The role of postoperative antibiotics in facial fractures: Comparing the efficacy of a 1-day versus a prolonged regimen

BACKGROUND The goal of this study was to evaluate the influence of the duration of postoperative antibiotics (1 day vs. ≥ 5 days) on wound infections following surgical treatment of facial fractures. METHODS Three hundred thirty-nine patient case histories with a total of 498 fractures were reviewed retrospectively with regard to infections occurring within a 6-month period following surgical management. Patients were divided into two groups based on the duration of postoperative antibiotics administered. Group A consisted of 125 patients who had 1 day of postoperative antibiotics, whereas Group B consisted of 214 patients who had five or more days of postoperative antibiotics. Statistical analysis was conducted to assess for possible differences in the rate of postoperative infections. RESULTS Five patients in Group A (4%) and seven patients in Group B (3.27%) developed infections within the follow-up period. Of these 12 patients, seven had sustained multiple facial bone fractures. Eleven infections occurred in patients with mandibular fractures and one in a midfacial fracture. Statistical analysis using Fisher's exact test showed no significant difference (p = 0.77) in the incidence of infection between Groups A and B. CONCLUSION In this retrospective study, the use of prolonged postoperative antibiotics in uncomplicated mandibular and midfacial fractures had no significant benefit in reducing the incidence of infections. LEVEL OF EVIDENCE Therapeutic study, level IV.

Extracortical plate fixation with new plate inserts and cerclage wires for the treatment of periprosthetic hip fractures

PURPOSE Fixation of periprosthetic hip fractures with intracortical anchorage might not be feasible in cases with bulky implants and/or poor bone stock. METHODS Rotational stability of new plate inserts with extracortical anchorage for cerclage fixation was measured and compared to the stability found using a standard technique in a biomechanical setup using a torsion testing machine. In a synthetic PUR bone model, transverse fractures were fixed distally using screws and proximally by wire cerclages attached to the plates using "new" (extracortical anchorage) or "standard" (intracortical anchorage) plate inserts. Time to fracture consolidation and complications were assessed in a consecutive series of 18 patients (18 female; mean age 81 years, range 55-92) with periprosthetic hip fractures (ten type B1, eight type C-Vancouver) treated with the new device between July 2003 and July 2010. RESULTS The "new" device showed a higher rotational stability than the "standard" technique (p < 0.001). Fractures showed radiographic consolidation after 14 ± 5 weeks (mean ± SD) postoperatively in patients. Revision surgery was necessary in four patients, unrelated to the new technique. CONCLUSION In periprosthetic hip fractures in which fixation with intracortical anchorage using conventional means might be difficult due to bulky revision stems and/or poor bone stock, the new device may be an addition to the range of existing implants.

Enhanced antibiotic multi-resistance in nasal and faecal bacteria after agricultural use of streptomycin

Streptomycin is used in arboriculture to control fire blight. Using sheep as a model, multidrug-resistant bacteria in mammals were found to be selected after the intentional release of streptomycin into the environment. Escherichia coli and Staphylococcus spp. were isolated from the faeces and nasal cavities, respectively, of sheep grazing on a field sprayed with streptomycin at concentrations used in orchards (test group) and on a field without streptomycin (control group). Before the application of streptomycin, the percentage of streptomycin-resistant E. coli isolates in faeces was 15.8% in the control group and 14.7% in the test group. After the application of streptomycin, the overall number of streptomycin-resistant E. coli isolates was significantly higher in the test group (39.9%) than in the control group (22.3%). Streptomycin-resistant Staphylococcus isolates were only detected after the application of streptomycin. Streptomycin resistance was frequently associated with resistance to sulfamethoxazole, ampicillin, tetracycline and chloramphenicol and less frequently to cefotaxime in E. coli, and to tetracycline, fusidic acid and tiamulin in Staphylococcus spp. This study shows that the application of low concentrations of streptomycin on grass, as occurs during the spraying of orchards, selects for multidrug-resistant nasal and enteric bacterial flora, including extended-spectrum beta-lactamase-producing E. coli.

A mutation in the SUV39H2 gene in Labrador Retrievers with hereditary nasal parakeratosis (HNPK) provides insights into the epigenetics of keratinocyte differentiation.

Hereditary nasal parakeratosis (HNPK), an inherited monogenic autosomal recessive skin disorder, leads to crusts and fissures on the nasal planum of Labrador Retrievers. We performed a genome-wide association study (GWAS) using 13 HNPK cases and 23 controls. We obtained a single strong association signal on chromosome 2 (p(raw) = 4.4×10⁻¹⁴). The analysis of shared haplotypes among the 13 cases defined a critical interval of 1.6 Mb with 25 predicted genes. We re-sequenced the genome of one case at 38× coverage and detected 3 non-synonymous variants in the critical interval with respect to the reference genome assembly. We genotyped these variants in larger cohorts of dogs and only one was perfectly associated with the HNPK phenotype in a cohort of more than 500 dogs. This candidate causative variant is a missense variant in the SUV39H2 gene encoding a histone 3 lysine 9 (H3K9) methyltransferase, which mediates chromatin silencing. The variant c.972T>G is predicted to change an evolutionary conserved asparagine into a lysine in the catalytically active domain of the enzyme (p.N324K). We further studied the histopathological alterations in the epidermis in vivo. Our data suggest that the HNPK phenotype is not caused by hyperproliferation, but rather delayed terminal differentiation of keratinocytes. Thus, our data provide evidence that SUV39H2 is involved in the epigenetic regulation of keratinocyte differentiation ensuring proper stratification and tight sealing of the mammalian epidermis.

Rib fractures at postmortem computed tomography (PMCT) validated against the autopsy

To evaluate the sensitivity of postmortem computed tomography (PMCT) in rib fracture detection validated against autopsy. Fifty-one forensic cases underwent a postmortem CT prior to forensic autopsy. Two image readers (radiologist and forensic pathologist) assessed high resolution CT data sets for rib fractures. Correct recognition rates (CRR), sensitivity and specificity values were calculated over all observations as well as individually for every rib and region. Additionally, for partial rib fractures the sensitivity of autopsy was calculated vice versa. 3876 entries in each study protocol (autopsy, PMCT radiologist and PMCT forensic pathologist) were investigated. A total of 690 fractures (autopsy), 491 (PMCT and radiologist) and 559 (PMCT and forensic pathologist) were detected. The CRR was 0.85. Sensitivity and specificity of PMCT for rib fracture detection were 0.63 (0.58 radiologist, 0.68 forensic pathologist) and 0.97 (both readers 0.97), respectively. Low CRR and sensitivity values were obtained for antero-lateral fractures. Partial rib fractures were better detected by PMCT. PMCT has a rather low sensitivity for rib fracture detection when validated against autopsy and indicates that clinical CT may also demonstrate a reasonable number of false negatives. Partial rib fractures often remain undetected at autopsy.

Birhombic flap, a modified bilobed flap, for repair of nasal defect

BACKGROUND Reconstruction of longitudinal defects of the lateral nasal alar might be challenging. Reconstruction with a bilobed flap is common for round defects normally the bilobed flap is less suited for longitudinal defects. OBJECTIVE We describe a birhombic flap for longitudinal defect. METHODS Demonstration of the technique and practical application for this kind of reconstruction. RESULTS The bilobed flap is a very useful flap for lateral nasal tip or distal alar reconstruction. We show that a small modification of the flap allows to cover also longitudinal defects on the lateral tip of the nose. As the first lobe movement corresponds more to the rhomboid transposition flap, we prefer to call it birhombic flap. CONCLUSION The birhombic flap has its place in reconstructive surgery. This flap has a specific indication and precise advantages to other repairs in particular to the bilobed flap.

Real-life results of balloon kyphoplasty for vertebral compression fractures from the SWISSspine registry

BACKGROUND CONTEXT The Swiss Federal Office of Public Health mandated a nationwide health technology assessment-registry for balloon kyphoplasty (BKP) for decision making on reimbursement of these interventions. The early results of the registry led to a permanent coverage of BKP by basic health insurance. The documentation was continued for further evidence generation. PURPOSE This analysis reports on the 1 year results of patients after BKP treatment. STUDY DESIGN Prospective multicenter observational case series. PATIENT SAMPLE The data on 625 cases with 819 treated vertebrae were documented from March 2005 to May 2012. OUTCOME MEASURES Surgeon-administered outcome instruments were primary intervention form for BKP and the follow-up form; patient self-reported measures were EuroQol-5D questionnaire, North American Spine Society outcome instrument /Core Outcome Measures Index (including visual analog scale), and a comorbidity questionnaire. Outcome measures were back pain, medication, quality of life (QoL), cement extrusions, and new fractures within the first postoperative year. METHODS Data were recorded preoperatively and at 3 to 6-month and 1-year follow-ups. Wilcoxon signed-rank test was used for comparison of pre- with postoperative measurements. Multivariate logistic regression was used to identify factors with a significant influence on the outcome. RESULTS Seventy percent of patients were women with mean age of 71 years (range, 18-91 years); mean age of men was 65 years (range, 15-93 years). Significant and clinically relevant reduction of back pain, improvement of QoL, and reduction of pain killer consumption was seen within the first postoperative year. Preoperative back pain decreased from 69.3 to 29.0 at 3 to 6-month and remained unchanged at 1-year follow-ups. Consequently, QoL improved from 0.23 to 0.71 and 0.75 at the same follow-up intervals. The overall vertebra-based cement extrusion rates with and without extrusions into intervertebral discs were 22.1% and 15.3%, respectively. Symptomatic cement extrusions with radiculopathy were five (0.8%). A new vertebral fracture within a year from the BKP surgery was observed in 18.4% of the patients. CONCLUSIONS The results of the largest observational study for BKP so far are consistent with published randomized trials and systematic reviews. In this routine health care setting, BKP is safe and effective in reducing pain, improving QoL, and lowering pain_killer consumption and has an acceptable rate of cement extrusions. Postoperative outcome results show clear and significant clinical improvement at early follow-up that remain stable during the first postoperative year.

What are predictors for patients' quality of life after pelvic ring fractures?

Background Our knowledge of factors influencing mortality of patients with pelvic ring injuries and the impact of associated injuries is currently based on limited information. Questions/purposes Weidentified the (1) causes and time of death, (2) demography, and (3) pattern and severity of injuries in patients with pelvic ring fractures who did not survive. Methods We prospectively collected data on 5340 patients listed in the German Pelvic Trauma Registry between April 30, 2004 and July 29, 2011; 3034 of 5340 (57%) patientswere female. Demographic data and parameters indicating the type and severity of injury were recorded for patients who died in hospital (nonsurvivors) and compared with data of patients who survived (survivors). The median followup was 13 days (range, 0–1117 days). Results A total of 238 (4%) patients died a median of 2 days after trauma. The main cause of death was massive bleeding (34%), predominantly from the pelvic region (62% of all patients who died because of massive bleeding). Fifty six percent of nonsurvivors and 43% of survivors were male. Nonsurvivors were characterized by a higher incidence of complex pelvic injuries (32% versus 8%), less isolated pelvic ring fractures (13% versus 49%), lower initial blood hemoglobin concentration (6.7 ± 2.9 versus 9.8 ± 3.0 g/dL) and systolic arterial blood pressure (77 ± 27 versus 106 ± 24 mmHg), and higher injury severity score (ISS) (35 ± 16 versus 15 ± 12). Conclusion Patients with pelvic fractures who did not survive were characterized by male gender, severe multiple trauma, and major hemorrhage.

Intra- and postoperative complications of navigated and conventional techniques in percutaneous iliosacral screw fixation after pelvic fractures: Results from the German Pelvic Trauma Registry

Background: Percutaneous iliosacral screw placement following pelvic trauma is a very demanding technique involving a high rate of screw malpositions possibly associated with the risk of neurological damage or inadequate stability. In the conventional technique, the screw’s correct entry point and the small target corridor for the iliosacral screw may be difficult to visualise using an image intensifier. 2D and 3D navigation techniques may therefore be helpful tools. The aim of this multicentre study was to evaluate the intra- and postoperative complications after percutaneous screw implantation by classifying the fractures using data from a prospective pelvic trauma registry. The a priori hypothesis was that the navigation techniques have lower rates of intraoperative and postoperative complications. Methods: This study is based on data from the prospective pelvic trauma registry introduced by the German Society of Traumatology and the German Section of the AO/ASIF International in 1991. The registry provides data on all patients with pelvic fractures treated between July 2008 and June 2011 at any one of the 23 Level I trauma centres contributing to the registry. Results: A total of 2615 patients were identified. Out of these a further analysis was performed in 597 patients suffering injuries of the SI joint (187 � with surgical interventions) and 597 patients with sacral fractures (334 � with surgical interventions). The rate of intraoperative complications was not significantly different, with 10/114 patients undergoing navigated techniques (8.8%) and 14/239 patients in the conventional group (5.9%) for percutaneous screw implantation (p = 0.4242). Postoperative complications were analysed in 30/114 patients in the navigated group (26.3%) and in 70/239 patients (29.3%) in the conventional group (p = 0.6542). Patients who underwent no surgery had with 66/197 cases (33.5%) a relatively high rate of complications during their hospital stay. The rate of surgically-treated fractures was higher in the group with more unstable Type-C fractures, but the fracture classification had no significant influence on the rate of complications. Discussion: In this prospective multicentre study, the 2D/3D navigation techniques revealed similar results for the rate of intraoperative and postoperative complications compared to the conventional technique. The rate of neurological complications was significantly higher in the navigated group.

Cortical bone loss at the tibia in postmenopausal women with osteoporosis is associated with incident non-vertebral fractures: Results of a randomized controlled ancillary study of HORIZON

BACKGROUND In postmenopausal women, yearly intravenous zoledronate (ZOL) compared to placebo (PLB) significantly increased bone mineral density (BMD) at lumbar spine (LS), femoral neck (FN), and total hip (TH) and decreased fracture risk. The effects of ZOL on BMD at the tibial epiphysis (T-EPI) and diaphysis (T-DIA) are unknown. METHODS A randomized controlled ancillary study of the HORIZON trial was conducted at the Department of Osteoporosis of the University Hospital of Berne, Switzerland. Women with ≥1 follow-up DXA measurement who had received ≥1 dose of either ZOL (n=55) or PLB (n=55) were included. BMD was measured at LS, FN, TH, T-EPI, and T-DIA at baseline, 6, 12, 24, and 36 months. Morphometric vertebral fractures were assessed. Incident clinical fractures were recorded as adverse events. RESULTS Baseline characteristics were comparable with those in HORIZON and between groups. After 36 months, BMD was significantly higher in women treated with ZOL vs. PLB at LS, FN, TH, and T-EPI (+7.6%, +3.7%, +5.6%, and +5.5%, respectively, p<0.01 for all) but not T-DIA (+1.1%). The number of patients with ≥1 incident non-vertebral or morphometric fracture did not differ between groups (9 ZOL/11 PLB). Mean changes in BMD did not differ between groups with and without incident fracture, except that women with an incident non-vertebral fracture had significantly higher bone loss at predominantly cortical T-DIA (p=0.005). CONCLUSION ZOL was significantly superior to PLB at T-EPI but not at T-DIA. Women with an incident non-vertebral fracture experienced bone loss at T-DIA.

The role of postoperative prophylactic antibiotics in the treatment of facial fractures: a randomised, double-blind, placebo-controlled pilot clinical study. Part 3: Le Fort and zygomatic fractures in 94 patients

The aim of this study was to evaluate the difference between the effect of a 5-day and a 1-day postoperative course of antibiotics on the incidence of infection after midfacial fractures. A total of 98 patients with displaced Le Fort or zygomatic fractures that required operation were randomly assigned into 2 groups, both of which were given amoxicillin/clavulanic acid 1.2g intravenously every 8h from the time of admission until 24h postoperatively. The 5-day group was then given amoxicillin/clavulanic acid 625mg orally 8-hourly for another 4 days. The 1-day group was given placebo orally at the same time points. Patients were followed up 1, 2, 4, 6, and 12 weeks, and 6 months, postoperatively. The development of an infection of the wound was the primary end point. Ninety-four of the 98 patients completed the study. Two of the 45 patients in the 5-day group (4%) and 2/49 in the 1-day group (4%) developed postoperative wound infections. One in each group had a purulent infection, while the others had only wound breakdown. Two patients of the 5-day group and one in the 1-day group developed rashes on the trunk. There were no significant differences in the incidence of infection or side effects between the groups. In midfacial fractures a 1-day course of antibiotics postoperatively is as effective in preventing infective complications as a 5-day regimen.