The Reduction Maneuver for Pediatric Extension Type 3 Supracondylar Humerus Fractures.

Extension type supracondylar humerus fractures in children commonly displace in two directions: posteromedial and posterolateral. The traditional maneuver to reduce posteromedial displaced fractures utilizes pronation of the forearm, while the maneuver for posterolateral displaced fractures utilizes supination. Traditional teaching suggests that the periosteum is an aid to reduction. The purpose of this study is to take a second look at this periosteal hinge theory and reexamine the maneuver performed when reducing an extension type 3 supracondylar fracture. Sixty-nine consecutive displaced extension type 3 supracondylar fractures were studied. Intraoperative fluoroscopic radiographs were graded as posteromedial, posterolateral, or direct posterior displacement. All fractures were treated with closed reduction and percutaneous pinning. The best maneuver used to align the fracture during surgery was recorded in the operative note. The direction of displacement on radiographs was 32 (46.3%) posteromedial, 31 (45%) posterolateral, and six (8.7%) direct posterior. All of the 32 posteromedial displaced fractures were best aligned when pronation was utilized. All of the 31 posterolaterally displaced fractures were best aligned when supination was utilized. The six direct posteriorly displaced fractures obtained the best alignment in pronation. The current study reaffirms the classic teaching that the direction of displacement of the fracture indicates the site of the intact periosteum. The intact periosteal hinge can be used to obtain fracture reduction.

Implant Retention or Removal for Management of Surgical Site Infection After Spinal Surgery.

STUDY DESIGN: A literature review. OBJECTIVE: To summarize the implant removal rate, common bacterial organisms found, time of onset, ratio of superficial to deep infection, and regurgitating the prevalence among all the retrospective and prospective studies on management and characterization of surgical site infections (SSIs). METHODS: PubMed was searched for articles published between 2000 and 2018 on the management or characterization of SSIs after spinal surgery. Only prospective and retrospective studies were included. RESULTS: A total of 49 articles were found relevant to the objective. These studies highlighted the importance of implant removal to avoid recurrence of SSI. The common organisms detected were methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermis, Staphylococcus epidermis, Staphylococcus aureus, and Propionibacterium acnes, with prevalence of 1% to 15%. A major proportion of all were deep SSI, with minority reporting on late-onset SSI. CONCLUSION: Long-term antibiotics administration, and continuous irrigation and debridement were common suggestion among the authors; however, the key measure undertaken or implied by most authors to avoid risk of recurrence was removal or replacement of implants for late-onset SSI.

A Multicenter Trial Demonstrating Presence or Absence of Bacterial Contamination at the Screw-Bone Interface Owing to Absence or Presence of Pedicle Screw Guard, Respectively, During Spinal Fusion.

STUDY DESIGN: A prospective multicenter study. OBJECTIVE: The objective of this study was to assess bacterial contamination in current practices of pedicle screw handling and comparing it to a novel method of using an intraoperative, sterile implant guard for screws. SUMMARY OF BACKGROUND DATA: Postoperative infections occur at the higher end of 2%-13%, as cited in the literature, and are underestimated due to various reasons in such publications. Despite concerns associated with vancomycin application immediately before closure, it is theoretically impossible to irrigate the screw-bone interface postimplantation. Consequently, any contamination of pedicle screw before implantation is permanent, and has the potential to cause deep-bone infection, or hardware loosening due to encapsulation of biofilm between the bone and the screw. Therefore, continued vigilance and effective preventive measures should be undertaken if available. MATERIALS AND METHODS: Two groups of presterile individually-packaged pedicle screws, one incased in a sterile, protective guard (group 1: G) and the other without such a guard (group 2: NG), 31 samples in each group were distributed over 28 spinal fusion surgeries at 5 independent hospitals groups. Each were loaded onto the insertion device by the scrub tech and left on the sterile table. Twenty minutes later, the lead surgeon who had just finished preparing the surgical site, handles the pedicle screw, to check the fit with the insertion device. Then, instead of implantation, it was transferred to a sterile container using fresh sterile gloves for bacterial analysis. RESULTS: The standard unguarded pedicle screws presented bioburden in the range of 10 to 10 colonies forming units per screw, whereas the guarded pedicle screws showed no bioburden. CONCLUSION: Standard, current, handling of pedicle screws leads to bacterial contamination, which can be avoided if the screws are sterilely prepackaged with an intraoperative guard (preinstalled).