Electrical Stimulation Use in Upper Extremity Peripheral Nerve Injuries.

Peripheral nerve injuries can be debilitating and often have a variable course of recovery. Electrical stimulation (ES) has been used as an intervention to attempt to overcome the limits of peripheral nerve surgery and improve patient outcomes after peripheral nerve injury. Little has been written in the orthopaedic literature regarding the use of this technology. The purpose of this review was to provide a focused analysis of past and current literature surrounding the utilization of ES in the treatment of various upper extremity peripheral nerve pathologies including compression neuropathies and nerve transection. We aimed to provide clarity on the clinical benefits, appropriate timing for its employment, risks and limitations, and the need for future studies of ES.

Diagnostic Quandary: Salmonella Agbeni Vertebral Osteomyelitis and Epidural Abscess.

Salmonella vertebral discitis/osteomyelitis is a rare manifestation of Salmonella infection. Here, we report a case of a 54-year-old Caucasian male who presented with five weeks of progressively worsening bilateral low back, buttock, and lower extremity pain following an 8-foot fall onto concrete from a ladder. Initial workup following the fall included hip X-ray and MRI of the lumbar spine and revealed only mild lumbar facet arthropathy and moderate left neural foraminal stenosis at L3-L4 without any concomitant hip or spine fracture. The patient's pain continued to increase in severity over the next several weeks, and he was evaluated by multiple healthcare professionals with no discovered pathology. Approximately 5 weeks following the fall, repeat CT scan and MRI were conducted which then revealed extensive findings of discitis/osteomyelitis at L5-S1 as well as an epidural abscess resulting in severe narrowing of the central spinal canal. Patient underwent emergent decompression laminectomy and discectomy at L5-S1 with evacuation of the epidural abscess. Intraoperative tissue and wound cultures revealed Salmonella enterica serovar Agbeni. The patient recovered well and was discharged on an eight-week regimen of IV ceftriaxone. He has since recovered appropriately with no neurologic deficits. Important takeaways from this case include continuing to work up patients whose pain or condition is not consistent with radiographic findings and the importance of clinical intuition. This case also highlights the use of intraoperative cultures and sensitivities to correctly direct antibiotic management. Lastly, this report adds to the paucity of literature surrounding Salmonella Agbeni-related discitis and epidural abscesses and makes the suggestion that traumatic incidents such as a fall may instigate these infections.

Local Versus Systemic Antibiotics for Surgical Infection Prophylaxis in a Rat Model.

BACKGROUND: The purpose of this study was to compare the local application of a variety of antimicrobial agents with intravenous (IV) antibiotics for infection prophylaxis in a rat model. METHODS: A total of 120 adult male Sprague-Dawley rats were implanted with an expanded polytetrafluoroethylene (ePTFE) vascular graft in a submuscular position and challenged with 2 × 10 colony-forming units of methicillin-sensitive Staphylococcus aureus (MSSA). Twenty rats received pretreatment with IV cefazolin and 20 rats were pretreated with IV vancomycin. The remaining 80 rats had application of local antimicrobials in the wound at the conclusion of the procedure: 20 rats received vancomycin powder; 20 rats, cefazolin powder; and 20 rats, tobramycin powder; 20 rats underwent dilute 0.35% Betadine (povidone-iodine) lavage for 3 minutes. One week after surgery, the grafts were retrieved and cultured. RESULTS: Twenty (100%) of 20 rats in each of the IV cefazolin, IV vancomycin, and dilute Betadine lavage groups had grossly positive cultures for MSSA (95% confidence interval [CI], 84% to 100%). Eighteen (90%) of 20 rats in the cefazolin local powder group demonstrated positive cultures for MSSA (95% CI, 77% to 100%). Four (20%) of 20 rats in the tobramycin local powder and vancomycin local powder groups demonstrated positive cultures for MSSA (95% CI, 3% to 38%). The infection rates for the local application of vancomycin and tobramycin powder were significantly lower compared with Betadine lavage, IV vancomycin, IV cefazolin, and local cefazolin powder (p < 0.000001). CONCLUSIONS: Local antimicrobial prophylaxis with vancomycin and tobramycin powder for infections in the rat model was statistically superior to systemic prophylaxis with IV antibiotics, local cefazolin powder, and Betadine lavage. CLINICAL RELEVANCE: This study supports the findings of prior clinical reports that intrawound vancomycin powder reduces the risk of surgical site infection. Local application of tobramycin powder was equivalent to vancomycin powder in this model. Additionally, the superiority of local antibiotic surgical prophylaxis suggests that clinical studies should be considered to determine the relative efficacy of local versus systemic antibiotics for surgical infection prophylaxis in humans.