Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 469 | Issue 11 | Nov, 2011

New Definition for Periprosthetic Joint Infection: From the Workgroup of the Musculoskeletal Infection Society

Javad Parvizi MD, Benjamin Zmistowski BS, Elie F. Berbari MD, Thomas W. Bauer MD, PhD, Bryan D. Springer MD, Craig J. Della Valle MD, Kevin L. Garvin MD, Michael A. Mont MD, Montri D. Wongworawat MD, Charalampos G. Zalavras MD

Surfactant-stabilized Emulsion Increases Gentamicin Elution From Bone Cement

Ryan B. Miller MD, Alex C. McLaren MD, Christine M. Leon MS, Brent L. Vernon PhD, Ryan McLemore PhD

Liquid antimicrobial use for antimicrobial-loaded bone cement is limited because of decreased strength and small volume that can be loaded. Emulsifying the liquid antimicrobial into the monomer may address both issues.

Amphotericin B Delivery From Bone Cement Increases With Porosity but Strength Decreases

Chris Kweon MD, Alex C. McLaren MD, Christine Leon MS, Ryan McLemore PhD

Amphotericin B is a highly hydrophobic antifungal used for orthopaedic infections. There is disagreement about whether amphotericin B is released when it is loaded in polymethylmethacrylate (PMMA). It is unknown how much a poragen will increase amphotericin B release or decrease the compressive strength of the PMMA.

Evaluation of Two Sources of Calcium Sulfate for a Local Drug Delivery System: A Pilot Study

Ashley C. Parker BS, J. Keaton Smith MS, Harry S. Courtney PhD, Warren O. Haggard PhD

Local drug delivery has substantial potential to prevent infections compared with systemic delivery. Although calcium sulfate (CaSO) has been studied for local drug delivery and two types are commercially available, it is unknown whether they differentially release antibiotics.

Amphotericin B Is Cytotoxic at Locally Delivered Concentrations

Samuel Harmsen MD, Alex C. McLaren MD, Christine Pauken PhD, Ryan McLemore PhD

Orthopaedic fungal infections are commonly treated with systemic amphotericin, which has a narrow therapeutic index and is associated with systemic toxicities. Local delivery of amphotericin has been described yet is poorly understood. As with bacterial infections, fungal infections are associated with biofilm. However, it is unclear whether experience with local delivery of antibacterials can be applied to local antifungal delivery.

Definition of Periprosthetic Joint Infection: Is There a Consensus?

Javad Parvizi MD, FRCS, Christina Jacovides BS, Benjamin Zmistowski BS, Kwang Am Jung MD

The diagnosis of periprosthetic joint infection (PJI) continues to pose a challenge. While many diagnostic criteria have been proposed, a gold standard for diagnosis is lacking. Use of multiple diagnostic criteria within the joint arthroplasty community raises concerns in patient treatment and comparison of research pertaining to PJI.

Leukocytosis Is Common After Total Hip and Knee Arthroplasty

Gregory K. Deirmengian MD, Benjamin Zmistowski BS, Christina Jacovides BS, Joseph O’Neil BA, Javad Parvizi MD, FRCS

Postoperative infection is a potentially devastating complication after THA and TKA. In the early postoperative period, clinicians often find nonspecific indicators of infection. Although leukocytosis may be a sign of a developing infection in the early postoperative period, it may also be part of a normal surgical response.

Molecular Techniques to Detect Biofilm Bacteria in Long Bone Nonunion: A Case Report

Michael Palmer MD, William Costerton PhD, Jeffrey Sewecke DO, Daniel Altman MD

Biofilms cause chronic infections including those associated with orthopaedic hardware. The only methods that are Food and Drug Administration-approved for detecting and identifying bacterial infections are cultures and selected DNA-based polymerase chain reaction methods that detect only specific pathogens (eg, methicillin-resistant Staphylococcus aureus). New DNA-based technologies enable the detection and identification of all bacteria present in a sample and to determine the antibiotic sensitivities of the organisms.

Infection Control Rate of Irrigation and Débridement for Periprosthetic Joint Infection

Loukas Koyonos MD, Benjamin Zmistowski BS, Craig J. Della Valle MD, Javad Parvizi MD, FRCS

Irrigation and débridement with retention of prosthesis is commonly performed for periprosthetic joint infection. Infection control is reportedly dependent on timing of irrigation and débridement relative to the index procedure.

Two-stage Exchange Arthroplasty for Infected Total Knee Arthroplasty: Predictors of Failure

S. M. Javad Mortazavi MD, David Vegari MD, Anthony Ho BA, Benjamin Zmistowski BS, Javad Parvizi MD, FRCS

In North America, a two-stage exchange arthroplasty remains the preferred surgical treatment for chronic periprosthetic joint infection (PJI). Currently, there are no proper indicators that can guide orthopaedic surgeons in patient selection for two-stage exchange or the appropriate conditions in which to reimplant.

An Articulating Antibiotic Spacer Controls Infection and Improves Pain and Function in a Degenerative Septic Hip

Erin E. Fleck MD, Mark J. Spangehl MD, Venkat R. Rapuri MD, FRCS, Christopher P. Beauchamp MD

Treating septic arthritis of the hip with coexisting advanced degenerative disease is challenging. The use of primary total hip arthroplasty (THA) has led to postoperative infection rates as high as 22%. Insertion of antibiotic spacers with subsequent reimplantation of a THA controls infection and improves pain and function in patients with periprosthetic infections.

Sterility of the Personal Protection System in Total Joint Arthroplasty

Kenneth A. Kearns MD, Dan Witmer BS, Junaid Makda MD, Javad Parvizi MD, FRCS, Donald Jungkind PhD

Bacteria shed by operating room personnel is a source of wound contamination and postoperative infections. The personal protection system (PPS) was designed to decrease airborne bacteria and intraoperative contamination in total joint arthroplasty.

Human Periosteum Is a Source of Cells for Orthopaedic Tissue Engineering: A Pilot Study

Michael D. Ball PhD, Ian C. Bonzani PhD, Melissa J. Bovis BSc, Andrew Williams MBBS, Molly M. Stevens PhD

Periosteal cells are important in embryogenesis, fracture healing, and cartilage repair and could provide cells for osteochondral tissue engineering.

Temporal Variation in Fixation Stiffness Affects Healing by Differential Cartilage Formation in a Rat Osteotomy Model

Bettina M. Willie PhD, Robert Blakytny PhD, Melanie Glöckelmann DVM, Anita Ignatius DVM, Lutz Claes PhD

Dynamization involves a reduction in fixation construct stiffness during bone healing, allowing increased interfragmentary movement of the fracture through physiologic weightbearing and muscle contraction. Within some optimal range, interfragmentary movement stimulates healing, but this range likely varies across stages of bone healing.

Influence of Gender and Fixation Stability on Bone Defect Healing in Middle-aged Rats: A Pilot Study

Manav Mehta PhD, Georg N. Duda PhD, Carsten Perka MD, Patrick Strube MD

Gender and stability of fixation independently influence bone regeneration but their combined effects are unclear.

Functional Restoration of Critically Sized Segmental Defects With Bone Morphogenetic Protein-2 and Heparin Treatment

Mela R. Johnson PhD, Joel D. Boerckel MS, Kenneth M. Dupont PhD, Robert E. Guldberg PhD

Bone defects and fracture nonunions remain a substantial challenge for clinicians. Grafting procedures are limited by insufficient volume and donor site morbidity. As an alternative, biomaterial scaffolds functionalized through incorporation of growth factors such as bone morphogenetic proteins (BMPs) have been developed and appear to regenerate the structure and function of damaged or degenerated skeletal tissue.

Human Early Fracture Hematoma Is Characterized by Inflammation and Hypoxia

Paula Kolar MD, Timo Gaber PhD, Carsten Perka MD, Georg N. Duda PhD, Frank Buttgereit MD

An effective immune system, especially during the inflammatory phase, putatively influences the quality and likelihood of bone healing. If and how this is reflected within the initial fracture hematoma is unclear.

How Much Vitamin D Do We Need for Skeletal Health?

Christoph Domarus MD, Jonathan Brown Dipl-Ing, Florian Barvencik MD, Michael Amling MD, Pia Pogoda MD

Vitamin D is critical for musculoskeletal health and has been implicated in the risk of extraskeletal diseases, including cancer, cardiovascular diseases, and autoimmune diseases, as well as overall mortality. Although numerous studies deal and have dealt with vitamin D deficiency and its consequences, experts cannot agree on the right 25-hydroxyvitamin D levels. This survey aims to shed light on the ongoing vitamin D controversy from different angles.

Validity of Goniometric Elbow Measurements: Comparative Study with a Radiographic Method

Julien Chapleau MD, Fanny Canet MScA, Yvan Petit PhD, G-Yves Laflamme MD, FRCSC, Dominique M. Rouleau MD, MSc, FRCSC

A universal goniometer is commonly used to measure the elbow’s ROM and carrying angle; however, some authors question its poor intertester reliability.

Sufficient Release of Antibiotic by a Spacer 6 Weeks after Implantation in Two-stage Revision of Infected Hip Prostheses

Bernd Fink MD, Sebastian Vogt PhD, Martin Reinsch PhD, Hubert Büchner PhD

Although antibiotic-loaded spacers are commonly used to treat periprosthetic infections, it is unclear whether spacers continue to release bactericidal levels of antibiotic 6 weeks after implantation.

High Dislocation Cumulative Risk in THA versus Hemiarthroplasty for Fractures

Alexandre Poignard MD, Mohamed Bouhou MD, Olivier Pidet MD, Charles-Henri Flouzat-Lachaniette MD, Philippe Hernigou MD

Although not all elderly patients with femoral neck fractures are candidates for THA, active, mentally competent, independent patients achieve the most durable functional scores with THA compared with hemiarthroplasty. However, a relatively high frequency of early or late dislocation could reduce the potential benefits with THA.

Hypesthesia after Anterolateral versus Midline Skin Incision in TKA: A Randomized Study

Jean-Michel Laffosse MD, Anna Potapov MD, Michel Malo MD, Martin Lavigne MD, Pascal-André Vendittoli MD

The anterior midline skin incision in a TKA provides excellent surgical exposure. However, it usually requires sectioning the infrapatellar branch of the saphenous nerve which may be associated with lateral cutaneous hypesthesia and neuroma formation.

Cementless Revision TKA with Bone Grafting of Osseous Defects Restores Bone Stock with a Low Revision Rate at 4 to 10 years

S. A. Hanna MRCS, W. J. S. Aston FRCS (Orth), N. J. Roeck FRCS (Orth), A. Gough-Palmer FRCR, D. P. Powles MD, FRCS

Addressing bone loss in revision TKA is challenging despite the array of options to reconstruct the deficient bone. Biologic reconstruction using morselized loosely-packed bone graft potentially allows for augmentation of residual bone stock while offering physiologic load transfer. However it is unclear whether the reconstructions are durable.

Tendinosis-like Histologic and Molecular Changes of the Achilles Tendon to Repetitive Stress: A Pilot Study in Rats

Nam Soon Cho MD, Ji Hye Hwang MD, PhD, Yong Taek Lee MD, PhD, Seoung Wan Chae MD, PhD

Tendinopathy (pain and tendon degeneration) is associated with repetitive use and mechanical overload. However, the etiology of tendinopathy remains unclear. Clarification of histologic and molecular changes of tendon to repetitive stress could provide better understanding of Achilles tendon disorders related to repetitive stress.

Surgical Technique: Lower Limb-length Equalization by Periosteal Stripping and Periosteal Division

Noppachart Limpaphayom MD, Pairatch Prasongchin MD

Stimulating growth in the shorter limb in patients with a lower limb length discrepancy (LLD) theoretically is a better alternative than retarding growth in the longer limb since it would not lead to loss of height. Periosteal stripping and/or division (PSPD) have been studied in animal models and in humans with encouraging results. We combined these procedures and used it to equalize lower limb length.

Endothelin-1 Promotes Osteosarcoma Cell Invasion and Survival against Cisplatin-induced Apoptosis

Yuanting Zhao MD, Qiande Liao MD, Yong Zhu MD, Haitao Long MD

Endothelin-1 (ET-1) participates in a wide range of cancer-relevant processes including cell proliferation, inhibition of apoptosis, matrix remodeling, bone deposition, and metastases. Although ET-1 reportedly promotes osteosarcoma (OS) cell invasion, suggesting an important role of ET-1 in OS metastasis, the role of ET-1 in OS remains unclear.

Similar Local Control between Phenol- and Ethanol-treated Giant Cell Tumors of Bone

Wei-Hsin Lin MD, Tsung-Yu Lan MD, Chih-Yu Chen MD, Karl Wu MD, Rong-Sen Yang MD

Giant cell tumors (GCTs) of bone often are treated with curettage, adjuvant therapy, and cementation. Phenol is a commonly used adjuvant associated with local control rates ranging from 9% to 25%. However, it is corrosive to the eyes, skin, and respiratory tract. Ethanol is readily available and does not cause chemical burns on contact, but it is unclear whether ethanol can achieve similar local control rates as phenol for treating GCTs.

A Minimally Invasive Stabilizing System for Dorsal Pelvic Ring Injuries

Thomas Dienstknecht MD, Arne Berner MD, Andreas Lenich MD, Michael Nerlich MD, Bernd Fuechtmeier MD

Open reduction and stabilization of dorsal pelvic ring injuries is accompanied by a high rate of soft tissue complications. Minimally invasive techniques have the potential to decrease soft tissue trauma, but the risk of iatrogenic nerve and vessel damage through the reduced surgical exposure should be considered. We treated these injuries using a transiliac internal fixator (TIFI) in a minimally invasive technique characterized by implantation of a pedicle screw and rod system, bridging the sacroiliac joints and the sacral area.

Effects of Delayed Hip Fracture Surgery on Mortality and Morbidity in Elderly Patients

Pedro Rodriguez-Fernandez MD, PhD, Dolores Adarraga-Cansino MD, PhD, Pedro Carpintero MD, PhD

The effects of delaying hip fracture surgery on mortality and morbidity in elderly patients are not completely understood.

Vancomycin Containing PLLA/β-TCP Controls MRSA In Vitro

Berna Kankilic MS, Erdal Bayramli PhD, Emine Kilic MS, Sezin Dağdeviren MS, Feza Korkusuz MD

Osteomyelitis caused by Methicillin-resistant Staphylococcus aureus (MRSA) often requires surgery and prolonged systemic antibiotic treatment. Local antibiotic delivery systems of bioceramics or polymers have been developed to treat osteomyelitis. A disadvantage of biodegradable polymers is the initial burst of antibiotics into the environment; one advantage of bioceramics is its osteoconductivity. We therefore developed a vancomycin-containing poly-l-lactic acid/β-tricalcium phosphate (PLLA/β-TCP) composite to control antibiotic release and stimulate bone formation.

The Cam-type Deformity of the Proximal Femur Arises in Childhood in Response to Vigorous Sporting Activity

K. A. Siebenrock MD, F. Ferner MD, P. C. Noble MD, PhD, R. F. Santore MD, PhD, S. Werlen MD, T. C. Mamisch MD

The prevalence of a cam-type deformity in athletes and its association with vigorous sports activities during and after the growth period is unknown.

Radiographic Risk Factors for Labral Lesions in Femoroacetabular Impingement

Thomas Kappe MD, Tugrul Kocak MD, Ralf Bieger MD, Heiko Reichel MD, Christian R. Fraitzl MD

Tears of the acetabular labrum can lead to pain, disability, and osteoarthritis. Several pathomechanisms have been proposed, including femoroacetabular impingement (FAI). Labral tears have been reported to occur in the presence of even subtle deformities of the acetabulum and femoral head-neck junction.

Evaluation and Imaging of an Untreated Grade III Hamstring Tear: A Case Report

Brett B. Clark PT, David Jaffe MD, R. Frank Henn MD, Richard M. Lovering PhD, PT

Muscle strains are one of the most common complaints treated by physicians. High-force lengthening contractions can produce very high forces resulting in pain and tissue damage; such strains are the most common cause of muscle injuries. The hamstring muscles are particularly susceptible as they cross two joints and regularly perform lengthening contractions during running. We describe a patient with return to full function after a large hamstring tear.

Reply to Letter to the Editor: Unexplained Fractures: Child Abuse or Bone Disease: A Systematic Review

Nirav K. Pandya MD, Keith Baldwin MD, MPH, MSPT, Atul F. Kamath MD, Dennis R. Wenger MD, Harish S. Hosalkar MD, MBMS (Ortho), FCPS (Ortho), DNB (Ortho)

Emerging Ideas: Interleukin-12 Nanocoatings Prevent Open Fracture-associated Infections

Bingyun Li PhD, Anne L. McKeague PhD

Infection is a major clinical complication of orthopaedic implants and prosthetic devices, and patients with traumatic open fractures have a high risk of infection that may exceed 30%. Surgical trauma, burns, and major injuries such as traumatic open fractures induce immunosuppression, decrease resistance to infection, and decrease production of T helper type 1 (Th1) cytokines.

Back to top