Acute Extremity Compartment Syndrome and the Role of Fasciotomy in Extremity War Wounds.

Acute compartment syndrome (CS) is a frequent and potentially devastating complication of blunt and penetrating extremity injuries. Extremity war injuries are particularly susceptible to CS due to associated vascular injuries; high Injury Severity Score; extensive bone and soft tissue injury; and frequent transportation that may limit close monitoring of the injured extremity. Treatment consists of prompt fasciotomy of all compartments in the involved segment, over their full length. Delayed or incomplete fasciotomy is associated with worse outcomes, including muscle necrosis, infection, and amputation. Enhanced pre-deployment training of surgeons decreases the need for revision fasciotomy at higher echelons of care and should be continued in future conflicts. We recommend the liberal use of prophylactic fasciotomy prior to aeromedical evacuation and after limb reperfusion. For leg fasciotomy, we recommend a two-incision approach as it is more reproducible and allows easy vascular exposure when necessary.

Intra-articular synovial sarcoma treated with a transfemoral amputation: a case report and review of the literature.

A case of monophasic intra-articular synovial sarcoma in the right knee of a 39-year-old active duty serviceman treated with a transfemoral amputation is presented. The patient was evaluated for right knee pain and fullness. After further workup, the patient underwent computed tomography guided biopsy, with the tissue specimen consistent with intra-articular synovial sarcoma. The patient elected for a transfemoral amputation rather than limb or joint-sparing surgery. The gross specimen measured 3.5 × 3.0 × 1.7 cm in the posteromedial knee. No metastatic lesions were seen on positron emission tomography-computed tomography. Chemotherapy and radiation therapy have not been utilized. The transfemoral amputation adds to the uniqueness of this report and is discussed with a review of the multimodality treatment toward intra-articular synovial sarcoma in prior published literature.

Does antibiotic elution from PMMA beads deteriorate after 1-year shelf storage?

Antibiotic-impregnated polymethylmethacrylate beads are widely used as an adjunct in the treatment of orthopaedic infections. Because there is no commercially available bead in the United States, surgeons must manufacture bead sets at the time of implantation. This can be time consuming and wasteful. We hypothesized antibiotic-impregnated beads would maintain consistent elution for up to 1 year after manufacturing and storage. Tobramycin-impregnated antibiotic beads were manufactured using a bead mold. The antibiotic was either hand-mixed into the polymethylmethacrylate powder (1.2 g/40 g) or came premixed from the factory (1 g/40 g). Packages of beads were gas-sterilized and stored at room temperature. Beads were tested at 0, 1, 2, 3, 6, and 12 months. Antibiotic levels in the eluent from each day of the month were measured. We were unable to detect any difference in the amount of antibiotic elution between beads tested immediately after manufacture and beads manufactured and stored for 6 or 12 months. Beads with hand-mixed antibiotics eluted higher levels of antibiotics than the beads prepared with factory-mixed antibiotics. We conclude antibiotic beads can be made, sterilized, and used after 1 year of storage with no deleterious effect on antibiotic elution characteristics.

Distal tibial osteoarticular allografts.

Osteoarticular allografts can be used for limb reconstruction following tumor excision. Most commonly, the distal femur, proximal tibia and distal radius have been studied, while distal tibial allografts receive only sporadic mention in the literature. We evaluated the functional outcomes of distal tibial allografts used in tumor reconstruction. Following FDA guidelines and using a questionnaire, we surveyed operating surgeons on the outcomes of 29 distal tibial allografts used to reconstruct osseous defects secondary to benign and malignant tumors. Twelve patient questionnaires were returned revealing nine complications in eight patients. These included nonunions (three), fracture (two), arthrosis (two), and delayed union (two). There were no reported infections. Two patients died of their disease. The average rating using the Musculoskeletal Tumor Society (MSTS) score was 67.3%. The 10 living patients had an average rating of 72.4%. Distal tibial osteoarticular allografts offer acceptable functional results when used in tumor reconstruction. Difficulties achieving union (delayed or nonunion) between the host and the graft appears the most common complication of this technique.