Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 468 | Issue 8 | Aug, 2010

Synovial Fluid Biomarkers for Periprosthetic Infection

Carl Deirmengian MD, Nadim Hallab PhD, Abdul Tarabishy MD, Craig Della Valle MD, Joshua J. Jacobs, Jess Lonner MD, Robert E. Booth MD

We have previously described a unique gene expression signature exhibited by synovial fluid leukocytes in response to bacterial infection, identifying a number of potential biomarkers for infection. However, the diagnostic performance of these potential biomarkers in an immunoassay format is unknown.

Irrigation and Débridement and Prosthesis Retention for Treating Acute Periprosthetic Infections

Jonathan P. Kleunen MD, Denise Knox BS, Jonathan P. Garino MD, Gwo-Chin Lee MD

Infections following hip and knee replacements can compromise the function and durability of arthroplasty. When these infections occur during the immediate postoperative period, irrigation and débridement can be attempted to salvage the implant. Prior studies have reported varying results likely due to lack of consistent inclusion criteria, variations in surgical technique, and lack of uniform treatment protocols.

A Two-stage Retention Débridement Protocol for Acute Periprosthetic Joint Infections

Chris S. Estes DO, Chris P. Beauchamp MD, Henry D. Clarke MD, Mark J. Spangehl MD

Due to the historically poor infection control rates with débridement and component retention for acute periprosthetic infections we developed a new approach for treating acute periprosthetic total joint infections: initial débridement with prosthesis retention and placement of antibiotic-impregnated cement beads followed by a second débridement within 7 days, at which time the beads are removed and new modular parts inserted. Intravenous antibiotics were used for 6 weeks followed by oral antibiotics. Depending on the clinical situation, antibiotics are discontinued or in selected patients continued indefinitely.

Prior Use of Antimicrobial Therapy is a Risk Factor for Culture-negative Prosthetic Joint Infection

Davud Malekzadeh, Douglas R. Osmon MD, MPH, Brian D. Lahr MS, Arlen D. Hanssen MD, Elie F. Berbari MD

Clinical characteristics and control of the infection of patients with culture-negative (CN) prosthetic joint infection (PJI) have not been well assessed. Prior use of antimicrobial therapy has been speculated but not proven as a risk factor for CNPJI.

Revision Hip Arthroplasty: Infection is the Most Common Cause of Failure

S. Mehdi Jafari MD, Catelyn Coyle BA, S. M. Javad Mortazavi MD, Peter F. Sharkey MD, Javad Parvizi MD, FRCS

Revision total hip arthroplasty (THA), although relieving pain and restoring function, fails in some patients. In contrast to failures in primary THA, the frequency of the causes of failure in revision THA has been less well established.

Revision Total Knee Arthroplasty Infection: Incidence and Predictors

S. M. Javad Mortazavi MD, Justin Schwartzenberger BS, Matthew S. Austin MD, James J. Purtill MD, Javad Parvizi MD, FRCS

Deep infection remains one of the most devastating and costly complications after total knee arthroplasty (TKA). The risk of deep infection after revision TKA is reportedly greater than that for primary TKA; however, we do not know the exact incidence of infection after revision TKA.

Two-stage Exchange Knee Arthroplasty: Does Resistance of the Infecting Organism Influence the Outcome?

Mark F. Kurd MD, Elie Ghanem MD, Jill Steinbrecher BS, Javad Parvizi MD, FRCS

Periprosthetic joint infection after TKA is a challenging complication. Two-stage exchange arthroplasty is the accepted standard of care, but reported failure rates are increasing. It has been suggested this is due to the increased prevalence of methicillin-resistant infections.

Outcomes of Revision Total Knee Arthroplasty After Methicillin-resistant Staphylococcus aureus Infection

Dann J. Laudermilch BS, Catherine J. Fedorka BA, Alma Heyl CCRC, Nalini Rao MD, Richard L. McGough MD

The incidence of infection by methicillin-resistant Staphylococcus aureus (MRSA) in total knee arthroplasty (TKA) is becoming a more frequent concern, as increased morbidity following TKA has been reported for infections by resistant organisms. This study investigates whether MRSA infections are associated with decreased functional scores.

Chitosan Sponges to Locally Deliver Amikacin and Vancomycin: A Pilot In Vitro Evaluation

Scott P. Noel MS, Harry S. Courtney PhD, Joel D. Bumgardner PhD, Warren O. Haggard PhD

Open orthopaedic wounds are ideal sites for infection. Preventing infection in these wounds is critical for reducing patient morbidity and mortality, controlling antimicrobial resistance and lowering the cost of treatment. Localized drug delivery has the potential to overcome the challenges associated with traditional systemic dosing. A degradable, biocompatible polymer sponge (chitosan) that can be loaded with clinician-selected antibiotics at the point of care would provide the patient and clinician with a desirable, adjunctive preventive modality.

Inhibition of Staphylococcus epidermidis Biofilms Using Polymerizable Vancomycin Derivatives

McKinley C. Lawson PhD, Kevin C. Hoth BS, Cole A. DeForest BS, Christopher N. Bowman PhD, Kristi S. Anseth PhD

Biofilm formation on indwelling medical devices is a ubiquitous problem causing considerable patient morbidity and mortality. In orthopaedic surgery, this problem is exacerbated by the large number and variety of material types that are implanted. Metallic hardware in conjunction with polymethylmethacrylate (PMMA) bone cement is commonly used.

An Approach for Determining Antibiotic Loading for a Physician-directed Antibiotic-loaded PMMA Bone Cement Formulation

Gladius Lewis PhD, Jennifer L. Brooks BS, Harry S. Courtney PhD, Yuan Li PhD, Warren O. Haggard PhD

When a physician-directed antibiotic-loaded polymethylmethacrylate (PMMA) bone cement (ALBC) formulation is used in total hip arthroplasties (THAs) and total knee arthroplasties (TKAs), current practice in the United States involves arbitrary choice of the antibiotic loading (herein defined as the ratio of the mass of the antibiotic added to the mass of the cement powder). We suggest there is a need to develop a rational method for determining this loading.

Strength of Antimicrobial Bone Cement Decreases with Increased Poragen Fraction

Matt Nugent MD, Alex McLaren MD, Brent Vernon PhD, Ryan McLemore PhD

Adding soluble particulate poragens to antimicrobial-loaded bone cement increases the permeability of the bone cement and increases the antimicrobial release, but the mechanical effect of adding poragens is not well known.

Microbiology of Bone and Joint Infections in Injecting Drug Abusers

Daniel C. Allison MD, Paul D. Holtom MD, Michael J. Patzakis MD, Charalampos G. Zalavras MD

The literature contains variable reports on the causative organisms of osteomyelitis and septic arthritis in patients with injecting drug abuse and on the rate of oxacillin-resistant S aureus. It is important to have a clear notion of the organisms to initiate empiric antimicrobial therapy.

Bacterial Colonization of Bone Allografts: Establishment and Effects of Antibiotics

Constantinos Ketonis PhD, Stephanie Barr BS, Christopher S. Adams PhD, Noreen J. Hickok PhD, Javad Parvizi MD

Bone grafts are frequently used to supplement bone stock and to establish structural stability. However, graft-associated infection represents a challenging complication leading to increased patient morbidity and healthcare costs.

Radiographic Stability of Ingrowth Humeral Stems in Total Shoulder Arthroplasty

Thomas W. Throckmorton MD, Peter C. Zarkadas MD, John W. Sperling MD, Robert H. Cofield MD

Cemented and uncemented stem types are available for TSA. An early uncemented stem designed for bone ingrowth had radiographic loosening of approximately 10% at intermediate followup (mean 4.6 years). Subsequent stem modifications included circumferential metaphyseal porous coating to enhance ingrowth and reduce loosening rates.

Sonographic Identification of the Intracompartmental Septum in de Quervain’s Disease

Bong Cheol Kwon MD, PhD, Soo-Joong Choi MD, Sung Hye Koh MD, Dong Jo Shin MD, Goo Hyun Baek MD, PhD

The intracompartmental septum in the first extensor compartment in patients with de Quervain’s disease has been associated with disease development and prognosis. However, with the exception of surgical exploration, there is no way of detecting the septum.

Immunologic Adverse Reaction Associated with Low-carbide Metal-on-metal Bearings in Total Hip Arthroplasty

Panagiotis Aroukatos MD, Maria Repanti MD, PhD, Thomas Repantis MD, Vassiliki Bravou MD, Panagiotis Korovessis MD, PhD

An increased incidence of periprosthetic osteolysis, resulting in loss of biologic fixation, has been reported in contemporary THAs with low-carbide metal-on-metal compared with metal-on-polyethylene couple bearings. Although a hypersensitivity reaction attributable to Co and Cr debris is reportedly a potential cause for failure of THAs with high-carbide bearings, there are no evidence-based data for this reaction in low-carbide metal-on-metal bearings, although such hypersensitivity might be related to osteolysis.

Cams and Pincer Impingement Are Distinct, Not Mixed: The Acetabular Pathomorphology of Femoroacetabular Impingement

Justin Cobb MCh, Kartik Logishetty BSc, Kinner Davda MRCS, Farhad Iranpour MD

Many impinging hips are said to have a mix of features of femoral cam and an overcovered acetabulum causing pincer impingement. Correction of such a mixed picture by reduction of the cam lesion and the acetabular rim is the suggested treatment.

The Efficacy of Periarticular Multimodal Drug Infiltration in Total Hip Arthroplasty

Constant A. Busch MB, BS, BSc (Hons), FRCS (Eng), FRCS (Tr and Orth), Michael R. Whitehouse MB, ChB, BSc (Hons), MSc (Orth Eng), MRCS (Eng), Benjamin J. Shore MD, Steven J. MacDonald MD, FRCSC, Richard W. McCalden MD, MPhil (Edin), FRCSC, Robert B. Bourne MD, FRCSC

Patient-controlled analgesia is a widely used and effective method of controlling pain after THA. This method is associated with substantial undesirable side effects. Local infiltration has been introduced in an attempt to reduce opioid requirements postoperatively, but its ability to reduce pain without complications is still questioned.

Cruciate-retaining TKA Using a Third-generation System with a Four-pegged Tibial Component: A Minimum 10-year Followup Note

Adam J. Schwartz MD, Craig J. Della Valle MD, Aaron G. Rosenberg MD, Joshua J. Jacobs MD, Richard A. Berger MD, Jorge O. Galante MD

A third-generation TKA system was designed to address problems encountered with earlier designs including a high rate of patellofemoral complications. At a minimum of 5 years, we previously reported survivorship of 98.7% using revision for any reason as the endpoint for a cohort that includes the patients described in this report. That cohort was unique in that a tibial component that uses four short pegs for fixation was used in a subset of patients undergoing cruciate-retaining TKA and the tibial and femoral components were precoated with polymethylmethacrylate.

Subcutaneous versus Intraarticular Indwelling Closed Suction Drainage after TKA: A Randomized Controlled Trial

Eun Seok Seo MD, Su Won Yoon RN, In Jun Koh MD, Chong Bum Chang MD, PhD, Tae Kyun Kim MD, PhD

TKA can involve substantial bleeding, and the issue regarding whether vacuum drainage should be used during TKA continues to be debated as both methods have disadvantages.

The Scarf Osteotomy: A Salvage Procedure for Recurrent Hallux Valgus in Selected Cases

Peter Bock MD, Ulrich Lanz MD, Andreas Kröner MD, Georg Grabmeier MD, Alfred Engel MD, PhD

The Scarf osteotomy was described as a technique to correct a metatarsus primus varus in primary hallux valgus surgery, but it is unclear whether the technique could correct recurrent hallux valgus when an initial procedure failed to provide any or an adequate lateral displacement of the metatarsal head.

Radiographic Predictability of Cartilage Damage in Medial Ankle Osteoarthritis

Jeong-Seok Moon MD, Jae-Chan Shim MD, Jin-Soo Suh MD, Woo-Chun Lee MD

Radiographic grading has been used to assess and select between treatment options for ankle osteoarthritis. To use radiographic grading systems in clinical practice and scientific studies one must have reliable systems that predict the fate of the cartilage.

Cemented Distal Femoral Endoprostheses for Musculoskeletal Tumor: Improved Survival of Modular versus Custom Implants

Adam J. Schwartz MD, J. Michael Kabo PhD, Fritz C. Eilber MD, Frederick R. Eilber MD, Jeffrey J. Eckardt MD

Advocates of newer implant designs cite high rates of aseptic loosening and failure as reasons to abandon traditional cemented endoprosthetic reconstruction of the distal femur.

MRI-guided Navigation Surgery with Temporary Implantable Bone Markers in Limb Salvage for Sarcoma

June Hyuk Kim MD, Hyun Guy Kang MD, PhD, Han-Soo Kim MD, PhD

Technical errors during navigation-assisted bone tumor resection may occur by: (1) incorrect registration of images and corresponding anatomic points of bone sent to the navigation system; and (2) incorrect fusion of two or more images that have been transported to the navigation system.

Medicine versus Orthopaedic Service for Hospital Management of Hip Fractures

Cynthia H. Chuang MD, MSc, Gregory J. Pinkowsky MD, Christopher S. Hollenbeak PhD, April D. Armstrong MD, MSc, FRCSC

Hospital care of patients with hip fractures often is managed primarily by either a medicine or orthopaedic service, depending on the institution. Whether complication rates, length of stay, or time to surgery differs on different services is unknown.

Influence of Acetabular and Femoral Version on Fractures of the Femoral Neck

A. Frost MRCS, G. Pavlou MRCS, P. J. Richards FRCR, J. Belcher BSc MPhil PhD, V. Jasani FRCS

Fractures through the proximal femur are broadly grouped into intertrochanteric fractures and intracapsular fractures. It is not clear why a patient may sustain an intertrochanteric fracture as compared with an intracapsular fracture. There is an established relationship between relative hip retroversion and the development of osteoarthritis. We postulate retroversion also may be a risk factor for having intracapsular fractures develop.

Laboratory Indicators for Early Detection and Surgical Treatment of Vibrio Necrotizing Fasciitis

Yao-Hung Tsai MD, Robert Wen-Wei Hsu MD, Kuo-Chin Huang MD, Tsung-Jen Huang MD

Vibrio necrotizing fasciitis is a rare and life-threatening soft tissue infection, with fulminant clinical courses and high mortality rates. However, the lack of specific disease characteristics and diagnostic tools during the initial examination may delay diagnosis.

Blood Culture Flasks for Culturing Synovial Fluid in Prosthetic Joint Infections

Lluís Font-Vizcarra MD, Sebastián García MD, PhD, Juan C. Martínez-Pastor MD, Josep M. Sierra MD, Alex Soriano MD, PhD

Identifying the etiologic microorganism is essential to guide antimicrobial therapy in prosthetic joint infection.

Minimizing Electromagnetic Interference from Surgical Instruments on Electromagnetic Surgical Navigation

Faustin Stevens BS, Michael A. Conditt PhD, Nikhil Kulkarni MS, Sabir K. Ismaily BS, Philip C. Noble PhD, David R. Lionberger MD

Electromagnetic computer-assisted surgery (EM-CAS) can be affected by various metallic or ferromagnetic factors.

N-acetylcysteine Protects Striated Muscle in a Model of Compartment Syndrome

Stephen R. Kearns FRCS (Tr&Orth), David E. O’Briain IMRCS, Katherine M. Sheehan MD, Cathal Kelly FRCSI (Gen), David Bouchier-Hayes FRCSI

To avoid ischemic necrosis, compartment syndrome is a surgical emergency treated with decompression once identified. A potentially lethal, oxidant-driven reperfusion injury occurs after decompression. N-acetylcysteine is an antioxidant with the potential to attenuate the reperfusion injury.

Effects of Pulsed Electromagnetic Fields on Human Osteoblastlike Cells (MG-63): A Pilot Study

Vincenzo Sollazzo MD, Annalisa Palmieri PhD, Furio Pezzetti PhD, Leo Massari MD, Francesco Carinci MD

Although pulsed electromagnetic fields (PEMFs) are used to treat delayed unions and nonunions, their mechanisms of action are not completely clear. However, PEMFs are known to affect the expression of certain genes.

Changes in the Number of Resident Publications after Inception of the 80-hour Work Week

Surena Namdari MD, MSc, Keith D. Baldwin MD, MSPT, MPH, Barbara Weinraub C-TAGME, Samir Mehta MD

Since the inception of resident work-hour regulations, there has been considerable concern regarding the influence of decreased work hours on graduate medical education. In particular, it is unclear whether implementation of work-hour restrictions has influenced resident academic performance as defined by quantity of peer-reviewed publications while participating in graduate medical education.

Case Report: Fibroxanthoma: A Complication of a Biodegradable Screw

Mir Sadat-Ali MD, PhD, FRCS, D Orth, Quamar Azzam MBBS, MS, Mohammed Bluwi MBBS, SSC (Ortho), Abdallah S. Al-Umran MBBS, SSC (Ortho)

Biodegradable interference screws in anterior cruciate ligament (ACL) reconstruction have gained popularity because of their similar or superior fixation strength in comparison to metallic interference screws and because they do not cause imaging artifacts and do not need to be removed.

Case Report: Mesenchymal Chondrosarcoma of the Lumbar Spine in a Child

Aristidis H. Zibis MD, PhD, M. Wade Shrader MD, Lee S. Segal MD

Chondrosarcomas of the spine constitute 4% to 10% of all primary spinal bone tumors and approximately 70% of the cases occur during the second or third decade of life. Mesenchymal chondrosarcoma is a rare aggressive variant of chondrosarcoma. The prognosis of mesenchymal chondrosarcoma is usually poor with a tendency for late local recurrence and metastasis.

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