Objectives: To evaluate the rate of, and reasons for, conversion of closed treatment of humeral shaft fractures using a fracture brace, to surgical intervention. Design: Multicenter, retrospective analysis. Setting: Nine Level 1 trauma centers across the United States. Patients: A total of 1182 patients with a closed humeral shaft fracture initially managed nonoperatively with a functional brace from 2005 to 2015 were reviewed retrospectively from 9 institutions. Intervention: Functional brace. Main outcome measurements: Conversion to surgery. Results: A total of 344 fractures (29%) ultimately underwent surgical intervention. Reasons for conversion included nonunion (60%), malalignment beyond acceptable parameters (24%), inability to tolerate functional bracing (12%), and persistent signs of radial nerve palsy requiring exploration (3.7%). Univariate comparisons showed that females and whites were significantly (P < 0.05) more likely to be converted to surgery. The multivariate logistic regression identified females as being 1.7 times more likely and alcoholics to be 1.4 times more likely to be converted to surgery (P < 0.05). Proximal shaft as well as comminuted, segmental, and butterfly fractures were also linked to a higher rate of conversion. Conclusions: This large multicenter study identified a 29% surgical conversion rate, with nonunion as the most common reason for surgical intervention after the failure of functional brace. These results are markedly different than previously reported. These results may be helpful in the future when counseling patients on the choice between functional bracing and surgical intervention in managing humeral shaft fractures. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Objectives: To compare the risks of surgical site infection (SSI) and postoperative complications after acetabular fracture open reduction internal fixation (ORIF) in patients receiving topical intrawound antibiotic powder compared with those not receiving antibiotic powder (control group). Design: Retrospective cohort. Setting: Level I trauma center. Patients and Intervention: We reviewed 789 acetabular fracture ORIF cases from 2010 to 2019 at our institution, with mean follow-up of 18 months (3–112 months). Overall, 326 patients comprised the control group and 463 received topical antibiotic powder (294 vancomycin and 169 vancomycin/tobramycin). Main Outcome Measurement: The study groups were compared for risk of SSI, seroma formation, wound dehiscence, acute kidney injury (AKI), and other postoperative complications. Results: There were 63 total SSI (8.0%), 50 (6.3%) deep SSI and 13 suprafascial SSI (1.6%) cases. There was no difference in the risk of total SSI (8.3% vs. 7.8%, P = 0.80) or deep SSI (6.1% vs. 6.5%, P = 0.64). This was confirmed by multivariate analysis adjusting for covariates (odds ratio = 0.93; 95% confidence interval, 0.52–1.67; P = 0.80). Similar results were demonstrated when comparing the control group with the vancomycin and vancomycin/tobramycin subgroups. The control group and antibiotic powder groups had similar risks of all outcomes of interest, including seroma formation (1.8% vs. 1.7%, P = 1.00), wound dehiscence (1.2% vs. 2.2%, P = 0.42), total AKI (5.2% vs. 8.2%, P = 0.12), and RIFLE classification AKI (injury; 0.9% vs. 2.2%, P = 0.50). Conclusions: The addition of topical intrawound antibiotic powder, whether vancomycin alone or vancomycin/tobramycin before closure, does not reduce the risk of SSI after acetabular fracture ORIF compared with standard normal saline irrigation alone. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Background: Intra-articular fractures of the calcaneus are a common injury to the hindfoot following high-energy trauma to the lower extremity. Treatment of these fractures has evolved. Due to the concern of wound complications associated with extensile open treatment, smaller incision techniques, such as the sinus tarsi approach, are increasing in popularity. A number of fixation strategies are utilized with this approach, and it is unknown which most accurately restores radiographic alignment. The purpose of this study was to compare the postoperative radiographic outcomes of a plate and screw construct versus a cannulated screw construct when using the sinus tarsi approach for open reduction and internal fixation (ORIF) of calcaneus fractures. Methods: After institutional review board approval, records for all patients treated surgically at our institution for calcaneus fractures from 2012 to 2017 were reviewed. Inclusion criteria were intra-articular calcaneus fractures, patients aged 18 years or older, and use of the sinus tarsi approach. Exclusion criteria were open fractures and fractures with less than 6 weeks of postoperative weightbearing, which were excluded for radiographic outcomes. A total of 51 fractures underwent ORIF using cannulated screws alone (group 1), and 23 fractures underwent ORIF using a sinus tarsi plate (group 2). Sixty-one fractures (41 vs 20, respectively) met criteria for radiographic comparison. The primary outcomes of interest included pre- and postoperative Bohler and Gissane angles, wound complications, unplanned return to the operating room (OR), and cost comparison. Results: There was no statistically significant difference between preoperative Bohler angles for group 1 (14.4 degrees) versus group 2 (12.2 degrees) ( P = .44), nor was there a significant difference between postoperative Bohler angles for group 1 (30.1 degrees) versus group 2 (27.1 degrees) ( P = .14). Similarly, preoperative Gissane angles for group 1 (130.5 degrees) and group 2 (133.4 degrees) ( P = .54) and postoperative Gissane angles for group 1 (118.2 degrees) and group 2 (119.8 degrees) ( P = .44) showed no statistically significant difference. There were a total of 3 wound complications in group 1 versus 2 wound complications in group 2 ( P = .66). There was no statistically significant difference in operative duration ( P = .97) or the number of unplanned returns to the OR between the 2 groups ( P = .68). Based on the implants used at this institution, and depending on the number of screws used, the estimated cost range of a plate construct was $1070 to $1235, while the estimated cost range of a cannulated screw construct was $717 to $1264. Conclusion: When comparing the cannulated screw and plate and screw fixation techniques, there was no difference in restoration of the Bohler and Gissane angles. Furthermore, the amount of angular correction achieved by initial reduction showed no statistically significant difference between groups, and the amount of reduction lost between initial and final postoperative radiographs showed no statistically significant difference between groups. With regard to the 2 techniques, there was no statistically significant difference in rates of postoperative complications and return to the OR. Our data suggest that fixation using cannulated screws alone versus sinus tarsi plate provides similar radiographic outcomes and risk of complications. The 2 techniques were also similar in terms of implant costs. Our results indicate that either technique effectively improved radiographic parameters. Level of Evidence: Level III, retrospective comparative study.
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