Skin Antisepsis before Surgical Fixation of Extremity Fractures

BACKGROUND

Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture).

METHODS

In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications.

RESULTS

A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups.

CONCLUSIONS

Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Misdiagnosis in Amyotrophic Lateral Sclerosis

The symptoms of amyotrophic lateral sclerosis (ALS) can mimic those of compressive neuropathies, such as carpal and cubital tunnel syndromes, especially early in a patient's clinical course. We surveyed members of the American Society for Surgery of the Hand and found that 11% of active and retired members have performed nerve decompression surgeries on patients later diagnosed with ALS. Hand surgeons are commonly the first providers to evaluate patients with undiagnosed ALS. As such, it is important to be aware of the history, signs, and symptoms of ALS to provide an accurate diagnosis and prevent unnecessary morbidities, such as nerve decompression surgery, which invariably results in poor outcomes. The major "red flag" symptoms warranting further work-up include weakness without sensory symptoms, profound weakness and atrophy in multiple nerve distributions, progressively bilateral and global symptoms, presence of bulbar symptoms (such as tongue fasciculations and speech/swallowing difficulties), and, if surgery is performed, failure to improve. If any of these red flags are present, we recommend neurodiagnostic testing and prompt referral to a neurologist for further work-up and treatment.

Augmentation of Arthroscopic Rotator Cuff Repair With Cannulated Dermal Allograft Implant

Arthroscopic rotator cuff repair (RCR) is a popular treatment for rotator cuff tears. Retear after RCR remains a significant concern even with modern techniques. Augmentation of RCR has been described using multiple different grafts, one option including a cannulated dermal allograft implant (DePuy Mitek). The utilization of this implant avoids significantly increased surgical time, allows for augmentation at the weakest area of repair, and does not lead to any wasted allograft material.

Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial

BACKGROUND

Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture.

METHODS

We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304.

FINDINGS

Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4).

INTERPRETATION

For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds.

FUNDING

US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

Cartilaginous defect of the lateral trochlea following suprapatellar nailing of an open tibial shaft fracture: a case report

A 34-year-old female sustained a 1.8 cm full-thickness chondral defect of the right lateral trochlear surface as the result of intramedullary tibial nailing via a suprapatellar portal to treat a displaced right sided open comminuted spiral fracture of the distal tibial shaft. An osteochondral allograft was used to treat the chondral defect. Iatrogenic injury to intraarticular structures is a potential complication when inserting a tibial nail via a suprapatellar portal. Using proper technique with cannula systems and guide pins is essential to lowering the risk of damage to intraarticular structures.

Effect of the COVID-19 Pandemic on Sports-Related Injuries Evaluated in US Emergency Departments

Background:

Organized athletics are undergoing a gradual resumption after a prolonged hiatus in 2020 because of the coronavirus disease 2019 (COVID-19) pandemic.

Purpose/Hypothesis:

The purpose of this study was to evaluate the effect of the 2020 COVID-19 period on emergency department (ED) visits for sports-related injuries in the United States. It was hypothesized that such visits decreased in response to the pandemic conditions.

Study Design:

Descriptive epidemiology study.

Methods:

A selection of sports (baseball, basketball, softball, soccer, American football, weightlifting, track and field, martial arts, boxing, golf, personal fitness, cycling, tennis, and ice hockey) were classified as being an organized team, organized individual, or nonorganized sport. The National Electronic Injury Surveillance System database was then queried for ED visits for sports-related injuries between January 1, 2018, and December 31, 2020, and we compared weighted national injury estimates and injury characteristics from athletes presenting to EDs in 2018 and 2019 versus those from the 2020 COVID-19 pandemic period and between March 1 and May 31, 2020 (government-imposed lockdown period). Bivariate comparisons between variables were conducted using chi-square analysis, with strength of association assessed using odds ratios.

Results:

The 164,151 unweighted cases obtained from the query resulted in a weighted national estimate of 5,664,795 sports-related injuries during the study period. Overall, there was a 34.6% decrease in sports-related ED visits in 2020 compared with the yearly average between 2018 and 2019 (baseline). The number of ED visits in 2020 decreased by 53.9% versus baseline for injuries incurred by participation in an organized team sport and by 34.9% for injuries incurred by participation in an organized individual sport. The number of ED visits during the 2020 lockdown period decreased by 76.9% versus baseline for injuries incurred by participation in an organized team sport and by 65.8% for injuries incurred by participation in an organized individual sport. Injuries sustained while participating in a nonorganized sport remained relatively unaffected and decreased by only 8.1% in 2020.

Conclusion:

ED visits in the United States for injuries sustained while participating in an organized team or individual sport underwent a decrease after the beginning of the COVID-19 pandemic in 2020, especially during the lockdown period.

OUP accepted manuscript

We report a 45-year-old man who presented with a rotator cuff tear and scapular dyskinesis of his left shoulder and underwent a pectoralis major split transfer with an allograft to the inferior border of his scapula. The patient reported significant improvement in shoulder function and decreased severity of his scapular dyskinesis. Combined arthroscopic rotator cuff repair and allograft scapula stabilization is a novel technique for the unusual clinical presentation reported in this case report. To the best of our knowledge, this is the first reported surgical management of a patient with rotator cuff repair and non-palsy-related scapular dyskinesis.

Experiences with a rat bio-assay in the diagnosis of the Zollinger-Ellison syndrome

Reported here are the assay results, using the anaesthetized rat preparation of Lai (1964), of plasma from patients known or suspected to have peptide-secreting adenomata and these are compared with assays carried out on plasma from patients whose clinical history excluded such pathology. It is suggested that these demonstrate that this technique is of diagnostic value in this condition and that it has practical advantages over other bio-assay methods currently available and physiological advantages over immunological methods. It may well be that identification of the presence of tumour in these patients may first be made by immunological techniques to be followed by functional identification using a bioassay procedure such as is described here.

Two cases of "pancreatic cholera" with features of peptide-secreting adenomatosis of the pancreas

The clinical data are presented of two women with profound metabolic upset from exceptional water and electrolyte losses in diarrhoea. One had an islet-cell adenoma of the pancreas and the other abnormal islets. Gastric and pancreatic function were abnormal in both, consistent with the subsequent demonstration of a pancreatic and choleretic secretagogue in the tumour tissue and pancreatic and gastric secretagogues in circulating blood (Cleator, Thomson, Sircus, and Coombes, 1970).

Bio-assay evidence of abnormal secretin-like and gastrin-like activity in tumour and blood in cases of "choleraic diarrhoea"

Methods for bio-assay of secretin-like humoral agents in both cat and dog are described. Bio-assay of tumour extracts and of plasma from patients with the pancreatic choleraic syndrome are described. The first patient was found to have choleretic and secretinlike activity in an extract of her pancreatic islet cell tumour and gastrin-like activity in her plasma. The second patient was found to have both secretin and gastrin-like activity in her plasma, as well as choleretic activity. It is concluded that at least part of the profuse, watery electrolyte diarrhoea of the ;pancreatic cholera' syndrome associated with peptide-secreting adenoma of the pancreas is likely to be a reflection of the excessive production of secretin, as well as of gastrin, and possibly also of a choleretic agent.