All-epiphyseal acl reconstruction: a three-year follow-up.

BACKGROUND/INTRODUCTION: With an increasing number of pre-adolescents participating in sports, anterior cruciate ligament injuries and resultant reconstruction in the skeletally immature athlete are becoming more common. Many different surgical techniques and rehabilitation protocols have been proposed for the treatment of anterior cruciate ligament (ACL) injuries, but there is a lack of agreement as to which approach results in the best outcome. Rehabilitation protocols have marked variation regarding postoperative weight bearing, immobilization, bracing, and length. CASE DESCRIPTION: This is a case of a ten year old female who sustained bilateral ACL tears within the period of a year. The purpose of this case report is to describe the early result and subsequent rehabilitation following bilateral physeal-sparing all-epiphyseal ACL reconstructions on a skeletally immature patient with a three-year follow-up. OUTCOMES: The early post-surgical recovery period on the first injured knee was complicated by knee stiffness requiring manipulation. Following this minor setback, the patient met all physical therapy goals and had no additional complications. The rehabilitation after the second surgery followed a typical course. At three-year follow-up, the patient had grown an additional seven inches, with radiographic evidence of symmetric physeal growth and joint stability. She has returned to playing competitive sports. DISCUSSION AND CONCLUSION: This innovative physeal-sparing technique has huge implications as, historically; the feared complication of growth disturbance and angular deformity from transphyseal ACL reconstruction has complicated the management of ACL injuries in children and pre-adolescents. This case report demonstrates the success of this technique, and the subsequent rehabilitation, as this patient did not experience a reduction in long-term bone growth. LEVEL OF EVIDENCE: 5 Case Report.

Does dual antibiotic prophylaxis better prevent surgical site infections in total joint arthroplasty?

INTRODUCTION: It is unclear which antibiotic regimen provides the best prophylaxis against surgical site infection (SSI) in patients undergoing hip and knee surgery. QUESTIONS/PURPOSES: Therefore, we determined whether dual antibiotic prophylaxis (1) reduced the rate of SSI compared to single antibiotic prophylaxis and (2) altered the microbiology of SSI. METHODS: We retrospectively reviewed 1828 primary THAs and TKAs performed between September 1, 2008 and December 31, 2010. We divided patients into two groups: (1) those who received a dual prophylactic antibiotic regimen of cefazolin and vancomycin (unless allergy), or (2) received cefazolin (unless allergy) as the sole prophylactic antibiotic. There were 701 males and 1127 females with an average age of 56 years (range, 15­97 years). We limited followup to 1 year, presuming subsequent infections were not related to the initial surgery. RESULTS: During this period, there were 22 SSIs (1.2%). The infection rates for dual antibiotic prophylaxis compared to a single antibiotic regimen were 1.1% and 1.4%, respectively. Of 1328 patients treated with dual antibiotic prophylaxis, only one (0.08%) SSI was culture positive for methicillin resistant Staphylococcus aureus (MRSA), while four of 500 patients (0.8%) receiving only cefazolin prophylaxis had culture positive MRSA infection at the time of reoperation. CONCLUSION: The addition of vancomycin as a prophylactic antibiotic agent apparently did not reduce the rate of SSI compared to cefazolin alone. Use of vancomycin in addition to cefazolin appeared to reduce the incidence of MRSA infections; however, the number needed to treat to prevent a single MRSA infection was very high. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Physical examination of the overhead athlete's shoulder.

Overhead athletes seek the services of an orthopedic surgeon because of pain and/or dysfunction. It is important to address the cause of the symptoms more so than the source of the patient's pain, so that treatment will eliminate the problem rather than merely ameliorate symptoms temporarily. In order to accomplish a thorough assessment of shoulder function, the examiner must expand his/her view from isolated assessment of the glenohumeral joint range of motion, stability, assessment of rotator cuff strength, palpation and provocative maneuvers, and add assessment of the shoulder in the context of the kinetic chain. The examination of the thrower's shoulder, coupled with a thorough history, will usually provide a solid functional diagnosis and provide a good idea as to the presence of structural damage. As a result, the value of rehabilitation and the benefit of surgical intervention are made more predictable.

Prevalence and etiology of intracranial hemorrhage in term children under the age of two years: a retrospective study of computerized tomographic imaging and clinical outcome in 798 children.

RATIONALE AND OBJECTIVES: The purposes of this study were to retrospectively identify various etiologies underlying intracranial hemorrhages (ICHs) in term infants aged <2 years and their respective prevalence in this population and to describe the long-term clinical outcomes in these patients. MATERIALS AND METHODS: A retrospective review of the medical records and computed tomographic studies of the head in 798 term infants aged 0 to 24 months with suspected or known ICHs was conducted. RESULTS: ICHs were present in 195 of the 798 infants (24%). More than one type of ICH was present in 32%. Subdural hemorrhage was the most frequent type of ICH, occurring in 63% of the infants. Good clinical outcomes were present in 49% of the infants but varied depending on the location, etiology, and timing of the ICH. CONCLUSION: The incidence of various etiologies of ICH depended on the ages of the infants. The overall clinical outcomes were good, with no long-term sequelae in half of the infants presenting with ICHs. In infants aged >4 weeks presenting with ICHs, special attention should be given to the possibility of nonaccidental trauma etiology, because this is common and has worse long-term outcomes.