Literature

Evidence based literature that is truly important to your orthopaedic clinical practice.

Many orthopaedists order cultures of tissue and synovial fluid samples during the reimplantation phase of two-stage exchange arthroplasties. Now, thanks to a retrospective study by Tan et al. in the August 3, 2016 JBJS, surgeons have some guidance on how to interpret the results from such cultures.The authors reviewed 267 cases of periprosthetic joint infections (186 knees and 81 hips) that were treated with two-stage exchange arthroplasty. Intraoperative tissue samples were obtained at the time of reimplantation, and 33 joints (12.4%) were found to have one or more positive cultures. Of those 33 cases, 15 (45.5%) had a subsequent arthroplasty failure, compared with 49 (20.9%) of the cases that were culture-negative at reimplantation.

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OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Chad Krueger, MD, in response to an Annals of Internal Medicine study investigating the effectiveness of tai chi for treating knee osteoarthritis (OA). We have put men on the moon, but we still have no cure for the osteoarthritis that affects millions of Americans. We try a variety of injections and other conservative measures to help slow the progression of the disease, but at some point arthritis wins. Undaunted, we search for new modalities of easing the disability the disease brings to our patients in hopes of offering an effective treatment.

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During the last two decades, we have made tremendous progress in orthopaedic surgery in terms of limiting the negative impact of surgical dissection on patient functional outcomes. The expanding use of the arthroscope has been at the forefront of these advances. Limiting the breadth, depth, and imprecision of surgical dissection has obvious benefits that have been well documented in hundreds of musculoskeletal procedures. In the August 3, 2016 issue of The Journal, Kim et al. demonstrate arthroscopic repair of elbow instability following elbow dislocations with injury to the lateral ulnar collateral ligament. Despite the notable success reported by the authors in 13 patients, arthroscopic elbow ligament repair is obviously a technique that requires careful preparation, and patients should be advised to work with a surgeon who is experienced in this specific application of arthroscopy.

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Developmental cervical stenosis is usually asymptomatic in adults until an acute injury or degenerative soft-tissue abnormalities cause nerve compression and associated symptoms. Thus, it would help orthopaedists and their patients to have a robust radiographic tool to assess for developmental cervical stenosis in its presymptomatic stages. Horne et al. seem to have developed such a tool, as they describe in the July 20, 2016 issue of The Journal of Bone & Joint Surgery. Using a canal diameter of <12 mm, as measured by computed tomography (CT), as the definition of developmental cervical stenosis, the authors made detailed measurements of lateral cervical radiographs from 150 adult patients.

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One of the newest features from JBJS Reviews is the “Team Approach” article. Team Approach articles highlight the individual and collective importance of the multiple physician and nonphysician providers who are involved in the care of a patient. Determining how the multidisciplinary interactions and contributions are key to the understanding of a medical condition and its treatment can be essential to a successful musculoskeletal health process. In the July 2016 issue of JBJS Reviews,Pinzur et al. describe the team approach to the treatment of diabetic foot ulcers. The authors note that an estimated 29.1 million people in the U.S.

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Despite advances in sterile techniques and evidence-based use of perioperative antibiotics, periprosthetic joint infections still occur in 1% of primary and 3% to 7% of revision total joint arthroplasties. But a “smart” antimicrobial polymer coating, described in the July 20, 2016 Journal of Bone & Joint Surgery, has great potential to cut those percentages. Stavrakis et al. devised a nontoxic, biodegradable polymer coating (called PEG-PPS for short) that locally delivers antibiotics (vancomycin and tigecycline in this study) both passively and actively, with the active release initiated by the presence of bacteria. The authors tested the efficacy of the coating both in vitro and in vivo.

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The ability of the small and complexly connected wrist bones to function properly supports everything from activities of daily living and work to the creation of art and music. This month’s “Case Connections” article explores wrist dislocations that required open reduction and some form of fixation. Considering the high degree of anatomical derangement and instability in these cases, the outcomes were remarkably good, thanks to carefully planned and executed orthopaedic interventions. The springboard case, from the July 27, 2016 edition of JBJS Case Connector, describes the treatment of a 47-year-old male bicyclist who was hit by a car and sustained complete scaphoid and lunate dislocations.

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In the July 20, 2016 issue of The Journal, Louer et al. detail the association between distal radial fractures and poor balance. We have long understood that inherently poor balance was a major contributor to fall risk, and now we have more hard evidence thanks to this research team. In this case-control evaluation comparing 23 patients ≥65 years of age who had sustained a low-energy distal radial fracture with 23 age- and sex-matched control patients, the authors found that those in the fracture cohort:Demonstrated poorer balance based on dynamic motion analysis (DMA) scoresWere able to perform the balance test for significantly less timeRated themselves as having worse mobilityAmong both cohorts, only 3 patients had completed an evaluation of or treatment for balance deficiencies.

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This month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) highlights the case of a 34-year-old man who presented with a 1-month history of hand and wrist pain after driving his golf club into the ground during a swing. Anteroposterior (AP) and lateral radiographs of the wrist are shown, and findings from the physical exam are described. The Image Quiz reviews the anatomy of the wrist, focusing on the symptoms and mechanisms of hamate injuries. The quiz question is: After standard AP and lateral radiographs, which imaging modality or view would be most helpful in arriving at a definitive diagnosis? Options for treating a fracture of the hook of the hamate are also discussed.

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In a population-based epidemiological study published in the July 6, 2016 Journal of Bone & Joint Surgery, Tibor et al. found that from 2007 to 2014:Many ACL-reconstruction surgeons changed from a transtibial approach to either an anteromedial portal or lateral approach for femoral-tunnel drilling.Most did not substantially change the types of grafts they used.Many eschewed first-generation bioabsorbable implants in favor of biocomposite fixation devices. The authors found no change in cumulative revision rates during the study period. Tibor et al. analyzed information from 21,686 primary ACL reconstructions housed in a Kaiser Permanente registry that collected data from surgeries performed in 33 hospitals by 246 surgeons in urban, rural, and suburban settings in three Western US states.

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