Diagnosis of Occult Infection Using Fracture-Related Infection Criteria at the Time of Nonunion Repair.

OBJECTIVES: To apply the recently developed fracture-related infection criteria to patients presenting for repair of fracture nonunion and determine the incidence and associated organisms of occult infection in these patients. DESIGN: Retrospective study. SETTING: Tertiary referral trauma center. PATIENTS AND PARTICIPANTS: Patients presenting with fracture nonunion after operative intervention. MAIN OUTCOME MEASUREMENTS: Demographic variables, injury characteristics, culture results, and physical examination and laboratory values at the time of presentation. RESULTS: A total of 270 nonunion patients were identified. Sixty-eight percent (n = 184) had no clinical or laboratory signs of infection at presentation before nonunion repair. After operative intervention, 7% of these clinically negative patients (n = 12/184) had positive intraoperative cultures indicating occult infection. The most common organisms causing occult infection were low-virulence coagulase-negative Staphylococcu s (83%) and Cutibacterium acnes (17%). Thirty-two percent of patients (n = 86/270) presented with clinical and/or laboratory signs of infection at presentation before nonunion repair, with 19% of these patients (n = 16/86) having negative cultures. The most common organisms in this group of patients with positive clinical signs and intraoperative cultures were methicillin-resistant Staphylococcus Aureus (21%) and gram-negative rods (29%). Patients with nonunion of the tibia were significantly more likely to have high-virulence organism culture results ( P < 0.001). CONCLUSIONS: Based on this analysis, occult infection occurs in 7% of patients presenting with nonunion and no clinical or laboratory signs of infection. We recommend that all patients should be carefully evaluated for infection with intraoperative cultures regardless of presentation. Organisms associated with occult infection at the time of nonunion repair were almost exclusively of low virulence ( CoNS and C. Acnes ) and were more likely to present in the upper extremity. Patients with nonunion of the tibia were more likely to have infection secondary to high-virulence organisms and demonstrate clinical or laboratory signs of infection at the time of presentation. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Angioembolization significantly improves vascular injuries in blunt splenic trauma.

PURPOSE: Non-operative management (NOM) of blunt splenic injury (BSI) uses angioembolization (AE) or observation (OBS). AE improves the success of NOM. However, how AE improves BSI is unknown. We hypothesized AE would decrease rate of pseudoaneurysm (PSA) presence, PSA size, PSA number, and rate of active extravasation. METHODS: We performed a retrospective review of computerized tomography (CT)-diagnosed BSI over a 2-year period. Patients undergoing NOM with an initial and repeat CT were included. Patients were excluded if they underwent primary splenectomy after BSI diagnosis or did not have repeat CT imaging. RESULTS: One hundred and fifteen patients with BSI had repeat CT imaging; 55/115 (47.8%) had AE; and 60/115 (52.2%) had OBS. On the initial CT, AE patients had more frequent PSA presence (52.7% vs. 6.7%, p < 0.001), higher median number of PSA (1.0 vs. 0, p < 0.001), higher median PSA size (1.15 mm vs. 0 mm, p < 0.001), and more frequent rates of active extravasation (10.9% vs. 0%, p = 0.01) compared with OBS patients. On repeat CT compared to the initial CT, AE patients had significant decrease in rate of PSA presence (21.8% vs. 52.7%, p < 0.001), median PSA size (0 mm vs. 1.15 mm, p < 0.001), median PSA number (p < 0.001), and rate of active extravasation (0% vs. 10.9%, p = 0.03). On repeat CT compared to the initial CT, OBS patients had an increase in rate of PSA presence (18.3% vs. 6.7%, p = 0.04). CONCLUSIONS: AE significantly decreases PSA presence, number, and size as well as rates of active extravasation. AE should be standard practice in vascular injuries undergoing NOM to maximize splenic salvage.

Single-shot liposomal bupivacaine interscalene block versus continuous interscalene catheter in total shoulder arthroplasty: Opioid administration, pain scores, and complications.

INTRODUCTION: We sought to evaluate the efficacy and safety of the liposomal bupivacaine interscalene block (LBB) compared with continuous interscalene catheter block (CISB) in primary shoulder arthroplasty patients. METHODS: A prospective database was retrospectively queried over a 4-year period. RESULTS: LBB (n = 34) patients had lower opioid consumption and pain scores than CISB (n = 70), especially in opioid naïve patients. LBB patients were discharged with less opioids and had fewer revisits to the emergency department. CONCLUSION: Compared with CISB, LBB patients consume fewer opioids, have less pain, are discharged with less opioids, and have fewer revisits to the emergency department.

Extra-parenchymal splenic abnormalities not vascular injury predict need for primary splenectomy.

PURPOSE: Radiographic indications for primary splenectomy (PS) in blunt splenic injury (BSI) after radiographic diagnosis are unknown. Improved understanding of radiographic characteristics of patients requiring splenectomy will help to appropriately triage patients to PS or non-operative management (NOM). METHODS: A retrospective, single-center review was performed of BSI diagnosed with computerized tomography (CT). Patients undergoing splenectomy prior to CT diagnosis were excluded. RESULTS: BSI was identified in 195 patients. On logistic regression, only subcapsular hematoma presence (OR 7.521, p = 0.002) and left upper quadrant hemoperitoneum (OR 6.146, p = 0.03) were associated with need for PS, while splenic laceration length, number of pseudoaneurysms (PSA), and active contrast extravasation (NS for all) were not. CONCLUSIONS: Need for PS is predicted by extra-parenchymal pathology in subcapsular hematoma and hemoperitoneum. Splenic vascular injuries through PSA and active contrast extravasation do not predict the need for PS and can be considered for NOM.