SOFT TISSUE INJURIES AND TREATMENTS (2011 JOURNAL AND UPDATES)

Methicillin-Resistant Staphylococcus aureus Skin and Soft Tissue Infections

Krista Estes. Critical Care Nursing Quarterly. Frederick: Apr-Jun 2011. Vol. 34, Iss. 2; pg.
101
With the emergence and rising prevalence of methicillin-resistant Staphylococcus aureus among
individuals in the community, it is imperative to standardize patient care and develop best
practices among health care providers. Evidence-based standard patient care guidelines for
community-acquired methicillin-resistant S aureus skin and soft tissue infections have the
potential to positively impact patient outcomes, decrease health risk, reduce hospitalization from
insufficient treatment, and decrease or even prevent further transmission to unaffected
individuals. Emergency department providers are in a unique position to lead in the management
and prevention of skin and soft tissue infections. It is essential that community-acquired
methicillin-resistant S aureus skin and soft tissue infections are consistently treated by evidence-
based treatment standards, especially with the growing number of pathogens displaying
resistance to antibiotics, rising mortality, rapid spread of antimicrobial resistant microbes, and
the escalating health care costs. The purpose of this literature review is to provide health care
providers with current evidence-based health care guidelines for the treatment and management
of community-acquired methicillin-resistant S aureus skin and soft tissue infections.

Injuries Associated With Cribs, Playpens, and Bassinets Among Young Children in the US,
1990-2008
Elaine S Yeh, Lynne M Rochette, Lara B McKenzie, Gary A Smith. Pediatrics. Evanston: Mar
2011. Vol. 127, Iss. 3; pg. 479

To describe the epidemiology of injuries related to cribs, playpens, and bassinets among young
children in the United States. A retrospective analysis was done using data from the National
Electronic Injury Surveillance System for children younger than 2 years of age treated in
emergency departments in the United States from 1990 through 2008 for an injury associated
with cribs, playpens, and bassinets. An estimated 181 654 (95% confidence interval: 148 548-
214 761) children younger than 2 years of age were treated in emergency departments in the
United States for injuries related to cribs, playpens, and bassinets during the 19-year study
period. There was an average of 9561 cases per year or an average of 12.1 injuries per 10 000
children younger than 2 years old per year. Most of the injuries involved cribs (83.2%), followed
by playpens (12.6%) and bassinets (4.2%). The most common mechanism of injury was a fall
from a crib, playpen, or bassinet, representing 66.2% of injuries. Soft-tissue injuries comprised
the most common diagnosis (34.1%), and the most frequently injured body region was the head
or neck (40.3%). Patients with fractures were admitted 14.0% of the time, making them 5.45
(95% confidence interval: 3.80-7.80) times more likely to be hospitalized than patients with
other types of injury. Children younger than 6 months were 2.97 (95% confidence interval: 2.07-
4.24) times more likely to be hospitalized than older children. This study is the first to use a
nationally representative sample to examine injuries associated with cribs, playpens, and
bassinets. Given the consistently high number of observed injuries, greater efforts are needed to
ensure safety in the design and manufacture of these products, ensure their proper usage in the
home, and increase awareness of their potential dangers to young children.
Randomized Controlled Trial of Cephalexin Versus Clindamycin for Uncomplicated
Pediatric Skin Infections
Aaron E Chen, Karen C Carroll, Marie Diener-West, Tracy Ross, et al. Pediatrics. Evanston:
Mar 2011. Vol. 127, Iss. 3; pg. e573

To compare clindamycin and cephalexin for treatment of uncomplicated skin and soft tissue
infections (SSTIs) caused predominantly by community-associated (CA) methicillin-resistant
Staphylococcus aureus (MRSA). We hypothesized that clindamycin would be superior to
cephalexin (an antibiotic without MRSA activity) for treatment of these infections. Patients aged
6 months to 18 years with uncomplicated SSTIs not requiring hospitalization were enrolled
September 2006 through May 2009. Eligible patients were randomly assigned to 7 days of
cephalexin or clindamycin; primary and secondary outcomes were clinical improvement at 48 to
72 hours and resolution at 7 days. Cultures were obtained and tested for antimicrobial
susceptibilities, pulsed-field gel electrophoresis type, and Panton-Valentine leukocidin status. Of
200 enrolled patients, 69% had MRSA cultured from wounds. Most MRSA were USA300 or
subtypes, positive for Panton-Valentine leukocidin, and clindamycin susceptible, consistent with
CA-MRSA. Spontaneous drainage occurred or a drainage procedure was performed in 97% of
subjects. By 48 to 72 hours, 94% of subjects in the cephalexin arm and 97% in the clindamycin
arm were improved (P = .50). By 7 days, all subjects were improved, with complete resolution in
97% in the cephalexin arm and 94% in the clindamycin arm (P = .33). Fevers and age less than 1
year, but not initial erythema > 5 cm, were associated with early treatment failures, regardless of
antibiotic used. There is no significant difference between cephalexin and clindamycin for
treatment of uncomplicated pediatric SSTIs caused predominantly by CA-MRSA. Close follow-
up and fastidious wound care of appropriately drained, uncomplicated SSTIs are likely more
important than initial antibiotic choice.

Is Supplementary Fixation Necessary in Anterior Cruciate Ligament Reconstructions?

John J Lee, Karimdad Otarodifard, Bong Jae Jun, Michelle H McGarry, et al. The American
Journal of Sports Medicine. Baltimore: Feb 2011. Vol. 39, Iss. 2; pg. 360

There has been concern regarding the fixation of anterior cruciate ligament reconstruction, with
soft tissue grafts being strong and stiff enough to allow for early accelerated postoperative
rehabilitation. Therefore, some have recommended supplementary fixation for soft tissue tibia
interference screw fixation with a staple, to improve the strength and stiffness of the fixation.
Unfortunately, with staple supplementation, there is a risk for symptomatic hardware, which may
require a second surgery to remove the staple. Supplementary fixation with a bioabsorbable
knotless suture anchor will improve the structural properties of soft tissue tibia bioabsorbable
interference screw (BIS) fixation and be comparable with supplementary fixation with a staple.
Controlled laboratory study. Fifteen porcine tibias and flexor profundus tendons were
randomized into 3 fixation study groups: group 1, BIS; group 2, BIS + staple; and group 3, BIS +
push-lock screw. The structural properties of the 3 fixation groups were tested under
displacement-controlled cyclic loading and load to failure. No significant difference in mean
stiffness (N/mm ± SEM) under cyclic loading was found for BIS (335.31 ± 15.43), BIS + staple
(344.81 ± 44.97), and BIS + push-lock (353.28 ± 38.93). Under load-to-failure testing, there
were no differences found in stiffness, yield load, displacement at yield load, displacement at
ultimate load, and energy absorbed among the 3 fixation methods. BIS + push-lock fixation had
a significantly higher ultimate load than BIS alone and BIS + staple (917.85 ± 58.30 N vs 479.83
± 66.04 N, P = .0003 vs 618.89 ± 8.94 N, P = .004). Supplementary fixation with staple or push-
lock screw did not significantly increase the structural strength and stiffness of the BIS soft
tissue graft fixation under cyclic loading, but it did show improvement under load-to-failure
testing for ultimate tensile load. The indication for supplementary fixation for tibial BIS soft
tissue graft fixation depends on the fixation that the BIS achieves at the time of the surgery
because the tensile load is transferred to the secondary fixation if and only when there is slippage
of graft at the primary fixation. The supplementary fixation may be of value in those cases with
poor bone quality, such as revision surgery with tunnel widening and/or graft-tunnel mismatch,
or possibly in cases with older patients or patients with disorders affecting bone mineral density.