PURPOSE OF THE STUDY The study aims to determine the incidence of fracture-related infection (hereinafter referred to as the FRI) at a Level I trauma centre over a three-year period. It also aimed to determine the risk factors, to observe confirmatory and suggestive criteria in line with the applicable recommendations, and to evaluate the bacterial spectrum in a diagnosed FRI. MATERIAL AND METHODS It is a retrospective-prospective study carried out through studying the documentation. The study included all patients diagnosed with FRI and treated between 2019 and 2021, except for the patients with hand fractures since minor phalangeal fractures of the fingers were largely treated by the outpatient department, no osteosynthesis was performed in the operating room, and these patients were not followed up at our department. RESULTS The FRI incidence was 2.33% of all osteosyntheses performed at the Level 1 trauma centre in the period 2019-2021. The FRI was most often caused by pyogenic cocci agents and the FRI developed most frequently within 6 months after osteosynthesis. The site at risk was the lower limb region. The FRI incidence was most often indicated by suggestive clinical criteria (redness, secretion, pain) and radiological criteria (delayed healing, non-union). Overall, 42.19% of treated nonunions were later diagnosed as FRI. At the time of FRI diagnosis, the CRP values were normal in 21.7% of patients. DISCUSSION The FRI incidence rate in 2019-2021 was 2.33%, which corresponds with the values reported in other papers focusing on the incidence of infectious complications after osteosynthesis. Fang and Depypere reported 1-2% of infectious complications. The most common risk factors are open fractures, which account for 20.16% in our cohort. Ktistakis and Depypere describe the incidence of osteomyelitis in 30% of treated open fractures. In our cohort, the incidence of FRI was significantly higher in lower limb fractures. Bezstarosti, Wang and Pesch published similar results, with some deviations. The time from osteosynthesis to final FRI diagnosis varied from a few weeks to several years. In more than half of the patients the FRI developed within 6 months after performed osteosynthesis. Metsemakers and Fang refer to the very same trend. The CRP levels in the study population varied a lot. Xing-qi Zhao describes CRP as a less sensitive (sensitivity 65.6%) but more specific marker (specificity 75.4%). According to the available literature, the most common agents causing infectious complications of osteosynthesis are gram-positive cocci, S. aureus in particular. In our study, G+ pyogenic cocci were clearly the most commonly detected, which is consistent with the results of studies by Fang and Depypere, focused on the incidence of infectious complications. The most common FRI clinical manifestations included wound secretion, redness, swelling and pain. Furthermore, suggestive radiological criteria, especially delayed healing and non-union also indicated the FRI occurrence. According to Fang, the most common clinical manifestations of infectious complications include pain, swelling, redness and wound dehiscence. Fang reports that the most common radiologic findings are the periosteal reaction, loosening of the implant and delayed healing or non-union, which is consistent with our cohort. In the cohort of non-unions surgically treated at our department, FRI was subsequently confirmed in 42.19% of cases. CONCLUSIONS The incidence of FRI at Level 1 trauma centre was 2.33% of operated fractures in 2019-2021, with pyogenic cocci being the most common infectious agents. The FRI usually developed within 6 months after osteosynthesis. The typical site for the FRI development was the lower limb region, the ongoing FRI was indicated by suggestive clinical criteria (redness, secretion, pain) and radiological criteria (delayed healing and a non-union). Overall, 42.19% of treated non-unions were later diagnosed as FRI. Key words: fracture-related infection, FRI, suggestive criteria, confirmatory criteria, FRI diagnosis, microbial, microbiology spectrum, osteosynthesis, complications, non-union.
BACKGROUND: Femoral posterior hip dislocation with associated femoral head fractures (Pipkin fractures) are rare high-energy injuries. Published treatment modalities involve conservative treatment, head fragment resection, open reduction and internal fixation, and total hip replacement. The experience with mini-invasive screw osteosynthesis of these fractures is the main focus of our study. METHODS: Seven Pipkin fractures (five Pipkin II and two Pipkin I) in six patients were treated by closed reduction of hip dislocation, followed by minimal invasive lag screw osteosynthesis. Cancellous screw(s) were inserted from the incision on the lateral hip through the femoral neck to the reduced fracture fragment. In all patients, postoperative CT was performed to check the quality of surgery. Active physiotherapy with immediate toe-touch weight bearing was the routine postoperative protocol. In all patients, radiological and clinical results were evaluated with the Thompson Epstein, Merle d'Aubigne and Postel score, and Harris hip score. RESULTS: All fractures united, and all femoral heads survived. Infectious complications were not observed, and no secondary surgery was needed. After an average follow-up of 18.4 months, the average Merle d'Aubigne and Postel score was 17.7 points, while the mean Harris hip score reached 98.1 points. The majority of patients achieved an excellent Thompson-Epstein clinical and radiological outcome. All patients returned to their original occupation. CONCLUSIONS: Mini-invasive screw osteosynthesis can be used for the treatment of Pipkin type I-II femoral head fractures. Successful reduction of hip dislocation and head fracture is necessary for using this technique. Long-term follow-up is necessary to confirm this technique.
- MeSH
- fraktury femuru * komplikace chirurgie MeSH
- fraktury kyčle * diagnostické zobrazování chirurgie komplikace MeSH
- hlavice femuru diagnostické zobrazování chirurgie zranění MeSH
- kostní šrouby škodlivé účinky MeSH
- lidé MeSH
- luxace kyčle * komplikace chirurgie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
ÚVOD: Otevřená repozice a osteosyntéza je spojena s určitým rizikem poruch hojení operační rány, zejména při nesprávném timingu. Miniinvazivní postupy umožňují toto riziko snížit, navíc s výhodou časnějšího ošetření zlomeniny. C-nail je implantát umožňující miniinvazivní, vysoce stabilní osteosyntézu zlomenin patní kosti. CÍL: Prospektivně zhodnotit vlastní soubor pacientů ošetřených pomocí hřebu C-nail a porovnat tyto výsledky se studiemi, kde byla použita dlahová osteosyntéza z otevřeného laterárního přístupu. HYPOTÉZA: Při použití patního hřebu C-nail předpokládáme vyšší biomechanickou stabilitu, nižší výskyt pooperačních komplikací, zejména nízké procento rozvoje infekce a lepší funkční výsledky oproti konvenční metodě dlahování se srovnatelnými funkčními výsledky. SOUBOR NEMOCNÝCH A METODA: Do souboru bylo zařazeno celkem 249 nemocných (222 mužů a 27 žen, průměrný věk 47,3 let) s 265 zlomeninami patní kosti indikovaných k operačnímu řešení, kteří byli operováni mezi roky 2011–2018 implantátem C-nail na oddělení úrazové chirurgie nemocnice Pardubice, dle zařazovacích kritérii. Data nemocných byla hodnocena z hlediska pooperačních komplikací, restituce Böhlerova úhlu, rekonstrukce zadní kloubní plochy na základě RTG a CT snímků zhotovených předoperačně, pooperačně a za 12 měsíců. Funkční výsledek byl hodnocen pomocí bodovacího systému AOFAS – Ankle-Hindfoot Scale (American Orthopaedic Foot and Ankle Society). Jako kontrolní soubor byla využita data z dostupné odborné literatury. VÝSLEDKY: Průměrná hodnota AOFAS po 12 měsících dosáhla hodnoty 90,5 bodů. Okrajová nekróza rány byla pozorována ve třech případech (1,1 %) a infekce měkkých tkání v jednom případě (0,4 %). Böhlerův úhel byl obnoven z průměrných hodnot 5,9° před operací na 32.1°pooperačně. Po 12 měsících byl zaznamenán mírný pokles Böhlerova úhlu na 27,6°. ZÁVĚR: Výsledky našeho souboru v komparaci se soubory, kde bylo použito konvenční dlahování s extenzivním laterálním přístupem, ukazují, že obě metody mají srovnatelné AOFAS skóre. Použití hřebu je zatíženo signifikantně nižším procentem komplikací, zejména nízkým rizikem vzniku infekce. C-nail je metoda použitelná pro všechny typy zlomenin patních kostí klasifikovaných dle Sanderse. S výhodou ji lze použít u luxačních a otevřených zlomenin.
- Klíčová slova
- C-Nail,
- MeSH
- fraktury kostí chirurgie MeSH
- kostní hřeby * MeSH
- lidé MeSH
- miniinvazivní chirurgické výkony metody MeSH
- patní kost * chirurgie zranění MeSH
- prospektivní studie MeSH
- vnitřní fixace fraktury metody MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- srovnávací studie MeSH
INTRODUCTION: Open reduction and osteosynthesis is associated with a certain risk of impaired healing of the surgical wound, especially with improper timing. Minimally invasive procedures make it possible to reduce this risk, with the advantage of earlier treatment of the fracture. The C-nail is an implant allowing for minimally invasive, highly stable osteosynthesis of calcaneal fractures. OBJECTIVE: To prospectively evaluate our own cohort of patients treated with the C-nail and compare these results with studies using plate osteosynthesis from an open lateral approach. HYPOTHESIS: With the use of the C-nail, we expect higher biomechanical stability, a lower incidence of postoperative complications, especially a low percentage of infection development and better functional results compared to the conventional plating method with comparable functional results. COHORT OF PATIENTS AND METHOD: A total of 249 patients (222 males and 27 females, mean age 47.3 years) with 265 calcaneal fractures indicated for surgical treatment were included in the cohort and were operated on between 2011-2018 with a C-nail implant at the Department of Trauma Surgery, Pardubice Hospital, according to the inclusion criteria. Patients‘ data were evaluated for postoperative complications, restitution of the Böhler’s angle, and reconstruction of the posterior articular surface based on radiographs and CT scans taken preoperatively, postoperatively, and at 12 months. Functional outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system - Ankle- Hindfoot Scale. Data from the available literature were used as a control set. RESULTS: The average AOFAS score after 12 months was 90.5. Marginal wound necrosis was observed in three cases (1.1 %) and soft tissue infection in one case (0.4 %). The Böhler’s angle was restored from an average of 5.9° preoperatively to 32.1° postoperatively. After 12 months, a slight decrease in the Böhler’s angle to 27.6° was observed. CONCLUSION: The results of our cohort compared with those using conventional plating with an extensive lateral approach show that both methods have comparable AOFAS scores. The use of the nail is burdened with a significantly lower percentage of complications, especially a low risk of infection. C-nail is a method applicable to all types of calcaneal fractures classified according to Sanders. It can preferably be used in dislocated and open fractures.
- Klíčová slova
- C-Nail,
- MeSH
- fraktury kostí chirurgie MeSH
- kostní hřeby * MeSH
- lidé MeSH
- miniinvazivní chirurgické výkony metody MeSH
- patní kost * chirurgie zranění MeSH
- prospektivní studie MeSH
- vnitřní fixace fraktury metody MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- srovnávací studie MeSH
PURPOSE OF THE STUDY The purpose of the study was to assess two therapeutic procedures of temporary fixation of displaced ankle fractures, namely the plaster fixation or Kirschner wire (KW) transfixation via the sole of the foot. MATERIAL AND METHODS Group of patients The randomised prospective study conducted in the period 02/2016-02/2017 compared two methods of temporary fixation of displaced ankle fractures. In total, 38 patients were included in the study (18 patients treated with plaster fixation, 20 patients treated with KW). Methods During the randomisation (by envelopes, drawing of lots by the patient), in one group of patients, temporary stabilisation by plaster fixation was performed, whereas the other group was treated by percutaneously inserted KWs. The attention was focused on the quality of achieved reduction, its retention until the final treatment, and soft tissue status. After one year, the final examination was performed, in which we focused on the assessment of the clinical condition of the ankle joint with the use of the Olerud-Molander Ankle Score (OMAS), the AOFAS (American Orthopedic Foot and Ankle Society) score, and the Visual Analogue Scale (VAS) measuring the overall satisfaction. Moreover, in both the methods potential incidence of arthritic changes was monitored on radiographs. RESULTS Both the methods achieved 100% successful reduction rate. The group with plaster fixation reported a loss of reduction in six patients (33.3%) as against the KW group where no loss of reduction occurred. This difference was significant (p = 0.007). In plaster fixation method, after its removal local complications occurred on skin in 56%, of which skin necrosis in 16.7%, and it always occurred in association with the loss of reduction, which was statistically significant (p = 0.245). In KW method, local complications on skin were present in 25% only. In the group of patients with KW, there was not a single case of surface or deep infection reported. No KW migration was observed. DISCUSSION Potential complications of conservative treatment of displaced fractures with plaster fixation include the migration of fragments and widening of the ankle fork during the further course which may threaten the vitality of soft tissues. A total of six patients (33.3%) treated with plaster fixation showed a failure of reduction, which is by approximately 10% more than described in literature. In seven cases after the plaster fixation removal bullae were observed (38.9%) and in three cases skin necrosis was present (16.7%), which occurred in re-displaced fractures only. The bullae were present whether the reduction was successfully maintained or not. In literature, local complications after plaster fixation removal are reported in roughly 14%. Temporary percutaneous ankle KW transfixation is applied to maintain the reduced fracture in a favourable position and to facilitate monitoring and treating the soft tissues. Prior to the final surgical solution, bullae were observedin four cases (20%), of which skin necrosis in one case (5%). Bullae formation and necrosis are most likely related to the initial damage to soft tissues due to the injury and were not caused by the KW insertion. The literature describes local complications in 7% with respect to the KW technique, however, the type of complications is not specified. In our group, at a one-year follow-up arthritic changes grade I and II according to Kellgren and Lawrence scale were reported in 70% of cases with KW technique. Whether the osteoarthritis was caused by fixation or the fracture itself and what would be the percentage of individual types of osteoarthritis after several years of follow-up is a question. CONCLUSIONS Plaster fixation or Kirschner wires for temporal fixation of displaced ankle fractures shall be applied on a case by case basis. Based on our findings, the application of plaster fixation to displaced ankle fractures does not provide adequate stability of the reduced fracture and in case of re-displacement the status of soft tissues deteriorates. The impossibility to control the status of soft tissues in plaster fixation and the lower complication rate in fixation with K wires constitute additional reasons why this fixation technique via the sole of the foot appears to reap more benefits. Key words:displaced ankle fractures, temporal fixation, plaster fixation, Kirschner wire transfixation, complications.
PURPOSE OF THE STUDY Peripheral fractures of the talus (lateral talar process and posterior talar process) are rare injuries, easy to miss on examination due to their location and clinical manifestation. They account for 0.3% to 1.0% of all fractures of the talus. An incorrect or late treatment of talar process fractures can result in permanent pain, impingement syndrome, healing in malposition, pseudoarthrosis development and also, due to joint instability, in a potential development of severe subtalar arthritis. The aim of this retrospective study was to evaluate the results of surgical management of these fractures in our department. MATERIAL AND METHODS The study included 14 adult patients with fractures of the peripheral talar processes who met the criteria of the retrospective study and were treated in our department between 2008 and 2014. All patients underwent clinical examination with evaluation based on the AOFAS Ankle-Hindfoot score, VAS score and radiographic evidence of arthritis. Follow-up ranged from 24 to 95 months. The average age of the patients at the time of surgery was 34 years (range, 21-59 years); there was one woman and 13 men. All underwent pre-operative CT scanning. The surgical procedure included open reduction and internal fixation (ORIF) which, in indicated cases, was preceded by partial or total removal of the processes. RESULTS Of the 14 patients, seven were treated for fractures of the lateral talar process (LTP group) and seven for the posterior talar process (PTP group). All fractures healed completely. The median AOFAS score was 87 (72-100) points in the LTP group, and 84 (58-100) points in the PTP group. Excellent and good results on the AOFAS Ankle-Hindfoot scale were achieved in 10 (72%), satisfactory in two (14%) and poor in two (14%) patients. Of the LTP group, six patients (86%) showed the VAS score ≤ 3, and one (14%) had the VAS score = 4. In the PTP group, the VAS score ≤ 3 was reported by three (43%) and values of up to 5 by four (57%) patients. Arthritis in the talocrural and subtalar joints was evaluated as zero or grade 1 in 11 (79%) of all patients; of these 11 patients only two (14%) had a VAS score higher than 3. Only one patient had marginal wound necrosis; no deep wound infection was recorded. DISCUSSION The majority of fractures in our group were due to falls from a height or traffic accidents, which is in accordance with the literature data. In about 70% of these injuries, more parts of the leg are affected and, therefore, a thorough medical inspection is necessary. These mechanisms of injury most frequently produce type II LTP fracture (Hawkins classification). Four patients with a LTP fracture, who had the process partially removed, achieved good results on the AOFAS scale and the VAS score less than or equal to 3. As also published in the literature, the removal of small fragments has no crucial effect on ankle stability. CONSLUSIONS An adequate surgical treatment of displaced peripheral fractures of the talar processes provides good functional outcomes. In fractures with associated leg injuries or high-energy traumata, the prognosis is poorer. Fractures of talar processes often show symptoms and signs similar to those of more serious forms of dislocation of the talus and therefore a careful assessment of standard X-ray images taken for a "swollen ankle" is necessary. If the findings are not clear, CT examination is indicated. Key words: fracture, talus, processus lateralis tali, processus posterior tali.
- MeSH
- dopravní nehody MeSH
- dospělí MeSH
- fraktury kostí diagnostické zobrazování etiologie chirurgie MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- počítačová rentgenová tomografie MeSH
- retrospektivní studie MeSH
- spokojenost pacientů MeSH
- talus diagnostické zobrazování zranění chirurgie MeSH
- úrazy pádem statistika a číselné údaje MeSH
- vnitřní fixace fraktury metody MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
