Visibility of surgical site marking: a prospective randomized trial of two skin preparation solutions.
J Bone Joint Surg Am. 2012 Jan 18;94(2):97-102
Authors: Thakkar SC, Mears SC
Abstract
BACKGROUND: An important component of the surgical time-out is to confirm surgical site skin markings to prevent wrong-site surgery. Different skin preparation solutions may have variable effects on the visibility of site markings after application. We performed a prospective randomized clinical trial to quantitatively and qualitatively evaluate the visibility of surgical site markings after the use of two commonly available skin preparation solutions.
METHODS: We enrolled twenty patients undergoing primary total hip arthroplasty at our institution. Preoperatively, a black permanent marker was used to mark the skin of each patient with a random combination of three letters, underlined by a single black line, and with the surgeon’s initials. Patients were randomly selected to receive a chlorhexidine-based or an iodine-based skin preparation according to manufacturer guidelines. The skin markings were photographed digitally, before and after the application of solution. The photographs made after the application of solution were assessed quantitatively, by calculating the contrast (marker to skin) before and after the application of the solutions, and qualitatively by ten orthopaedic surgeons to identify the random initials and to recognize skin markings.
RESULTS: The mean change in contrast level after application of the chlorhexidine-based solution was significantly greater than that after application of the iodine-based solution (mean and standard deviation, 59.8 ± 15.7 U versus 14.9 ± 11.4 U, respectively; p < 0.0001). Surgeons were an average of twenty-two times less likely (95% confidence interval, eight to sixty-eight) to judge markings as acceptable for site identification after preparation with the chlorhexidine-based solution than after preparation with the iodine-based solution. When examining individual letters, the surgeons correctly identified 296 of 300 letters in the group prepared with the iodine-based solution and 209 of 300 letters in the group prepared with the chlorhexidine-based solution; the difference was significant (p < 0.0001).
CONCLUSIONS: The use of the chlorhexidine-based solution for skin preparation resulted in significantly greater erasure of the surgical site marking than did the use of the iodine-based solution.
LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Vacuum-assisted minimally invasive biopsy of soft-tissue tumors.
J Bone Joint Surg Am. 2012 Jan 18;94(2):103-9
Authors: Mohr Z, Hirche C, Klein T, Kneif S, Hünerbein M
Abstract
BACKGROUND: Although exact histological characterization of soft-tissue tumors is essential for determining the appropriate therapy, the quality of the histological assessment is often limited by the size of the tissue samples. Incisional biopsy and core needle biopsy have been the most effective techniques for obtaining tissue samples from soft-tissue tumors. This study was performed to investigate whether vacuum-assisted biopsy can serve as a new diagnostic tool for soft-tissue neoplasms.
METHODS: This retrospective study compared the characterization made with use of vacuum-assisted biopsy of soft-tissue tumors in seventy-five patients between 2004 and 2006 and the characterization made with use of incisional biopsy of tumors in a comparison group of seventy-four patients between 2000 and 2005 with the final characterization made after radical tumor excision. All vacuum-assisted and incisional biopsies were performed by the same experienced surgeons and evaluated by the same experienced pathologists at a single tumor center. The sensitivity, specificity, positive and negative predictive values, and accuracy of the preliminary characterization made with use of each method were calculated on the basis of the final characterization made after excision.
RESULTS: The vacuum-assisted biopsy procedure was performed successfully in seventy-four (99%) of the seventy-five patients. The accuracy of vacuum-assisted biopsy (96%) was comparable with that of incisional biopsy (99%). Vacuum-assisted biopsy correctly characterized the tumor as benign or malignant in 96% (95% confidence interval [CI], 92% to 100%) of the seventy-five patients compared with 99% (95% CI, 96% to 100%) of the seventy-four patients who underwent incisional biopsy. Vacuum-assisted biopsy correctly characterized the tumor diagnosis in 95% (95% CI, 90% to 100%) of the patients compared with 95% (95% CI, 89% to 100%) for incisional biopsy. Vacuum-assisted biopsy correctly characterized the tumor grade in 89% (95% CI, 82% to 96%) of the patients compared with 88% (95% CI, 80% to 95%) for incisional biopsy. The sensitivity of vacuum-assisted biopsy was 93% (95% CI, 71% to 100%), the specificity and the positive predictive value were both 100%, and the negative predictive value was 91% (95% CI, 85% to 98%). The overall accuracy of vacuum-assisted biopsy was 96% (95% CI, 92% to 100%).
CONCLUSIONS: Vacuum-assisted biopsy appears to be safe and provides a new tool for the diagnosis of soft-tissue tumors. One advantage of vacuum-assisted biopsy is that it can be performed with use of local anesthesia in an outpatient setting.
LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Indications and reoperation rates for total elbow arthroplasty: an analysis of trends in new york state.
J Bone Joint Surg Am. 2012 Jan 18;94(2):110-7
Authors: Gay DM, Lyman S, Do H, Hotchkiss RN, Marx RG, Daluiski A
Abstract
BACKGROUND: Total elbow arthroplasty was originally used to treat patients with arthritis. As familiarity with total elbow arthroplasty evolved, the indications were expanded to include other disorders. There continues to be a low number of total elbow arthroplasties performed each year in comparison with hip, knee, and shoulder arthroplasties, and few large studies have examined the indications and associated complications of total elbow arthroplasty. The purposes of this study were to evaluate the changes with time in the indications for total elbow arthroplasty and to examine the complications of this procedure in a large database.
METHODS: The Statewide Planning and Research Cooperative System database from the New York State Department of Health, a census of all ambulatory and inpatient surgical procedures in the state of New York, was used to identify individuals who underwent primary total elbow arthroplasty during the time period of 1997 to 2006. These total elbow arthroplasties were evaluated for admitting diagnoses, sex and age of patient, readmission and complication data, and time to subsequent elbow surgery.
RESULTS: From 1997 to 2006, there were 1155 total elbow arthroplasties performed in New York State. In 1997, 43% of the total elbow arthroplasties were associated with trauma and 48%, with inflammatory conditions. In 2006, this changed to 69% and 19%, respectively. Within ninety days after the primary total elbow arthroplasty, 12% of the patients were readmitted to the hospital with approximately one-half (5.6%) admitted for problems related to the total elbow arthroplasty. The overall revision rate was 6.4%. The revision rates for the traumatic, inflammatory arthritis, and osteoarthritis groups were 4.8%, 8.3%, and 14.7%, respectively. Of particular interest, 90.5% of the total elbow arthroplasties were performed by surgeons with no recorded experience in the database, which began collecting these data in 1986.
CONCLUSIONS: This study provides useful information regarding patients undergoing total elbow arthroplasty in New York State. During the study period, the most common indication for total elbow arthroplasty changed from inflammatory arthritis to trauma. Although the number of total elbow arthroplasties being performed each year has increased, there continues to be a high complication and revision rate.
LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Skin sterility after application of ethyl chloride spray.
J Bone Joint Surg Am. 2012 Jan 18;94(2):118-20
Authors: Polishchuk D, Gehrmann R, Tan V
Abstract
BACKGROUND: Ethyl chloride topical anesthetic spray is labeled as nonsterile, yet it is widely used during injection procedures performed in an outpatient setting. The purpose of this study was to investigate the sterility of ethyl chloride topical anesthetic spray applied before an injection. Our a priori hypothesis was that application of the spray after the skin has been prepared would not alter the sterility of the injection site.
METHODS: We conducted a prospective, blinded, controlled study to assess the effect of ethyl chloride spray on skin sterility. Fifteen healthy adult subjects (age, twenty-three to sixty-one years) were prepared for mock injections into both shoulders and both knees, although no injection was actually performed. Three culture samples were obtained from each site on the skin: one before skin preparation with isopropyl alcohol, one after skin preparation and before application of ethyl chloride, and one after ethyl chloride had been sprayed on the site. In addition, the sterility of the ethyl chloride was tested directly by inoculating cultures with spray from the bottles.
RESULTS: Growth occurred in 70% of the samples obtained before skin preparation, 3% of the samples obtained after skin preparation but before application of ethyl chloride, and 5% of the samples obtained after the injection site had been sprayed with ethyl chloride. The percentage of positive cultures did not increase significantly after application of ethyl chloride (p = 0.65). Spraying of ethyl chloride directly on agar plates resulted in growth on 13% of these plates compared with 11% of the control plates; this difference was also not significant (p = 0.80).
CONCLUSIONS: Although ethyl chloride spray is not sterile, its application did not alter the sterility of the injection sites in the shoulder and knee.
Development of knee function after hamstring lengthening as a part of multilevel surgery in children with spastic diplegia: a long-term outcome study.
J Bone Joint Surg Am. 2012 Jan 18;94(2):121-30
Authors: Dreher T, Vegvari D, Wolf SI, Geisbüsch A, Gantz S, Wenz W, Braatz F
Abstract
BACKGROUND: Hamstring lengthening commonly is performed for the treatment of flexed knee gait in patients with spastic diplegic cerebral palsy. Satisfactory short-term results after hamstring lengthening have been demonstrated in various studies. However, evidence for the effectiveness of hamstring lengthening to correct flexed knee gait is scant because of small and inhomogeneous case series, different surgical techniques, and short follow-up.
METHODS: The long-term results for thirty-nine patients with spastic diplegia and flexed knee gait who were managed with intramuscular hamstring lengthening as a part of multilevel surgery are presented. Standardized three-dimensional gait analyses and clinical examinations were performed for all patients preoperatively and at one, three, and six to twelve years postoperatively.
RESULTS: Significant improvements in kinematic parameters and the popliteal angle were noted at short-term follow-up (p < 0.01), supporting the results of previous studies. Long-term results showed significant deterioration of minimum knee flexion in stance and the popliteal angle (p < 0.01), whereas the improvements in the Gross Motor Function Classification System and Gillette Gait Index were maintained. This recurrence of flexed knee gait is partial and measurable. Increased pelvic tilt was found in 49% of the limbs postoperatively, which may represent one factor leading to recurrence of flexed knee gait. Genu recurvatum was seen in eighteen patients (twenty-seven limbs; 35%) one year postoperatively, especially in the patients with a jump knee gait pattern preoperatively. At long-term follow-up, genu recurvatum resolved in many limbs, but 12% of the limbs showed residual genu recurvatum, indicating that overcorrection represents a problem following hamstring lengthening.
CONCLUSIONS: The results of the present study are crucial for the prognosis of knee function after hamstring lengthening as a part of multilevel surgery. Recurrence and possible overcorrection should be considered in treatment planning.
LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
BACKGROUND: In brachial plexus injuries with nerve root avulsions, the options for nerve reconstruction are limited. In select situations, half or all of the contralateral C7 (CC7) nerve root can be transferred to the injured side for brachial plexus reconstruction. Although encouraging results have been reported, CC7 transfer has not gained universal popularity. The purpose of this study was to critically evaluate hemi-CC7 transfer for restoration of shoulder function or median nerve function in patients with severe brachial plexus injury.
METHODS: A retrospective review of all patients with traumatic brachial plexus injury who had undergone hemi-CC7 transfer at a single institution during an eight-year period was performed. Complications were evaluated in all patients regardless of the duration of follow-up. The results of electrodiagnostic studies and modified British Medical Research Council (BMRC) motor grading were reviewed in all patients with more than twenty-seven months of follow-up.
RESULTS: Fifty-five patients with traumatic brachial plexus injury underwent hemi-CC7 transfer performed between 2001 and 2008 for restoration of shoulder function or median nerve function. Thirteen patients who underwent hemi-CC7 transfer to the shoulder and fifteen patients who underwent hemi-CC7 transfer to the median nerve had more than twenty-seven months of follow-up. Twelve of the thirteen patients in the shoulder group demonstrated electromyographic evidence of reinnervation, but only three patients achieved M3 or greater shoulder abduction motor function. Three of the fifteen patients in the median nerve group demonstrated electromyographic evidence of reinnervation, but none developed M3 or greater composite grip. All patients experienced donor-side sensory or motor changes; these were typically mild and transient, but one patient sustained severe, permanent donor-side motor and sensory losses.
CONCLUSIONS: The outcomes of hemi-CC7 transfer for restoration of shoulder motor function or median nerve function following posttraumatic brachial plexus injury do not justify the risk of donor-site morbidity, which includes possible permanent motor and sensory losses.
LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Mid-Term Results of Third-Generation Alumina-on-Alumina Ceramic Bearings in Cementless Total Hip Arthroplasty: A Ten-Year Minimum Follow-up.
J Bone Joint Surg Am. 2012 Jan 18;94(2):138-44
Authors: Yeung E, Bott PT, Chana R, Jackson MP, Holloway I, Walter WL, Zicat BA, Walter WK
Abstract
BACKGROUND: Alumina ceramic-on-ceramic bearings have gained popularity in hip arthroplasty because of their properties of low wear and chemical inertness. In a previous study, we reported the excellent clinical results in a series of cementless ceramic-on-ceramic primary total hip arthroplasties at a minimum of five years of follow-up. The purpose of the present study was to determine the results in the same patient cohort at a minimum of ten years of follow-up.
METHODS: A series of 301 consecutive primary cementless total hip arthroplasties was assessed clinically and radiographically. Clinical information was available for 244 hips in 227 surviving patients at a minimum of ten years of follow-up, and radiographic information was available for 184 hips in 172 patients.
RESULTS: Twenty-six (9.2%) of the patients had died of an unrelated cause and eight (2.7%) had undergone revision arthroplasty by the time of the latest follow-up. The average Harris hip score was 94 points, with 95% (232) of the patients having an excellent or good result and <4% (nine) having moderate residual pain. All radiographic assessments showed evidence of stable osseous ingrowth. Nine revisions had been performed, including four femoral component revisions due to periprosthetic fracture, one femoral revision due to aseptic loosening, one femoral revision secondary to a femoral shortening osteotomy for nerve palsy, two acetabular cup revisions due to psoas tendinitis, and a repeat revision in one of the patients with psoas tendinitis due to acetabular osteolysis. The overall survival rate of the implants was 98% (95% confidence interval, 94.2% to 99.6%) at ten years with revision for any reason as the end point.
CONCLUSIONS: The patients in our series had a good implant survival rate, good function, a low implant wear rate as reported in the previous study, and no further radiographic evidence of failure at ten years after cementless primary total hip arthroplasty with alumina ceramic-on-ceramic bearings.
LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Patterns of Loosening of Polyethylene Keeled Glenoid Components After Shoulder Arthroplasty for Primary Osteoarthritis: Results of a Multicenter Study with More Than Five Years of Follow-up.
J Bone Joint Surg Am. 2012 Jan 18;94(2):145-50
Authors: Walch G, Young AA, Boileau P, Loew M, Gazielly D, Molé D
Abstract
BACKGROUND: The aim of this study was to radiographically analyze the long-term glenoid migration patterns following total shoulder arthroplasty to better understand the factors responsible for loosening.
METHODS: Complete radiographic follow-up of more than five years was available for 518 total shoulder arthroplasties performed for primary glenohumeral osteoarthritis with use of an anatomically designed prosthesis with a cemented, all-polyethylene, keeled glenoid component. Radiographs were assessed for humeral head subluxation, periprosthetic radiolucent lines, and shifting of the position of the glenoid component. The type of migration of the glenoid was defined according to the direction of tilt, or as subsidence in the case of medial migration.
RESULTS: Definite radiographic evidence of glenoid loosening was observed in 166 shoulders (32%) and was characterized by radiolucency of ≥2 mm over the entire bone-cement interface in thirty shoulders and by a migration of the glenoid component (shift or subsidence) in 136 shoulders. Three predominant patterns of migration of the glenoid component were observed: superior tilting in fifty-two shoulders (10%), subsidence in forty-one shoulders (7.9%), and posterior tilting in thirty-three shoulders (6.4%). Superior tilting of the glenoid was associated with three risk factors: low positioning of the glenoid component, superior tilt of the glenoid component on the immediate postoperative coronal plane radiographs, and superior subluxation of the humeral head (p < 0.05 for all). Subsidence of the glenoid component was associated with the use of reaming to optimize the seating and positioning of the glenoid component (p < 0.001). Posterior tilting of the glenoid component was associated with preoperative posterior subluxation (i.e., a Walch type-B glenoid) and with excessive reaming (p < 0.01 for both).
CONCLUSIONS: The three patterns of migration observed in this study underscore the potential importance of the supporting bone beneath the glenoid component. In some shoulders, use of a keel or pegs to provide fixation of a polyethylene component in the absence of good support from subchondral bone may not be sufficient to resist compressive and eccentric forces, resulting in loosening. Preserving subchondral bone may be important for long-term longevity of the glenoid component.
LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
We previously reported the ten to fourteen-year results for 311 Porous Coated Anatomic total hip replacements that had been inserted by two surgeons in 279 patients. The purpose of the present report is to update that study and to report the outcome beyond twenty years. The patients were followed prospectively with clinical assessment with use of the Harris hip score and radiographic analysis, and the results were collected in a database. Two hundred and sixty-eight hips were functioning at the time of death or at the time of the latest follow-up. A total of forty-three hips (14%) underwent major revision for all causes, and an additional four hips underwent minor revision. At a mean of twenty-three years of follow-up, Kaplan-Meier analysis revealed a survival rate of 83% with revision for any reason as the end point. The survival rate was 95% for the femoral component and 88% for the acetabular component with revision for any reason as the end point. The rate of survival of the acetabular component was significantly higher in hips with a 26-mm femoral head than in those with a 32-mm femoral head (91% compared with 80%; p = 0.026). LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
The natural progression of symptomatic humeral head osteonecrosis in adults with sickle cell disease.
J Bone Joint Surg Am. 2012 Jan 18;94(2):156-62
Authors: Poignard A, Flouzat-Lachaniette CH, Amzallag J, Galacteros F, Hernigou P
Abstract
BACKGROUND: Osteonecrosis of the humeral head is a frequent complication in adults with sickle cell disease. However, little is known about the rate of, and the factors influencing, progression of symptomatic shoulder osteonecrosis in patients with this disease.
METHODS: Eighty-two adult patients with sickle cell disease and symptomatic osteonecrosis of the humeral head (104 shoulders) were identified with magnetic resonance imaging (MRI) between 1985 and 1993. Nineteen of the eighty-two patients were homozygous for hemoglobin S (S/S genotype), thirty-seven had hemoglobin S/hemoglobin C (S/C), and twenty-six had hemoglobin S/beta-thalassemia (S/T). Shoulder osteonecrosis was graded with the method of Cruess with an adaptation for MRI as proposed by Steinberg et al. for hip osteonecrosis. Annual radiographs were obtained. At the initial evaluation, thirty-eight symptomatic shoulders were designated as stage I (with osteonecrosis seen only on MRI), forty-two symptomatic shoulders were designated as stage II (radiographic evidence without collapse), and twenty-four symptomatic shoulders were designated as stage III or IV (a crescent line or collapse).
RESULTS: Partial or total repair with a decrease in the size of the osteonecrotic lesion or in the stage was never observed on MRI. At the time of the most recent follow-up (average, twenty years; range, fifteen to twenty-four years), collapse had occurred in eighty-nine shoulders (86%). The mean interval between the onset of pain and collapse was six years (range, six months to seventeen years; median, eight years). Of the 104 symptomatic shoulders, sixty-three (61%) with collapse worsened clinically until surgical treatment was needed. The principal risk factors for development of shoulder osteonecrosis in adults with sickle cell disease were the presence of hip osteonecrosis and the S/T or S/C genotype. The rate and risk of progression of the lesion until collapse occurred were significantly related to the S/S genotype, to a stage of II, to a large size of the osteonecrotic lesion, and to a medial or posterior location of the lesion.
CONCLUSION: Untreated symptomatic shoulder osteonecrosis related to sickle cell disease has a high likelihood of progressing to humeral head collapse, and the natural evolution in the long term requires surgical treatment for many of these patients.
LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
PMID: 22258003 [PubMed - in process]
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