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2016 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Risk Factors for Deep Infection Following Plate

Fixation of Proximal Tibial Fractures
Markus Parkkinen, MD, Rami Madanat, MD, PhD, Jan Lindahl, MD, PhD, and Tatu J. Makinen, MD, PhD

Investigation performed at the Department of Orthopaedics and Traumatology, University of Helsinki, Helsinki,
and Helsinki University Hospital, Helsinki, Finland

Background: The risk factors are unclear for deep surgical site infection after plate xation of proximal tibial fractures.
The objective of this study was to identify the patient and surgical procedure-related risk factors for infection using
established criteria for deep surgical site infection.
Methods: A total of 655 proximal tibial fractures were treated with open reduction and plate xation at our center
between 2004 and 2013. We identied 34 patients with deep surgical site infection. A control group of 136 patients was
randomly selected from the non-infected cohort. Potential risk factors for deep surgical site infection were identied by
reviewing surgical, medical, and radiographic records. Independent risk factors for infection were identied from multi-
variable logistic regression analysis using a stepwise procedure.
Results: The prevalence of deep surgical site infection was 5.2%, the mean age of affected patients was 55 years (range,
16 to 84 years), and 35% of patients were female. Twenty-eight of 34 deep infections were diagnosed within 2 months
(acute onset), and only 6 infections were diagnosed >6 months after the index surgical procedure. Nine of the 28 acute-
onset infections were treated with antibiotic therapy and debridement. Seventeen patients (50%) required muscle ap
coverage, and 5 patients (15%) eventually required above-the-knee amputation. In the multivariable logistic regression
analysis with odds ratios (ORs) and 95% condence intervals (95% CIs), independent predictors of infection were patient
age of 50 years (OR, 3.6 [95% CI, 1.3 to 10.1]); obesity, dened as a body mass index of 30 kg/m2 (OR, 6.5 [95% CI,
2.2 to 18.9]); alcohol abuse (OR, 6.7 [95% CI, 2.4 to 19.2]); OTA/AO-type-C fracture (OR, 2.8 [95% CI, 1.1 to 7.5]); use of a
temporary spanning external xator (OR, 3.9 [95% CI, 1.4 to 11.1]); and a 4-compartment fasciotomy (OR, 4.5 [95% CI,
1.3 to 15.7]).
Conclusions: There is high morbidity associated with deep surgical site infection in plated proximal tibial fractures.
Patients who are 50 years of age, obese patients, those with a history of alcohol abuse, or those with an OTA/AO-type-C
fracture are at high risk for infection. Performing a fasciotomy also increases the risk of deep infection and should be
implemented with meticulous technique when deemed necessary.
Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed
by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a nal review by the Editor-in-Chief prior to publication.
Final corrections and clarications occurred during one or more exchanges between the author(s) and copyeditors.

F
ractures of the proximal part of the tibia are prone to
postoperative infection1. Deep infection is an especially
severe complication following plate xation of these frac-
tures. These infections lead to subsequent revision procedures,
extend the total hospital stay, result in substantial morbidity, and
may triple the cost of care2-4. In the early 1990s, infection rates as
high as 80% were reported after operative treatment of these
fractures5,6. With the introduction of staged procedures, in-
cluding delayed denitive surgical procedures and careful
soft-tissue handling, these infection rates have been reduced.
Still, deep infection rates of up to 24% have been reported7-14.
More data are needed on the risk factors for deep surgical
site infection associated with plate xation of proximal tibial
fractures. Previous studies have shown smoking, open fractures,
fasciotomy, use of a dual-incision approach with dual plating,
and prolonged operative time to be independent predictors of

Disclosure: There were no external funding sources for this study. The Disclosure of Potential Conicts of Interest forms are provided with the online
version of the article.

J Bone Joint Surg Am. 2016;98:1292-7 d http://dx.doi.org/10.2106/JBJS.15.00894

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TABLE I Demographic and Preoperative Characteristics of the Study Groups
Patients with Deep Surgical Site
Characteristics Infection (N = 34)
Age* (yr) 55 (16 to 84)
Female sex 12 (35%)
BMI* (kg/m2) 29.1 (17 to 46)
Right side involved 19 (56%)
OTA/AO classication
Type A 5 (15%)
Type B 9 (26%)
Type C 20 (59%)
*The values are given as the mean, with the range in parentheses. The values are given as the number of patients, with the percentage in
parentheses.
deep postoperative infection12,14. However, many of these risk
factors are controversial, as other studies have failed to show
similar associations12-14. This may be explained by discrepancies
in the denition of supercial and deep infections and detection
bias12-14. Most commonly, deep infections have only been dened
by the need for reoperation, and bacteriological conrmation is
rarely included as a part of the diagnostic criteria. Furthermore,
most studies have included only bicondylar fractures; thus, little
is known about other fracture types, such as unicondylar or
proximal metaphyseal fractures11-13.
The objective of this study was to determine the patient
and surgical procedure-related risk factors for deep surgical
site infection after plate xation of proximal tibial fractures
using established criteria for deep infection15. We hypothesized
that there are previously unidentied risk factors, including
fracture type, injury mechanism, timing of prophylactic anti-
biotics, use of a drain, and use of external xation. Identifying
risk factors and executing appropriate interventions could
further reduce the prevalence of deep surgical site infections in
these patients.
Materials and Methods
Study Design
W e performed a nested case-control study at a Level-I trauma center. This
study was approved by the institutional review board. All patients who
had a surgically treated proximal tibial fracture at our institution from January
2004 through December 2013 were identied by querying the hospital surgical
database for diagnoses with the International Classication of Diseases, Ninth
Revision (ICD-9) or Tenth Revision (ICD-10) code for proximal tibial fractures
(823.0, 823.1, S82.1) and procedure codes for external or internal xation of
proximal tibial fractures. Eligible surgical procedures were restricted to those
performed primarily at our institution in patients who were 16 years of age.
We identied 655 proximal tibial fracture operations in 652 patients, who were
all treated with open reduction and plate xation.
A standardized surgical and postoperative protocol was implemented
during the study period. First, an initial trauma survey was performed, followed
by radiographic and clinical evaluations. If a patient presented with clinical
signs of acute compartment syndrome, an urgent 4-compartment fasciotomy
16
using 2 incisions was performed with spanning external xation . In nearly all
cases, the diagnosis of compartment syndrome was a clinical one, and com-
R I S K F A C T O R S F O R D E E P I N F E C T I O N F O L L O W I N G P L AT E F I X AT I O N
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Control Patients (N = 136)
48 (16 to 86)
55 (40%)
26.8 (17 to 63)
56 (41%)
6 (4%)
83 (61%)
47 (35%)
partment pressure measurement devices were not used consistently. For pa-
tients who did not have signs of acute compartment syndrome, immediate
splinting or external xation was used depending on the soft-tissue condition.
External xation was used when there was substantial shortening or subluxa-
tion of the tibia because of a comminuted or unstable fracture. The presence
of vascular injury, blistering, severe abrasions, and polytrauma were also con-
sidered indications for temporary external xation.
Denitive open reduction and plate xation was performed according
to OTA/AO principles when the swelling had decreased and the wrinkle test was
positive. The treating surgeon decided on the use of a tourniquet or drain. The
surgical wound was closed in 3 layers (the fascia, subcutaneous tissue, and skin).
The principles of treatment included a meticulous soft-tissue handling tech-
nique, an anatomic reduction of the articular surface, and restoration of the
normal mechanical axis of the limb. For bicondylar fractures, a dual-incision
surgical approach and double-plating technique were used in 47% of the
procedures. In bicondylar fractures with a less comminuted fracture pattern
and a more stable medial column, a single, lateral, locking-plate technique was
used at the surgeons discretion. Postoperative management included immo-
bilization in a removable cast for the rst 2 weeks. This was followed by early
mobilization and non-weight-bearing using a hinged brace with a free range of
motion for 10 weeks. Our protocol included a 1-year follow-up period after the
index procedure, which 626 (96%) of the patients had completed.
Identification of Deep Surgical Site Infection
The medical records of all 652 patients were assessed for signs and symptoms of
surgical site infection that had been recorded. Fifty-seven (8.7%) of the 652
patients had signs of surgical site infection. Infections were classied as deep
when all 3 of the following criteria were met simultaneously: clinical signs
of surgical site infection (swelling, redness, drainage, or wound dehiscence),
positive bacterial cultures of wound specimens, and osteosynthesis material
15
palpable or visible in the wound . Thirty-four (5.2%) of the 652 patients
fullled the abovementioned criteria and were classied as having a deep in-
fection. A control group was randomly selected, in a 1:4 ratio, from the cohort
of patients who had undergone plate xation but did not subsequently develop
17,18
a surgical site infection . There were 23 patients who had signs of surgical
site infection but did not fulll all 3 criteria for deep infection simultaneously
and were classied as having supercial infections. None of these patients had
osteosynthesis material palpable or exposed, and 6 of these patients also had
negative bacterial cultures. Seventeen (74%) of these 23 patients were treated
successfully with antibiotics and local wound therapy only. The remaining 6
patients needed surgical debridement, and 4 of these patients also needed a
split-thickness skin graft. The demographic features of the patients included in
the study are presented in Table I.
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TABLE II Univariate Logistic Regression Analyses for Patient and Surgical Risk Factors in Patients with and without Deep Surgical Site
Infection Following Proximal Tibial Fracture Plate Fixation

Patients with Deep

Surgical Site Infection* Control Patients*
Characteristics (N = 34) (N = 136) OR P Value

Age 50 years 24 (71%) 64 (47%) 2.7 (1.2 to 6.1) 0.016

American Society of Anesthesiologists grade 2 to 4 29 (85%) 87 (64%) 4.1 (1.4 to 12.3) 0.012
BMI 30 kg/m2 14 (41%) 25 (18%) 3.2 (1.4 to 7.3) 0.005
Tobacco use 15 (44%) 33 (24%) 2.4 (1.1 to 5.3) 0.026
Alcohol abuse 15 (44%) 19 (14%) 4.9 (2.1 to 11.2) <0.001
OTA/AO-type fractures
A 5 6
B 9 83
C 20 47
C compared with B 3.9 (1.7 to 9.3) 0.002
A compared with B 7.7 (1.9 to 30.3) 0.004
Open fracture 6 (18%) 7 (5%) 3.9 (1.2 to 12.7) 0.021
Compartment syndrome (fasciotomy performed) 13 (38%) 12 (9%) 6.4 (2.6 to 15.9) <0.0001
Use of external xator 21 (62%) 33 (24%) 5.0 (2.3 to 11.2) <0.0001
Use of external xator for bicondylar fractures only 16 (80%) 24 (51%) 3.8 (1.1 to 13.2) 0.033
Mean time from injury to denitive surgical 8.7 5.6 1.1 (1.0 to 1.2) 0.012
procedure (days)
Mean operative time# (min) 211 171 1.3 (1.0 to 1.6) 0.031
Use of a tourniquet 17 (50%) 108 (79%) 0.3 (0.1 to 0.6) <0.001
Mean tourniquet time# (min) 121 111 1.0 (1.0 to 1.1) 0.11
Dual-incision approach 18 (53%) 39 (29%) 2.8 (1.3 to 6.0) 0.009
Bicondylar plating 12 (35%) 22 (16%) 2.8 (1.2 to 6.5) 0.015

*The values are given as the number of patients, with or without the percentage in parentheses, or as the mean. The values are given as the OR,
with the 95% CI in parentheses. All open fractures were classied as Gustilo grade III. Twenty patients with deep surgical site infections and 47
control patients had a bicondylar fracture. #The OR is for a 1-hour increase in these continuous risk factors.

Data Collection
Potential patient and surgical procedure-related risk factors for infection were
assessed by reviewing medical, microbiological, surgical, and radiographic re-
cords. We collected the demographic data and possible patient comorbidities,
injury mechanism (high-energy injury dened as a fall from a height of >1 m or a
19
motor vehicle accident), severity of open fractures (Gustilo grade I to III ), and
20
fracture type (OTA/AO classication system ). We recorded the use of a tempo-
rary spanning external xator, the distance between denitive plate xation and
external xation pin sites, tourniquet use and time, 4-compartment fasciotomy,
dual-incision approach, bicondylar plating, concomitant arthroscopic examina-
tion, and bone graft, as well as the duration of external xation in situ, the timing
of the denitive surgical procedure, the duration of the surgical procedure, and
the timing of the fasciotomy closure. The timing of antibiotic prophylaxis (with
suboptimal timing dened as the antibiotic being given >60 minutes before the
incision, after the incision, or <5 minutes before or after tourniquet ination) and
use of a drain were assessed. Additionally, blood leukocyte counts, C-reactive
protein levels, and the causative pathogens were noted at infection onset.
Data Analysis
An independent biostatistician conducted the statistical analyses. Differences in
categorical variables between the infected and non-infected groups were ana-
lyzed using cross-tabulation. The Mann-Whitney U test was used to test the
difference in the duration of the external xator treatment between groups.
Univariate logistic regression analysis was used to assess signicant risk
factors for deep surgical site infection. Signicant risk factors (p < 0.05) in
the univariate analyses and diabetes as a clinically important factor were
included in the multivariable model. Independent risk factors for infection
were identied by multivariable logistic regression analysis using a stepwise
procedure. In addition, multivariable analysis was performed including one
or two of the injury severity indicators (bicondylar plating, OTA/AO clas-
sication, external xation usage, time to denitive xation) at a time in the
multivariable logistic regression model to avoid multicollinearity problems
and to see the real effects of the injury severity indicators. The results of
logistic regression analyses were expressed using odds ratios (ORs) with
corresponding 95% condence intervals (95% CIs). Statistical analyses were
performed using the SAS System for Windows, version 9.4 (SAS Institute).
Signicance was set at p < 0.05.
Results
T he cumulative prevalence of deep surgical site infection
was 5.2% (95% CI, 3.5% to 6.9%) (34 of 655). The mean
patient age was 55 years (range, 16 to 84 years), and 35% of

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TABLE III Independent Risk Factors in the Multivariable Logistic
Regression Analysis for Deep Surgical Site Infection
Following Plate Fixation of Proximal Tibial Fractures
Characteristics OR*
Age 50 years 3.6 (1.3 to 10.1)
Obesity, BMI 30 kg/m2 6.5 (2.2 to 18.9) <0.001
Alcohol abuse 6.7 (2.4 to 19.2) <0.001
OTA/AO type fractures
C compared with B 2.8 (1.1 to 7.5)
A compared with B 2.1 (0.4 to 12.3)
Use of external xator 3.9 (1.4 to 11.1)
Four-compartment 4.5 (1.3 to 15.7)
fasciotomy
*The values are given as the OR, with the 95% CI in parentheses.
These categories, as well as diabetes, were included in the
stepwise logistic model. These categories were adjusted for age,
obesity, alcohol abuse, fasciotomy, and diabetes.
patients were women. Twenty-eight of the 34 deep infections
were diagnosed within 2 months (acute onset), and only 6
infections were diagnosed >6 months after the index surgical
procedure (late onset). At the onset of infection, 76% of the
patients had a raised C-reactive protein value (>10 mg/L).
Similarly, 44% of the patients had an elevated blood leukocyte
count (>8.2 109/L). Twenty (59%) of the 34 infections were
monobacterial, and the 3 most prevalent pathogens were
Staphylococcus aureus (n = 9), Staphylococcus epidermidis (n = 5),
and Pseudomonas aeruginosa (n = 2). Patients with a deep sur-
gical site infection underwent a mean of 2.3 (range, 1 to 7)
additional operations.
Nine of the 28 patients with acute-onset infection were
treated with antibiotic therapy and debridement only, 17 pa-
tients (50%) required muscle ap coverage, and 1 patient was
treated with an above-the-knee amputation because of fulmi-
nant infection. One elderly patient with multiple comorbid-
ities, including severe arteriosclerosis and decubital wound
problems, rst underwent angioplasty to improve circulation of
the limb. However, this was unsuccessful, and an elective above-
the-knee amputation was planned, but the patient died from
other causes before the operation. Two patients with muscle
ap coverage eventually required above-the-knee amputation
because of a severe persistent infection. Five of the 6 late in-
fections were treated with implant removal and debridement.
One patient with an aggressive infection had a nonunion of the
fracture >1 year after the index surgical procedure. This patient
had severe bone loss after debridement and was eventually also
treated with above-the-knee amputation.
When comparing the infected and non-infected groups
in the univariate analysis, we found several signicant differ-
ences in patient and surgical procedure-related risk factors
(Table II). Patients who were treated initially with a tempo-
rary spanning external xator had a higher risk of infection
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(p < 0.0001). We found that, in the infection group, 62%
(13 of 21) of the patients had external xator and plate overlap,
whereas only 36% (12 of 33) in the non-infected group had
overlap; however, this difference was not signicant (p = 0.07).
P Value Performing a 4-compartment fasciotomy also increased the
risk for deep infection. A comprehensive list of all tested risk
0.015
factors is shown in the Appendix.
To control for confounding effects between variables, mul-
tivariable logistic regression modeling was performed, and in this
analysis, patient age of 50 years, body mass index (BMI) of
0.039 30 kg/m2, alcohol abuse, OTA/AO type-C fracture, use of a tem-
0.42 porary spanning external xator, and a 4-compartment fasciot-
0.009
omy were all independent predictors of deep infection (Table III).
0.017
Discussion
T he aim of this study was to identify risk factors for deep
surgical site infection following plate xation of proximal
tibial fractures using established criteria for deep infection. We
found that age of 50 years, BMI of 30 kg/m2, alcohol abuse,
OTA/AO type-C fracture, 4-compartment fasciotomy, and use
of temporary external xation were all independent risk factors
for deep infection. We also showed that deep infection in plated
proximal tibial fractures carries substantial morbidity.
The prevalence of deep infection in this series was 5.2%,
which is somewhat lower than that found in previous studies
that assessed risk factors for infection in patients with plated
proximal tibial fractures12-14. The reported prevalence in those
studies varied from 8% to 24%12-14. This is most likely due to the
stricter denition of deep infection used in our study. This is
further supported by the observation that half of the patients
with deep infection in the current study required muscle ap
coverage and 15% of patients (5 patients, including the patient
who died before the amputation could be performed) required
above-the-knee amputation as a consequence of their surgical
site infection. These ndings also further emphasize the true
morbidity associated with deep surgical site infection.
There are some commonly recognized patient-related
risk factors for surgical site infection including obesity, smok-
ing, and diabetes with complications12,21-23. Obesity was found to
increase the infection rate, as was previously shown in the op-
erative treatment of acetabular fractures21,22. Morris et al.12 and
Colman et al.14 reported in their studies of proximal tibial frac-
tures that patient age did not correlate with increased infection
risk. On the contrary, we found that patient age of 50 years was
an independent risk factor for deep surgical site infection. Also,
alcohol abuse was an independent risk factor for deep infection
in our study. Tobacco use was a signicant risk factor in our uni-
variate analysis, but it was not an independent risk factor in the
multivariable analysis. This may be a b-type error. A recent study
by Morris et al. showed tobacco use to be a risk factor for in-
fection when treating bicondylar fractures12. Diabetes was not
found to increase the infection rate in our study, in accordance
with previous studies of proximal tibial fractures12-14.
Early attempts at plate xation through a single midline
incision were complicated by an unacceptably high rate of in-
fection5,6. Staged treatment with a temporary spanning external
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xator and the dual-incision approach have decreased the in-
fection rate by allowing the soft-tissue envelope to recover be-
fore denitive xation and also by avoiding extensive soft-tissue
dissection10-12. However, fractures requiring a temporary span-
ning external xator may have an increased risk of infection.
Colman et al. found that use of an external xator in proximal
tibial fractures was associated with a higher infection rate
compared with no external xator use, but it was not an in-
dependent predictor of surgical site infection14. In a study by
Morris et al., 81.4% of bicondylar fractures with infection had a
temporary external xator before open reduction and internal
xation and this was found to be a risk factor for infection in
their univariate analysis, but not in multivariate analysis12. It has
been speculated that external xator use may merely be a sur-
rogate for injury severity, thereby reecting the more frequent
use of external xation in complex injuries. We found that use
of a temporary spanning external xator was an independent
risk factor for infection, and so was fracture severity (OTA/AO
type C). The premise is that pin-track contamination may lead
to infection if the plate extends to this area, yet data are limited
on this subject. Laible et al. found no correlation between in-
fection and overlapping of the xator pin site with the plate
when treating tibial plateau fractures with a temporary external
xator24. However, Shah et al.25 found that this increased the risk
of infection. We found that pin overlap was associated with
higher infection risk, but the difference was not found to be
signicant. On the basis of recent ndings, we recommend pin
placement away from the eld of planned internal xation. This
will reduce the likelihood of pin-site colonization interfering
with denitive xation. We also suggest that pin sites should be
debrided and should be covered until the wounds are closed
after internal xation to minimize the risk of contamination.
The reported prevalence of compartment syndrome and
fasciotomy ranges from 7% to 27% per year after bicondylar
fractures11-13,26. The concern is that internal xation in the pres-
ence of an open fasciotomy wound could increase the infection
rate. Morris et al. found that 38% of patients who had fasciot-
omies performed prior to open reduction and internal xation
for bicondylar fractures developed infection requiring additional
surgical procedures12. In their study, patients with fasciotomies
carried the highest likelihood of deep infection. Ruffolo et al. did
not nd compartment syndrome to be associated with an in-
creased rate of deep infection, but they noticed that fasciotomy
closure before denitive xation was associated with signicantly
fewer deep infections compared with internal xation with open
fasciotomy wounds13. Interestingly, Zura et al. found no differ-
ence in infection rate according to whether the denitive xation
was performed before, at the same time as, or after fasciotomy
closure27. Additionally, a recent study found no difference in the rate
of infection when performing single or dual-incision fasciotomies
in patients with tibial plateau or shaft fractures28. In the pres-
ent study, development of compartment syndrome leading to
4-compartment fasciotomy was an independent risk factor for
deep infection. The diagnosis of compartment syndrome in our
study was clinical in nearly all cases, with no compartment
measurement devices used. Compartment pressure monitoring
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may be a useful supplement to clinical assessment in deciding
when to perform fasciotomies29. Compartment pressure moni-
toring, type-C fractures, and the use of external xation are also
likely markers of injury severity, which is tied to infection risk.
The current study had some limitations. Because deep
surgical site infections are uncommon, it was not practical to
conduct a prospective study. A retrospective case-control study
is a recognized design for an analysis of risk factors for post-
operative infection30. Another limitation was the reliance on
data provided by the medical charts, as there may be under-
reporting, especially of patient-specic factors, such as smoking.
To control for these reporting deciencies, the records from all
other medical elds were also assessed. To our knowledge, this is
the largest case-control study of risk factors for deep infection
after proximal tibial fracture plate xation that has utilized es-
tablished criteria for deep infection.
In conclusion, deep infection in plated proximal tibial
fractures carries a high morbidity. Up to 10% to 20% of patients
will have wound complications after plate xation of proximal
tibial fractures and 5% will have serious complications requiring
multiple operations and potentially even an amputation. Patients
who were 50 years of age, obese patients, those with a history
of alcohol abuse, or those with OTA/AO type-C fractures
should be considered at high risk for infection. Performing a
4-compartment fasciotomy also increases the risk of deep in-
fection after delayed denitive plate xation and should be im-
plemented with meticulous technique when deemed necessary.
Appendix
A table showing univariate logistic regression analyses
for patient and surgical risk factors in patients with and
without deep surgical site infection following proximal tibial
fracture plate xation is available with the online version of this
article as a data supplement at jbjs.org. n
NOTE: The authors thank biostatistician Tero Vahlberg, MSc, for performing the statistical analyses.
Markus Parkkinen, MD1,2
Rami Madanat, MD, PhD3,4
Jan Lindahl, MD, PhD1,2
Tatu J. Makinen, MD, PhD5,6
1Department
of Orthopaedics and Traumatology, University of Helsinki,
Helsinki, Finland
2Helsinki University Hospital, Helsinki, Finland
3Harris Orthopaedic Laboratory, Massachusetts General Hospital,
Boston, Massachusetts
4Harvard
Medical School, Boston, Massachusetts
5Division
of Orthopaedic Surgery, Mount Sinai Hospital, Toronto,
Ontario, Canada
6University of Toronto, Toronto, Ontario, Canada
E-mail address for M. Parkkinen: markus.parkkinen@hus.
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References
1. Bachoura A, Guitton TG, Smith RM, Vrahas MS, Zurakowski D, Ring D. Inrmity
and injury complexity are risk factors for surgical-site infection after operative frac-
ture care. Clin Orthop Relat Res. 2011 Sep;469(9):2621-30. Epub 2010 Dec 16.
2. Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The im-
pact of surgical-site infections following orthopedic surgery at a community hospital
and a university hospital: adverse quality of life, excess length of stay, and extra
cost. Infect Control Hosp Epidemiol. 2002 Apr;23(4):183-9.
3. de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB. Surgical
site infection: incidence and impact on hospital utilization and treatment costs. Am J
Infect Control. 2009 Jun;37(5):387-97. Epub 2009 Apr 23.
4. Broex EC, van Asselt AD, Bruggeman CA, van Tiel FH. Surgical site infections: how
high are the costs? J Hosp Infect. 2009 Jul;72(3):193-201. Epub 2009 May 31.
5. Young MJ, Barrack RL. Complications of internal xation of tibial plateau frac-
tures. Orthop Rev. 1994 Feb;23(2):149-54.
6. Mallik AR, Covall DJ, Whitelaw GP. Internal versus external xation of bicondylar
tibial plateau fractures. Orthop Rev. 1992 Dec;21(12):1433-6.
7. Stevens DG, Beharry R, McKee MD, Waddell JP, Schemitsch EH. The long-term
functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma.
2001 Jun-Jul;15(5):312-20.
8. Rademakers MV, Kerkhoffs GMMJ, Sierevelt IN, Raaymakers ELFB, Marti RK.
Operative treatment of 109 tibial plateau fractures: ve- to 27-year follow-up results.
J Orthop Trauma. 2007 Jan;21(1):5-10.
9. Manidakis N, Dosani A, Dimitriou R, Stengel D, Matthews S, Giannoudis P. Tibial
plateau fractures: functional outcome and incidence of osteoarthritis in 125 cases.
Int Orthop. 2010 Apr;34(4):565-70. Epub 2009 May 14.
10. Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged management of
high-energy proximal tibia fractures (OTA types 41): the results of a prospective,
standardized protocol. J Orthop Trauma. 2005 Aug;19(7):448-55; discussion 456.
11. Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK. Complications asso-
ciated with internal xation of high-energy bicondylar tibial plateau fractures utilizing
a two-incision technique. J Orthop Trauma. 2004 Nov-Dec;18(10):649-57.
12. Morris BJ, Unger RZ, Archer KR, Mathis SL, Perdue AM, Obremskey WT. Risk
factors of infection after ORIF of bicondylar tibial plateau fractures. J Orthop Trauma.
2013 Sep;27(9):e196-200.
13. Ruffolo MR, Gettys FK, Montijo HE, Seymour RB, Karunakar MA. Complications
of high-energy bicondylar tibial plateau fractures treated with dual plating through
2 incisions. J Orthop Trauma. 2015 Feb;29(2):85-90.
14. Colman M, Wright A, Gruen G, Siska P, Pape HC, Tarkin I. Prolonged operative
time increases infection rate in tibial plateau fractures. Injury. 2013 Feb;44(2):
249-52. Epub 2012 Nov 28.
15. Ovaska MT, Makinen TJ, Madanat R, Huotari K, Vahlberg T, Hirvensalo E,
Lindahl J. Risk factors for deep surgical site infection following operative treatment
of ankle fractures. J Bone Joint Surg Am. 2013 Feb 20;95(4):348-53.
R I S K F A C T O R S F O R D E E P I N F E C T I O N F O L L O W I N G P L AT E F I X AT I O N
O F P ROX I M A L TI B I A L FR AC T U R E S
16. Mubarak SJ, Owen CA. Double-incision fasciotomy of the leg for decompression
in compartment syndromes. J Bone Joint Surg Am. 1977 Mar;59(2):184-7.
17. Biesheuvel CJ, Vergouwe Y, Oudega R, Hoes AW, Grobbee DE, Moons KGM.
Advantages of the nested case-control design in diagnostic research. BMC Med Res
Methodol. 2008 Jul 21;8:48.
18. Miettinen OS. Individual matching with multiple controls in the case of all-or-
none responses. Biometrics. 1969 Jun;25(2):339-55.
19. Gustilo RB, Merkow RL, Templeman D. The management of open fractures.
J Bone Joint Surg Am. 1990 Feb;72(2):299-304.
20. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L,
Sirkin MS, Ziran B, Henley B, Audige L. Fracture and dislocation classication
compendium 2007: Orthopaedic Trauma Association Classication, Database and
Outcomes Committee. J Orthop Trauma. 2007 Nov-Dec;21(10 Suppl):S1-133.
21. Suzuki T, Morgan SJ, Smith WR, Stahel PF, Gillani SA, Hak DJ. Postoperative
surgical site infection following acetabular fracture xation. Injury. 2010 Apr;41
(4):396-9. Epub 2009 Dec 11.
22. Karunakar MA, Shah SN, Jerabek S. Body mass index as a predictor of com-
plications after operative treatment of acetabular fractures. J Bone Joint Surg Am.
2005 Jul;87(7):1498-502.
23. Wukich DK, Crim BE, Frykberg RG, Rosario BL. Neuropathy and poorly controlled
diabetes increase the rate of surgical site infection after foot and ankle surgery.
J Bone Joint Surg Am. 2014 May 21;96(10):832-9.
24. Laible C, Earl-Royal E, Davidovitch R, Walsh M, Egol KA. Infection after spanning
external xation for high-energy tibial plateau fractures: is pin site-plate overlap a
problem? J Orthop Trauma. 2012 Feb;26(2):92-7.
25. Shah CM, Babb PE, McAndrew CM, Brimmo O, Badarudeen S, Tornetta P 3rd,
Ricci WM, Gardner MJ. Denitive plates overlapping provisional external xator pin
sites: is the infection risk increased? J Orthop Trauma. 2014 Sep;28(9):518-22.
26. Stark E, Stucken C, Trainer G, Tornetta P 3rd. Compartment syndrome in
Schatzker type VI plateau fractures and medial condylar fracture-dislocations treated
with temporary external xation. J Orthop Trauma. 2009 Aug;23(7):502-6.
27. Zura RD, Adams SB Jr, Jeray KJ, Obremskey WT, Stinnett SS, Olson SA;
Southeastern Fracture Consortium Foundation. Timing of denitive xation of severe
tibial plateau fractures with compartment syndrome does not have an effect on the
rate of infection. J Trauma. 2010 Dec;69(6):1523-6.
28. Bible JE, McClure DJ, Mir HR. Analysis of single-incision versus dual-incision
fasciotomy for tibial fractures with acute compartment syndrome. J Orthop Trauma.
2013 Nov;27(11):607-11.
29. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures.
The pressure threshold for decompression. J Bone Joint Surg Br. 1996 Jan;78(1):
99-104.
30. Busse JW, Obremskey WT. Principles of designing an orthopaedic case-control
study. J Bone Joint Surg Am. 2009 May;91(Suppl 3):15-20.