Biofilm and How It Relates to Prosthetic Joint Infection.

Prosthetic joint infection following total joint arthroplasty is a devastating complication, resulting in increased morbidity and mortality for the patient. The formation of a biofilm on implanted hardware contributes to the difficulty in successful identification and eradication of the infection. Antibiotic therapy and surgical intervention are necessary for addressing this condition; we present a discussion on different treatment options, including those that are not yet routinely utilized in the clinical setting or are under investigation, to highlight the present and future of PJI management.

The Association Between Mental Health, Substance Use Disorder, and Outcomes After Total Joint Arthroplasty.

BACKGROUND: Prior studies suggest that distressed patients or those who have poor mental health have inferior postoperative outcomes when compared to nondistressed patients. However, these studies typically do not account for substance use or other comorbidities often found in this population, which can independently contribute to postoperative complications. This study sought to control for these factors and assess if a diagnosis of a mental health condition is directly associated with worse outcomes after total joint arthroplasty. METHODS: A retrospective chart review was performed for 3,182 patients who underwent a total hip arthroplasty and 4,430 patients who underwent a total knee arthroplasty. Diagnosis of the mental health disorders included depression, anxiety disorder, adjustment disorder, bipolar disorder, trauma, stressor-related disorder, and schizophrenia or schizoaffective disorder. Multivariable analyses were performed to control for alcohol use, drug use, tobacco use, body mass index, and a comorbidity index. RESULTS: When controlling for body mass index and Charlson comorbidity index, no statistically significant associations were found between a diagnosis of any mental health condition or a specific diagnosis of depression or anxiety, and 90-day readmission, reoperation, or 1 year mortality for patients undergoing total knee arthroplasty or total hip arthroplasty. CONCLUSIONS: When accounting for confounding factors, there does not appear to be a direct association between diagnosis of any of the psychiatric conditions we studied and outcomes after primary total joint arthroplasty. While prior studies suggest addressing the mental health condition may improve outcomes, this study suggests that preoperative medical optimization and potentially addressing substance use may be more effective strategies.

Risk Factors for Radiotherapy Failure in the Treatment of Spinal Metastases.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To build a predictive model for risk factors for failure of radiation therapy, hypothesizing a higher SINS would correlate with failure. METHODS: Patients with spinal metastasis being treated with radiation at a tertiary care academic center between September 2014 and October 2018 were identified. The primary outcome measure was radiation therapy failure as defined by persistent pain, need for re-irradiation, or surgical intervention. Risk factors were primary tumor type, Karnofsky and ECOG scores, time to treatment, biologically effective dose (BED) calculations using α/ß ratio = 10, and radiation modality. A logistic regression was used to construct a prediction model for radiation therapy failure. RESULTS: One hundred and seventy patients were included. Median follow up was 91.5 days. Forty-three patients failed radiation therapy. Of those patients, 10 required repeat radiation and 7 underwent surgery. Thirty-six patients reported no pain relief, including some that required re-irradiation and surgery. Total SINS score for those who failed reduction therapy was <7 for 27 patients (62.8%), between 7-12 for 14 patients (32.6%), and >12 for 2 patients (4.6%). In the final prediction model, BED (OR .451 for BED > 43 compared to BED ≤ 43; P = .174), Karnofksy score (OR .736 for every 10 unit increase in Karnofksy score; P = .008), and gender (OR 2.147 for male compared to female; P = .053) are associated with risk of radiation failure (AUC .695). A statistically significant association between SINS score and radiation therapy failure was not found. CONCLUSIONS: In the multivariable model, BED ≤ 43, lower Karnofksy score, and male gender are predictive for radiotherapy failure. SINS score was among the candidate risk factors included in multivariable model building procedure, but it was not selected in the final model. LEVEL OF EVIDENCE: Prognostic level III.

Treatment Trends in Pediatric Trigger Thumb Among Hand Surgeons, Pediatric Orthopedic Surgeons, and Pediatric Hand Surgeons.

BACKGROUND: The appropriate initial management of pediatric trigger thumb (PTT) remains controversial. Some providers advocate for prolonged nonoperative management, whereas others may offer surgical release to provide a reliable and expedient resolution. The goal of this study was to elucidate the practice patterns of surgeons with different fellowship training who treat patients with PTT. We hypothesized that an association between surgeon specialty training and treatment algorithm would be identified. METHODS: A cross-sectional survey was sent to mailing lists of 3 professional organizations whose members represent most providers caring for pediatric hand patients. Respondents were asked their training background and treatment recommendations for several clinical scenarios. Responses were compared across subspecialties. RESULTS: Of the respondents, 444 completed a fellowship in hand surgery, 167 completed a pediatric orthopedic fellowship, and 155 completed an additional congenital hand fellowship. Providers with hand fellowship training were more likely to offer surgical intervention as a first-line treatment for a 3-year-old patient with a flexible trigger thumb than those who completed a pediatric orthopedic fellowship (P = .001), and more likely to offer surgical intervention to a 3-year-old patient with an intermittent (P = .007), painful (P = .015), or locked (P = .012) trigger thumb than those providers who completed additional training in congenital hand surgery. No statistically significant differences in practice patterns were appreciated for children aged 6 and 18 months. CONCLUSION: Variability was appreciated in practice patterns for initial treatment recommendation for a patient presenting with PTT. Subspecialty training does appear to affect treatment recommendations for clinical scenarios involving a 3-year-old patient with PTT, although this trend is not observed when treating younger patients.

An objective assessment of the impact of tendon retraction on sleep efficiency in patients with full-thickness rotator cuff tears: a prospective cohort study.

BACKGROUND: Sleep quality, quantity, and efficiency have all been demonstrated to be adversely affected by rotator cuff pathology. Previous measures of assessing the impact of rotator cuff pathology on sleep have been largely subjective in nature. This study was undertaken to objectively analyze this relationship through the use of activity monitors. METHODS: Patients with full-thickness rotator cuff tears at a single institution were prospectively enrolled between 2018 and 2020. Waistworn accelerometers were provided for the patients to use each night for 14 days. Sleep efficiency was calculated using the ratio of the time spent sleeping to the total amount of time that was spent in bed. Retraction of the rotator cuff tear was classified using the Patte staging system. RESULTS: This study included 36 patients: 18 with Patte stage 1 disease, 14 with Patte stage 2 disease, and 4 patients with Patte stage 3 disease. During the study, 25 participants wore the monitor on multiple nights, and ultimately their data was used for the analysis. No difference in the median sleep efficiency was appreciated amongst these groups (P>0.1), with each cohort of patients demonstrating a generally high sleep efficiency. CONCLUSIONS: The severity of retraction of the rotator cuff tear did not appear to correlate with changes in sleep efficiency for patients (P>0.1). These findings can better inform providers on how to counsel their patients who present with complaints of poor sleep in the setting of full-thickness rotator cuff tears. Level of evidence: Level II.

Prevention Techniques Have Had Minimal Impact on the Population Rate of Prosthetic Joint Infection for Primary Total Hip and Knee Arthroplasty: A National Database Study.

BACKGROUND: Several studies over the years have offered modalities that may greatly decrease the rate of periprosthetic joint infection when implemented. As a result, one would expect a drastic decrease in infection rate among the implementing population with its widespread use. The purpose of this study was to assess whether there exists a decrease in infection rate over time, after accounting for available confounding variables, within a large national database. METHODS: A large national database from 2005 to 2019 was queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). In total, 221,416 THAs and 354,049 TKAs were performed over the study period. Differences in 30-day infection rate were assessed with time and available preoperative risk factors using multinominal logistic regressions. RESULTS: Rate of infection overall trended downward for both THA and TKA. After accounting for confounding variables, odds of THA infection marginally decreased over time (odds ratio 0.968 [0.952-0.985], P < .0001), while the odds of a TKA infection marginally increased with time (odds ratio 1.037 [1.020-1.054], P < .0001). CONCLUSION: Individual peer-reviewed publications have presented infection control modalities demonstrating dramatic decreases in infection rate while analysis at a population level shows almost no changes in infection rate over a 15-year time period. This study supports continued investigation for influential modalities in preventing periprosthetic joint infection and care in patient selection for primary hip and knee arthroplasty.

Extremity Pressure in Splints Wrapped With an Elastic Bandage Versus Bias Cut Stockinette: An Experimental Model.

BACKGROUND: Many variables affect the pressure caused by splinting or casting. The purpose of this study was to compare pressure underlying a splint wrapped with either an elastic bandage or a bias cut stockinette. METHODS: Thirty-two plaster volar resting splints were applied to a simulated extremity with a saline bag secured to it. A pressure transducer was connected to the saline bag to monitor changes in pressure once splints were applied, and 15 mL increments of saline were added to the bag to simulate swelling. Each dressing type was tested with normal application and tight application. RESULTS: Normal application splints wrapped with either bias cut stockinette or an elastic bandage demonstrated similar initial splint pressures (P = .81). With simulated swelling, splints wrapped with bias cut stockinette demonstrated a 15 mmHg (95% confidence interval [CI], 1.5-28.5) higher average pressure than those wrapped with an elastic bandage (P = .035). Tight application splints with an elastic bandage wrap demonstrated a 46 mmHg (95% CI, 16-77) higher initial splint pressure than those wrapped with bias cut stockinette (P = .009). CONCLUSIONS: Splints wrapped using either an elastic bandage or bias cut stockinette appear to have a similar safety profile, although in cases of excessive swelling, an elastic bandage may provide additional compliance. Tight splint application appears to be more hazardous with the use of an elastic bandage compared with a bias cut stockinette. Further study of the use of elastic bandages and bias cut stockinettes in the clinical setting may be warranted.

Radiolucent Implants for Fixation of Impending and Pathologic Fractures.

Radiolucent implants offer theoretical advantages of increased ability to evaluate the fracture site for healing and recurrence and potentially less effect on radiation treatment, avoiding scatter. Their clinical utility and outcomes have yet to be proven in a well-designed randomized trial or large cohort study, although studies based on other indications have shown relative safety and they are approved by the US Food and Drug Administration for treatment of pathologic fractures. Further research is necessary to better understand when and how these implants should be implemented in practice. [Orthopedics. 2022;45(3):e115-e121.].