Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 472 | Issue 11 | Nov, 2014

Diagnosing Periprosthetic Joint Infection: Has the Era of the Biomarker Arrived?

Carl Deirmengian MD, Keith Kardos PhD, Patrick Kilmartin, Alexander Cameron, Kevin Schiller, Javad Parvizi MD

The diagnosis of periprosthetic joint infection (PJI) remains a serious clinical challenge. There is a pressing need for improved diagnostic testing methods; biomarkers offer one potentially promising approach.

Diagnosis of Periprosthetic Joint Infection in Medicare Patients: Multicriteria Decision Analysis

Claudio Diaz-Ledezma MD, Paul M. Lichstein MD, MS, James G. Dolan MD, Javad Parvizi MD, FRCS

In the setting of finite healthcare resources, developing cost-efficient strategies for periprosthetic joint infection (PJI) diagnosis is paramount. The current levels of knowledge allow for PJI diagnostic recommendations based on scientific evidence but do not consider the benefits, opportunities, costs, and risks of the different diagnostic alternatives.

Performance Characteristics of Broth-only Cultures After Revision Total Joint Arthroplasty

Eric B. Smith MD, Jenny Cai BS, Rachael Wynne RN, Mitchell Maltenfort PhD, Robert P. Good MD

Surgeons frequently obtain intraoperative cultures at the time of revision total joint arthroplasty. The use of broth or liquid medium before applying the sample to the agar medium may be associated with contamination and false-positive cultures; however, the degree to which this is the case is not known.

Systemic Inflammatory Markers and Aspiration Cell Count May Not Differentiate Bacterial From Fungal Prosthetic Infections

Colten D. Bracken BS, Elie F. Berbari MD, Arlen D. Hanssen MD, Tad M. Mabry MD, Douglas R. Osmon MD, Rafael J. Sierra MD

Fungal periprosthetic joint infections (PJIs) are rare. Fewer than 200 cases have been reported in the literature. The characteristics of systemic inflammatory markers and joint aspirate cell count analysis obtained in patients with fungal PJIs have not been fully assessed. The ability to diagnose involvement of fungal PJI preoperatively may optimize the surgical and medical management of these patients.

Arthrodesis Should Be Strongly Considered After Failed Two-stage Reimplantation TKA

Chia H. Wu MD, MBA, Chancellor F. Gray MD, Gwo-Chin Lee MD

A two-stage reimplantation procedure is a well-accepted procedure for management of first-time infected total knee arthroplasty (TKA). However, there is a lack of consensus on the treatment of subsequent reinfections.

Biofilm Growth Has a Threshold Response to Glucose in Vitro

Robert Waldrop MD, Alex McLaren MD, Francis Calara BSE, Ryan McLemore PhD

Hyperglycemia is a risk factor for nosocomial infections with known host effects. Increased glucose levels also increase pathogenicity of infecting microbes through greater biofilm formation. The dose response of biofilm formation to glucose concentration is not known.

Does Implant Coating With Antibacterial-Loaded Hydrogel Reduce Bacterial Colonization and Biofilm Formation in Vitro?

Lorenzo Drago PhD, Willemijn Boot MSc, Kostantinos Dimas PhD, Kostantinos Malizos PhD, Gertrud M. Hänsch PhD, Jos Stuyck PhD, Debby Gawlitta PhD, Carlo L. Romanò MD

Implant-related infections represent one of the most severe complications in orthopaedics. A fast-resorbable, antibacterial-loaded hydrogel may reduce or prevent bacterial colonization and biofilm formation of implanted biomaterials.

Antimicrobial Distribution From Local Delivery Depends on Dose

Alex McLaren MD, Morgan B. Giers PhD, James Fraser MD, MPH, Luke Hosack MD, Michael R. Caplan PhD, Ryan McLemore PhD

Tissue distribution after local delivery has been quantified over a period of 5 hours on 7-T MRI in a rabbit model using gadolinium-labeled diethylenetriamine pentaacetic acid (Gd-DTPA) as an antimicrobial surrogate; however, it is unknown how the Gd-DTPA load in a local depot will affect the duration of high-concentration Gd-DTPA in local tissues after surgical débridement.

The Epidemiology and Injury Patterns of Acetabular Fractures: Are the USA and China Comparable?

Cyril Mauffrey MD, FACS, FRCS, Jiandong Hao MD, PhD, Derly O. Cuellar MD, Benoit Herbert MD, Xiao Chen MD, Bo Liu MD, Yingze Zhang MD, Wade Smith MD, FACS

Acetabular fractures are rare injuries in heterogeneous patient groups, making it difficult to develop adequately powered prospective single-center clinical trials in the USA or Europe. Chinese trauma centers treat a high volume of these injuries, and if the patient population and injury patterns are comparable to those in the USA, this might support development of multicenter studies in Level I trauma centers in the two countries.

A Surgical Approach Algorithm for Transverse Posterior Wall Fractures Aids in Reduction Quality

Yelena Bogdan MD, Shashank Dwivedi MS, Paul Tornetta MD

Transverse posterior wall fractures are difficult to treat and historically have been associated with stiffness, posttraumatic arthritis, and pain, which correlate with the reduction. The Kocher–Langenbeck approach is used most often, whereas the extended iliofemoral approach has been reserved for more complex injury patterns. The latter approach has substantially more risks. No data to our knowledge exist on the use of sequential anterior and posterior approaches for this pattern.

Treatment of Acetabulum Fractures Through the Modified Stoppa Approach: Strategies and Outcomes

Mark J. Isaacson DO, Benjamin C. Taylor MD, Bruce G. French MD, Attila Poka MD

Since the original description by Letournel in 1961, the ilioinguinal approach has remained the predominant approach for anterior acetabular fixation. However, modifications of the original abdominal approach described by Stoppa have made another option available for reduction and fixation of pelvic and acetabular fractures.

Are Quadrilateral Surface Buttress Plates Comparable to Traditional Forms of Transverse Acetabular Fracture Fixation?

Brian J. Kistler MD, Ian R. Smithson MD, Seth A. Cooper MD, Jacob L. Cox MD, Aniruddh N. Nayak MS, Brandon G. Santoni PhD, H. Claude Sagi MD

Several construct options exist for transverse acetabular fracture fixation. Accepted techniques use a combination of column plates and lag screws. Quadrilateral surface buttress plates have been introduced as potential fixation options, but as a result of their novelty, biomechanical data regarding their stabilizing effects are nonexistent. Therefore, we aimed to determine if this fixation method confers similar stability to traditional forms of fixation.

CT-generated Radiographs in Obese Patients With Acetabular Fractures: Can They Be Used in Lieu of Plain Radiographs?

Philip M. Sinatra MD, Berton R. Moed MD

Acetabular fracture diagnosis is traditionally made with AP and oblique pelvic plain radiographs. Obesity may impair diagnostic accuracy of plain radiographs. New CT reconstruction algorithms allow for simulated radiographs that may eliminate the adverse imaging effects of obesity.

Modifier 22 for Acetabular Fractures in Morbidly Obese Patients: Does It Affect Reimbursement?

Patrick F. Bergin MD, Christopher Kneip MD, Christine Pierce MD, Stephen T. Hendrix MD, Scott E. Porter MD, Matthew L. Graves MD, George V. Russell MD

Modifier 22 in the American Medical Association’s Current Procedural Terminology (CPT) book is a billing code for professional fees used to reflect an increased amount of skill, time, and work required to complete a procedure. There is little disagreement that using this code in the setting of surgery for acetabulum fractures in the obese patient is appropriate; however, to our knowledge, the degree to which payers value this additional level of complexity has not been determined.

Managing Acetabular Fractures in the Elderly With Fixation and Primary Arthroplasty: Aiming for Early Weightbearing

Mark Rickman MD, MBChB, FRCS, James Young MBBS, MRCS(Eng), Alex Trompeter MBBS, BSc, FRCS(Tr&Orth), Rachel Pearce RGN, BSc, Mark Hamilton FRCA

Osteoporotic acetabular fractures in the elderly are becoming more common. Regardless of treatment, most patients are managed with a period of protected weightbearing, even if a THA has been performed. We have tried to treat these patients analogously to geriatric femoral neck fractures in a way that allows immediate full weightbearing.

Risk Factors for the Development of Heterotopic Ossification After Acetabular Fracture Fixation

Reza Firoozabadi MD, MA, Timothy J. O’Mara MD, Alan Swenson MD, Julie Agel MA, ATC, John D. Beck MD, Milton Routt MD

Heterotopic ossification (HO) is a common complication of the operative treatment of acetabular fractures. Although the surgical approach has been shown to correlate with the development of ectopic bone, specific risk factors have not been elucidated.

Is Preoperative Radiation Therapy as Effective as Postoperative Radiation Therapy for Heterotopic Ossification Prevention in Acetabular Fractures?

Michael T. Archdeacon MD, MSE, Albert d’Heurle MD, Nicole Nemeth MD, Bradley Budde MD

Prophylactic approaches to prevent heterotopic ossification after acetabular fracture surgery have included indomethacin and/or single-dose external beam radiation therapy administered after surgery. Although preoperative radiation has been used for heterotopic ossification prophylaxis in the THA population, to our knowledge, no studies have compared preoperative and postoperative radiation therapy in the acetabular fracture population.

What Is the Frequency of Nerve Injuries Associated With Acetabular Fractures?

Wolfgang Lehmann MD, Michael Hoffmann MD, Florian Fensky MD, Jakob Nüchtern MD, Lars Großterlinden MD, Emin Aghayev MD, Helmar Lehmann MD, Fabian Stuby MD, Johannes M. Rueger MD

Acetabular fractures and surgical interventions used to treat them can result in nerve injuries. To date, only small case studies have tried to explore the frequency of nerve injuries and their association with patient and treatment characteristics. High-quality data on the risk of traumatic and iatrogenic nerve lesions and their epidemiology in relation to different fracture types and surgical approaches are lacking.

A Novel System Improves Preservation of Osteochondral Allografts

James L. Cook DVM, PhD, Aaron M. Stoker PhD, James P. Stannard MD, Keiichi Kuroki DVM, PhD, Cristi R. Cook DVM, MS, Ferris M. Pfeiffer PhD, Chantelle Bozynski DVM, MSc, Clark T. Hung PhD

Osteochondral allografting is an option for successful treatment of large articular cartilage defects. Use of osteochondral allografting is limited by graft availability, often because of loss of chondrocyte viability during storage.

Does Advanced Cryotherapy Reduce Pain and Narcotic Consumption After Knee Arthroplasty?

Emmanuel Thienpont MD, MBA

Cryotherapy has been used to enhance recovery after orthopaedic surgery. Several cooling devices are available but few can guarantee a fixed temperature during a prolonged time and therefore have been criticized. The arrival of new advanced cryotherapy devices made it possible to test the effect of prolonged cooling on rehabilitation after joint replacement.

Collateral Ligament Laxity in Knees: What Is Normal?

Kamal Deep MBBS, MS, DNB, FRCS, MCh Orth, FRCS(Orth)

Proper alignment and balancing of soft tissues of the knee are important goals for TKA. Despite standardized techniques, there is no consensus regarding the optimum amount of collateral ligament laxity one should leave at the end of the TKA.

High Tibial Valgus Osteotomy: Closing, Opening or Combined? Patellar Height as a Determining Factor

Oliver Portner BSc, MDCM, FRCSC

According to the literature, closing and opening wedge high tibial valgus osteotomies can raise or lower the patella, and diffèrent methods of patella height measurement show similarly conflicting results. Clarification of this was thought to be important because there is much literature describing morbidity secondary to patella alta or patella infera (baja). Effects on tibial slope and patellar tendon length are not well delineated and the influence of sex and age is unknown.

The National Hospital Discharge Survey and Nationwide Inpatient Sample: The Databases Used Affect Results in THA Research

Stijn Bekkers BSc, Arjan G. J. Bot MD, PhD, Dennis Makarawung BSc, Valentin Neuhaus MD, David Ring MD, PhD

The National Hospital Discharge Survey (NHDS) and the Nationwide Inpatient Sample (NIS) collect sample data and publish annual estimates of inpatient care in the United States, and both are commonly used in orthopaedic research. However, there are important differences between the databases, and because of these differences, asking these two databases the same question may result in different answers. The degree to which this is true for arthroplasty-related research has, to our knowledge, not been characterized.

Are Harris Hip Scores and Gait Mechanics Related Before and After THA?

Omar A. Behery MPH, Kharma C. Foucher MD, PhD

Discordance between subjective and objective functional measures hinders the development of new ways to improve THA outcomes.

What Are the Results Using the Modified Trapdoor Procedure to Treat Chondroblastoma of the Femoral Head?

Hairong Xu MD, Xiaohui Niu MD, Yuan Li MD, Odion T. Binitie MD, G. Douglas Letson MD, David Cheong MD

Treatment of chondroblastoma in the femoral head is challenging owing to the particular location and its aggressive nature. There is little published information to guide the surgeon regarding the appropriate approach to treating a chondroblastoma in this location. We developed a modified trapdoor procedure to address this issue. The primary modification is that the window surface of the femoral head is covered by the ligamentum teres rather than cartilage as in the traditional procedure.

Do Long Term Survivors of Ewing Family of Tumors Experience Low Bone Mineral Density and Increased Fracture Risk?

Gerhard M. Hobusch MD, Iris Noebauer-Huhmann MD, PhD, Christoph Krall PhD, Gerold Holzer MD, PhD

Multimodal treatment regimens for Ewing’s sarcoma have led to survival rates approaching 70% of patients with no metastases at diagnosis. However, these treatments have long-term side effects. Low bone mineral density (BMD) and risk of fractures can occur owing in part to chemotherapy and limited mobility from local control of the primary tumor.

Is Curettage and High-speed Burring Sufficient Treatment for Aneurysmal Bone Cysts?

Edward H. M. Wang MD, MSc, Michael L. Marfori MD, Ma Victoria T. Serrano PTRP, Donnel Alexis Rubio MD

To decrease the recurrence rate after intralesional curettage for aneurysmal bone cysts, different adjuvant treatments have been recommended. Liquid nitrogen spray and argon beam coagulation have provided the lowest recurrence rates, but unlike the high-speed burr, these adjuvants are not always available in operating rooms.

How Does Ulnar Shortening Osteotomy Influence Morphologic Changes in the Triangular Fibrocartilage Complex?

Yoshiaki Yamanaka MD, Toshiyasu Nakamura MD, PhD, Kazuki Sato MD, PhD, Yoshiaki Toyama MD, PhD

Ulnar shortening osteotomy often is indicated for treatment of injuries to the triangular fibrocartilage complex (TFCC). However, the effect of ulnar shortening osteotomy on the changes in shape of the TFCC is unclear. In our study, quantitative evaluations were performed using MRI to clarify the effect of ulnar shortening on triangular fibrocartilage (TFC) thickness attributable to disc regeneration of the TFC and TFC angle attributable to the suspension effect of ulnar shortening on the TFC.

Does Patient Sex Affect the Anatomic Relationships Between the Sternoclavicular Joint and Posterior Vascular Structures?

Jarrad A. Merriman MD, MPH, Diego Villacis MD, Brian Wu BS, Dakshesh Patel MD, Anthony Yi BS, George F. Rick Hatch MD

Despite increased concern for injury during surgical reconstruction of the sternoclavicular joint, to our knowledge there are few studies detailing the vascular relationships adjacent to the joint.

High Incidence of Hemiarthroplasty for Shoulder Osteoarthritis Among Recently Graduated Orthopaedic Surgeons

Tobias Mann MD, MSc, Judith F. Baumhauer MD, MPH, Regis J. O’Keefe MD, PhD, John Harrast PhD, Shepard R. Hurwitz MD, Ilya Voloshin MD

Primary glenohumeral osteoarthritis is a common indication for shoulder arthroplasty. Historically, both total shoulder arthroplasty (TSA) and hemi-shoulder arthroplasty (HSA) have been used to treat primary glenohumeral osteoarthritis. The choice between procedures is a topic of debate, with HSA proponents arguing that it is less invasive, faster, less expensive, and technically less demanding, with quality of life outcomes equivalent to those of TSA. More recent evidence suggests TSA is superior in terms of pain relief, function, ROM, strength, and patient satisfaction. We therefore investigated the practice of recently graduated orthopaedic surgeons pertaining to the surgical treatment of this disease.

Bilateral Clubfeet Are Highly Correlated: A Cautionary Tale for Researchers

Kelly Gray B App Sc, Paul Gibbons MBBS, David Little MBBS, PhD, Joshua Burns PhD

Congenital talipes equinovarus, or clubfoot, is a common pediatric orthopaedic condition of unknown origin. In many clubfoot clinical trials, interventions are assigned to a patient, but response to treatment is assessed separately in each foot. Trials commonly report x patients with y feet where y is greater than x (eg, 35 patients with 56 feet). However, common statistical tests assume that each data point is independent. Although data from unilateral cases of clubfoot are independent, it is unknown if each foot of patients with bilateral clubfeet are correlated.

Fractures in Geriatric Mice Show Decreased Callus Expansion and Bone Volume

Luke A. Lopas MD, Nicole S. Belkin MD, Patricia L. Mutyaba BS, Chancellor F. Gray MD, Kurt D. Hankenson DVM, MS, PhD, Jaimo Ahn MD, PhD

Poor fracture healing in geriatric populations is a significant source of morbidity, mortality, and cost to individuals and society; however, a fundamental biologic understanding of age-dependent healing remains elusive. The development of an aged-based fracture model system would allow for a mechanistic understanding that could guide future biologic treatments.

Surgery for Hip Fracture Yields Societal Benefits That Exceed the Direct Medical Costs

Qian Gu PhD, Lane Koenig PhD, Richard C. Mather MD, John Tongue MD

A hip fracture is a debilitating condition that consumes significant resources in the United States. Surgical treatment of hip fractures can achieve better survival and functional outcomes than nonoperative treatment, but less is known about its economic benefits.

Cosmetic Lower Limb Lengthening by Ilizarov Apparatus: What are the Risks?

Konstantin I. Novikov PhD, Koushik N. Subramanyam MS, Serghei O. Muradisinov MD, Olga S. Novikova MD, Elina S. Kolesnikova MD

Compelled by the psychosocial implications of short stature, patients with short stature are increasingly undergoing distraction osteogenesis for cosmetic limb lengthening. To the degree that this is true, evaluation of the risks and benefits of this treatment are very important, but to date, there are few studies reporting on using distraction osteogenesis for this indication.

Minorities Are Less Likely to Receive Autologous Blood Transfusion for Major Elective Orthopaedic Surgery

Mariano E. Menendez MD, David Ring MD, PhD

Surgeons commonly arrange for patients to perform autologous blood donation before elective orthopaedic surgery. Understanding sociodemographic patterns of use of autologous blood transfusion can help improve quality of care and cost containment.

Do Patients With Insulin-dependent and Noninsulin-dependent Diabetes Have Different Risks for Complications After Arthroplasty?

Francis Lovecchio BA, Matthew Beal MD, Mary Kwasny ScD, David Manning MD

Patients with diabetes are known to be at greater risk for complications after arthroplasty than are patients without diabetes. However, we do not know whether there are important differences in the risk of perioperative complications between patients with diabetes who are insulin-dependent (Type 1 or 2) and those who are not insulin-dependent.

What is the Work Environment of Orthopaedic Surgeons in China?

Zhen-Sheng Ma MD, PhD, Lin Wang MD, PhD, Guo-Sheng Du MD, Lynn Wang PhD, Xiao-Jun Chen MD, PhD

Physicians in China face heavy demands from patients and the government for services but deal with the threat of unpredictable legal and physical conflicts with patients, some ending with the death of doctors. More than 40 doctors and nurses have been killed by patients since 2001.

Left Knee Pain and Bilateral Knee Swelling in an Adolescent

R. Justin Mistovich MD, Patrick O. J. O’Toole MD, Nancy A. Chauvin MD, Benjamin J. Wilkins MD, Theodore J. Ganley MD
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