Procalcitonin as a Predictor of Septic Knee Arthritis: A Retrospective Cohort Study.

INTRODUCTION: Differentiating septic arthritis from aseptic arthritis (AA) of the knee is difficult without arthrocentesis. Although procalcitonin (PCT) has shown diagnostic value in identifying bacterial infections, it has not been established as a reliable marker for identifying septic arthritis (SA). Recent studies have shown promise in the use of PCT as a useful systemic marker for identifying septic arthritis versus AA. This observational retrospective review compares PCT with routine inflammatory markers as a tool for differentiating septic arthritis versus AA in patients with acute, atraumatic knee pain. METHODS: Fifty-three consecutive patients (24 SA, 29 AA) were retrospectively reviewed at one institution with concern for SA. SA was diagnosed based on a physical examination, laboratory markers, and arthrocentesis. Laboratory indices were compared between the septic arthritis and AA groups. Data analysis was conducted to define sensitivity and specificity. Receiver operator characteristic curve analysis and regression were conducted to determine the best marker for acute SA of the knee. RESULTS: Using multiple logistic regression, bacteremia (OR 6.75 ± 5.75) was determined to be the greatest predictor of SA. On linear regression, concomitant bacteremia (coef 3.07 ± 0.87), SA (coef 2.18 ± 0.70), and the presence of pseudogout crystals (coef 1.80 ± 0.83) on microscopy predicted an increase in PCT. Using a PCT cutoff of 0.25 ng/mL yields a sensitivity of 91.7% and specificity of 55.2% for predicting SA; however, the ideal cutoff in our series was 0.32 ng/mL with a sensitivity of 79.2% and specificity of 72.4%. PCT was superior to the white blood cell count, erythrocyte sedimentation rate, and C-reactive protein in the area under the receiver-operating characteristic curve analysis. DISCUSSION: Procalcitonin seems to be the most sensitive and specific systemic marker in differentiating septic from AA.

A Quantitative Evaluation of Functional Recovery after Traumatic Lower Extremity Salvage.

INTRODUCTION: Soft tissue reconstruction is a routine component of lower extremity trauma care and focus is increasingly being directed towards understanding functional outcomes. This study aims to quantify functional recovery and identify variables associated with functional outcomes of patients who undergo traumatic limb salvage. METHODS: A retrospective review was performed of patients with lower extremity traumatic injuries requiring vascularized soft tissue reconstruction at a Level 1 trauma center between July 2007-December 2015. Postoperatively, patients were administered the 36-Item Short Form Health Survey Version 2 (SF-36v2) and the Lower Extremity Functional Scale (LEFS) questionnaires by telephone. Demographics, perioperative variables, and postoperative outcomes were analyzed by univariate and bivariate analysis. RESULTS: Forty-two patients with 42 flaps and a mean of 12.7 months follow up were included in the study. Limb salvage was successful in 38 patients (90.5%). Patients ≥ 40 years old had significantly worse SF-36v2 scores in physical functioning (P ≤0.01) and mental health (P ≤0.05) than their younger counterparts. Patients who had pre-existing hypertension demonstrated significantly lower physical functioning (P ≤0.01). Role limitation due to emotional health was significantly lower in patients who were female (P ≤0.01) or required revision surgery (P ≤0.01). The mean LEFS score was 37.7 ± 18.5. CONCLUSIONS: Patients exhibited poor functional outcomes following major limb trauma with attempted limb salvage based on two validated patient reported outcomes measures (PROMs). Patient characteristics should be considered in evaluating candidates for reconstruction to optimize outcomes and to effectively counsel patients on their functional prognosis.

The Declining Use of Wrist-Spanning External Fixators.

Background: External fixation has been traditionally used to treat comminuted or open distal radius fractures that are not amenable to open reduction internal fixation. This procedure is associated with a relatively high complication rate and has been used with decreasing frequency in recent years. However, trends in external fixation utilization for the treatment of distal radius fractures have not been described. Methods: Using the Nationwide Inpatient Sample, patients with a distal radius fracture treated with external fixation from 2003 to 2014 were identified. The annual incidence was reported, and hospital and demographic variables associated with external fixation use were determined. Results: During the study period, 593 929 patients with a distal radius fracture were identified, of which 51 766 (8.7%) were treated with a wrist-spanning external fixator. Wrist external fixation for the treatment of distal radius fractures declined steadily from 2003 to 2014. In 2003, external fixation use was highest, accounting for 17.4% of distal radius fractures. By 2014, only 4.9% of distal radius fracture were treated with external fixation. During this period, the incidence of distal radius fractures declined by 6.9% while external fixator utilization decreased by 73.7%. Patients receiving an external fixator were more likely to be male, low-income, and treated in a rural, nonteaching, privately owned hospital. Conclusions: External fixator use for the treatment of distal radius fractures steadily declined during the study period. Males and those with lower incomes treated in rural, nonteaching, and privately owned hospitals are more likely to receive external fixation.

The Efficacy of Negative Pressure Wound Therapy and Antibiotic Beads in Lower Extremity Salvage.

BACKGROUND: Antibiotic beads and negative pressure wound therapy (NPWT) represent two methods of wound management used during staged debridement in the post-trauma limb salvage pathway. The efficacy of NPWT and antibiotic beads in preventing infection remains unclear. METHODS: This study is a retrospective review of patients with traumatic lower extremity open fractures who received NPWT and/or antibiotic beads before soft tissue reconstruction at an urban level 1 trauma center between August 2007 and December 2015. Patients with wound infections before application of NPWT and/or antibiotic beads were excluded. RESULTS: In 73 lower extremities requiring soft tissue coverage, 46 received antibiotic beads and 48 received NPWT. Overall infection rate was 15.1%. Use of antibiotic beads was associated with a decreased risk of infection (6.4% versus 30.7%; P = 0.01). Use of NPWT was associated with an increased risk of one or more complications (45.7% versus 4.2%; P = 0.001). The development of infection was associated with a greater period of time between application of antibiotic beads (22 ± 13 versus 12 ± 6 d, P = 0.01) or NPWT (23 ± 15 versus 10 ± 11 d, P = 0.004) and soft tissue coverage. Overall limb salvage rate was 95.9%; secondary amputation was associated with development of infection (P = 0.001) but not with use of NPWT or antibiotic beads. CONCLUSIONS: Antibiotic beads may prevent infections in patients awaiting soft tissue coverage of wounds. NPWT may contribute to a greater rate of complication. Limb salvage was successful in most cases regardless of method of wound management.

Effect of Preoperative Opioid Usage on Pain After Total Shoulder Arthroplasty.

INTRODUCTION: Preoperative opioid use has recently been associated with increased perioperative pain. This study evaluates the effect of preoperative opioid use on postoperative pain and duration of opioid use after total shoulder arthroplasty (TSA). METHODS: We retrospectively identified 138 TSAs (69.1% reverse and 30.9% anatomic) between January 2013 and April 2017 that met inclusion criteria. Patients were stratified into two groups based on opioid usage within the 4 weeks before surgery. Primary outcome was resting pain at 3 months postoperatively using a 10-point numerical rating scale system. Duration of postoperative opioid consumption was also recorded and compared between cohorts. RESULTS: The opioid cohort (n = 50) reported significantly greater resting pain and pain with activity at 3 months postoperatively, at which time the reported numerical rating scale pain scores were 1.6 and 2.8 points greater in the opioid cohort compared with the non-opioid cohort (P < 0.001). Preoperative opioid use strongly predicted postoperative opioid use at all follow-up time points (P < 0.0001). DISCUSSION: Preoperative opioid consumption is associated with higher pain and increased duration of opioid use after TSA.

Functional outcomes of traumatic lower extremity reconstruction.

BACKGROUND: Lower extremity trauma accounts for over 300,000 injuries annually. While soft tissue transfer is a well-accepted practice for open fracture coverage, functional outcomes remain unclear. HYPOTHESIS: This study investigates functional outcomes following soft tissue reconstruction for open tibial fractures. MATERIALS AND METHODS: A retrospective review of a prospectively maintained database of open tibia fractures requiring soft tissue reconstruction was performed at an urban level 1 trauma center between October 2013 and March 2015. OUTCOMES: were evaluated using Pearson's chi square test with significant p value < 0.05. RESULTS: In 30 patients, fractures were graded Gustilo-Anderson type I (3.3%), 30% type II, 3.3% type IIIa, 53.3% type IIIb, and 10% type IIIc. Fixation was 56.7% plate and screw, 20% intramedullary nail, and 16.7% external fixator. Definitive closure was achieved in 43.3% through local rotational flap (38.5% gastrocnemius, 61.5% soleus), and in 56.7% by free tissue transfer (29.4% latissimus, 23.5% rectus, 17.6% ALT, 17.6% gracilis). In 10 patients, 70% returned to full ambulation, 30% required an assistance device, and 50% achieved union in 6 months. Local flap use was predictive of ambulation at discharge. DISCUSSION: Following lower extremity fracture, 70% of patients returned to pre-injury function. Use of a local tissue flap was associated with early ambulation.

Hip dislocations and concurrent injuries in motor vehicle collisions.

INTRODUCTION: Motor Vehicle Collisions (MVC) can cause high energy hip dislocations associated with serious injury profiles impacting triage. Changes in safety and regulation of restraint devices have likely lowered serious injuries from what was previously reported in the 1990s. This study aims to describe modern-day injury profile of patients with traumatic hip dislocations, with special attention to aortic injury. METHODS: Retrospective review of a prospectively maintained trauma database at an urban level 1 trauma center was conducted. Patients with hip dislocation following MVC between January 2005 and December 2015 were grouped based on seatbelt use and airbag deployment. Patients with unknown restraint use were excluded. Multiple logistic regression was used to identify risk of injury profile between groups. RESULTS: Of 204 patients with hip dislocation after MVC, nearly 57% were unrestrained. Seatbelt alone was used in 36 (17.7%), airbag deployed in 14 (6.9%), and 38 (18.6%) with both. Gender and number of injuries were similar between groups. The most common concomitant injury was acetabular fracture (53.92%) and the abdominopelvic region was the most injured. Use of a seatbelt with airbag deployment was protective of concomitant pelvic ring injury (OR = 0.22). Airbag deployment was significantly protective of lumbar fracture (OR = 0.15) while increasing the likelihood of radial and ulnar fracture or dislocation (OR = 3.27), acetabular fracture (OR = 5.19), and abdominopelvic injury (OR = 5.07). The no restraint group had one patient (0.80%) with an intimal tear of the thoracic aorta identified on CT chest that was successfully medically managed. DISCUSSION AND CONCLUSION: Hip dislocations are high energy injuries with severe associated injuries despite upgrades in restraint devices. These patients require careful examination and heightened awareness when evaluating for concomitant injuries.

Soft tissue reconstruction and salvage of infected fixation hardware in lower extremity trauma.

BACKGROUND: Tibial fracture management may be complicated by infection of internal fixation hardware (iIFH) resulting in increased morbidity and amputation rate. When iIFH removal is not possible, salvage of the lower extremity is attempted through debridement, antibiotics, and vascularized soft tissue coverage. This study investigates lower extremity salvage with retention of iIFH. METHODS: Demographics, outcomes, and bacterial speciation in patients with tibial fractures at a level 1 trauma center from 2007 to 2014 were reviewed. The primary outcome was infection suppression, while secondary outcomes included limb salvage, amputation, and osseous union. RESULTS: Twenty-five patients underwent soft tissue reconstruction for salvage of iIFH. Average age was 41, 19 (76%) were male, average BMI 30.1 kg/m2 , 10 (40%) patients smoked. Tibial fractures were closed in 8 (32%), Gustilo-Anderson grade I in 1 (4%), II in 8 (32%), IIIb in 5 (20%), and IIIc in 1 (4%). Staphylococcus was most commonly cultured with 11 (44%) demonstrating methicillin-resistance. Soft tissue reconstruction was performed by local flap in 15 (60%) and free flap in 10 (40%). At an average of 16.1 months, 19 (76%) hardware salvage patients demonstrated clinical suppression of infection, 11 of 19 (57.9%) patients had bony union, and 24 (96%) maintained a salvaged limb. One patient was amputated for recurrent infection. CONCLUSIONS: Following complex, infected tibial fractures, salvage of the lower extremity may be attempted even when iIFH cannot be removed. Thorough debridement, antibiotics, and vascularized soft tissue may suppress infection long enough to facilitate osseous union and subsequent removal of iIFH.

Outcomes of Soft Tissue Reconstruction for Traumatic Lower Extremity Fractures with Compromised Vascularity.

Traumatic lower extremity fractures with compromised arterial flow are limb-threatening injuries. A retrospective review of 158 lower extremities with traumatic fractures, including 26 extremities with arterial injuries, was performed to determine the effects of vascular compromise on flap survival, successful limb salvage and complication rates. Patients with arterial injuries had a larger average flap surface area (255.1 vs 144.6 cm2, P = 0.02) and a greater number of operations (4.7 vs 3.8, P = 0.01) than patients without vascular compromise. Patients presenting with vascular injury were also more likely to require fasciotomy [odds ratio (OR): 6.5, confidence interval (CI): 2.3-18.2] and to have a nerve deficit (OR: 16.6, CI: 3.9-70.0), fracture of the distal third of the leg (OR: 2.9, CI: 1.15-7.1) and intracranial hemorrhage (OR: 3.84, CI: 1.1-12.9). After soft tissue reconstruction, patients with arterial injuries had a higher rate of amputation (OR: 8.5, CI: 1.3-53.6) and flap failure requiring a return to the operating room (OR: 4.5, CI: 1.5-13.2). Arterial injury did not correlate with infection or overall complication rate. In conclusion, arterial injuries resulted in significant complications for patients with lower extremity fractures requiring flap coverage, although limb salvage was still effective in most cases.

Patient and Surgical Factors Contributing to Perioperative Infection in Complex Lower Extremity Trauma.

Infections in the traumatized lower extremity are a significant source of morbidity and expense. Outcomes after vascularized soft tissue reconstruction were analyzed to determine impact on infection rates. A retrospective review of a prospectively maintained database was performed, including 114 trauma patients requiring soft tissue reconstruction of lower extremity injuries at an urban Level I tertiary referral center from 2008 to 2015. Patient characteristics and perioperative outcomes were analyzed. After trauma, 39 (34.2%) patients developed wound infections, of which 74.4 per cent of infections occurred before soft tissue coverage. Isolated lower extremity injury yielded a 4-fold increase in the incidence of infection. Infection rates doubled in patients who smoked, sustained a fall, had a proximal third of the lower leg wound, or underwent external fixation. Comorbid diabetes, underlying fracture, and wound size were not predictive of infection. Overall, there was a 97.4 per cent rate of limb salvage after soft tissue reconstruction. In patients with infection before soft tissue reconstruction, a salvage rate of 96.6 per cent was achieved. Soft tissue reconstruction in the traumatized and infected lower extremity resulted in high limb salvage success rates, demonstrating vascularized tissue transfer in lower extremity injuries is effective in treating lower extremity infection.