JAAOS

JAAOS, Volume 18, No. 12


Diagnosis of Periprosthetic Joint Infections of the Hip andKnee

No preferred test for diagnosis of periprosthetic joint infection exists,and the algorithm for the workup of patients suspected of infection remainsunclear. The work group evaluated the available literature to determine therole of each diagnostic modality and devise a practical algorithm that allowsphysicians to reach diagnosis of periprosthetic joint infection. Ten of the15 recommendations have strong or moderate evidence in support. These includematters involving erythrocyte sedimentation rate and C-reactive protein leveltesting, knee and hip aspiration, and stopping the use of antibiotics priorto obtaining intra-articular cultures. The group recommends against the useof intraoperative Gram stain but does recommend the use of frozen sectionsof peri-implant tissues in reoperation patients in whom infection has notbeen established, as well as multiple cultures in reoperation patients beingassessed for infection. The group recommends against initiating antibiotictreatment in patients with suspected infection until after joint cultureshave been obtained, but recommends that prophylactic preoperative antibioticsnot be withheld in patients at lower probability for infection.

      • Subspecialty:
      • Adult Reconstruction

    Management of Venomous Snakebite Injury to the Extremities

    Pit vipers (subfamily Crotalinae) are responsible for most venomous snakebitesin the United States. The mixture of proteins with cytotoxic, proteolytic,and/or neurotoxic enzymes in snake venom varies by species. Treatment in thefield consists of safe identification of the species of snake and rapid transportof the patient to the nearest health care facility. Swelling, bruising, andsystemic symptoms are seen following snakebite. Most patients respond to elevationof the affected extremity and observation. Some require the administrationof antivenin. Crotalidae Polyvalent Immune Fab (Ovine) (CroFab, BTG International,West Conshohocken, PA) antivenin is safe and effective for the managementof local and systemic effects of envenomation. Rarely, compartment syndromemay develop in the affected limb because of edema and tissue necrosis. Closemonitoring of the extremity via serial physical examination and measurementof compartment pressure is a reliable method of determining whether surgicalintervention is required.

        • Subspecialty:
        • Trauma

      Perioperative Management of Chronic Anticoagulation in Orthopaedic Surgery

      The orthopaedic patient on chronic anticoagulation therapy is at risk ofthromboembolism and hemorrhage in the perioperative period. To establish themost effective anticoagulation regimen, patients should be stratified accordingto the risk of arterial or venous thromboembolism. Timing of surgery, thromboembolicrisk, and bleeding risk should be considered when developing an anticoagulationprotocol. Retrievable inferior vena cava filters may be a viable alternativeto bridging therapy in patients at high risk of venous thromboembolism and/orbleeding.

          • Subspecialty:
          • Trauma

          • Adult Reconstruction

        Revision Spine Surgery to Manage Pediatric Deformity

        Revision deformity surgery in the growing child is a complex clinical problem.Excellent outcomes can be obtained with meticulous patient evaluation followedby well-planned and well-executed treatment. A multidisciplinary team is crucialto a satisfactory overall outcome. Diagnosis of failed index spine fusionrequires a thorough patient history and physical examination, careful patientassessment, and imaging between the index procedure and the presentation forrevision and confirmatory testing that validates the diagnosis. Revision surgerymay include irrigation and dbridement, implant removal, or revisionspine fusion with deformity correction. Correction may require either an anteriorapproach or a posterior approach with osteotomy. For best results, the plannedrevision must address the mechanism of the failure of the index procedure.If the symptoms or observations are not explained by the diagnosis, then alternativeetiologies should be considered.

            • Subspecialty:
            • Pediatric Orthopaedics

          Subscapularis Management in Open Shoulder Surgery

          Management of the subscapularis in open shoulder surgery is a controversialtopic. Subscapularis tenotomy has been the traditional approach, but othertechniques have recently been developed to preserve the integrity of the subscapularistendon. These include subscapularis peel, subscapularis split, and lessertuberosity osteotomy. The biologic healing and biomechanical properties associatedwith each surgical approach must be evaluated to determine the best optionfor each patient. A strong, anatomic repair is required to achieve optimalclinical outcomes.

              • Subspecialty:
              • Shoulder and Elbow

            Treatment of Lisfranc Joint Injury: Current Concepts

            Injuries to the tarsometatarsal joint complex, also known as the Lisfrancjoint, are relatively uncommon. However, the importance of an accurate diagnosiscannot be overstated. These injuries, especially when missed, may result inconsiderable long-term disability as the result of posttraumatic arthritis.A high level of suspicion, recognition of the clinical signs of injury, andappropriate radiographic studies are needed for correct diagnosis. When surgeryis indicated, closed reduction with percutaneous screw fixation should beattempted. If reduction is questionable, open reduction should be performed.Screw fixation remains the traditional fixation technique.

                • Subspecialty:
                • Foot and Ankle

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