As a chief of orthopaedics at an urban country hospital where we already use routine vancomycin for surgical prophylaxis, and as an assistant high-school basketball coach, I was very interested in the article on methicillin-resistant Staphylococcus aureus (MRSA) infections in the October 2008 issue (“Preventing MRSA in the locker room”).

The article recommends that “athletes shower with soap immediately after workouts.” In my coaching experience, high school athletes currently do not routinely shower in the locker room after workouts, and instead head home or somewhere else to shower who-knows-when. I have encountered this “no-shower” concept in several states; it seems to have evolved over several years for reasons nobody has been able to explain to me.

It may be that not showering in the locker room area is better for [reducing] communicable diseases, but it goes strongly against the idea of “showering immediately after workouts.” Perhaps further investigation is needed to develop a recommendation on whether showering in the locker room, as has been done traditionally in the past, is a good idea today.

Peter B. Slabaugh, MD
Piedmont, Calif.

I strongly agree with Dr. Nusbickel’s letter presented in the November 2008 issue. I am in my mid-50s and have discontinued much of what I used to practice in orthopaedics. There is nothing wrong with slowing down and limiting one’s practice. However, the requirements for continued board certification do not allow a competent and well-respected orthopaedic surgeon to finally relax and allow his ongoing practice to focus on specific interests rather than maintain a very academically oriented practice.

I certainly applaud the need for board certification and even for recertification, but the present process is overly burdensome for many doctors. For some, the loss of board certification could have a detrimental effect on their practices. I do not believe that the [American] Board [of Orthopaedic Surgery] intends long-term members to be adversely affected by the recertification process. After 20 or 30 years of practicing as a board-certified orthopaedic surgeon, I believe a doctor has earned the privilege to modify and limit his practice. If the [ABOS] does not appreciate and act upon the plea of older doctors, a more organized platform may be appropriate in the future.

Gary L. Painter, MD
Loma Linda, Calif.

The front page article in the December 2008 issue of AAOS Now entitled “Spot Check: Arthroscopic débridement for OA Knee” caught my eye because the AAOS Board of Directors approved Clinical Practice Guidelines (CPG) on Osteoarthritis (OA) of the Knee just a few days before I received the issue. The AAOS is committed to the considerable effort of guideline development and a star team of staff has been assembled and trained under the leadership of Charles Turkelson, PhD.

The OA Knee guideline is the fourth CPG to be approved and is available on the AAOS Web site. Within the first 10 days after the guideline was posted, the Web site had approximately 5,000 hits.

The guidelines are evidence-based and developed with a strict methodology that combats bias and promotes transparency. They are based on the highest levels of available evidence in the literature and are graded as to the strength of the recommendations.

Opinion, even expert opinion, may have wide variations. Given the establishment of evidence-based clinical practice guidelines and the current emphasis on evidence-based medicine in general, I wonder about the timing and content of such a column.

Kristy L. Weber, MD
Baltimore, Md.

AAOS Now responds: Timing is everything. This month’s issue includes an article on the CPG on OA Knee (see cover story) and summarizes the 22 recommendations on page 50. The “Spot Check” column was prepared several weeks prior to the AAOS Board meeting in December, before we were aware that the CPG was being presented. Dr. Weber, as chair of the Council on Research, Quality Assessment, and Technology, makes a good point, however; interesting as some expert opinion might be, it should not be used to guide treatment decisions when stronger, evidence-based guidelines are available.

If you want to set Now straight, send your letters to the Editor, AAOS Now, 6300 N. River Rd., Rosemont, IL, 60018; fax them to (847) 823-8033; or e-mail them to aaoscomm@aaos.org