Evaluating variation in pre-operative evaluation and planning for children undergoing atrial or ventricular septal defect repair.

BACKGROUND: CHD care is resource-intensive. Unwarranted variation in care may increase cost and result in poorer health outcomes. We hypothesise that process variation exists within the pre-operative evaluation and planning process for children undergoing repair of atrial septal defect or ventricular septal defect and that substantial variation occurs in a small number of care points. METHODS: From interviews with staff of an integrated congenital heart centre, an initial process map was constructed. A retrospective chart review of patients with isolated surgical atrial septal defect and ventricular septal defect repair from 7/1/2018 through 11/1/2020 informed revisions of the process map. The map was assessed for points of consistency and variability. RESULTS: Thirty-two surgical atrial septal defect/ventricular septal defect repair patients were identified. Ten (31%) were reviewed by interventional cardiology before surgical review. Of these, 6(60%) had a failed catheter-based closure and 4 (40%) were deemed inappropriate for catheter-based closure. Thirty (94%) were reviewed in case conference, all attended surgical clinic, and none were admitted prior to surgery. The process map from interviews alone identified surgery rescheduling as a point of major variability; however, chart review revealed this was not as prominent a source of variability as pre-operative interventional cardiology review. CONCLUSIONS: Significant variation in the pre-operative evaluation and planning process for surgical atrial septal defect/ventricular septal defect patients was identified. If such process variation is widespread through CHD care, it may contribute to variations in outcome and cost previously documented within CHD surgery. Future research will focus on determining whether the variation is warranted or unwarranted, associated health outcomes and cost variation attributed to these variations in care processes.

Federally mandating motorcycle helmets in the United States.

BACKGROUND: Motorcycle helmets reduce both motorcycle-related fatalities and head injuries. Motorcycle crashes are a major public health concern which place economic stress on the U.S. healthcare system. DISCUSSION: Although statewide universal motorcycle helmet laws effectively increase helmet use, most state helmet laws do not require every motorcycle rider to wear a helmet. Herein, we propose and outline the solution of implementing federal motorcycle helmet law, while addressing potential counterarguments. CONCLUSIONS: The decision to ride a motorcycle without a helmet has consequences that affect more than just the motorcyclist. In an effort to prevent unnecessary healthcare costs, injuries, and deaths, public health efforts to increase helmet use through education and legislation should be strongly considered. Helmet use on motorcycles fits squarely within the purview of the federal government public health and economic considerations.

Intra-articular Placement of an Intraosseous Catheter.

Gaining vascular access is essential in the resuscitation of critically ill patients. Intraosseous (IO) placement is a fundamentally important alternative to intravenous (IV) access in conditions where IV access delays resuscitation or is not possible. This case report presents a previously unreported example of prehospital misplacement of an IO catheter into the intra-articular space of the knee joint. This report serves to inform civilian and military first responders, as well as emergency medicine physicians, of intra-articular IO line placement as a potential complication of IO vascular access. Infusion of large amounts of fluid into the joint space could damage the joint and be catastrophic to a patient who needs immediate IV fluids or medications. In addition, intra-articular IO placement could result in septic arthritis of the knee.

Complications of short versus long cephalomedullary nail for intertrochanteric femur fractures, minimum 1 year follow-up.

INTRODUCTION: Hip fractures are becoming increasingly common resulting in significant morbidity, mortality and raising healthcare costs. Both short and long cephalomedullary devices are currently employed to treat intertrochanteric hip fractures. However, which device is optimal continues to be debated as each implant has unique characteristics and theoretical advantages. This study looked to identify rates of complications associated with both long and short cephalomedullary nails for the treatment of intertrochanteric hip fractures. METHODS: We retrospectively reviewed charts from 2006 to 2011, and we identified 256 patients were identified with AO class 31.1-32.3 fractures. Sixty were treated with short nails and 196 with long nails. Radiographs and charts were then analysed for failures and hardware complications. RESULTS: Catastrophic failure and hardware complication rates were not statistically different between short or long cephalomedullary nails. The overall catastrophic failure rate was 3.1 %; there was a 5 % failure rate in the short-nail group compared with a 2.6 % failure rate in the long-nail group (p = 0.191). There was a 3.33 % secondary femur fracture rate in the short-nail group, compared with none in the long-nail cohort (p = 0.054). The rate of proximal fixation failure was 1.67 % for the short-nail group and 2.0 % in the long-nail group (p = 0.406). DISCUSSION: Our data suggests equivocal outcomes as measured by similar catastrophic failure rate between both short and long cephalomedullary nails for intertrochanteric femur fractures. However, there was an increased risk of secondary femur fracture with short cephalomedullary nails when compared to long nails that approached statistical significance.

Fungal osteomyelitis and septic arthritis.

Management of fungal osteomyelitis and fungal septic arthritis is challenging, especially in the setting of immunodeficiency and conditions that require immunosuppression. Because fungal osteomyelitis and fungal septic arthritis are rare conditions, study of their pathophysiology and treatment has been limited. In the literature, evidence-based treatment is lacking and, historically, outcomes have been poor. The most common offending organisms are Candida and Aspergillus, which are widely distributed in humans and soil. However, some fungal pathogens, such as Histoplasma, Blastomyces, Coccidioides, Cryptococcus, and Sporothrix, have more focal areas of endemicity. Fungal bone and joint infections result from direct inoculation, contiguous infection spread, or hematogenous seeding of organisms. These infections may be difficult to diagnose and eradicate, especially in the setting of total joint arthroplasty. Although there is no clear consensus on treatment, guidelines are available for management of many of these pathogens.

Is tip apex distance as important as we think? A biomechanical study examining optimal lag screw placement.

BACKGROUND: Intertrochanteric hip fractures pose a significant challenge for the orthopaedic community as optimal surgical treatment continues to be debated. Currently, varus collapse with lag screw cutout is the most common mode of failure. Multiple factors contribute to cutout. From a surgical technique perspective, a tip apex distance less than 25 mm has been suggested to decrease the risk of cutout. We hypothesized that a low-center lag screw position in the femoral head, with a tip apex distance greater than 25 mm will provide equal, if not superior, biomechanical stability compared with a center-center position with a tip apex distance less than 25 mm in an unstable intertrochanteric hip fracture stabilized with a long cephalomedullary nail. QUESTIONS/PURPOSES: We attempted to examine the biomechanical characteristics of intertrochanteric fractures instrumented with long cephalomedullary nails with two separate lag screw positions, center-center and low-center. Our first research purpose was to examine if there was a difference between the center-center and low-center groups in cycles to failure and failure load. Second, we analyzed if there was a difference in fracture translation between the study groups during loading. METHODS: Nine matched pairs of femurs were assigned to one of two treatment groups: low-center lag screw position and center-center lag screw position. Cephalomedullary nails were placed and tip apex distance was measured. A standard unstable four-part intertrochanteric fracture was created in all samples. The femurs were loaded dynamically until failure. Cycles to failure and load and displacement data were recorded, and three-dimensional (3-D) motion was recorded using an Optotrak(®) motion tracking system. RESULTS: There were no significant differences between the low-center and center-center treatment groups regarding the mean number of cycles to failure and mean failure load. The 3-D kinematic data showed significantly increased motion in the center-center group compared with the low-center group. At the time of failure, the magnitude of fracture translation was statistically significantly greater in the center-center group (20 ± 2.8 mm) compared with the low-center group (15 ± 3.4 mm; p = 0.004). Additionally, there was statistically significantly increased fracture gap distraction (center-center group, 13 ± 2.8 versus low-center group, 7 ± 4; p < 0.001) and shear fracture gap translation (center-center group, 12 ± 2.3 mm; low-center group, 6 ± 2.7 mm; p < 0.001). CONCLUSIONS: Positioning of the lag screw inferior in the head and neck was found to be at least as biomechanically stable as the center-center group although the tip apex distance was greater than 25 mm. CLINICAL RELEVANCE: Our findings challenge previously accepted principles of optimal lag screw placement.

Characterization and bioactive properties of zirconia based polymeric hybrid for orthopedic applications.

Zirconia is a transition metal oxide with current applications to orthopedic implants. It has been shown to up-regulate specific genes involved in bio-integration and injury repair. This study examines the effects of zirconia and polydimethylsiloxane (PDMS) hybrids on the proliferation and viability of human primary osteoblast and fibroblast cells. In this study, zirconia-PDMS hybrid coatings were synthesized using a modified sol gel process. The hybrid material was characterized using optical microscopy, scanning electron microscopy, X-ray photoelectron spectroscopy, and contact angle analysis. This study demonstrates that Zr-PMDS surface materials display hydrophobic surface properties coupled with a preferential deposition of polymer near the surface. Primary osteoblast and fibroblast proliferation and viability on hybrid coated surfaces were evaluated via a rapid screening methodology using WST-1 and calcein AM assays. The cells were seed at 5,000 cells per well in 96-well plates coated with various composition of Zr-PDMS hybrids. The results showed increasing cell proliferation with increasing zirconia concentration, which peaked at 90 % v/v zirconia. Proliferation of osteoblasts and fibroblasts displayed similar trends on the hybrid material, although osteoblasts displayed a bi-phasic dose response by the calcein AM assay. The results of this current study show that Zr-PDMS may be used to influence tissue-implant integration, supporting the use of the hybrid as a promising coating for orthopedic trauma implants.

Initial management of ankle fractures in the overweight and obese: the providence pinch.

BACKGROUND: Obese and overweight people have higher rates of ankle injury, particularly operative ankle fractures. The initial management of unstable ankle fractures includes closed reduction and splinting to limit soft tissue injury and articular cartilage damage until definitive operative fixation can be performed. Adequate reduction can be more difficult in the obese patient due to the weight and additional padding provided by the larger soft tissue envelope. DISCUSSION: A novel technique, described herein by the authors, may be useful in obtaining a suitable reduction of the ankle in the initial management of unstable ankle fractures in the overweight and obese. CONCLUSIONS: Obese patients have unique musculoskeletal injury profiles and special considerations in their management. The authors have found this technique useful in the management of their ankle fractures.

J-splint use for temporizing management of pediatric femur fractures: a review of 18 cases.

OBJECTIVES: Pediatric femoral fractures are common injuries encountered in the field and in emergency departments. Currently described temporizing management strategies include skeletal traction, skin traction, traction splinting, and posterior splinting, all of which are suboptimal in some instances. J-splinting femur fractures may be advantageous in temporizing management of pediatric femur fractures. The objective of this study was to evaluate the safety and effectiveness of J-splint use for temporizing management of pediatric femur fractures. METHODS: This study used a retrospective review of 18 pediatric patients with femur fractures treated with J-splinting in the emergency department. Patient age, weight, and presplinting and postsplinting pain scale ratings were recorded, as well as presplint and postsplint anteroposterior and lateral radiographic fracture angulation. Pain before and after J-splinting was compared using a paired t test. RESULTS: The mean age of this cohort was 5.4 years (range, 6 months-13 y), with a mean weight of 21.1 kg (range, 7.7-57 kg). In this cohort, there was a significant reduction in pain after reduction and splinting from a mean of 6 to a mean of 1 (P < 0.001). No significant difference in fracture alignment was noted after J-splinting. No complications were noted. CONCLUSIONS: The J-splint is a reliable, simple, and rapidly applied splint that prevents many of the complications and downfalls of other described temporizing measures and helps to provide excellent pain management in the acute setting.

Costs of non-helmeted motorcycle riding in Connecticut.

Motorcycle-related head injuries and fatalities are a serious public health concern that can be reduced with helmet use. Caring for crash victims places additional economic stress on the healthcare system. The current Connecticut motorcycle helmet law does not require all motorcyclists to wear helmets. Universal motorcycle helmet laws increase helmet use. Efforts to increase helmet use through education and legislation should be considered for review, given the number of deaths and injuries that could be prevented.

Silver carboxylate-TiO2/polydimethyl siloxane is a safe and effective antimicrobial with significant wound care potential.

Introduction: With the rise in antibiotic resistance, new methodologies are needed to combat musculoskeletal infections. Silver is an antimicrobial that can be synthesized in different forms, but its pharmacokinetics are difficult to control. This study details the antibacterial efficacy and cellular cytotoxicity of a formulation consisting of silver carboxylate (AgCar) released through a titanium dioxide/polydimethylsiloxane matrix with a predictable release profile on Pseudomonas aeruginosa, Acinetobacterium baumannii, and human-derived primary osteoblasts. Methods: Through an Institutional Animal Care and Use Committee and IRB-approved protocol, AgCar was applied to live Yucatan porcine skin and histologically analyzed for skin penetration. Graphite Furnace Atomic Absorption Spectroscopy (GFAAS) was used to measure elution of AgCar. Dose-response curves were generated through optical density to assess potency. Finally, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay was used to quantify the cellular cytotoxicity of the novel formulation. The results were subject to statistical analysis using analysis of variance and post hoc Tukey tests. Results: The silver carboxylate coating demonstrated deep penetration into the epithelium at the level of the deep pilosebaceous glands in animal models. GFAAS testing demonstrated the extended elution profile of silver carboxylate over 96 hours, while 100% silver with no titanium dioxide-polydimethylsiloxane matrix fully eluted within 48 hours. 10x silver carboxylate demonstrated superior antimicrobial activity to antibiotics and other silver formulations and showed minimal cytotoxicity compared with other silver formulations. Discussion/Clinical Relevance: Current antimicrobial therapies in wound care and surgical antisepsis, such as chlorhexidine gluconate, have pitfalls including poor skin penetration and short duration of efficacy. The broad antimicrobial activity, extended elution, and deep skin penetration of this AgCar formulation show great promise for surgical site infection and wound care treatment. Novel technology to fight the growing threat of microbial resistance should be at the forefront of orthopaedic surgical site infection prevention and treatment.

Comparison of periprosthetic joint infection rates in the direct anterior approach and non-anterior approaches to primary total hip arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Periprosthetic joint infection is a serious complication and devastating mode of failure of total hip arthroplasty. Various surgical approaches exist for total hip arthroplasty, including the increasingly popularised direct anterior approach. There is no clear consensus on which approach is least associated with periprosthetic joint infection. The objective of this meta-analysis was to compare the rate of periprosthetic joint infection between surgical approaches to primary total hip arthroplasty for osteoarthritis. METHODS: A search of 3 electronic databases (PubMed/MEDLINE, Embase, and Cochrane Library) was conducted for relevant studies up to June 2020 with a defined list of inclusion and exclusion criteria. Randomised controlled trials and longitudinal studies reporting periprosthetic joint infection rates after primary total hip arthroplasty for osteoarthritis were included based on surgical approach. Data extraction was completed, and a meta-analysis was then performed using OpenMeta[Analyst] software. RESULTS: A total of 24,407 hips were included for meta-analysis with an overall PJI incidence of 0.57%. The incidence rate for periprosthetic joint infection was 0.77% in the direct anterior approach group and 0.44% in the non-anterior approach group. The use of an anterior approach for a total hip arthroplasty was associated with an increased risk for periprosthetic joint infection (odds ratio = 1.404; 95% confidence interval, 0.711-2.771; p = 0.03). CONCLUSIONS: The direct anterior approach to total hip arthroplasty may be associated with a significantly increased risk for periprosthetic joint infection compared to non-anterior approaches, even though the overall rate was still small. This should be considered by orthopedic surgeons when choosing the surgical approach.

Locked Lateral Plating Versus Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial.

OBJECTIVES: The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter randomized controlled trial. SETTING: Twenty academic trauma centers. PATIENTS/PARTICIPANTS: One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. RESULTS: Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Evolution of acute orthopaedic care.

Current combat battlefield injuries are among the most complex and challenging orthopaedic cases. These injuries carry high risks for exsanguination and global contamination of extensive soft-tissue and complicated bony injuries. Military orthopaedic surgeons must employ the latest advances in acute combat casualty care to achieve favorable outcomes. Adaptive changes over the past 10 years of war have given today's surgeons the armamentarium to optimize patient care. Innovative methods of damage control resuscitation and surgery have led to increased survival. However, the fundamentals of surgical hemostasis and decontamination remain critical to successful management. The acute treatment of combat casualties involves a continuum of care from the point of injury through transport out of theater. Future research and education are paramount to better prepare military orthopaedic surgeons to further increase survivability and enhance the outcomes of service members with complex wounds.

Updates on disaster preparedness and progress in disaster relief.

Immediately after the January 2010 earthquake in Haiti, many private citizens, governmental and nongovernmental organizations, and medical associations struggled to mount an effective humanitarian aid response. The experiences of these groups have led to changes at their institutions regarding disaster preparedness and response to future events. One of the main challenges in a humanitarian medical response to a disaster is determining when to end response efforts and return responsibility for delivery of medical care back to the host nation. For such a transition to occur, the host nation must have the capacity to deliver medical care. In Haiti, minimal capacity to deliver such care existed before the earthquake, making subsequent transition difficult. If successful, several initiatives proposed to improve disaster response and increase surgical capacity in Haiti could be deployed to other low- and middle-income countries.

Reprioritization of research for combat casualty care.

Since the beginning of the conflicts in Iraq and Afghanistan more than a decade ago, much has been learned with regard to combat casualty care. Although progress has been significant, knowledge gaps still exist. The seventh Extremity War Injuries symposium, held in January 2012, reviewed the current state of knowledge and defined knowledge gaps in acute care, reconstructive care, and rehabilitative care in order to provide policymakers information on the areas in which research funding would be the most beneficial.

Critically assessing the Haiti earthquake response and the barriers to quality orthopaedic care.

BACKGROUND: Although numerous authors have described surgical experiences following major disasters, little is known regarding the needs of and barriers to care faced by surgeons during such disasters. QUESTIONS/PURPOSES: We therefore (1) identified and compared recurrent interview themes essential to the disaster response following the 2010 Haiti earthquake; (2) determined the difference in reported disaster equipment management task difficulty between disaster-trained and untrained volunteers; and (3) approximated the quantity of various procedures performed. METHODS: We conducted 14 interviews with selected orthopaedic surgeon volunteers. We also invited the 504 members of the American Academy of Orthopaedic Surgeons (AAOS), who registered as Haiti earthquake volunteers, to complete an online survey; 174 (35%) completed the survey and 131 (26%) were present in Haiti during the 30 days after the earthquake. Recurrent interview themes were identified, quantified, and compared using Poisson regression analysis. The difference in disaster equipment management difficulty scores was determined with a Wilcoxon rank-sum test. RESULTS: Of 10 recurrent interview themes, group organization (31 occurrences) was mentioned much more often than all but two of the remaining nine themes. Compared with disaster-untrained respondents, equipment management tended to be less challenging for disaster-trained respondents. Transporting to the treatment site and security during storage at the site were less challenging (19.5% and 16.5% decreases, respectively). Revision surgeries, guillotine amputations, fasciotomies, and internal fixations, suggestive of inappropriate disaster care, were frequently reported. CONCLUSIONS: Organizational and training barriers obstructed orthopaedic care delivery immediately after the Haiti earthquake. Disaster training and outcomes require further study to improve care in future catastrophes.

Pre-Operative Medications as a Predictor for Post-Operative Complications Following Geriatric Hip Fracture Surgery.

Background: Fragility hip fractures are a common orthopedic injury seen in Emergency Departments, with variable outcomes that can range from average to devastating. Currently, few reliable metrics to predict which patients will suffer post-operative complications exist. The aim of this study was to determine if the number and type of pre-operative medications can help predict post-operative complications. Methods: A prospectively collected database of hip fracture patients was retrospectively reviewed. Patients with isolated greater trochanteric fractures, periprosthetic fractures, or re-fractures were excluded. Pre-operative baseline characteristics as well as number and type of post-operative complications were reviewed. Any complication within 6 months of surgery and complications that could be directly attributable to the surgical procedure within 2 years of surgery were examined. Major complications (return to the operating room, deep infection, pulmonary, cardiac, and hematologic) and minor medical complications were assessed. A multivariate regression model was performed to identify independent risk factors. Results: Three-hundred ninety-one patients were included. A majority were aged 80-90 and female, and lived at home prior to presentation. Overall, 33.7% of patients suffered a complication within a 2-year follow-up period. Mortality rates were 5.4%, 10.0%, and 14.9% over 30 days, 1 year, and 2 years, respectively. After assessing this relationship while controlling for age, sex, injury type, pre-operative residence, ambulatory status, ASA score, and CCI score, the relationship remained significant for both an increased number of complications (P = .048) and a higher likelihood of having a complication (P = .008). Cardiovascular (P = .003), pulmonary (P = .001), gout (P = .002), or diabetes (P = .042) medications were associated with a higher likelihood for experiencing a complication. Conclusions: Our study suggests that there is a strong and linear relationship between the number and type of pre-operative medications taken and risk of post-operative complications. This exists for up to 8 medications, at which point further increase does not contribute to an increased risk of complication. This relationship exists even after controlling for confounding variables and can be used by surgeons to better counsel patients and families regarding their specific risk for suffering perioperative complications.

Silver Carboxylate as an Antibiotic-Independent Antimicrobial: A Review of Current Formulations, in vitro Efficacy, and Clinical Relevance.

The increasing prevalence of multi-drug resistant pathogens has led to a renewed focus on the use of silver as an antibiotic-independent antimicrobial. Unfortunately, the use of many silver formulations may be limited by an uncontrolled release of silver with the potential for significant cytotoxic effects. Silver carboxylate (AgCar) has emerged as an alternative formulation of silver with the potential to mitigate these concerns while still displaying significant bactericidal activity. This article reviews the efficacy of silver carboxylate formulations as a promising novel antibiotic-independent antimicrobial. This study was conducted through a search of five electronic databases (PubMed, Embase, MEDLINE, Cochrane Library, and Web of Science) for relevant studies up to September 2022. Searches were conducted for types of "silver carboxylate" formulations. Sources were compiled based on title and abstract and screened for inclusion based on relevance and study design. A review of the antimicrobial activity and cytotoxicity of silver carboxylate was compiled based on this search. Current body of data suggests that silver carboxylate shows promise as an emerging antibiotic-independent antimicrobial, with significant bactericidal effects while minimizing cytotoxicity. Silver carboxylate addresses several of the limitations of more primitive formulations, including controlled dosing and fewer negative effects on eukaryotic cell lines. These factors are concentration-dependent and largely rely on the vehicle system used to deliver it. Although several silver carboxylate-based formulations like titanium dioxide/polydimethylsiloxane (TiO2/PDMS) matrix-eluting AgCar have shown promising results in vitro, and could potentially be utilized independently or in conjunction with current and future antimicrobial therapies, there is a need for further in vivo studies to validate their overall safety and efficacy profile.

Silver as an Antibiotic-Independent Antimicrobial: Review of Current Formulations and Clinical Relevance.

Background: The increase of multi-drug-resistant organisms has revived the use of silver as an alternative antibiotic-independent antimicrobial. Although silver's multimodal mechanism of action provides low risk for bacterial resistance, high local and uncontrolled concentrations have shown toxicity. This has resulted in efforts to develop novel silver formulations that are safer and more predictable in their application. Optimization of silver as an antimicrobial is crucial given the growing resistance profile against antibiotics. This article reviews formulations of silver used as antimicrobials, focusing on the mechanisms of action, potential for toxicity, and clinical applications. Methods: A search of four electronic databases (PubMed, Embase, MEDLINE, and Cochrane Library) was conducted for relevant studies up to January 2022. Searches were conducted for the following types of silver: ionic, nanoparticles, colloidal, silver nitrate, silver sulfadiazine, silver oxide, silver carboxylate, and AQUACEL® (ConvaTec, Berkshire, UK). Sources were compiled based on title and abstract and screened for inclusion based on relevance and study design. Results: A review of the antimicrobial activity and uses of ionic silver, silver nanoparticles, colloidal silver, silver nitrate, silver sulfadiazine, silver oxide, Aquacel, and silver carboxylate was conducted. The mechanisms of action, clinical uses, and potential for toxicity were studied, and general trends between earlier and more advanced formulations noted. Conclusions: Early forms of silver have more limited utility because of their uncontrolled release of silver ions and potential for systemic toxicity. Multiple new formulations show promise; however, there is a need for more prospective in vivo studies to validate the clinical potential of these formulations.