Patients admitted to the ICU are more likely to sustain an acute ischemic event of an upper extremity with more vasopressor usage. Patients who received alpha-adrenergic activating vasopressors were more likely to sustain limb ischemia. When discoloration of an extremity is detected, patients should receive counteractive treatments in an effort to salvage the extremity and prevent function loss.

BackgroundRecent literature has demonstrated that emergent administration of antibiotics is perhaps more critical than even emergent debridement. Most recent studies recommend patients receive antibiotics no later than 1 hour after injury to prevent infection. The objective of this study is to evaluate the time to antibiotic administration after patients with open fractures arrive to a trauma center depending on triaging team.MethodsA retrospective study at a level 1 Trauma center from January 2013 to March 2015 where 117 patients with open fractures were evaluated. Patients who presented with open fractures of the extremities or pelvis were considered. Subjects were identified using Current Procedural Terminology (CPT) codes. Patients aged 18 and older were analyzed for Gustilo type, antibiotics administered in the emergency room (ER), presence of an antibiotic allergy, post-operative antibiotic regimen and number of debridements, among others. Additionally, whether a patient was triaged by ER doctors or trauma surgeons (and made a trauma activation) was evaluated. Outcome measurements included time to intravenous (IV) antibiotic administration and time to surgical debridement.ResultsPatients received IV cefazolin a median of 17 minutes after arrival. Eighty-five patients who were made trauma activations received cefazolin 14 minutes after arrival while 24 non-trauma patients received cefazolin 53 minutes after arrival (p = <0.0001). The median time to gentamicin administration for all patients was 180 minutes. Patients not upgraded to a trauma received gentamicin 263 minutes after arrival, while patients upgraded received gentamicin 176 minutes after arrival. There was no statistically significant difference between the timing to cefazolin or gentamicin based on Gustilo type.ConclusionsOverall, patients that arrive at our institution with open fractures receive IV cefazolin significantly faster when trauma surgeons evaluate the patient. Additionally, delays in gentamicin administration are demonstrated in both triaging groups. This is due to the fact that cefazolin is stocked in the hospital ER, while gentamicin is commonly not due to weight-based dosing requirements precluding a standard dose. Improvements can be made to antibiotic administration of non-trauma patients and those requiring gentamicin via improved education and awareness of open fractures.

Purpose:Excessive blood loss with hip fracture management has been shown to result in increased rates of complications. Our goal is to compare blood loss and transfusion rates between patients with intracapsular and extracapsular (both intertrochanteric (IT) and subtrochanteric (ST)) hip fractures.Methods:472 patients were evaluated over a five-year period. Those who presented to the hospital with a proximal femur fracture (femoral neck, IT or ST) were considered for the study. Exclusion criteria included polytrauma, gunshot injuries, periprosthetic fractures, and non-operative management. Primary endpoint was hemoglobin (Hgb) drop from admission to day of surgery (DOS); secondary endpoint was need for pre-op transfusion and discharge location.Results:304 patients were analyzed who sustained a proximal femur fracture. Median IC Hgb drop was 0.6g/dL; median EC Hgb drop was 1.1g/dL from admission to DOS (p = 0.0272). Rate of pre-operative transfusions was higher in EC (36/194 = 18.6%) than IC fractures (5/105 = 4.5%) (p = 0.0006), and overall transfusion rates remained higher throughout hospital stay (55.7% EC vs. 32.7% IC; p = 0.0001). Breakdown of bleeding rate and tranfusion rates between IT and ST fractures were not significant (p = 0.07; p = 0.4483). Extracapsular hip fractures were more likely to be discharged to a skilled nursing facility (SNF) (84.4% EC vs. 73.8% IC; p = 0.027).Conclusion:Intracapsular hip fractures have significantly less pre-operative blood loss and fewer pre-operative transfusions than their extracapsular counterparts. These findings can be used to establish appropriate pre-operative resuscitative efforts, ensuring that hip fracture protocols account for the increased likelihood of blood loss in extracapsular fractures.

Background: Hip abductor tendon tears are a well-recognized entity that results in progressive lateral hip pain, weakness, and limping. These can occur in patients with native hips or in patients following total hip arthroplasty. However, treatment of these 2 distinct groups does not differ. We describe a new repair technique utilizing a longitudinal bone trough in the greater trochanter. We compare our results (focusing on gluteus medius tendon avulsions) and traditional repair with suture anchors or transosseous bone tunnels. Additionally, we propose a classification system that attempts to describe the different types of tears to guide treatment, as the current classification system is not helpful in defining pathology or guiding treatment. Our proposed classification will help to better describe tear types anatomically and thereby guide appropriate surgical interventions based on these types. Description: Abductor tears were classified, according to our system, as Type I when there was no gluteus medius avulsion from bone (with subtype A indicating a partial tear of the gluteus minimus or gluteus medius; B, a complete tear of the gluteus minimus; and C, a longitudinal tear of the gluteus medius) or Type II when there was a gluteus medius avulsion (with subtype A indicating an avulsion of <50% of the insertion into the greater trochanter, and B, an avulsion of ≥50% of the insertion). Repair into a bone trough involves (1) freeing up and mobilizing the tendon from overlying fascia, (2) placing 2 evenly spaced Krackow stitches in the tendon, (3) creating a bone trough using a burr in the midline of the greater trochanter, (4) creating bone tunnels out the lateral wall of the trough to pass sutures, and (5) passing sutures through the bone tunnels to allow inset of the tendon into the trough, and later tying the sutures over the lateral osseous bridge. Alternatives: Alternative treatment options include nonoperative and operative management. Nonoperative treatment choices include physical therapy, nonsteroidal anti-inflammatory drugs, and activity modification with assistive walking devices. Surgical alternatives include endoscopic or open direct soft-tissue repair, suture anchor repair, bone tunnel repair, graft jacket reconstruction, or gluteus maximus muscle transfer. Rationale: Because of discouraging outcomes experienced by us and others, a new technique (a greater trochanter longitudinal bone trough) was developed to improve surgical results. This technique, utilizing an abductor tendon repair into a bone trough, improved our surgical outcomes for abductor tendon avulsions. We found that outcomes after surgical treatment of abductor tendon tears without avulsion are superior to those after repairs of abductor tendon avulsions, which is an important distinction compared with previous literature on abductor tendon repairs.

Vascular injuries following total hip arthroplasty (THA) are very rare, with pseudoaneurysm being a small subset. We report a case of profunda femoris artery (PFA) pseudoaneurysm in a 61-year-old male following a posterior approach revision left THA. Presentation involved continued blood transfusion requirements several weeks postoperatively. Diagnosis of the pseduoaneurysm was made by contrast CT of the lower extremity, with confirmation via IR angiography. Successful embolization was achieved with selective coiling and Gelfoam. Presenting complaints of such complications are often vague and therefore lead to delayed diagnosis. Causes of such complications are not completely understood, particularly with PFA injuries in THA. Possible mechanisms are discussed in this paper. Vascular complications following THA can be difficult to diagnose. High suspicion in the setting of continued postoperative pain or bleeding may allow prompt diagnosis and avoidance of serious limb-threatening complications.

Although compartment syndrome can occur in any compartment in the body, it rarely occurs in the paraspinal musculature and has therefore only been reported in a few case reports. Despite its rare occurrence, acute paraspinal compartment syndrome has been shown to occur secondary to reperfusion injury and traumatic and atraumatic causes. Diagnosis can be based on clinical examination findings, MRI or CT studies, or through direct measurement of intramuscular pressures. Conservative management should only be used in the setting of chronic presentation. Operative decompression via fasciotomy in cases of acute presentation may improve the patient’s symptoms and outcomes. When treating acute paraspinal compartment syndrome via surgical decompression, an important aspect is the anatomical consideration. Although grouped under one name, each paraspinal muscle is enclosed within its own fascial compartment, all of which must be addressed to achieve an adequate decompression. The authors present the case of a 43-year-old female patient who presented to the emergency department with increasing low-back and flank pain after a fall. Associated sensory deficits in a cutaneous distribution combined with imaging and clinical findings contributed to the diagnosis of acute traumatic paraspinal compartment syndrome. The authors discuss this case and describe their surgical technique for managing acute paraspinal compartment syndrome.

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Background: Vancomycin is a commonly used prophylactic antibiotic for total joint replacement surgery to protect against methicillin-resistant Staphylococcus aureus. Studies have suggested intraosseous (IO) infusions provide superior local tissue antibiotic concentration compared with intravenous (IV) access in total knee arthroplasty (TKA). We reviewed patients receiving IO vancomycin before TKA, comparing complication rates to a matched group receiving IV prophylactic vancomycin. Methods: Retrospective review of TKA patients administered IO vancomycin (500 mg vancomycin in 200 mL normal saline),