Harm Hoekstra

Infection after fracture fixation of the tibia: Analysis of healthcare utilization and related costs

INTRODUCTION One of the most challenging complications in musculoskeletal trauma surgery is the development of infection after fracture fixation (IAFF). It can delay healing, lead to permanent functional loss, or even amputation of the affected limb. The main goal of this study was to investigate the total healthcare costs and length-of-stay (LOS) related to the surgical treatment of tibia fractures and furthermore identify the subset of clinical variables driving these costs within the Belgian healthcare system. The hypothesis was that deep infection would be the most important driver for total healthcare costs. PATIENTS AND METHODS Overall, 358 patients treated operatively for AO/OTA type 41, 42, and 43 tibia fractures between January 1, 2009 and January 1, 2014 were included in this study. A total of 26 clinical and process variables were defined. Calculated costs were limited to hospital care covered by the Belgian healthcare financing system. The five main cost categories studied were: honoraria, materials, hospitalization, day care admission, and pharmaceuticals. RESULTS Multivariate analysis showed that deep infection was the most significant characteristic driving total healthcare costs and LOS related to the surgical treatment of tibia fractures. Furthermore, this complication resulted in the highest overall increase in total healthcare costs and LOS. Treatment costs were approximately 6.5-times higher compared to uninfected patients. CONCLUSION This study shows the enormous hospital-related healthcare costs associated with IAFF of the tibia. Treatment costs for patients with deep infection are higher than previously mentioned in the literature. Therefore, future research should focus more on prevention rather than treatment strategies, not only to reduce patient morbidity but also to reduce the socio-economic impact.

Corrective limb osteotomy using patient specific 3D-printed guides: A technical note

We describe the step-by-step process of a corrective osteotomy using 3D printed patient specific guides. Before surgery, bilateral computed tomography (CT) scans are made to plan correction in the affected limb. The digital pre-planning defines the location of the K-wires, drill holes, and the osteotomy site(s). Subsequently, a 3D printed patient specific guide is applied, which indicates the exact position of these drill holes and the osteotomies. This increases the accuracy of the surgery by means of patient specific fit of the guide. During surgery an incision is made and the guide is applied on the bone, which allows the surgeon to perform a very precise osteotomy. Next, the bone is reduced either directly using the plate and marked drill holes, or indirectly using a second reduction guide. In the latter case, the previously drilled K-wires are used to adequately position the reduction guide. Fixation of the bone fragments using plating osteosynthesis finalizes the process. Although this technique has its specific limitations, it might serve as a powerful tool in the treatment of malunion of both articular and nonarticular fractures of the limb.

A combined posterior reversed L-shaped and anterolateral approach for two column tibial plateau fractures in Caucasians: A technical note.

OBJECTIVE Open reduction and internal fixation of two column posterior and lateral tibial plateau fractures through a combined posterior reversed L-shaped and anterolateral approach in floating position in Caucasians. INDICATIONS Two column posterior and lateral tibial plateau fractures. CONTRAINDICATIONS Tibial plateau fractures that do not involve the posterior and lateral column. SURGICAL TECHNIQUE The patient is positioned in floating position, a reversed L-shaped skin incision is made, the posterior column after lateral retraction of the medial head of the gastrocnemius muscle is exposed, and the posterior fragments are reduced and fixed. Subsequently, flexion and varus stress on the knee is applied, an anterolateral skin incision is made, the lateral column is exposed, and the lateral fragments are reduced and fixed. CONCLUSION Despite a different physique as Asians, a combined posterior reversed L-shaped and anterolateral approach in a floating position for the surgical treatment of two column posterior and lateral tibial plateau fractures is technically possible in Caucasians. In our experience, this combined approach is an excellent strategy in most patients for surgical treatment of two column posterior and lateral column fractures.

Functional outcome of intra-articular tibial plateau fractures: the impact of posterior column fractures

AbastractIntroductionAlthough regularly ignored, there is growing evidence that posterior tibial plateau fractures affect the functional outcome. The goal of this study was to assess the incidence of posterior column fractures and its impact on functional outcome and general health status. We aimed to identify all clinical variables that influence the outcome and improve insights in the treatment strategies.MethodsA retrospective cohort study including 218 intra-articular tibial plateau fractures was conducted. All fractures were reclassified and applied treatment was assessed according to the updated three-column concept. Relevant demographic and clinical variables were studied. The patient reported outcome was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS).ResultsMedian follow-up was 45.5 (IQR 24.9-66.2) months. Significant outcome differences between operatively and non-operatively treated patients were found for all KOOS subscales. The incidence of posterior column fractures was 61.9%. Posterior column fractures, sagittal malalignment and an increased complication rate were associated with poor outcome. Patients treated according to the updated three-column concept, showed significantly better outcome scores than those patients who were not. We could not demonstrate the advantage of posterior column fracture fixation, due to a limited patient size.ConclusionOur data indicates that implementation of the updated three-column classification concept may improve the surgical outcome of tibial plateau fractures. Failure to recognize posterior column fractures may lead to inappropriate utilization of treatment techniques. The current concept allows us to further substantiate the importance of reduction and fixation of posterior column fractures with restoration of the sagittal alignment.Level of Evidence: 3

Are there four tibia plateau columns

Letter to the editor, We read with great interest the article in the last issue on the validation of the four-column classification of tibial plateau fractures [1]. However, we have some reservations about the introduction of a fourth posterolateral column of the proximal tibia. The authors demonstrate very high intraand inter-observer agreement. This is in line with others, who validated the three-column classification approach, depicting the posteromedial and posterolateral column as a whole [2–4]. Addressing posterior tibial plateau fractures is indeed increasingly recognized as an important prognostic factor. Neglected posterior column fractures and subsequent sagittal malalignment predispose for significantly worse outcome scores [5]. This underscores the need for new classification approaches. Recently, Krause et al. [6] further strengthen the evidence of frequent involvement of the posterior tibial plateau fractures and proposed a ten segment classification of tibial plateau fractures. Nevertheless, it does not provide an appropriate tool for surgical guiding. In contrast, the three-column classification approach, introduced by Luo et al. in 2010 [7], has proven very useful and reliable for the pre-operative planning and treatment of tibial plateau fractures. Subsequently, with the updated three-column concept they supported the surgical approach and implant choice for the treatment of multiple column fractures on the basis of the mechanism of injury and fracture pattern [8]. In addition, we established and validated the revised three-column classification approach, which proved to be of high reliability as well [9]. According to the revised approach the posterior border of the lateral column lies posterior instead of anterior of the fibula (Fig. 1a). Because of this, a blind-zone is created (i.e. posterolateral corner). Proximal tibia variable angle LCPs make it possible to adequately fixate lateral column fractures that extend posteriorly into the posterolateral corner and provide articular support, whereas posterior column fractures (with or without extension into the posterolateral corner) can sufficiently be treated using a posteromedial reversed Lshaped approach. The latest LCP implant with an identical configuration, allows for both buttress and articular support of the entire posterior column (Fig. 1b). Furthermore, treatment of (isolated) posterolateral corner injury is aimed at ligament repair or reconstruction using graft techniques. Hence, from the surgical point of view, posterolateral tibial plateau fractures should not be considered as full-fledged fourth-column fractures. After all, Chang et al. [11], as referred by the authors [1], previously described in a small cases series the combined anterolateral and posteromedial L-shaped approach for the treatment of complex bicondylar four-quadrant tibial plateau fractures, rather than establishing a four-column classification approach. Comment on reliability of a four-column classification for tibial plateau fractures

Functional outcome and general health status after treatment of AO type 43 distal tibial fractures

INTRODUCTION Distal tibial fractures are uncommon, but they result in poor overall outcome. The objective of this study was to assess functional outcome and general health status after the treatment of distal tibial fractures and identify factors that affect these outcome measures. PATIENTS AND METHODS A retrospective cohort study including 118 AO type 43 distal tibial fractures in 116 patients was conducted. With regard to articular involvement, fractures were classified as either simple (A1-B2, n=70) or complex (B3-C3, n=48). Twenty relevant demographic and operative variables were studied. Functional outcome, quality of life and pain were assessed using the Foot Function Index (FFI) and AOFAS ankle score, physical and mental SF-36, and Visual Analog Scale (VAS) questionnaires, respectively. RESULTS Over 75% of patients experienced noteworthy loss of ankle function. The general health status assessment showed markedly affected quality of life with more than two-third of all responding patients suffering from pain every day. In fact, complex fractures and increased complication rate were associated with worse functional outcome, whereas prolonged time to definite surgery affected both functional outcome and general health status significantly. CONCLUSIONS Complex distal tibial fractures were associated with poor functional outcome scores and delayed (-staged) surgery has been shown to prevent postoperative soft tissue problems. However, soft tissue injury associated with distal tibial fractures itself affected both the postoperative functional outcome and general health status as well. This should contribute to the understanding of treatment and outcome of distal tibial fractures. LEVEL OF EVIDENCE 3.

Are the current guidelines for surgical delay in hip fractures too rigid? A single center assessment of mortality and economics

PURPOSE Controversy remains around acceptable surgical delay of acute hip fractures with current guidelines ranging from 24 to 48 h. Increasing healthcare costs force us to consider the economic burden as well. We aimed to evaluate the adjusted effect of surgical delay for hip fracture surgery on early mortality, healthcare costs and readmission rate. We hypothesized that shorter delays resulted in lower early mortality and costs. METHODS In this retrospective cohort study 2573 consecutive patients aged ≥50 years were included, who underwent surgery for acute hip fractures between 2009 and 2017. Main endpoints were thirty- and ninety-day mortality, total cost, and readmission rate. Multivariable regression included sex, age and ASA score as covariates. RESULTS Thirty-day mortality was 5% (n = 133), ninety-day mortality 12% (n = 304). Average total cost was €11960, dominated by hospitalization (59%) and honoraria (23%). Per 24 h delay, the adjusted odds ratio was 1.07 (95% CI 0.98-1.18) for thirty-day mortality, 1.12 (95% CI 1.04-1.19) for ninety-day mortality, and 0.99 (95% CI = 0.88-1.12) for readmission. Per 24 h delay, costs increased with 7% (95% CI 6-8%). For mortality, delay was a weaker predictor than sex, age, and ASA score. For costs, delay was the strongest predictor. We did not find clear cut-points for surgical delay after which mortality or costs increased abruptly. CONCLUSIONS Despite only modest associations with mortality, we observed a steady increase in healthcare costs when delaying surgery. Hence, a more pragmatic approach with surgery as soon as medically and organizationally possible seems justifiable over rigorous implementation of the current guidelines.

Functional outcome and economic burden of operative management of patellar fractures: the pivotal role of onerous implants

ObjectivesThe complication rate following operative treatment of patellar fractures remains high and is associated with a poor functional outcome. The primary goal of this study was to evaluate our functional outcome of patellar fracture osteosynthesis and define strategies to improve the outcome. The healthcare costs and utilization were calculated.MethodsAll demographic, clinical, radiographic variables and hospital-related costs of 111 patients with 113 surgically treated patellar fractures between January 2005 and December 2014 were analyzed. Fractures were grouped as either simple or complex. Functional outcome was assessed using Knee Injury and Osteoarthritis Outcome Score (KOOS).ResultsThere were 67 simple fractures (59.3%) and 46 complex fractures (40.7%). The overall complication rate was 48.7%, including 19.5% implant-related complications. In 69 patients (61.1%), implants were removed. The outcome was rather poor, with considerable impairment in all KOOS subscales with the knee-related quality of life rated worst (median 62.5, IQR 37.5–81.25). Poor outcome correlated significantly with complex patellar fractures and extensive tension-band constructs.ConclusionsThe operative treatment of patellar fractures was associated with a high complication rate, functional impairment and reduced quality of life. Complex patellar fractures and extensive tension-band constructs were identified as the main determinants of poor outcome and increased economic burden due to higher reinterventions rates. Strategies to reduce complications and improve outcome should focus on less onerous implants.

Direct fixation of fractures of the posterior pilon via a posteromedial approach

The treatment of fractures of the posterior pilon is a timely issue. Restoration of the integrity of the incisura fibularis and subsequent anatomic reduction of the fibula are essential for reconstruction of the ankle mortise after trauma, and syndesmotic stability. Inappropriate treatment ultimately will lead to a poor functional outcome and quality of life. Open reduction and direct internal fixation through a posterolateral or posteromedial approach are increasingly preferred over indirect reduction and anteroposterior screw fixation. The posteromedial approach, although elegant, straightforward, and offering an excellent exposure of the fracture site, is used less frequently than the posterolateral approach. In this technical note we describe the posteromedial approach for the treatment of posterior pilon fractures in a step-by-step fashion. We will discuss the indications, its benefits and limitations.

Fibular Nailing Seems an Effective Strategy to Decrease Treatment Crude Costs for AO-Type 44B Ankle Fractures in Elderly Patients

In the article, “Health Care Usage and Related Costs in Fibular Plating for AO Type 44-B Ankle Fractures in a Belgian University Hospital: An Exploratory Analysis,” which appears in this issue (1), we show that the costs for the operative treatment of unstable ankle fractures (AO type 44-B) strongly correlate with the length of stay (LOS) of the patient. In turn, the LOS itself is influenced not only by easily objectifiable variables such as treatment type and patient age but also by more difficult to measure parameters such as the level of process standardization and individual preferences of the surgeon, the patients, and their families. Hence,weposethehypothesis that treatmentcostscanbereduced by defining clear-cut clinical pathways. These clinical pathways should distinguish between treatment type and age of the patient. Moreover, innovative surgical strategies can potentially both contribute to and decrease the LOS while retaining the same level of outcome. Bugler et al (2) reported in 2012 satisfactory operative outcome of unstable ankle fractures in elderly patients with the use of a fibular nail (Acumed, Hillsboro, OR), which allowed early minimal invasive fixation of the fibula. Building on these results, we hypothesized that early percutaneous intramedullary fibular nailing of AO type 44-B fractures in the elderly ( 65 years) can reduce treatment costs by realizing a shorter preoperative LOS in elderly patients who normally would have been treated using a delayed or delayed-staged surgery protocol. Recently, we launched a prospective observational study including elderly patients with an AO type 44-B fracture, treated with a fibular nail. The purpose of this study is foremost to evaluate the use and outcome of this nail.