Over the past decade, osteochondral allograft transplantation has soared in popularity. Advances in storage techniques have demonstrated improved chondrocyte viability at longer intervals and allowed for potential of increased graft availability. Recent studies have stratified outcomes according to location and etiology of the chondral or osteochondral defect. Unipolar lesions generally have favorable outcomes with promising 10-year survival rates. Though those undergoing osteochondral allograft transplantation often require reoperation, patient satisfaction remains high.
Patients with community-onset methicillin-resistant (CO-MRSA) infections contribute to MRSA contamination of the home environment, and may be re-exposed to MRSA strains from this reservoir. This study evaluates One Health risk factors that focus on the relationship between humans, animals and the environment for increased prevalence of multiple antimicrobial resistant MRSA in the home environment. During a trial of patients with CO-MRSA infection, MRSA was isolated from the household environment at baseline and three months later, following randomization of patients and household members to mupirocin-based decolonization therapy or education control. Up to two environmental MRSA isolates per visit were tested. MRSA isolates were identified in 68% (65/95) of homes at baseline (=104 isolates) and 51% (33/65) of homes three months later (=56 isolates). Rates of MDR were 61% at baseline and 55% at the three-month visit. At baseline, 100% (14/14) of MRSA isolates from rural homes were MDR. While antimicrobial use in humans or pets was associated with an increased risk for the isolation of MDR MRSA from the environment, clindamycin use was not associated risk for isolation of MDR MRSA. Two (5%) of 39 homes that were randomized to mupirocin treatment, but none of the control families, had incident low-level mupirocin resistant MRSA isolated at three months. Among patients recently treated for a CO-MRSA infection, MRSA and MDR MRSA were common contaminants in the home environment. This study contributes to evidence that occupant use of antimicrobial drugs--except clindamycin--is associated with MDR MRSA in the home environmental reservoir. MRSA is a common bacterial agent implicated in skin and soft tissue infections (SSTIs) in both community and healthcare settings. Patients with CO-MRSA infections contribute to MRSA contamination and may be re-exposed to MRSA strains from these reservoirs. People interact with natural and built environments, therefore understanding the relationships between humans and animals as well as characteristics of environmental reservoirs is important to advance strategies to combat antimicrobial resistance. Household interactions may influence the frequency and duration of exposure, which in turn may impact the duration of MRSA colonization or probability for recurrent colonization and infection. Therefore, MRSA contamination of the home environment may contribute to human and animal recolonization and decolonization treatment failure. The aim of this study was to evaluate One Health risk factors that may be amenable to intervention and may influence the recovery of MDR and mupR resistance in CO-MRSA isolates.
Patient: Male, 56
Final Diagnosis: Anterior compartment syndrome of the thigh
Symptoms: Unrelenting pain on the anterior aspect of the right thigh
Medication: Morphine • Lyrica • Flexeril • Percocet 5/325 • Hydromorphone • Synthroid • Metformin
Clinical Procedure: Adductor canal catheter placement, emergent fasciotomy
Specialty: Anesthesiology
Objective:
Unusual clinical course
Background:
Acute compartment syndrome (ACS) of the thigh after elective primary total knee arthroplasty is rare. If not recognized and treated promptly, devastating consequences may result. Certain regional anesthesia techniques are thought to mask the symptoms of acute compartment syndrome, but there are no cases reported of adductor canal catheters masking the symptoms of thigh compartment syndrome. We report a case where symptoms and diagnosis of acute anterior thigh compartment syndrome were not masked by a functioning adductor canal catheter.
Case Report:
A 56-year-old male developed anterior thigh compartment syndrome after an elective primary total knee arthroplasty. Surgery was performed under spinal anesthesia with periarticular local infiltration analgesia. Postoperatively, an adductor canal catheter was placed, atraumatically, under ultrasound guidance in the recovery room with a plan to begin a continuous infusion of 0.2% ropivacaine 10 hours after the periarticular injection. Six hours after surgery, the patient complained of tightness and 10/10 pain in his right thigh, which was initially managed with parenteral opioids with moderate success.
Continuous infusion through the adductor canal catheter was started and pain improved to 6/10 aching pain. Nonetheless, two hours after starting the continuous infusion, the patient reported tightness, swelling, and 10/10 pressure-like pain that was not relieved by the peripheral catheter infusion or PRN boluses of additional opioids. Due to the patient’s symptomatology compartment pressures were measured. The anterior compartment pressure was 47 mm Hg and emergent anterior compartment fasciotomy was performed.
Conclusions:
In this case, a functioning adductor canal catheter did not mask symptoms of, or delay diagnosis of, acute compartment syndrome in the thigh.
In this Pro-Con commentary article, we discuss the controversial debate of whether to provide peripheral nerve blockade (PNB) to patients at risk of acute extremity compartment syndrome (ACS). Traditionally, most practitioners adopt the conservative approach and withhold regional anesthetics for fear of masking an ACS (Con). Recent case reports and new scientific theory, however, demonstrate that modified PNB can be safe and advantageous in these patients (Pro). This article elucidates the arguments based on a better understanding of relevant pathophysiology, neural pathways, personnel and institutional limitations, and PNB adaptations in these patients.
The use of local anesthetics for improved pain management is well established. However, significant morbidity may be caused by local anesthetic systemic toxicity (LAST) from inadvertent intravascular injection or excessive dosing of local anesthetics. Despite incomplete understanding of the mechanism of action of intravenous lipid emulsions (ILE), their use has become a first-line therapy for treating LAST. We present a case report of LAST, successfully treated with ILE with a secondary effect of complete reversal of a successful peripheral nerve block as quickly as the LAST symptoms resolved.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.