Injury
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We review prevention strategies to minimise the risk of MRSA soft tissue and bone infections, which can be devastating for the patient and costly for the healthcare provider. Department of Health (England) policy is that screening for emergency admissions will be mandatory from 2011, in addition to existent elective admission screening. Rapid screening technology has not been shown to be cost-effective, meaning that there will be a lag time between admission and the patient's MRSA status being known. ⋯ Prevention of orthopaedic infections clearly involves general operating theatre protocols, such as suitable antiseptic skin preparation, and additional measures including the use of laminar airflow. Antibiotic prophylaxis is adjusted in patients known to have MRSA to include a glycopeptide, and local guidelines may adopt such regimens for all patients due to the burden of MRSA in the local patient population. A future development that may have an effect on practice is the development of a Staphylococcus aureus vaccine, which has been shown to be cost-effective in a computer-modelled evaluation.
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Multicenter Study Clinical Trial
Standardised cement augmentation of the PFNA using a perforated blade: A new technique and preliminary clinical results. A prospective multicentre trial.
Pertrochanteric fractures are a rising major health-care problem in the elderly and their operative stabilisation techniques are still under discussion. Furthermore, complications like cut-out are reported to be high and implant failure often is associated with poor bone quality. The PFNA(®) with perforated blade offers a possibility for standardised cement augmentation using a polymethylmethacrylate (PMMA) cement which is injected through the perforated blade to enlarge the load-bearing surface and to diminish the stresses on the trabecular bone. ⋯ A mean volume of 4.2ml of cement was injected. We did not find any cut-out, cut through, unexpected blade migration, implant loosening or implant breakage within the study period. Our findings lead us to conclude that the standardised cement augmentation using the perforated blade for pertrochanteric fracture fixation enhances the implant anchorage within the head-neck fragment and leads to good functional results.
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Review
What is the effect of compartment syndrome and fasciotomies on fracture healing in tibial fractures?
Acute compartment syndrome (ACS) in tibial diaphyseal fractures has been associated with such complications as infection, delayed fracture healing or non-union, sensory and motor deficits, deformities, and poor functional outcome. Essential condition of an uncomplicated recovery is early diagnosis with prompt decompression. ⋯ There were statistically significant differences in the time to healing, being longer by 4.90 weeks (p<0.001), and in the rates of delayed union or non-union (55% versus 17.8%) (p<0.001) when these fractures were compared to tibial fractures without compartment syndrome. Patients with ACS of the tibia undergoing leg fasciotomies should be informed about the increased risk of impaired fracture healing and longer time to union.
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MRSA is becoming increasingly common worldwide. With the emergence of new highly spreadable strains (community associated or CA-MRSA) novel presentation skin and soft tissue infections (SSTI) are being seen. ⋯ Empirical antimicrobial management choices can be difficult, but clues to the nature of the MRSA may be gleaned from the history and clinical presentation. More severe SSTI due to necrotising fasciitis and purpura fulminans are emerging and warrant the broadest possible empirical Gram-positive cover, ideally with antimicrobials that stop exotoxin production, and sometimes intravenous immunoglobulin to neutralise exotoxins already produced.
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Infections in vascular surgery are usually of multifactorial nature resulting from a complex interplay of patient, surgical and environmental factors. Preventative measures initiated from the stage of pre-operative screening, maintenance of patient homeostasis and the use of organism-directed antibiotics can contribute to reduce infection rates. ⋯ In this article we report on the current trends and techniques on the management of infections in vascular surgery. Ongoing studies are required to continue to accumulate data on the effectiveness of these techniques.