Justin E. Richards

Relationship of hyperglycemia and surgical-site infection in orthopaedic surgery.

BACKGROUND The impact of perioperative hyperglycemia in orthopaedic surgery is not well defined. We hypothesized that hyperglycemia is an independent risk factor for thirty-day surgical-site infection in orthopaedic trauma patients without a history of diabetes at hospital admission. METHODS Patients eighteen years of age or older with isolated orthopaedic injuries requiring acute operative intervention were studied. Patients with diabetes, injuries to other body systems, a history of corticosteroid use, or admission to the intensive care unit were excluded. Blood glucose values were obtained, and hyperglycemia was defined in two ways. First, patients with two or more blood glucose levels of ≥200 mg/dL were identified. Second, the hyperglycemic index, a validated measure of overall glucose control during hospitalization, was calculated for each patient. A hyperglycemic index of ≥1.76 (equivalent to ≥140 mg/dL) was considered to indicate hyperglycemia. The primary outcome was thirty-day surgical-site infection. Multivariable logistic regression models evaluating the effect of the markers of hyperglycemia, after controlling for open fractures, were constructed. RESULTS Seven hundred and ninety patients were identified. There were 268 open fractures (33.9%). Twenty-one thirty-day surgical-site infections (2.7%) were recorded. Age, race, comorbidities, injury severity, and blood transfusion were not associated with the primary outcome. Of the 790 patients, 294 (37.2%) had more than one glucose value of ≥200 mg/dL. This factor was associated with thirty-day surgical-site infection, with thirteen (4.4%) of the 294 patients with that indication of hyperglycemia having a surgical-site infection versus eight (1.6%) of the 496 patients without more than one glucose value of ≥200 mg/dL (p = 0.02). One hundred and thirty-four (17.0%) of the 790 patients had a hyperglycemic index of ≥1.76, and this was also associated was thirty-day surgical-site infection (ten [7.5%] of 134 versus eleven [1.7%] of 656; p < 0.001). Multivariable logistic regression models demonstrated that two or more blood glucose levels of ≥200 mg/dL was a risk factor for thirty-day surgical-site infection (odds ratio [OR]: 2.7, 95% confidence interval [CI]: 1.1 to 6.7) after adjustment for open fractures (OR: 3.2, 95% CI: 1.3 to 7.8). A second model demonstrated that a hyperglycemic index of ≥1.76 was an independent risk factor for surgical-site infection (OR: 4.9, 95% CI: 2.0 to 11.8) after controlling for open fractures (OR: 3.3, 95% CI: 1.4 to 8.3). CONCLUSIONS Hyperglycemia was an independent risk factor for thirty-day surgical-site infection in orthopaedic trauma patients without a history of diabetes.

Stress-induced hyperglycemia as a risk factor for surgical-site infection in nondiabetic orthopedic trauma patients admitted to the intensive care unit.

Objectives: The aim of this study was to evaluate the association between stress-induced hyperglycemia and infectious complications in nondiabetic orthopedic trauma patients admitted to the intensive care unit (ICU). Design: This study was a retrospective review. Setting: The study was conducted at an academic level-1 trauma center. Patients: One hundred and eighty-seven consecutive trauma patients with isolated orthopedic injuries were studied. Intervention: Blood glucose values during initial hospitalization were evaluated. The admission blood glucose (BG) and hyperglycemic index (HGI) were determined for each patient. Main Outcome Measures: Perioperative infectious complications: pneumonia, urinary tract infection (UTI), surgical-site infection (SSI), sepsis were the outcome measures. Results: An average of 21.5 BG values was obtained for each patient. The mean ICU and hospital length of stay was 4.0 ± 4.9 and 10.0 ± 8.1 days, respectively. Infections were recorded in 43 of 187 patients (23.0%) and SSIs specifically documented in 16 patients (8.6%). Open fractures were not associated with SSI (8/83, 9.6% vs. 8/104, 7.7%). There was no difference in admission BG or HGI and infection. However, there was a significant difference in HGI when considering SSI alone (2.1 ± 1.7 vs. 1.2 ± 1.1). Patients with an SSI received a greater amount of blood transfusions (14.9 ± 12.1 vs. 4.9 ± 7.6). No patient was diagnosed with a separate infection (ie, pneumonia, UTI, bacteremia) before SSI. There was no significant difference in injury severity score among patients with an SSI (11.1 ± 4.0 vs. 9.6 ± 3.0). Multivariable regression testing with HGI as a continuous variable demonstrated a significant relationship (odds ratio: 1.8, 95% confidence interval: 1.3–2.5) with SSI after adjusting for blood transfusions (odds ratio: 1.1, 95% confidence interval: 1.1–1.2). Conclusions: Stress-induced hyperglycemia demonstrated a significant independent association with SSIs in nondiabetic orthopedic trauma patients who were admitted to the ICU. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Outcome of nonoperative vs operative treatment of humeral shaft fractures: a retrospective study of 213 patients.

Standard treatment for most humeral shaft fractures is nonoperative functional bracing; however, certain clinical scenarios necessitate operative intervention. There have been few studies in the literature comparing nonoperative and operative fixation of humeral shaft fractures. Two-hundred thirteen adult patients with a humeral shaft fracture who satisfied inclusion criteria were treated at 2 level 1 trauma centers with either a functional brace (nonoperative treatment group) or compression plating (operative treatment group). Main outcome measures were evaluated retrospectively and included time to union, nonunion, malunion, infection, incidence of radial nerve palsy, and elbow range of motion (ROM). The occurrence of nonunion (20.6% vs 8.7%; P=.0128) and malunion (12.7% vs 1.3%; P=.0011) was statistically significant and more common in the nonoperative group. There was no significant difference in infection rate between nonoperative and operative treatment (3.2% vs 4.7%; P=1.0000). Radial nerve palsy presented after fracture treatment in 9.5% of patients in the nonoperative group and in 2.7% of patients managed operatively (P=.0678). No difference in time to union or ultimate ROM was found between the 2 groups. Closed treatment of humerus fractures had a significantly higher rate of nonunion and malunion while operative intervention demonstrated no significant differences in time to union, infection, or iatrogenic radial nerve palsy. Nonoperative management has historically been the treatment of choice for many humeral shaft fractures, however, in certain clinical scenarios these fractures may be well served by compression plating.

Patient variables which may predict length of stay and hospital costs in elderly patients with hip fracture.

Objectives: To investigate what factors contribute to increased length of stay (LOS) and increased costs in treatment of elderly patients with hip fractures. Design: Retrospective chart review. Setting: All patients who presented to a large tertiary care center between January 2000 and December 31, 2009. Participants: Charts for all patients older than 60 years who presented with isolated low-energy hip fractures were reviewed. Of the 719 patients identified, 660 were included. Intervention: Patients who underwent operative fixation or hemiarthroplasty secondary to hip fracture were identified using a search of Current Procedural Terminology (CPT) codes search. Main Outcome Measurements: Gender, height, weight, body mass index, length of procedure, American Society of Anesthesiologists (ASA) classification, and medical comorbidities were gathered and compared with LOS and direct daily inpatient hospital cost. Results: No correlation existed between body mass index or specific comorbidities and LOS, but ASA classification was a predictor. For each ASA increase of 1, average LOS increased 2.053 days (P < 0.001). Given total daily cost to the hospital for these patients was

Stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries

4530, each increase in ASA classification translated to an increase of

Bone Morphogenetic Protein-2 Compared to Autologous Iliac Crest Bone Graft in the Treatment of Long Bone Nonunion

9300. Conclusions: ASA classification proved useful in estimating LOS and cost for patients undergoing operative fixation of hip fractures. Because ASA classification and cost are universally collected, this method can be employed in almost any hospital. This highlights a role for ASA classification in preoperative estimation of the elderly patients cost and a potential advantage for incorporating patient factors in the development of tiered reimbursement models. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Plate fixation of femoral nonunions over an intramedullary nail with autogenous bone grafting.

BACKGROUND Hyperglycemia in nondiabetic patients outside the intensive care unit is not well defined. We evaluated the relationship of hyperglycemia and surgical site infection (SSI) in stable nondiabetic patients with orthopedic injuries. METHODS We conducted a prospective observational cohort study at a single academic Level 1 trauma center over 9 months (Level II evidence for therapeutic/care management). We included patients 18 years or older with operative orthopedic injuries and excluded patients with diabetes, corticosteroid use, multisystem injuries, or critical illness. Demographics, medical comorbidities (American Society of Anesthesiologists class), body mass index, open fractures, and number of operations were recorded. Fingerstick glucose values were obtained twice daily. Hyperglycemia was defined as a fasting glucose value greater than or equal to 125 mg/dL or a random value greater than or equal to 200 mg/dL on more than one occasion before the diagnosis of SSI. Glycosylated hemoglobin level was obtained from hyperglycemic patients; those with glycosylated hemoglobin level of 6.0 or greater were considered occult diabetic patients and were excluded. SSI was defined by a positive intraoperative culture at reoperation within 30 days of the index case. RESULTS We enrolled 171 patients. Of these 171, 40 (23.4%) were hyperglycemic; 7 of them were excluded for occult diabetes. Of the 164 remaining patients, 33 were hyperglycemic (20.1%), 50 had open fractures (6 Type I, 22 Type II, 22 Type III), and 12 (7.3%) had SSI. Hyperglycemic patients were more likely to develop SSI (7 of 33 [21.2%] vs. 5 of 131 [3.8%], p = 0.003). Open fractures were associated with SSI (7 of 50 [14%] vs. 5 of 114 [4.4%], p = 0.047) but not hyperglycemia (10 of 50 [20.0%] vs. 23 of 114 [20.2%], p = 0.98). There was no significant difference between infected and noninfected patients in terms of age, sex, race, American Society of Anesthesiologists class, obesity (body mass index > 29), tobacco use, or number of operations. CONCLUSION Stress hyperglycemia was associated with SSI in this prospective observational cohort of stable nondiabetic patients with orthopedic injuries. Further prospective randomized studies are necessary to identify optimal treatment of hyperglycemia in the noncritically ill trauma population. LEVEL OF EVIDENCE Therapeutic study, level III.

External Fixation Versus ORIF for Distal Intra-articular Tibia Fractures

This retrospective study investigated the effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) mixed with cancellous allograft on fracture healing compared to iliac crest autograft in the treatment of long bone nonunion. Eighty-nine patients with 93 established long bone nonunions treated between January 2002 and June 2004 at a single academic Level I trauma center were evaluated. Patients with clinical and radiographic evidence of failed fracture union underwent nonunion debridement, revision of fixation, and implantation at the nonunion site of either rhBMP-2 or the standard treatment autologous iliac crest bone graft. Union rate, operative time, estimated intraoperative blood loss, hospital length of stay, and postoperative infections were recorded. Nineteen nonunions received rhBMP-2 on a specialized carrier matrix (an absorbable collagen sponge) mixed with cancellous allograft, and 74 nonunions were treated with autologous iliac crest bone graft. There was no statistical difference in the rate of healing between treatment groups (68.4% vs 85.1%, respectively; P=.09). Incidence of postoperative infection was 16.2% after autologous iliac crest bone graft and 5.3% after rhBMP-2/absorbable collagen sponge (P=.22). Iliac crest autograft was associated with longer operative procedures (257.9±93.0 vs 168.9±86.5 minutes; P=.0007) and greater intraoperative blood loss (554.6±447.8 vs 331.6±357.2 mL; P=.01). These outcomes suggest that rhBMP-2 may provide a suitable alternative to autologous iliac bone graft, with the possible advantages of shorter operative time and reduced intraoperative blood loss, and may be considered as part of the orthopedic surgeons treatment options.

One-year mortality after acetabular fractures in elderly patients presenting to a level-1 trauma center.

Objective: To describe a novel approach for the treatment of nonunions of diaphyseal femur fractures. Design: Retrospective review. Setting: University hospital. Patients: Seven patients (six men, one woman, average age 42.5 years) with diaphyseal femoral fracture nonunions treated between November 2006 and November 2007 were reviewed. The injuries included two open and five closed fractures. All were treated initially with intramedullary nail fixation (two antegrade, five retrograde) and went on to develop a symptomatic nonunion by radiographic and clinical criteria. Intervention: Nonunions were treated with operative débridement of the nonunion with plate fixation and autogenous bone grafting without removal or exchange of the intramedullary nail. Main Outcome Measures: Clinical criteria of decreased pain and return to function as well as radiographic evidence of fracture consolidation. Results: All patients demonstrated radiographic evidence of fracture consolidation with an average follow-up time of 17.9 months (range 12-26 months). All were allowed immediate weightbearing and reported decreased pain with improved function. Six patients reported absolutely no pain with ambulation as related to the fracture site, whereas one noted discomfort about the distal femoral compression plate. Independent ambulation was observed in six subjects. None of the patients required additional operations for implant removal or bone grafting procedures. Conclusion: Treatment of diaphyseal femoral fracture nonunion after intramedullary nail fixation with large fragmentary compression plating and bone grafting is a reasonable option, especially for complex fractures about the metadiaphyseal region. The procedure appears to be successful in reducing pain, improving function, and predictably leads to radiographic consolidation of the nonunion.

Does hypoxia affect intensive care unit delirium or long-term cognitive impairment after multiple trauma without intracranial hemorrhage?

Tibia plafond fractures have historically demonstrated high complication rates. The purpose of this study was to assess the outcomes of tibia plafond fractures following treatment with definitive external fixation vs delayed open reduction and internal fixation (ORIF). Sixty patients were enrolled in a prospective cohort trial at 1 Level I trauma center. No differences were noted between the 2 treatment groups in terms of age, smoking history, presence of comorbidities, mechanism of injury, incidence of open fractures, or Orthopaedic Trauma Association fracture classification. Complete 12-month follow-up was available for 18 patients in the definitive external fixation group and 27 patients in the ORIF group. No difference was noted in articular reduction between the groups at 6 and 12 months postoperatively. Delayed union or non-union occurred in 4 (22.2%) of 18 patients in the external fixation group and 1 (3.7%) of 27 patients in the ORIF group (P=.05). Deep infection was equally likely in either group (P=.33). The ORIF group had improved Iowa Ankle Scores at 6 (23.6 ± 12.1 vs 11.1 ± 7.7; P<.05) and 12 months (5.5 ± 2.2 vs 3.1 ± 1.7; P<.05) postopertively and improved Short Form-36 Physical Function scores at 6 months (49.7 ± 30.1 vs 25.5 ± 8.0; P<.05) postoperatively compared with the external fixation group.External fixation and ORIF can attain bony union with adequate articular reduction and similar infection rates. Patients treated with ORIF appeared to have improved union rates and early outcomes with ankle function and Short Form-36 Physical Function scores.