The management of the shoulder skin microbiome (Cutibacterium acnes) in the context of shoulder surgery: a review of the current literature.

BACKGROUND: This review aims to establish current knowledge of the shoulder skin microbiome and how to manage the bacteria that reside within it. METHODS: A review was undertaken of the current literature through OvidSP. All abstracts were reviewed by three independent researchers. RESULTS: Thirty-five studies met the inclusion criteria. With forward referencing an additional 14 were included. None commented on organisms specific to the shoulder microbiome other than Cutibacterium acnes. Therefore, this review is focussed on the current knowledge of C. acnes. DISCUSSION: C. acnes is a skin commensal within the pilo-sebaceous glands reported to be the primary pathogen in up to 86% of shoulder joint infections. Pre-operative culture of unprepared skin can be indicative of underlying joint infection in shoulder arthroplasty revision. Intra-articular biopsies may have a high false positive due to skin contamination. Correlating the number of positive samples and certain associated signs can give a greater than 90% probability of a true infection. Standard surgical skin preparation, peri-surgical intravenous antibiotics and oral pre-operative antibiotics do not reduce bacterial load within the skin. However, topical benzoyl peroxide and clindamycin have both demonstrated significantly reduced bacteria load. Phylogenetically there are six main types. Patients may have more than one phenotype present during infection.

Traumatic tracheobronchial injuries: incidence and outcome of 136.389 patients derived from the DGU traumaregister.

To describe the incidence, therapy and outcome of traumatic tracheobronchial injuries (TTBI) in trauma patients with multiple injuries derived from the DGU TraumaRegister. We analyzed the data on all patients listed on the TraumaRegister DGU (TR-DGU) in Germany between 2002 and 2015 aged 16 years or older and with an Injury Severity Score (ISS) of ≥ 9. We analyzed the data on 136,389 trauma patients, 561 of whom had suffered tracheobronchial injuries (0.4%). The majority were male (73.4%) and had a mean age of 43.7 years. In total, 84.0% of all TTBI injuries occurred secondary to blunt trauma, caused mainly by accidents (71.2%). TTBI was accompanied by several concomitant thoracic injuries such as pneumo- (41.2%) and hemothorax (23.2%), lacerations (7.8%) and contusions (32.3%) of the lung, as well as multiple rib fractures (29.6%). The severity of injury was classified via the abbreviated injury scale (AIS): 39.3% with AIS = 3, 51.3% with AIS = 4 and 60% with AIS = 5 patients underwent surgical interventions. The mortality of patients with tracheobronchial injuries was higher: 24.6%, versus 13.7% in all patients (control group). This high percentage reflects their generally severe injury burden through concomitant injuries. The incidence of TTBI in this large cohort of trauma patients is very low. However, its high mortality rate emphasizes its importance. Mortality was associated with higher ISS and AIS scores. Higher rates of concomitant injuries were therefore associated with a higher mortality rate. TTBI injuries revealed a higher rate of progression to surgical management, with 35% undergoing surgery within the first 24 h. This excessive mortality rate demonstrates a high overall injury burden in patients with TTBI and high mortality of associated injuries. A surgical intervention's impact on mortality cannot be assessed in this study, as it would need to be investigated in a case-matched study.

Chloroquine-induced bilateral anterior shoulder dislocation: a unique aetiology for a rare clinical problem.

Bilateral anterior shoulder dislocation is a rare clinical entity with few case reports and limited series published in the literature. Bilateral shoulder dislocations are rare and of them, most are posterior. We present a highly unusual case of bilateral, atraumatic, anterior shoulder dislocation with concomitant comminuted greater tuberosity fracture on the right side, secondary to seizure, in a patient without known epilepsy, induced by oral chloroquine medication. We demonstrate the treatment approach that led to a satisfactory clinical outcome, evidenced by radiological union, clinical assessment and Patient Reported Outcome Measure data, following non-operative management of both shoulders. The unusual mechanism for anterior shoulder dislocation, the asymmetric dislocation pattern and peculiar precipitant for the causative seizure all provide interesting learning points from this case.

The fabella syndrome - a rare cause of posterolateral knee pain: a review of the literature and two case reports.

BACKGROUND: The purpose of this article was to evaluate the risks and benefits of non-operative treatment versus surgical excision of a fabella causing posterolateral knee pain. We performed a systematic review of literature and also present two case reports.Twelve publications were found in a PubMed literature review searching the word "fabella syndrome". Non-operative treatment and surgical excision of the fabella has been described. CASE PRESENTATION: Two patients presented to our outpatient clinic with persisting posterolateral knee pain. In both cases the presence of a fabella was identified, located in close proximity to the posterolateral femoral condyle. All other common causes of intra- and extra articular pathologies possibly causing the posterolateral knee pain were excluded.Following failure to respond to physiotherapy both patients underwent arthroscopy which excluded other possible causes for posterolateral knee pain. The decision was made to undertake surgical excision of the fabella in both cases without complication.Both patients were examined 6 month and one year after surgery with the Tegner activity score, the Visual Analogue Scale (VAS), and International Knee Documentation Committee Score (IKDC). CONCLUSION: Consistent posterolateral pain during exercise might indicate the presence of a fabella syndrome. Resecting the fabella can be indicated and is a minor surgical procedure with minimal risk. Despite good results in the literature posterolateral knee pain can persist and prevent return to a high level of sports. LEVEL OF EVIDENCE: IV, case reports and analysis of literature.

Acute calcific deposition in the lateral collateral ligament of the knee.

We present a rare case of a patient presenting with acute onset knee pain, which was subsequently diagnosed and treated as acute calcific deposition in the lateral collateral ligament. A 51-year-old gentleman presented to the emergency department with acute onset, excruciating, and left knee pain. There was no preceding history of trauma or systemic upset. Examination revealed exquisite tenderness over the lateral aspect of the knee with leg edema and an associated knee effusion. Blood tests showed a raised C-reactive protein. Plain radiographs of the knee showed a poorly defined calcific deposition with a "cloud-like" configuration. Following exclusion of all more threatening causes of symptoms, the patient was diagnosed with acute calcific tendinitis. The patient's pain was unremitting despite intravenous opiates, and he was taken to the operation theater for exploration and removal of the irritant crystal deposition from the lateral fibular collateral ligament resulting in complete resolution of symptoms. Acute calcific deposition in the lateral collateral ligament is a rare condition. There have been very few reports of this in the literature to date, and no reported cases of surgical excision. Calcific deposition can be treated successfully using conservative measures with symptoms settling after 4 to 6 weeks, however operative excision has been shown to be appropriate in specific cases. Acute calcific deposition should be considered in patients with unexplained acute knee pain and swelling, following the exclusion of other more common conditions. We present the first operatively treated case with accompanying radiology images, intraoperative medical photography, and histological slides.