Clinical Orthopaedics & Related Research最新文献

{"title":"Thirty-day Postoperative Complications After Surgery For Metastatic Long Bone Disease Are Associated With Higher Mortality at 1 Year.","authors":"B. Bindels, Q. Thio, K. Raskin, M. Ferrone, Santiago A. Lozano Calderón, J. Schwab","doi":"10.1097/CORR.0000000000001036","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001036","url":null,"abstract":"BACKGROUND\u0000The benefits of surgical treatment of a metastasis of the extremities may be offset by drawbacks such as potential postoperative complications. For this group of patients, the primary goal of surgery is to improve quality of life in a palliative setting. A better comprehension of factors associated with complications and the impact of postoperative complications on mortality may prevent negative outcomes and help surgeons in surgical decision-making.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) What is the risk of 30-day postoperative complications after surgical treatment of osseous metastatic disease of the extremities? (2) What predisposing factors are associated with a higher risk of 30-day complications? (3) Are minor and major 30-day complications associated with higher mortality at 1 year?\u0000\u0000\u0000METHODS\u0000Between 1999 and 2016, 1090 patients with osseous metastatic disease of the long bones treated surgically at our institution were retrospectively included in the study. Surgery included intramedullary nailing (58%), endoprosthetic reconstruction (22%), plate-screw fixation (14%), dynamic hip screw fixation (2%), and combined approaches (4%). Surgery was performed if patients were deemed healthy enough to proceed to surgery and wished to undergo surgery. All data were retrieved by manually reviewing patients' records. The overall frequency of complications, which were defined using the Clavien-Dindo classification system, was calculated. We did not include Grade I complications as postoperative complications and complications were divided into minor (Grade II) and major (Grades III-V) complications. A multivariate logistic regression analysis was used to identify factors associated with 30-day postoperative complications. A Cox regression analysis was used to assess the association between postoperative complications and overall survival.\u0000\u0000\u0000RESULTS\u0000Overall, 31% of the patients (333 of 1090) had a postoperative complication within 30 days. The following factors were independently associated with 30-day postoperative complications: rapidly growing primary tumors classified according to the modified Katagiri classification (odds ratio 1.6; 95% confidence interval, 1.1-2.2; p = 0.011), multiple bone metastases (OR 1.6; 95% CI, 1.1-2.3; p = 0.008), pathologic fracture (OR 1.5; 95% CI, 1.1-2.0; p = 0.010), lower-extremity location (OR 2.2; 95% CI, 1.6-3.2; p < 0.001), hypoalbuminemia (OR 1.7; 95% CI, 1.2-2.4; p = 0.002), hyponatremia (OR 1.5; 95% CI, 1.0-2.2; p = 0.044), and elevated white blood cell count (OR 1.6; 95% CI, 1.1-2.4; p = 0.007). Minor and major postoperative complications within 30 days after surgery were both associated with greater 1-year mortality (hazard ratio 1.6; 95% CI, 1.3-1.8; p < 0.001 and HR 3.4; 95% CI, 2.8-4.2, respectively; p < 0.001).\u0000\u0000\u0000CONCLUSION\u0000Patients with metastatic disease in the long bones are vulnerable to postoperative adverse events. When selecting patients for surgery, surgeons should carefully assess a patient's cance","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"78 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88289547","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is Treatment at a High-Volume Center Associated with an Improved Survival for Primary Malignant Bone Tumors?","authors":"A. Malik, J. Alexander, Safdar N. Khan, T. Scharschmidt","doi":"10.1097/CORR.0000000000001034","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001034","url":null,"abstract":"BACKGROUND\u0000Centralization of cancer care to high-volume facilities has been shown to improve the overall survival of patients with soft-tissue sarcomas. Current evidence regarding the impact of increased hospital volume on treatment patterns and survival rates for patients with primary malignant bone tumors remains limited. Understanding the facility volume-outcome relationship for primary malignant bone tumors will further discussion on ways to promote delivery of quality cancer care across the nation.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) Is there a difference in overall survival for patients with primary malignant bone tumors undergoing treatment at a high-volume facility (at least 20 patients per year) versus those treated at a low-volume facility (less than 20 patients per year)? (2) Do surgical treatment patterns (limb-salvage versus amputation) and margin status (positive versus negative) vary between high-volume and low-volume facilities?\u0000\u0000\u0000METHODS\u0000The 2004 to 2015 National Cancer Database was queried using International Classification of Disease for Oncology topographical codes to identify patients undergoing treatment (surgery, chemotherapy, and/or radiation therapy) for primary malignant bone tumors of the extremities (C40.0-C40.3, C40.8, and C40.9) or pelvis (C41.4). Histologic codes were used to group the tumors into the following categories: osteosarcomas, Ewing's sarcomas, chondrosarcomas, chordomas, and other or unspecified. Patients who did not receive any treatment (surgery, chemotherapy, and/or radiotherapy) at the reporting facility were excluded from the study. Facility volume was calculated based on the average number of patients per year for the entire study period. A preliminary stratified Cox regression model was used to identify evidence-based thresholds or cutoffs for high-volume and low-volume facilities, while adjusting for differences in patient, tumor, and treatment characteristics. We identified high-volume facilities as those treating at least 20 patients per year and low-volume facilities as those treating fewer than 20 patients per year. A Kaplan-Meier survival analysis was used to report overall unadjusted 5-year survival rates at high-volume and low-volume facilities. Multivariate Cox regression analyses were used to assess whether undergoing treatment at a high-volume facility was associated with a lower risk of overall mortality, after controlling for differences in baseline demographics, tumor presentation, and treatment characteristics. For patients undergoing surgery, multivariate regression models were used to evaluate whether patients receiving care in a high-volume facility were more likely to receive resections with limb salvage surgery than to receive amputation and whether facility volume was associated with a patient's likelihood of having a positive or negative surgical margin.\u0000\u0000\u0000RESULTS\u0000A total of 14,039 patients were included, 15% (2115) of whom underwent treatment in a high-volume facility. Patients undergo","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"38 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82190142","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Classification in Brief: The Spinal Deformity Study Group Classification of Lumbosacral Spondylolisthesis.","authors":"G. C. Camino Willhuber, G. Kido","doi":"10.1097/CORR.0000000000001005","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001005","url":null,"abstract":"Spondylolisthesis is characterized by vertebral slippage from a variety of causes, including degenerative changes, trauma, tumors or congenital dysplasia. Isthmic spondylolisthesis is an acquired condition that results from a pars interarticularis disruption usually at the L5 vertebra that exhibits a similar male:female distribution. The most common symptoms are low back pain and unilateral or bilateral leg pain caused by L5 radiculopathy, depending on severity. The first classification of spondylolisthesis was developed by Meyerding [14] in 1932, who described four types depending on the degree of slippage between two vertebral bodies. In that classification, Grade I involved a slip of 0% to 25%, Grade II was defined as 25% to 50%, Grade III as 50% to 75%, and Grade IV as 75% to 100%. Later, a Grade V was added with a slip greater than 100% slippage (a condition called spondyloptosis). In 1976, Wiltse et al. [17] described a classification based on etiological and anatomical factors with 5 types: I-dysplastic (congenital); II-isthmic (described as a pars lysis (type IIA), a pars elongation (type IIB) or an acute pars fracture (type IIC); III-degenerative; IV-traumatic and V-neoplastic conditions. This system was useful in terms of etiology. Marchetti and Bartolozzi [13] distinguished between developmental and acquired forms of spondylolisthesis and divided developmental spondylolisthesis into two major types, highand low-dysplastic, depending on the severity of bony dysplastic changes of the lumbosacral region and the risk of further slippage. The high-dysplastic type is mainly associated with substantial lumbosacral kyphosis, a trapezoidal L5 vertebra, dysplastic posterior elements of L5 and S1, and an anomaly of the upper endplate of S1. By contrast, the low-dysplastic type corresponds to minimal lumbosacral kyphosis, almost rectangular L5 vertebra, minimal sacral doming and relatively normal transverse processes. Although they introduced the concept of low and high dysplasia in the classification, they did not provide strict criteria on how to differentiate between these two subtypes. Many studies demonstrated the importance of global and spinopelvic balance, mainly assessed through radiographic measurements such as pelvic incidence, sacral slope, pelvic tilt, sagittal vertical axis, and lumbar lordosis in the evaluation and progression of spondylolisthesis [2, 4, 7]. The relationship between pelvic and global balance and spondylolisthesis progression has garnered more interest recently. Glassman et al. [3] and Mac-Thiong et al. [12] demonstrated a direct relationship between sagittal balance and health-related quality of life in patients with spinal deformity. In addition, the relationship between pelvic and global balance with spondylolisthesis progression has garnered more interest recently [5]. For this reason, the Spinal Deformity Study Group developed a classification system that consists of six types of progressive lumbosacral spondylo","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"15 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85960611","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Equity360: Gender, Race, and Ethnicity-Trapped in the Joint Pain Vicious Cycle (Part I).","authors":"M. O’Connor","doi":"10.1097/corr.0000000000000977","DOIUrl":"https://doi.org/10.1097/corr.0000000000000977","url":null,"abstract":"Orthopaedic surgeons treat patients with lower extremity joint pain on a regular basis. But are we effectively communicating with our patients that joint pain can be the beginning of a cycle that leads to poor health, and that this cycle affects women and individuals of color more so than men and whites? Movement is Life, a multistakeholder coalition formed in 2009 to decrease musculoskeletal healthcare disparities [13], calls this the Joint Pain Vicious Cycle—knee joint pain leading to limited mobility, which decreases overall physical activity, and likely results in weight gain. The addedweight increases pressure on the knee, potentially leading to more joint pain and raises the risk of developing co-morbid conditions (Fig. 1). Although any individual can fall into the Joint Pain Vicious Cycle, women and individuals of color are more likely to have joint pain related to arthritis [4]. The co-morbid and often life-threatening conditions seen in the cycle (heart disease [12], diabetes [14], and depression [1]) impact women or indiviudals of color more so than men or whites. This is important because the United States will be a non-white majority nation by 2045 (49.7% white, 24.6% Hispanic, 13.1% black, 7.9%Asian, 3.8%multiracial) [8]. We should also consider that:","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"49 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73156923","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Isolated Trochanteric Descent and Greater Trochanteric Apophyseodesis Are Not Effective in the Treatment of Post-Perthes Deformity.","authors":"Jonathan D. Haskel, Oren I. Feder, J. Mijares, P. Castañeda","doi":"10.1097/CORR.0000000000000990","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000990","url":null,"abstract":"BACKGROUND\u0000Greater trochanteric apophyseodesis and isolated trochanteric descent seek to prevent abductor weakness in patients with a hip deformity because of Legg-Calvé-Perthes disease; however, no studies have evaluated radiographic findings or abductor strength in children treated with these procedures.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) Do children with Waldenström Stage III Legg-Calvé-Perthes disease treated with either isolated greater trochanteric descent or isolated greater trochanteric apophyseodesis achieve improved radiographic findings (Stulberg classification or neck-shaft angle) compared with those who underwent no surgical treatment? (2) Do children treated with one of those procedures achieve greater abductor strength than those who did not have surgery?\u0000\u0000\u0000METHODS\u0000Between 2006 and 2010, we treated 89 children with Waldenström Type III Legg-Calvé-Perthes disease (reossification). Of these, 27.9% (12 patients) underwent greater trochanteric descent, 25.6% (11 patients) underwent greater trochanteric apophyseodesis, and 46.5% (20 patients) did not have surgery. During that time, the decision to perform either apophyseodesis or trochanteric descent was made by the surgeon based on the subjective appearance of remaining growth from the greater trochanter. Nonsurgical management was chosen by the parents of the patients after the risks and benefits of surgery were discussed. During greater trochanteric descent, the greater trochanter was osteotomized and fixed distally with two 7.0-mm screws. During greater trochanteric apophyseodesis, the physis was identified fluoroscopically, and the lateral half of the growth plate was drilled. Nonoperative treatment involved serial clinical and radiographic evaluations every 3 to 6 months. All children in all groups were available for follow-up at a minimum of 6 years. The median follow-up durations for children undergoing greater trochanteric descent, greater trochanteric apophyseodesis, and control cohorts were 6.6 years (range 6.0-8.2 years), 6.5 years (range 6.1-9.2 years), and 7.4 years (range 6.0-9.1 years), respectively. On presentation, each patient's affected hip was classified according to the Stulberg classification by the operating surgeon and an orthopaedic surgeon not involved in the child's care. The neck-shaft angle was measured for each patient before surgery and at the final follow-up examination. Abductor strength was assessed by a pediatric orthopaedic fellow and a physical therapist with the patient in the lateral decubitus position. Each patient was given a muscle strength score on a scale of 0 to 10 points, per a modification of the Medical Research Council scale to allow for a narrower range. We had 80% power to detect an 8° difference in the neck-shaft angle between the greater trochanteric apophyseodesis and nonoperative management cohorts. A sample size of 6.8 patients per cohort would be necessary to detect the above endpoint.\u0000\u0000\u0000RESULTS\u0000With the numbers available, we found no diff","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"145 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84942589","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Does Universal Insurance and Access to Care Influence Disparities in Outcomes for Pediatric Patients with Osteomyelitis?","authors":"J. Young, E. Dee, Adele A Levine, D. Sturgeon, T. Koehlmoos, A. Schoenfeld","doi":"10.1097/CORR.0000000000000994","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000994","url":null,"abstract":"BACKGROUND\u0000Healthcare disparities are an issue in the surgical management of orthopaedic conditions in children. Although insurance expansion efforts may mitigate racial disparities in surgical outcomes, prior studies have not examined these effects on differences in pediatric orthopaedic care. To assess for racial disparities in pediatric orthopaedic care that may persist despite insurance expansion, we performed a case-control study of the outcomes of children treated for osteomyelitis in the TRICARE system, the healthcare program of the United States Department of Defense and a model of universal insurance and healthcare access.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000We asked whether (1) the rates of surgical intervention and (2) 90-day outcomes (defined as emergency department visits, readmission, and complications) were different among TRICARE-insured pediatric patients with osteomyelitis when analyzed based on black versus white race and military rank-defined socioeconomic status.\u0000\u0000\u0000METHODS\u0000We analyzed TRICARE claims from 2005 to 2016. We identified 2906 pediatric patients, of whom 62% (1810) were white and 18% (520) were black. A surgical intervention was performed in 9% of the patients (253 of 2906 patients). The primary outcome was receipt of surgical intervention for osteomyelitis. Secondary outcomes included 90-day complications, readmissions, and returns to the emergency department. The primary predictor variables were race and sponsor rank. Military rank has been used as an indicator of socioeconomic status before and during enlistment, and enlisted service members, particularly junior enlisted service members, may be at risk of having the same medical conditions that affect civilian members of lower socioeconomic strata. Patient demographic information (age, sex, race, sponsor rank, beneficiary category [whether the patient is an insurance beneficiary from an active-duty or retired service member], and geographic region) and clinical information (prior comorbidities, environment of care [whether clinical care was provided in a civilian or military facility], treatment setting, and length of stay) were used as covariates in multivariable logistic regression analyses.\u0000\u0000\u0000RESULTS\u0000After controlling for demographic and clinical factors including age, sex, sponsor rank, beneficiary category, geographic region, Charlson comorbidity index (as a measure of baseline health), environment of care, and treatment setting (inpatient versus outpatient), we found that black children were more likely to undergo surgical interventions for osteomyelitis than white children (odds ratio 1.78; 95% confidence interval, 1.26-2.50; p = 0.001). When stratified by environment of care, this finding persisted only in the civilian healthcare setting (OR 1.85; 95% CI, 1.26-2.74; p = 0.002). Additionally, after controlling for demographic and clinical factors, lower socioeconomic status (junior enlisted personnel) was associated with a higher likelihood of 90-day emergency department","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"354 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80093077","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"CORR Insights®: What Are the Effects of Irreversible Electroporation on a Staphylococcus aureus Rabbit Model of Osteomyelitis?","authors":"J. Jennings","doi":"10.1097/CORR.0000000000000938","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000938","url":null,"abstract":"Osteomyelitis is a rare, but serious bone infection that may result from trauma, hematogenous spread, or chronic open wounds [12]. Treating osteomyelitis can be challenging because of antimicrobial resistance [9], biofilm formation [19], the presence of an avascular necrotic sequestrum [3], or internalization of bacteria within osteoblasts [25]. For elective surgical procedures like joint arthroplasty, antimicrobial therapy and aseptic techniques successfully prevent infection approximately 99% of the time [22], but once osteomyelitis has been established, the likelihood of treatment success varies widely, from 25% to 90% for established osteomyelitis, depending on many factors [6]. Early in the infectious process, antibiotic chemotherapy alone may eradicate osteomyelitis [5], though in moreadvanced or more severe infections, surgical débridement often comes into the picture [3], and surgical approaches may be augmented with targeted delivery of antibiotics directly to the affected tissue through local delivery devices such as antibiotic-loaded bone cement, calcium sulfate, or polymer sponges and gels [7, 10, 16, 24]. However, infection recurrence resulting from inadequate débridement or not clearing dormant biofilm bacteria can result in infection persistence, the need for repeat (andmore-aggressive) débridement, and even amputation of the affected limb [4, 8]. Novel therapeutics that both treat affected tissue and eradicate bacteria are desperately needed. The aim of the exploratory study by Muñoz and colleagues [13] is to determine whether a novel technique currently investigated for ablation of cancerous soft-tissue tumors might also have effective application in the treatment of osteomyelitis. The small preclinical study only followed animal outcomes for a 28-day period following treatment, but nonetheless provides promising evidence of a synergistic effect in killing Staphylococcus aureus within osteomyelitic bone.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"9 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91241015","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Editor's Spotlight/Take 5: Do Skills Acquired from Training with a Wire Navigation Simulator Transfer to a Mock Operating Room Environment?","authors":"S. Leopold","doi":"10.1097/CORR.0000000000000947","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000947","url":null,"abstract":"Surgical education is frustrating. I don't mean that it’s hard to keep residents away from the popliteal artery during knee replacement (though sometimes they do seem rather determined to hit it). I’m talking about the fact that surgical education may have more in common with the guild system that enabled the professional formation of saddlemakers in medieval Italy than it does with, say, pilot training in the 21st century. Pure coincidence that there were 14 lesser guilds in classical Florence [2] and there are 14 surgical subspecialties [1]? I hope so. Regardless, the quality of flight simulation vastly exceeds that of surgical simulation, and I’m not just talking about tools available to sharpen the skills of fighter pilots who want to land on pitching carrier decks at night, or even commercial pilots who fly 737s for Delta Airlines. A private pilot—a hobbyist, paying for simulator time with a credit card at a few bucks an hour—has better technology to help her improve his crosswind landings in a 40-year-old Cessna than does an orthopaedic resident at most university programs today who is trying to improve her surgical skills. This is frustrating. Happily, in this month’s Clinical Orthopaedics and Related Research, a research group from the University of Iowa, led by Donald D. Anderson PhD, demonstrated the efficacy of what they call a wire navigation simulator they developed, testing it in a mock operating room environment [5]. Wire navigation is a key surgical skill for orthopaedic trainees because it is used in so many diverse procedures (like hip fracture surgery, tension-band wiring, and many pediatric trauma applications), and because the skills required to manipulate a wire in three dimensions in advance of placing a cannulated screw may also generalize to other procedures that don’t use wires but do require three-dimensional aptitude, like arthroscopic surgery. Dr. Anderson’s team evaluated three approaches to surgical training: Simple pedagogy with didactic training, deliberate practice (didactics plus some relatively unsupervised training with the simulator, which gives helpful, specific feedback to its users), and proficiency training. The latter included all of the interventions from the two previous groups, plus supervised, hands-on skills testing in the simulator that required demonstration of proficiency with simpler tasks before moving on to more-advanced ones. In a bit of perhaps unexpected good news, residents allocated to self-study in the simulator (deliberate practice) did as well those who underwent moreintensive proficiency training on some of the more-important endpoints, including achieving correct tip-apex distance for simulated hip fracture surgery [5]. What was most impressive to me about this study was the level of A note from the Editor-In-Chief: In “Editor’s Spotlight,” one of our editors provides brief commentary on a paper we believe is especially important and worthy of general interest. Following the explanat","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"10 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72737825","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"CORR Insights®: Is Elective Soft Tissue Hand Surgery Associated with Periprosthetic Joint Infection after Total Joint Arthroplasty?","authors":"R. Delanois","doi":"10.1097/CORR.0000000000000944","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000944","url":null,"abstract":"In the United States, it is believed that the overutilization of antibiotics has resulted in an increased incidence of drug resistance and led to the creation of pathogens that are resistant to multiple antibiotics [11]. Recently, the Centers for Disease Control and Prevention (CDC) changed its recommendation for prophylaxis for clean, single incision surgeries, including total joint replacement from three doses to a single preoperative dose of antibiotics [4]. The need for prophylaxis in orthopaedic surgery has also been a topic of debate. Although in the past, the American Academy of Orthopaedic Surgeons (AAOS) has recommended surgeons consider prophylactic antibiotics for patients with a total joint arthroplasty undergoing a procedure that could cause bacteremia, more recently the AAOS (in conjunction with the American Dental Association [ADA]) released a guideline that suggested that most patients do not need prophylactic antibiotics before undergoing dental procedures [3]. However, no recommendations cover other routine procedures, including soft-tissue hand surgery. The current study by Li and colleagues [8] seeks to provide evidence to help fill this gap. Preoperative antibiotics are theorized to prevent transient bacteremia, the postulated mechanism of PJI in total joint arthroplasty patients undergoing routine procedures [12]. Several studies have argued that surgical procedures such as dental extractions and colonoscopies with biopsies can introduce small amounts of bacteria into the bloodstream, which could then seed a hip or knee implant [7, 10]. However, the patients most susceptible to bacteremia often are immunocompromised, or have active malignancies or other comorbid conditions (like poorly controlled diabetes) that could render them susceptible to infections [10]. Sincemost patients don’t have these problems, and since this sort of hematogenous seeding is believed to be extremely rare among patients without them, the current AAOS/ADA recommendation suggests that most patients do not benefit from prophylactic antibiotics in advance of dental procedures, and that in aggregate, the use of prophylactic antibiotics in those patients can cause more harm than good [10]. Despite the lack of current evidence for prophylaxis and the AAOS/ADA statement, many orthopaedic surgeons still prescribe antibiotics to all TJA patients before routine procedures that might induce PJI, with the goal of preventing PJI [6]. One concern with this practice is that it may lead to the prescription of antibiotics that might be unnecessary; this can cause complications like Clostridium difficile colitis and antibiotic resistance. C difficile is a serious complication that can result in death in patients with orthopaedic conditions [5]. In their study, Li and colleagues demonstrated that prophylactic antibiotic use was not correlated with a decreased risk of PJI, as has been shown by several other studies [1, 12].","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84861954","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"What Are the Effects of Irreversible Electroporation on a Staphylococcus aureus Rabbit Model of Osteomyelitis?","authors":"Nina M. Muñoz, Adeeb A. Minhaj, C. Dupuis, J. Ensor, N. Golardi, J. Jaso, K. Dixon, T. A. Figueira, J. Galloway-Peña, Lori R. Hill, S. Shelburne, A. Tam","doi":"10.1097/CORR.0000000000000882","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000882","url":null,"abstract":"BACKGROUND\u0000The treatment of osteomyelitis can be challenging because of poor antibiotic penetration into the infected bone and toxicities associated with prolonged antibiotic regimens to control infection. Irreversible electroporation (IRE), a percutaneous image-guided ablation technology in which the targeted delivery of high-voltage electrical pulses permanently damages the cell membrane, has been shown to effectively control bacterial growth in various settings. However, IRE for the management of bone infections has yet to be evaluated.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000We aimed to evaluate IRE for treating osteomyelitis by assessing (1) the efficacy of IRE to suppress the in vitro growth of a clinical isolate of S. aureus, alone or combined with cefazolin; and (2) the effects of IRE on the in vivo treatment of a rabbit model of osteomyelitis.\u0000\u0000\u0000METHODS\u0000S. aureus strain UAMS-1 expanded in vitro to the log phase was subjected to an electric field of 2700 V/cm, which was delivered in increasing numbers of pulses. Immediately after electroporation, bacteria were plated on agar plates with or without cefazolin. The number of colony-forming units (CFUs) was scored the following day. ANOVA tests were used to analyze in vitro data. In a rabbit osteomyelitis model, we inoculated the same bacterial strain into the radius of adult male New Zealand White rabbits. Three weeks after inoculation, all animals (n = 32) underwent irrigation and débridement, as well as wound culture of the infected forelimb. Then, they were randomly assigned to one of four treatment groups (n = eight per group): untreated control, cefazolin only, IRE only, or combined IRE + cefazolin. Serial radiography was performed to assess disease progression using a semiquantitative grading scale. Bone and soft-tissue specimens from the infected and contralateral forelimbs were collected at 4 weeks after treatment for bacterial isolation and histologic assessment using a semiquantitative scale.\u0000\u0000\u0000RESULTS\u0000The in vitro growth of S. aureus UAMS-1 was impaired by IRE in a pulse-dependent fashion; the number of CFUs/mL was different among seven pulse levels, namely 0, 10, 30, 60, 90, 120, and 150 pulses. With the number of CFUs/mL observed in untreated controls set as 100%, 10 pulses rendered a median of 50.2% (range 47.1% to 58.2%), 30 pulses rendered a median of 2.7% (range 2.5% to 2.8%), 60 pulses rendered a median of 0.014% (range 0.012% to 0.015%), 90 pulses rendered a median of 0.004% (range 0.002% to 0.004%), 120 pulses rendered a median of 0.001% (range 0.001% to 0.001%), and 150 pulses rendered a median of 0.001% (range 0.000% to 0.001%) (Kruskal-Wallis test: p = 0.003). There was an interaction between the effect of the number of pulses and the concentration of cefazolin (two-way ANOVA: F [8, 30] = 17.24; p < 0.001), indicating that combining IRE with cefazolin is more effective than either treatment alone at suppressing the growth of S. aureus UAMS-1. Likewise, the clinical response in the rabbit","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"40 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89504651","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}