JAAOS

JAAOS, Volume 25, No. 3


Clostridium difficile Infection: An Orthopaedic Surgeon’s Guide to Epidemiology, Management, and Prevention

Clostridium difficile infection is a growing concern in health care and is a worrisome complication in orthopaedics. The incidence and severity of this infection are increasing, although the incidence following orthopaedic surgery is comparatively lower than that seen in patients in most other surgical specialties. The typical geriatric orthopaedic patient may have many risk factors that increase the likelihood of C difficile infection, including advanced age, residence in a long-term care facility, multiple comorbidities, the use of perioperative antibiotics, and a long length of stay. Many antibiotics used for prophylaxis in orthopaedic procedures have been correlated with an increased incidence of C difficile infection. The indications for C difficile testing may vary, and diagnostic methods differ in sensitivity and specificity. The prevention of this infection is multifaceted and consists of practitioner and patient hand hygiene, antibiotic stewardship, contact precautions, and proper environmental cleaning. The main treatment options are metronidazole for mild cases and vancomycin for moderate to severe disease. Up to 40% of cases may have one or more recurrence. Further research is needed to identify novel therapeutic and prevention strategies for C difficile infection.

      • Subspecialty:
      • General Orthpaedics

    Decision Making for Labral Treatment in the Hip: Repair Versus Débridement Versus Reconstruction

    The role and function of the acetabular labrum have been studied extensively in the past decade. Recent studies have proposed that, in addition to causing pain and mechanical symptoms, labral tears may accelerate arthritis. Labral preservation is believed to be important because of the role the labrum plays in maintaining a healthy joint. Treatment of the acetabular labrum is becoming one of the fastest growing fields in orthopaedics; therefore, the treatment decision-making process must be refined. Currently, three commonly practiced labral treatments are available: repair, débridement, and reconstruction. Arguments for and against each treatment option exist in the literature. Reviewing the currently proposed indicators for labral tear treatments in conjunction with the treatment procedures yields a thorough decision-making guide for choosing the appropriate labral procedure.

        • Subspecialty:
        • Sports Medicine

      Distal Radius Fractures in the Elderly

      Distal radius fractures are common in elderly patients, and the incidence continues to increase as the population ages. The goal of treatment is to provide a painless extremity with good function. In surgical decision making, special attention should be given to the patient’s bone quality and functional activity level. Most of these fractures can be treated nonsurgically, and careful closed reduction should aim for maintenance of anatomic alignment with a focus on protecting fragile soft tissues. Locked plating is typically used for fracture management when surgical fixation is appropriate. Surgical treatment improves alignment, but improvement in radiographic parameters may not lead to better clinical outcomes. Treatment principles, strategies, and clinical outcomes vary for these injuries, with elderly patients warranting special consideration.

          • Subspecialty:
          • Shoulder and Elbow

          • Shoulder

        Firearm-related Musculoskeletal Injuries in Children and Adolescents

        Firearm injuries are a major cause of morbidity and mortality among children and adolescents in the United States and take financial and emotional tolls on the affected children, their families, and society as a whole. Musculoskeletal injuries resulting from firearms are common and may involve bones, joints, and neurovascular structures and other soft tissues. Child-specific factors that must be considered in the setting of gunshot injuries include physeal arrest and lead toxicity. Understanding the ballistics associated with various types of weaponry is useful for guiding orthopaedic surgical treatment. Various strategies for preventing these injuries range from educational programs to the enactment of legislation focused on regulating guns and gun ownership. Several prominent medical societies whose members routinely care for children and adolescents with firearm-related injuries, including the American Academy of Pediatrics and the American Pediatric Surgical Association, have issued policy statements aimed at mitigating gun-related injuries and deaths in children. Healthcare providers for young patients with firearm-related musculoskeletal injuries must appreciate the full scope of this important public health issue.

            • Subspecialty:
            • Pediatric Orthopaedics

          Functional Bracing After Anterior Cruciate Ligament Reconstruction: A Systematic Review

          Introduction: The purpose of this study was to evaluate the current literature on the use of functional knee braces after anterior cruciate ligament (ACL) reconstruction with respect to clinical and in vivo biomechanical data.

          Methods: A systematic search of both the PubMed and Embase databases was performed to identify all studies that reported clinical and/or in vivo biomechanical results of functional bracing versus nonbracing after ACL reconstruction. Extracted data included study design, surgical reconstruction techniques, postoperative rehabilitation protocols, objective outcomes, and subjective outcomes scores. The in vivo biomechanical data collected included kinematics, strength, function, and proprioception. Subjective clinical outcomes scores were collected when available. Quality appraisal analyses were performed using the Cochrane Collaboration tools for randomized and nonrandomized trials to aid in data interpretation.

          Results: Fifteen studies met the selection criteria (including 3 randomized trials [level II], 11 nonrandomized trials [level II], and 1 retrospective comparative study [level III]), with follow-up intervals ranging from 3 to 48 months. Most studies were designed to compare the effects of functional bracing versus nonbracing on subjective and objective results in patients who underwent previous primary ACL reconstruction. Functional bracing significantly improved kinematics of the knee joint and improved gait kinetics, although functional bracing may decrease quadriceps activation without affecting functional tests, range of motion, and proprioception. Four studies reported no differences in subjective outcomes scores with brace use; however, one study reported increased patient confidence with brace use, whereas another study reported decreased pain and quicker return to work when the brace was not used.

          Conclusions: The effectiveness of postoperative functional bracing following ACL reconstruction remains elusive. Some data suggest that functional bracing may have some benefit with regard to in vivo knee kinematics and may offer increased protection of the implanted graft after ACL reconstruction without sacrificing function, range of motion, or proprioception. However, limited evidence exists supporting the use of routine functional bracing to decrease the rate of reinjury after ACL reconstruction.

              • Subspecialty:
              • Sports Medicine

              • Sports Injuries

            Management of Open Tibial Shaft Fractures: Does the Timing of Surgery Affect Outcomes?

            Background: Open tibial shaft fractures require emergent care. Treatment with intravenous antibiotics and fracture débridement within 6 to 24 hours is recommended. Few studies have examined outcomes when surgical treatment is performed >24 hours after occurrence of the fracture.

            Methods: This retrospective study included 227 patients aged ≥18 years with isolated open tibial shaft fractures in whom the time to initial débridement was >24 hours. The statistical analysis was based on time from injury to surgical débridement, Gustilo-Anderson classification, method of fixation, union status, and infection status.

            Results: Fractures débrided within 24 to 48 hours and 48 to 96 hours after injury did not show a statistically significant difference in terms of infection rates (P = 0.984). External fixation showed significantly greater infection rates (P = 0.044) and nonunion rates (P = 0.001) compared with intramedullary nailing.

            Conclusion: Open tibial shaft fractures should be débrided within 24 hours after injury. Our data indicate that after the 24-hour period and up to 4 days, the risk of infection remains relatively constant independent of the time to débridement. Patients treated with external fixation had more complications than did patients treated with other methods of fixation. Primary reamed intramedullary nailing appears to be a reasonable option for the management of Gustilo-Anderson types 1 and 2 open tibial shaft fractures.

            Level of Evidence: Level III retrospective study.

                • Subspecialty:
                • Trauma

              Management of the Relapsed Clubfoot Following Treatment Using the Ponseti Method

              The Ponseti method to treat idiopathic clubfoot deformity has proven to be reliable, and several centers have reported excellent outcomes. Although the method has been dependable in obtaining initial correction of the foot, relapse rates ranging from 26% to 48% have been reported. When a relapsed deformity is detected early, treatment with a short series of manipulations and cast applications followed by resumption of postcorrective bracing may be all that is required to regain and maintain correction. In patients aged >2.5 years, especially those who may be refractory to further brace use, deformity correction by preoperative cast treatment, followed by anterior tibial tendon transfer to the third cuneiform, is a good treatment option. Other procedures, such as combined cuboid-cuneiform osteotomy, posterior ankle and subtalar release, and, rarely, comprehensive posteromedial release or correction by gradual distraction, may be useful in select patients.

                  • Subspecialty:
                  • Foot

                  • Children

                  • Pediatric Orthopaedics

                Morbid Obesity and Total Knee Arthroplasty: A Growing Problem

                Obesity is an epidemic, with approximately 35% of the US population affected. This rate is unlikely to decline and may increase the demand for total knee arthroplasty (TKA). Data regarding the risks, benefits, and potential complications of TKA in this patient population are conflicting. Preoperative considerations are optimization of nutritional status, safe weight loss strategies, and bariatric surgery. Intraoperative concerns unique to this population include inadequate exposure, implant alignment, and durable implant fixation; postoperative issues include tibial loosening, wound complications, cardiovascular events, and respiratory complications. A thorough understanding of the medical and surgical complications associated with TKA in the obese patient will facilitate research efforts and improve outcomes.

                    • Subspecialty:
                    • Knee

                  Prosthetic Joint Infections in Patients Undergoing Carpal Tunnel Release

                  Introduction: Little information is available regarding the rate of prosthetic joint infections (PJIs) in patients undergoing carpal tunnel release (CTR) without antibiotic prophylaxis. Hand surgeons should be aware of patients’ history of arthroplasty.

                  Methods: All patients who underwent CTR at our institution between 2012 and 2014 were identified and their charts were reviewed to identify those who had a history of total hip, knee, and/or shoulder arthroplasty. Further chart review consisted of identifying a history of PJI, use of perioperative antibiotics, and surgeon awareness of prior arthroplasty.

                  Results: Two hundred seventy-five CTR surgeries were performed in patients who had previously undergone total joint arthroplasty (TJA). There were no PJIs in any group of patients (P = 0.01). Hand surgeon awareness of the presence of an arthroplasty history had no discernable effect on the choice to use antibiotics.

                  Conclusions: There was a 0% rate of PJI in our series of patients with a history of TJA who underwent CTR. Overall hand surgeon awareness of TJA status was poor or poorly documented. Routine prophylactic antibiotics may not be indicated in patients undergoing CTR, even with the presence of a prosthetic joint.

                  Level of Evidence: IV

                      • Subspecialty:
                      • Hand

                      • Hand and Wrist

                      • Wrist

                    Reconstruction Following Tumor Resections in Skeletally Immature Patients

                    Reconstruction options in children after bone tumor resection are as varied as they are challenging. Advances in biologic and endoprosthetic design have led to many choices, all of which must be considered in the context of prognosis, treatment limitations, and patient/family expectations. The current experience and results of limb-sparing surgery following bone sarcoma resection in growing children are discussed, including allograft, autograft, and metallic prostheses alone and in combination, especially as they pertain to the knee. In some cases, the ablative options of amputation and rotationplasty must be seen as equal and, at times, superior choices to limb salvage.

                        • Subspecialty:
                        • Treatment and Surgery

                        • Treatments and Surgeries

                        • Surgery and Treatment

                        • Treatments and Surgery

                      Strategies for Proximal Femoral Nailing of Unstable Intertrochanteric Fractures: Lateral Decubitus Position or Traction Table

                      Background: The aim of this prospective randomized study was to compare the traction table and lateral decubitus position techniques in the management of unstable intertrochanteric fractures.

                      Methods: Eighty-two patients with unstable intertrochanteric fractures between 2011 and 2013 were included in this study. All patients were treated surgically with the Proximal Femoral Nail Antirotation implant (DePuy Synthes). Patients were randomized to undergo the procedure in the lateral decubitus position (42 patients) or with the use of a traction table (40 patients). Patients whose procedure was not performed entirely with a semi-invasive method or who required the use of additional fixation materials, such as cables, were excluded from the study. The groups were compared on the basis of the setup time, surgical time, fluoroscopic exposure time, tip-to-apex distance, collodiaphyseal angle, and modified Baumgaertner criteria for radiologic reduction.

                      Results: The setup time, surgical time, and fluoroscopic exposure time were lower and the differences were statistically significant in the lateral decubitus group compared with the traction table group. The collodiaphyseal angles were significantly different between the groups in favor of the lateral decubitus method. The tip-to-apex distance and the classification of reduction according to the modified Baumgaertner criteria did not demonstrate a statistically significant difference between the groups.

                      Conclusions: The lateral decubitus position is used for most open procedures of the hip. We found that this position facilitates exposure for the surgical treatment of unstable intertrochanteric fractures and has advantages over the traction table in terms of set up time, surgical time and fluoroscopic exposure time.

                          • Subspecialty:
                          • Trauma

                        The Role of the Orthopaedic Surgeon in Workers’ Compensation Cases

                        Workers’ compensation is an employer-funded insurance program that provides financial and medical benefits for employees injured at work. Because many occupational injuries are musculoskeletal in nature, the orthopaedic surgeon plays an important role in the workers’ compensation system. Along with establishing the correct diagnosis and implementing an appropriate treatment plan, the clinician must understand the fundamental components of the workers’ compensation system to manage an injured employee. Ultimately, effective claim management requires collaboration among the employer, the employee, the legal representatives, the insurance company, and the orthopaedic surgeon.

                            • Subspecialty:
                            • General Orthpaedics

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