Dataset Information

Risk Factors Associated With Infection in Open Fractures of the Upper and Lower Extremities.

ABSTRACT:

Introduction

Open fractures are associated with a high risk of infection. The prevention of infection is the single most important goal, influencing perioperative care of patients with open fractures. Using data from 2,500 participants with open fracture wounds enrolled in the Fluid Lavage of Open Wounds trial, we conducted a multivariable analysis to determine the factors that are associated with infections 12 months postfracture.

Methods

Eighteen predictor variables were identified for infection a priori from baseline data, fracture characteristics, and surgical data from the Fluid Lavage of Open Wounds trial. Twelve predictor variables were identified for deep infection, which included both surgically and nonoperatively managed infections. We used multivariable Cox proportional hazards regression analyses to identify the factors associated with infection. Irrigation solution and pressure were included as variables in the analysis. The results were reported as adjusted hazard ratios (HRs), 95% confidence intervals (CIs), and associated P values. All tests were two tailed with alpha = 0.05.

Results

Factors associated with any infection were fracture location (tibia: HR 5.13 versus upper extremity, 95% CI 3.28 to 8.02; other lower extremity: HR 3.63 versus upper extremity, 95% CI 2.38 to 5.55; overall P < 0.001), low energy injury (HR 1.64, 95% CI 1.08 to 2.46; P = 0.019), degree of wound contamination (severe: HR 2.12 versus mild, 95% CI 1.35 to 3.32; moderate: HR 1.08 versus mild, 95% CI 0.78 to 1.49; overall P = 0.004), and need for flap coverage (HR 1.82, 95% CI 1.11 to 2.99; P = 0.017).

Discussion

The results of this study provide a better understanding of which factors are associated with a greater risk of infection in open fractures. In addition, it can allow for surgeons to better counsel patients regarding prognosis, helping patients to understand their individual risk of infection.

SUBMITTER: Tornetta P

PROVIDER: S-EPMC7725249 | biostudies-literature | 2020 Dec

REPOSITORIES: biostudies-literature

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Publications

Risk Factors Associated With Infection in Open Fractures of the Upper and Lower Extremities.

Tornetta Paul P Della Rocca Gregory J GJ Morshed Saam S Jones Clifford C Heels-Ansdell Diane D Sprague Sheila S Petrisor Brad B Jeray Kyle J KJ Del Fabbro Gina G Bzovsky Sofia S Bhandari Mohit M

Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews 20201208 12

<h4>Introduction</h4>Open fractures are associated with a high risk of infection. The prevention of infection is the single most important goal, influencing perioperative care of patients with open fractures. Using data from 2,500 participants with open fracture wounds enrolled in the Fluid Lavage of Open Wounds trial, we conducted a multivariable analysis to determine the factors that are associated with infections 12 months postfracture.<h4>Methods</h4>Eighteen predictor variables were identif ...[more]

PMID: 33986214

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Project description:Open fractures are often classified according to a system described by Gustilo and Anderson. However, this system was applied to open long bone fractures, which may not predict the incidence of infection in open metaphyseal fractures of the upper extremity. Other studies have found that wound contamination and systemic illness were the best predictors of infections in open hand fractures. Our study assessed infection in open distal radius fractures and identifies factors that are associated with these infections. We hypothesize that contamination, rather than absolute wound size, is the best predictor of infection associated with open distal radius fractures. A review by CPT code yielded 42 patients with open distal radius fractures between 1997 and 2002 treated at a level one trauma center. Medical records and radiographic follow-up were reviewed to assess the time to irrigation and debridement, the number of debridements in initial treatment period, the method of operative stabilization, the Gustilo and Anderson type of fracture, the Swanson type of fracture, and description of wound contamination. Forty-two patients were followed up for an average of 15 months (range 4 to 68 months). Twenty-four fractures were classified as Gustilo and Anderson type I, ten were type II, and eight were type III, 30 were Swanson type I, and 12 were Swanson type II. Five of the 42 fractures were considered contaminated. Two were exposed to fecal contamination. The others were contaminated with tar, dirt/grass, and gravel, respectively. Three of 42 (7%) fractures developed infections. All three infected cases received a single irrigation and debridement. Two of five contaminated fractures (40%) developed a polymicrobial infection. Both were exposed to fecal contamination and, therefore, considered Swanson type II fractures. They were classified as Gustilo and Anderson type II and IIIB based solely upon the size of the wound. Both required multiple debridements and eventually wrist fusions. The third infection occurred in a Gustilo and Anderson type II and Swanson type I open fracture treated with one debridement and plate fixation. Hardware removal, debridement, and antibiotics resolved the infection. Three contaminated fractures that healed uneventfully received two debridements. Statistical analysis revealed a correlation with infection and contamination (p = 0.0331). The number of initial debridements played a role in infection, but was not statistically significant. No relationship between infection and time to initial irrigation and debridement, method of fixation, Gustilo and Anderson type, or Swanson type was found. We propose that open distal radius fractures behave differently than open long bone fractures. Infection developed in 7% of the distal radius fractures in our study and was significantly associated with wound contamination. We recommend that contamination be included as factor for prognosis in open distal radius fractures. Contaminated fractures should be treated with multiple debridements as part of the initial plan not based upon subsequent development of an infection.

Project description:BackgroundPatients with open fractures often experience complications during their injury. The treatments incur high costs. Interdisciplinary cooperation between different medical disciplines may improve treatment outcomes. Such cooperation has not yet been envisaged in the German health care system.ObjectiveThe aim of the study is to improve the treatment of fractures with open soft tissue damage or postoperative complications in terms of duration and sustainability in a region in northwest Germany. Largely standardized diagnostics and therapy are intended to optimize processes in hospitals. In addition, a reduction in the duration of treatment and treatment costs is to be achieved.MethodsUsing a digital platform, physicians from 31 hospitals present patient cases to an interdisciplinary group of experts from the fields of plastic surgery, infectiology, hygiene, and others. The group of experts from the environment of the University Hospital Münster promptly makes a joint treatment recommendation for the individual case. The plan is to examine 3300 patients with open fractures or surgical complications. As consortium partners, there are also 3 statutory health insurance companies. The extent to which the therapy recommendations are effective and contribute to cost reduction in the health care system will be empirically investigated in a stepped-wedge cluster-randomized design. In addition, medical and nonmedical professional groups involved in the project will be asked about their work in the project (in total, 248 clinic employees). The primary outcome is the complication rate of open fractures or the occurrence of postoperative complications. As secondary outcomes, the number of antibiotics administered, limb function, and quality of life will be assessed. The health economic evaluation refers to the costs of health services and absenteeism. For the work-related evaluation, workload, work engagement, work-related resources, readiness for technology, and ergonomic aspects of the new telemedical technology will be collected. In addition, clinic employees will give their assessments of the success of the project in a structured telephone interview based on scaled and open-ended questions.ResultsThe project started in June 2022; data collection started in April 2023. As of mid-June 2024, data from 425 patients had been included. In total, 146 members of staff had taken part in the questionnaire survey and 15 had taken part in the interviews.ConclusionsStandardized treatment pathways in the standard care of patients with open fractures and postoperative infections will be established to reduce complications, improve chances of recovery, and reduce costs. Unnecessary and redundant treatment steps will be avoided through standardized diagnostics and therapy. The interdisciplinary treatment perspective allows for a more individualized therapy. In the medium term, outpatient or inpatient treatment centers specialized in the patient group could be set up where the new diagnostic and therapeutic pathways could be competently applied.Trial registrationGerman Clinical Trials Register DRKS00031308; https://drks.de/search/de/trial/DRKS00031308.International registered report identifier (irrid)DERR1-10.2196/57820.

Project description:Objective: To investigate the correlation between cerebral small vessel disease (CSVD) burden and motor performance of lower and upper extremities in community-dwelling populations. Methods: We performed a cross-sectional analysis on 770 participants enrolled in the Shunyi study, which is a population-based cohort study. CSVD burden, including white matter hyperintensities (WMH), lacunes, cerebral microbleeds (CMBs), perivascular spaces (PVS), and brain atrophy were measured using 3T magnetic resonance imaging. All participants underwent quantitative motor assessment of lower and upper extremities, which included 3-m walking speed, 5-repeat chair-stand time, 10-repeat pronation-supination time, and 10-repeat finger-tapping time. Data on demographic characteristics, vascular risk factors, and cognitive functions were collected. General linear model analysis was performed to identify potential correlations between motor performance measures and imaging markers of CSVD after controlling for confounding factors. Results: For motor performance of the lower extremities, WMH was negatively associated with gait speed (standardized β = -0.092, p = 0.022) and positively associated with chair-stand time (standardized β = 0.153, p < 0.0001, surviving FDR correction). For motor performance of the upper extremities, pronation-supination time was positively associated with WMH (standardized β = 0.155, p < 0.0001, surviving FDR correction) and negatively with brain parenchymal fraction (BPF; standardized β = -0.125, p = 0.011, surviving FDR correction). Only BPF was found to be negatively associated with finger-tapping time (standardized β = -0.123, p = 0.012). However, lacunes, CMBs, or PVS were not found to be associated with motor performance of lower or upper extremities in multivariable analysis. Conclusion: Our findings suggest that cerebral microstructural changes related to CSVD may affect motor performance of both lower and upper extremities. WMH and brain atrophy are most strongly associated with motor function deterioration in community-dwelling populations.

Project description:BackgroundInfection remains a costly, devastating complication following the treatment of open fractures. The appropriate timing of debridement is controversial, and available evidence has been conflicting.MethodsThis study is a retrospective analysis of the SIGN (Surgical Implant Generation Network) Surgical Database (SSDB), a prospective registry of fracture cases in predominantly low-resource settings. Skeletally mature patients (≥16 years of age) who returned for follow-up at any time point after intramedullary nailing of an open femoral or tibial fracture were included. Patients were excluded if they had delays in debridement exceeding 7 days after the injury. Utilizing a model adjusting for potential confounders, including patient demographic characteristics, injury characteristics, country income level, and hospital type and resources, local logistic regression analysis was performed to evaluate the probability of infection with increasing time to debridement in 6-hour increments.ResultsIn this study, 27.3% of patients met the eligibility criteria and returned for follow-up, with a total of 10,651 fractures from 61 countries included. Overall, the probability of infection increased by 0.17% for every 6-hour delay in debridement. On subgroup analysis, the probability of infection increased by 0.23% every 6 hours for Gustilo-Anderson type-III injuries compared with 0.13% for Gustilo-Anderson type-I or II injuries. The infection risk increased every 6 hours by 0.18% for tibial fractures compared with 0.13% for femoral fractures.ConclusionsThere was a linear and cumulative increased risk of infection with delays in debridement for open femoral and tibial fractures. Such injuries should be debrided promptly and expeditiously. The size and international nature of this cohort make these findings uniquely generalizable to nearly all environments where such injuries are treated.Level of evidenceTherapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Project description:ImportanceComplications that arise after treatment of mandible fractures can result in significant morbidity. Identifying modifiable risk factors associated with these complications is valuable in guiding clinical practice for improved patient outcomes.ObjectiveTo describe the risk factors associated with complications in patients undergoing treatment for mandible fracture.Design, setting, and participantsA retrospective review was conducted of 137 patients presenting to a tertiary care, level 1 trauma center with mandible fractures between January 1, 2014, and January 1, 2017. Outcomes and demographic characteristics for patients with at least 3 weeks of follow-up were compared using multivariate logistic regression analysis.ResultsOf the 137 patients meeting inclusion criteria, there were 113 males (82.5%) and 24 females (17.5%), with a mean (SD) age at presentation of 32.3 (15.7) years. Median follow-up was 71 days (range, 22-1189 days). Postoperative complications were identified in 29 patients (21.2%); complications included wound dehiscence or surgical site infection (n = 17), bony nonunion (n = 5), and hardware exposure (n = 13). Complications were managed surgically in 19 patients and nonsurgically in 10 patients. On univariate analysis, the initial surgery was completed later (mean [SD], 5.9 [6.6] days after injury) in patients who developed complications than in those who did not (mean [SD], 3.8 [4.0] days). On multivariate analysis, complications were associated with increased time from injury to treatment (odds ratio [OR], 1.60; 95% CI, 1.02-2.53; P = .04), tobacco use (OR, 8.10; 95% CI, 1.26-52.00; P = .03), and dental extraction (OR, 93.00; 95% CI, 1.19 to >999.00; P = .04). Residence in the same city as the medical center was associated with fewer complications (OR, 0.08; 95% CI, 0.01-0.69; P = .02).Conclusions and relevanceIn a 3-year review of mandible fractures managed at a single academic center, complications were associated with an increased time to treatment, tobacco use, dental extraction, and living farther from the treatment facility. On a systems level, the results of this study suggest that expediting intervention for mandible fractures may improve outcomes.Level of evidence3.

Dataset Information

Risk Factors Associated With Infection in Open Fractures of the Upper and Lower Extremities.

Introduction

Methods

Results

Discussion

Publications

Risk Factors Associated With Infection in Open Fractures of the Upper and Lower Extremities.

Similar Datasets

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