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PubMed1993

Infections complicating joint replacement and other orthopedic conditions.

The principles underlying the diagnosis and management of infection in the orthopedic patient are well established. Despite this, the patient with an infected implant still presents the orthopedic surgeon with a challenging problem. In this review, I consider the recent developments in the diagnosis and management of the infected arthroplasty, infected tibial nonunions, spinal infections, and disease transmission by bone allografts.

Bacterial Infections↗
PubMed1991

An evaluation of preoperative and postoperative ventilation and perfusion lung scintigraphy in the screening for pulmonary embolism after elective orthopedic surgery.

One hundred two patients undergoing elective knee or hip arthroplasty were studied with radionuclide ventilation scans (V) and perfusion scans (Q) preoperatively (preop) and postoperatively (postop) to assess their relative value in the diagnosis of asymptomatic pulmonary embolism (PE) after orthopedic surgery. Postop Q were read in combination with preop V and Q and postop V using prospective investigation of pulmonary embolism diagnosis (PIOPED) criteria. Of 25 postop Q interpreted as either high or intermediate probability for PE, preop Q were judged useful in 96%; the postop V were useful in 78%; and the preop V were not helpful in any of the cases. Of 63 postop Q interpreted as low probability, preop Q were useful in 74%; the postop V were useful in only 33%; and the preop V were useful in only one case. When postop Q were read as normal (14 cases), none of the three auxiliary studies were found to be useful. Overall, postop V were more helpful than preop Q in only 2%, and preop V contributed significantly in only 1%. This experience suggests that preop Q alone is the most useful adjunct to the postop Q in the postoperative evaluation for PE. The authors conclude that to screen for asymptomatic PE after elective orthopedic surgery, preop Q should be performed in all cases, preop V are not necessary, and postop V need be performed only if a baseline preop Q is not available.

Aged↗
PubMed1989

Outcome of treatment of combined orthopedic and arterial trauma to the lower extremity.

To ascertain morbidity and disability associated with vigorous attempts at limb salvage after lower extremity combined orthopedic and arterial injuries we reviewed more than 10,000 trauma admissions. Twenty-two patients (0.2%) suffered 14 blunt and eight penetrating lower extremity orthoarterial injuries. In all, more than 90 extremity operations were performed within 30 days of admission. The mechanism of injury, ISS, sequence of orthopedic and vascular procedures, use of temporary arterial shunts, the nature of the arterial reconstruction, length of ischemic time, and the presence of open fractures did not affect limb salvage or outcome. The presence of neurosensory/motor impairment and/or serious soft-tissue loss and injuries at or distal to the popliteal artery were associated with a high frequency of disability and amputation. Tremendous effort was expended to achieve limb salvage in the patients of this review. Patients who underwent amputation had the more uneventful hospitalizations and the lower rates of disability. The notion that limb salvage need to be obtained in all patients at all costs may often lead to the triumph of technique and technology over reason.

Adult↗
PubMed1994

Orthopedic injuries from the Andover, Kansas, tornado.

Devastating tornados struck the state of Kansas on Friday, April 26, 1991. Twenty lives were lost and many people were injured. Property damage was extensive. Overall, the outcome of those admitted to the various hospitals was good, with few orthopedic-related complications. The low complication rate can be attributed to thorough open wound management and suspicion and recognition of other potential orthopedic complications such as compartment syndrome.

Abdominal Injuries↗
PubMed1994

Postoperative infections in asymptomatic HIV-seropositive orthopedic trauma patients.

In a retrospective study of 476 surgical orthopedic trauma patients, we compared postoperative infection rates between individuals seropositive for the human immunodeficiency virus (HIV) and with no associated clinical symptoms with HIV-seronegative patients. Overall, the surgical postoperative infection rate was 16.7% in seropositive patients and 5.4% in the seronegative group (Chi-square, p = 0.035). When open fractures were considered separately, the seropositive group had a 55.6% infection rate compared with 11.3% in the seronegative group (Fisher's exact test, p = 0.004). Similarly, seropositive patients also had significantly increased rates of postoperative non-wound infections and complications (Chi-square p < 0.001). Asymptomatic HIV-seropositive orthopedic trauma patients are at significantly higher risk for postoperative infections than their seronegative counterparts. For HIV-seropositive patients with open fractures, this risk is especially pronounced.

Adult↗
PubMed2000

Psychosocial support in rehabilitation after orthopedic injuries.

OBJECTIVE: Several studies have shown that psychosocial factors play a significant role in the recovery process after injuries. The aim of this study was to investigate whether psychosocial support would have a beneficial effect on outcome. METHODS: A total of 151 patients with orthopedic injuries were randomized into an intervention group and a control group. The intervention group was offered a psychosocial support program during the early phase of rehabilitation. RESULTS: One year after the injury, patients in the control group had an excess risk of having psychiatric complaints compared with patients in the intervention group (odds ratio = 2.74). They also reported a poorer quality of life according to Short Formula 36 Health Survey subscores for General Health (odds ratio = 2.3) and Vitality (odds ratio = 2.45). The length of the sick leave period did not differ between the groups. CONCLUSION: Psychosocial support during the early phase of rehabilitation after orthopedic injuries may have a beneficial effect on outcome when measured as quality of life.

Adolescent↗
PubMed2000

External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics.

BACKGROUND: The advantages of early fracture fixation in patients with multiple injuries have been challenged recently, particularly in patients with head injury. External fixation (EF) has been used to stabilize pelvic fractures after multiple injury. It potentially offers similar benefits to intramedullary nail (IMN) in long-bone fractures and may obviate some of the risks. We report on the use of EF as a temporary fracture fixation in a group of patients with multiple injuries and with femoral shaft fractures. METHODS: Retrospective review of charts and registry data of patients admitted to our Level 1 trauma center July of 1995 to June of 1998. Forty-three patients initially treated with EF of the femur were compared to 284 patients treated with primary IMN of the femur. RESULTS: Patients treated with EF had more severe injuries with significantly higher Injury Severity Scores (26.8 vs. 16.8) and required significantly more fluid (11.9 vs. 6.2 liters) and blood (1.5 vs. 1.0 liters) in the initial 24 hours. Glasgow Coma Scale score was lower (p < 0.01) in those treated with EF (11 vs. 14.2). Twelve patients (28%) had head injuries severe enough to require intracranial pressure monitoring. All 12 required therapy for intracranial pressure control with mannitol (100%), barbiturates (75%), and/or hyperventilation (75%). Most patients had more than one contraindication to IMN, including head injury in 46% of cases, hemodynamic instability in 65%, thoracoabdominal injuries in 51%, and/or other serious injuries in 46%, most often multiple orthopedic injuries. Median operating room time for EF was 35 minutes with estimated blood loss of 90 mL. IMN was performed in 35 of 43 patients at a mean of 4.8 days after EF. Median operating room time for IMN was 135 minutes with an estimated blood loss of 400 mL. One patient died before IMN. One other patient with a mangled extremity was treated with amputation after EF. There was one complication of EF, i.e., bleeding around a pin site, which was self-limited. Four patients in the EF group died, three from head injuries and one from acute organ failure. No death was secondary to the fracture treatment selected. One patient who had EF followed by IMN had bone infection and another had acute hardware failure. CONCLUSION: EF is a viable alternative to attain temporary rigid stabilization in patients with multiple injuries. It is rapid, causes negligible blood loss, and can be followed by IMN when the patient is stabilized. There were minimal orthopedic complications.

Adolescent↗
PubMed2002

Marfan syndrome: orthopedic and genetic review.

Marfan syndrome is an autosomal dominant disorder of connective tissue that affects the cardiac, eye, and skeletal systems. More than 135 mutations have been identified in the fibrillin-1 gene, localized on chromosome 15q21.1 [corrected] and responsible for the clinical manifestations of Marfan syndrome. The major orthopedic manifestations of Marfan syndrome include scoliosis, chest wall deformity, dural ectasia, joint hypermobility, and acetabular protrusion. In addition, decreased bone mineral density has been reported in patients with Marfan syndrome. This review summarizes recent developments in the genetic and orthopedic aspects of Marfan syndrome. Increased practitioner awareness of the clinical features associated with Marfan syndrome may facilitate earlier diagnosis and optimize patient treatment.

Acetabulum↗
PubMed2005

Radiographic correlation in orthopedic pathology.

Radiographic correlation is an essential adjunct for the accurate diagnosis of orthopedic lesions, yet it is a skill neglected by pathologists. The purpose of this review is to demonstrate why performing this correlation is an essential part of the diagnostic process and not merely an interesting adjunct to the surgical pathology of orthopedic lesions. The relationships between x-rays and tissues are explored with an emphasis on bone and soft tissue composition and structure. In addition, the rudiments of complementary imaging studies and how to incorporate their data into diagnoses are examined.

Age Factors↗
PubMed2004

Evaluation of a 3-hour indium-111 leukocyte image as a surrogate for a technetium-99m nanocolloid marrow scan in the diagnosis of orthopedic infection.

OBJECTIVES: This is a retrospective study to evaluate a 3-hour In-111-labeled leukocyte image as a surrogate for a Tc-99m nanocolloid marrow scan in the investigation of suspected orthopedic infection using In-111 leukocyte scintigraphy. METHODS: Images from 51 patients who had received contemporaneous In-111-labeled leukocyte scintigraphy and Tc-99m nanocolloid marrow scintigraphy were reviewed. Initially, the 3-hour and 22-hour In-111-labeled leukocyte images were compared. Sites of abnormal uptake on the 22-hour image were correlated with the 3-hour image and were graded according to the level of concordance or discordance. One week later, the Tc-99m nanocolloid images and 22-hour In-111-labeled leukocyte images of the same patients were compared and graded for concordance or discordance. When discrepancies in grading arose between the observers, a consensus opinion was achieved after additional review of the images a week later. RESULTS: On inspection of the 22-hour In-111 leukocyte images, 93 sites of focal, potentially abnormal leukocyte accumulation were identified. When the grading system was reduced to simply "concordant" or "discordant," there was good agreement between the observers in the majority of cases, with kappa statistics 0.77 for Tc-99m nanocolloid versus 22-hour In-111-labeled leukocyte images and 0.78 for 3-hour versus 22-hour In-111-labeled leukocyte images. Using the comparison of the Tc-99m nanocolloid marrow scan and the 22-hour In-111-labeled leukocyte images to identify concordance or discordance as the "gold standard" for scintigraphic evaluation of suspected orthopedic infection, comparison of the 3-hour In-111-labeled leukocyte images with the 3-hour In-111-labeled leukocyte images gave a sensitivity of 77%, a specificity of 77%, and an accuracy of 77%. CONCLUSIONS: A 3-hour image is helpful using In-111-labeled leukocyte scintigraphy.

Humans↗
PubMed2006

A comparison of self-reported and independently observed disability in an orthopedic trauma population.

BACKGROUND: Although outcome measures that assess disability after isolated orthopedic injuries have been found to be valid and responsive to change, the reliability of self-reported disability has not been studied in these patients. The purpose of this study was to compare self-reported and independently observed disability in patients with isolated orthopedic injuries. METHODS: Items were selected from the Short Musculoskeletal Functional Assessment (SMFA) and Disabilities of the Arm, Shoulder, and Hand (DASH) outcome assessment instruments. Participants had either an isolated upper (n = 61) or lower extremity (n = 55) injury or were noninjured controls (n = 40). Participants completed the SMFA and DASH before being videotaped completing items selected from the outcome assessment instruments. Observers reviewed the video and rated participants' levels of disability in performing the items. RESULTS: Observers consistently rated the disability levels for the items lower than the participants. Overall, agreement in levels of disability between observers and participants varied greatly across the different items (quadratic weighted kappa; range, 0.00-0.82). CONCLUSION: The results emphasize that patients and observers differ in their assessment of an individual's level of disability in performing items related to activities of daily living. Therefore, caution should be used when data collected by a proxy observer is used to substitute self-reported data.

Activities of Daily Living↗
PubMed2005

Evidence-based medicine and clinical trials in pain practice and orthopedics.

Medical practices should be based on scientific findings pursuant to the rules of evidence-based medicine. Quality standards for interventional pain therapy and orthopedic clinical studies have been lacking. As a result, the efficacy of many forms of therapy is insufficiently documented, making the level of evidence low. This article identifies common deficiencies in the conduct of clinical trials, as well as limitations in conducting randomized controlled studies. Recommendations for improvement are provided. The discussion provides the clinically active physician with interpretation aids for the evaluation of meta-analyses, supports personal evidence-based decisions, and reviews the most important principles for planning and conducting of experimental clinical studies. Current examples in the literature verify the implementation of these principles and present current findings in accordance with evidence-based medicine (EBM) criteria. In spite of an increasing emergence of EBM-based studies, we conclude that the number of well-designed, high quality, controlled studies conducted in accordance with the guidelines of Good Clinical Practice examining interventional pain therapy and orthopedic clinical studies remains unacceptably low.

Journal Article↗
PubMed2005

Risk for postoperative infection after transfusion of white blood cell-filtered allogeneic or autologous blood components in orthopedic patients undergoing primary arthroplasty.

BACKGROUND: This study was designed to obtain data on the incidence of postoperative infection in patients undergoing elective orthopedic surgery and receiving white blood cell (WBC)-filtered blood components prepared according to current standards. STUDY DESIGN AND METHODS: A total of 308 consecutive orthopedic patients who opted for preoperative autologous blood donation (PAD) for primary unilateral hip and knee replacement surgery were enrolled in a prospective observational study of the incidence of postoperative infection. Patients with contraindications for PAD or with any infectious disease were not included in the study. To identify probably confounding factors, differences between patient groups were analyzed first. Identified factors, which differed between groups, and variables describing blood supply were further tested in uni- and multivariate logistic regression analysis for their independent influence on development of postoperative infection. Infection rates were compared on the basis of actual transfusion groups. RESULTS: Of the 308 study patients, 101 were not transfused, 85 received their PAD, 100 received allogeneic WBC-filtered red blood cells (RBCs), and 22 were given autologous RBCs and additionally allogeneic WBC-filtered RBCs. Overall the infection rate was 6.82 percent (21/308). Infection rates varied significantly between transfusion groups (no transfusion, 6.9%; autologous RBCs, 1.2%; allogeneic WBC-filtered RBCs, 12.0%; both transfusion types, 4.6%; p = 0.03). Allogeneic recipients showed significantly more infections compared to autologous recipients (p = 0.0053). Multivariate regression analysis confirmed transfusion of allogeneic WBC-filtered RBCs as an independent variable predicting postoperative infection (odds ratio, 23.65; confidence interval, 1.3-422.1; p = 0.01). CONCLUSION: Differences in postoperative infection rates between allogeneic and autologous recipients are still observable, although universal WBC filtration has been introduced into clinical practice.

Aged↗
PubMedDate not supplied

Scintigraphic detection of equine orthopedic infection using Tc-HMPAO labeled leukocytes in 14 horses.

The aim of this study was to evaluate the diagnostic value of 99mTc-HMPAO leukocyte scintigraphy (LS) by means of a retrospective review of its use in 14 horses that were evaluated for orthopedic infection as a cause of lameness. A total of 17 LS exams were performed in 14 horses. LS studies were positive in 10 of 14 horses. A bacterial infection was confirmed with cytology or culture in 9 of 10 positive horses. Negative LS studies occurred in 4 of 14 horses. Necropsy confirmed the lack of infection in 2 of the 4 horses. Other clinical data and a favorable clinical outcome supported a negative study in the other 2 horses. No false negative or false positive studies were identified. It may be concluded that HMPAO-LS is an effective tool for the diagnosis of orthopedic infection in horses.

Animals↗
PubMed2005

Effect of antibiotic treatment on bacterial attachment to a DePuy Enduron orthopedic implant.

BACKGROUND: The increasing incidence of bacterial infections in orthopedic surgery might be related to the increasing application of artificial devices. In most cases, bacteria multiply on the surface of implants in biofilms. Poor penetration of antibiotics, frequent necessity of prosthesis removal, chronic processes and financial costs emphasize the significance of preventive measures. METHOD: Adhesion of bacterial strains (two Staphylococcus aureus, two coagulase-negative staphylococci and two Pseudomonas aeruginosa strains isolated from orthopedic patients' wounds) to the surface of a polyethylene cup was investigated using an ultrasonic method. Results were compared to the adhesive ability of three Hungarian standard strains. The effect of antibiotic treatment (cefuroxime, cefotaxime, amoxicillin with clavulanic acid and amikacin) has been examined. RESULTS: The staphylococcal strains showed significantly higher adhesive ability than Pseudomonas strains. Antibiotic treatment significantly reduced the attachment of bacteria. The higher the concentration of the antibiotics, the higher was the decrease in bacterial adhesion. CONCLUSIONS: Antibiotic prophylaxis was proven to be effective against bacterial adhesion, and, if applied at the proper time at the highest tolerable dose, it might prevent the formation of biofilms.

Anti-Bacterial Agents↗
PubMed1998

Tissue factor expression by rat osteosarcoma cells adherent to tissue culture polystyrene and selected orthopedic biomaterials.

Tissue factor (TF), a transmembrane glycoprotein expressed by numerous cell types, plays a critical role in the initiation of blood coagulation at sites of vascular injury. Activated products of the coagulation cascade may then enhance the inflammatory responses associated with wound healing. In the present investigation the ability of rat osteosarcoma (ROS) cells to express TF activity was examined following their growth on tissue-culture polystyrene (TCPS) and selected orthopedic biomaterials (titanium and zirconium alloys, and stainless steel). ROS cells exhibited significant TF activity as evidenced by the conversion of Factor X to Factor Xa in the presence of TF, Factor VIIa, and Ca2+. Factor Xa concentrations ranged from 1.0 fM per cell at 10 min to 6.0 fM per cell after 60 min. Additionally, ROS cells stimulated with calcium ionophore (A23187) exhibited approximately twice the activity of non-stimulated cells when grown on TCPS but not on the metallic substrates. ROS cells (stimulated or unstimulated) adherent to the zirconium alloy generated lower amounts of Factor Xa compared to those bound to the other alloys and unstimulated cells grown on TCPS. These results indicate that ROS cells cultured on these synthetic surfaces differentially express procoagulant activity and that cells grown on TCPS, but not the metallic alloys, exhibit increased TF activity in response to stimulation by calcium ionophore. This procoagulant activity may potentiate subsequent inflammatory responses associated with the use of orthopedic biomaterials and thereby influence the tissue compatibility of the implant.

Alloys↗
PubMedDate not supplied

Anodization: a promising nano-modification technique of titanium implants for orthopedic applications.

Anodization is a well-established surface modification technique that produces protective oxide layers on valve metals such as titanium. Many studies have used anodization to produce micro-porous titanium oxide films on implant surfaces for orthopedic applications. An additional hydrothermal treatment has also been used in conjunction with anodization to deposit hydroxyapatite on titanium surfaces; this is in contrast to using traditional plasma spray deposition techniques. Recently, the ability to create nanometer surface structures (e.g., nano-tubular) via anodization of titanium implants in fluorine solutions have intrigued investigators to fabricate nano-scale surface features that mimic the natural bone environment. This paper will present an overview of anodization techniques used to produce micro-porous titanium oxide structures and nano-tubular oxide structures, subsequent properties of these anodized titanium surfaces, and ultimately their in vitro as well as in vivo biological responses pertinent for orthopedic applications. Lastly, this review will emphasize why anodized titanium structures that have nanometer surface features enhance bone forming cell functions.

Coated Materials, Biocompatible↗
PubMed1985

Variation in prophylactic antibiotic use in pediatric orthopedic surgery.

Fifty-two pediatric patients undergoing orthopedic surgery were evaluated to determine the pattern of prophylactic antibiotic use. Of the 50 patients receiving antibiotics, 43 patients were given the antibiotic prior to surgery; 38 patients received the drug within two hours prior to surgery. All patients received the postoperative antibiotic for a duration ranging from 2 to 14 days. Thirty-one patients received the postoperative antibiotic for longer than 48 hours without documentation of infection. Cephapirin and/or cefazolin were the most common antibiotics used. Due to fixed postoperative doses (0.5-2 g), the dose/kg/d exceeded the maximum recommended therapeutic doses in one-third of the patients. The results of this study illustrate that the use of prophylactic antibiotics in pediatric orthopedic surgery can be improved to maximize benefits and minimize costs and the potential for adverse effects. Until data from controlled studies become available, it seems appropriate to follow the Centers for Disease Control guidelines in establishing hospital policy for surgical prophylaxis.

Adolescent↗