Tim Schepers

Increased rates of wound complications with locking plates in distal fibular fractures

INTRODUCTIONnThere is a growing use of locking compression plates in fracture surgery. The current study was undertaken to investigate the wound complication rates of locking versus non-locking plates in distal fibular fractures.nnnPATIENTS AND METHODSnDuring a 6-year study period all consecutive, closed distal fibular fractures treated with either a locking or a non-locking plate were included and retrospectively analysed for complication related to the fibula.nnnRESULTSnA total of 165 patients received a one-third tubular plate and 40 patients were treated with a locking plate. The two groups were comparable with respect to patient characteristics (age, gender, smokers and diabetics), injury characteristics (affected side, fracture dislocations, number of fractured malleoli and classification) and operation characteristics (surgical delay and duration, use of a tourniquet and plate length). The wound complication rate was 5.5% in the conventional plating group, and 17.5% in the locking plate group (p=0.019). This difference was largely due to an increase in major complications, for which removal of the plate was necessary (p=0.008).nnnCONCLUSIONnThere is a significant increase in wound complications in distal fibular fractures treated with a locking compression plate. In light of the current study, we would caution against the application of the currently used locking compression plates in the treatment of distal fibular fractures.

Demographics and outcome of metatarsal fractures.

IntroductionAlthough metatarsal fractures are amongst the most common injuries of the foot, this is the first study on outcome after metatarsal fractures.MethodAll consecutive patients with metatarsal fractures treated between January 2006 and September 2008 were re-evaluated. Patients aged 16 to 75 were sent a questionnaire consisting of the American Orthopaedic Foot Ankle Society midfoot score and a Visual Analogue Scale (VAS) for patient satisfaction.ResultsFour-hundred metatarsal fractures were identified in 322 patients. The fifth metatarsal was involved in more than 50% of patients. Most fractures were caused by an inversion injury or fall from height (75%). Out of 247 patients between 16 and 75xa0years, a total of 166 patients (67.2%) returned the questionnaire with a median follow-up of 33xa0months. All patients were treated conservatively. The median AOFAS score was 100 points (P25–P75, 87–100), the median VAS was 9 points (P25–P75, 8–10). The AOFAS and VAS scores correlated negatively with the body mass index (BMI) (Rsxa0=xa0−0.409 and −0.305; pxa0<xa00.001). Patients with diabetes reported lower VAS (pxa0=xa00.010) and AOFAS scores (pxa0=xa00.020). Females reported a lower AOFAS score (pxa0=xa00.034). An increase in dislocation (>2xa0mm) resulted in a decrease in VAS score (pxa0=xa00.017). Multivariable analysis indicated that the VAS score was significantly affected by BMI and dislocation >2xa0mm (pxa0=xa00.013). The AOFAS score was affected by BMI (pxa0=xa00.011).ConclusionThis is the first investigation using two validated outcome scoring systems to determine functional outcome in metatarsal fractures. Overall outcome in metatarsal fractures is high, as almost all fractures healed without complaints at 33xa0months. Outcome is dependent on BMI, diabetes, gender, and dislocation at the fracture site.

Functional Outcomes After Temporary Bridging With Locking Plates in Lisfranc Injuries

The standard operative treatment of Lisfranc fracture dislocations currently consists of open reduction and transarticular fixation. Recently, bridge plating has been used more often. Using joint spanning, the reduced fracture dislocation is temporary stabilized to minimize articular damage. The present study describes the outcomes of patients treated with bridge plating after tarsometatarsal fracture dislocations compared with transarticular screw fixation. A retrospective cohort study was performed. Patients with an isolated tarsometatarsal injury who had been treated operatively from June 2000 to October 2013 were included. The primary functional outcome was measured using the American Orthopaedic Foot and Ankle Society midfoot score and the Foot Function Index. The secondary outcome was patient satisfaction, which was measured using the EuroQol 5 dimensions questionnaire and a visual analog scale. A total of 34 patients were included. Bridge plating was used in 21 patients. In 13 patients, Kirschner wires or transarticular screws or a combination were used. The median follow-up period was 49xa0(interquartile range 18 to 89) months. The implants were removed in 10 of 13 patients in the transarticular group and 17 of 21 patients in the bridge plating group. The incidence of wound complications was comparable in both groups. The median American Orthopaedic Foot and Ankle Society score was lower in the transarticular group (77 versus 66). The Foot Function Index score was 18 in both groups. Patient satisfaction was 90% in the bridge plating group and 80% in the transarticular group. Bridge plating for Lisfranc injuries led to at least similar results compared with transarticular fixation in terms ofxa0functional outcomes and patient satisfaction. Longer follow-up is necessary to determine whether the prevention of secondary damage to the articular surface leads to less post-traumatic arthritis and better functional outcomes.

Effect of Single Dose of RANKL Antibody Treatment on Acute Charcot Neuro-osteoarthropathy of the Foot

Charcot neuro-osteoarthropathy is a rare condition that affects subjects with diabetes with neuropathy (1). Although the underlying pathophysiology is largely unknown, increased receptor activator of nuclear factor κ-B ligand (RANKL) activation in Charcot neuro-osteoarthropathy has been observed (2). As monoclonal RANKL antibody treatment (denosumab, Prolia) reduces osteoporosis-related fractures (3), we studied its effect on fracture resolution time and clinical outcomes in acute Charcot neuro-osteoarthropathy. All patients with diabetes seen at our foot clinic between 2012 and 2016 were categorized by modified Brodsky classification (4) and treated according to a standardized total contact cast (TCC) protocol. This comprises weekly TCC changes and subsequent conventional X-ray imaging every 4 weeks, as well as supplementation daily with calcium 500 mg/cholecalciferol 800 IE to achieve adequate plasma calcium (between 2.2 and 2.5 mmol/L) and vitamin D levels …

Acute syndesmotic instability in ankle fractures: A review

Ankle fractures are among the most common fracture types, and 10% of all ankle fractures lead to accessory syndesmotic injury. An injury that is challenging in every respect is syndesmotic instability. Since the range of diagnostic techniques and the therapeutic options is extensive, it still is a controversial subject, despite the abundance of literature. This review aimed to summarize the current knowledge on syndesmotic instability in ankle fractures and to formulate some recommendations for clinical practice. Chronic instability and the operative osseous treatment of ankle fractures are not part of this review.

Complications of Kirschner Wire Use in Open Reduction and Internal Fixation of Calcaneal Fractures

The most important goal of surgical management of displaced intra-articular calcaneal fractures is anatomic correction. This reduction is usually stabilized using plate and screw osteosynthesis. In addition, Kirschner wires (K-wires) can be used to maintain the surgical reduction or stability of the construct. In the present study, we evaluated the frequency and type of use of additional K-wires and subsequent migration in the surgical management of displaced intra-articular calcaneal fractures. The data from 279 patients treated surgically from January 1, 2000 to December 31, 2014 in a level 1 trauma center using an extended lateral approach were analyzed after 1 year of follow-up. All postoperative radiographic images were reviewed to identify the cases in which K-wires were used. Data on the number and type of K-wires used, K-wire location, and K-wire migration found on follow-up imaging studies were collected. Of the 279 patients, 69 K-wires had been used in 49 (18%) patients. A total of 25 (36%) lost (buried), 38 (55%) bent, and 6 (9%) unmodified straight K-wires had been placed. Overall, in 4 (5.8%) of 69 K-wires, secondary dislocation was seen. One (4%) of the lost, 3 (50%) of the unmodified, and none of the bent K-wires showed secondary dislocation. K-wire migration was seen in 5.8% of the cases. None of the bent K-wires and only 1 of the lost K-wires had migrated in the present study. These 2 techniques are preferred when using K-wire fixation in the treatment of displaced intra-articular calcaneal fractures. The use of unmodified straight K-wires should be discouraged.

Predicting loss of height in surgically treated displaced intra-articular fractures of the calcaneus.

PurposeThe goal of calcaneal fracture surgery is to restore its anatomy and good foot function. However, loss of height of the subtalar joint can occur post-operatively, as expressed by a decrease in Böhler’s angle (BA). The aim of this study was to identify potential factors associated with a post-operative decrease in BA.MethodsAll consecutive adult patients treated with open reduction and internal fixation (ORIF) by an extended lateral approach (ELA) between 2000 and 2013 were retrospectively included. Primary outcome was the occurrence of a calcaneal collapse, defined as a postoperative decrease of ≥10° in BA. The BA was measured pre-operatively, directly following surgery and at one year follow-up. Patient characteristics (body mass index, diabetes mellitus, smoking/alcohol/substance abuse, American Society of Anaesthesiologist classification), fracture classification and treatment characteristics: per-operative increase in BA and occurrence of post-operative wound infection (POWI) were collected.ResultsA total of 262 patients with 276 calcaneal fractures were included. A calcaneal collapse occurred in 46 cases (17xa0%). The median preoperative BA, per-operative increase in BA and post-operative decrease in BA were, respectively, 2°, 27° and 4°. A calcaneal collapse was seen more often following a per-operative increase of >25° in BA, but no significant association was found (pu2009=u20090.056). Uni- and multivariate analysis showed that patients with substance abuse and those with POWI had significantly more calcaneal collapse (pu2009<u20090.05). No association was found between substance abuse and the occurrence of POWI (pu2009=u20090.293).ConclusionsIn nearly one in six patients with an intra-articular calcaneal fracture treated with ORIF by an ELA,xa0a post-operative collapse of ≥10° was found during follow-up. Calcaneal collapse was correlated with the occurrence of a POWI and substance abuse.

Wound Infections Following Implant removal below the knee: the effect of antibiotic prophylaxis; the WIFI-trial, a multi-centre randomized controlled trial

BackgroundIn the Netherlands about 18,000 procedures with implant removal are performed annually following open or closed reduction and fixation of fractures, of which 30-80% concern the foot, ankle and lower leg region. For clean surgical procedures, the rate of postoperative wound infections (POWI) should be less than ~2%. However, rates of 10-12% following implant removal have been reported, specifically after foot, ankle and lower leg fractures. Currently, surgeons individually decide if antibiotics prophylaxis is given, since no guideline exists. This leads to undesirable practice variation. The aim of the study is to assess the (cost-)effectiveness of a single intravenous gift of Cefazolin prior to implant removal following surgical fixation of foot, ankle and/or lower leg fractures.MethodsThis is a double-blind randomized controlled trial in patients scheduled for implant removal following a foot, ankle or lower leg fracture. Primary outcome is a POWI within 30xa0days after implant removal. Secondary outcomes are quality of life, functional outcome and costs at 30xa0days and 6xa0months after implant removal. With 2 x 250 patients a decrease in POWI rate from 10% to 3.3% (expected rate in clean-contaminated elective orthopaedic trauma procedures) can be detected (Poweru2009=u200980%, 2-sided alphau2009=u20095%, including 15% lost to follow up).DiscussionIf administration of prophylactic antibiotics prior to implant removal reduces the infectious complication rate, this will offer a strong argument to adopt this as standard practice of care. This will consequently lead to less physical and social disabilities and health care use. A preliminary, conservative estimation suggests yearly cost savings in the Netherlands of € 3.5 million per year.Trial registrationThis study is registered at Clinicaltrials.gov (NCT02225821) and the Netherlands Trial Register (NTR4393) and was granted permission by the Medical Ethical Review Committee of the Academic Medical Centre on October 7 2014.

Routine versus on demand removal of the syndesmotic screw; a protocol for an international randomised controlled trial (RODEO-trial)

BackgroundSyndesmotic injuries are common and their incidence is rising. In case of surgical fixation of the syndesmosis a metal syndesmotic screw is used most often. It is however unclear whether this screw needs to be removed routinely after the syndesmosis has healed. Traditionally the screw is removed after six to 12 weeks as it is thought to hamper ankle functional and to be a source of pain. Some studies however suggest this is only the case in a minority of patients. We therefore aim to investigate the effect of retaining the syndesmotic screw on functional outcome.DesignThis is a pragmatic international multicentre randomised controlled trial in patients with an acute syndesmotic injury for which a metallic syndesmotic screw was placed. Patients will be randomised to either routine removal of the syndesmotic screw or removal on demand. Primary outcome is functional recovery at 12xa0months measured with the Olerud-Molander Score. Secondary outcomes are quality of life, pain and costs. In total 194 patients will be needed to demonstrate non-inferiority between the two interventions at 80% power and a significance level of 0.025 including 15% loss to follow-up.DiscussionIf removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. This means that patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs.Trial registrationThis study was registered at the Netherlands Trial Register (NTR5965), Clinicaltrials.gov (NCT02896998) on July 15th 2016.

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

INTRODUCTIONnCalcaneal 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.nnnMETHODSnA 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.nnnRESULTSn3068 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).nnnCONCLUSIONnLarge 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.