Manouk Backes

Indications for implant removal following intra-articular calcaneal fractures and subsequent complications.

Introduction: Implant removal following operative calcaneal fracture treatment has received little attention in the literature. The aim of the current retrospective cohort study was to assess the indications and number of wound complications following calcaneal plate removal. Methods: All consecutive adult patients who had their plate and screws removed following the operative treatment of a closed uni- or bilateral intra-articular calcaneal fracture using a stainless steel nonlocking calcaneal plate between 2000 and 2011 were included. Results: In 102 patients (46% of the total number of operated calcaneal fractures) implants were removed. Implant removal was performed in 75 patients for symptomatic reasons, in 10 patients due to implant malposition and in 19 patients because of a persistent wound infection or fistula. Following implant removal 17 (16%) patients had a wound complication (2 wound dehiscence, 15 culture positive wound infections). In 6 patients (9%) a wound complications was seen following implant removal after uncomplicated fracture surgery. Implant removal for active infection or plate fistula displayed an infection rate of 8 out of 19 (42%). Conclusion: Implant removal after an intra-articular calcaneal fracture treated with open reduction and internal fixation via an extended lateral approach was followed by a wound complication in 1 of every 10 patients without a preexisting wound infection. Infection rates were especially high in patients in whom the implants were removed for an active wound problem. Level of Evidence: Level IV, retrospective case series.

Effect of Antibiotic Prophylaxis on Surgical Site Infections Following Removal of Orthopedic Implants Used for Treatment of Foot, Ankle, and Lower Leg Fractures: A Randomized Clinical Trial

Importance Following clean (class I, not contaminated) surgical procedures, the rate of surgical site infection (SSI) should be less than approximately 2%. However, an infection rate of 12.2% has been reported following removal of orthopedic implants used for treatment of fractures below the knee. Objective To evaluate the effect of a single dose of preoperative antibiotic prophylaxis on the incidence of SSIs following removal of orthopedic implants used for treatment of fractures below the knee. Design, Setting, and Participants Multicenter, double-blind, randomized clinical trial including 500 patients aged 18 to 75 years with previous surgical treatment for fractures below the knee who were undergoing removal of orthopedic implants from 19 hospitals (17 teaching and 2 academic) in the Netherlands (November 2014-September 2016), with a follow-up of 6 months (final follow-up, March 28, 2017). Exclusion criteria were an active infection or fistula, antibiotic treatment, reimplantation of osteosynthesis material in the same session, allergy for cephalosporins, known kidney disease, immunosuppressant use, or pregnancy. Interventions A single preoperative intravenous dose of 1000 mg of cefazolin (cefazolin group, n = 228) or sodium chloride (0.9%; saline group, n = 242). Main Outcomes and Measures Primary outcome was SSI within 30 days as measured by the criteria from the US Centers for Disease Control and Prevention. Secondary outcome measures were functional outcome, health-related quality of life, and patient satisfaction. Results Among 477 randomized patients (mean age, 44 years [SD, 15]; women, 274 [57%]; median time from orthopedic implant placement, 11 months [interquartile range, 7-16]), 470 patients completed the study. Sixty-six patients developed an SSI (14.0%): 30 patients (13.2%) in the cefazolin group vs 36 in the saline group (14.9%) (absolute risk difference, −1.7 [95% CI, −8.0 to 4.6], P = .60). Conclusions and Relevance Among patients undergoing surgery for removal of orthopedic implants used for treatment of fractures below the knee, a single preoperative dose of intravenous cefazolin compared with saline did not reduce the risk of surgical site infection within 30 days following implant removal. Trial Registration clinicaltrials.gov Identifier: NCT02225821

Predictors of Nonunion and Infectious Complications in Patients With Posttraumatic Subtalar Arthrodesis

Objective: The objective of the present study was (1) to identify predictors of both nonunion and postoperative wound infections (POWI) and (2) to assess the union and complication rate following posttraumatic subtalar arthrodesis (STA). Design: Retrospective comparative cohort study. Setting: Level 1 trauma center. Patients: All consecutive adult patients with STA following traumatic injuries between 2000 and May 2015. Intervention: STA for posttraumatic deformities. Main Outcome Measurements: Union (described as a combination of radiographic signs of osseous bridging and a clinically fused joint) and POWI as classified by the Centers for Disease and Control. Results: A total number of 93 (96 feet) patients met the inclusion criteria. Union was achieved in 89% of patients. For primary, secondary in situ, and secondary correction arthrodesis, these percentages were 94%, 84,% and 90%, respectively (NS). The union rate significantly increased over time (P = 0.02). In 17 patients (18%), a POWI occurred, of which 2 were classified as superficial and 15 as deep POWIs. The POWI rate did not differ between the groups. Alcohol, nicotine, and drug abuse were not significantly associated with the occurrence of POWIs. Patients with an open fracture or an infection following open reduction internal fixation had a greater risk of a POWI following STA (P = 0.03 and P = 0.04, respectively). Conclusions: We could not identify predictors for nonunion. In 18% of the patients, an infectious complication following surgery occurred. Patients with an open fracture or an infection after primary surgical treatment (ie, open reduction internal fixation) have a higher chance of POWIs following STA. The union rate following posttraumatic STA is 89%. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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

ABSTRACT 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. Level of Clinical Evidence: 3

Evaluation and quantification of geographical differences in wound complication rates following the extended lateral approach in displaced intra-articular calcaneal fractures – A systematic review of the literature

INTRODUCTION Calcaneal fracture surgery is often performed via the extended lateral approach (ELA). Large differences are reported in literature on wound complication rates. Aim was to perform a systematic review on reported postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following the ELA and evaluate and quantify geographical differences. METHODS A literature search was conducted in the MEDLINE and EMBASE databases and Cochrane Library. Studies before 2000, with <10 patients, biomechanical studies and reviews were excluded. No restrictions regarding language were applied. RESULTS 3068 articles were identified of which 123 were included, with 8584 calcaneal fractures in 28 different countries. The average total number of POWC was 14.3%, with 3.8% of superficial and 2.2% of deep infections. The highest POWI rate was found in Europe (12.1%) and the lowest in North America (2.8%). A significant difference in incidence of deep POWI between continents was detected (median 0-3.8%). No differences were found in incidence of POWC and POWI between retro- and prospective studies (respectively p=0.970, p=0.748) or studies with <10 or ≥10 operations per year (respectively p=0.326, p=0.378). However, lower rates of POWI were found in studies with a follow up of >3months (p=0.01). CONCLUSION Large differences were detected in incidence of POWC and POWI following calcaneal fracture surgery with the ELA between countries and continents. We did not find a lower POWC or POWI rate in retrospective studies compared to prospective studies, larger studies or in studies in which more patients were treated annually. However, the rate of POWI was significantly lower in studies with a follow up of >3months. We advise the use of a reliable postoperative complication registration system and uniformity in the use of standardized definitions of wound complications for calcaneal fracture surgery.

Correction to: Functional outcome following a locked fracture-dislocation of the calcaneus

The published online version contains a mistake in the author list for the name of the author “J. Carel Goslings” was incorrectly presented in the HTML version.

Correction to: Prophylactic negative pressure wound therapy after lower extremity fracture surgery: a pilot study

The published online version contain mistake in the author list for the name of the author “J. Carel Goslings” was incorrectly presented in the HTML version.

A systematic review and meta-analysis of the sinus tarsi and extended lateral approach in the operative treatment of displaced intra-articular calcaneal fractures

BACKGROUND The optimal surgical approach for displaced intra-articular calcaneal fractures (DIACF) is subject of debate. The primary aim of this systematic review and meta-analysis was to assess wound-healing complications following the sinus tarsi approach (STA) compared to the extended lateral approach (ELA). Secondary aims were to assess time to surgery, operative time, calcaneal anatomy restoration, functional outcome, implant removal and injury to the peroneal tendons and sural nerve. METHODS MEDLINE, EMBASE and Cochrane databases were searched for clinical studies comparing the STA and the ELA (until September 2017). RESULTS Nine studies were included (two randomized controlled trials; seven comparative studies). 326 patients (331 fractures) were treated by the STA and 383 patients (390 fractures) by ELA. Ninety-nine per cent were Sanders type II/III fractures. Wound healing complications in the STA and ELA occurred in 11/331 and 82/390 fractures, respectively. Weighted means were 4.9% and 24.9%, respectively. Meta-analysis showed significantly less wound healing complications in the STA compared to ELA (risk ratio 0.20; 95% CI 0.11-0.36; P<0.00001; I2=0%). In general, time to surgery and operative time were shorter in the STA. Meta-analysis was not possible due to heterogeneity between studies. No differences were found in remaining secondary outcomes. CONCLUSIONS The STA is associated with significantly less wound healing complications. With similar functional outcome and calcaneal anatomy restoration, the STA may be the preferred approach in the operative treatment of Sanders type II/III DIACF.

Outcome following osteosynthesis or primary arthrodesis of calcaneal fractures: A cross-sectional cohort study

BACKGROUND Calcaneal fractures are uncommon and have a substantial impact on hindfoot function and quality of life. Several surgical treatment options are available; both in surgical approach and type of operation. The aim of this study was to compare functional outcome and quality of life following ORIF and primary arthrodesis. Furthermore, predictors of worse functional outcome were explored. METHODS A retrospective cross-sectional cohort study was performed in patients with surgical fixation of a calcaneal fracture with a minimum follow-up of 18 months. Patients received ORIF through the 1) Extended Lateral Approach (ELA), 2) Sinus Tarsi Approach (STA) or 3) primary arthrodesis via STA. Participants were presented a questionnaire containing demographics, the AOFAS hindfoot scale, Foot Function Index, SF-36, EQ-5D and patient satisfaction. RESULTS In total 95 patients participated in this study. The three groups were comparable regarding patient characteristics. A median score of 74.5 points on the AOFAS hindfoot scale and 11.9 on the FFI was found for the entire group. There were no statistically significant differences between patients with ORIF of primary arthrodesis. Patients scored a median of 49.0 on the Physical Component Scale of the SF-36 and 55.4 on the Mental Component Scale. On the EQ-5D patients scored a median of 0.8 points. Again no statistically significant differences were observed between the three subgroups. Socio-economic status was the only statistically significant predictor of worse functional outcome (β: 4.06, 95% CI: 0.50-7.62) after multivariable analysis. INTERPRETATION Good midterm outcomes following in terms of functional outcome and in quality of life are observed. We observed no statistical significant difference in functional outcome between patients with ORIF and patients with primary arthrodesis. The only predictor of worse functional outcome is a lower socio-economic status.