Increased oxacillin resistance in thigh pyomyositis in diabetic patients

Thigh abscesses due to pyomyositis are uncommon. To guide empiric antibiotic therapy in diabetics we determined the rate of such infections due to oxacillin-resistant Staphylococcus aureus and Gram-negative organism infections, and whether the occurrence of oxacillin-resistant pathogens increased during the study period. We retrospectively reviewed 39 adult patients with diabetes mellitus treated for a deep thigh abscess. There were 29 men and 10 women; their mean age was 45 years. Comorbidities were present in 15 patients. S. aureus was the most common pathogen, present in 82% (32/39) of our patients. Gram-negative organisms were cultured in 14% (6/39) of patients and anaerobes in 10% (4/39). The infection was polymicrobial in 12 of 39 patients (31%). Oxacillin-resistant S. aureus comprised 25% (8/32) of infections due to S. aureus. Oxacillin-resistance increased during the last 3 years of this study from one of 18 S. aureus isolates from 1994 to 2004 to seven of 14 isolates from 2004 to 2006. In diabetic patients with thigh pyomyositis, empiric antibiotic therapy should provide broad spectrum coverage for oxacillin-resistant S. aureus, Gram-negative, as well as anaerobic organisms.

LEVEL OF EVIDENCE

Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Culture results and amputation rates in high-pressure paint gun injuries of the hand

High-pressure paint gun injuries have been well described in the literature, and the use of antibiotics is recommended as part of their management. However, there is no scientific evidence to support the use of antibiotics. In addition, the type of paint injected (water- versus oil-based) has never been investigated to determine the extent of morbidity resulting from these injuries. This study examines the organisms cultured in wounds resulting from these injuries and whether the type of paint injected had an influence on amputation rates. Charts of 35 patients with high-pressure paint gun injuries to their hands were reviewed. The amputation rate was 50% with oil-based paints and 0% with water-based paints. Forty-seven percent of wound cultures were positive, with gram-negative bacteria found in 58% of isolates. Our findings support the use of antibiotics, which should cover both gram-positive and gram-negative organisms.

Sepsis and osteomyelitis about the ankle joint

Sepsis and osteomyelitis about the ankle joint present a challenging clinical problem. Osteomyelitis usually follows open fracture of the distal tibia, often with a pilon fracture component. This article outlines the prevention of osteomyelitis in these difficult fractures. Treatment of subsequent osteomyelitis and sepsis, including the authors' experiences, is discussed. Septic ankle arthritis can occur hematogenously. In some patients, the optimal treatment for concomitant osteomyelitis and sepsis is a below knee amputation.

Mucormycosis of the tibia: a case report and review of the literature

Mucormycosis is an uncommon but highly aggressive fungal infection most commonly occurring in hosts who are immunologically predisposed to infection. Only seven previously documented cases of tibial osteomyelitis attributable to Mucorales infection exist in the literature. An unusual case is reported of mucormycosis osteomyelitis developing in a patient who was immunocompromised after routine tibial Steinmann pin placement for the application of traction. Surgical debridement and amphotericin B were not sufficient to control the infection, and the patient subsequently underwent above-knee amputation. To the authors' knowledge this is the first description of mucormycosis causing osteomyelitis as a result of Steinmann pin tract infection.

Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds

OBJECTIVE

The purpose of this study was to compare the efficacy of a single agent, ciprofloxacin, with that of combination antibiotic therapy consisting of cefamandole and gentamicin in all types of open fracture wounds.

STUDY DESIGN

A prospective double-blind randomized clinical trial.

SETTING

A Level 1 trauma center.

PATIENTS

One hundred ninety-five consecutive patients with 203 open fractures were enrolled over a twenty-month period. Twenty-nine fractures from low-velocity gunshot wounds were excluded, and three other patients were excluded because of protocol violations. Our final number of patients were 163, with 171 open fractures.

MAIN OUTCOME MEASUREMENT

The infection rates for Type I and Type II open fractures for both antibiotic groups were calculated. The infection rate of Type III open fractures for both antibiotic groups was also calculated. Chi-square analysis with Yates correction was used to assess statistical significance of two treatment groups.

RESULTS

The infection rate for Types I and II open fractures in the ciprofloxacin group was 5.8 percent and 6 percent for the cefamandole/gentamicin group (p = 1.000). The infection rate for Type III open fractures for the ciprofloxacin group was 31 percent (8 of 26) versus 7.7 percent (2 of 26) for the cefamandole/gentamicin group (p = 0.079). There were no statistically significant differences in infection rate between the group treated with ciprofloxacin and that treated with cefamandole/gentamicin for Types I and II open fracture wounds. However, there appeared to be a high failure rate for the ciprofloxacin Type III open fracture group, with patients being 5.33 times more likely to become infected than those in the combination therapy group. Although this difference was not statistically significant, possibly because of the small sample size, there was a definite trend toward statistical significance.

CONCLUSION

Single-agent antibiotic therapy with ciprofloxacin is effective in treatment of Type I and Type II open fracture wounds. However, on the basis of our results, we cannot recommend ciprofloxacin alone for Type III wounds. Possibly one can use fluoroquinolones in combination therapy, specifically as an alternate to an aminoglycoside.

Inhibitory effects of the quinolone antibiotics trovafloxacin, ciprofloxacin, and levofloxacin on osteoblastic cells in vitro

We studied the inhibitory effects of the fluoroquinolones levofloxacin, ciprofloxacin, and trovafloxacin on growth and extracellular matrix mineralization in MC3T3-E1 osteoblast-like cell cultures. Levofloxacin had the least inhibitory effect on cell growth, with a 50% inhibitory concentration of approximately 80 microg/ml at 48 and 72 hours. Ciprofloxacin had an intermediate degree of inhibition, with a 50% inhibitory concentration of 40 microg/ml at 48 and 72 hours. Trovafloxacin exerted a profound inhibitory effect on cell growth, with a 50% inhibitory concentration of 0.5 microg/ml, lower than clinically achievable serum levels. The decreased cell counts with up to 2.5 microg/ml of trovafloxacin and with up to 40 microg/ml of ciprofloxacin were not associated with decreased rates of 5-bromo-2'-deoxyuridine incorporation per cell. Alatrovafloxacin, the L-alanyl-l-alanine prodrug of trovafloxacin, exerted effects on proliferation and 5-bromo-2'-deoxyuridine incorporation similar to those of the parent compound. The quinolones evaluated also inhibited extracellular matrix mineralization by MC3T3-E1 cells. Treatment of confluent cultures with trovafloxacin, ciprofloxacin, or levofloxacin resulted in strong inhibition of calcium deposition, as determined on day 14 by alizarin red staining and biochemical analysis. The effect was apparent with 2.5-5 microg/ml of each of the three antibiotics tested and progressively increased to more than a 90% decline in the calcium/protein ratio with 20-40 microg/ml antibiotic concentration. Further in vivo studies are advocated to evaluate the relevance of the in vitro cytotoxicity reported here to bone healing in orthopaedic patients.

Management of chronic deep infection following rotator cuff repair

BACKGROUND

Deep infection of the shoulder following rotator cuff repair is uncommon. There are few reports in the literature regarding the management of such infections.

METHODS

We retrospectively reviewed the charts of thirteen patients and recorded the demographic data, clinical and laboratory findings, risk factors, bacteriological findings, and results of surgical management.

RESULTS

The average age of the patients was 63.7 years. The interval between the rotator cuff repair and the referral because of infection averaged 9.7 months. An average of 2.4 procedures were performed prior to referral because of infection, and an average of 2.1 procedures were performed at our institution. All patients had pain on presentation, and most had a restricted range of motion. Most patients were afebrile and did not have an elevated white blood-cell count but did have an elevated erythrocyte sedimentation rate. The most common organisms were Staphylococcus epidermidis, Staphylococcus aureus, and Propionibacterium species. At an average of 3.1 years, all patients were free of infection. Using the Simple Shoulder Test, eight patients stated that the shoulder was comfortable with the arm at rest by the side, they could sleep comfortably, and they were able to perform activities below shoulder level. However, most patients had poor overhead function.

CONCLUSIONS

Extensive soft-tissue loss or destruction is associated with a worse prognosis. Extensive débridement, often combined with a muscle transfer, and administration of the appropriate antibiotics controlled the infection, although most patients were left with a substantial deficit in overhead function of the shoulder.

Limb salvage for chronic tibial osteomyelitis: an outcomes study

BACKGROUND

The decision to undergo a limb salvage procedure is difficult and multifaceted. This study reviews the outcomes of patients with chronic tibial osteomyelitis who underwent limb salvage and hopes to enhance our understanding of the impact this complex procedure has on the patient's ability to have a functional and fulfilling life.

METHODS

Forty-six patients, with at least 18 months follow-up, who had undergone limb salvage for chronic, refractory tibial osteomyelitis were evaluated. A modification of the Limb Extremity Outcomes Instrument was utilized emphasizing inquiries pertaining to quality of life.

RESULTS

Thirty-nine (85%) of the 46 patients were able to ambulate independently without pain. All patients younger than 45 years of age had successful outcomes. Thirty-one percent of the patients with a positive smoking history were failures, and 71% of all failures were smokers.

CONCLUSION

Limb salvage seems to be a satisfactory option for patients with chronic tibial osteomyelitis. A history of smoking and advanced age may have adverse affects and are relative contraindications.

The incidence of joint involvement with adjacent osteomyelitis in pediatric patients

Sixty-six patients admitted to our institution over an 8-year period with the diagnosis of osteomyelitis were analyzed to determine the incidence of adjacent joint involvement. Patients with osteomyelitis of the hand, foot, spine, and extraarticular pelvis were excluded from this study. The average age was 5.8 years (range, 1 month to 17 years). Forty-two percent of our patients who had osteomyelitis had evidence of adjacent joint involvement (either septic or nonseptic). One third of our patients had evidence of septic joint involvement. The most commonly involved joint was the knee. There was no difference in the incidence of adjacent joint involvement in those patients who were younger than 18 months compared with the incidence in older children. Our study suggests that the incidence of adjacent joint involvement in children who have osteomyelitis is higher than that suggested in the literature. We believe that careful evaluation of the adjacent joint should be an important part of the evaluation of any child who has osteomyelitis.

Culture results in open wound treatment with muscle transfer for tibial osteomyelitis

Fifty-three patients who underwent a two-staged protocol of debridement and muscle flap coverage for chronic osteomyelitis of the tibia between 1991 and 1996 were evaluated. All patients underwent a thorough debridement of all nonviable tissue and bone at initial debridement. Multiple cultures were taken, including aerobic, anaerobic and fungal cultures from the pus, soft tissue, bone curettings and bone. All patients were treated with open wound management and dressing changes. Between 2 to 7 days, median 4 days, all patients underwent a second debridement with a complete set of identical cultures, and immediate soft tissue muscle transfer. There were 42 free vascularized and 11 local tissue transfers. The 53 patients were classified according to the Cierny-Mader classification for chronic osteomyelitis. Twenty-four patients had Stage IVA osteomyelitis, 10 patients had Stage IIIA osteomyelitis, nine patients had Stage IIIB osteomyelitis, eight patients had Stage IVB osteomyelitis, one patient had Stage IA osteomyelitis, and one patient had Stage IIB osteomyelitis. All 53 patients had positive cultures at the time of their initial debridement, and 14 of 53 (26%) had a positive culture at the time of the second debridement. Based on the results, it seems from a bacteriologic stand-point that the second debridement allows for the opportunity for redebridement and wound sterilization of organisms that still may be present.

Estimation of defect volume in segmental defects of the tibia and femur

BACKGROUND

With the advent of modern limb salvage techniques, segmental bone loss in the lower extremity has become more common.

METHODS

To aid preoperative planning when dealing with segmental bone loss in the femur and tibia, we performed a cadaveric study to estimate the volume of autogenous or allograft material required to fill defects located in various areas of the bones.

RESULTS

The greatest volume was generally required in metaphyseal defects, with an average of 12 cc/cm in the distal femur and proximal tibia, 11 cc/cm in the proximal femur, and 6 cc/cm in the distal tibia. Diaphyseal defects were found to have the least variability with regard to the volume of graft material required for different specimens. Femoral diaphyseal defects required 7 cc/cm and tibial diaphyseal defects required 5 cc/cm. A slightly larger volume of allograft material was needed to fill all defects compared with autograft.

CONCLUSION

This method allows one to estimate the amount of graft required for a defect of the femur and the tibia.

Local or free muscle flaps and unreamed interlocked nails for open tibial fractures

The treatment of open tibial fractures associated with severe soft tissue injuries remains a difficult dilemma, even to the experienced fracture surgeon. To ascertain the efficacy of nailing tibial fractures with severe soft tissue injuries, a review of all open tibial fractures treated at the authors' institution was done. Those fractures initially stabilized with nonreamed nails which required muscle flaps for coverage were selected for study. Thirty-three patients (26 men, seven women) were treated with intramedullary nailing and muscle flap coverage for the soft tissue defects. The average length of followup was 12.1 months (range, 7-42 months). The average time to union was 27 weeks (range, 14-45 weeks). There were five (15%) infections: two (6%) superficial wound infections, one (3%) flap infection, and two (6%) cases of osteomyelitis. In no patient did the infection result in limb ablation. Thirteen of 33 (42%) patients required secondary procedures to enhance union. In this study, it was found that although delayed procedures frequently were required to promote fracture union, the time to union, and infection rates were not significantly different from those reported for external fixation of fractures that require local or free muscle transfers.

In vitro elution of tobramycin and vancomycin polymethylmethacrylate beads and spacers from Simplex and Palacos

In vitro studies of antibiotic elution from polymethylmethacrylate cement comparing Simplex (Howmedica, Rutherford, NJ) with Palacos brands (Richards, Memphis, TN) have shown variable results. This study compares the elution of tobramycin and vancomycin from Simplex and Palacos beads and spacers. Six-millimeter beads and spacers were incubated in phosphate-buffered saline, and the solution was sampled and changed daily until the concentration of antibiotic fell below the minimum inhibitory concentration (MIC) for Staphylococcus aureus. In all groups, the Palacos PMMA beads and spacers showed elution at higher levels and remained above the MIC longer than did the Simplex PMMA beads. Tobramycin had superior elution to vancomycin in all groups. This in vitro study shows that Palacos PMMA has superior elution properties to Simplex PMMA in tobramycin and vancomycin beads and spacers.

Relation of surface area to in vitro elution characteristics of vancomycin-impregnated polymethylmethacrylate spacers

To study the relationship between surface area and antibiotic elution from antibiotic-impregnated polymethylmethacrylate (PMMA) spacers, a standard block spacer made of vancomycin (4 g) and 40 g of PMMA was compared with two unique spacer designs, the "donut" and "fenestrated." The spacers were incubated in phosphate-buffered saline, which was changed daily, and a microbiologic assay was used to measure the antibiotic activity of the eluates. The donut and fenestrated spacers had 12% and 40% more surface area than the standard spacer, respectively. There was no significant difference, however, in daily elution levels of antibiotic between the donut spacer and the standard spacer. The fenestrated spacer displayed significantly better elution than either the standard or donut spacers, with an average of 20% more antibiotic eluted on any given day.

Infected total knee arthroplasty. Two-stage reimplantation with a gastrocnemius rotational flap

This study reviews a consecutive series of 21 patients undergoing two-stage reimplantation total knee arthroplasty for late chronic infection. All 21 patients had late chronic infections, and 20 of 21 patients were compromised hosts. Seven different organisms were isolated at the time of prosthetic resection. Staphylococcus coagulase negative species was the most frequently isolated organism. At the time of reimplantation, a medial gastrocnemius rotational flap was rotated over the proximal tibia and knee for wound closure. The average explantation time was 25 weeks (range, 7-76 weeks), and no methylmethacrylate spacers were used. At an average 17-month followup (range, 5.1-33.1 months) all reimplanted total knee replacements remained in place with one patient having recurrent infection. At reimplantation, 11 patients had positive bacterial cultures from tissue specimens. Sixteen of the 33 (40%) positive cultures were from specimens taken from the medullary canal. At followup, the average Knee Society Score was 77.4 (range, 40-100). The lack of a methylmethacrylate spacer and a long explantation time were considered important factors in diminishing functional performance and determining the need for a gastrocnemius flap. A medial gastrocnemius rotational flap should be considered at the time of reimplantation total knee arthroplasty if the soft tissue envelope about the knee is compromised and cannot be closed without undue tension.

Salvage of the septic ankle with concomitant tibial osteomyelitis

Five patients with concomitant distal tibia osteomyelitis and ankle sepsis with an open, draining wound were treated. All of the patients were men with an average age of 54.8 years. All of the bone infections were polymicrobial and had open draining wounds. A standardized protocol of radical soft tissue and bone debridement, soft tissue transfer, intravenous antibiotics, and delayed ankle fusion was employed. All five fusions were successful on first attempt, with an average time to fusion of 3.5 months. All patients were free of infection at an average follow-up of 27 months. We believe our aggressive treatment protocol can salvage these extremities and preclude amputation in properly selected cases.

Comparison of intravenous and oral antibiotic therapy in the treatment of fractures caused by low-velocity gunshots. A prospective, randomized study of infection rates

One hundred and ninety consecutive patients (222 fractures) who had an extra-articular fracture of a long bone as a result of a low-velocity gunshot were randomized into two groups on the basis of the method of administration of antibiotics. Group 1 consisted of 101 patients (120 fractures) who were managed with intravenous administration of cephapirin sodium and gentamicin for three days. Group 2 comprised eighty-nine patients (102 fractures) who were managed with oral administration of ciprofloxacin for three days. The two groups were comparable in terms of the age of the patient, the locations of the fractures, and the time from the injury to the commencement of antibiotic therapy. Injuries that needed operative débridement or fixation were excluded. All patients were followed until the fracture had healed. Two infections developed in two of the ninety-nine patients (118 fractures) who completed the study in Group 1, and two infections developed in two of the eighty-seven patients (100 fractures) who completed the study in Group 2. With the numbers available, there was no significant difference in the rates of infection (2 per cent for both) between the two groups. All four fractures that were complicated by infection were located in the distal half of the tibia. We concluded that oral and intravenous administration of antibiotics were equally effective for prophylaxis against infection after an extra-articular fracture from a low-velocity gunshot.

Acute hematogenous osteomyelitis. An unusual cause of compartment syndrome in a child

Acute compartment syndrome of the leg developed in a 4-year-old child due to acute hematogenous osteomyelitis of the proximal fibula. Because of its unusual presentation, the diagnosis of osteomyelitis initially was missed. This report suggests that the diagnosis of acute hematogenous osteomyelitis of the proximal part of the fibula should be considered in young children who present with acute compartment syndrome of the leg and who have no history of recent surgery or trauma.

Results of bone grafting for infected tibial nonunion

Thirty-two patients with infected tibial nonunions were treated, including 24 men and 8 women whose ages ranged from 21 to 72 years (mean, 40 years). Thirty of 32 patients had bone defects < 3 cm. Using the Cierney-Mader classification of osteomyelitis, 11 of 32 (35%) patients were Stage 4A, and 21 of 32 (65%) patients were Stage 4B. All patients had irrigation, debridement, and stabilization using an external fixation device. Twenty-seven (84%) patients had muscle transfers. The time between initial debridement and muscle transfer ranged from 3 to 24 days (mean, 4 days). Bone grafting was performed between 6 weeks and 8 months (mean, 8 weeks) after soft tissue coverage. Patients received intravenous antibiotics for 2 to 6 weeks (mean, 6 weeks). Twenty patients received anterior grafting, 10 received posterolateral grafting, and 2 received both. Followup times ranged from 12 to 49 months (mean, 28 months). Twenty-nine of the 32 (91%) patients had tibial unions between 3 to 10 months (mean, 5.5 months) after bone grafting. The 3 failed tibias united after posterolateral grafting. Infection was controlled in all 32 patients. Autogenous cancellous bone grafting using infection control principles is an effective means to treat infected tibial nonunions.

Comparison of the results of bacterial cultures from multiple sites in chronic osteomyelitis of long bones. A prospective study

We evaluated the results of aerobic, anaerobic, and fungal cultures of specimens that had been obtained from multiple sites in thirty patients who had traumatic osteomyelitis with a sinus track. In each patient, we obtained specimens of material from the sinus track; specimens of purulent fluid, of soft tissue, and of bone obtained from curettage; and specimens from the bed of the involved bone. More than one organism grew on culture of the specimens from twenty-one of the patients; more than three organisms, from those of eleven patients; and ten organisms, from those of two patients. The same organisms grew on culture of the specimens from every site in only fourteen (47 per cent) of the thirty patients. We recommend that specimens of material from the sinus track; specimens of purulent material, of soft tissue, and of bone obtained from curettage; and specimens from the bed of the involved bone be obtained for culture before the treatment of chronic osteomyelitis with a draining sinus, so that as many of the infecting organisms as possible will be identified.

Septopal beads and autogenous bone grafting for bone defects in patients with chronic osteomyelitis

Thirty-five patients with chronic osteomyelitis were treated with autogenous bone grafts for bone defects. Of 35 patients, two were lost to follow-up evaluation. There were 27 men and six women. The age range was from 18 to 62 years (median age, 29 years). The bones included 22 tibias, nine femurs, and two ulnas. The size of the bone defects ranged from 2.5 x 15 cm (median defect, 2.5 x 6 cm). The length of infection ranged from two to 540 months (median, 31 months). Twenty patients had nonunions and 19 patients required soft-tissue muscle transfers. Patients were treated with systemic antibiotics and/or gentamicin (Septopal) antibiotic beads. Twelve patients were treated with Septopal beads. The range of follow-up evaluation was 24 to 68 months (median, 47 months). Thirty-one of 33 patients had one bone-graft procedure and two patients required two. The time from initial debridement and infection control to bone graft for patients not requiring soft-tissue muscle flaps was one to six weeks (median time, four weeks). For patients requiring soft-tissue muscle transfer, the range was six to nine weeks (median, six weeks). The median time to bone-graft incorporation was six months. All fractures united. Complications included two refractures from auto accidents in the immediate postoperative period, one partial muscle loss, one skin-graft loss, four pin tract draining sites, and two antibiotic-related skin rashes. There was one recurrent infection, and the infection arrest rate was 97%.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of gentamicin-impregnated polymethylmethacrylate bead implantation to conventional parenteral antibiotic therapy in infected total hip and knee arthroplasty

A multicenter study of infected total knee and total hip arthroplasties was conducted from 1985 until 1990. Twenty-eight patients (22 total hip arthroplasties and six total knee arthroplasties) who had periprosthetic infections were treated according to a prospective, randomized protocol. After initial debridement for their infections, patients were randomized into one of the two following groups: Group I, debridement and the implantation of gentamicin-polymethylmethacrylate (PMMA) beads; and Group 2, debridement and conventional parenteral systemic antibiotic therapy. After initial treatment, the patients were then scheduled for a delayed reconstruction total joint arthroplasty. Of the 28 patients, 25 subsequently had delayed total arthroplasty, and if acrylic bone cement was used for fixation at the time of reimplantation, antibiotics were not added to the cement. The average follow-up period was three years (range, six months to 5.6 years). Infection recurred in two patients treated by debridement and the implantation of gentamicin-PMMA beads (15%) and in four patients treated with debridement and conventional systemic antibiotic therapy (30%). All recurrences occurred in patients who had infected total hip arthroplasties; none occurred in patients with total knee arthroplasties. The conditions that were common in patients with recurrent infection were (1) multiple previous surgeries, (2) host compromise and malnutrition, (3) extensive infection, and (4) inadequate debridement. The recurrence of infection was not statistically significantly more common in either treatment group. The outcome of treatment in patients with infected total joint arthroplasties using debridement, gentamicin-PMMA bead implantation,and a two-stage delayed reconstruction was similar to that of patients treated with debridement combined with conventional parenteral systemic arthroplasty and two-stage reconstruction.

Treatment of chronic osteomyelitis with muscle flaps

This article discusses a study of 36 patients with chronic osteomyelitis that had local or free muscle flaps. Reconstruction of chronic osteomyelitis requires infection control and assessment of soft tissue and bone. In patients with osteomyelitis with an ununited fracture or nonunion, stabilization of the fracture is needed.

Analysis of 61 cases of vertebral osteomyelitis

Sixty-one cases of bacterial vertebral osteomyelitis from July 1969 to July 1979 were analyzed. The ages of the 49 men and 12 women ranged from 21 to 66 years. The portal of entry was hematogenous in 58 cases, gunshot wounds in two cases, and and adjacent retroperitoneal abscess in one case. Biopsy was performed in 60 patients. There were 15 complications related to the disease. Gram-negative rods were the predominant bacteria isolated. Blood culture was positive in 13 of the 26 (50%) patients tested. Eleven of the 13 (85%) organisms isolated from the blood cultures correlated with organisms recovered from biopsy specimens. Eleven of the patients had more than one disk level involved. Of the 61 patients, 29 went on to spontaneous fusion, 17 were lost to follow-up study, 11 failed to fuse, three had surgical fusion, and one patient died. Recommendations for diagnosis included the collection of blood cultures and radionuclide bone scans. Management recommendations included systemic antibiotics for at least three weeks and immobilization with either bed rest or spinal orthoses. Surgery was indicated if an abscess was present, neurologic complications occurred, instability became a factor, or the medical treatment failed.

Peripheral teflon catheters. Potential source for bacterial contamination of orthopedic implants?

To detect low numbers of bacterial cells on Teflon catheters removed from peripheral veins, 74 catheter tips were incubated in thioglycollate media for up to ten days. Fifteen (20.3%) of the catheters were found to be culture-positive. Propionibacterium acnes was isolated from seven, Staphylococcus epidermidis from six, and Staphylococcus haemolyticus and Staphylococcus hominis from one each, all common skin organisms associated with infection of implants. An increase in documentation of bacterial contamination resulted from incubating greater than 72 hours; this allowed the slower-replicating Propionibacterium acnes to grow to detectable numbers. Because of these findings and those of others, attention is focused on the peripheral vein conduit as a potential source for hematogenous seeding of implants with bacterial cells. Changing peripheral catheters within 24 hours is recommended to reduce the constant risk of occult bacteremia.

Factors influencing infection rate in open fracture wounds

Seventy-seven infections in 1104 open fracture wounds were evaluated to identify those factors that predisposed to infection. Factors could be placed into three categories: (1) increased risk, (2) no effect, and (3) inconclusive. The single most important factor in reducing the infection rate was the early administration of antibiotics that provide antibacterial activity against both gram-positive and gram-negative microorganisms. In this study, surgical debridement was performed on all open fracture wounds.

Wound site as a predictor of complications following deep nail punctures to the foot

The site of injury, condition of the nail, and type of foot covering were compared in 36 inpatients and 34 outpatients with nail puncture wounds to the foot. Of the 36 inpatients, 34 (94%) had pyarthrosis, osteomyelitis, or both. The plantar surface of the foot was divided into 3 zones. Of the 36 inpatients, 35 (97%) had deep puncture wounds in zone 1. In contrast, only 6 of 34 (18%) outpatients had injury to this area. Tennis shoes were shown to predispose to infection with Pseudomonas aeruginosa. Based on our findings, an early hospital admission should be considered for all patients with deep puncture wounds located in zone 1 and for patients who give a history of bone penetration in zone 2 or 3 at the time of injury. All patients who meet the above criteria and who are not admitted to hospital should be observed closely.

Ipsilateral diaphyseal femur fractures and knee ligament injuries

Three hundred and nine consecutive patients with 320 diaphyseal femur fractures were retrospectively reviewed to determine the incidence of ligament injury in the ipsilateral knee. Ligamentous injuries were diagnosed if serious (Grades II and III) instability was apparent on admission, found at surgery for femoral stabilization, or disclosed on roentgenograms during closed management. Seventeen patients with unilateral shaft fractures of the femur had ipsilateral knee ligament injuries, or 5.3%. There was no relationship between specific ligament damage and the cause of the injury or level of fracture. Twelve patients were followed for an average of 34 months. Five patients lacked full extension and ten lacked full flexion. Two of seven patients with ligament repair and three of five patients without ligament repair had at least one unstable ligament. Better range of knee motion was obtained when both the femur and ligament injuries were surgically managed, but most (seven of 12) patients were disabled.

Surgical findings in clenched-fist injuries

A total of 191 patients (representing 194 skin lacerations) hospitalized for clenched-fist injuries were evaluated for deep structure involvement. Tendon, joint, cartilage, and/or bone were damaged in 75%. Tendon involvement occurred in 28 of 138 (20.3%), joint capsule violation in 99 of 146 (67.8%), free articular cartilage fragments in 8 of 139 (5.8%) and articular-bone indentations in 23 of 139 (16.5%). All patients with clenched-fist lacerations or puncture wounds over joints should be treated by surgical debridement and exploration of the deep structures, including the joint, at the time they first seek medical care.

Infection following intramedullary nailing of long bones. Diagnosis and management

In 30 patients (23 femurs and 7 tibias) with infection of long bone fractures following intramedullary (IM) nailing, the follow-up study ranged from eight to 84 months (mean, 20 months). Six patients retained active infection at the time of follow-up examination. Ununited fractures were present in four and sequestra in two patients. Stabilization for fracture healing after irrigation and debridement with appropriate systemic antibiotic therapy was the critical factor in the orthopedic management of this series of patients.

Results of compression-plating of closed Galeazzi fractures

Diaphyseal fractures of the distal third of the radius that are associated with disruption of the distal radio-ulnar joint accounted for eighty-four (6.8 per cent) of 1236 fractures in the forearm that were treated during a five-year period at the Los Angeles County-University of Southern California Medical Center. Thirty-six closed Galeazzi fractures, twenty-eight in male and eight in female patients, were followed for 1.5 to seven years after treatment using standard AO-compression plates with four to seven holes. Complications included seven injuries to the sensory or dorsal interosseous branch of the radial nerve, two infections, two non-unions, two re-fractures after plate removal, and shortening of the radius of five millimeters in one patient. The complication rate was 39 per cent. The average grip strength at follow-up was 71 per cent of the calculated normal value. The loss of strength was not related to use of a volar or dorsal surgical approach, the patient's age, or a delay of surgery for more than ten days after injury. The average loss of grip strength in the seven upper extremities with restricted motion of the wrist and forearm was 48 per cent, compared with an average loss of 29 per cent in the whole group. Of the twelve patients who were operated on more than ten days after injury, six had loss of motion at follow-up, compared with three who had such a loss among the twenty-four patients who were operated on within ten days after injury.(ABSTRACT TRUNCATED AT 250 WORDS)

The mechanisms of action for beta-lactam antibiotics and inhibitors of bacterial protein synthesis

The replication of bacteria, when unchecked, may lead to morbidity or mortality in a susceptible host. The majority of antimicrobial agents either modify or inhibit the synthesis of key substances and are reflected by morphologic, if not lethal, changes. Activity occurs during synthesis of the bacterial cell wall and synthesis of bacterial protein. These two events are described in terms of the local mechanism of action of different classes of antibiotics. The role of antibacterial agents in the replication of bacteria should be clearly understood before antibiotic therapy is administered.

Use of antibiotics in open tibial fractures

Data concerning 1102 open fractures are presented with bacteriologic and antibiotic considerations analyzed in 363 open tibiae fractures treated in three prospective one-year studies during the period from 1970 to 1980. The highest infection rate was in open tibiae receiving no antibiotics (24%, 6 infections in 25 open tibial fracture wounds), and the lowest was in the group receiving a cephalosporin and an aminoglycoside (4.5%, 5 infections in 109 open tibial fracture wounds).

Considerations in reducing the infection rate in open tibial fractures

During the period from 1979 to 1980, 109 patients with open tibial fractures were treated by a cephalosporin and an aminoglycoside, and by saline and topical antibiotic wound irrigation; partial closure was used for Types I and II open tibial wounds, and all Type III wounds were left open. Stabilization was accomplished by plaster alone, external pins in plaster, or an external fixator with full transfixion pins. The overall infection rate was 4.5% (5 of 109 wounds) in this study. This represents a significant reduction from the previous infection rate of 14% in 254 open tibial fractures treated by the authors in previous years by all methods.

Closed biopsy of musculoskeletal lesions

Five hundred and thirty-one closed biopsies have been done in our general hospital since 1967. Four hundred and eighty-four were for lesions of bone and forty-seven were for soft-tissue lesions. More than half of the lesions were infections or nonspecifically reactive. The procedure was done under local anesthesia in 73 per cent and roentgenographic or image-intensifier control was generally required. The Craig needle was used for cancellous bone near vital structures; the Michele trephine, for cortical or sclerotic bone at a distance from vital structures; and a special needle was used for soft tissue. Closed biopsy provided an adequate specimen that was accurately diagnosed in 66 per cent of bone lesions and in 76 per cent of soft-tissue lesions. This compared favorably with both aspiration and open-biopsy success rates reported by others, and was accompanied by a 1 per cent complication rate, mostly neural and mostly in association with vertebral lesions.

Total hip replacement in children with arthritis

Fourteen children with juvenile rheumatoid arthritis and two with ankylosing spondylitis received 29 total hip replacements (THR). The ages at THR were 12 to 18 years, the median duration of prior hip disease was 7.1 years, and the minimum followup was one year (range 1--4 years, median 2.2 years). The primary indication for THR was pain in 5 hips and severe malposition or flexion contractures in 24 hips. (Sixteen of these also had some degree of pain.) All 29 hips demonstrated improved postoperative range of motion, and all were free of pain. In children, active rheumatic disease in other joints, prosthesis longevity, and possible lack of adequate motivation all merit special consideration prior to THR, but the results are encouraging.

The effect of antibiotics, primary and secondary closure on clostridial contaminated open fracture wounds in rats

In a study of experimentally induced open tibial or femoral fractures in rats, after either closing or leaving the wounds open, the animals were given: no antibiotic, cephalothin (Keflin), or penicillin. The rats with wounds closed primarily and receiving no antibiotics had the highest mortality rate (11 of 25) from experimentally produced clostridial myonecrosis. The lowest overall mortality rate (5 of 99) was found in the penicillin-treated groups. The higher mortality rate in the femur fracture groups was probably because of the large muscle mass of the thigh. The importance of ideal anaerobic conditions for producing experimental clostridial myonecrosis is emphasized.

Antibiotic and bacteriologic considerations in open fractures

A prospective study involving 581 open fracture wounds was conducted to evaluate the antibiotic and bacteriologic considerations in the treatment of open fractures. Multiple cultures were taken of each wound, and each wound had formal surgical irrigation and debridement. An organism was present in at least one of the multiple cultures in 62.1% of the cases. Open fractures should be considered as contaminated wounds, and antibiotics are given for treatment rather than prophylaxis.

The use of antibiotics in open fractures

The use of the term "prophylactic antibiotics" is probably not appropriate because we are in fact treating contaminated wounds. Only broad spectrum antibiotics that can be expected to be effective against coagulase-positive Staphylococcus aureus should be selected for antibiotic therapy in open fractures. We have found cephalothin-cephalexin therapy to be effective in significantly reducing the infection rate. However, the final selection of antibiotic treatment should be determined by the previous experience of organisms isolated and sensitivity studies done from open fracture wounds in each institution. These organisms will vary from hospital to hospital.

The early management of open joint injuries. A prospective study of one hundred and forty patients

A study of open joint injuries treated at the Los Angeles County-University of Southern California Medical Center from July 1969 through July 1973 showed that the vast majority of these injuries were at the knee. Three types of injury were identified: those associated with fractures, injuries without fracture, and gunshot wounds. All patients were treated with antibiotics, surgical débridement and irrigation, and installation of polyethylene tubes into the joint as a system of postoperative closed irrigation. The over-all infection rate was 2.1 per cent. The results of treatment indicate that the irrigation system can be a source of contamination. Our recommended treatment for open wounds in joints is wide-spectrum systemic antibiotics, surgical débridement, irrigation of the joint and soft tissues, and primary closure. Prolonged suction-irrigation treatment postoperatively should only be done for specific indications: excessive contamination or excessive tissue damage when the wound to the joint should be closed primarily.