Empirical Treatment of Uncomplicated Septic Olecranon Bursitis Without Aspiration.

PURPOSE: Although aspiration of septic olecranon bursitis is recommended in the literature, no high-level evidence exists to support this practice. The purpose of this study was to retrospectively compare the results of traditional bursal aspiration (TBA) with empirical management without aspiration (EM). We hypothesized that EM of uncomplicated septic olecranon bursitis results in resolution, with fewer chronic draining sinuses and less progression to bursectomy. METHODS: We performed a retrospective review of all cases of septic olecranon bursitis seen by the orthopedic surgery department at a single tertiary referral center over a 5-year period. Cases were manually reviewed to determine patient demographics, management, and treatment results. The primary outcome was success of nonsurgical management versus requirement for surgical bursectomy. RESULTS: Thirty cases of uncomplicated septic olecranon bursitis were identified within the study period. Eleven patients were initially managed with TBA (performed by an emergency or primary care physician prior to orthopedic consultation), resulting in 11 positive cultures. Only 1 of these prompted a change of antibiotic management, and despite this information, 5 patients required a second course of antibiotics for incomplete resolution. Eight of the TBA cases went on to bursectomy. Nineteen patients underwent EM. Sixteen of these cases resolved with a single course of empirical antibiotics, and 3 (16%) cases required a second antibiotic course. One patient had a recurrence of symptoms 2 months after resolution with a single course of empirical antibiotics. This resolved with a second course of oral antibiotics. No patients who underwent EM went on to require bursectomy. The number needed to harm when aspiration was performed was 1.46. CONCLUSIONS: We found EM of uncomplicated septic olecranon bursitis to be effective. Although 1 recurrence did occur in the EM group, no other complications occurred. Empirical management without aspiration may be considered in cases of uncomplicated septic olecranon bursitis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Sporotrichosis in a U.S. Army Basic Trainee.

Lymphocutaneous sporotrichosis is a mycotic disease caused by traumatic inoculation of the dimorphic fungus Sporothrix schenckii, found ubiquitously in decaying vegetation. The potential for outbreaks, difficulty with timely diagnosis, as well as the prolonged treatment course and recovery from surgical intervention can have a substantial impact on the medical readiness of service members. Treatment with the antifungal therapy of choice, itraconazole, requires close patient monitoring for the duration of treatment for clinical response, drug tolerance, as well as therapeutic drug levels. We present a case of a U.S. Army enlistee with sporotrichosis contracted during basic training, highlighting the impact of delayed diagnosis and prolonged treatment course and recovery on medical readiness.

Thigh compartment syndrome, presentation and complications.

To describe the patient population, etiology, and complications associated with thigh compartment syndrome (TCS). TCS is a rare (0.3% of trauma patients) condition of elevated pressure within a constrained space that may cause necrosis of all tissues within the compartment resulting in severe local (infection, amputation) and systemic complications (renal insufficiency, even death). Retrospective cohort This study examines the course of treatment of nine consecutive patients with thigh compartment syndrome sustained during an eight-year period at our Level 1 trauma centre, admitting more than 2,000 trauma patients yearly. Patients developing TCS were young (average 34.8 years) and likely to have a vascular injury on presentation (55.5%). A tense and edematous thigh was the most consistent clinical exam finding prompting the compartment release (77.8%). Average time from admission to the operating room was 19.8 +/- 6 hours and 3/9 (33%) were noted to have ischemic muscle changes upon compartment releases. Complications ranging from infection to amputation developed in 4/9 (44.4%) patients. TCS is associated with high energy trauma and it is difficult to diagnose in non-cooperative -- obtunded and polytrauma patients. Vascular injuries are a common underlying cause and require prompt recognition and team work including surgical intensive care, interventional radiology, vascular and orthopaedic surgery in order to avoid severe medical and legal consequences.

Debridement and Irrigation: Evolution and Current Recommendations.

Debridement is an integral step in the orthopaedic management of traumatic wounds, from open soft tissue injuries and routine open fracture care to the management of extensive high-energy blast injuries. While the necessity of debridement has been well established, the level of energy and degree of contamination of blast wounds encountered in recent armed conflict has offered a challenge and a new opportunity for military surgeons to revisit the most recent literature to guide our practice with the best evidence currently available. While the core tenants of removing the nonviable tissue and preserving the viable to maintain the best functional outcome have not changed, new wound care therapies and advances in prosthetics and salvage techniques and the ability to rapidly evacuate casualties have changed the approach to care provided on the front lines. This paper seeks to review the core principles of debridement and guide treatment using evidence-based methods that can be applied to contaminated open injuries on the battlefront and disaster and intentional violence injuries abroad and at home.

Use of intraoperative temporary invasive distraction to reduce a chronic talar neck fracture-dislocation.

Temporary invasive distraction can facilitate fracture reduction in the setting of delayed surgical intervention resulting in shortening and contracted soft tissues.

Acute morbidity and complications of thigh compartment syndrome: A report of 26 cases.

BACKGROUND: To describe the patient population, etiology, and complications associated with thigh compartment syndrome (TCS). TCS is a rare condition, affecting less than 0.3% of trauma patients, caused by elevated pressure within a constrained fascial space which can result in tissue necrosis, fibrosis, and physical impairment in addition to other complications. Compartment releases performed after irreversible tissue ischemia has developed can lead to severe infection, amputation, and systemic complications including renal insufficiency and death. METHODS: This study examines the course of treatment of 23 consecutive patients with 26 thigh compartment syndromes sustained during an eight-year period at two Level 1 trauma centers, each admitting more than 2,000 trauma patients yearly. RESULTS: Patients developing TCS were young (average 35.4 years) and likely to have a vascular injury on presentation (57.7%). A tense and edematous thigh was the most consistent clinical exam finding leading to compartment release (69.5%). Average time from admission to the operating room was 18 +/- 4.3 hours and 8/23 (34.8%) were noted to have ischemic muscle changes at the time of release. Half of those patients (4/8) developed local complications requiring limb amputations. CONCLUSION: TCS is often associated with high energy trauma and is difficult to diagnose in uncooperative, obtunded and multiply injured patients. Vascular injuries are a common underlying cause and require prompt recognition and a multidisciplinary approach including the trauma and orthopaedic surgeons, intensive care team, vascular surgery and interventional radiology. Prompt recognition and treatment of TCS are paramount to avoid the catastrophic acute and long term morbidities.

Transforaminal lumbar interbody fusion: clinical and radiographic results and complications in 100 consecutive patients.

OBJECTIVE: We retrospectively reviewed the results of 100 consecutive transforaminal lumbar interbody fusions (TLIFs) performed at one institution. The preoperative diagnoses included degenerative disk disease (55), spondylolisthesis (41; 22 isthmic, 19 degenerative), and degenerative adult scoliosis (4). There were 64 single-level, 33 two-level, 2 three-level, and 1 four-level TLIF (140 levels). METHODS: The fusion mass was assessed by an independent observer using biplanar radiography, whereas clinical outcomes were assessed by means of several established outcome measures. RESULTS: By level, the posterolateral fusion was judged to be probably or definitely solid in 78% of levels, whereas the interbody fusion was radiographically solid in 88% of levels, for an overall 93% fusion success/patient (94%/level). All patients had >24 months of postoperative clinical follow-up, and 82 patients (82%) were available for outcome measure assessment at an average follow-up of 34 months (range 24-61 months) postoperatively. Eighty-one percent of these patients reported a >50% decrease in their symptoms, and 76% of patients were satisfied with their results to the degree that they would have the procedure again. However, a large percentage of patients experienced incomplete relief of their symptoms. Twenty patients sustained minor complications, and there were no major complications. CONCLUSIONS: We conclude that TLIF is a safe and effective method of achieving lumbar fusion with a 93% radiographic fusion success and a nearly 80% rate of overall patient satisfaction but frequently results in incomplete relief of symptoms. Complications resulting from the procedure are uncommon and generally minor and transient.