Emerging multidrug resistance of methicillin-resistant Staphylococcus aureus in hand infections.

BACKGROUND: Methicillin-resistant Staphylococcus aureus has been the most commonly identified pathogen in hand infections at urban centers, but the evolving antibiotic sensitivity profiles of methicillin-resistant Staphylococcus aureus are not known. The purposes of this study are to determine if multidrug resistance in methicillin-resistant Staphylococcus aureus is emerging and to provide current recommendations for empiric antibiotic selection for hand infections in endemic regions. METHODS: An eight-year longitudinal, retrospective chart review was performed on all culture-positive hand infections encountered by an urban hospital from 2005 to 2012. The proportions of all major organisms were calculated for each year. Methicillin-resistant Staphylococcus aureus infections were additionally analyzed for antibiotic sensitivity. RESULTS: A total of 683 culture-positive hand infections were identified. Overall, methicillin-resistant Staphylococcus aureus grew on culture in 49% of cases; the annual incidence peaked at 65% in 2007. Over the study period, methicillin-resistant Staphylococcus aureus was universally resistant to penicillin, oxacillin, and ampicillin. Clindamycin resistance significantly increased, approaching 20% by 2012 (p = 0.02). Levofloxacin resistance linearly increased from 12% to 50% (p < 0.01). Resistance to trimethoprim-sulfamethoxazole, tetracycline, gentamicin, and moxifloxacin was only sporadically observed. Resistance to vancomycin, daptomycin, linezolid, and rifampin was not observed. CONCLUSIONS: Significant increases in resistance to clindamycin and levofloxacin were observed in recent years, and empiric therapy with these drugs may have limited efficacy, especially in urban centers. CLINICAL RELEVANCE: Hand infections caused by methicillin-resistant Staphylococcus aureus may be developing increasing resistance to clindamycin and levofloxacin in recent years. This longitudinal study examines the effectiveness of a variety of antibiotics to methicillin-resistant Staphylococcus aureus.

Povidone-iodine soaks for hand abscesses: a prospective randomized trial.

PURPOSE: To determine the effect of povidone-iodine soaks on outcomes of hand infections after operative drainage. METHODS: We performed a single-center, prospective, randomized trial to evaluate 100 consecutive hand infections. Forty-nine patients received povidone-iodine soaks 3 times daily, and 51 patients received only daily dressing changes. Outcome measures were the number of operations, readmissions, reoperations for wound complications, and days spent in the hospital. RESULTS: Patients treated with povidone soaks averaged 1.6 operations, and patients treated with daily dressing changes averaged 1.4 operations, a statistically insignificant difference. The mean number of operations was also not different between groups for the dorsal hand or dorsal finger abscess subcategories. No significant differences were found in length of stay, number of readmissions, or number of reoperations for wound complications. CONCLUSIONS: Povidone-iodine soaks are not helpful in the postoperative management of hand infections TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Evolving incidence of MRSA in urban hand infections.

Methicillin-resistant Staphylococcus aureus (MRSA) is the most commonly cultured bacteria in hand infections. Understanding the most common bacteria involved in hand infections allows appropriate and efficient administration of antibiotics. Delay in treatment may lead to increased morbidity, including stiffness, contracture, and amputation. The purposes of this study are to determine whether the incidence of MRSA in culture-positive hand infections continues to increase and whether MRSA is a risk factor for increased length of stay. Electronic medical records were queried to identify patients admitted to a large, academic urban medical center with the diagnosis of a hand infection between January 1, 2005, and December 31, 2009. Methicillin-resistant S aureus accounted for 220 of the positive cultures over the 5-year study period. Polymicrobial infection represented 81 positive cultures, and MRSA was only present in 10 of these cases. Patients with MRSA were found to have a mean length of hospital stay of 4.1 days compared with 4.5 days in non-MRSA infections. Understanding the most common bacteria involved in hand infections allows appropriate and efficient administration of antibiotics. Methicillin-resistant S aureus is the most commonly cultured bacteria in the hand. However, polymicrobial infections have become increasingly more common. Although incidences of polymicrobial infections increased over the study period in this series, clinical judgment should be exercised before initiating broad-spectrum antibiotic coverage.

Physical examination of upper extremity compressive neuropathies.

A thorough history and physical examination are vital to the assessment of upper extremity compressive neuropathies. This article summarizes relevant anatomy and physical examination findings associated with upper extremity compressive neuropathies.

De quervain tenosynovitis of the wrist.

De quervain disease, or stenosing tenosynovitis of the first dorsal compartment of the wrist, is a common wrist pathology. Pain results from resisted gliding of the abductor pollicis longus and the extensor pollicis brevis tendons in the fibro-osseus canal. de Quervain tenosynovitis of the wrist is more common in women than men. Diagnosis may be made on physical examination. Radiographs are helpful in ruling out offending bony pathology. Nonsurgical management, consisting of corticosteroid injections and supportive thumb spica splinting, is usually successful. In resistant cases, surgical release of the first dorsal compartment is done, taking care to protect the radial sensory nerve and identify all accessory compartments. Repair of the extensor retinaculum by step-cut lengthening or other techniques is rarely required.

Dll3 and Notch1 genetic interactions model axial segmental and craniofacial malformations of human birth defects.

Mutations in the Notch1 receptor and delta-like 3 (Dll3) ligand cause global disruptions in axial segmental patterning. Genetic interactions between members of the notch pathway have previously been shown to cause patterning defects not observed in single gene disruptions. We examined Dll3-Notch1 compound mouse mutants to screen for potential gene interactions. While mice heterozygous at either locus appeared normal, 30% of Dll3-Notch1 double heterozygous animals exhibited localized, segmental anomalies similar to human congenital vertebral defects. Unexpectedly, double heterozygous mice also displayed statistically significant reduction of mandibular height and decreased length of the [corrected] maxillary hard palate. Examination of somite-stage embryos and perinatal anatomy and histology did not reveal any organ defects, so we used microarray-based analysis of Dll3 and Notch1 mutant embryos to identify gene targets that may be involved in notch-regulated segmental or craniofacial development. Thus, Dll3-Notch1 double heterozygous mice model human congenital scoliosis and craniofacial disorders.

Primary non-Hodgkin's lymphoma of bone in children.

BACKGROUND: Primary non-Hodgkin's lymphoma of bone, often more simply referred to as primary lymphoma of bone, is a rare subset of non-Hodgkin's lymphoma in children. There are only a few small series of primary lymphoma of bone in children with long-term follow-up, and none have appeared in the orthopaedic literature. METHODS: A review of our institution's Pediatric Tumor Registry identified fifteen cases of primary lymphoma of bone among 306 cases of diagnosed non-Hodgkin's lymphoma between 1970 and 2003. Retrospective evaluation included collection of demographic, clinical, radiographic, treatment, and follow-up data. A univariate analysis was used to assess the prognostic significance of risk factors with respect to survival of patients from this series and in a summary analysis of data collected from similar series in the literature. RESULTS: The patients included ten male and five female patients with a mean age of 11.6 years. Most patients had a presenting complaint of pain and had swelling and/or tenderness on physical examination. Eight children had a solitary bone lesion, and seven had multiple bone lesions. Overall, the mean number of bones involved was 3.1 per patient. The femur and the pelvis were the most frequently involved bones. The ten surviving patients were followed for a mean of 13.6 years. Five patients died: three of disease progression, one of treatment-related complications, and one of an unrelated cause. The mean time from diagnosis to death was 2.1 years. Nine patients received chemotherapy only, whereas six patients received a combination of chemotherapy and radiation therapy. In the present study, an age of nine years or less was predictive of poor survival (p < 0.05). In the summary analysis of cases collected from the literature, advanced stage, young age, non-large-cell histology, and multiple-bone involvement were predictive of poor survival (p < 0.05). CONCLUSIONS: On the basis of the present series and a comprehensive review of similar series in the literature involving patients with primary lymphoma of bone, it appears that younger age, advanced-stage disease, multiple-bone involvement, and non-large-cell histology are associated with decreased survival as compared with older age, localized disease, single-bone involvement, and large-cell histology, respectively.

Developmental anomalies of the cervical spine in patients with fibrodysplasia ossificans progressiva are distinctly different from those in patients with Klippel-Feil syndrome: clues from the BMP signaling pathway.

STUDY DESIGN: A radiographic analysis of the cervical spine of 70 patients diagnosed with fibrodysplasia ossificans progressiva (FOP) and 33 diagnosed with Klippel-Feil (KF) syndrome was conducted. OBJECTIVES: The objectives of this study were to describe cervical spine abnormalities in patients with FOP, to compare and contrast those findings with the malformations in patients with KF syndrome, and to examine the possible etiology of these abnormalities. SUMMARY OF BACKGROUND DATA: Congenital features of diseases often provide seminal clues to underlying etiology and developmental pathways. While progressive metamorphosis of connective tissue to heterotopic bone is the most dramatic and disabling feature of FOP, less severe congenital anomalies of the skeleton are also present. Vertebral fusions observed in KF are consistent with defects in embryonic segmentation. METHODS: The cervical spine plain films of 70 FOP patients and 33 KF patients with documented congenital abnormalities were reviewed. RESULTS: Generalized neck stiffness and decreased range of motion were noted in most children with FOP. In the FOP patient group, characteristic anomalies, including large posterior elements, tall narrow vertebral bodies,and fusion of the facet joints between C2 and C7, were observed. Most notably, these characteristic anomalies of the cervical spine in patients with FOP were distinctly different from those of 33 patients with KF that were examined but were strikingly similar to those seen in mice with homozygous deletions of the gene-encoding noggin, a bone morphogenetic protein (BMP) antagonist. CONCLUSIONS: FOP patients exhibit a characteristic set of congenital spine malformations. While the noggin gene (NOG) is not mutated in patients who have FOP, these findings extend a growing body of evidence implicating overactivity of the BMP signaling pathway in the molecular pathogenesis of FOP.

Molecular analysis of congenital scoliosis: a candidate gene approach.

The etiology of congenital scoliosis is largely unknown. The severe vertebral disorder, spondylocostal dysostosis type 1, is associated with a homozygous delta-like 3 (DLL3) mutation. Scoliosis has been observed in a heterozygous DLL3 carrier, raising the possibility of its involvement in congenital scoliosis. We present the first molecular study of congenital scoliosis by analysis of the candidate gene DLL3 and demonstrate one novel missense variant. However, no novel or previously described mutations are present in our cohort, indicating that DLL3 mutations may not be a major cause of congenital scoliosis. Additionally, we have evaluated patients with congenital scoliosis not diagnosed with a known syndrome and identified a significant number of associated renal and cardiac anomalies and familial incidence of idiopathic scoliosis in this group.