Evaluation of Risk to the Suprascapular Nerve During Arthroscopic SLAP Repair: Is a Posterior Portal Safer?

PURPOSE: The purpose of this study was to compare the risk of glenoid perforation during SLAP repair for suture anchors placed through an anterolateral portal versus a posterolateral portal of Wilmington. METHODS: Ten bilateral cadaveric shoulders were randomized to suture anchor placement through an anterolateral portal on one shoulder and a posterolateral portal on the contralateral shoulder. Anchors were placed into anterior, posterior, and far posterior positions on the glenoid rim (1 o'clock, 11 o'clock, and 10 o'clock positions for right shoulders). The shoulder was then dissected, and the distance from the suture anchor tip to the nerve was measured if perforation occurred. The maximum load and failure mechanism of each anchor was assessed with a materials testing system machine. RESULTS: Only 2 of 20 anchors placed in the posterosuperior glenoid through the posterolateral portal perforated compared with 16 of 20 of the anchors placed through the anterolateral portal (P < .05). The mean distance from the perforated anchor tip to the suprascapular nerve was 2.5 ± 1.4 mm for the anterolateral portal and 4.4 ± 0.6 mm for the posterolateral portal (P = .18). We did not observe a significant difference in biomechanical strength (P > .05). CONCLUSIONS: There is a high rate of glenoid perforation in close proximity to the suprascapular nerve when placing anchors in the posterosuperior glenoid through an anterolateral portal. Use of the posterolateral portal results in a much lower incidence of glenoid perforation for anchors placed in the posterosuperior glenoid, but there is a higher risk of glenoid perforation for an anchor placed in the anterosuperior glenoid from the posterolateral portal. CLINICAL RELEVANCE: There is a higher risk of injury to the suprascapular nerve when suture anchors are placed in the posterosuperior glenoid through an anterolateral portal compared with a posterolateral portal for SLAP repair.

Identifying Hidden Zones of the Far Posterior Cartilage of the Femoral Condyles Not Visible During Knee Arthroscopy.

OBJECTIVE: The purpose of this study was to compare standard knee arthroscopic and MRI findings and measurements for visualization of the femoral condyle articular cartilage. The hypothesis was that certain posterior cartilage defects identified with MRI may not be accessible with routine arthroscopy. MATERIALS AND METHODS: Six cadaveric knees were examined by routine arthroscopy through standard inferomedial and inferolateral portals. Suture anchors were inserted into the femoral condyles at 30°, 60°, 90°, and 120° of flexion as markers of the cartilage surface at the most posterior aspect of the condyle that could be accessed at each degree of flexion. Each specimen was then examined with 3-T MRI and gross dissection. Measurements were obtained and compared. RESULTS: During arthroscopy at 90° of knee flexion, only 5.83 mm of the medial femoral condyle and 6.83 mm of the lateral femoral condyle were visualized posterior to the anchor placed at 90° of flexion. These arthroscopic measurements were statistically significant underestimates of the actual amount of cartilage identified posterior to the 90° anchor at gross dissection (medial condyle, 44.20 mm; lateral condyle, 37.50 mm) and MRI (medial, 41.33 mm; lateral, 38.87 mm). This indicates that 85.9% of the medial and 81.8% of the lateral posterior articular cartilage of the femoral condyle seen at MRI were not visualized during arthroscopy. CONCLUSION: More than 80% of the articular cartilage proximal to the menisci seen at MRI is not visible during routine arthroscopy. This far posterior articular cartilage should be called the hidden zone.

Fever and leukocytosis in critically ill trauma patients: it's not the urine.

BACKGROUND: Infectious complications are a major cause of morbidity and mortality in critically ill trauma patients. Therefore, fever and leukocytosis often trigger an extensive laboratory workup that includes a urine culture (UCx). The purposes of this study were to: 1) Define the current practice for obtaining UCxs in trauma patients admitted to the surgical and trauma intensive care unit (STICU); and 2) determine if there is an association between fever or leukocytosis and urinary tract infections (UTIs) during the initial 14 hospital days. METHODS: An 18-month retrospective cohort analysis was performed on consecutive trauma patients admitted for at least two days to the STICU at a level I trauma center. Data collected included demographics, injuries, and daily maximal temperature (T(max)), leukocyte count, and UCx results for the first 14 days. Fever and leukocytosis were defined as T(max) > or =38.5 degrees C and leukocyte count > or =12,000/mm(3), respectively. Urinary tract infections were diagnosed with a positive UCx (> or =10(5) organisms/mL of urine). RESULTS: Five hundred ten patients were evaluated for a total of 3,839 patient-days. Their mean age and Injury Severity Score were 49 +/- 1 years and 19 +/- 1 points, respectively. Seventy-two percent were men, and 91% had sustained blunt injuries. Four hundred seven UCxs were obtained; 42 patients (8%) had 60 UTIs. The cohort had an indwelling urinary catheter for 97% of the patient-days, yielding an infection density of 16 UTIs/1,000 urinary catheter-days. There was a significant association between obtaining a UCx and fever and between fever and leukocytosis (both, p < 0.001), but no association of UTI with fever, leukocytosis, or the combination of fever and leukocytosis. Analysis using temperature and leukocyte count as continuous variables identified no temperature or leukocyte range associated with UTIs. Independent risk factors for UTI calculated by logistic regression were female sex, older age, low Injury Severity Score, and no antibiotics within 24 h before the UCx was obtained. CONCLUSIONS: The practice of obtaining a UCx from the STICU trauma patient was related to fever and fever with leukocytosis. However, neither fever nor leukocytosis nor both were associated with UTIs. These data suggest that there is an unnecessary emphasis on UTI as a source of fever and leukocytosis in injured patients during their first 14 STICU days. Our results suggest that the paradigm for evaluating UTI as a cause of fever needs to be reevaluated in critically ill trauma patients.

The "fever workup" and respiratory culture practice in critically ill trauma patients.

PURPOSE: Fever and leukocytosis (FAL) in critically ill patients often triggers a "workup" that includes a respiratory secretion culture (RCx). We evaluated our respiratory culture practice associated with FAL. We hypothesized that FAL would be associated with a RCx, but would not be associated with a positive culture or treating a respiratory infection in critically injured patients during their first 14 intensive care unit (ICU) days. MATERIALS AND METHODS: An 18-month retrospective analysis was performed on consecutive ICU trauma patients admitted for 2 days or more to a level I trauma center. Data collected included demographics, injuries, RCxs (bronchoalveolar lavage or tracheal aspirate), maximum daily temperature, and a daily leukocyte count during the first 14 ICU days. RESULTS: A total of 510 patients with a mean age of 49 and injury severity score of 19 were evaluated for a total of 3839 patient-days. Two hundred eleven patients had 489 RCxs obtained (2.4 RCxs/patient); 94 (19%) were obtained on consecutive days. Obtaining a RCx was associated with fever (relative risk, 4.8; 95% confidence interval, 4.1-5.8) and the combination of FAL (relative risk, 2.6; 95% confidence interval, 2.2-3.1), but not leukocytosis alone. Fever, leukocytosis, or FAL did not predict a positive RCx. One hundred twenty-eight patients were treated for a respiratory infection. Treatment of respiratory infections was contrary to the RCx results 24% of the time. The sensitivity and specificity of a positive RCx being associated with respiratory infection were 97% and 46%, respectively. CONCLUSIONS: Fever and leukocytosis were associated with the decision to obtain RCxs but were not associated with positive RCxs in our ICU practice. Respiratory secretion culture results had a low specificity and did not consistently impact treatment decisions. Factors other than fever and leukocytosis alone should influence the decision to obtain RCxs during the first 14 days in the ICU after trauma.

Therapeutic anticoagulation in the trauma patient: is it safe?

PURPOSE: Trauma patients who require therapeutic anticoagulation pose a difficult treatment problem. The purpose of this study was to determine: (1) the incidence of complications using therapeutic anticoagulation in trauma patients, and (2) if any patient factors are associated with these complications. METHODS: An 18-month retrospective review was performed on trauma patients >or= 15 years old who received therapeutic anticoagulation using unfractionated heparin (UH) and/or fractionated heparin (FH). Forty different pre-treatment and treatment patient characteristics were recorded. Complications of anticoagulation were documented and defined as any unanticipated discontinuation of the anticoagulant for bleeding or other adverse events. RESULTS: One-hundred-fourteen trauma patients were initiated on therapeutic anticoagulation. The most common indication for anticoagulation was deep venous thrombosis (46%). Twenty-four patients (21%) had at least 1 anticoagulation complication. The most common complication was a sudden drop in hemoglobin concentration requiring blood transfusion (11 patients). Five patients died (4%), 3 of whom had significant hemorrhage attributed to anticoagulation. Bivariate followed by logistic regression analysis identified chronic obstructive pulmonary disease (OR = 9.2, 95%CI = 1.5-54.7), UH use (OR = 3.8, 95%CI = 1.1-13.0), and lower initial platelet count (OR = 1.004, 95%CI = 1.000-1.008) as being associated with complications. Patients receiving UH vs. FH differed in several characteristics including laboratory values and anticoagulation indications. CONCLUSION: Trauma patients have a significant complication rate related to anticoagulation therapy, and predicting which patients will develop a complication remains unclear. Prospective studies are needed to determine which treatment regimen, if any, is appropriate to safely anticoagulate this high risk population.