Efficacy of surgical skin preparation solutions in hip arthroplasty: a prospective randomized trial.

BACKGROUND: The use of an effective antimicrobial preoperative skin preparation solution is essential in preventing infections after surgery, but the findings in the literature regarding efficacy are not necessarily applicable to surgery involving the hip. The purpose of the present study was twofold: 1) to examine the native bacteria on the skin at the hip and 2) to determine the efficacy of 2 surgical skin preparation solutions at eliminating bacteria from the hip site in patients undergoing total hip arthroplasty. METHODS: We conducted a prospective randomized controlled trial in consecutive adult patients who underwent primary total hip arthroplasty at a single institution from October 2014 to December 2015. Each patient was randomly allocated to be treated with 1 of 2 commonly used surgical skin preparation solutions: ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol) or DuraPrep (0.7% iodophor and 74% isopropyl alcohol). Aerobic and anaerobic samples were obtained for culture before skin preparation, immediately after skin preparation and after skin closure. RESULTS: Full data were obtained for 105 patients: 54 in the ChloraPrep group and 51 in the DuraPrep group. Staphylococcus epidermidis, Corynebacterium and Micrococcus luteus were the organisms most commonly isolated from the hip before skin preparation. Positive bacterial culture results were obtained in 50 patients (93%) in the ChloraPrep group and 48 patients (94%) in the DuraPrep group. Immediately after skin preparation, the overall proportion of positive culture results was significantly lower in the DuraPrep group than the ChloraPrep group (14% v. 35%, adjusted relative risk 0.40, 95% confidence interval 0.18-0.85). After wound closure, there was no significant difference in the rate of positive culture results between the 2 groups. CONCLUSION: DuraPrep was more effective than ChloraPrep at eliminating skin flora at the hip initially on application, but the 2 solutions were equally effective at the time of closure. Further study with larger samples is required to identify any influence of skin preparation solution on the incidence of prosthetic joint infection.

Fracture of the femoral head.

Fracture of the femoral head is a severe, relatively uncommon injury; typically, it occurs following traumatic posterior dislocation of the hip joint. The Pipkin classification is the most commonly used classification system. Diagnosis is aided by a complete history, physical examination, and imaging, including computed tomography. Treatment consists of urgent closed reduction of the dislocated hip followed by nonsurgical or surgical management of any associated fractures. Controversies include the preferred surgical approach (anterior versus posterior) and whether to perform femoral head fragment excision or internal fixation. Complications associated with fracture of the femoral head and subsequent treatment include osteonecrosis, posttraumatic osteoarthritis, and heterotopic ossification. Fracture of the femoral head has been associated with a relatively poor functional outcome.

Carotid-jugular arteriovenous fistula: case report of an iatrogenic complication following internal jugular vein catheterization.

Central venous catheterization is frequently performed for perioperative management and long-term intravenous access. Although the complications of central venous catheter insertion have been widely reported, there are few reports of carotid-jugular arteriovenous fistula formation. We describe a case of a carotid-jugular arteriovenous fistula following the insertion of a double-lumen catheter for hemodialysis access. We provide recommendations for the prevention and early detection of this iatrogenic complication.

The results of early primary open reduction and internal fixation for treatment of OTA 43.C-type tibial pilon fractures: a cohort study.

OBJECTIVES: The optimal treatment for pilon fractures remains controversial. We have used early single-stage open reduction and internal fixation (ORIF) to treat these injuries and the purpose of this study was to determine the safety and efficacy of this strategy. DESIGN: Cohort study. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Ninety-five patients with Orthopaedic Trauma Association type 43.C pilon fractures. INTERVENTION: Primary ORIF. MAIN OUTCOME MEASUREMENT: Primary: Wound dehiscence or deep infection requiring surgery; secondary: quality of fracture reduction, functional outcomes (SF-36 and Foot and Ankle Outcome Score). RESULTS: Primary ORIF was performed within 24 hours in 70% of cases and within 48 hours in 88%. Reduction was judged to be anatomic in 90% cases. Six patients developed a deep wound infection or dehiscence that required surgical débridement, four after open fractures (four of 21 [19%]) and two after closed fractures (two of 74 [2.7%]). Complications were associated with local scarring, chronic alcohol abuse, schizophrenia, diabetes, and peripheral neuropathy. CONCLUSIONS: Provided surgery is performed expeditiously by experienced orthopaedic trauma surgeons, most tibial pilon fractures can be stabilized by primary ORIF within a safe and effective operative window with relatively low rates of wound complications, a high quality of reduction, and functional outcomes that compare favorably with the published results for all other reported surgical treatments of these severe injuries.

Wound complications after total knee arthroplasty.

Some wound complications can be prevented with attention to patient, surgical, and postoperative factors; others develop despite all efforts. Some practices that affect wound healing, such as the use of drains and methods of thromboprophylaxis are contentious. Superficial wound problems must always be discriminated from deep infection, which is not the focus of this article. Wound complications require prompt attention. As there is little morbidity from early irrigation and debridement of problem total knee arthroplasties (Weiss AP, Krackow KA. Persistent wound drainage after primary total knee arthroplasty. J Arthroplasty. 1993;8(3):285-9), early intervention is generally preferred.

The use of postoperative bone scintigraphy to predict graft retention.

BACKGROUND: Osteonecrosis of the femoral head commonly occurs in patients aged under 50 years. Because of a high rate of complications associated with joint replacement surgery in this population, surgical techniques, such as vascularized fibular grafting, have been devised in an attempt to salvage the femoral head. The purpose of this study was to investigate the use of bone scintigraphy to predict graft retention after vascularized fibular grafting for osteonecrosis of the hip. METHODS: We evaluated single photon emission computed tomography images from 104 subjects whose hips were treated with vascularized fibular grafts between 1994 and 2000. We compared the signal intensity of the graft with the intensity of the ipsilateral proximal femoral diaphysis and assigned a score of 1 if less than diaphysis, 2 if equal to diaphysis and 3 if greater than diaphysis. We defined graft failure as conversion to or on the waiting list for total hip arthroplasty. RESULTS: Thirty percent of hips failed treatment (n = 31, mean graft survival 34.9 mo), while 70% of grafts were retained (n = 73, mean follow-up 56.6 mo). Bone scan scores were significantly lower in the failed group (mean 7.1, range 6-12), compared with the retained group (mean 8.5, range 6-18; p = 0.03). Logistic regression demonstrated that a bone scan score > 6 was associated with graft retention (p = 0.028), with an odds ratio of 3.08 (range 1.13-8.40). CONCLUSION: These results suggest that having a well-perfused graft in the early postoperative period improves the chances of graft retention in the future.

Outcomes following plate fixation of fractures of both bones of the forearm in adults.

BACKGROUND: Internal fixation of diaphyseal forearm fractures has been associated with high union rates and satisfactory forearm motion. The purpose of this study was to investigate patient-based functional outcomes and to objectively measure strength following plate fixation of fractures of both bones of the forearm. METHODS: Range of motion, quantitative strength measurements, and validated outcome measures-i.e., DASH (Disabilities of the Arm, Shoulder and Hand) and SF-36 (Short Form-36) scores-were assessed in a cohort of thirty patients (nineteen men and eleven women with a mean age of 43.9 years) treated with plate fixation for fractures of both bones of the forearm. The mean duration of follow-up was 5.4 years, and standardized radiographs of the forearm were evaluated. Univariate and multivariate analyses were performed to identify determinants of the DASH and SF-36 Physical and Mental Component Summary (PCS and MCS) scores. RESULTS: Compared with the uninjured arms, the injured arms had reduced strength of forearm pronation (70% of that of the normal arm, p < 0.0001), forearm supination (68%, p < 0.0001), wrist flexion (84%, p = 0.0011), wrist extension (63%, p < 0.0001), and grip (75%, p < 0.0001). In addition, the injured arms had a significantly reduced active range of forearm supination (90% of that of the uninjured arm, p = 0.0001), forearm pronation (91%, p = 0.0028), and wrist flexion (82%, p < 0.0001). The mean DASH score (18.6 points; range, 0 to 61 points) was significantly higher than the normative value in the United States (p = 0.02). Limitations in strength correlated with worse DASH and SF-36 PCS scores. Pain and a work-related injury were independent determinants of the DASH score. CONCLUSIONS: Stabilization with internal plate fixation following fracture of both bones of the forearm restores nearly normal anatomy and motion. However, a moderate reduction in the strength of the forearm, the wrist, and grip should be expected following this injury. Perceived disability as measured with the DASH and SF-36 questionnaires is determined by pain more than by objective physical impairment.