PRESENT Journal Club
Journal Club - PRESENT Podatry
     Vol. 1 Issue 16
July 8, 2010   
In this issue we examine articles from the following journals: The Journal of Bone and Joint Surgery and the journal Annals of Emergency Medicine.   In addition, in the “critical analysis” section we’ll take a closer look at the specific topic of how study design can influence conclusions as it applies to these articles.   And finally, please join us for an online discussion of these and other articles on our eTalk page.
   PODIATRY JOURNAL REVIEW
Section 1
Berkes M, Obremskey WT, Scannell B, Ellington K, Hymes RA, Bosse M; Southeast Fracture Consortium.  Maintenance of hardware after early postoperative infection following fracture internal fixation.  J Bone Joint Surg Am.  2010 Apr; 92(4): 823-8.  

WHY did the authors undertake this study?
Deep wound infection in the presence of internal fixation represents a clinical challenge without a clear evidence-based solution.  Should irrigation and debridement include the removal of hardware, or can osseous union be achieved by fighting the infection with other means?  The authors of this study aim to determine the rate of osseous union and infection clearance when hardware is retained following the development of acute infection following fracture open reduction and internal fixation. 

HOW did they attempt to answer this question?
The primary outcome measure of the study was to determine the rate of osseous union when hardware was retained following treatment for acute infection.  A secondary measure attempted to determine patient factors that may have been associated with treatment failure and the need to remove internal fixation.

Inclusion criteria of the population cohort were patients who were retrospectively identified for having surgical irrigation and debridement of a deep postoperative wound infection (within 6 weeks of the initial surgery) following open reduction and internal fixation of an acute extremity fracture.  Treatment consisted of operative irrigation and debridement, antibiotic therapy, and removal of the hardware at the discretion of the surgeon.

WHAT were the specific results?
Of the 123 infections that were identified that met inclusion criteria, 71% (87/123) went on to successful fracture union with the retention of hardware.  Of note, 30% (26/87) of the treatment “successes”, or 21% (26/123) of the total number of patients, eventually went on to hardware removal secondary to infection recurrence after successful osseous union.  Only the presence of open fracture (p=0.03) and the use of intramedullary nail (p=0.01) demonstrated statistical significance in terms of patient risk factors for failure.

HOW did the authors interpret these results?
From these results, the authors concluded  that deep postoperative wound infection can be successfully treated without the removal of hardware until after osseous union has occurred. 

There are several other review articles in this issue that readers may find both beneficial and interesting. Furia et al compare intramedullary screw fixation to shock wave therapy with equivocal results in the treatment of Jones fracture non-unions.  Hou et al provide a review of the surgical treatment for unicameral bone cysts.  Shuler et al attempt to determine if near-infrared spectroscopy is a viable option for the diagnosis of acute compartment syndrome of the lower leg.  Zionts et al demonstrate that the rates of extensive surgery for the treatment of idiopathic clubfoot have significantly decreased in the United States over a recent 10-year period.  Jungbluth et al present results of a case series of 97 patients with subtalar joint dislocation.  Saldua et al provide evidence useful in the radiographic evaluation of ankle fractures, specifically with respect to the effect of plantarflexion on the medial clear space.   And Langeveld et al discuss a case report utilizing the Pirogoff amputation with calcaneotibial arthrodesis.

   MEDICAL JOURNAL REVIEW
Section 2
Duong M, Markwell S, Peter J, Barenkamp S.  Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient.  Ann Emerg Med.  2010 May; 55(5): 401-7.  (Pubmed ID#: 19409657)

WHY did the authors undertake this study?
Localized skin and soft tissue abscesses infected with MRSA have become increasingly prevalent in United States emergency departments.  The need for incision and drainage is clear, but does the treatment also require additional antibiotic therapy in order to be effective? The authors of this study aim to determine the effect of antibiotics on outcomes following surgically managed pediatric skin abscesses. 

HOW did they attempt to answer this question?
The primary outcome measure of this study was the 10-day treatment failure rate following surgical incision, irrigation and drainage of pediatric skin abscesses.  Utilizing a randomized and double-blind study design, patients were treated with either a 10-day course of Bactrim or placebo following I&D.

WHAT were the specific results?
There was no statistically significant difference in treatment failure rates between the groups at 10 day follow-up.  However, patients who were treated with antibiotics may have been less likely to develop a new abscess at a different location.

HOW did the authors interpret these results?
From these results, the authors concluded that antibiotic therapy is not required for resolution of pediatric skin abscesses in addition to incision and drainage.

There are several other articles in this issue that readers may find both beneficial and interesting. Courtney et al enrolled nearly 8000 patients in a study attempting to determine which features of the history and physical examination predict the presence or absence of pulmonary embolism in the ED setting. Horwitz, Green and Bradley provide further evidence of the overextended nature of US emergency departments by showing overall poor performance with respect to waiting times.  And finally, Newgard et al objectify the “golden hour” with respect to the acute trauma patient and show that it may not be as important as originally supposed.


   CRITICAL ANALYSIS OF THE LITERATURE
Section 3

Let’s take a closer look at the topic of how study design can influence the conclusions of an experiment.  Both of the studies from our journal club this week are actually fairly similar in terms of the question they are attempting to answer.   Generally speaking, they are trying to determine how some intervention (hardware retention in the Berkes et al, and antibiotic therapy in the Duong et al) influences the resolution of infection.  But because the authors go about trying to answer this question in different ways, we eventually arrive at two different conclusions.

The Duong et al study attempts to answer the question with the use of a prospective, interventional, and randomized study design.  We are clearly comparing two groups of patients with infection; half of whom receive antibiotics, while the other half do not.  Based on their study design and results, we can appropriately conclude that their variable (PO antibiotics) had no effect on the outcome (infection resolution at 10 days).
 
On the other hand, the Berkes et al study attempts to answer the question with the use of a retrospective study design.  Here we are not actively intervening in the therapy, and there is really only one group of patients that we are analyzing.  This one group is patients with infection who had retained hardware.  While we can arrive at some conclusions with respect to this one group of patients (like that 71% went on to successful fracture union), we cannot reach any conclusion with respect to the effect of the variable (hardware retention) on the outcome (osseous union).  Here it would be inappropriate to reach similar conclusions as the Duong study, namely that variable had no effect (or any effect) on the outcome. 

One way to think about this is that retrospective study designs usually do a good job at describing some variable, but don’t usually compare variables.


   DISCUSSION
Section 4
Please join us for an online discussion of these topics:
Journal Club Forum


I hope you find PRESENT Journal Club a valuable resource. Look out for the eZine in your inbox. Please do not hesitate to contact me if there is anything I can do to make this a more educational and clinically relevant journal club.


AJM
Andrew Meyr, DPM
PRESENT Podiatry Journal Club Editor
Assistant Professor, Department of Podiatric Surgery,
Temple University School of Podiatric Medicine,
Philadelphia, Pennsylvania
[email protected]
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