Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 474 | Issue 7 | Jul, 2016

To Cast, to Saw, and Not to Injure: Can Safety Strips Decrease Cast Saw Injuries?

Natalie C. Stork MD, Rachel L. Lenhart PhD, Blaise A. Nemeth MD, MS, Kenneth J. Noonan MD, Matthew A. Halanski MD

Placement and removal of fiberglass casts are among the more-common interventions performed in pediatric orthopaedic surgery offices. However, cast removal is associated with abrasive injuries and burns from the oscillating cast saw, and these injuries can occur even when the cast is removed by experienced personnel. It is unknown whether an added barrier, such as a safety strip, can mitigate injuries from blade-to-skin contact during cast removal with the oscillating saw.

Is Prophylactic Intervention More Cost-effective Than the Treatment of Pathologic Fractures in Metastatic Bone Disease?

Alan T. Blank MD, MS, Daniel M. Lerman MD, Neeraj M. Patel MD, MPH, Timothy B. Rapp MD

Metastatic bone disease is a substantial burden to patients and the healthcare system as a whole. Metastatic disease can be painful, is associated with decreased survival, and is emotionally traumatic to patients when they discover their disease has progressed. In the United States, more than 250,000 patients have metastatic bone disease, with an estimated annual cost of USD 12 billion. Prior studies suggest that patients who receive prophylactic fixation for impending pathologic fractures, compared with those treated for realized pathologic fractures, have decreased pain levels, faster postoperative rehabilitation, and less in-hospital morbidity. However, to our knowledge, the relative economic utility of these treatment options has not been examined.

Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Hip Arthroplasty?

Bhaveen H. Kapadia MD, Julio J. Jauregui MD, Daniel P. Murray BA, Michael A. Mont MD

Periprosthetic hip infections are among the most catastrophic complications after total hip arthroplasty (THA). We had previously proven that the use of chlorhexidine cloths before surgery may help decrease these infections; hence, we increased the size of the previously reported cohort.

Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Knee Arthroplasty?

Bhaveen H. Kapadia MD, Peter L. Zhou BA, Julio J. Jauregui MD, Michael A. Mont MD

Many preventive methodologies seek to reduce the risk of surgical site infections after total knee arthroplasty (TKA), including the use of preoperative chlorhexidine baths and cloths. Although we have demonstrated in previous studies that this may be an efficacious method for infection prevention, our study was underpowered and we therefore set out to evaluate this with a larger sample size.

Is Vancomycin-only Prophylaxis for Patients With Penicillin Allergy Associated With Increased Risk of Infection After Arthroplasty?

Timothy L. Tan MD, Bryan D. Springer MD, John A. Ruder MD, Michael R. Ruffolo MD, Antonia F. Chen MD, MBA

Preoperative antibiotic prophylaxis remains one of the most important strategies for prevention of postoperative infection. In patients with penicillin allergy, alternative medications such as vancomycin are often used despite reduced antimicrobial coverage and recent literature questioning the efficacy of vancomycin monotherapy.

The Alpha-defensin Test for Periprosthetic Joint Infections Is Not Affected by Prior Antibiotic Administration

Alisina Shahi MD, Javad Parvizi MD, FRCS, Gregory S. Kazarian AB, Carlos Higuera MD, Salvatore Frangiamore MD, Joshua Bingham MD, Christopher Beauchamp MD, Craig Della Valle MD, Carl Deirmengian MD

Previous studies have demonstrated that the administration of antibiotics to patients before performing diagnostic testing for periprosthetic joint infection (PJI) can interfere with the accuracy of test results. Although a single-institution study has suggested that alpha-defensin maintains its concentration and sensitivity even after antibiotic treatment, this has not yet been demonstrated in a larger multiinstitutional study.

Are Frozen Sections and MSIS Criteria Reliable at the Time of Reimplantation of Two-stage Revision Arthroplasty?

Jaiben George MBBS, Grzegorz Kwiecien MD, Alison K. Klika MS, Deepak Ramanathan MBBS, Thomas W. Bauer MD, PhD, Wael K. Barsoum MD, Carlos A. Higuera MD

Frozen section histology is widely used to aid in the diagnosis of periprosthetic joint infection at the second stage of revision arthroplasty, although there are limited data regarding its utility. Moreover, there is no definitive method to assess control of infection at the time of reimplantation. Because failure of a two-stage revision can have serious consequences, it is important to identify the cases that might fail and defer reimplantation if necessary. Thus, a reliable test providing information about the control of infection and risk of subsequent failure is necessary.

Synovial Cytokines and the MSIS Criteria Are Not Useful for Determining Infection Resolution After Periprosthetic Joint Infection Explantation

Salvatore J. Frangiamore MD, Marcelo B. P. Siqueira MD, Anas Saleh MD, Thomas Daly MD, Carlos A. Higuera MD, Wael K. Barsoum MD

Diagnosing periprosthetic joint infection (PJI) requires a combination of clinical and laboratory parameters, which may be expensive and difficult to interpret. Synovial fluid cytokines have been shown to accurately differentiate septic from aseptic failed total knee (TKA) and hip (THA) arthroplasties. However, after first-stage explantation, there is still no reliable test to rule out PJI before a second-stage reimplantation procedure.

The ACS NSQIP Risk Calculator Is a Fair Predictor of Acute Periprosthetic Joint Infection

Nathaniel C. Wingert MD, James Gotoff BA, Edgardo Parrilla BA, BS, Robert Gotoff MD, Laura Hou MSc, Elie Ghanem MD

Periprosthetic joint infection (PJI) is a severe complication from the patient’s perspective and an expensive one in a value-driven healthcare model. Risk stratification can help identify those patients who may have risk factors for complications that can be mitigated in advance of elective surgery. Although numerous surgical risk calculators have been created, their accuracy in predicting outcomes, specifically PJI, has not been tested.

Antibiotic-tolerant Staphylococcus aureus Biofilm Persists on Arthroplasty Materials

Kenneth L. Urish MD, PhD, Peter W. DeMuth BS, Brian W. Kwan PhD, David W. Craft PhD, Dongzhu Ma PhD, Hani Haider PhD, Rocky S. Tuan PhD, Thomas K. Wood PhD, Charles M. Davis MD

The continued presence of biofilm may be one cause of the high risk of failure observed with irrigation and débridement with component retention in acute periprosthetic joint infection (PJI). There is a poor understanding of the role of biofilm antibiotic tolerance in PJI.

Biofilm Antimicrobial Susceptibility Increases With Antimicrobial Exposure Time

Paulo Castaneda BSE, Alex McLaren MD, Gamuchirai Tavaziva, Derek Overstreet PhD

The antimicrobial concentration required to kill all the bacteria in a biofilm, known as the minimum biofilm eradication concentration (MBEC), is typically determined in vitro by exposing the biofilm to serial concentrations of antimicrobials for 24 hours or less. Local delivery is expected to cause high local levels for longer than 24 hours. It is unknown if longer antimicrobial exposures require the same concentration to eradicate bacteria in biofilm. Questions/purposes Does MBEC change with increased antimicrobial exposure time?

Cathodic Voltage-controlled Electrical Stimulation Plus Prolonged Vancomycin Reduce Bacterial Burden of a Titanium Implant-associated Infection in a Rodent Model

Scott R. Nodzo MD, Menachem Tobias MS, Richard Ahn MD, Lisa Hansen MS, Nicole R. Luke-Marshall PhD, Craig Howard BS, Linda Wild MD, Anthony A. Campagnari PhD, Mark T. Ehrensberger PhD

Cathodic voltage-controlled electrical stimulation (CVCES) of titanium implants, either alone or combined with a short course of vancomycin, has previously been shown to reduce the bone and implant bacterial burden in a rodent model of methicillin-resistant(MRSA) implant-associated infection (IAI). Clinically, the goal is to achieve complete eradication of the IAI; therefore, the rationale for the present study was to evaluate the antimicrobial effects of combining CVCES with prolonged antibiotic therapy with the goal of decreasing the colony-forming units (CFUs) to undetectable levels.

Does Anteromedial Portal Drilling Improve Footprint Placement in Anterior Cruciate Ligament Reconstruction?

Sally Arno PhD, Christopher P. Bell MSc, Michael J. Alaia MD, Brian C. Singh BS, Laith M. Jazrawi MD, Peter S. Walker PhD, Ankit Bansal MD, Garret Garofolo BS, Orrin H. Sherman MD

Considerable debate remains over which anterior cruciate ligament (ACL) reconstruction technique can best restore knee stability. Traditionally, femoral tunnel drilling has been done through a previously drilled tibial tunnel; however, potential nonanatomic tunnel placement can produce a vertical graft, which although it would restore sagittal stability, it would not control rotational stability. To address this, some suggest that the femoral tunnel be created independently of the tibial tunnel through the use of an anteromedial (AM) portal, but whether this results in a more anatomic footprint or in stability comparable to that of the intact contralateral knee still remains controversial.

Supine and Standing AP Pelvis Radiographs in the Evaluation of Pincer Femoroacetabular Impingement

Timothy J. Jackson MD, Allyson A. Estess MD, Gregory J. Adamson MD

Pelvic tilt can affect the presence of the ischial spine sign and crossover sign. Numerous studies of pelvic tilt on radiographic measurements of pincer impingement have shown that increasing anterior tilt is associated with more radiographic signs of pincer impingement. However, to our knowledge, no study has directly compared supine and standing plain radiographs in patients with respect to lateral center-edge (LCE) angle, acetabular inclination, crossover sign, and ischial spine sign.

Early Migration Predicts Aseptic Loosening of Cementless Femoral Stems: A Long-term Study

Marcus R. Streit MD, MSc, Daniel Haeussler MD, Thomas Bruckner PhD, Tanja Proctor BSc, Moritz M. Innmann MD, Christian Merle MD, MSc, Tobias Gotterbarm MD, PhD, Stefan Weiss MD, PhD

Excessive early migration of cemented stems and cups after THA has been associated with poor long-term survival and allows predictable evaluation of implant performance. However, there are few data regarding the relationship between early migration and aseptic loosening of cementless femoral components, and whether early migration might predict late failure has not been evaluated, to our knowledge. Einzel-Bild-Röntgen-Analyse-femoral component analysis (EBRA-FCA) is a validated technique to accurately measure axial femoral stem migration without the need for tantalum markers, can be performed retrospectively, and may be a suitable tool to identify poor performing implants before their widespread use.

Do Longer Surgical Procedures Result in Greater Contamination of Surgeons’ Hands?

Pooria Hosseini MD, MSc, Gregory M. Mundis MD, Robert Eastlack MD, Allen Nourian MD, Jeff Pawelek BS, Stacie Nguyen MPH, Behrooz A. Akbarnia MD

A surgical site infection is a substantial cause of complications in patients. Different methods are being used to decrease surgical site infections; however, these infections still can cause complications, especially in patients undergoing longer operations (> 3 hours). There is evidence that the efficacy of the scrubbing material fades after 3 hours. However, we do not know the longevity of hand cleanliness after application of scrubbing materials in a long operation. It can be postulated that if the surgeon’s scrubbed hands are recolonized after a certain time, they may serve as a progressive source of contamination during surgery.

How Often Does Spindle Failure Occur in Compressive Osseointegration Endoprostheses for Oncologic Reconstruction?

Lauren H. Goldman MD, Lee J. Morse MD, Richard J. O’Donnell MD, Rosanna L. Wustrack MD

Compressive osseointegration is a promising modality for limb salvage in distal femoral oncologic tumors. However, few studies have explored short-term survival rates in a large patient cohort of distal femur compressive endoprostheses or highlighted the risk factors for spindle failures.

Functional Assessment of Clubfoot Associated HOXA9, TPM1, and TPM2 Variants Suggests a Potential Gene Regulation Mechanism

Katelyn S. Weymouth PhD, Susan H. Blanton PhD, Tamar Powell MS, Chandrashekhar V. Patel PhD, Stuart A. Savill PhD, Jacqueline T. Hecht PhD

Isolated nonsyndromic clubfoot is a common birth defect affecting 135,000 newborns worldwide each year. Although treatment has improved, substantial long-term morbidity persists. Genetic causes have been implicated in family-based studies but the genetic changes have eluded identification. Previously, using a candidate gene approach in our family-based dataset, we identified associations between clubfoot and four single nucleotide polymorphisms (SNPs) located in potential regulatory regions of genes involved in muscle development and patterning () and muscle function (and) were identified.

End-of-life Care Planning and Fragility Fractures of the Hip: Are We Missing a Valuable Opportunity?

Robin H. Dunn MD, Jaimo Ahn MD, PhD, Joseph Bernstein MD

Approximately 20% of all geriatric patients who sustain low-energy hip fractures will die within 1 year of the injury, and approximately 3% will die during the initial inpatient hospital stay. Accordingly, the event of a geriatric hip fracture might be an apt prompt for discussing end-of-life care: in light of the risk of death after this injury, the topic of mortality certainly is germane. However, it is not clear to what degree physicians and patients engage in end-of-life planning even when faced with a hospital admission for this potentially life-threatening condition.

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