Richard L. Purcell

The Use of Dilute Dakin's Solution for the Treatment of Angioinvasive Fungal Infection in the Combat Wounded: A Case Series

Disseminated fungal infections are normally opportunistic infections in the immunocompromised population. Current literature has documented a high mortality rate with these infections in civilian trauma or as complications of severe burns. There is only one published case of fungal infection in a combat-injured individual to date, which resulted in mortality despite aggressive debridement and appropriate antifungal agents. We present here three patients in whom aggressive debridement, antifungals, and the addition of dilute Dakins solution with negative pressure wound therapy was used to treat angioinvasive mold. Angioinvasive fungal infection continue to be one of the most aggressive and devastating infections that our combat-injured patients face. With the addition of dilute Dakins solution, we successfully managed three critically ill patients. Previous literature had shown close to 30% mortality associated with cutaneous mucormycosis and the mortality rate approaches 100% with disseminated angioinvasive fungal infections. These results provide hope not only for the combat-injured patients being treated for both local and disseminated angioinvasive fungal infections, but also for the civilian trauma and immunocompromised patients.

Combat-related pelvic ring fractures in survivors

Background: Pelvic fractures have been associated with rates of mortality up to 20%, with open injuries approaching rates up to 50%. This study compares differences in patients with open and closed pelvic ring injuries sustained during combat. Methods: Retrospective review of 114 patients who sustained a pelvic ring fracture and were alive upon presentation to the United States. We collected demographics, associated injuries, transfusion requirements, and outcomes to include residual bowel or bladder dysfunction and ambulatory status. Results: There were 114 patients, 98% male, with 75 closed and 39 open injuries. Average age was 26.6 yr. An average of 8.1 and 28.1 units of red blood cells were transfused in closed and open injuries, respectively (P<0.0001). Bilateral lower extremity amputations occurred in 11% of closed and 59% of open injuries (P<0.0001). Unstable fracture patterns occurred in 39% of closed fractures compared to 51% in open fractures (P=0.233). The time to weight bearing was 93 and 126 days for closed and open injuries (P=0.039). At latest follow-up, abnormal bladder and bowel function both occurred in 10% of closed and, respectively, 39% and 33% of open injuries (P=0.006). The rate of ambulation was 94% for closed injuries and 89% for open injuries (P=0.439). Conclusions: In the largest report of combat-related pelvic fractures in surviving patients, the incidence of open fractures was 34%. Although there are significant differences in associated injuries, transfusion requirements and time to weight bearing, patients with open pelvic fractures are able to return to a similar level of ambulatory function as those with closed fractures.

No clinically meaningful weight changes in a young cohort following total joint arthroplasty at 3-year follow-up

Total joint arthroplasty (TJA) is one of the most successful operations. There is little in the literature regarding weight change following TJA, particularly in a young cohort.

Extensile Exposures for Total Knee Arthroplasty

A well-planned surgical approach allowing for adequate exposure is one of the more common difficulties encountered in revision total knee arthroplasty. Careful attention must be paid to patients who have undergone previous knee operations as the skin may have become densely scarred into the deep fascial layers or even to the underlying bone. As a result, the surgical approach is particularly difficult secondary to a loss of tissue elasticity, which can place the patient at risk for wound breakdown.

Clinical Outcomes After Extracorporeal Shock Wave Therapy for Chronic Plantar Fasciitis in a Predominantly Active Duty Population

ABSTRACT Chronic plantar fasciitis is a common cause of foot pain, with conservative treatment providing relief for most patients. However, because of the common occurrence of this pathology, this leaves many patients dissatisfied. The purpose of the present study was to determine the effectiveness of extracorporeal shock wave therapy (ESWT) to treat chronic plantar fasciitis (PF) in a largely active duty population. A review of 82 patients (115 heels) who had undergone ESWT for chronic PF was performed. Outcome data were obtained by patient telephone interviews. All ESWT was conducted at 24 kV for 2000 shocks. Of the 82 patients (115 heels), 76 (93%; 111 heels) agreed to participate. Their mean age was 42 ± 10 years, with 41 males (54%) and 35 females (46%). The mean follow‐up period was 42 ± 22 months. Of the patients, 73.6% were active duty military personnel. The mean preoperative pain score of 7.8 ± 2 had improved to 2.5 ± 2 at the last follow‐up visit (p < .0001). Active duty patients reported a mean improvement in pain of 4.8 ± 3 compared with 6.8 ± 3 in non‐active duty patients (p = .005). Of the 76 patients, 75 (98%) underwent 1 ESWT session, and 1 (2%) requiring 2 sessions. Overall, 74% of patients rated the outcome of their procedure as either good or excellent, with 87% stating that ESWT was successful. Ten patients (18%) left the military because of continued foot pain, with 76% able to return to running. For patients with chronic PF, these results support the use of ESWT to relieve pain in >85% of patients, with a preponderance for better pain relief in patients who are not active duty military personnel. Level of Clinical Evidence: 4

Operating room traffic in total joint arthroplasty: Identifying patterns and training the team to keep the door shut

Background: Surgical site infections after joint arthroplasty are devastating complications and are influenced by patient, surgical, and operating room environmental factors. Methods: In an effort to reduce the incidence of door openings (DOs) during total joint arthroplasty cases, this prospective observational study consisted of 3 phases. Phase 1 determined the baseline incidence of DOs, followed by installation of a mechanical door counter (phase 2). Finally, an educational seminar was presented to all personnel (phase 3) regarding the implications frequent DOs have on patient and surgical outcomes. Results: The average openings per case (OPC) for each of the 3 phases were 33.5, 34.2, and 27.7, respectively. There was a 17% reduction in OPC between phases 1 and 3 (P = .02). There were no significant differences between knee and hip arthroplasty cases during the 3 phases (P = .21, P = .46, and P = .81, respectively). There was a strong correlation between length of surgery and OPC, with a Pearson coefficient of r = 0.87 during phase 3. To account for differences in average operative time between phases, data were normalized for the length of surgery with the ratio of door openings per minute determined (0.36, 0.34, and 0.32 for each phase, respectively). Conclusions: We were able to show that simply monitoring door openings during joint arthroplasty was not effective in reducing the occurrences. However, after a novel educational seminar given to all personnel, we were able to significantly reduce the incidence of operating room door openings, reducing a potential risk factor for surgical site infections.

Combat-related acetabular fractures: outcomes of open versus closed injuries

INTRODUCTION Since the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma. METHODS We performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed. RESULTS The mechanism of injury was an explosive device in 59% (n=19) of patients with an open acetabular fracture; the remaining 40% (n=13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n=34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p=0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level. DISCUSSION Open acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures.

Pelvic Floor Reconstruction Utilizing a Residual Hamstring Rotational Flap Following Traumatically Induced Subtotal Hemipelvectomy in a Combat Blast Casualty: A Case Report

OBJECTIVE There are several options for soft tissue coverage following external hemipelvectomy; however, in cases of war-related blast trauma, standard flaps are not always available as a result of the extensive soft tissue damage. METHODS We detail a novel closure technique following a subtotal hemipelvectomy with exposed abdominal viscera using a residual hamstring myofascial cutaneous flap. RESULTS This flap allowed for fascial tissue to fill the pelvic defect and provided excellent soft tissue coverage for future prosthetic wear. DISCUSSION In the current literature, there is limited information regarding surgical options for soft tissue coverage following traumatic hip disarticulation. Most cases result from malignancies or severe infection, where tissue distal to the lesion is viable and provides adequate coverage. This case report used a novel technique, provided excellent soft tissue coverage with no wound healing complications, allowed for excellent prosthetic fitting, and the patients ability to ambulate without assistance.