合,减少并发症。     

A staged protocol for soft tissue management in the treatment of complex pilon fractures

OBJECTIVE: To determine whether open reduction and internal fixation of intra-articular pilon fractures using a staged treatment protocol results in minimal surgical wound complications. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Between January 1991 and December 1996, 226 pilon fractures (AO types 43A-C) were treated, of which 108 were AO type 43C. Fifty-six fractures were included in a retrospective analysis of a treatment protocol. Injuries were divided into Group I, thirty-four closed fractures, and Group II, twenty-two open fractures (three Gustilo Type 1, six Type II, eight Type IIIA, and five Type IIIB). METHODS: The protocol consisted of immediate (within twenty-four hours) open reduction and internal fixation of the fibula when fractured, using a one-third tubular or 3.5-millimeter dynamic compression plate and application of an external fixator spanning the ankle joint. Patients with isolated injuries were discharged after initial stabilization and readmitted for the definitive reconstruction. Polytrauma patients remained hospitalized and were observed. Formal open reconstruction of the articular surface by plating was performed when soft tissue swelling had subsided. Complications were defined as wound problems requiring hospitalization. All affected limbs were then evaluated via chart and radiograph review, patient interviews, and physical examination until surgical wound healing was complete, for a minimum of twelve months. RESULTS: Group 1 (closed pilon): Follow-up was possible in twenty-nine out of thirty fractures (97 percent). Average time from external fixation to open reduction was 12.7 days. All wounds healed. None exhibited wound dehiscence or full-thickness tissue necrosis requiring secondary soft tissue coverage postoperatively. Seventeen percent (five out of twenty-nine patients) had partial-thickness skin necrosis. All were treated with local wound care and oral antibiotics and healed uneventfully. There was one late complication (3.4 percent), a chronic draining sinus secondary to osteomyelitis, which resolved after fracture healing and metal removal. Group II (open pilon): Follow-up was possible in seventeen patients with nineteen fractures (86 percent). Average time from external fixation to formal reconstruction was fourteen days (range 4 to 31 days). By definition, all Gustilo Type IIIB fractures required flap coverage for the injury. Two patients experienced partial-thickness wound necrosis. These were treated with local wound care and antibiotics. All surgical wounds healed. There were two complications (10.5 percent), both deep infections. One Type I open fracture developed wound dehiscence and osteomyelitis requiring multiple debridements, intravenous antibiotics, subsequent removal of hardware, and re-application of an external fixator to cure the infection. One Type IIIA open fracture of the distal tibia and calcaneus developed osteomyelitis and required a below-knee amputation. CONCLUSION: Based on our data, it appears that the historically high rates of infection associated with open reduction and internal fixation of pilon fractures may be due to attempts at immediate fixation through swollen, compromised soft tissues. When a staged procedure is performed with initial restoration of fibula length and tibial external fixation, soft tissue stabilization is possible. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation can then be performed semi-electively with only minimal wound problems. This is evidenced by the lack of skin grafts, rotation flaps, or free tissue transfers in our series. This technique appears to be effective in closed and open fractures alike.     

Efficacy of Pie-Crusting Technique on Soft Tissues in Distal Tibia and Fibula Fractures

Distal tibia and fibula fractures are challenging injuries to treat as evidenced by the high rates of wound complications because of vulnerable soft tissue coverage. The aim of this study was to examine the effect on soft tissue complications of the pie-crusting technique when applied between 2 incisions in distal tibia and fibula fractures treated with open reduction and internal fixation. We reviewed 34 patients with distal tibia and fibula fractures treated between September 2014 and March 2017. The pie-crusting technique was performed during wound closure in 16 (47.06%) fractures (group 1) and classic wound closure was done in 18 (52.94%) fractures (group 2). The primary outcome was evaluated as the presence or absence of soft tissue complications such as superficial skin necrosis, deep skin necrosis, and deep infection. The mean age was 50.44 ± 13.51 (range 23 to 65) years in group 1 and 51.67 ± 14.49 (range 18 to 68) years in group 2. The mean follow-up time was 27.35 ± 9.02 (range 16 to 46) months. The mean surgery time after injury was 5.88 ± 3.5 (range 1 to 14) days in group 1 and 7.32 ± 4.25 (range 1 to 16) days in group 2. No soft tissue complications were seen in any patient in group 1. Five (27.77%) occurrences of superficial skin necrosis were observed in group 2. In 2 (11.11%) patients in group 2, deep necrosis and wound dehiscence occurred, and subsequent deep infection developed in 1 (5.55%) of these patients. The overall complication rate was higher in group 2 (p = .005). We believe that the pie-crusting technique is beneficial for wound closure in distal tibia and fibula fractures, because it reduces the tension of the skin and allows leakage of subcutaneous fluids.     

The use of trochanteric slide osteotomy in the treatment of displaced acetabular fractures

From January 2003 and February 2006, 31 displaced acetabular fractures were treated by open reduction and internal fixation. The fractures were managed using a single approach, involving a straight lateral incision centered over the greater trochanter, trochanteric osteotomy and dislocation of the femoral head. The mean age of the patients was 48 (range 20-74 years) with a mean follow up 24 months (range from 20 to 42 months). Ten fractures were classified as simple, and 21 as complex fractures. The mean time to surgery was 4.5 days (range from 0 to 14 days). Mean operating time was 118 min (range 52-168). Five patients presented with posterior dislocation of the hip joint at the time of initial presentation. The trochanteric fragment was fixed with three 3.5mm cortical screws. Congruent reduction was achieved in all patients and all osteotomies healed within 5 months. Clinical evaluation was based on the modified Merle d'Aubigne and Postel scoring. Motor strength of abduction was evaluated according to the Medical Research Council grading. Clinical scoring was excellent to good in 24%. The strength of the abductors was grade 0/5 in a patient with Brooker's class IV heterotopic ossification, and 3/5 in the two patients with necrosis of the femoral head. There were five patients with grade 4/5 and the 5/5 in the rest. Complications included two segmental femoral head necrosis, one of them combined with necrosis of the weight bearing acetabular dome area. These patients required total hip replacement. Mild heterotopic ossification grade II was seen in one patient and significant (grade IV), in another patient. Two patients developed superficial wound infection over the trochanteric area and another two patients persistent pain due to irritation caused by the screws. One patient developed peroneal nerve palsy which resolved 3 months after the surgery. The trochanteric slide osteotomy can enhance the exposure of the whole acetabulum and the femoral head. This allows better evaluation of any osteochondral lesions, intra-articular bony fragments and fracture steps, providing a more accurate reduction and easier fixation of the acetabular fracture.     

Fracture of the distal lower limb: two-stage surgical treatment with external fixator and locked-screw plate

From January 1999 until October 2004 we treated 42 patients with closed fractures of the distal calf by a two-stage treatment plan: first the fracture was stabilized with an external fixator bridging the ankle joint. Second, after an average period of 8.3 days, an open reduction and internal fixation with a locked-screw implant followed. As complications we saw a superficial wound necrosis in 3 cases, 2 patients needed an early bone graft after insufficient bone healing and in one case a deep vein thrombosis of the thigh occurred. A deep infection or osteitis were not seen. 17 patients showed no deficit in the range of movement of the ankle joint compared to their opposite side, 21 patients had a deficit of movement of one third compared to the opposite side and 4 patients suffered from a deficit of (2/3). Radiologically we saw in 31 fractures of the pilon-tibiale in 19 cases no or only few arthrosis of the ankle joint, in 9 cases intermediate and in 3 cases advanced arthrosis. With a two-stage surgical treatment with external fixator and locked-screw implant we achieved a good functional result with only few complications.     

Reduction mammaplasty using superior pedicle in macromastia

SUBJECT: The authors present technical details, complications, morphologic and aesthetic results of 26 breast reduction mammaplasty for macromastia (breast reduction more than 1000 g) showing advantages and reliability of technique. MATERIALS AND METHODS: From January 2000 to December 2001, 223 patients underwent bilateral reduction mammaplasty with superior-based pedicled dermo-glandular flap. In 26 of them the weight of removed mammary tissue was over 1000 g in each breast. These 26 cases were evaluated, and the criteria adopted to analyse the results was morphologic and aesthetic evaluation of patient herself (very good, good, acceptable, unacceptable). RESULTS: Mean follow-up for all patients was 15 months. Twenty-six patients (mean age 33.2 years) underwent an average weight of 1131 g (930/2200 g) removed per breast. The following complications were observed: 1 Nipple Areolar Complex ischemia without necrosis; three infections (abscess); four delayed wound closure. The patient subjective evaluation of result was: "very good" in 19 cases (73%); "good" in 5 cases (19.2%) and "acceptable" in the others two cases (7.8%). No case was evaluated "unacceptable". CONCLUSION: Superior dermoglandular pedicle mammaplasty represent a very good and reliable solution for the treatment of macromastia, giving satisfactory cosmetics results with good nipple viability without necrosis. This technique is actually our first choice in the management of macromastia.     

Continuous Irrigation as a Therapeutic Option for Graft Infections of the Groin

Background

Wound infections following vascular procedures occur in 1–7 % of patients and can lead to severe problems including amputation and death. There are no established treatment options for this complication. The aim of our study was to introduce continuous irrigation as a new treatment technique.

Methods

We retrospectively evaluated patients who had undergone bypass surgery involving the groin and had been treated with continuous irrigation because of deep wound infections. The irrigation solution was saline in all cases. The patients were additionally treated with antibiotics. The end point of the study was either complete wound healing or complications such as recurrent infection, amputation, or death.

Results

Wound complications occurred in 65 (15.3 %) of 424 operations. Overall, 20 patients (4.7 %) developed a deep wound infection involving prosthetic graft material. They were treated with continuous irrigation. Complete wound healing was achieved in 13 cases (65.0 %). One patient died. No amputations were necessary.

Conclusions

Based on our results, constant irrigation may be a therapeutic option in patients with deep wound infections. The main advantages of continuous irrigation over other treatments are ongoing bacterial reduction despite primary wound closure and the ability to measure the remaining colonization by microbiologic examination of the irrigation fluid.     

A level one trauma center's experience with the posterior approach to the pelvis

A retrospective review of the experience at Los Angeles County and University of Southern California Medical Center was conducted as part of a multicenter study to evaluate the true complication rate of the posterior approach to the sacroiliac joint. Between 1995 and 1997, 35 patients underwent 42 approaches, representing all patients who underwent the posterior approach by a single staff surgeon at these medical centers. All patients underwent follow-up > or = 1 year postoperatively. (11%) neurologic complications were found postoperatively, all of which resolved prior to discharge. There was 1 (2.4%) wound complication. There was 1 gluteal flap for closure (open fracture) and 1 secondary wound closure. Five patients had prolonged wound drainage (> 5 days). There were no skin sloughs in the series and only 1 patient developed a deep wound infection. Contrary to reports by advocates of anterior approaches and closed reductions, the posterior approach allows anatomic reduction of posterior lesions with an acceptable complication rate.     

Immediate internal fixation of high-energy open forearm fractures

Eighteen patients with Gustilo and Anderson Grade III A (7), III B (8) or III C (3) open diaphyseal forearm fractures were treated with a protocol consisting of extensive primary debridement, immediate open reduction, dynamic compression plate fixation, and vascular repair when indicated. This was followed by routine redebridement at 24 to 48-h intervals until wound status allowed completion of soft tissue reconstruction. Bone grafting was performed at 8 to 10 weeks following obtainment of a closed soft tissue envelope for injuries with extensive comminution or bone loss (5 patients, 7 fractures). Subsequent procedures such as tendon transfers, scar revision, joint arthrodesis, or secondary nerve reconstruction were required in 8 of 18 patients. Minor complications related to delayed wound healing occurred in 3 individuals (15%). One deep infection of a fractured radius occurred in a patient with a floating elbow and failed free flap. Salvage with debridement, retention of hardware, and a second free flap resulted in fracture union. One patient required a second bone graft to obtain union of a segmental forearm defect. Amputation was performed in one patient following failed forearm replantation with greater than 8 h warm ischemia time. Immediate debridement and plate fixation of Grade III forearm fractures performed in conjunction with aggressive soft tissue management provided good or excellent results in 12 patients (66%) and is an acceptable treatment alternative in these difficult injuries.     

Calcaneal fractures: indirect reduction and external fixation

BACKGROUND: The current treatment of displaced intra-articular calcaneal fractures has been surgical fixation. The objective of this study was to evaluate the use of indirect reduction with Ilizarov external fixation as a viable alternative in the surgical treatment of certain calcaneal fractures. METHODS: Thirty-one patients with 33 fractures of the calcaneus (Sanders types II, III, and IV) were treated using small wire circular external fixation. A limited percutaneous plantar skin incision was used to improve reduction of the posterior facet. Fractures were evaluated by preoperative CT scans and classified by an independent observer. Patients were evaluated by physical examination as well as by the AOFAS hindfoot score questionnaire. Followup ranged from 6 months to 4 years. RESULTS: The average AOFAS score for 18 patients available for examination was 66 (42 to 92). The average score increased to 74 for patients with more than 10 months followup and to 77 for patients with isolated calcaneal fractures. Open fractures also had early debridement and soft-tissue coverage; no deep infections were seen in this subgroup. There were 11 complications, including nine superficial pin track infections, one superficial skin necrosis under an area of fracture blister, and one deep infection in a diabetic smoker with severe hemorrhagic fracture blisters. All superficial infections responded to local pin or wound care and oral antibiotics. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done. All open fractures healed and maintained soft-tissue coverage. CONCLUSIONS: Indirect reduction and external fixation is a viable surgical alternative for intra-articular calcaneal fractures. Particularly favorable results were obtained in open fractures when soft-tissue reconstruction also was done. Advantages include shorter time to surgery, immediate weightbearing, minimal invasiveness, few serious wound problems, and no residual hardware. Disadvantages include technical difficulty, incomplete reduction of fracture fragments, and the need for secondary surgery (fixator removal).     

Is perioperative blood transfusion a risk factor for mortality or infection after hip fracture?

OBJECTIVES: To assess whether allogeneic blood transfusion in the perioperative period is associated with changes in mortality or complication rates in patients undergoing surgical treatment for hip fracture (proximal femoral fracture). DESIGN: Retrospective case-control series, all patients followed up for 1 year or until death. SETTING: District General Hospital in Peterborough, UK. PATIENTS PARTICIPANTS: Three thousand six hundred twenty-five consecutive patients admitted and operated for hip fracture (proximal femoral fracture) during July 1989 to January 2002 (151 months); 1068 (29.9%) received a perioperative allogeneic blood transfusion. MAIN OUTCOME MEASURES: Thirty- 120-, and 365-day mortality, deep and superficial wound infection rates. RESULTS: Overall mortality for all patients at 1 year post fracture was 28.2% (1007 patients). Transfusion was associated with a statistically significant increase in mortality from 120 days onward after hip fracture. However, when this was adjusted with a statistical regression model for baseline characteristics and confounding variables, this difference became statistically insignificant (P = 0.17). Infection rates in the transfusion group were 2.0% for superficial infection and 0.9% for deep infection compared with 1.9% and 0.6%, respectively, in the nontransfusion group. These figures were not statistically significantly different. Other complications of deep venous thrombosis, chest infection, and congestive cardiac failure showed no statistically significant increase in those patients who received transfusion. CONCLUSIONS: Our data suggest that transfusion is not associated with a change in mortality or infection rates in the hip-fracture patient.     

Wound complications of the in situ saphenous vein bypass technique.

Wound complications after in situ saphenous vein bypass occur frequently, lengthen hospitalization, and threaten graft viability. From May 1981 to March 1991, 117 consecutive male patients underwent 126 in situ operations: 45 (36%) femoropopliteal, 75 (59%) femorotibial, and 6 (5%) grafts to the dorsal pedal artery for gangrene or ulcer (n = 69), rest pain (n = 54), or claudication (n = 3). Wound complications developed in 55 grafts (44%): erythema developed in 11, but they healed primarily, 19 had skin edge necrosis or localized lymph leaks, 12 had necrosis or infection into the subcutaneous tissue without danger to the graft, and invasive infections that threatened the graft developed in 13. Risk factors for a subsequent wound infection included the development of a lymph leak (p less than or equal to 0.05) and early postoperative graft revision for thrombosis, wound hematoma, retained valve or arteriovenous fistula (p less than or equal to 0.05). The mean time to appearance of a graft-threatening wound infection was 31 days, and 10 of 13 were located in the distal limb. Twelve of the 13 deep infections required operative debridement, and seven required a flap or split thickness skin graft for coverage. Gram-negative as well as gram-positive infections responded equally well. No grafts were lost, and no deaths occurred. Despite the high incidence of wound complications, an aggressive therapy regimen permitted universal graft salvage.     

Metronidazole in the prophylaxis and treatment of anaerobic infection.

The influence of prophylactic metronidazole on vaginal carriage rates of anaerobes and the development of postoperative anaerobic infection was studied in 104 women who underwent abdominal hysterectomy. Metronidazole prophylaxis in 54 patients led to a decrease in the anaerobe vaginal carriage rate from 65% pre-operatively to 17% and 28% on the 3rd and 7th postoperative days respectively. In the control group (50 patients) no significant decrease in anaerobe yield was noted, corresponding percentages being 72%, 64%, and 74%. Postoperative infection occurred in 36 patients (28 controls; 8 on prophylactic metronidazole). Wound swabs from all 8 patients in the latter group yielded aerobes, and in 1 patient mixed infection (aerobes/anaerobes) occurred. In 7 of these patients (including the patient with mixed infection), the infection resolved spontaneously, while the 8th patient responded to therapy with metronidazole, kanamycin and ampicillin. In the control patients, 21 cases of postoperative wound infection and 4 of vault infection were seen; wound swabs from patients in the former group yielded aerobes in only 6 cases, and mixed growth of aerobes/anaerobes in 10 cases. Postoperative wound/vault infections in control patients cleared spontaneously in 18 cases and responded to imidazole therapy, with or without ampicillin and kanamycin, in 7 cases.     

Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach.

This is a review of 183 patients with 218 displaced intraarticular fractures of the calcaneus treated by open reduction and internal fixation. One hundred and ninety four (89%) wounds underwent primary uneventful healing. Twenty-four wounds (11%) required local wound care. One deep infection occurred in a neuropathic foot that required below-knee amputation. No free-tissue transfers, local tissue flaps or skin grafts were needed in patients who presented initially with a closed fracture. Ninety-five fractures (43.5%) required subsequent surgical procedures (hardware removal-88/95 [93% of secondary procedures]). Six patients (2.8%) had postoperative sural nerve findings. Seventeen procedures other than hardware removal were performed. There were five subtalar fusions including two subtalar distraction bone-block arthrodeses. There were seven claw toe correction procedures, four calcaneal valgus osteotomies for varus malunions and one subtalar arthrolysis at the time of hardware removal. These results suggest internal fixation of displaced intra-articular calcaneus fractures using a single lateral approach is a safe, reliable method of treatment.     

Determination of Pathogens in Postoperative Wound Infection After Surgically Reduced Calcaneal Fractures and Implications for Prophylaxis and Treatment

High rates of postoperative wound infection (POWI) have been reported after surgery for calcaneal fractures. This is a retrospective cohort study to determine the causative pathogens of these infections and subsequent treatment strategies. In addition, microbacterial growth from superficial wound swabs and deep fluid or tissue cultures were compared. Patients with a unilateral surgically treated calcaneal fracture during a 15-year period were included. Patient, fracture, and surgical characteristics were collected from the electronic medical records. An infection was categorized as deep or superficial using the Centers for Disease Control and Prevention criteria. Secondary outcomes were wound edge necrosis and wound dehiscence. The collection of culture swabs, their results, and treatment strategies were documented. Of 357 patients, 92 (26%) developed a POWI; 55 (60%) deep and 37 (40%) superficial. The most frequent causative pathogens were Enterobacteriaceae and Staphylococcus aureus. Of the 55 patients with deep infection, 31 (56%) were treated with intravenous antibiotics and surgical debridement, 2 (4%) with intravenous antibiotics, and 22 (40%) with implant removal. In 33 of 92 patients (36%) with a POWI, both superficial and deep cultures were obtained, with a microorganism not cultured from the superficial swab 13 (39%) times. In conclusion, we found that one quarter of patients with operative calcaneal fracture treatment developed a POWI, mainly caused by Enterobacteriaceae or S. aureus. Physicians should not rely on the results of superficially obtained cultures for adequate treatment of deep infection. Because the spectrum of sensitivity profiles varies greatly between hospitals and countries, we recommend empiric antibiotic treatment of both gram-positive and gram-negative microorganisms on suspicion of deep infection.