Low Adherence to Recommended Guidelines for Open Fracture Antibiotic Prophylaxis.

BACKGROUND: Prompt administration of antibiotics is a critical component of open fracture treatment. Traditional antibiotic recommendations have been a first-generation cephalosporin for Gustilo Type-I and Type-II open fractures, with the addition of an aminoglycoside for Type-III fractures and penicillin for soil contamination. However, concerns over changing bacterial patterns and the side effects of aminoglycosides have led to interest in other regimens. The purpose of the present study was to describe the adherence to current prophylactic antibiotic guidelines. METHODS: We evaluated the antibiotic-prescribing practices of 24 centers in the U.S. and Canada that were participating in 2 randomized controlled trials of skin-preparation solutions for open fractures. A total of 1,234 patients were evaluated. RESULTS: All patients received antibiotics on the day of admission. The most commonly prescribed antibiotic regimen was cefazolin monotherapy (53.6%). Among patients with Type-I and Type-II fractures, there was 61.1% compliance with cefazolin monotherapy. In contrast, only 17.2% of patients with Type-III fractures received the recommended cefazolin and aminoglycoside therapy, with an additional 6.7% receiving piperacillin/tazobactam. CONCLUSIONS: There is moderate adherence to the traditional antibiotic treatment guidelines for Gustilo Type-I and Type-II fractures and low adherence for Type-III fractures. Given the divergence between current practice patterns and prior recommendations, high-quality studies are needed to determine the most appropriate prophylactic protocol.

Allograft reconstruction of chronic pectoralis major tendon ruptures.

In chronic pectoralis tendon tears, primary repair may not be possible and allograft reconstruction may be required. The goal of this study was to report the authors' experience with chronic pectoralis major tendon reconstructions using an Achilles tendon allograft in three military patients. Three consecutive patients presenting with chronic, complete pectoralis major tendon tears underwent reconstruction by a single surgeon using the same described technique at a mean of 22.2 months after initial injury. Final outcomes were assessed at a mean of 24.5 months postoperatively, yielding one excellent and two good results. All patients were satisfied. All patients returned to full active duty military service and recreational weight lifting by 6 months. Achilles allograft reconstruction of chronic pectoralis major tendon ruptures is a viable treatment option. Good to excellent results can be achieved in active patients, even when reconstruction is performed nearly 2 years from the time of injury.

Anatomic location and morphology of symptomatic, operatively treated osteochondral lesions of the talus.

BACKGROUND: Historically, osteochondral lesions of the talus (OCLTs) were thought to occur most commonly in the anterolateral and posteromedial talar dome; however, new classification systems are able to describe OCLT location more precisely. A recent magnetic resonance imaging (MRI) study introduced a novel nine-zone anatomic grid of the talar dome, demonstrating that most OCLTs occur in the central portion of the medial and lateral talar dome, with medial lesions being more common as well as larger in depth and surface area. The current study sought to determine if similar location and morphology patterns were consistent in symptomatic, operatively treated OCLTs. MATERIALS AND METHODS: The preoperative MRI images of 65 consecutive patients who underwent operative management for symptomatic OCLTs at a single institution were reviewed using a previously described nine-zone anatomic grid of the talar dome to determine location frequency, morphology, and Hepple et al. MRI staging classification characteristics. All patients were active-duty service members in the United States Armed Forces. The cohort consisted of 60 (92%) males and 5 (8%) females with an overall mean patient age of 34 (range, 19 to 58) years. Statistical analyses were performed, and significant differences are reported. RESULTS: The most common location for symptomatic, operatively treated OCLTs was the central third of the lateral talar dome, followed by the central third of the medial talar dome. Anterolateral and posteromedial lesions accounted for relatively few OCLTs. Compared with lateral OCLTs, medial OCLTs were significantly larger in transverse and anteroposterior diameters and surface area, but no significant differences existed with regard to lesion depth. Overall, the majority of lesions were MRI stage II; however, stage II lesions were more likely located laterally, whereas stage III lesions were more likely located medially. CONCLUSIONS: With regard to symptomatic, operatively treated OCLTs, the results of the current study parallel current evidence that posteromedial and anterolateral OCLTs are not the most common locations of OCLTs. As well, medial OCLTs were larger in surface area than lateral OCLTs, but no differences existed with regard to lesion depth. It is interesting that operatively treated OCLTs were twice as commonly located in the centrolateral third rather than the centromedial third of the talar dome.