Fate of Patients With a "Surprise" Positive Culture After Nonunion Surgery.

OBJECTIVE: Review the impact of unexpected positive cultures from definitive surgery for nonunion regarding postoperative treatment and ultimate result. DESIGNS: Retrospective multicenter case series. SETTING: Three level-one trauma centers. PATIENTS: Six-hundred sixty-six consecutive nonunions were treated during the study period. Four-hundred fifty-three cases (68%) were considered at risk for indolent infection (prior open fracture, surgery, or infection) and had cultures taken at the time of definitive surgery. INTERVENTION: Intraoperative cultures during definitive operative treatment of nonunions. MAIN OUTCOME MEASUREMENT: The incidence of "surprise" positive cultures was determined, and the course of the patients was documented including the use of antibiotics, surgery performed, and the outcome regarding infection and union. RESULTS: Ninety-one (20%) cases had a surprise positive culture despite negative inflammatory markers. Most of bacteria isolated from the cultures were Staphylococcus species. Eight (9%) of the ninety-one cultures were considered probable contaminants and no antibiotics were given, 5 of these patients healed. The other 83 patients were treated with antibiotics, initially 66 (80%) healed and 12 (14%) remained infected. Eighty-two percent of patients with augmentation healed as compared with 86% of those not grafted. CONCLUSIONS: The treatment of nonunions is challenging, and in patients with a history of surgery or open fracture, we found that 20% had positive intraoperative cultures from the definitive surgery. We recommend intraoperative cultures for all patients undergoing revision surgery. The use of culture-specific antibiotics is justified based on the overall low rate of infection in this complex population and the high rate of chronic infection (25%) for those treated as contaminants. Patients may be counseled that a positive culture after nonunion surgery is a treatable problem but does increase the risk of infection and additional surgery as compared with those with a negative intraoperative culture. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Postoperative radiographs after ACL reconstruction are not cost-effective.

Postoperative radiographs have become standard after anterior cruciate ligament (ACL) reconstruction, even though few findings in the literature substantiate their efficacy. The goal of this study was to determine whether routine postoperative radiographs were cost-effective in patients undergoing ACL reconstruction. In addition, the authors sought to determine whether these radiographs provided meaningful clinical information that changed postoperative management. Between January and December 2010, the authors retrospectively reviewed all patients who underwent ACL reconstruction at their institution. The clinical course of all patients was reviewed to determine whether the results of the radiograph at the time of interpretation changed the plan of care. All radiographs were then scrutinized for abnormal findings that could have changed the plan of care if noted at the time of follow-up. Of 624 patients who underwent ACL reconstruction, 340 (54.4%) had a postoperative radiograph within 30 days. No radiograph showed a complication as interpreted by the surgeon at the time the radiograph was obtained, and no changes were made in routine postoperative care. On final review of each radiograph, none showed findings that would have changed management. The cost of performing and interpreting radiographs was $42.62 per patient, with a combined cost of $14,490.80. The findings of the study showed that postoperative radiographs after ACL reconstruction should not be considered "routine" practice. In addition, because these studies provided little clinical information, they are recommended only when symptoms suggest a mechanical complication and in cases of unforeseen postoperative trauma.

Predicting alignment after closed reduction and casting of distal radius fractures.

PURPOSE: We sought to independently validate the McQueen equation and LaFontaine's criteria as predictors of instability in a large series of distal radius fractures treated nonsurgically. In addition, we hypothesized that restoring the volar cortical integrity (ie, volar hook) would be another factor that would independently predict the maintenance of a closed reduction in a cast. METHODS: We screened 546 consecutive distal radius fractures with 168 meeting all inclusion criteria. Dorsal tilt, radial height, radial inclination, ulnar variance, and carpal malalignment were measured on initial postreduction and final radiographs. A univariate analysis evaluated the predictability of the McQueen equation, Lafontaine's criteria, and volar hook on each radiographic parameter. A multivariate analysis was performed using the significant results from the univariate analysis. RESULTS: In the univariate analysis, the McQueen formula, the number of Lafontaine criteria, and age all correlated with radial height, radial inclination, and ulnar variance. In the multivariate analysis, age correlated with the most radiographic factors including radial height, radial inclination, ulnar variance, and carpal alignment at healing. Volar hook correlated with dorsal tilt and carpal alignment at healing, and dorsal comminution correlated with dorsal tilt. CONCLUSIONS: In the nonsurgical treatment of distal radius fractures, we were able to validate the McQueen equation and Lafontaine's criteria in predicting the final radial height and inclination and final ulnar variance. Neither method was predictive of final dorsal tilt or carpal malalignment. However, restoring volar cortical continuity by hooking the volar cortex in the initial reduction proved to be the strongest predictor of final volar tilt, the change in volar tilt, and carpal malalignment at union. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Management of acromioclavicular joint injuries.

Although recent advances have been made in the treatment of acromioclavicular (AC) joint injuries, they are still challenging for shoulder surgeons. There is a consensus that type I and II injuries should be treated nonoperatively, whereas acute type IV, V, and VI injuries should be treated surgically. There is no algorithm for correctly diagnosing and treating type III injuries, but the current trend is toward nonoperative treatment except for those with persistent symptoms and functional limitations after a course of conservative management. If surgery is indicated, newer anatomic techniques of reconstructing the coracoclavicular (CC) and AC ligaments are recommended.

Distal biceps and triceps injuries in athletes.

Biceps and triceps ruptures are rare, but can cause significant disability. They typically result from a forceful eccentric contraction, resulting in weakness and pain. Biceps and triceps tendon injuries represent the most and least common tendinous injuries about the elbow, respectively. Nonoperative management of these injuries is generally reserved for partial ruptures or patients unfit for surgery. Surgical repair has become the preferred method of treatment for acute, complete ruptures. Anatomy, epidemiology, clinical evaluation, and treatment of these injuries are described in this review.

Preoperative diagnosis of infection in patients with nonunions.

BACKGROUND: The surgical treatment of a fracture nonunion is complicated in the presence of infection. The purpose of the present study is to report on the utility of a standardized protocol to rule out infection in high-risk patients and to evaluate the efficacy of each component of the protocol. METHODS: A single protocol of preoperative laboratory tests (white blood-cell count, C-reactive protein level, and erythrocyte sedimentation rate) and a combined white blood cell/sulfur colloid scan were performed for patients with a high risk of fracture nonunion. Infection was diagnosed on the basis of positive intraoperative cultures, evidence of gross infection at the time of the procedure, or evidence of gross infection during the immediate postoperative period. With use of infection as the end point, univariate analysis and multiple logistic regression analysis were used to compare tests. A risk stratification method was used to combine tests. RESULTS: Ninety-three patients with ninety-five nonunions were evaluated. Thirty of the ninety-five nonunions were ultimately diagnosed as being infected. With use of a combination of elevated white blood-cell count, erythrocyte sedimentation rate, and C-reactive protein level and a positive scan, the predicted probabilities of infection associated with zero, one, two, and three positive tests were 18%, 24%, 50%, and 86%, respectively. With the elimination of the nuclear scan, the predicted probabilities for zero, one, two, and three risk factors were 20%, 19%, 56%, and 100%. CONCLUSIONS: The erythrocyte sedimentation rate and the C-reactive protein level were both independently accurate predictors of infection. Use of a risk stratification method showed that the likelihood of infection increased with each additional positive test. A combined white blood cell/sulfur colloid scan was the least predictive method of revealing infection and is not cost effective, even as part of a stratification scheme. LEVEL OF EVIDENCE: Diagnostic level III. See instructions for authors for a complete description of levels of evidence.

Infections in anterior cruciate ligament reconstruction.

CONTEXT: Anterior cruciate ligament (ACL) reconstruction is a safe, common, and effective method of restoring stability to the knee after injury, but evolving techniques of reconstruction carry inherent risk. Infection after ACL reconstruction, while rare, carries a high morbidity, potentially resulting in a poor clinical outcome. EVIDENCE ACQUISITION: Data were obtained from previously published peer-reviewed literature through a search of the entire PubMed database (up to December 2012) as well as from textbook chapters. RESULTS: Treatment with culture-specific antibiotics and debridement with graft retention is recommended as initial treatment, but with persistent infection, consideration should be given to graft removal. Graft type likely has no effect on infection rates. CONCLUSION: The early diagnosis of infection and appropriate treatment are necessary to avoid the complications of articular cartilage damage and arthrofibrosis.

Compartment syndrome in Schatzker type VI plateau fractures and medial condylar fracture-dislocations treated with temporary external fixation.

OBJECTIVE: Bicondylar tibial plateau fracture with metaphyseal-diaphyseal dissociation. Schatzker VI and medial plateau fracture-dislocations are commonly treated with initial external fixation until the soft tissues allow for more definitive internal fixation. The purpose of this study was to review the incidence of compartment syndrome (CS) in these injuries and the timing of their occurrence in relation to placement of the external fixator. DESIGN: Retrospective cohort, consecutive series. SETTING: Academic level I trauma center. PATIENTS/PARTICIPANTS: Over a 5-year period, 67 patients with tibial plateau fractures and fracture-dislocations were treated with initial external fixation within 48 hours of injury. There were 50 fractures (type VI) and 17 fracture-dislocations. INTERVENTION: CS was documented prospectively, and all patients were examined for signs of missed CS during office visits. MAIN OUTCOME MEASURE: The timing of the CS was noted as present at presentation and diagnosis after external fixation but during the initial operative session, late, or missed. RESULTS: Overall, there were 18 CSs (27%) in 67 extremities. CS was more common after fracture-dislocations (9 of 17) than plateau fractures (9 of 50) (P = 0.009, chi). Most CSs were diagnosed after frame placement (10), either in the operating room at the initial session (4 of 10) or within the first 48 hours after frame placement (3 of 10). There were 3 delayed cases diagnosed after the CS had run its course. All 3 of these patients had external fixators that included the foot in the neutral position. CONCLUSION: The incidence of CS for Schatzker type VI (18%) and medial plateau fracture-dislocations (53%) is high. When compared with the Schatzker type VI injuries, our data suggest that medial plateau fracture-dislocations may be at increased risk of developing CS after placement of spanning external fixation. We recommend careful monitoring of Schatzker type VI fractures and especially medial plateau fracture-dislocations after placement of spanning external fixators.