Current Concepts in Diagnosis and Management of Hand Infections.

Hand and upper-extremity infections span a broad spectrum of presentations for the hand surgeon, primary care provider, and emergency medicine practitioner. As many hand infections arise from penetrating trauma, knowledge of the offending pathogen, location, and mode of spread allows the clinician to determine the appropriate intervention. Along with a thorough history and physical examination, patient factors such as age, occupation, medical comorbidities, and surgical history should be noted. Timely diagnosis and appropriate management allow for optimal recovery and outcomes. In this article, we describe the ongoing debate regarding the timing and influence of preoperative antibiotics on culture yield, timing of debridement for open fractures as it relates to infection risk, and strategies for obtaining adequate cultures to guide antibiotic therapy for complex infections such as periprosthetic joint and hardware infections. Given the changing epidemiological landscape and increased rates of antibiotic resistance, it is critical to promote antibiotic stewardship. We provide updated treatment recommendations and antibiotic profiles for the treatment of common hand infections. Finally, we discuss newer technologies such as next-generation sequencing and development of promising diagnostic and treatment strategies that will enhance the hand surgeon's ability to treat complex hand infections.

CONSENSUS ON THE APPLICATION AND CARE OF BROMELAIN-BASED ENZYMATIC DEBRIDEMENT ON BURNS.

Treatment of burned patients involves early excision of the burn. The approach to this excision has changed since bromelain-based enzymatic debridement was introduced. This treatment option reduces complications from the surgical procedure and improves scar quality. It is indicated for partial and full thickness burns. It is important to agree on the nursing care before, during and after enzymatic debridement treatment to ensure an optimal preparation and maintenance of the wound bed for later treatment to be most successful. A multi-centre Delphi study was conducted with enzymatic debridement nursing care on burned patient experts. A coordinating group developed a 29-item questionnaire based on clinical guidelines and experience. Two question rounds were asked, reaching consensus on answers > 70%. Nine panellists from nine leading burns centres in Spain participated. The aim was to develop a national consensus on enzymatic debridement treatment based on clinical practice and evidence from almost 1500 cases. The experts reached 29 agreements on different aspects of treatment and patient condition: general considerations about the treatment, burned patient admission, treatment prior to enzymatic debridement, applying debridement, removing enzymatic debridement and the post-enzymatic debridement phase. The expert consensus on nursing care of the burn patient and application of bromelain-based enzymatic debridement includes general recommendations for the patient before, during and after application and the planning of localised care after debridement. This consensus document supports knowledge on enzymatic debridement technique, increasing safety in clinical nursing practice and ensuring successful treatment for the patient.

L'excision précoce est la référence dans le traitement des brûlures. Sa technique a été transformée par le débridement enzymatique à la bromélaïne. Cette technique, indiquée dans les brûlures intermédiaires et profondes, réduit les complications chirurgicales et améliore la qualité cicatricielle. La qualité des soins locaux, avant, pendant et après l'application de bromélaïne, est un paramètre important d'efficacité. Nous avons organisé une étude basée sur la méthode Delphi auprès de 9 experts de 9 CTB espagnols. Le groupe de coordination a réalisé un questionnaire à 29 items à partir des recommandations et de leur expérience (quasiment 1 500 cas au total). Deux séances ont été organisées, dans le but d'obtenir les agréments de plus de 70% des participants. Un consensus a été obtenu sur les 29 questions posées, se rapportant aux généralités, aux critères d'admission, au traitement avant bromélaïne, à son application, à son retrait et aux soins ultérieurs. Les recommandations de soins locaux consécutives recouvrent les phases avant, pendant et après utilisation. Elles permettent une amélioration de l'efficacité et de la sécurité du débridement enzymatique.

Higher Morbidity and Mortality in Females With Fournier's Gangrene Compared to Males: Insights From National Inpatient Sample Data.

PURPOSE: To compare Fournier's gangrene in female and male patients, and identify mortality-associated characteristics in both. MATERIALS AND METHODS: We employed National Inpatient Sample data (2016-2020) to identify Fournier's gangrene cases and extracted demographic, comorbidity, and procedural variables. Multivariable regression models were utilized to identify mortality risk factors for both cohorts. RESULTS: We identified 2875 females (31%) and 6451 males (69%) with Fournier's gangrene corresponding to an estimated 14,375 (95% CI 13,784-14,966) and 32,255 (95% CI 31,390-33,120) cases, respectively. Females were more likely to die than males (7.1% vs 5.7%, P < .0001, respectively). Median incidence rates were 1.7 (IQR 1.5-1.8) and 4 (IQR 3.6-4.3) cases per 100,000 person-years for females and males, respectively. Females had higher median age, longer hospital stays, more charges, procedures, and fecal diversion rates, but lower routine discharges than males (P < .05). Non-White females had increased mortality odds compared to White females (odds ratio [OR] 1.49, 95% CI 1.07-2.07, P = .019). Prolonged interval until initial perineal debridement correlated with higher mortality odds in both females and males (OR 1.02, 95% CI 1-1.04, P = .034 vs OR 1.03, 95% CI 1.01-1.05, P < .0001). Diabetes lowered mortality odds in females and males (OR 0.68, 95% CI 0.47-0.99, P = .046 vs OR 0.54, 95% CI 0.41-0.7, P < .0001). CONCLUSIONS: In females, Fournier's gangrene incidence surpasses previous reports, with slightly worse outcomes compared to males, emphasizing the need for precise clinical assessment and early intensive interventions.

Comparison of Clinical Outcomes of Posterior-Only Transforaminal Debridement and Interbody Fusion With Preservation of Posterior Ligamentous Complex Versus Conventional Posterior-Only Debridement and Interbody Fusion for Thoracic Spine Tuberculosis: A Prospective, Randomized, Controlled, Clinical Trial - A Pilot Study.

OBJECTIVE: The main objective of this study was to analyze the efficacy and feasibility of surgical management for patients with thoracic spinal tuberculous spondylitis (STB) by using posterior-only transforaminal debridement and interbody fusion (PTDIF) with preservation of posterior ligamentous complex (PLC) and noninferior of PTDIF compared with conventional posterior-only debridement and interbody fusion (CPDIF). METHODS: From January 2019 to January 2022, a prospective, randomized, controlled trial was conducted in which patients with thoracic STB were enrolled and assigned to undergo either the PTDIF group (group A) or CPDIF group (group B) in a 1:1 ratio. The clinical efficacy was evaluated on average operation time, blood loss, hospitalization durations, visual analogue scale, Oswestry Disability Index scores, erythrocyte sedimentation rate (ESR), C-Reactive protein (CRP), and neurological function recovery using the American Spinal Injury Association's impairment scale and operative complications. Radiological measurements included kyphosis correction, loss of correction. The outcomes were compared between the groups at preoperation, postoperaion, and final follow-up. RESULTS: All 65 patients were completely cured during the follow-up. The intraoperative blood loss and operation time in group B were more than that in group A. All patients were pain-free at the final follow-up visit. ESR, CRP returned to normal limits in all patients 3 months after surgery. All patients had improved neurological signs. No significant difference was found in kyphosis angle correction, loss of correction between the 2 groups. CONCLUSION: PTDIF, with preservation of PLC, achieved debridement, decompression, and reconstruction of the spine's stability, similar to CPDIF in the surgical treatment of thoracic STB. PTDIF has less surgical trauma with less intraoperative blood loss and operation time.

Do Post-debridement Cultures have a Role in Reduction of Infection in Open Fractures? Report of 166 Cases and Literature Review.

Objective: To evaluate the role of post-debridement cultures in the prevention of future infection following open fractures. Design: Retrospective Cohort Study and Literature Review. Setting: Division of Orthopaedic Surgery, Sultan Qaboos University Hospital, Academic and tertiary health care, Muscat, Oman. Participants: A total of 166 patients from a cohort study and 539 patients from the literature review with open fractures. There were 640 cumulative patients fit the inclusion and exclusion criteria. Intervention: Using predetermined inclusion and exclusion criteria, data on all open fractures were gathered from the electronic health system of a single institution between 2010 and 2019. PubMed and Embase electronic databases were also searched for relevant articles relating to post-surgical debridement culture and its correlation with future infection. Main outcome measures: Assessing the benefit, role of post-debridement cultures in the prevention of future infection following open fractures. Results: Combining the results of this retrospective cohort study and previously published data, there were 640 Gustilo-Anderson grades II and III open fractures which had post-debridement screening. Eighty-eight patients (13.8%) developed an infection, out of which 16 had positive post- debridement cultures (18.2%). Only four grew similar organisms at screening and infection stages, two of which had different antibiotic resistance patterns at the infection stage. Seventy-two fractures had negative post-debridement screening swabs (81.8%). Of the 59 (9.2%) fractures with positive screening only four (6.8% of the infected fractures) developed later deep infection. All these 59 cases had culture-guided antibiotic treatment, with or without surgical debridement. Conclusion: Although the bacterial growth of post-debridement cultures is low, post-debridement screening as part of a comprehensive management protocol may have a role in reducing deep infection in open fractures. This is particularly the case in Gustilo and Anderson type 3 open fractures, the risk of infection is high. The poor association between organisms isolated from screening and those from subsequent deep infection may mean that the later infective organisms have been acquired from a secondary colonisation source after the debridement. Level of evidence: III. How to cite this article: Kindi NA, Abri FA, Yaseen A, et al. Do Post-debridement Cultures have a Role in Reduction of Infection in Open Fractures? Report of 166 Cases and Literature Review. Strategies Trauma Limb Reconstr 2024;19(2):94-98.

Meleney's Gangrene of the Abdomen Managed With Serial Debridement and Negative Pressure Wound Therapy: A Case Report.

Meleney's gangrene (necrotizing fasciitis (NF)), also known as progressive bacterial synergistic gangrene, is a potentially fatal subcutaneous tissue infection with abdominal wall necrosis that progresses rapidly and systematically. It has been observed to exhibit the cultural characteristics of a symbiotic organism. Due to its rarity and high mortality rate, this infection needs to be diagnosed promptly and treated aggressively with antibiotics and rigorous debridement. There are several approaches to management, which include intravenous antibiotics, aggressive debridement, and dressings, along with the application of negative pressure wound therapy (NPWT). Herein, we report the case of a 45-year-old male patient with type 2 diabetes mellitus who presented to our facility after being bitten by an insect and exhibiting symptoms of Meleney's gangrene of the abdomen.

Modular component exchange has no advantage in Debridement, Antibiotics and Implant Retention (DAIR) for early onset hip and knee prosthetic joint infection.

INTRODUCTION: Debridement, Antibiotics and Implant Retention (DAIR) has been the mainstay of treatment for early onset periprosthetic joint infection in spite of variable results. Modular component exchange is a widely recommended strategy to improve success rates with DAIR though very strong evidence to support its practice is still lacking. MATERIALS AND METHODS: Eighty six patients underwent DAIR for early onset PJI following primary hip and knee arthroplasty were divided into two groups for this retrospective review. 45 patients (group 1) underwent DAIR with modular component exchange and 41 patients without exchange (group 2). We compared success rates based on infection eradication (primary outcome variable) and need for revision surgical procedures between these two groups. We also assessed differences in primary outcome based on type of arthroplasty, timing of DAIR and addition of local antibiotics. RESULTS: The overall success rate after DAIR was 71%. The outcome was similar in both groups (69% vs 74%, P = 0.66). The need for revision surgical procedures was 27% which was similar in both groups (P = 0.98) with 23% needing revision of prosthetic components. Type of arthroplasty (hip or knee) and addition of local antibiotics had no bearing on infection eradication after DAIR with or without modular component exchange. DAIR with in 45 days of primary arthroplasty had significantly higher success rate compared to DAIR after 45 days in both groups. CONCLUSIONS: We observed that modular component exchange did not improve infection eradication after DAIR for early onset PJI following hip and knee arthroplasty. Reasonable success rates can be expected after DAIR especially if the patient develops early clinical signs and the procedure is carried out as early as possible.

Comparison of Early Versus Late Debridement Outcomes in the Management of Open Distal Radius Fractures.

PURPOSE: The optimal timing for surgical treatment of open distal radius fractures remains an area of debate. The purpose of this study was to examine the outcomes of open distal radius fractures treated surgically before or after 24 hours. METHODS: A multicenter retrospective review was performed on all open distal radius fractures treated over 11 years. Patient demographics, injury mechanism, and initial treatment were recorded. Fracture severity was graded by the Gustilo-Anderson classification. Comparisons were made between those treated surgically within and after 24 hours. Outcomes examined included infection, revision surgery, osteomyelitis, and nonunion. RESULTS: A total of 230 cases met the inclusion criteria. The cohorts of early and delayed surgical intervention were similar with regard to preoperative demographics. The most common mechanism of injury was motor vehicle accident. Approximately 40% of cases were graded as type I, 40% as type II, and 20% as type III. Mean time to debridement in the group treated after 24 hours was 5 days. A mean postoperative follow-up of greater than 6 months was obtained in both cohorts. Similar outcomes were found between cohorts with respect to postoperative infection, revision surgery, osteomyelitis, and nonunion. CONCLUSIONS: Similar outcomes with regards to infection, revision, osteomyelitis, and nonunion were found between open distal radius fractures treated emergently versus those managed in a delayed fashion. Patient- and injury-specific factors are important in dictating care. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IIB.

The adjunctive use of Leukocyte-Platelet Rich Fibrin (L-PRF) in the management of Medication Related Osteonecrosis of the Jaw (MRONJ): a retrospective observational study.

PURPOSE: Medication related osteonecrosis of the jaw (MRONJ) is a risk for patients taking anti-resorptive or anti-angiogenic medications. The American Association of Oral and Maxillofacial Surgeons (AAMOS) has classified MRONJ in stages to reflect the severity of the disease and allows implementation of suitable treatment pathways. MRONJ risk is < 5% in cancer patients and < 0.05% in osteoporosis patients. Management is subdivided into operative and non-operative, with advances in the literature investigating adjuvants. Leukocyte-Platelet Rich Fibrin (L-PRF) is an autologous biomaterial consisting of leukocytes and platelets embedded within a fibrin matrix with the ability to release growth factors enabling angiogenesis, bone regeneration and soft tissue healing. This paper's aim is to investigate the effects of L-PRF in conjuction with surgical debridement for management of MRONJ. METHODS: Twenty-two cases with established MRONJ were treated with either surgical intervention (Group A) or with surgical intervention and L-PRF (Group B), from 2016 to 2023 at Edinburgh Dental Institute (EDI). Treatments were deemed successful when the patients were asymptomatic, displayed complete soft tissue healing with the absence of infection/inflammation, fistula, or exposed bone. RESULTS: All cases in Group B had healed in contrast to 54.5% not healed in Group A; p value < 0.05 indicating statistical significance. CONCLUSION: The use of L-PRF as an adjuvant to surgical management of MRONJ is promising with its favourable functional capacity, simple application, and success of treatment outcomes.

Outcome of Fournier's gangrene in relation to Fournier Gangrene Severity Index (FGSI) score.

Introduction: Fournier's gangrene is a rapidly progressive necrotizing fasciitis, involving perineum mainly. The purpose of the study is to evaluate etiology, treatment, and outcome of Fournier's gangrene so that such type patient's management can be done by primary care physicians with best outcomes. Method: This was a retrospective study including 156 patients, treated for Fournier's gangrene, between Jan 2012 and Dec 2018. The outcome and prognosis of Fournier's gangrene were reviewed. Result: The mean age and mode among survival patients were 47.94 ± 14.9 and 60 years, and the mean age and mode in nonsurvival patients was 47.64 ± 15.9 and 65 years. The most common predisposing factor was diabetes mellitus (n = 49, 31.4%) having mortality rate was 9% (n = 14). Most common causative bacteria were E. coli. In the study, the survival rate was 100% in patients having Fournier Gangrene Severity Index (FGSI)≤3. As FGSI increased from 3, the mortality rate increased. Conclusion: Fournier gangrene is a surgical emergency. Early diagnosis, serial surgical debridement, and broad-spectrum antibiotics decrease the mortality and morbidity of patients. The sensitivity and specificity of FGSI determine the prognosis of Fournier's gangrene. FGSI is a simple method to know the severity and prognosis.