Complications of antibiotic cement spacers used for elbow infections.

BACKGROUND: Antibiotic cement spacers have been widely used in the treatment of joint infections. There are no commercially available antibiotic spacers for the elbow. Instead, they are typically fashioned by the surgeon at the time of surgery using cement alone or a combination of cement with sutures, Steinmann pins, external fixator components, or elbow arthroplasty components. There is no consensus regarding the ideal elbow antibiotic spacer and no previous studies have examined the complications associated with these handmade implants in relation to their unique structural design. METHODS: We retrospectively reviewed 55 patients who had 78 static antibiotic cement spacers implanted between January 1998 and February 2021 as part of a 2-stage treatment plan for infection of an elbow arthroplasty, other elbow surgery, or primary elbow infection. Several antibiotic spacer structures were used during the study period. For analysis purposes, the spacers were classified into linked and unlinked spacers based on whether there was a linking mechanism between the humerus and the ulna. Complications related to these spacers that occurred either during the implantation, between implantation and removal, or during removal were recorded and analyzed from chart review and follow-up x rays. Reoperations due to spacer-related complications were also recorded. RESULTS: Among the 55 patients (78 spacers), there were 23 complications, including 17 minor and 6 major complications. The most common complication of unlinked spacers (intramedullary [IM] dowels, beads and cap spacer) was spacer displacement. Other complications included IM dowel fracture and difficulty locating beads during spacer removal. The major complications of linked cement spacers included two periprosthetic humerus fractures after internal external fixator cement spacers and re-operation due to breakage and displacement of one bushing cement spacer. The major complications of unlinked cement spacers included two reoperations due to IM dowel displacement and one reoperation due to displacement of beads. Among patients who had removal of all components and those with native joints, there was no statistically significant difference between internal external fixator cement spacers and unlinked cement spacers in minor complication rates (30% vs. 16%, P = .16), major complication rates (7% vs. 8%, P = .85) and reoperation rates (0% vs. 8%, P = .12). CONCLUSIONS: Static handmade antibiotic elbow spacers have unique complications related to their structural designs. The most common complication of linked and nonlinked cement spacers were failure of the linking mechanism and displacement, respectively. Surgeons should keep in mind the possible complications of different structures of cement spacers when choosing 1 antibiotic spacer structure over another.

Geriatric distal femoral fractures: post-operative complications and nine-year mortality-a retrospective analysis of two tertiary trauma centres.

PURPOSE: This study aimed to estimate the mortality at various post-operative intervals and explore influential variables for these outcomes in elderly patients with distal femur fractures (DFF). METHODS: A retrospective observational study was conducted across two tertiary care institutions, between 2014 and 2020. The primary outcomes were mortality rates at 30-day, six month, and one year post-surgery. Secondary outcomes included 1-year readmission and reintervention rates along with their correlated complications. RESULTS: A total of 37 DFF in 35 patients was analyzed; average age was 83.6 years (range, 65-98 years). The overall mortality rate at a maximum follow-up of 8.8 years was 74% (26/35 patients). The median survival time was 3.2 years and the survival probability at five years was 27% (95% confidence interval [CI], 13 to 43%). Mortality rates at 30 days, six months, and one year after surgery were 8.6% (3 patients), 23% (8 patients), and 34% (12 patients), respectively. Overall mortality rate was 64% (15/24 patients) for native distal femur fractures, and 92% (13/14 patients) for periprosthetic fractures (p = 0.109). Patients older than 85 years and male gender were identified as risk factors for mortality within the first year post-operatively. CONCLUSION: Elderly fractures have a high mortality at eight years of follow-up. Mortality at one year was much higher than in other studies of the same nature. We did not find statistically significant differences when comparing native bone fractures with periprosthetic fractures. Factors that impact mortality were being a man, advanced age, elevated index comorbidity, and dementia. There is no relationship between the time to be taken to the surgical procedure and mortality results.

Unusual Combination of Lateral Condyle Mass Fracture and Olecranon Fracture in a Child: A Case Report.

Fractures of the lateral condyle and olecranon are two of the most common elbow injuries in the pediatric age group. However, their simultaneous occurrence is rare. Proper understanding and management of these injuries are essential to prevent long-term complications. This case report presents a patient who suffered both fractures, with surgical intervention for the condyle and non-surgical management for the olecranon. A two-year-old female child was brought to the emergency department following a fall from monkey bars, landing on her outstretched left arm. Clinical examination showed a markedly swollen and tender elbow with a restricted range of motion. No neurovascular deficit was noted. Plain radiographs revealed a displaced fracture of the lateral condyle and an associated non-displaced olecranon fracture. Given the displacement of the lateral condyle fracture, surgical intervention was deemed necessary. The patient underwent open reduction and internal fixation (ORIF) of the lateral condyle using Kirschner wires. The olecranon fracture, being non-displaced, was managed conservatively with a posterior splint. The patient's postoperative recovery was uneventful. The Kirschner wires were removed at six weeks of follow-up, and active mobilization was started. The patient achieved full range of motion at three months post-injury. At a one-year follow-up, she had no pain, restriction, or any deformity, and radiographs confirmed the complete union of both fractures. Simultaneous fractures of the lateral condyle and olecranon in children are rare. The mechanism of injury is complex and warrants a high index of suspicion for associated injuries. Surgical fixation of the lateral condyle and conservative management of the olecranon fracture can yield excellent outcomes.

Long-Term Patient-Reported Outcomes After Arthroscopic Debridement of Grade 3 or 4 Capitellar Osteochondritis Dissecans Lesions.

BACKGROUND: Arthroscopic debridement for osteochondritis dissecans (OCD) lesions of the capitellum is a relatively common and straightforward surgical option for failure of nonoperative management. However, the long-term outcomes of this procedure remain unknown. HYPOTHESIS: Arthroscopic debridement of capitellar OCD would provide satisfactory long-term improvement in patient-reported outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients aged ≤18 years who underwent arthroscopic debridement procedures for OCD lesions (International Cartilage Repair Society grades 3 and 4) were identified. Procedures included loose body removal when needed and direct debridement of the lesion; marrow stimulation with drilling or microfracture was added at the discretion of each surgeon. The cohort consisted of 53 elbows. Patient evaluation included visual analog scale for pain; motion; subjective satisfaction; Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; reoperation; and rate of return to sports. RESULTS: At a mean 11 years of follow-up (range, 5-23 years), the median visual analog scale score for pain was 0, and 96% of patients reported being improved as compared with how they were before surgery. The mean ± SD QuickDASH score was 4 ± 9 points (range, 0-52 points), and 80% of patients returned to their sports of interest. The arc of motion significantly improved from 115°± 28° preoperatively to 130°± 17° at latest follow-up (P = .026). Seven elbows (13%) required revision surgery for OCD lesions, resulting in high rates of overall survivorship free of revision surgery: 90% (95% CI, 80%-96%) at 5 years and 88% (95% CI, 76%-94%) at 10 years. At final follow-up, 7 all-cause reoperations were performed without revision surgery on the OCD lesion. CONCLUSION: Arthroscopic debridement of grade 3 or 4 OCD lesions of the capitellum produced satisfactory patient-reported outcomes in a majority of elbows, although a subset of patients experienced residual symptoms. The inherent selection bias of our cohort should be considered when applying these results to the overall population with OCD lesions, as we do not recommend this procedure for all patients.

Bloqueos supraescapular e interescalénico como analgesia después de la reparación artroscópica del manguito rotador: estudio de cohorte comparativo retrospectivo / Suprascapular and interscalene nerve block as analgesia after arthroscopic rotator cuff repair: a retrospective comparative cohort study

Introducción: El objetivo de este estudio fue comparar la eficacia de los bloqueos interescalénico y supraescapular, solos y combinados, como analgesia posoperatoria en las primeras 3 horas tras la reparación artroscópica del manguito rotador. Materiales y métodos: Estudio de cohorte comparativo retrospectivo, realizado entre 2019 y 2021. El criterio de valoración principal fue el puntaje del dolor de hombro en la sala de recuperación evaluado con una escala analógica visual por el paciente. Los criterios de valoración secundarios fueron el consumo de opioides en la sala de recuperación y las complicaciones de la anestesia locorregional. Resultados: Se incluyó a 175 pacientes, 13 en el grupo de bloqueo interescalénico, 61 en el grupo de bloqueos interescalénico más supraescapular y 101 en el grupo de bloqueo supraescapular. Los grupos de bloqueo interescalénico y de bloqueo interescalénico más supraescapular tuvieron significativamente menos dolor en la sala de recuperación y una tasa total menor de opioides consumidos en miligramos equivalentes de morfina que el grupo de bloqueo supraescapular (p = 0,001 y p <0,01, respectivamente). No hubo diferencias significativas en el dolor ni el consumo de opioides entre el bloqueo interescalénico solo o combinado con bloqueo supraescapular. Conclusiones: El bloqueo interescalénico fue más eficaz que el bloqueo supraescapular para aliviar el dolor y disminuir el consumo de opioides en la sala de recuperación tras la reparación artroscópica del manguito rotador. La combinación de bloqueo interescalénico más bloqueo supraescapular no resultó en un incremento de la eficacia, y se sugiere no combinar estas dos técnicas. Nivel de evidencia: III

Introduction: This study aimed to compare the efficacy of interscalene block (ISB) and suprascapular nerve block (SSNB), individually and in combination (ISB+SSNB), used as postoperative analgesia within the first 3 hours after arthroscopic rotator cuff repair. Materials and methods: Retrospective comparative cohort study, conducted between 2019 and 2021. The primary endpoint was shoulder pain score in the immediate postoperative period as reported on a visual analog scale (VAS) by the patient. Secondary endpoints were opioid use in the recovery room (first 3 hours) and locoregional anesthesia complications. Results:175 patients were included; 13 in the ISB group, 61 in the ISB+SSNB group, and 101 in the SSNB group. The ISB group and the ISB+SSNB group had significantly less pain in the recovery room than the SSNB group (p = 0.001 and p < 0.001, respectively). The percentage of patients who required at least one dose of opioid and the total number of opioids consumed in milligrams of morphine equivalent were significantly lower for the ISB and ISB+SSNB groups than for the SSNB group (p < 0.001). There were no significant differences in pain or opioid use between ISB alone or combined with SSNB (ISB+SSNB). Conclusions: In this retrospective comparative study, ISB was more effective in relieving pain and reducing opioid use in the recovery room after ar-throscopic rotator cuff repair than SSNB. The ISB+SSNB combination did not increase effectiveness, and therefore it is suggested not to combine these two techniques. .Level of Evidence: III

Patients Use Fewer Opioids Than Prescribed After Arthroscopic Release of Elbow Contracture: An Evidence-Based Opioid Prescribing Guideline to Reduce Excess.

PURPOSE: To generate an evidence-based opioid-prescribing guideline by assessing the pattern of total opioid consumption and the factors that may predict opioid consumption following arthroscopic release of elbow contracture and to investigate whether the use of continuous passive motion (CPM), as compared to physical therapy (PT), was associated with a decrease in pain and opioid consumption after arthroscopic release of elbow contracture. METHODS: Data collected from a randomized controlled trial that compared continuous passive motion (CPM) (n = 24) to physical therapy (PT) (n = 27) following arthroscopic release of elbow contracture was analyzed for opioid use. Fifty-one participants recorded their daily opioid consumption in a postoperative diary for 90 days. Multivariate analysis was performed to identify factors associated with opioid use. Recommended quantities for postoperative prescription were generated using the 50th percentile for patients without and the 75th percentile for patients with factors associated with higher opioid use. RESULTS: The median total opioid prescription was 437.5-mg morphine milligram equivalents (MMEs) (58 pills of 5 mg oxycodone) and the median total opioid consumption was 75 MMEs (10 pills of 5-mg oxycodone). Twenty-two percent of patients took no opioid medication, 53% took ≤10 pills, 69% took ≤20 pills and 75% took ≤30 pills. Predictors of higher opioid use were preoperative opioid use, age <60 years and inflammatory arthritis. The total opioid consumption appeared similar between the CPM and the PT group. Seventy-five percent of patient's home opioid requirements would be satisfied using the following guideline: Patients undergoing contracture release for osteoarthritis or post-traumatic contracture should be given a prescription for 10 pills of 5 mg oxycodone or its equivalent at discharge. Patients with inflammatory conditions or those taking preoperative opioids should be prescribed 30 pills of 5 mg oxycodone or its equivalent. CONCLUSION: This study suggests that most patients undergoing arthroscopic release of elbow contracture use relatively few opioid pills after surgery. Use of an evidence-based guideline could decrease opioid prescriptions substantially, while still effectively treating patients' pain.