Povidone-Iodine-Based Solutions for Decolonization of Nasal Staphylococcus aureus: A Randomized, Prospective, Placebo-Controlled Study.

BACKGROUND: Nasal Staphylococcus aureus decolonization reduces the risk of surgical site infections after orthopedic procedures. Povidone-iodine (PI)-based solutions have shown promising results in bacteria decolonization. The unique physiology of the nose may pose challenges for the bioactivity profiles of PI solutions. This study compared the antibacterial efficacy of an off-the-shelf PI product with a specifically manufactured PI-based skin and nasal antiseptic (SNA). METHODS: This randomized, placebo-controlled study was conducted at a single institution between April 2014 and July 2015. Four hundred and twenty-nine patients undergoing primary or revision total joint arthroplasty, femoroacetabular osteoplasty, pelvic osteotomy, or total shoulder arthroplasty were included. 10% off-the-shelf PI, 5% PI-based SNA, or saline (placebo) were used for nasal decolonization. Baseline cultures were taken immediately preoperatively, followed by treatment of both nares twice for 2 minutes with 4 applicators. Reculturing of the right nostril occurred at 4 hours and the left at 24 hours. RESULTS: Ninety-five of the 429 patients (22.1%) had a positive culture result for S. aureus; 13 (3.03%) were methicillin-resistant S. aureus. Of these 95, 29 were treated with off-the-shelf PI, 34 with SNA, and 32 with saline swabs. At 4 hours post-treatment, S. aureus culture was positive in 52% off-the-shelf PI patients, 21% SNA patients, and 59% saline patients. After 24 hours posttreatment, S. aureus culture was positive in 72% off-the-shelf PI patients, 59% SNA patients, and 69% saline group. SNA was significantly more effective at decolonizing S. aureus over the 4-hour time interval (P = .003); no significant difference was observed over the 24-hour time interval between the 3 groups. CONCLUSION: A single application of PI-based SNA before surgery may be effective in eliminating nasal S. aureus in over two-thirds of patients. Off-the-shelf PI swabs were not as effective at 4 hours as the specifically manufactured product for S. aureus decolonization.

Periarticular Liposomal Bupivacaine Injection Versus Intra-Articular Bupivacaine Infusion Catheter for Analgesia After Total Knee Arthroplasty: A Double-Blinded, Randomized Controlled Trial.

BACKGROUND: Intra-articular bupivacaine hydrochloride (HCl) infusion catheters and periarticular injections of liposomal bupivacaine are often used as postoperative local anesthetics. The purpose of this study was to compare the efficacies of these local anesthetics following total knee arthroplasty. METHODS: This study was a superiority trial with a randomized, controlled, double-blinded design. Patients were randomly assigned to either delivery of bupivacaine HCl by the ON-Q* Pain Relief System pump (n = 96) or by an injection of Exparel (liposomal bupivacaine) (n = 104). The primary outcome of this study was cumulative narcotic consumption on postoperative days 0 through 3. Narcotic consumption data were collected retrospectively from in-hospital records while patients were in the hospital. Following discharge, narcotic consumption data were gathered from patient surveys, as were secondary outcomes measures. RESULTS: We did not identify greater narcotic use in the ON-Q* group compared with the Exparel group (p = 0.641). The mean difference between the groups was 0.5 morphine equivalent (95% confidence interval [CI] = -1.7 to +2.8), with the ON-Q* group consuming an average 10.4 morphine equivalents (95% CI = 8.7 to 12.0) compared with 10.9 (95% CI = 9.3 to 12.5) in the Exparel group. There were no significant differences between groups with regard to any of the secondary measures of pain with the exception of pain while walking and pain with physical therapy (p = 0.019 and p = 0.010, respectively), both of which showed an approximately 1-point difference in favor of the ON-Q* group on a visual analog scale (VAS). There were also no differences in the postoperative side effects, including nausea, constipation, or vomiting, or in the rates of study-related complications, patient satisfaction, or length of hospital stay. CONCLUSIONS: Exparel did not have superior efficacy compared with the ON-Q* Pain Relief System as reflected by narcotic consumption, our primary outcome. There were small significant differences, in favor of the ON-Q* group, in 2 secondary measures of pain during activity, but these approximately 1-point VAS differences are unlikely to be clinically relevant. The choice of a local anesthetic modality should be based on a combination of safety, convenience, and cost considerations. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Systematic Reviews in Sports Medicine.

BACKGROUND: The number of systematic reviews published in the orthopaedic literature has increased, and these reviews can help guide clinical decision making. However, the quality of these reviews can affect the reader's ability to use the data to arrive at accurate conclusions and make clinical decisions. PURPOSE: To evaluate the methodological and reporting quality of systematic reviews and meta-analyses in the sports medicine literature to determine whether such reviews should be used to guide treatment decisions. The hypothesis was that many systematic reviews in the orthopaedic sports medicine literature may not follow the appropriate reporting guidelines or methodological criteria recommended for systematic reviews. STUDY DESIGN: Systematic review. METHODS: All clinical sports medicine systematic reviews and meta-analyses from 2009 to 2013 published in The American Journal of Sports Medicine (AJSM), The Journal of Bone and Joint Surgery (JBJS), Arthroscopy, Sports Health, and Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA) were reviewed and evaluated for level of evidence according to the guidelines from the Oxford Centre for Evidence-Based Medicine, for reporting quality according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, and for methodological quality according to the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Analysis was performed by year and journal of publication, and the levels of evidence included in the systematic reviews were also analyzed. RESULTS: A total of 200 systematic reviews and meta-analyses were identified over the study period. Of these, 53% included evidence levels 4 and 5 in their analyses, with just 32% including evidence levels 1 and 2 only. There were significant differences in the proportion of articles with high levels of evidence (P < .001) and low levels of evidence (P = .005) by journal. The average PRISMA score was 87% and the average AMSTAR score was 73% among all journals. The average AMSTAR and PRISMA scores were significantly different by journal (P = .002 and .001, respectively) and by year (P = .046 and .019, respectively). Arthroscopy, AJSM, and JBJS all scored higher than Sports Health and KSSTA on the PRISMA and AMSTAR. The average PRISMA score by year varied from 85% to 89%, and the average AMSTAR score varied from 70% to 76%. CONCLUSION: Systematic reviews and meta-analyses in orthopaedics sports medicine literature relied on evidence levels 4 and 5 in 53% of studies over the 5-year study period. Overall, PRISMA and AMSTAR scores are high and may be better than those in other disciplines. Readers need to be conscious of potential shortcomings when reading systematic reviews and using them in practice.

Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time?

BACKGROUND: There has been an increased emphasis on improving the level of evidence used as the basis for clinical treatment decisions. Several journals now require a statement of the level of evidence as a basic gauge of the study's strength. PURPOSE: To review the levels of evidence in published articles in the clinical sports medicine literature and to determine if there has been an improvement in the levels of evidence published over the past 15 years. STUDY DESIGN: Systematic review. METHODS: All articles from the years 1995, 2000, 2005, and 2010 in The American Journal of Sports Medicine (AJSM), Arthroscopy, and sports medicine-related articles from The Journal of Bone and Joint Surgery-American (JBJS-A) were analyzed. Articles were categorized by type and ranked for level of evidence according to guidelines from the Centre for Evidence-Based Medicine. Excluded were animal, cadaveric, and basic science articles; editorials; surveys; special topics; letters to the editor; and correspondence. Statistical analysis was performed with chi-square. RESULTS: A total of 1580 articles over the 4 periods met the inclusion criteria. The percentage of level 1 and 2 studies increased from 6.8% to 12.6%, 22.9%, and 23.5%, respectively (P < .0001), while level 4 and 5 studies decreased from 78.9% to 72.4%, 63.9%, and 53.0% (P < .0001). JBJS-A had a significant increase in level 1 and 2 studies (4.1%, 5.1%, 28.2%, 27.8%; P < .0001), as did AJSM (9.4%, 17.1%, 36.1%, 30.1%; P < .0001). Arthroscopy showed no significant change over time. Diagnostic, therapeutic, and prognostic studies all showed significant increases in level 1 and 2 studies over time (P < .05). CONCLUSION: There has been a statistically significant increase in the percentage of level 1 and 2 studies published in the sports medicine literature over the past 15 years, particularly in JBJS-A and AJSM. The largest increase was seen in diagnostic studies, while therapeutic and prognostic studies demonstrated modest improvement. The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect.

Effect of lidocaine gel anesthesia on endophthalmitis rates following intravitreal injection.

BACKGROUND AND OBJECTIVE: To determine whether the use of lidocaine gel before application of povidone-iodine affects endophthalmitis rates following intravitreal injections. PATIENTS AND METHODS: Retrospective consecutive case series of all intravitreal injections and post-intravitreal injection endophthalmitis cases at one institution from 2000 to 2009. A review of medical records of post-intravitreal injection endophthalmitis cases was performed to determine whether lidocaine gel was applied prior to povidone-iodine antisepsis and to analyze the clinical course and outcomes. RESULTS: A total of 8,802 intravitreal injections were administered during the study period. When no lidocaine gel was used prior to povidone-iodine antisepsis, four cases of endophthalmitis following 4,120 intravitreal injections (0.097%) were recorded. When 2% lidocaine gel was applied before povidone-iodine, four cases of endophthalmitis following 4,682 intravitreal injections (0.085%) were observed (P = 1.00, odds ratio = 1.12). CONCLUSION: The use of lidocaine gel prior to povidone-iodine antisepsis did not significantly alter post-intravitreal injection endophthalmitis rates.