JANUARY 2008 VOLUME XXXVII NUMBER 1 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

E-FOCUS ON infection in orthopedic practice

1	Guest Editorial—Orthopedic Infections: Important Issues in Prevention and Diagnosis Carolyn Gould, MD, MS Carolyn Gould, MD, MS, is Medical Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Abstract not available. Am J Orthop . 2008;37(1):E1, E16.
2	Infection Prevention in Total Knee and Total Hip Arthroplasties Mark Kuper, DO, and Alexander Rosenstein, MD Alexander Rosenstein, MD, Division of Adult Reconstruction, Department of Orthopaedic Surgery, University of Texas Health Science Center, 6431 Fannin St, Suite 6.136, Houston, TX 77030 (tel, 713-500-7003; fax, 713-500-0729; e-mail, alexander.d.rosenstein@uth.tmc.edu). Infection after primary joint arthroplasty is responsible for severe morbidity to the patients and staggering costs to society. Understanding the patient population undergoing these procedures and the use of appropriate prophylactic regiments and precautions in the perioperative and postoperative periods is crucial for the ultimate success of the procedures. In this article, we review the current related literature and our techniques for reducing the likelihood of infection after total knee and total hip arthroplasties. Am J Orthop. 2008;37(1):E2-E5.
6	Wichita Fusion Nail for Patients With Failed Total Knee Arthroplasty and Active Infection Christopher Hogg, DO, Viktor Krebs, MD, Alison K. Klika, MS, and Wael K. Barsoum, PhD Alison K. Klika, MS, Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195 (tel, 216-444-4954; fax, 216-445-6255; e-mail, klikaa@ccf.org). In the study reported here, we retrospectively evaluated short-term results of knee arthrodesis using the Wichita® fusion nail (WFN) in patients with active infection. Clinical examinations, x-rays, time to union, knee pain after fusion, and ambulatory status were compared in 7 patients who received the WFN. Mean fusion rate was 86%, mean time to fusion was 9.8 months, and mean complication rate was 57%. Complication rates were high, but clinical outcomes were acceptable, supporting use of WFN as a reasonable way to salvage failed total knee arthroplasty in patients with active infection. Am J Orthop. 2008;37(1):E6-E10.
11	Psoas Abscess: A Diagnostic Dilemma Nabil A. Ebraheim, MD, Jason D. Rabenold, MD, Vishwas Patil, MD, and Christopher G. Sanford, BS Vishwas Patil, MD, Department of Orthopaedic Surgery, University of Toledo Medical Center, 3000 Arlington Ave, Toledo, OH 43614 (tel, 419-383-4553; fax, 419-383-3526; e-mail, vishwasorth@yahoo.com). Abstract not available. Introduction provided instead. Iliopsoas muscles are located in the retrofascial space, which lies between the transversalis fascia and the posterior psoas fascia.1 Abscesses of the iliopsoas result most commonly from osseous sources, such as the spine, ileum, and sacroiliac joint. They seldom arise from pyomyositis, trauma, lymphatic spread, or puerperal infections. Immunocompromised patients and drug users are particularly susceptible. Iliopsoas abscess may initially present with signs and symptoms in the buttock, hip, or thigh. Such signs and symptoms may be obscure, nonspecific, and misleading.1 Diagnosis is often overlooked, as a patient lies supine and refuses to move or resists being turned for examination. With psoas involvement, the hip is flexed and has a limited and painful range of motion that diverts attention from the abdominal or pelvic source of the abscess.2 Pain is referred along the distribution of the gluteal or obturator nerves or along the distribution of the lumbar and sacral nerve roots, thus directing attention elsewhere.2 The abscess may also be overlooked given the deep location of the iliopsoas muscle.3 Iliopsoas abscess is best detected through use of computed tomography (CT), which defines its pathway and allows for appropriate surgical treatment. Am J Orthop. 2008;37(1):E11-E13.
14	Acute Gonococcal Thenar Abscess With Associated Focal Flexor Tenosynovitis Masquerading as a Soft-Tissue Mass Donald W. Hurst, MD, Michael A. Thompson, MD, and Eric P. Hofmeister, MD Eric P. Hofmeister, MD, c/o Clinical Investigation Department (KCA), Naval Medical Center San Diego, 34800 Bob Wilson Dr, Suite 5, San Diego, CA 92134- 1005 (tel, 619-532-8427; fax, 619-532-8467; e-mail, ephofmeister@ nmcsd.med.navy.mil). Abstract not available. Introduction provided instead. Neisseria gonorrhoeae infection is a common sexually transmitted disease (STD) that may cause a disseminated infection. Some patients with disseminated gonococcal infection (DGI) have tenosynovitis as its only manifestation, most often involving the extensor tendons of the hand, wrist, or ankle.1 The typical presentation of DGI is fever, chills, and generalized malaise, but symptomatic genital infection is uncommon in both males and females.2 DGI occurs in 0.1% to 0.3% of patients infected with N gonorrhoeae,3 and approximately two thirds of patients with DGI develop tenosynovitis.4 We present an unusual case of gonococcal flexor tenosynovitis presenting as a soft-tissue mass. Am J Orthop. 2008;37(1):E14-E15.

11	AAOS Journal Editors Speak With One Voice Peter D. McCann, MD Peter D. McCann, MD, is Chair, Department of Orthopaedic Surgery at Beth Israel Medical Center, New York, New York. Abstract not available. Am J Orthop. 2008;37(1):11-13.
14	Percutaneous Fixation of the Medial Condyle in Bicondylar Tibial Plateau Fractures: Novel Use of the 3.5-mm Medial Distal Tibia Plate Rakesh P. Mashru, MD, Amir A. Jahangir, MD, Mark S. Parrella, MD, and Susan P. Harding, MD Rakesh P. Mashru, MD, Section Head and Chief of Service, Division of Orthopaedic Traumatology, Brandywine Institute of Orthopaedics, 600 Creekside Drive, Suite 611, Pottstown, PA 19464 (tel, 610-792-9292; fax, 610-792-9293; e-mail, mashru@brandywineortho.com). Internal fixation for fractures involving the medial tibial plateau is a controversial topic. Surgical options include buttress plating with antiglide plate, T-shaped proximal tibia plates, external fixation, and isolated screw fixation. Operative management is often complicated by soft-tissue concerns. In this article, we describe a percutaneous surgical technique in which a 3.5-mm medial distal tibia plate, originally designed for distal tibial shaft or pilon fractures, is used in osteosynthesis of the medial tibial plateau. Use of this implant reduces soft-tissue dissection and thereby decreases risk for soft-tissue infection or slough while preventing medial column collapse and varus deformity of the knee. Orthopedic surgeons should consider this novel hardware application as an option for osteosynthesis in certain bicondylar tibial plateau fractures. Am J Orthop. 2008;37(1):14-17.
18	Minimizing Leg-Length Inequality in Total Hip Arthroplasty: Use of Preoperative Templating and an Intraoperative X-Ray Aaron A. Hofmann, MD, Michael Bolognesi, MD, Amit Lahav, MD, and Stephen Kurtin, MD Aaron A. Hofmann, MD, Department of Orthopaedic Surgery, 590 Wakara Way, Salt Lake City, UT 84108 (tel, 801-587-5457; fax, 801-587-5411; e-mail, aaron.hofmann@hsc.utah.edu). Leg-length inequality after total hip arthroplasty remains a controversial issue. In the study reported here, we sought to determine whether significant leg-length discrepancies (>6 mm) can be minimized with use of an intraoperative x-ray. In each case, preoperative templating was carefully performed, an intraoperative pelvis x-ray was obtained to assess accuracy, and appropriate adjustments were made. Eighty-six consecutive primary total hip arthroplasties and their associated x-rays were retrospectively reviewed. Mean postoperative leg-length discrepancy was 0.3 mm (SD, 2.6 mm; range, –6 to +6 mm). No legs were lengthened or shortened by more than 6 mm. Significant leg-length discrepancies can be minimized with use of an intraoperative pelvis x-ray. Am J Orthop. 2008;37(1):18-23.
24	Quantification of Two-Dimensional Glenohumeral Rhythm in Persons With and Without Symptoms of Shoulder Impingement Wendy S. Burke, DPT, PT, OCS, C. Thomas Vangsness, Jr., MD, and Christopher M. Powers, PhD, PT C. Thomas Vangsness, Jr., MD, Department of Orthopaedic Surgery, University of Southern California, 1520 San Pablo St, Suite 2000, Los Angeles, CA 90033 (tel, 323-442-5860; fax, 323-442-6990; e-mail, vangsnes@usc.edu). A repeated-measures design was used to assess glenohumeral rhythm in 10 patients with shoulder impingement and 10 pain-free persons and to assess the effects of subacromial injection on glenohumeral rhythm within the impingement group. Scapular-plane anterior-to-posterior x-rays of the scapula and humerus were obtained at 5 angles of arm elevation (resting, 30°, 60°, 90°, 120°). For the impingement group, x-rays were repeated after subacromial injection (10 mL of 1% lidocaine). No significant differences in glenohumeral rhythm were found between the impingement and control groups across all arm-elevation angles. Am J Orthop. 2008;37(1):24-30.
32	Preoperative Cardiac Evaluation of Patients With Acute Hip Fracture Jonathan Cluett, MD, Jill Caplan, MD, and Warren Yu, MD Jill Caplan, MD, Department of Orthopedic Surgery, 2150 Pennsylvania Avenue, Suite 7-416, Washington, DC 20037 (tel, 202-741-3311; fax, 202-741-3313; e- mail, cappyj@ gwu.edu). The goals of the present study were to assess if there is an association between preoperative cardiac evaluation and surgery timing in patients with a hip fracture, to evaluate the relationship between surgery timing and postoperative morbidity and mortality, and to determine if the proper patients are being selected for noninvasive cardiac testing based on the practice guidelines published by the American College of Cardiology/American Heart Association Task Force. Surgery delay secondary to cardiac clearance may be a risk factor for increased postoperative complications that is independent of a patient’s general medical condition. Surgical treatment of acute hip fractures may be delayed by many factors besides preoperative cardiac clearance, but it is the job of the orthopedic surgeon, who best understands the importance of timely surgery for a hip fracture, to minimize delays. Careful screening of patients who have sustained a hip fracture can improve overall outcomes by minimizing the number of patients whose surgical treatment is unnecessarily delayed for cardiac clearance. Am J Orthop. 2008;37(1):32-36.
39	Use of Femoral Nerve Blocks in Adolescents Undergoing Patellar Realignment Surgery Scott J. Luhmann, MD, Mario Schootman, PhD, Perry L. Schoenecker, MD, J. Eric Gordon, MD, and Charles Schrock, MD Scott J. Luhmann, MD, St. Louis Children’s Hospital, One Children’s Place, Suite 4S20, St. Louis, MO 63110 (tel, 314-454-2045; fax, 314-454-4562; e-mail, luhmanns@wustl.edu). The purpose of this study was to analyze the efficacy of femoral nerve blocks (FNBs) in decreasing postoperative narcotic use in adolescents undergoing patellar realignment surgery (PRS). All patients who underwent PRS at 2 children’s hospitals between 1998 and 2002 were included in the study. Patients were grouped according to postoperative analgesia: FNB (n = 14), as-needed intravenous morphine (PRN-IV; n = 16), or patient-controlled analgesia using morphine (PCA; n = 13). Total postoperative IV morphine use was statistically significantly different among the 3 groups: 9.0 mg for FNB, 26.43 mg for PRN- IV, and 64.7 mg for PCA. FNB use was effective in significantly decreasing postoperative IV narcotic use. Am J Orthop .2008;37(1):39-43.
44	Delayed Diagnosis of a Flexion-Distraction (Seat Belt) Injury in a Patient With Multiple Abdominal Injuries: A Case Report Michael Burdi, MD, Christopher M. Bono, MD, Christopher P. Kauffman, MD, David Hoyt, MD, and Steven R. Garfin, MD Christopher M. Bono, MD, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 (tel, 617-732-7238; fax, 617-732-6397; e-mail, bonocm@prodigy.net). Abstract not available. Am J Orthop. 2008;37(1):44-46.
47	Anterior Cruciate Ligament Reconstruction in Adolescents: A Survivorship Analysiss Wudbhav N. Sankar, MD, Robert B. Carrigan, MD, John R. Gregg, MD, and Theodore J. Ganley, MD Theodore J. Ganley, MD, Children’s Hospital of Philadelphia, Wood Building, 2nd Floor, 34th St & Civic Center Blvd, Philadelphia, PA 19104 (tel, 215-590-1527; fax, 215-590-1101; e-mail, ganley@email.chop.edu). There are few reports on the longevity of anterior cruciate ligament (ACL) reconstruction in adolescents. In the study reported here, we performed a survivorship analysis of our experience with ACL reconstructions in adolescents. We retrospectively reviewed the cases of 276 consecutive patients (girls’ bone age, >13 years; boys’ bone age, >14 years; chronological age, <18 years) who underwent primary ACL reconstruction. All patients underwent transphyseal ACL reconstruction with Achilles tendon soft-tissue allograft using the same technique. Twenty-nine patients (10.5%) were excluded or lost to follow-up. Mean follow-up of the remaining 247 patients was 6.3 years (range, 2- 10 years). Data were collected from charts and telephone interviews. Failure was defined as the report of symptomatic knee instability and/or revision ACL surgery. The Kaplan-Meier method showed that 1-year survivorship of ACL reconstruction was 96.4% and 5-year survivorship was 93.1%. Am J Orthop . 2008;37(1):47-49.
50	Morton Neuroma Paul D. Clifford, MD, and Rachel B. Hulen, MD Paul D. Clifford, MD, Department of Radiology, Applebaum Outpatient Center, University of Miami, 1115 NW 14th St, Miami, FL 33136-2106 (tel, 305-243- 5449; fax, 305-243-8422; e-mail, pclifford@med.miami.edu). Abstract not available. Am J Orthop. 2008;37(1):50-51.

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