Acute Compartment Syndrome: Do guidelines for diagnosis and management make a difference?

BACKGROUND: The best outcomes following Acute Compartment Syndrome (ACS) are attributed to early diagnosis and treatment. National guidelines were issued in the United Kingdom in 2014 (BOAST 10) to standardise and improve management. We analysed standards of diagnosis and management before and after the introduction of the guidelines. METHODS: We retrospectively reviewed the data of all patients with ACS requiring fasciotomy between March 2010 and May 2015 across four Major Trauma Centres (MTCs) in the Northwest of England. We analysed the pooled data for variations between the centres and the effect of BOAST10 implementation. RESULTS: 75 fasciotomies were recorded, with trauma being the cause in 42 cases (56%). The commonest site was the leg (44, 59%) followed by the forearm (15, 20%). The median time from decision to operate to fasciotomy was 2 h (range 0-6) and thereafter a median of 2 days (1-7) until a second visit. The practice across the four centres was similar up to diagnosis and treatment, but there was significant variation in practice after fasciotomy. The BOAST guidelines did not improve the time to surgery, time to second visit nor the recording of clinical signs. 21 patients had severe complications, including one death and 4 amputations. CONCLUSIONS: There continues to be significant variability in the definitive management of ACS. National guidelines do not appear to make a discernible impact on practice, and additional methods of ensuring safe management of this critical condition seem warranted.

Review of MRSA screening and antibiotics prophylaxis in orthopaedic trauma patients; The risk of surgical site infection with inadequate antibiotic prophylaxis in patients colonized with MRSA.

AIMS: The primary aim of this study was to determine whether orthopaedic trauma patients receive appropriate antibiotic prophylaxis keeping in view the results of their MRSA screening. The secondary aim was to analyse the risk of developing MRSA surgical site infection with and without appropriate antibiotic prophylaxis in those colonized with MRSA. PATIENTS AND METHODS: We reviewed 400 consecutive orthopaedic trauma patient episodes. Preoperative MRSA screening results, operative procedures, prophylactic antibiotics and postoperative course were explored. In addition to these consecutive patients, the hospital MRSA database over the previous 5 years identified 27 MRSA colonized acute trauma patients requiring surgery. RESULTS: Of the 400 consecutive patient episodes, 395(98.7%) had MRSA screening performed on admission. However, in 236 (59.0%) cases, the results were not available before the surgery. Seven patient episodes (1.8%) had positive MRSA colonization. Analysis of 27 MRSA colonized patients revealed that 20(74%) patients did not have the screening results available before the surgery. Only 5(18.5%) received Teicoplanin and 22(81.4%) received cefuroxime for antibiotic prophylaxis before their surgery. Of those receiving cefuroxime, five (22.73%) patients developed postoperative MRSA surgical site infection (SSI) but none of those (0%) receiving Teicoplanin had MRSA SSI. The absolute risk reduction for SSI with Teicoplanin as antibiotic prophylaxis was 22.73% (CI=5.22%-40.24%) and NNT (Number Needed to Treat) was 5 (CI=2.5-19.2) CONCLUSION: Lack of available screening results before the surgery may lead to inadequate antibiotic prophylaxis increasing the risk of MRSA surgical site infection. Glycopeptide (e.g.Teicoplanin) prophylaxis should be considered when there is history of MRSA colonization or MRSA screening results are not available before the surgery.

Treatment of distal tibia metaphyseal fractures; plating versus intramedullary nailing: a systematic review of recent evidence.

INTRODUCTION: Treatment of distal tibia metaphyseal fractures is challenging. The purpose of this study was to systematically review the recent literature regarding management of extra-articular distal tibia fractures with a view to compare the outcome of intramedullary nailing with plate fixation. METHODS: Advanced literature search was performed using Medline (Ovid), Embase (Ovid) and Cochrane databases. Data were extracted regarding number of participants, fracture fixation devices, percentage of open fractures, malunions, nonunions, wound infections and metal removal etc. RESULTS: After inclusion, exclusion criteria, two RCTs and four retrospective comparative studies were deemed suitable for this review. The overall results showed relatively higher rate of infection in plating group as compared to intramedullary nailing. However malalignment was more common with intramedullary nailing. CONCLUSION: Both techniques can provide adequate treatments in appropriately selected patients. None of the studies had sufficient power to show clinically significant difference. Further studies are required to compare new locking plates with intramedullary nails.

Diagnostic value of MR arthrogram in SLAP lesions of the shoulder.

BACKGROUND: Superior labrum anterior to posterior (SLAP) lesions are important cause of shoulder pain and instability. MR Arthrogram is key investigation for assessment of these lesions. We aimed this study to evaluate the diagnostic performance of MR Arthrogram in SLAP tears. MATERIALS AND METHODS: This was a retrospective study of 124 clinically diagnosed SLAP cases who had MR Arthrogram performed. Clinical, radiological and operative records were reviewed. MR Arthrogram findings were compared with arthroscopy. Those patients who did not undergo arthroscopy were not included in the final sensitivity analysis. RESULTS: Out of 124 cases, 54(43.54%) had normal MR Arthrogram, 32 (25.8%) had impingement or cuff related problems, 2 (1.61%) had Bankart lesions, and in 36 (29%) cases SLAP lesions were identified. Out of 54 patients with normal MR Arthrogram, 44 were discharged to physiotherapy and 10 underwent arthroscopy, showing SLAP lesion in one patient. Out of 32 patients with impingement or cuff problems, 19 were discharged to rehabilitation and 13 underwent surgery. Out of 36 patients with SLAP lesions, 5 recovered spontaneously, 5 were awaiting outpatient review and 26 underwent arthroscopy showing SLAP lesions in 22 cases. Overall, only 51 patients underwent arthroscopy. The MR Arthrogram was falsely positive in 4 cases (15.38%) and falsely negative in one case (3.84%). The sensitivity of MR Arthrogram was 95.6% (22/23), specificity 85.7% (24/28), positive predictive value 84.6% (22/26) and the negative predictive value was 96% (24/25). CONCLUSION: MR Arthrogram is a useful technique for the diagnosis and preoperative planning of suspected SLAP lesions. It may also save patients from unnecessary diagnostic arthroscopy.

Audit of orthopaedic audits in an english teaching hospital: are we closing the loop?

BACKGROUND: Clinical audit is an important tool to improve patient care and outcomes in health service. A significant proportion of time and economic resources are spent on activities related to clinical audit. Completion of audit cycle is essential to confirm the improvements in healthcare delivery. We aimed this study to evaluate audits carried out within trauma and orthopaedic unit of a teaching hospital over the last 4 years, and establish the proportions which were re-audited as per recommendations. METHODS: Data was collected from records of the clinical audit department. All orthopaedic audit projects from 2005 to 2009 were included in this study. The projects were divided in to local, regional and national audits. Data regarding audit lead clinicians, completion and presentation of projects, recommendations and re-audits was recorded. RESULTS: Out of 61 audits commenced during last four years, 19.7% (12) were abandoned, 72.1% (44) were presented and 8.2 % (5) were still ongoing. The audit cycle was completed in only 29% (13) projects. CONCLUSION: Change of junior doctors every 4~6 months is related to fewer re-audits. Active involvement by supervising consultant, reallocation of the project after one trainee has finished, and full support of audit department may increase the ratio of completion of audit cycles, thereby improving the patient care.

Primary Nocardia farcinica brain abscess with secondary meningitis and ventriculitis in an immunocompetent patient, successfully treated with moxifloxacin.

We report a rare case of Nocardia farcinica occipital brain abscess in an immunocompetent patient with no underlying risk factors successfully treated with the antibiotic moxifloxacin. The patient underwent craniotomy and abscess drainage. Initial post-operative treatment with co-trimoxazole produced a limited response. Despite the development of skull base meningitis and ventriculitis subsequent addition of moxifloxacin produced an excellent outcome.