Advertisement

Definition of infection after fracture fixation: A systematic review of randomized controlled trials to evaluate current practice

Published:February 19, 2017DOI:https://doi.org/10.1016/j.injury.2017.02.010

      Abstract

      Introduction

      One of the most challenging musculoskeletal complications in modern trauma surgery is infection after fracture fixation (IAFF). Although infections are clinically obvious in many cases, a clear definition of the term IAFF is crucial, not only for the evaluation of published research data but also for the establishment of uniform treatment concepts. The aim of this systematic review was to identify the definitions used in the scientific literature to describe infectious complications after internal fixation of fractures. The hypothesis of this study was that the majority of fracture-related literature do not define IAFF.

      Material and methods

      A comprehensive search was performed in Embase, Cochrane, Google Scholar, Medline (OvidSP), PubMed publisher and Web-of-Science for randomized controlled trials (RCTs) on fracture fixation. Data were collected on the definition of infectious complications after fracture fixation used in each study. Study selection was accomplished through two phases. During the first phase, titles and abstracts were reviewed for relevance, and the full texts of relevant articles were obtained. During the second phase, full-text articles were reviewed. All definitions were literally extracted and collected in a database. Then, a classification was designed to rate the quality of the description of IAFF.

      Results

      A total of 100 RCT’s were identified in the search. Of 100 studies, only two (2%) cited a validated definition to describe IAFF. In 28 (28%) RCTs, the authors used a self-designed definition. In the other 70 RCTs, (70%) there was no description of a definition in the Methods section, although all of the articles described infections as an outcome parameter in the Results section.

      Conclusion

      This systematic review shows that IAFF is not defined in a large majority of the fracture-related literature. To our knowledge, this is the first study conducted with the objective to explore this important issue. The lack of a consensus definition remains a problem in current orthopedic trauma research and treatment and this void should be addressed in the near future.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Metsemakers W.J.
        Long Bone Fractures in (Poly)Trauma Patients: Risk Analyses of Muskuloskeletal Complications and Strategies to Prevent Them [Thesis].
        Catholic University Leuven, Leuven2015
        • Bonnevialle P.
        • Bonnomet F.
        • Philippe R.
        • Loubignac F.
        • Rubens-Duval B.
        • Talbi A.
        • et al.
        Early surgical site infection in adult appendicular skeleton trauma surgery: a multicenter prospective series.
        Orthop Traumatol Surg Res. 2012; 98: 684-689
        • Arens S.
        • Hansis M.
        • Schlegel U.
        • Eijer H.
        • Printzen G.
        • Ziegler W.J.
        • et al.
        Infection after open reduction and internal fixation with dynamic compression plates-clinical and experimental data.
        Injury. 1996; 27: SC27-SC33
        • Parvizi J.
        • Zmistowski B.
        • Berbari E.F.
        • Bauer T.W.
        • Springer B.D.
        • Della Valle C.J.
        • et al.
        New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society.
        Clin Orthop Relat Res. 2011; 469: 2992-2994
        • Osmon D.R.
        • Berbari E.F.
        • Berendt A.R.
        • Lew D.
        • Zimmerli W.
        • Steckelberg J.M.
        • et al.
        Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America.
        Clin Infect Dis. 2013; 56: e1-e25
        • Metsemakers W.J.
        • Moriarty T.F.
        • Morgenstern M.
        • Kuehl R.
        • Borens O.
        • Kates S.
        • et al.
        Letter to the Editor: new definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society.
        Clin Orthop Relat Res. 2016; 474: 2726-2727
        • Horan T.C.
        • Gaynes R.P.
        • Martone W.J.
        • Jarvis W.R.
        • Emori T.G.
        CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections.
        Infect Control Hosp Epidemiol. 1992; 13: 606-608
        • Mangram A.J.
        • Horan T.C.
        • Pearson M.L.
        • Silver L.C.
        • Jarvis W.R.
        Guideline for prevention of surgical site infection, 1999. Centers for disease control and prevention (CDC) hospital infection control practices advisory committee.
        Am J Infect Control. 1999; 27 (quiz 3–4; discussion 96): 97-132
      1. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN) Overview. 2016. http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf2016.

        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • Group P.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        Ann Intern Med. 2009; 151 (W64): 264-269
      2. Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures I, Bhandari M, Guyatt G, Tornetta P, 3rd, Schemitsch EH, Swiontkowski M, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 2008;90:2567-78.

        • Saveli C.C.
        • Morgan S.J.
        • Belknap R.W.
        • Ross E.
        • Stahel P.F.
        • Chaus G.W.
        • et al.
        Prophylactic antibiotics in open fractures: a pilot randomized clinical safety study.
        J Orthop Trauma. 2013; 27: 552-557
        • Akinyoola A.L.
        • Adegbehingbe O.O.
        • Odunsi A.
        Timing of antibiotic prophylaxis in tourniquet surgery.
        J Foot Ankle Surg. 2011; 50: 374-376
        • Akinyoola A.L.
        • Odunsi A.
        • Yusu M.B.
        Use of wound drains following open reduction and internal fixation of femoral shaft fractures.
        J Wound Care. 2012; 21 (82-4): 279-280
        • Bodoky A.
        • Neff U.
        • Heberer M.
        • Harder F.
        Antibiotic prophylaxis with two doses of cephalosporin in patients managed with internal fixation for a fracture of the hip.
        J Bone Jt Surg Am. 1993; 75: 61-65
        • Boxma H.
        • Broekhuizen T.
        • Patka P.
        • Oosting H.
        Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial.
        Lancet. 1996; 347: 1133-1137
        • Esan O.
        • Ikem I.C.
        • Oginni L.M.
        • Esan O.T.
        Comparison of unreamed interlocking nail and external fixation in open tibia shaft fracture management.
        West Afr J Med. 2014; 33: 16-20
        • Gaebler C.
        • McQueen M.M.
        • Vecsei V.
        • Court-Brown C.M.
        Reamed versus minimally reamed nailing: a prospectively randomised study of 100 patients with closed fractures of the tibia.
        Injury. 2011; 42: S17-21
        • Garcia S.
        • Lozano M.L.
        • Gatell J.M.
        • Soriano E.
        • Ramon R.
        • Sanmiguel J.G.
        Prophylaxis against infection: single-dose cefonicid compared with multiple-dose cefamandole.
        J Bone Jt Surg Am. 1991; 73: 1044-1048
        • Gatell J.M.
        • Garcia S.
        • Lozano L.
        • Soriano E.
        • Ramon R.
        • SanMiguel J.G.
        Perioperative cefamandole prophylaxis against infections.
        J Bone Jt Surg Am. 1987; 69: 1189-1193
        • Govender S.
        • Csimma C.
        • Genant H.K.
        • Valentin-Opran A.
        • Amit Y.
        • Arbel R.
        • et al.
        Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients.
        J Bone Jt Surg Am. 2002; 8 (84-A): 2123-2134
        • Hedstrom S.A.
        • Lidgren L.
        • Sernbo I.
        • Torholm C.
        • Onnerfalt R.
        Cefuroxime prophylaxis in trochanteric hip fracture operations.
        Acta Orthop Scand. 1987; 58: 361-364
        • Keating J.F.
        • O'Brien P.J.
        • Blachut P.A.
        • Meek R.N.
        • Broekhuyse H.M.
        Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft A prospective, randomized study.
        J Bone Jt Surg Am. 1997; 79: 334-341
        • Lin T.
        • Liu J.
        • Xiao B.
        • Fu D.
        • Yang S.
        Comparison of the outcomes of cannulated screws vs: modified tension band wiring fixation techniques in the management of mildly displaced patellar fractures.
        BMC Musculoskelet Disord. 2015; 16: 282
        • Mathur P.
        • Trikha V.
        • Farooque K.
        • Sharma V.
        • Jain N.
        • Bhardwaj N.
        • et al.
        Implementation of a short course of prophylactic antibiotic treatment for prevention of postoperative infections in clean orthopaedic surgeries.
        Indian J. Med. Res. 2013; 137: 111-116
        • Miedel R.
        • Ponzer S.
        • Tornkvist H.
        • Soderqvist A.
        • Tidermark J.
        The standard Gamma nail or the Medoff sliding plate for unstable trochanteric and subtrochanteric fractures A randomised, controlled trial.
        J Bone Jt Surg Br. 2005; 87: 68-75
        • Moehring H.D.
        • Gravel C.
        • Chapman M.W.
        • Olson S.A.
        Comparison of antibiotic beads and intravenous antibiotics in open fractures.
        Clin Orthop Relat Res. 2000; 25: 4-61
        • Narsaria N.
        • Singh A.K.
        • Arun G.R.
        • Seth R.R.S.
        Surgical fixation of displaced midshaft clavicle fractures: elastic intramedullary nailing versus precontoured plating.
        J Orthop Taumatol Off J Ital Soc Orthop Traumatol. 2014; 15: 165-171
        • Okcu G.
        • Ozkayin N.
        • Okta C.
        • Topcu I.
        • Aktuglu K.
        Which implant is better for treating reverse obliquity fractures of the proximal femur: a standard or long nail.
        Clin Orthop Relat Res. 2013; 471: 2768-2775
        • Ramos T.
        • Eriksson B.I.
        • Karlsson J.
        • Nistor L.
        Ilizarov external fixation or locked intramedullary nailing in diaphyseal tibial fractures: a randomized, prospective study of 58 consecutive patients.
        Arch Orthop Trauma Surg. 2014; 134: 793-802
        • Richards J.E.
        • Magill M.
        • Tressler M.A.
        • Shuler F.D.
        • Kregor P.J.
        • Obremskey W.T.
        • et al.
        External fixation versus ORIF for distal intra-articular tibia fractures.
        Orthopedics. 2012; 35: e862-7
        • Robinson C.M.
        • Goudie E.B.
        • Murray I.R.
        • Jenkins P.J.
        • Ahktar M.A.
        • Read E.O.
        • et al.
        Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial.
        J Bone Jt Surg Am Vol. 2013; 95: 1576-1584
        • Soleimanpour J.
        • Feizi H.H.
        • Mohseni M.A.
        • Moradi A.
        • Arzromchilar A.
        Comparison between ender and unreamed interlocking nails in tibial shaft fractures.
        Saudi Med J. 2008; 29: 1458-1462
        • Wang C.
        • Li Y.
        • Huang L.
        • Wang M.
        Comparison of two-staged ORIF and limited internal fixation with external fixator for closed tibial plafond fractures.
        Arch Orthop Trauma Surg. 2010; 130: 1289-1297
        • Zou J.
        • Shi Z.-M.
        • Zhang W.
        • Zhang C.-Q.
        Open reduction and internal fixation better than percutaneous plate osteosynthesis in distal tibial fractures.
        J Investig Surg Off J Acad Surg Res. 2012; 25: 326-329
        • Zou J.
        • Zhang W.
        • Zhang C.Q.
        Comparison of minimally invasive percutaneous plate osteosynthesis with open reduction and internal fixation for treatment of extra-articular distal tibia fractures.
        Injury. 2013; 44: 1102-1106
        • Hughes S.P.
        • Miles R.S.
        • Littlejohn M.
        • Brown E.
        Is antibiotic prophylaxis necessary for internal fixation of low-energy fractures.
        Injury. 1991; 22: 111-113
        • Sorger J.I.
        • Kirk P.G.
        • Ruhnke C.J.
        • Bjornson S.H.
        • Levy M.S.
        • Cockrin J.
        • et al.
        Once daily, high dose versus divided, low dose gentamicin for open fractures.
        Clin Orthop Relat Res. 1999; 19: 7-204
        • Luthje P.
        • Nurmi I.
        • Aho H.
        • Honkanen P.
        • Jokipii P.
        • Kataja M.
        • et al.
        Single-dose antibiotic prophylaxis in osteosynthesis for hip fractures: a clinical multicentre study in Finland.
        Ann Chir Gynaecol. 2000; 89: 125-130
        • Arens D.
        • Wilke M.
        • Calabro L.
        • Hackl S.
        • Zeiter S.
        • Zderic I.
        • et al.
        A rabbit humerus model of plating and nailing osteosynthesis with and without Staphylococcus aureus osteomyelitis.
        Eur Cell Mater. 2015; 30: 148-161
        • Aro H.T.
        • Govender S.
        • Patel A.D.
        • Hernigou P.
        • Perera de Gregorio A.
        • Popescu G.I.
        • et al.
        Recombinant human bone morphogenetic protein-2: a randomized trial in open tibial fractures treated with reamed nail fixation.
        J Bone Jt Surg Am. 2011; 93: 801-808
        • Assobhi J.E.
        Reconstruction plate versus minimal invasive retrograde titanium elastic nail fixation for displaced midclavicular fractures.
        J Orthop Traumatol. 2011; 12: 185-192
        • Bach A.W.
        • Hansen Jr., S.T.
        Plates versus external fixation in severe open tibial shaft fractures. A randomized trial.
        Clin Orthop Relat Res. 1989; : 89-94
        • Bar-On E.
        • Sagiv S.
        • Porat S.
        External fixation or flexible intramedullary nailing for femoral shaft fractures in children A prospective, randomised study.
        J Bone Jt Surg Br. 1997; 79: 975-978
        • Blachut P.A.
        • O'Brien P.J.
        • Meek R.N.
        • Broekhuyse H.M.
        Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft A prospective, randomized study.
        J Bone Jt Surg Am. 1997; 79: 640-646
        • Cassidy C.
        • Jupiter J.B.
        • Cohen M.
        • Delli-Santi M.
        • Fennell C.
        • Leinberry C.
        • et al.
        Norian SRS cement compared with conventional fixation in distal radial fractures: a randomized study.
        J Bone Jt Surg Am. 2003; 8 (85-A): 2127-2137
        • Hanschen M.
        • Aschenbrenner I.M.
        • Fehske K.
        • Kirchhoff S.
        • Keil L.
        • Holzapfel B.M.
        • et al.
        Mono- versus polyaxial locking plates in distal femur fractures: a prospective randomized multicentre clinical trial.
        Int Orthop. 2014; 38: 857-863
        • Kortekangas T.
        • Savola O.
        • Flinkkila T.
        • Lepojarvi S.
        • Nortunen S.
        • Ohtonen P.
        • et al.
        A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography.
        Injury. 2015; 46: 1119-1126
        • Liu Q.H.
        • Fu Z.G.
        • Zhou J.L.
        • Lu T.
        • Liu T.
        • Shan L.
        • et al.
        Randomized prospective study of olecranon fracture fixation: cable pin system versus tension band wiring.
        J Int Med Res. 2012; 40: 1055-1066
        • Luna-Pizarro D.
        • Amato D.
        • Arellano F.
        • Hernandez A.
        • Lopez-Rojas P.
        Comparison of a technique using a new percutaneous osteosynthesis device with conventional open surgery for displaced patella fractures in a randomized controlled trial.
        J Orthop Trauma. 2006; 20: 529-535
        • McCormack R.G.
        • Brien D.
        • Buckley R.E.
        • McKee M.D.
        • Powell J.
        • Schemitsch E.H.
        Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail A prospective, randomised trial.
        J Bone Jt Surg Br. 2000; 82: 336-339
        • Mohseni M.A.
        • Soleimanpour J.
        • Mohammadpour H.
        • Shahsavari A.
        AO tubular external fixation vs: unreamed intramedullary nailing in open grade IIIA-IIIB tibial shaft fractures: a single-center randomized clinical trial.
        Pak J Biol Sci. 2011; 14: 490-495
        • Olerud P.
        • Ahrengart L.
        • Ponzer S.
        • Saving J.
        • Tidermark J.
        Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial.
        J Shoulder Elbow Surg. 2011; 20: 747-755
        • Polat A.
        • Kose O.
        • Canbora K.
        • Yanik S.
        • Guler F.
        Intramedullary nailing versus minimally invasive plate osteosynthesis for distal extra-articular tibial fractures: a prospective randomized clinical trial.
        J Orthop Sci Off J Jpn Orthop Assoc. 2015; 20: 695-701
        • Raschke M.
        • Rasmussen M.H.
        • Govender S.
        • Segal D.
        • Suntum M.
        • Christiansen J.S.
        Effects of growth hormone in patients with tibial fracture: a randomised, double-blind, placebo-controlled clinical trial.
        Eur J Endocrinol. 2007; 156: 341-351
        • Rodrigues F.L.
        • de Abreu L.C.
        • Valenti V.E.
        • Valente A.L.
        • da Costa Pereira Cestari R.
        • Pohl P.H.I.
        • et al.
        Bone tissue repair in patients with open diaphyseal tibial fracture treated with biplanar external fixation or reamed locked intramedullary nailing.
        Injury. 2014; 45: S32-5
        • Rodriguez-Merchan E.C.
        Plaster cast versus percutaneous pin fixation for comminuted fractures of the distal radius in patients between 46 and 65 years of age.
        J Orthop Trauma. 1997; 11: 212-217
        • Roh Y.H.
        • Lee B.K.
        • Baek J.R.
        • Noh J.H.
        • Gong H.S.
        • Baek G.H.
        A randomized comparison of volar plate and external fixation for intra-articular distal radius fractures.
        J Hand Surg. 2015; 40: 34-41
        • Saied A.
        • Zyaei A.
        Tourniquet use during plating of acute extra-articular tibial fractures: effects on final results of the operation.
        J Trauma. 2010; 69: E94-7
        • Shemshaki H.R.
        • Mousavi H.
        • Salehi G.
        • Eshaghi M.A.
        Titanium elastic nailing versus hip spica cast in treatment of femoral-shaft fractures in children.
        J Orthop Traumatol. 2011; 12: 45-48
        • Sloan J.P.
        • Dove A.F.
        • Maheson M.
        • Cope A.N.
        • Welsh K.R.
        Antibiotics in open fractures of the distal phalanx.
        J Hand Surg Br. 1987; 12: 123-124
        • Stall A.
        • Paryavi E.
        • Gupta R.
        • Zadnik M.
        • Hui E.
        • O'Toole R.V.
        Perioperative supplemental oxygen to reduce surgical site infection after open fixation of high-risk fractures: a randomized controlled pilot trial.
        J Trauma Acute Care Surg. 2013; 75: 657-663
        • Zehir S.
        • Zehir R.
        • Sahin E.
        • Calbiyik M.
        Comparison of novel intramedullary nailing with mini-invasive plating in surgical fixation of displaced midshaft clavicle fractures.
        Arch Orthop Trauma Surg. 2015; 135: 339-344
        • Benegas E.
        • Ferreira Neto A.A.
        • Gracitelli M.E.C.
        • Malavolta E.A.
        • Assuncao J.H.
        • Prada F.D.S.
        • et al.
        Shoulder function after surgical treatment of displaced fractures of the humeral shaft: a randomized trial comparing antegrade intramedullary nailing with minimally invasive plate osteosynthesis.
        J Shoulder Elbow Surg Am Shoulder Elbow Surg [et al]. 2014; 23: 767-774
        • Changulani M.
        • Jain U.K.
        • Keswani T.
        Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study.
        Int Orthop. 2007; 31: 391-395
        • Chiu K.Y.
        • Lau S.K.
        • Fung B.
        • Ng K.H.
        • Chow S.P.
        Plastic adhesive drapes and wound infection after hip fracture surgery.
        Aust N Z J Surg. 1993; 63: 798-801
        • Colaris J.
        • Reijman M.
        • Allema J.H.
        • Kraan G.
        • van Winterswijk P.
        • de Vries M.
        • et al.
        Single-bone intramedullary fixation of unstable both-bone diaphyseal forearm fractures in children leads to increased re-displacement: a multicentre randomised controlled trial.
        Arch Orthop Trauma Surg. 2013; 133: 1079-1087
        • Costa M.L.
        • Achten J.
        • Plant C.
        • Parsons N.R.
        • Rangan A.
        • Tubeuf S.
        • et al.
        UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius.
        Health Technol Assess. 2015; 19 (v-vi): 1-124
        • Fadel M.
        • Ahmed M.A.
        • Al-Dars A.M.
        • Maabed M.A.
        • Shawki H.
        Ilizarov external fixation versus plate osteosynthesis in the management of extra-articular fractures of the distal tibia.
        Int Orthop. 2015; 39: 513-519
        • Ferran N.A.
        • Hodgson P.
        • Vannet N.
        • Williams R.
        • Evans R.O.
        Locked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: a randomized clinical trial.
        J Shoulder Elbow Surg. 2010; 19: 783-789
        • Griffin D.
        • Parsons N.
        • Shaw E.
        • Kulikov Y.
        • Hutchinson C.
        • Thorogood M.
        • et al.
        Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial.
        BMJ (Clin Res Ed). 2014; 349: g4483
        • Hjortrup A.
        • Sorensen C.
        • Mejdahl S.
        • Horsnaes M.
        • Kjersgaard P.
        Antibiotic prophylaxis in surgery for hip fractures.
        Acta Orthop Scand. 1990; 61: 152-153
        • Im G.I.
        • Tae S.K.
        Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation.
        J Trauma. 2005; 59 (discussion 23): 1219-1223
        • Juhn A.
        • Krimerman J.
        • Mendes D.G.
        Intertrochanteric fracture of the hip: comparison of nail-plate fixation and Ender's nailing.
        Arch Orthop Trauma Surg. 1988; 107: 136-139
        • Lee S.K.
        • Kim K.J.
        • Lee J.W.
        • Choy W.S.
        Plate osteosynthesis versus intramedullary nailing for both forearm bones fractures.
        Eur J Orthop Surg Traumatol Orthop Traumatol. 2014; 24: 769-776
        • Lehtonen H.
        • Jarvinen T.L.
        • Honkonen S.
        • Nyman M.
        • Vihtonen K.
        • Jarvinen M.
        Use of a cast compared with a functional ankle brace after operative treatment of an ankle fracture. A prospective, randomized study.
        J Bone Jt Surg Am. 2003; 85-A: 205-211
        • Canadian Orthopaedic Trauma Society
        Are locking constructs in distal femoral fractures always best? a prospective multicenter randomized controlled trial comparing the less invasive stabilization system with the minimally invasive dynamic condylar screw system.
        J Orthop Trauma. 2016; 30: e1-6
        • Leung F.
        • Chow S.P.
        A prospective, randomized trial comparing the limited contact dynamic compression plate with the point contact fixator for forearm fractures.
        J Bone Jt Surg Am. 2003; 85-A: 2343-2348
        • Li Y.
        • Jiang X.
        • Guo Q.
        • Zhu L.
        • Ye T.
        • Chen A.
        Treatment of distal tibial shaft fractures by three different surgical methods: a randomized, prospective study.
        Int Orthop. 2014; 38: 1261-1267
        • Madsen J.E.
        • Naess L.
        • Aune A.K.
        • Alho A.
        • Ekeland A.
        • Stromsoe K.
        Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw.
        J Orthop Trauma. 1998; 12: 241-248
        • Meena R.C.
        • Meena U.K.
        • Gupta G.L.
        • Gahlot N.
        • Gaba S.
        Intramedullary nailing versus proximal plating in the management of closed extra-articular proximal tibial fracture: a randomized controlled trial.
        J Orthop Traumatol. 2015; 16: 203-208
        • Ozkayin N.
        • Okcu G.
        • Aktuglu K.
        Intertrochanteric femur fractures in the elderly treated with either proximal femur nailing or hemiarthroplasty: a prospective randomised clinical study.
        Injury. 2015; 46: S3-8
        • Paiement G.D.
        • Renaud E.
        • Dagenais G.
        • Gosselin R.A.
        Double-blind randomized prospective study of the efficacy of antibiotic prophylaxis for open reduction and internal fixation of closed ankle fractures.
        J Orthop Trauma. 1994; 8: 64-66
        • Parker M.J.
        • Bowers T.R.
        • Pryor G.A.
        Sliding hip screw versus the Targon PF nail in the treatment of trochanteric fractures of the hip: a randomised trial of 600 fractures.
        J Bone Jt Surg Br Vol. 2012; 94: 391-397
        • Canadian Orthopaedic Trauma Society
        Nonunion following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial.
        J Bone Jt Surg Am. 2003; 85-A: 2093-2096
        • Sanders D.W.
        • Tieszer C.
        • Corbett B.
        • Canadian Orthopedic Trauma Society
        • Sanders D.
        • Tieszer C.
        • et al.
        Operative versus nonoperative treatment of unstable lateral malleolar fractures: a randomized multicenter trial.
        J Orthop Trauma. 2012; 26: 129-134
        • Tsukada S.
        • Otsuji M.
        • Shiozaki A.
        • Yamamoto A.
        • Komatsu S.
        • Yoshimura H.
        • et al.
        Locking versus non-locking neutralization plates for treatment of lateral malleolar fractures: a randomized controlled trial.
        Int Orthop. 2013; 37: 2451-2456
        • Vallier H.A.
        • Cureton B.A.
        • Patterson B.M.
        Randomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fractures.
        J Orthop Trauma. 2011; 25: 736-741
        • Vioreanu M.
        • Dudeney S.
        • Hurson B.
        • Kelly E.
        • O'Rourke K.
        • Quinlan W.
        Early mobilization in a removable cast compared with immobilization in a cast after operative treatment of ankle fractures: a prospective randomized study.
        Foot Ankle Int. 2007; 28: 13-19
        • Vossinakis I.C.
        • Badras L.S.
        The external fixator compared with the sliding hip screw for pertrochanteric fractures of the femur.
        J Bone Jt Surg Br. 2002; 84: 23-29
        • Zhang J.
        • Ebraheim N.
        • Lause G.E.
        • Xiao B.
        • Xu R.
        A comparison of absorbable screws and metallic plates in treating calcaneal fractures: a prospective randomized trial.
        J Trauma Acute Care Surg. 2012; 72: E106-10
        • Zhang S.
        • Zhang K.
        • Jia Y.
        • Yu B.
        • Feng W.
        InterTan nail versus Proximal Femoral Nail Antirotation-Asia in the treatment of unstable trochanteric fractures.
        Orthopedics. 2013; 36: e288-94
        • Zhang T.
        • Yan Y.
        • Xie X.
        • Mu W.
        Minimally invasive sinus tarsi approach with cannulated screw fixation combined with vacuum-Assisted closure for treatment of severe open calcaneal fractures with medial wounds.
        J Foot Ankle Surg Off Publ Am Coll Foot Ankle Surg. 2016; 55: 112-116
        • Holbrook J.L.
        • Swiontkowski M.F.
        • Sanders R.
        Treatment of open fractures of the tibial shaft: ender nailing versus external fixation. A randomized, prospective comparison.
        J Bone Jt Surg Am. 1989; 71: 1231-1238
        • Horton T.C.
        • Hatton M.
        • Davis T.R.
        A prospective randomized controlled study of fixation of long oblique and spiral shaft fractures of the proximal phalanx: closed reduction and percutaneous Kirschner wiring versus open reduction and lag screw fixation.
        J Hand Surg Br. 2003; 28: 5-9
        • Karn N.K.
        • Singh G.K.
        • Kumar P.
        • Shrestha B.
        • Singh M.P.
        • Gowda M.J.
        Comparison between external fixation and sliding hip screw in the management of trochanteric fracture of the femur in Nepal.
        J Bone Jt Surg Br. 2006; 88: 1347-1350
        • Hargreaves D.G.
        • Drew S.J.
        • Eckersley R.
        Kirschner wire pin tract infection rates: a randomized controlled trial between percutaneous and buried wires.
        J Hand Surg Br. 2004; 29: 374-376
        • Varley G.W.
        • Milner S.A.
        Wound drains in proximal femoral fracture surgery: a randomized prospective trial of 177 patients.
        J R Coll Surg Edinb. 1995; 40: 416-418
        • Sadighi A.
        • Elmi A.
        • Jafari M.A.
        • Sadeghifard V.
        • Goldust M.
        Comparison study of therapeutic results of closed tibial shaft fracture with intramedullary nails inserted with and without reaming.
        Pak J Biol Sci. 2011; 14: 950-953
        • Williams M.M.
        • Askins V.
        • Hinkes E.W.
        • Zych G.A.
        Primary reamed intramedullary nailing of open femoral shaft fractures.
        Clin Orthop Relat Res. 1995; 18: 2-90
        • Mandal A.
        • Dutta P.
        • Sarkar P.S.
        • Bandyopadhyay U.
        • Santra S.
        Single long midline incision versus two small incision techniques in treatment of Schatzker type V and type VI tibial plateau fractures–a comparative study.
        J Indian Med Assoc. 2013; 111: 804-805
        • Tabatabaei S.
        • Arti H.
        • Mahboobi A.
        Treatment of open tibial fractures: comparison between unreamed and reamed nailing A prospective randomized trial.
        Pak J Med Sci. 2012; 28: 917-920
        • Rafique A.
        • Ghani S.
        • Sadiq M.
        • Siddiqui I.A.
        Kirschner wire pin tract infection rates between percutaneous and buried wires in treating metacarpal and phalangeal fractures.
        J Coll Phys Surg Pak. 2006; 16: 518-520
        • Karachalios T.
        • Lyritis G.
        • Hatzopoulos E.
        • Sapkas G.
        Single-dose prophylaxis of ceftriaxone versus standard dosage of cefotaxime in the prophylaxis of bacterial complications in orthopedic surgery.
        Chemioterapia. 1987; 6: 573-575
        • Chen L.
        • Zhang G.
        • Hong J.
        • Lu X.
        • Yuan W.
        Comparison of percutaneous screw fixation and calcium sulfate cement grafting versus open treatment of displaced intra-articular calcaneal fractures.
        Foot Ankle Int. 2011; 32: 979-985
        • Chen L.
        • Zhang G.
        • Song D.
        • Guo X.
        • Yuan W.
        A comparison of percutaneous reduction and screw fixation versus open reduction and plate fixation of traumatic symphysis pubis diastasis.
        Arch Orthop Trauma Surg. 2012; 132: 265-270
        • Chen X.
        • Wang S.C.
        • Cao L.H.
        • Yang G.Q.
        • Li M.
        • Su J.-C.
        Comparison between radial head replacement and open reduction and internal fixation in clinical treatment of unstable, multi-fragmented radial head fractures.
        Int Orthop. 2011; 35: 1071-1076
        • Tavakoli A.
        • Mousavi Tadi H.
        • Mahmoodian A.
        A comparison between unreamed locked intramedullary nailing and plate-Screw fixation in the treatment of tibial diaphyseal fractures.
        Iran Red Crescent Med J. 2010; 12: 640-643
        • Kadar A.
        • Eisenberg G.
        • Yahav E.
        • Drexler M.
        • Salai M.
        • Steinberg E.L.
        Surgical site infection in elderly patients with hip fractures, silver-coated versus regular dressings: a randomised prospective trial.
        J Wound Care. 2015; 24 (4-5): 441-442
        • Zoubos A.B.
        • Galanakos S.P.
        • Soucacos P.N.
        Orthopedics and biofilm-what do we know? A review.
        Med Sci Monit Int Med J Exp Clin Res. 2012; 18: RA89-RA96
        • Metsemakers W.
        • Kuehl R.
        • Moriarty T.
        • Richards R.
        • Verhofstad M.
        • Borens O.
        • et al.
        Infection after fracture fixation: current surgical and microbiological concepts.
        Injury. 2016;
        • Rittmann W.
        • Perren S.
        Cortical bone healing after internal fixation and infection.
        Springer, Berlin, Heidelberg, New York1974
        • Worlock P.
        • Slack R.
        • Harvey L.
        • Mawhinney R.
        The prevention of infection in open fractures: an experimental study of the effect of fracture stability.
        Injury. 1994; 25: 31-38