Outcomes of Foot Infections Secondary to Puncture Injuries in Patients With and Without Diabetes

It is difficult to compare foot infections in patients with diabetes to those without diabetes because foot infections are uncommon in people without diabetes. The aim of this study is to compare clinical outcomes in people with and without diabetes admitted to the hospital for an infected puncture wound. We evaluated 114 consecutive patients from June 2011 to March 2019 with foot infection resulting from a puncture injury; 83 had diabetes and 31 did not have diabetes. We evaluated peripheral arterial disease (PAD), sensory neuropathy, the need for surgery and amputation, length of hospitalization, and presence of osteomyelitis. Patients with diabetes were 31 times more likely to have neuropathy (91.6% versus 25.8%, p < .001, confidence interval [CI] 10.2 to 95.3), 8 times more likely to have PAD (34.9% versus 6.5%, p = .002, CI 1.7 to 35), and 7 times more likely to have kidney disease (19.3% versus 3.2%, p < .05, CI 0.9 to 56.5). They also took longer before presenting to the hospital (mean 20.1 ± 36.3 versus 18.8 ± 34.8 days, p = .09, CI 13 to 26.5); however, this result was not statistically significant. Patients with diabetes were 9 times more likely to have osteomyelitis (37.3% versus 6.5%, p = .001, CI 1.9 to 38.8). In addition, they were more likely to require surgery (95% versus 77%, p < .001, CI 1.6 to 21.4), required more surgeries (2.7 ± 1.3 versus 1.3 ± 0.8, p < .00001, CI 2.1 to 2.5), were 14 times more likely to have amputations (48.2% versus 6.5%, p < .0001, CI 3.0 to 60.2), and had 2 times longer hospital stays (16.2 ± 10.6 versus 7.5 ± 9 days, p = .0001, CI 11.9 to 15.9. Infected puncture wounds in patients with diabetes often fair much worse with more detrimental outcomes than those in patients without diabetes.     

Outcomes and complications for portal vein or superior mesenteric vein injury: No improvement in the era of damage control resuscitation

IntroductionPortal vein (PV) and superior mesenteric vein (SMV) injuries are lethal. We hypothesised outcomes have improved with modern trauma care.MethodsWe reviewed patients presenting to our Level 1 trauma centre over ten-years with PV/SMV injuries, analysing physiology, operative management, associated injuries, and outcomes.ResultsTwenty-four patients had 7 PV and 15 SMV injuries, 2 had both; all had operative exploration. Sixty-seven percent had penetrating trauma. While many had normal vitals, profound acidosis was common. All patients had ≥2 additional abdominal injuries, liver most common (50%). Additional abdominal vascular injuries were more common in non-survivors than survivors: IVC 46% vs 22%, common hepatic artery 20% vs 0%, SMA 26% vs 11%. The mean injury severity score (ISS) was 32.4, and the mean new injury severity score (NISS) was 44.5. Mortality was 63%. Eleven patients died from exsanguination, two from SMV thrombosis, and two from sequelae of other injuries. All survivors had venorrhaphy, as did 8 non-survivors. Non-survivors were also shunted; had ligation; or bypass, shunting, and ligation. Three exsanguinated prior to repair. Two survivors had SMV related complications. One with proximal SMV injury developed severe venous congestion and multiple enterocutaneous fistulae. Another developed an arterioportal fistula, managed with embolisation and percutaneous portal vein stenting.ConclusionDespite advances (REBOA, damage control surgery and resuscitation, liberal use of ED thoracotomy), PV and SMV injuries remain lethal. Injuries to other structures are ubiquitous. Early exsanguination is the major cause of death. All survivors had successful venorrhaphy; those who required more complex repairs died. Compromised mesenteric venous flow causes morbidity and mortality.     

Incidence,risk factors and clinical implications of postoperative urinary tract infection in geriatric hip fractures

IntroductionPostoperative urinary tract infection (UTI) is common in geriatric patients; however, little is known about the impact of UTI in orthopedic trauma. The present study was designed to determine the risk factors and clinical impact of postoperative urinary tract infection (UTI) in acute geriatric hip fractures.Patients and methodsGeriatric patients (≥65 years of age) undergoing hip fracture surgery were identified within the American College of Surgeons National Surgical Quality Improvement Program between 2016 and 2019. Patients presenting with UTI at the time of surgery were excluded. Baseline characteristics and outcomes were compared between patients with and without postoperative UTI. Multivariate logistic regression was performed, controlling for potential confounders.ResultsA total of 46,263 patients included in the study. Overall, 1,397 (3.02%) patients had postoperative UTI. Patients who developed postoperative UTI had higher rates of pneumonia (6.44% vs. 3.76%, p < 0.001), DVT (2.22% vs. 1.04%, p < 0.001), sepsis (7.73% vs. 0.62%, p < 0.001), and more frequently experienced postoperative hospital lengths of stay exceeding 6 days (37.94% vs. 20.33%, p < 0.001). Hospital readmission occurred more frequently in patients with postoperative UTI (24.55% vs. 7.85%, p < 0.001), but surprisingly, these patients had a lower mortality rate (1.36% vs. 2.2%, p < 0.001). Adjusted analysis demonstrated the following variables associated with postoperative UTI: age ≥ 85 (OR = 1.37, 95%CI = 1.08 - 1.73), ASA class ≥ 3 (OR = 1.59, 95%CI = 1.21 – 2.08,), chronic steroid use (OR = 1.451, 95%CI = 1.05 - 1.89), blood transfusion (OR = 1.24, 95%CI = 1.05 - 1.48), and >2 days delay from admission to operation (OR = 1.37, 95%CI = 1.05 - 1.79). Postoperative UTI was significantly associated with sepsis (OR = 7.65, 95%CI = 5.72 – 10.21), postoperative length of stay >2 days (OR = 1.83, 95%CI = 1.07 – 3.13), and readmission (OR = 3, 95%CI = 2.54 – 3.55).ConclusionsIn our study, postoperative UTI was found in 3% of geriatric hip fracture patients. Predictors of postoperative UTI were age ≥ 85, ASA class ≥ 3, chronic steroid use, blood transfusion, and time to operation > 2 days from admission. Results showed that postoperative UTI is independently associated with sepsis, postoperative length of stay beyond 2 days, and hospital readmission. To diminish the risk of UTI and its consequences, we recommend operating geriatric hip fractures in 24–48 hours after admission.     

Decompression status of the spinal cord after cervical laminoplasty in various body positions and neck postures observed using percutaneous ultrasonography: Relationship with neurological recovery

BackgroundPercutaneous ultrasonography (PUS) is used to evaluate the status of the spinal cord after cervical laminoplasty (CLP). This technique helps assess real-time movements of the spinal cord and provides immediate information regarding the decompression status. Additionally, it can also be utilized to evaluate the status of the spinal cord in various body positions and neck postures. This study aimed to examine changes in the decompression status of the spinal cord after CLP for cervical spondylotic myelopathy (CSM) in different body positions and neck postures using PUS and to assess whether these decompression statuses are related to clinical outcomes at each time point.MethodsThe study included 66 consecutive participants with CSM who underwent double-door CLP with suture anchors. PUS was performed postoperatively at 2 weeks, 3 months, 6 months, and 1 year in sitting [neck flexion (Flexion), neutral (Neutral), and extension (Extension)] and supine (Supine) positions. The decompression status was classified into grade I (noncontact), grade II (contact and apart), and grade III (contact). Clinical outcomes were evaluated using Japanese Orthopaedic Association (JOA) scores.ResultsThe decompression status improved until 3 months postoperatively in all body positions and neck postures and was stable onwards. It changed depending on body positions and neck postures and was worse in Flexion and better in Supine at all postoperative time points. Participants with grade I decompression status in Supine had a significantly better recovery rate of JOA scores after 3 months, 6 months, and 1 year postoperatively than those with grade II + III decompression status. However, this significant relationship was not observed in each sitting position.ConclusionsThe spinal cord after CLP is most decompressed in Supine. Sufficient and continuous restoration of the anterior subarachnoid space in supine position may indicate positive clinical outcomes after CLP.