Orthopedic CME Activities

Infection of tumor prostheses has been a major concern because of the extensive soft tissue dissection, long operating times, and patients’ immunosuppression by cancer and adjuvant treatments. Infections most often present within 2 years postoperatively, with approximately 70% of postoperative deep infections presenting within 12 months after surgery. They are typically low organism burden infections, the pathogenesis of which is related to bacteria growing in biofilms. Staphylococci are the most common pathogens involved in prosthetic joint infections, accounting for approximately 50% of infections overall, followed by streptococci, enterococci, Enterobacteriaceae species, Pseudomonas aeruginosa, and anaerobe species. Multiple pathogens may be isolated in approximately 25% of cases, with the most common combination being coagulase-negative Staphylococcus and group-D Streptococcus. Early diagnosis and appropriate treatment are necessary. However, diagnosis may be challenging because clinical symptoms are highly variable and numerous preoperative and intraoperative diagnostic laboratory tests are nonspecific. In most cases, a 1- or 2-stage revision surgery is necessary for eradicating the megaprosthetic infection. Prevention of infection is important. The future will see technical advances for infections of tumor prostheses in areas such as microbiological diagnostics and biofilm-resistant prostheses.

Traumatic intrasubstance ruptures of the biceps brachii are rare and historically specific to military static line parachute jumps; however, these injuries have recently been reported in the civilian literature. Diagnosis is made by history, clinical weakness in supination and elbow flexion, extensive ecchymosis and edema, and a palpable defect. Ultrasound and magnetic resonance imaging are useful to confirm the diagnosis and injury severity. Nonoperative treatment involves splinting in acute flexion. Early surgical intervention with primary repair has been shown to be more successful than late reconstruction.

Osteoarthritis (OA) is a chronic, progressive and multifactorial disease characterized by degenerative and inflammatory processes affecting joints and surrounding tissues, resulting in pain and functional disability. Despite the availability of practice guidelines for the management of OA, inadequacies in practices of clinicians and patients have been found, leading to suboptimal outcomes. This publication series explores a structured, multidisciplinary approach to care to optimize long-term outcomes for patients with this chronic disease.

Outpatient use of anticoagulants to prevent venous thromboembolism after total hip or knee arthroplasty may be hampered either by requirements for parenteral administration or high variability and frequent monitoring of anticoagulant activity. Trials of the new oral direct factor Xa inhibitors rivaroxaban and apixaban and the direct thrombin inhibitor dabigatran indicate that they can be administered in fixed doses without monitoring and that they generally have efficacy at least equivalent to enoxaparin, although with potential minor differences in the balance of efficacy vs risk for bleeding. This article reviews the results and pharmacokinetic properties that may influence their use in clinical practice.

Infection is a feared complication and a common cause of loss of function following open fractures. Despite the evidence supporting the administration of prophylactic antibiotics after open fractures, data demonstrating the optimal regimen is lacking. We reviewed the data supporting the current prophylaxis recommendations and the changing epidemiology of Staphylococcus aureus, the most common cause of surgical site infection in patients with open fractures. Until well-designed randomized trials are conducted, we recommend that providers consider selecting antibiotics active against MRSA for open fracture prophylaxis based on the local prevalence of MRSA carriage and individualized risk factors.

Mobility of the glenohumeral joint is facilitated through the complex interplay of soft tissue and osseous anatomy. Arthroscopic shoulder stabilization is commonly used in the surgical management of shoulder instability. However, the management of the unstable shoulder associated with bony defects (glenoid, humeral, or combined) can be challenging. Adequate recognition of bony defects is paramount to successful treatment and entails a careful history, clinical examination, and advanced radiographic imaging. Nonoperative methods of treatment are often insufficient for treating patients with large bony defects. Bony procedures, as opposed to soft procedures, may yield better outcomes in this patient population. However, respective surgical techniques used to address these defects are technically challenging with a significant learning curve and may lead to significant morbidity. This represents a paradigm shift in treatment and replaces the old paradigm of “open vs arthroscopic” instability surgery.

1. Recognize the increased possibility of heterotopic ossification after total hip arthroplasty (THA).
2. Outline the increased percentage of serious complications with the use of conventional nonsteroidal anti-inflammatory drugs (NSAIDs).
3. Identify a safer drug for prophylaxis of heterotopic ossification after THA.
4. Recognize that the risk of side effects with COX-2 inhibitors is lower compared to conventional NSAIDs and directly related to the time of administration.

The often debilitating condition of hemophilic arthropathy is treated with elective total joint arthroplasty. Little has been published addressing the role of thromboembolic prophylaxis in the hemophilic patient population following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Although the American College of Chest Physicians and the American Academy of Orthopaedic Surgeons have set guidelines for thromboembolic prophylaxis in the general population, no such standard of care is in place for hemophilic patients. While the risk of thrombosis in hemophilic patients following THA and TKA is thought to be lower, cases have been reported of pulmonary embolism and deep vein thrombosis (DVT) in hemophilic patients.

Embolization is performed in primary bone tumors, as well as metastatic lesions, in an ever-increasing number. It provides for devascularization, size reduction, calcification of margins and pain relief. It can be palliative or adjunctive and primary or serial. The main indications for embolization are definitive treatment of benign lesions such as hemangiomas or arteriovenous malformations, reducing the risk of bleeding prior to biopsy or surgery, palliation of pain, bleeding, fever and hypercalcemia-like symptoms in inoperable tumors, preventing further dissemination of a tumor, increasing the response to chemotherapy and radiotherapy, and retention of selectively delivered anti-mitotic agents or monoclonal antibodies deep into the tumor substance. The outcome ranges from complete tumor devascularization and necrosis to degrees of ischemia and hypovascularity. Vascular mapping of and the hemodynamic status of the tumor, as well as the anatomic region must be determined using selective angiography before embolization. Feeding arteries of the tumor and collaterals, the tumor’s relationship with adjacent vascular processes, and possible arteriovenous fistulas inside the tumor must be evaluated carefully. Embolic agents must be nontoxic, sterile, radiopaque and easy to prepare or to obtain. Major considerations for choosing an embolic agent are speed and reliability of delivery, duration of occlusive effect, preservation of normal tissue, and operator’s experience. Complications related to the procedure or the embolic agent may occur. When embolization is followed by surgery, it is recommended that surgery be performed within 24 to 48 hours to avoid revascularization.

This article represents a comprehensive literature review regarding the use of antibiotic-loaded bone cement in the context of septic revision total hip arthroplasty (THA). A comprehensive literature search was performed using Medline and PubMed databases dating from 1970 through November, 2009. The literature regarding treatment of primary THA revision spans 4 decades, is not cohesive, and is severely lacking in level-I clinical trials. Only 2 level-I publications were found, which express different results. Based on the literature, we recommend a comprehensive level-I study to determine if using antibiotic spacers alone is superior to using spacers with concurrent intravenous antibiotic therapy.