RESUMO
Purpose: To evaluate the use of computed tomography (CT) imaging as a diagnostic tool for elbow arthrotomies using a standardized cadaveric arthrotomy model. Method: Nineteen intact fresh frozen cadaver elbows were CT scanned using 2 mm cuts with sagittal and coronal reformats in the plane of the joint and used as controls. An elbow arthrotomy at the posterocentral arthroscopic portal site was performed in all specimens using a 4.5 millimeter trocar. After arthrotomy, all elbows underwent a second CT scan followed by a standard saline load test (SLT). Images were randomized and reviewed by 2 blinded, independent reviewers. Bimodal scoring was performed for each specimen with regard to the presence of an arthrotomy indicated by presence of air in the joint. Regarding the SLT, saline exiting the arthrotomy wound was considered a positive test. Results: CT scans were found to have 100% sensitivity and 86% specificity for diagnosing elbow arthrotomies. Interrater reliability calculated with Cohen kappa statistic was near perfect at r = 0.89. The SLT had a sensitivity of 79% when 20 mL was injected. A total of 25 mL of saline was required to be injected for a sensitivity greater than 95%. Conclusion: This study demonstrates that CT scan is a reliable and less technically demanding method of diagnosis arthrotomies with high interrater reliability and high sensitivity and with results comparable with SLT. This technique may be useful in centers where trained providers are not readily available to perform SLT. Clinical study is required to validate our results. Level of Evidence: Level II.
RESUMO
Open fractures are often associated with high-energy trauma and have an increased risk of infection because of surrounding soft-tissue damage and the introduction of environmental contaminants that may communicate with the fracture site. The Gustilo-Anderson classification of open fractures has been used to guide prophylactic antibiotic therapy because different types of open fracture have been shown to have varying rates of surgical site infections with different combinations of pathogens. Prophylactic treatment with various classes of antibiotics, including penicillins and cephalosporins, aminoglycosides, and fluoroquinolones, has evolved over the past half century. More recently, broader spectrum agents including monobactams and glycopeptides have been used for additional coverage. Duration of antibiotic therapy remains variable between institutions, and antibiotic choice is not standardized. Coverage for nosocomial and multidrug-resistant organisms is an ongoing area of clinical research.
Assuntos
Antibacterianos/classificação , Antibioticoprofilaxia , Fraturas Expostas/complicações , Infecção dos Ferimentos/etiologia , Infecção dos Ferimentos/prevenção & controle , Antibacterianos/administração & dosagem , Infecção Hospitalar/etiologia , Infecção Hospitalar/microbiologia , Infecção Hospitalar/prevenção & controle , Farmacorresistência Bacteriana , Resistência a Múltiplos Medicamentos , Humanos , Infecção dos Ferimentos/microbiologiaRESUMO
Remembering that preoperative planning, surgical indications, and fracture reduction are paramount for this procedure, presented here is our technique for performing percutaneous sacroiliac screws, both transiliac-transsacral and sacral style. A combination of video, still pictures, and fluoroscopy images will guide the viewer through the process we routinely use highlighting specific details. Patient positioning and intraoperative fluoroscopy imaging are critical to a successful procedure. Although inlet and outlet films remain important, we find the procedure best started on the lateral sacral view to reduce the need for start site, trajectory, and imaging position changes during the case. A cannulated pig sticker (drill guide) used with long drill tip guide wires provide improved manual control to both finding a good start site and directing the trajectory. For patient safety, sacral anatomy and safe zones are discussed as well. Using these technical points will help make this a successful procedure.
Assuntos
Parafusos Ósseos , Fixação Interna de Fraturas/instrumentação , Fraturas Ósseas/cirurgia , Ossos Pélvicos/lesões , Ossos Pélvicos/cirurgia , Articulação Sacroilíaca/cirurgia , Medicina Baseada em Evidências , Fixação Interna de Fraturas/métodos , Fraturas Ósseas/diagnóstico por imagem , Humanos , Ossos Pélvicos/diagnóstico por imagem , Articulação Sacroilíaca/diagnóstico por imagem , Resultado do TratamentoRESUMO
Clostridium myonecrosis or gas gangrene is a life-threatening infection characterized by either traumatic or atraumatic etiology. It has been widely described in patients with traumatic open wounds and in immunocompromised patients, including malignancy. A third source can result from natural flora in the gastrointestinal tract after bowel ischemia. This is a rare occurrence and is even less commonly described in the pediatric population. We present a pediatric patient who developed Clostridium septicum myonecrosis as an iatrogenic complication from clindamycin-induced Clostridium difficile ischemic colitis.
Assuntos
Clindamicina/efeitos adversos , Clostridioides difficile/isolamento & purificação , Infecções por Clostridium/etiologia , Clostridium septicum , Gangrena Gasosa/etiologia , Criança , Colite Isquêmica/microbiologia , Feminino , Humanos , Doença Iatrogênica , Choque Séptico/etiologiaRESUMO
OBJECTIVES: To determine whether previously reported high mortality rates associated with bilateral femoral fractures have decreased over time. DESIGN: Retrospective review. SETTING: Urban academic trauma center. STUDY GROUP: 54 adults with bilateral femoral fractures treated at our center from 2000 to 2006. The 108 fractures were initially treated with external fixation (11%), reamed antegrade nailing (23%), and reamed retrograde nailing (67%). Unilateral control group: 461 patients with unilateral femoral fractures treated at our center from 2002 to 2005. INTERVENTION: Univariate analysis compared our results with those of a published historical control group from the same center approximately 15 years ago (study period, 1984-1990). MAIN OUTCOME MEASUREMENTS: Mortality rates. RESULTS: We noted marked differences between the current mortality rate associated with bilateral femoral fractures and that of the historical control group. The mortality rate decreased over time at our center for both bilateral (26%-7%, P = 0.002) and unilateral (12%-2%, P = 0.0001) fractures. Mortality rates were still significantly higher (P = 0.037) for bilateral (7%) than for unilateral (2%) fractures. CONCLUSIONS: Mortality rates and Injury Severity Scores were reduced for bilateral and unilateral femoral fractures compared with data reported 15 years ago from the same center. The improved outcome might be related in part to changes in resuscitation, triage, intensive care, and orthopaedic management of the patients. However, considering that the Injury Severity Score also significantly decreased, the improvement might have occurred because of changes in injury patterns, perhaps secondary to improved safety features in motor vehicles. LEVEL OF EVIDENCE: Prognostic level III. See instructions for authors for a complete description of levels of evidence.