AUGUST 2009 VOLUME XXXVIII NUMBER 8 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

129	Analgesia for Total Hip and Knee Arthroplasty: A Review of Lumbar Plexus, Femoral, and Sciatic Nerve Blocks MaCalus V. Hogan, MD, Richard E. Grant, MD, and Larry Lee, Jr., MD Dr. Hogan is Resident Physician, Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia. Use of peripheral nerve blocks (PNBs) during lower extremity surgery has evolved. In this article, we review the pertinent anatomy and the literature concerning the advantages and disadvantages of both PNBs and traditional methods of postoperative analgesia (neuraxial and patient-controlled) for total hip arthroplasty and total knee arthroplasty. We conclude that use of PNBs for total hip and total knee arthroplasty compares favorably with traditional methods of postoperative analgesia. As use of PNBs becomes more widespread, understanding their risks and benefits will be of great value to orthopedic surgeons. Am J Orthop. 2009;38(8):E129-E133.
134	Blood Cultures for Evaluation of Fever After Total Joint Arthroplasty John T. Anderson, MD, and John D. Osland, MD Dr. Anderson is Assistant Professor, Department of Orthopaedic Surgery, University of Missouri–Kansas City School of Medicine, Children’s Mercy Hospital, Kansas City, Missouri. Fever after total joint arthroplasty (TJA) is common. Fearing the potential complications of bacteremia, physicians often obtain blood cultures to evaluate fever after TJA. In this study, we retrospectively examined the results of 102 sets (204 samples) of blood cultures that had been obtained from 50 patients (mean age, 67.3 years) during the first 2 postoperative days for evaluation of fever of 38.3°C or higher. All patients had been receiving antibiotic prophylaxis. Of the 50 patients, 39 had undergone total knee arthroplasty, and 11 had undergone total hip arthroplasty. There had been 49 primary operations and 1 revision. Of the 204 blood culture samples, none had grown a pathogen. The cultures had been ordered by both surgical (61%) and medical (39%) services. The 2008 institution charge to process the 2 blood culture samples (1 set) routinely collected for each evaluation was $120 (true cost, $44.29). Therefore, in the current health care market, the charge to the payer for processing 102 sets would be $12,240. We conclude that blood cultures are neither useful nor cost-effective in evaluating fever immediately after TJA. We believe that the results of this study will be helpful to both orthopedists and medical consultants involved in the care of TJA patients. Am J Orthop. 2009;38(8):E134-E136.
137	Venous Hemodynamic Alterations in Lower Limbs Undergoing Total Joint Arthroplasty Kousuke Sasaki, MD, Hiromasa Miura, MD, PhD, Shinichiro Takasugi, MD, PhD, Seiya Jingushi, MD, PhD, Eiji Suenaga, MD, PhD, and Yukihide Iwamoto, MD, PhD Dr. Sasaki is Orthopaedic Surgeon, Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. Using duplex ultrasonography, we measured preoperative and postoperative venous flow volume in 32 operated lower limbs without deep vein thrombosis (DVT) after total hip arthroplasty (THA, n = 17) and total knee arthroplasty (TKA, n = 15). We also calculated percentage decrease in mean venous flow volume (MVFV) from before surgery to after surgery. Patients with a history of one of several venous diseases, congestive heart failure, or morbid obesity were excluded. In both groups (THA, TKA), MVFV 3 days after surgery and MVFV 1 week after surgery were significantly lower than preoperative MVFV, but MVFV at 2 or more weeks after surgery did not differ significantly from preoperative MVFV (result 1). Incidentally, the decrease in MVFV in the lower limbs was significantly larger 3 days after TKA than 3 days after THA (result 2). As venous stasis has a central role in thrombus formation, result 1 suggests that the risk for DVT initiation is low at 2 or more weeks after THA and TKA in patients with normal preoperative venous physiologic functions. Result 2 is probably correlated with the evidence that DVT incidence is higher after TKA than after THA. Am J Orthop. 2009;38(8):E137-E140.
141	Joint Arthroplasty Within 10 Years After Primary Charnley Total Hip Arthroplasty Siraj A. Sayeed, MD, MEng, Robert T. Trousdale, MD, Sunni A. Barnes, PhD, Kenton R. Kaufman, PhD, and Mark W. Pagnano, MD Dr. Sayeed is Surgeon, Department of Orthopedics, Mayo Clinic, Rochester, Minnesota. To evaluate the need for joint arthroplasty within 10 years after index primary Charnley total hip arthroplasty (THA) performed for osteoarthritis, we retrospectively reviewed the cases of 2,547 patients, 50 to 75 years old, from 1969 to 1984, with a minimum potential 20-year follow-up. In this article, we report the age, sex, and time data from this study. For the entire patient population, the 10-year rate of undergoing contralateral THA was 35.0%; ipsilateral hip revision, 6.2%; ipsilateral total knee arthroplasty (TKA), 0.6%; contralateral TKA, 1.9%; and bilateral TKA, 0.2%. The 10-year death rate was 21.8%. With more than 200,000 THAs being performed in the United States each year, these numbers can guide orthopedic surgeons in their discussions about subsequent arthroplasty procedures on other joints. Am J Orthop. 2009;38(8):E141-E143.

382	Making Ethical Decisions in Current Orthopedic Practice Howard S. An, MD Dr. An, this journal’s Associate Editor for Spine, is the Morton International Endowed Chair, Professor of Orthopaedic Surgery, and Director, Division of Spine Surgery and Spine Fellowship Program, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois. Abstract not available. Am J Orthop. 2009;38(8):382-383.
387	Computer-Assisted Spinal Navigation Using a Percutaneous Dynamic Reference Frame for Posterior Fusions of the Lumbar Spine Natalie M. Best, MD, Rick C. Sasso, MD, and Ben J. Garrido, MD Dr. Best is Resident Physician, University of Utah Health Sciences Center, Salt Lake City, Utah. We report a 6-year retrospective review of screw placement utilizing a percutaneous dynamic reference frame attached to the posterior superior iliac spine performed by a single orthopedic surgeon. We included all lumbar spine procedures utilizing computer-assisted spinal navigation (StealthStation® Navigation System, Medtronic Navigation, Louisville, Colo) performed from 2000 to 2005, with 272 of 289 patients (94.1%) having at least a 4-month follow-up with radiographs. Six hundred seventy-two screws were placed. Following surgery, none of these patients had screw misplacements. One patient (0.4%) had a screw backing out of the pedicle. Eighteen patients (6.6%) had their posterior instrumentation removed. Three had repeat operations but did not have their instrumentation removed. No patient with repeat operations had a screw misplaced. Am J Orthop. 2009;38(8):387-391.
394	Thromboprophylaxis in Orthopedic Surgery: How Long Is Long Enough? James Muntz, MD, FACP Dr. Muntz is Clinical Professor of Medicine and Clinical Associate Professor of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas; Clinical Associate Professor of Internal Medicine, University of Texas Health Center, Houston, Texas; and Co-Director, Memorial Hermann Sports Medicine Institute, Houston, Texas. Pharmacologic thromboprophylaxis with low-molecular-weight heparins, vitamin K antagonists, or fondaparinux is well tolerated and effective in preventing venous thromboembolism (VTE) in major orthopedic surgery but is often limited to in-hospital use. However, 45% to 80% of all symptomatic VTE events occur after hospital discharge. Extended-duration VTE prophylaxis for 28 to 35 days reduces risk for late VTE by up to 70%. In this article, I review the evidence supporting guideline recommendations regarding extended-duration prophylaxis after major orthopedic surgery and provide an overview of current and emerging literature regarding prevention of postoperative VTE in patients undergoing this surgery. Am J Orthop. 2009;38(8):394-401.
404	Risk of Progression in De Novo Low-Magnitude Degenerative Lumbar Curves: Natural History and Literature Review Kingsley R. Chin, MD, Christopher Furey, MD, and Henry H. Bohlman, MD Dr. Chin is a spine surgeon with the Institute for Minimally Invasive Spine Surgery (iMIS), West Palm Beach, Florida. Natural history studies have focused on risk for progression in lumbar curves of more than 30°, while smaller curves have little data for guiding treatment. We studied curve progression in de novo degenerative scoliotic curves of no more than 30°. Radiographs of 24 patients (17 women, 7 men; mean age, 68.2 years) followed for up to 14.3 years (mean, 4.85 years) were reviewed. Risk factors studied for curve progression included lumbar lordosis, lateral listhesis of more than 5 mm, sex, age, convexity direction, and position of intercrestal line. Curves averaged 14° at presentation and 22° at latest follow-up and progressed a mean of 2° (SD, 1°) per year. Mean progression was 2.5° per year for patients older than 69 years and 1.5° per year for younger patients. Levoscoliosis progressed 3° per year and dextroscoliosis 1° per year (P<.05). Forty-six percent of patients had lateral listhesis of more than 5 mm at L3 and L4. Curve progression was not linear and might occur rapidly, particularly in women older than 69 with lateral listhesis of more than 5 mm and levoscoliosis. Small curves can progress and therefore should be individualized in the context of other risk factors. Am J Orthop. 2009;38(8):404-409.
410	Treatment of Displaced Type II Odontoid Fractures in Elderly Patients Hossein Elgafy, MD, MCh, FRCSEd, FRCSC, Marcel F. Dvorak, MD, FRCSC, Alexander R. Vaccaro, MD, PhD, and Nabil Ebraheim, MD Dr. Elgafy is Assistant Professor, Department of Orthopaedics, University of Toledo Medical Center, Toledo, Ohio. Odontoid fractures are the most common cervical spine fractures for patients older than 70 years and are the most common of all spinal fractures for patients older than 80. Type II fracture, the most common type of odontoid fracture, is considered relatively unstable. It occurs at the base of the odontoid between the level of the transverse ligament and the C2 vertebral body. In the geriatric population, it is important to look for any associated clinical comorbidities that might affect management. Treatment options for displaced odontoid fractures can be conservative or surgical. Conservative management includes immobilization in a cervical collar or in a halo vest. External immobilization with a cervical collar has had inconsistent results. Halo vest immobilization in the elderly is associated with a significant nonunion rate and several complications. Generally accepted surgical indications are polytrauma, neurologic deficit, associated unstable subaxial spine injury that requires surgical fixation, and symptomatic nonunion. Surgical management includes either anterior odontoid screw fixation or posterior C1–C2 instrumentation with fusion. Am J Orthop. 2009;38(8):410-416.
417	Word of Mouth in the Digital Age: Online Physician Ratings Steve Gillies, BA; for KarenZupko & Associates, Inc. Mr. Gillies is Research Analyst, KarenZupko & Associates, Inc., Chicago, Illinois. Abstract not available. Am J Orthop. 2009;38(8):417-419.

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