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Orthopaedics Current Awareness Newsletter

February 2016

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Contents

Your Friendly Local Librarian… ................................................................................................................ 3

New Activity in Up-to-Date ................................................................................................................. 4

Current Awareness Database Articles related to Orthopaedics ............................................................. 7

Medical ............................................................................................................................................ 7

Patient care and management ...................................................................................................... 13

Other ............................................................................................................................................. 26

Journal Tables of Contents .................................................................................................................... 30

Journal of Bone and Joint Surgery; Vol. 97, iss. 15, August 2015 ....... Error! Bookmark not defined.

Journal of Orthopaedic Trauma; Vol. 29, iss. 8, Augustl 2015 ............. Error! Bookmark not defined.

Injury; Vol. 46, iss. 8, August 2015 ...................................................... Error! Bookmark not defined.

Strategies in Trauma and Limb Construction; Vol. 10, iss. 1, April 2015 ............ Error! Bookmark not

defined.

Clinical Orthopaedics and Related Research; Vol. 473, iss. 8, August 2015 ..... Error! Bookmark not

defined.

Your Friendly Local Librarian

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appraisal – just email me at library@uhbristol.nhs.uk

OUTREACH: Your Outreach Librarian can help facilitate evidence-based practise for all in the

Orthopaedics team, as well as assisting with academic study and research. We can help with

literature searching, obtaining journal articles and books, and setting up individual current

awareness alerts. We also offer one-to-one or small group training in literature searching,

accessing electronic journals, and critical appraisal. Get in touch: library@uhbristol.nhs.uk

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Please email requests to library@uhbristol.nhs.uk

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UpToDate is the leading evidence-based clinical decision support system, designed for use at the point of care.

It contains more than 9,500 searchable topics across the following specialities:

Adult and paediatric emergency medicine Allergy and immunology Cardiovascular medicine Dermatology Drug therapy Endocrinology and diabetes mellitus Family medicine Gastroenterology and hepatology General surgery Geriatrics Haematology Hospital Medicine Infectious diseases Nephrology and hypertension Neurology Obstetrics and gynaecology Oncology Paediatrics Primary care internal medicine Psychiatry Pulmonary, critical care and sleep medicine Rheumatology

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You can access UpToDate from any computer via www.uptodate.com. You will need your NHS Athens username

(register through http://openathens.nice.org.uk/).

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New Activity in Up-to-Date

Initial management of trauma in adults

Authors Ali Raja, MD, MBA, MPH; Richard D Zane, MD

Literature review current through: Jan 2016. | This topic last updated: Feb 02, 2016.

INTRODUCTION — Trauma is regularly encountered in the emergency department (ED). While injuries can range from isolated extremity wounds to complex injuries involving multiple organ systems, all trauma patients require a systematic approach to management in order to maximize outcomes and reduce the risk of undiscovered injuries.

This review will discuss the initial management of adult trauma patients. The management of pediatric trauma patients and specific injuries are reviewed separately.

Management of transvaginal mesh exposure and pain following pelvic surgery

Authors: John B Gebhart, MD, MS; Emanuel C Trabuco, MD, MS

Literature review current through: Jan 2016. | This topic last updated: Jun 22, 2015.

INTRODUCTION — Vaginal synthetic mesh is inserted to augment native tissue; however, these materials have been associated with numerous complications including mesh exposure, perforation, or contraction; pelvic pain; dyspareunia; infection; urinary and bowel dysfunction; and fistula formation. This topic will discuss the diagnosis and management of exposure (erosion) and pain resulting from vaginal mesh insertion. Other types of mesh complications are reviewed separately.

Antimicrobial prophylaxis for prevention of surgical site infection in adults

Authors: Deverick J Anderson, MD, MPH; Daniel J Sexton, MD

Literature review current through: Jan 2016. | This topic last updated: Dec 08, 2015.

INTRODUCTION — Surgical site infections (SSIs) are a common cause of healthcare-associated infection. The United States Centers for Disease Control and Prevention (CDC) has developed criteria that define surgical site infection as infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted at surgery. SSIs are often localized to the incision site but can also extend into deeper adjacent structures.

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de-mystified…

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Current Awareness Database Articles

related to Orthopaedics

Below is a selection of articles related to orthopaedics recently added to the healthcare databases,

grouped in the following categories:

Medical

Patient care and management

Other

If you would like any of the following articles in full text, or if you would like a more focused

search on your own topic, then get in touch: library@uhbristol.nhs.uk

Medical

Title: Investigating the structure and biocompatibility of niobium and titanium oxides as coatings for orthopedic metallic implants. Citation: Materials science & engineering. C, Materials for biological applications, Jan 2016, vol. 58, p. 918-926 (January 1, 2016) Author(s): Pradhan, D, Wren, A W, Misture, S T, Mellott, N P Abstract: Applying sol gel based coatings to orthopedic metallic implant materials can significantly improve their properties and lifespan in vivo. For this work, niobium (Nb2O5) and titanium (TiO2) oxides were prepared via solution processing in order to determine the effect of atomic arrangement (amorphous/crystalline) on bioactivity. Thermal evaluation on the synthesized materials identified an endotherm for Nb2O5 at 75 °C with 40% weight loss below 400 °C, and minimal weight loss between 400 and 850 °C. Regarding TiO2 an endotherm was present at 92 °C with 25% weight loss below 400 °C, and 4% between 400 and 850 °C. Phase evolution was determined using High Temperature X-ray Diffraction (HT-XRD) where amorphous-Nb2O5 (450 °C), hexagonal-Nb2O5 (525 °C), orthorhombic-Nb2O5 (650 °C), amorphous-TiO2 (275 °C) and tetragonal TiO2 (500 °C) structures were produced. Simulated body fluid (SBF) testing was conducted over 1, 7 and 30 days and resulted in positive chemical and morphological changes for crystalline Nb2O5 (525 °C) and TiO2 (500 °C) after 30 days of incubation. Rod-like CaP deposits were observed on the surfaces using Scanning Electron Microscopy (FE-SEM) and Grazing Incidence-X-ray Diffraction (GI-XRD) shows that the deposits were X-ray amorphous. Cell viability was higher with the TiO2 (122%) samples when compared to the growing cell population while Nb2O5 samples exhibited a range of viability (64-105%), partially dependent on materials atomic structure.

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Title: Optimizing thickness of ceramic coatings on plastic components for orthopedic applications: A finite element analysis. Citation: Materials science & engineering. C, Materials for biological applications, Jan 2016, vol. 58, p. 381-388 (January 1, 2016) Author(s): Marchiori, G, Lopomo, N, Boi, M, Berni, M, Bianchi, M, Gambardella, A, Visani, A, Abstract: Realizing hard ceramic coatings on the plastic component of a joint prosthesis can be strategic for the mechanical preservation of the whole implant and to extend its lifetime. Recently, thanks to the Plasma Pulsed Deposition (PPD) method, zirconia coatings on ultra-high molecular weight polyethylene (UHMWPE) substrates resulted in a feasible outcome. Focusing on both the highly specific requirements defined by the biomedical application and the effective possibilities given by the deposition method in the perspectives of technological transfer, it is mandatory to optimize the coating in terms of load bearing capacity. The main goal of this study was to identify through Finite Element Analysis (FEA) the optimal coating thickness that would be able to minimize UHMWPE strain, possible insurgence of cracks within the coating and stresses at coating-substrate interface. Simulations of nanoindentation and microindentation tests were specifically carried out. FEA findings demonstrated that, in general, thickening the zirconia coating strongly reduced the strains in the UHMWPE substrate, although the 1 μm thickness value was identified as critical for the presence of high stresses within the coating and at the interface with the substrate. Therefore, the optimal thickness resulted to be highly dependent on the specific loading condition and final applications.

Title: Development of porous Ti6Al4V/chitosan sponge composite scaffold for orthopedic applications. Citation: Materials science & engineering. C, Materials for biological applications, Jan 2016, vol. 58, p. 1177-1181 (January 1, 2016) Author(s): Guo, Miao, Li, Xiang Abstract: A novel composite scaffold consisting of porous Ti6Al4V part filled with chitosan sponge was fabricated using a combination of electron beam melting and freeze-drying. The mechanical properties of porous Ti6Al4V part were examined via compressive test. The ultimate compressive strength was 85.35 ± 8.68 MPa and the compressive modulus was 2.26 ± 0.42 GPa. The microstructure of composite scaffold was characterized using scanning electron microscopy. The chitosan sponge filled in Ti6Al4V part exhibited highly porous and well-interconnected micro-pore architecture. The osteoblastic cells were seeded on scaffolds to test their seeding efficiency and biocompatibility. Significantly higher cell seeding efficiency was found on composite scaffold. The biological response of osteoblasts on composite scaffolds was superior in terms of improved cell attachment, higher proliferation, and well-spread morphology in relation to porous Ti6Al4V part. These results suggest that the Ti6Al4V/chitosan composite scaffold is potentially useful as a biomedical scaffold for orthopedic applications.

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Title: Are Orthopaedic Residents Competent at Performing Basic Nonoperative Procedures in an Unsupervised Setting? A "Pop Quiz" of Casting, Knee Arthrocentesis, and Pressure Checks for Compartment Syndrome. Citation: Journal of pediatric orthopedics, Jan 2016, vol. 36, no. 1, p. e10. (January 2016) Author(s): Abzug, Joshua M, O'Toole, Robert V, Paryavi, Ebrahim, Sterling, Robert Abstract: Many patient care procedures are routinely performed by orthopaedic residents while not directly supervised by attending physicians. However, resident competence to perform these procedures is often presumed and not confirmed by objective measures. The purpose of this study was to formally evaluate 3 basic pediatric orthopaedic procedures commonly performed without attending supervision. All orthopaedic residents (n=20) were asked to complete 3 procedures (placement and removal of a short arm cast, aspiration of a knee joint, and compartment pressure checks of a leg) under direct attending supervision. Attending faculty developed a checklist for each procedure, listing the appropriate steps required and criteria with which to assess the final results. Scores were calculated, including means and SDs. Change in score by postgraduate year level was determined by simple linear regression. The mean score for short arm cast application and removal was 6.2 of a total possible score of 8, with an average 1.1 increase in score per year of training (P<0.001). Uneven cast padding and lack of full thumb motion were the most common reasons for losing points. Knee joint aspiration had an average score of 6.2 of 7, with an average increase in score of 0.3 per year of training (P=0.046). Lack of equipment preparation and not donning gloves in a sterile manner were the most common reasons for losing points. Measure of leg compartment pressures had an average score of 9.7 of 12, with an average increase in score of 0.5 per increase in year of training (P=0.087). Injecting an inappropriate amount of fluid and not recording measurements were the most common reasons for losing points. The ability of a resident to appropriately perform certain procedures without direct supervision improves with advancing Source: Medline

Title: Minocycline-Induced Cutaneous Hyperpigmentation in an Orthopedic Patient Population. Citation: Open forum infectious diseases, Jan 2016, vol. 3, no. 1, p. ofv107. (January 2016) Author(s): Hanada, Yuri, Berbari, Elie F, Steckelberg, James M Abstract: Background. The objectives of this study were to estimate the incidence and evaluate risk factors for development of minocycline-induced cutaneous hyperpigmentation in patients with orthopedic infections. Methods. Patients with orthopedic infections evaluated at Mayo Clinic (Rochester, MN) and treated with minocycline from 1 January 2002 to 31 December 2011 were retrospectively identified. Long-term minocycline suppression was defined as daily minocycline use for at least 3 months. A proportional hazards model was used to evaluate potential risk factors. Results. Of 291 patients receiving long-term minocycline suppression, 54% (156 of 291) developed hyperpigmentation after a mean follow-up of 4.8 years (range, 0.3-13.2 years); 88% involved blue-gray pigmentation of normal skin that appeared most commonly in the lower (75%) and upper extremities (44%).

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The mean duration of minocycline therapy before hyperpigmentation was 1.5 years (range, 0.1-9 years) with a mean cumulative dosage of 107.3 g (range, 8.6-657 g). Notable risk factors include a history of vitamin D deficiency (relative risk [RR], 6.29; 95% confidence interval [CI], 1.91-15.27; P = .0052), presence of a shoulder prosthesis (RR, 3.2; 95% CI, 1.23-6.56; P = .0062), noncirrhotic liver pathology (RR, 3.63; 95% CI, 1.11-8.75; P = .0359), and use of a concurrent medication also known to cause hyperpigmentation (RR, 4.75; 95% CI, 1.83-10.1; P = .0029). Conclusions. Hyperpigmentation associated with the use of long-term minocycline suppression in patients with orthopedic infections is common.

Title: Local delivery of mutant CCL2 protein-reduced orthopaedic implant wear particle-induced osteolysis and inflammation in vivo. Citation: Journal of orthopaedic research : official publication of the Orthopaedic Research Society, Jan 2016, vol. 34, no. 1, p. 58-64 (January 2016) Author(s): Jiang, Xinyi, Sato, Taishi, Yao, Zhenyu, Keeney, Michael, Pajarinen, Jukka, Lin, Abstract: Total joint replacement (TJR) has been widely used as a standard treatment for late-stage arthritis. One challenge for long-term efficacy of TJR is the generation of ultra-high molecular weight polyethylene wear particles from the implant surface that activates an inflammatory cascade which may lead to bone loss, prosthetic loosening and eventual failure of the procedure. Here, we investigate the efficacy of local administration of mutant CCL2 proteins, such as 7ND, on reducing wear particle-induced inflammation and osteolysis in vivo using a mouse calvarial model. Mice were treated with local injection of 7ND or phosphate buffered saline (PBS) every other day for up to 14 days. Wear particle-induced osteolysis and the effects of 7ND treatment were evaluated using micro-CT, histology, and immunofluorescence staining. Compared with the PBS control, 7ND treatment significantly decreased wear particle-induced osteolysis, which led to a higher bone volume fraction and bone mineral density. Furthermore, immunofluorescence staining showed 7ND treatment decreased the number of recruited inflammatory cells and osteoclasts. Together, our results support the feasibility of local delivery of 7ND for mitigating wear particle-induced inflammation and osteolysis, which may offer a promising strategy for extending the life time of TJRs. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:58-64, 2016.

Title: Incidence of Deep Vein Thrombosis and Pulmonary Embolism in the Elective Pediatric Orthopaedic Patient. Citation: Journal of pediatric orthopedics, Jan 2016, vol. 36, no. 1, p. 101-109 (January 2016) Author(s): Georgopoulos, Gaia, Hotchkiss, Mark S, McNair, Bryan, Siparsky, Georgette, Abstract: Although venous thromboembolism (VTE) has been well studied in the pediatric trauma population, rates of VTE associated with elective pediatric orthopaedic procedures have not been addressed in current literature. The purpose of this retrospective study was to identify the incidence of VTE in the elective pediatric orthopaedic surgical population and

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delineate subsets of this population at greatest risk. This study may provide valuable data to begin the process of resolving the controversy surrounding deep vein thrombosis prophylaxis in the pediatric orthopaedic population. The Pediatric Health Information System was queried for patients admitted on an ambulatory or inpatient basis, aged below 18 years, from January 2006 to March 2011 during which an elective orthopaedic surgery was the principal procedure performed. Patients with diagnoses or procedures related to infection, trauma, malignancy, or coagulopathies were excluded. Patients admitted through the emergency department or whose orthopaedic procedure was not performed on the admission date were excluded. Age, sex, ethnicity, race, admission year, and all procedures/diagnoses were recorded. The presence of VTE at the index admission or any subsequent readmission within 90 days was recorded. All criteria were coded using ICD-9-CM codes. Generalized logistic regression analyses were used to identify factors related to VTE. A total of 143,808 admissions (117,676 patients) matched the inclusion criteria. Thirty-three had a VTE during the index admission with an additional 41 at subsequent readmissions, for a total incidence of 0.0515% by admission and 0.0629% by patient. In the multivariable model, variables significantly (P<0.05) related to VTE included increasing age, admission type, diagnosis of metabolic conditions, obesity, and/or syndromes, and complications of implanted devices and/or surgical procedures. No procedure variables were significantly related to VTE in the multivariable model. The incidence of VTE in this cohort of pediatric patients undergoing elective orthopaedic surgery was 0.0515%. In children, underlying diagnosis seems to be a stronger predictor of VTE than procedures performed. Diagnosis with a metabolic condition, syndrome, and/or obesity, complications of implanted devices and/or surgical procedures, older age, and admission as an inpatient were significantly related to the development of a VTE. Level II-retrospective prognostic study.

Title: Addressing the Global Disparities in the Delivery of Pediatric Orthopaedic Services: Opportunities for COUR and POSNA. Citation: Journal of pediatric orthopedics, Jan 2016, vol. 36, no. 1, p. 89-95 (January 2016) Author(s): Shirley, Eric D, Sabharwal, Sanjeev, Schwend, Richard M, Cabral, Cristina, Abstract: The burden of musculoskeletal conditions, especially injuries, is increasing in low-income and middle-income countries. Road traffic injuries have become epidemic. There are multiple barriers to accessing surgical services at both the individual (utilization) and the health system (availability) levels, and deficiencies in education and training of health providers. Specialty societies such as the Pediatric Orthopaedic Society of North America (POSNA) have an opportunity to play an important role through teaching and training. The POSNA Children's Orthopedics in Underserved Regions (COUR) committee has supported the Visiting Scholars Program, which invites surgeons from the developing world to attend a scientific meeting and facilitates the scholar's visit to North American pediatric orthopaedic centers. POSNA members have held global educational courses that support an educational exchange between lecturers and attendees. The COUR web site allows for submission of trip reports that document successes and obstacles experienced by members performing overseas clinical care and teaching. The web site also provides educational resources relevant to providing care in these environments. POSNA collaborates with other societies,

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such as the American Academy of Orthopaedic Surgeons and the Society of Military Orthopaedic Surgeons, to provide education in disaster management. In addition to increasing member involvement, specialty societies have the opportunity for continued data collection from overseas care, application of US registry data to disease processes in the developing world, and further collaboration with one another.

Title: Renal and Gastrointestinal Considerations in Patients Undergoing Elective Orthopaedic Surgery. Citation: The Journal of the American Academy of Orthopaedic Surgeons, Jan 2016, vol. 24, no. 1, p. e1. (January 2016) Author(s): Pyrko, Peter, Parvizi, Javad Abstract: To minimize perioperative complications after orthopaedic procedures, patients may undergo medical optimization, which includes an assessment of their renal function and gastrointestinal (GI) system. The GI and renal systems are complex, and their proper optimization in the preoperative period can influence the success of any procedure. Several factors can prevent complications and reduce morbidity, mortality, and the cost of care, including a thorough evaluation and screening, with particular emphasis on anemia and its renal and GI causes; management of medications that are metabolized by the liver and excreted by the kidneys; and careful attention to the patient's nutritional status.

Title: Thromboprophylaxis after major orthopedic surgery: Improving compliance with clinical practice guidelines. Citation: Thrombosis research, Jan 2016, vol. 137, p. 113-118 (January 2016) Author(s): Bautista, Maria, Llinás, Adolfo, Bonilla, Guillermo, Mieth, Klaus, Diaz, Mario, Rodriguez, Fernanda, Clinical Care Program in Joint Replacements Abstract: Identifying risk factors and strategies for the prevention of deep venous thromboembolism in major orthopedic surgery has allowed the development of Clinical Practice Guidelines (CPGs). Currently, there is a gap between clinical practice and the implementation of the recommendations of CPGs. The purpose of this paper is to report the impact of the implementation of improvement strategies on adherence to venous thromboembolism (VTE) prophylaxis guidelines. We defined 3 quality indicators to assess the adequate use of thromboprophylaxis according to CPGs. We obtained a baseline measurement and identified several barriers for adherence. Six improvement strategies to promote adherence to CPGs were designed and applied. A systematic monitoring of these indicators was performed in real time and a description of the data was completed for patients undergoing primary joint replacement of the hip, knee and shoulder, during February 2012 and August 2014. Data from 773 patients were obtained. In the first trimester, the average of adherence was: 98.3% for medical order in the post-operative note, 60.3% for opportune administration and 67% for adherence to therapy at home. In the

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trimester, the rates of adherence were 100%, 95.7% and 100% respectively. Combined strategies for improvement of adherence to VTE prophylaxis is associated with higher compliance with clinical practice guidelines.

Title: Randomized, controlled, two-arm, interventional, multicenter study on risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple-trauma patients. Citation: Trials, Jan 2016, vol. 17, no. 1, p. 47. (2016) Author(s): Rixen, Dieter, Steinhausen, Eva, Sauerland, Stefan, Lefering, Rolf, Maegele, Marc G, Bouillon, Bertil, Grass, Guido, Neugebauer, Edmund A M, members of the Damage Control Study Group Abstract: Long bone fractures, particularly of the femur, are common in multiple-trauma patients, but their optimal management has not yet been determined. Although a trend exists toward the concept of "damage control orthopedics" (DCO), current literature is inconclusive. Thus, a need exists for a more specific controlled clinical study. The primary objective of this study was to clarify whether a risk-adapted procedure for treating femoral fractures, as opposed to an early definitive treatment strategy, leads to an improved outcome (morbidity and mortality). The study was designed as a randomized controlled multicenter study. Multiple-trauma patients with femur shaft fractures and a calculated probability of death of 20 to 60 % were randomized to either temporary fracture fixation with external fixation and defined secondary definitive treatment (DCO) or primary reamed nailing (early total care). The primary objective was to reduce the extent of organ failure as measured by the maximum sepsis-related organ failure assessment (SOFA) score. Thirty-four patients were randomized to two groups of 17 patients each. Both groups were comparable regarding sex, age, injury severity score, Glasgow Coma Scale, prothrombin time, base excess, calculated probability of death, and other physiologic variables. The maximum SOFA score was comparable (nonsignificant) between the groups. Regarding the secondary endpoints, the patients with external fixation required a significantly longer ventilation period (p = 0.049) and stayed on the intensive care significantly longer (p = 0.037), whereas the in-hospital length of stay was balanced for both groups. Unfortunately, the study had to be terminated prior to reaching the anticipated sample size because of unexpected low patient recruitment. Thus, the results of this randomized study reflect the ambivalence in the literature. No advantage of the damage control concept could be detected in the treatment of femur fractures in multiple-trauma patients. The necessity for scientific evaluation of this clinically relevant question remains. Current Controlled Trials ISRCTN10321620 Date assigned: 9 February 2007.

Title: The Choice Between Total Hip Arthroplasty and Arthrodesis in Adolescent Patients: A Survey of Orthopedic Surgeons. Citation: The Journal of arthroplasty, Jan 2016, vol. 31, no. 1, p. 70-75 (January 2016) Author(s): Kelman, Mark G, Studdert, David M, Callaghan, John J, Farid, Monica S, Titan, Ashley L, Dietz, Frederick R

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Abstract: For adolescent patients with end-stage hip disease, the choice between total hip arthroplasty (THA) and arthrodesis is complex; the clinical evidence is not definitive, and there are difficult trade-offs between clear short-term benefits from THA and uncertain long-term risks. We surveyed nearly 700 members of the Pediatric Orthopedic Society of North America and the American Association of Hip and Knee Surgeons. Respondents chose between a recommendation of THA or arthrodesis in four clinical vignettes. A clear majority of surgeons recommended THA in two of the vignettes, however opinion was somewhat divided in one vignette (overweight adolescent) and deeply divided in another (adolescent destined for manual labor job). Across all vignettes, recommendations varied systematically according to surgeons' age and their attitudes regarding tradeoffs between life stages.

Title: Substance P and Acute Pain in Patients Undergoing Orthopedic Surgery. Citation: PloS one, Jan 2016, vol. 11, no. 1, p. e0146400. (2016) Author(s): Lisowska, Barbara, Siewruk, Katarzyna, Lisowski, Aleksander Abstract: There is a limited information about the role of Substance P (SP) in acute pain nociception following surgical stimulation in patients with a chronic inflammatory state not to mention the link between this neuropeptide level changes and intensity of pain. The goal of the research was to find the correlation between SP level changes and acute pain intensity in patients with rheumatoid arthritis undergoing elective orthopedic surgery. Patients with rheumatoid arthritis (RA) were enrolled in the study. The correlation between acute pain intensity and concentration of SP in serum as well as in drainage fluid from postoperative wound was assessed in patients with RA who underwent Total Knee Replacement (TKA) under spinal anesthesia. In patients with RA a correlation between intensity of acute pain and serum SP was found postoperatively, whereas there was no correlation between intensity of acute pain and concentration of SP in drainage fluid. 1. The correlation between acute pain intensity and SP serum concentration was found postoperatively in patients with RA. 2. The correlation between acute pain intensity and SP concentration in drainage fluid was not found postoperatively in patients with RA.

Title: Proportion of Obese Patients Presenting to Orthopedic Total Joint Arthroplasty Clinics. Citation: Orthopedics, Jan 2016, vol. 39, no. 1, p. e127. (January 1, 2016) Author(s): Welton, K Linnea, Gagnier, Joel J, Urquhart, Andrew G Abstract: The purpose of this study is to demonstrate that the percentage of obese individuals initially presenting to total joint arthroplasty clinics in a public, tertiary hospital is greater than the proportion of obese individuals in the general population. In a retrospective, comparative study of patients seen in total joint replacement clinics at a public, tertiary hospital with an ICD-9 diagnosis of hip or knee osteoarthritis and documented body mass index, the proportion of obese individuals was compared with recent obesity data for the general population from the Centers for Disease Control and Prevention. Patients who had previously undergone hip or knee replacement surgery were

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excluded. Comorbid conditions, functional comorbidity index (FCI) scores, and Charlson comorbidity index scores were compared between obese and nonobese cohorts. The study included 499 patients aged 20 to 92 years (mean, 64.3 years), 58.9% of whom were female. Fifty-five percent of patients were obese, a significantly greater percentage than in the national (34.9%; P<.0005; odds ratio [OR]=2.23), regional (29.5%; P<.0005; OR=2.85), and state (31.1%; P<.0005; OR=2.64) populations. Obese patients had significantly more comorbid conditions (P<.002) and higher functional comorbidity index scores (P<.0009). The number of comorbidities and having Medicare/Medicaid insurance were predictive of obesity. This study highlights that the majority of patients presenting to orthopedic total joint arthroplasty clinics are obese and that they come with significantly more comorbidities. The total joint surgeon has a unique opportunity to facilitate weight loss in the obese osteoarthritic patient prior to joint replacement. [Orthopedics. 2016; 39(1):e127-e133.].

Title: Patient radiation doses in various fluoroscopically guided orthopaedic procedures. Citation: Radiation protection dosimetry, Jan 2016, vol. 168, no. 1, p. 72-75 (January 2016) Author(s): Tsapaki, V, Tsalafoutas, I A, Fagkrezos, D, Lazaretos, I, Nikolaou, V S, Efstathopoulos, N Abstract: All orthopaedic fluoroscopic procedures performed using C-arm guidance were monitored for 1 y. The type of procedure, fluoroscopy time (T), kerma-area product (KAP) values and number of radiographs (F) were recorded. The two most often performed techniques were as follows: intramedullary nailing (IMN) of intertrochanteric/peritrochanteric (IP) fractures (101 cases, 49.3 %) and antergrade IMN of femur or tibia shaft (TS) fractures (28 cases, 13.7 %). For the remaining procedures, none accounted for >5 %, categorised as 'various' (76 cases, 37 %). Large variations in T, KAP and F were observed. For IMN of IP fractures, antergrade IMN of femur and TS fractures and for various procedures, respectively, median values were T-2.1, 2.2 and 0.6 min, KAP-6.3, 6.3 and 0.6 Gy cm(-2) and F-21, 2.2 and 6.7. The patient doses during fluoroscopically guided procedures are relatively low compared with other interventional procedures. © The Author 2015.

Title: A Bariatric Surgery Primer for Orthopedic Surgeons. Citation: American journal of orthopedics (Belle Mead, N.J.), Jan 2016, vol. 45, no. 1, p. E1. Author(s): Kingsberg, Jessica G, Halpern, Alan A, Hill, Brian C Abstract: Increasing numbers of patients who have undergone bariatric surgery are now presenting to orthopedic surgeons for elective arthroplasties. In addition, orthopedic surgeons themselves are referring more patients for consideration of bariatric surgery in anticipation of future elective procedures. Although the full effects of bariatric surgery on metabolism are not yet known, the altered digestion associated with these surgeries poses several issues for orthopedic surgeons. In this article, we address 3 aspects of care of this class of patient: review of the most commonly performed procedures and their metabolic

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consequences; suggested preoperative assessment of bariatric patients for any conditions that should be corrected before surgery; and evaluation of outcomes of elective procedures performed after bariatric surgery. Awareness of the unique characteristics of this group of patients helps minimize the potential for complications of planned orthopedic surgeries.

Title: Bioinspired anchoring AgNPs onto micro-nanoporous TiO2 orthopedic coatings: Trap-killing of bacteria, surface-regulated osteoblast functions and host responses. Citation: Biomaterials, Jan 2016, vol. 75, p. 203-222 (January 2016) Author(s): Jia, Zhaojun, Xiu, Peng, Li, Ming, Xu, Xuchen, Shi, Yuying, Cheng, Yan, Abstract: The therapeutic applications of silver nanoparticles (AgNPs) against biomedical device-associated infections (BAI), by local delivery, are encountered with risks of detachment, instability and nanotoxicity in physiological milieus. To firmly anchor AgNPs onto modified biomaterial surfaces through tight physicochemical interactions would potentially relieve these concerns. Herein, we present a strategy for hierarchical TiO2/Ag coating, in an attempt to endow medical titanium (Ti) with anticorrosion and antibacterial properties whilst maintaining normal biological functions. In brief, by harnessing the adhesion and reactivity of bioinspired polydopamine, silver nanoparticles were easily immobilized onto peripheral surface and incorporated into interior cavity of a micro/nanoporous TiO2 ceramic coating in situ grown from template Ti. The resulting coating protected the substrate well from corrosion and gave a sustained release of Ag(+) up to 28 d. An interesting germicidal effect, termed "trap-killing", was observed against Staphylococcus aureus strain. The multiple osteoblast responses, i.e. adherence, spreading, proliferation, and differentiation, were retained normal or promoted, via a putative surface-initiated self-regulation mechanism. After subcutaneous implantation for a month, the coated specimens elicited minimal, comparable inflammatory responses relative to the control. Moreover, this simple and safe functionalization strategy manifested a good degree of flexibility towards three-dimensional sophisticated objects. Expectedly, it can become a prospective bench to bedside solution to current challenges facing orthopedics.

Title: Daptomycin for the treatment of osteomyelitis and orthopaedic device infections: real-world clinical experience from a European registry. Citation: European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology, Jan 2016, vol. 35, no. 1, p. 111-118 Author(s): Malizos, K, Sarma, J, Seaton, R A, Militz, M, Menichetti, F, Riccio, G, Gaudias, J, Abstract: Osteomyelitis is a serious infection predominantly caused by Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA). Orthopaedic device-related infections are complex and require a careful combination of surgical intervention and antimicrobial therapy. Daptomycin, a cyclic lipopeptide, effectively penetrates soft tissue and bone and demonstrates rapid concentration-dependent bactericidal activity

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against Gram-positive pathogens. This retrospective, non-interventional study evaluated clinical outcomes in patients with osteomyelitis or orthopaedic device infections treated with daptomycin from the European Cubicin® Outcomes Registry and Experience (EU-CORE(SM)) study. Patients were treated between January 2006 and April 2012, with follow-up to 2014. Clinical outcomes were assessed as success (cured or improved), failure or non-evaluable. Of 6,075 patients enrolled, 638 (median age, 63.5 years) had primary infections of osteomyelitis or orthopaedic device infections, 224 had non-prosthetic osteomyelitis, 208 had osteomyelitis related to a permanent or temporary prosthetic device, and 206 had orthopaedic device infections. The most commonly isolated pathogen was S. aureus (214 [49.1 %]; 24.8 % were MRSA). Overall, 455 (71.3 %) patients had received previous antibiotic therapy. Patients underwent surgical interventions, including tissue (225 [35.3 %]) and bone (196 [30.7 %]) debridement, as part of their treatment. Clinical success rates were 82.7 % and 81.7 % in S. aureus and coagulase-negative staphylococcal infections. Adverse events (AEs) and serious AEs assessed as possibly related to daptomycin were observed in 6.7 % and 1.9 % of patients, respectively. Daptomycin was discontinued by 5.5 % of patients due to AEs and 10 (1.6 %) deaths were reported. In conclusion, daptomycin was effective and safe in patients with osteomyelitis or orthopaedic device infections.

Title: Associations of diabetes mellitus with orthopaedic infections.

Citation: Infectious diseases (London, England), Jan 2016, vol. 48, no. 1, p. 70-73 (2016) Author(s): Al-Mayahi, Mohamed, Cian, Anais, Kressmann, Benjamin, Abstract: Clinical experience suggests that a high proportion of orthopaedic infections occur in persons with diabetes. We reviewed several databases of adult patients hospitalized for orthopaedic infections at Geneva University Hospitals from 2004 to 2014 and retrieved 2740 episodes of infection. Overall, diabetes was noted in the medical record for 659 (24%) of these cases. The patients with, compared with those without, diabetes had more than five times more foot infections (274/659 [42%] vs 155/2081 [7%]; p < 0.01) and a significantly higher serum C-reactive protein level at admission (median 96 vs 70 mg/L; p < 0.01). Diabetic patients were older (median 67 vs 52 years; p < 0.01), more often male (471 [71%] vs 1398 [67%]; p = 0.04), and had more frequent polymicrobial infections (219 [37%] vs 353 [19%]; p < 0.01), including more gram-negative non-fermenting rods (90 [15%] vs 168 [9%]; p < 0.01). Excluding foot infections from these analyses did not change the statistically significant differences. Diabetes was present in 17% of all infected orthopaedic patients without foot involvement. In Geneva canton, the overall prevalence of diabetes is estimated at 5.1%, while we have found that the prevalence is 13% in our hospitalized adults. Diabetes is present in 24% of all adult patients hospitalized for surgery for an orthopaedic infection, a prevalence that is several times higher than for the general population and twice as high as that for the population of hospitalized patients. Compared with non-diabetics, patients with diabetes have significantly more infections that are polymicrobial, including gram-negative non-fermenting rods.

Title: Orthopedic complications in diabetes. Citation: Bone, Jan 2016, vol. 82, p. 79-92 (January 2016)

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Author(s): Gehling, Daniel J, Lecka-Czernik, Beata, Ebraheim, Nabil A Abstract: Diabetes is associated with a number of lower extremity orthopedic conditions and complications including fractures, Charcot neuroarthropathy, plantar ulcers, and infection. These complications are of significant clinical concern in terms of morbidity, mortality, and socioeconomic costs. A review of each condition is discussed, with particular emphasis on the clinical importance, diagnostic considerations, and orthopedic treatment recommendations. The goal of the article is to provide a clinical picture of the challenges that orthopedic surgeons confront, and highlight the need for specific clinical guidelines in diabetic patients.

Patient care and management

Title: Electronic health record-based triggers to detect adverse events after outpatient orthopaedic surgery. Citation: BMJ quality & safety, Jan 2016, vol. 25, no. 1, p. 25-30 (January 2016) Author(s): Menendez, Mariano E, Janssen, Stein J, Ring, David Abstract: Adverse events (AEs) after outpatient orthopaedic surgery are common, but difficult to detect. Electronic health records facilitate abstraction of large quantities of data, and may allow automated identification of 'triggers' or clues indicating the possibility of an AE. We evaluated electronic health record-based triggers to detect AEs after outpatient orthopaedic surgery. The medical records of 1464 patients undergoing outpatient surgical procedures in one of five orthopaedic services at our institution were manually reviewed for the occurrence of 90-day postoperative AEs. We used electronic health records to identify triggers suggestive of an AE. Each trigger was evaluated for positive predictive value (PPV). We constructed a logistic regression model to determine triggers associated with AEs and used the beta coefficients derived from the model to produce a formula for the likelihood of identifying an AE in the medical record. The overall rate of 90-day AEs was 10%, with surgical site infection being the most common (3.3%). Electronic triggers with the highest PPVs for the occurrence of 90-day AEs were antibiotic prescription (75%), emergency department visit (41%), bone/joint or blood culture (41%), repeat surgery (39%) and consult with infectious disease specialist (33%). Using our formula to predict the likelihood of identifying an AE in the medical record, a predicted probability of >0.10 had a specificity of 80% and sensitivity of 53% for actual AE. Electronic health record-based triggers may facilitate quality-improvement efforts to monitor morbidity after outpatient orthopaedic surgery. Further research is needed to understand the optimal use of electronic triggers as surgical quality indicators and as screening tools to flag cases for manual review. Level III, prognostic study.

Title: Regional anesthesia and lipid resuscitation for local anesthetic systemic toxicity in China: results of a survey by the orthopedic anesthesia group of the chinese society of anesthesiology.

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Citation: BMC anesthesiology, Jan 2016, vol. 16, no. 1, p. 1. (2016) Author(s): Xu, Mao, Jin, Shanliang, Li, Zhengqian, Xu, Xuzhong, Wang, Xiuli, Zhang, Lan, Abstract: Intravenous lipid emulsions have been introduced for the management of patients with Local Anesthetic Systemic Toxicity (LAST). These emulsions have been stated as a first-line treatment in the guidelines of several international anesthesia organizations. Nevertheless, the adoption of lipid rescue therapy by Chinese practitioners remains unknown. We, therefore, evaluated the current approaches to treat LAST and the use of lipid rescue therapy among anesthesiologists in China. In September 2013, a 23-question survey on regional anesthesia practice and availability of lipid emulsions was sent by e-mail to directors or designated individuals at 41 academic anesthesiology departments listed by the orthopedic anesthesia group of the Chinese Society of Anesthesiology. Responses were received from 36 of the 41 (88 %) anesthesiology departments. To simplify the analysis, responses were divided into two groups according to the annual percentage of patients who received regional anesthesia (RA) for orthopedic anesthesia: 14 departments (39 %) with high-utilization (≥50 %) and 22 departments (61 %) low-utilization (<50 %) of RA. Ropivacaine and bupivacaine were the common drugs used for RA, which were independent of RA utilization. Interestingly, ultrasound-guided techniques were much more frequently used in low-utilization institutions than in high-utilization institutions (P = 0.025). Lipid emulsion was readily available in 8 of the 36 (22 %) responding institutions, with 7 of the other 28 (25 %) institutions planning to stock lipid emulsion. No differences in lipid availability and storage plans were observed between high- and low-utilization institutions. Lipid resuscitation was performed in five of the eight departments that had lipid emulsion. Eleven patients were successfully resuscitated and one was not. Lipid emulsion is not widely available in China to treat LAST resulted from RA for orthopedic patients. Efforts are required to promote lipid rescue therapy nationwide. Chinese Clinical Trail Registry (Registration number # ChiCTR-EOR-15006960 ; Date of Retrospective Registration on August 23rd, 2015) http://www.chictr.org.cn/showproj.aspx?proj=11703 .

Title: Comparing sutures versus staples for skin closure after orthopaedic surgery: systematic review and meta-analysis. Citation: BMJ open, Jan 2016, vol. 6, no. 1, p. e009257. (2016) Author(s): Krishnan, Rohin, MacNeil, S Danielle, Malvankar-Mehta, Monali S Abstract: To determine whether there still remains a significant advantage in the use of sutures to staples for orthopaedic skin closure in adult patients. Systematic Review/ Meta-Analysis. MEDLINE-OVID, EMBASE-OVID, CINAHL and Cochrane Library. Grey and unpublished literature was also explored by searching: International Clinical Trial Registry, Grey Matters BIOSIS Previews, Networked Digital Library of Theses and Dissertations, ClinicalTrials.gov, UK Clinical Trials Gateway, UK Clinical Research Network Study Portfolio, Open Grey, Grey Literature Report, and Web of Science. Articles were from any country, written in English and published after 1950. We included all randomised control trials and observational studies comparing adults (≥18 years) undergoing orthopaedic surgery who

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either received staples or sutures for skin closure. The primary outcome was the incidence of surgical site infection. Secondary outcomes included closure time, inflammation, length of stay, pain, abscess formation, necrosis, discharge, wound dehiscence, allergic reaction and health-related quality of life. 13 studies were included in our cumulative meta-analysis conducted using Review Manager V.5.0. The risk ratio was computed as a measure of the treatment effect taking into account heterogeneity. Random-effect models were applied. There was no significant difference in infection comparing sutures to staples. The cumulative relative risk was 1.06 (0.46 to 2.44). In addition, there was no difference in infection comparing sutures to staples in hip and knee surgery, respectively. Lastly, except for closure time, there was no significant difference in secondary outcomes comparing sutures to staples. Except for closure time, there was no significant difference in superficial infection and secondary outcomes comparing sutures to staples was found. Given that there may in fact be no difference in effect between the two skin closure and the methodological limitations of included studies, authors should begin to consider the economic and logistic implications of using staples or sutures for skin closure. CRD42015017481.

Title: New Oral Anticoagulants in Prophylaxis of Venous Thromboembolic Disease in Major Orthopedic Surgery. Citation: Cardiovascular & hematological disorders drug targets, Jan 2016, vol. 15, no. 3, p. 204-209 (2016) Author(s): Rostagno, Carlo Abstract: Despite widespread diffusion of pharmacological prophylaxis, deep venous thrombosis (DVT) is still a common cause of morbidity after major orthopedic surgery (total hip replacement - THR- and total knee replacement -TKR). At present, clear evidence has been provided that pharmacological primary prophylaxis with low molecular weight heparin (LMWH) is associated with a significant decrease in the incidence of venous thromboembolism. The main limitation of LMWH prophylaxis however is the need for parenteral administration with a not negligible drop-out of treatment. Newer oral anticoagulants (NAOs) dabigatran, rivaroxaban, apixiban and edoxaban may be valid alternatives in elective surgery. Several studies have demonstrated the efficacy and safety of NAOs after THR and TKR. The research for new compounds and their antidote is under continuous development Aim of this paper was to review the indications and clinical results of DVT prophylaxis with NAO in patients undergoing major orthopaedic surgery.

Title: Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. Citation: Blood transfusion = Trasfusione del sangue, Jan 2016, vol. 14, no. 1, p. 23-65, 1723-2007 (January 2016) Author(s): Vaglio, Stefania, Prisco, Domenico, Biancofiore, Gianni, Rafanelli, Daniela,

Title: Long-term employment outcomes following traumatic brain injury and orthopaedic trauma: A ten-year prospective study.

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Citation: Journal of rehabilitation medicine, Jan 2016, vol. 47, no. 10, p. 932-940 Author(s): Dahm, Jane, Ponsford, Jennie Abstract: To investigate the trajectory and predictors of employment over a period of 10 years following traumatic brain injury and traumatic orthopaedic injury. Prospective follow-up at 1, 2, 5 and 10 years post-injury. Seventy-nine individuals with traumatic brain injury and 79 with traumatic orthopaedic injury recruited from Epworth HealthCare in Melbourne, Australia during inpatient rehabilitation. Information was obtained from medical files and self-report questionnaires. Individuals with traumatic brain injury were less likely to be competitively employed during the period up to 10 years post-injury compared with individuals with traumatic orthopaedic injury, although there was evidence of increasing employment participation during that time. More severe traumatic brain injury, older age, pre-injury psychological treatment, and studying or having a blue-collar occupation at time of injury were associated with poorer employment outcomes. Individuals with traumatic brain injury had spent less time with their current employer and were less likely to have increased responsibility since the injury than those with traumatic orthopaedic injury. At least half of each group reported difficulty at work due to fatigue. Given the potential for gains in employment participation over an extended time-frame, there may be benefit in ongoing access to individualized vocational rehabilitation. Particular areas of focus would include managing fatigue and psychiatric disorders, and exploring supported occupational activity for all levels of injury severity.

Title: The American Academy of Orthopaedic Surgeons Appropriate Use Criteria on the Management of Anterior Cruciate Ligament Injuries. Citation: The Journal of bone and joint surgery. American volume, Jan 2016, vol. 98, no. 2, p. 153-155 (January 20, 2016) Author(s): Members of the Writing, Review, and Voting Panels of the AUC on Prevention and Treatment of Anterior Cruciate Ligament Injuries, Quinn, Robert H, Sanders, James O, Brown, Gregory Alexander, Murray, Jayson, Pezold, Ryan

Title: The burden of bone, native joint and soft tissue infections on orthopaedic emergency referrals in a city hospital. Citation: Annals of the Royal College of Surgeons of England, Jan 2016, vol. 98, no. 1, p. 34-39 (January 2016) Author(s): Howell, A, Parker, S, Tsitskaris, K, Oddy, M J Abstract: Introduction Bone, native joint and soft tissue infections are frequently referred to orthopaedic units although their volume as a proportion of the total emergency workload has not been reported previously. Geographic and socioeconomic variation may influence their presentation. The aim of this study was to quantify the burden of such infections on the orthopaedic department in an inner city hospital, determine patient demographics and

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associated risk factors, and review our current utilisation of specialist services. Methods All cases involving bone, native joint and soft tissue infections admitted under or referred to the orthopaedic team throughout 2012 were reviewed retrospectively. Prosthetic joint infections were excluded. Results Almost 15% of emergency admissions and referrals were associated with bone, native joint or soft tissue infection or suspected infection. The cohort consisted of 169 patients with a mean age of 43 years (range: 1-91 years). The most common diagnosis was cellulitis/other soft tissue infection and the mean length of stay was 13 days. Two-thirds of patients (n=112, 66%) underwent an operation. Fifteen per cent of patients were carrying at least one blood borne virus, eleven per cent were alcohol dependent, fifteen per cent were using or had been using intravenous drugs and nine per cent were homeless or vulnerably housed. Conclusions This study has shown that a significant number of patients are admitted for orthopaedic care as a result of infection. These patients are relatively young, with multiple complex medical and social co-morbidities, and a long length of stay.

Title: Risk Factors for Complications during Outpatient Parenteral Antimicrobial Therapy for Adult Orthopedic and Neurosurgical Infections. Citation: Southern medical journal, Jan 2016, vol. 109, no. 1, p. 53-60 Author(s): Felder, Kimberly K, Marshall, Lynn M, Vaz, Louise E, Barnes, Penelope D Abstract: Outpatient parenteral antimicrobial therapy (OPAT) is an effective way of treating infections, but complications are common. We identified patient characteristics and OPAT treatment factors associated with increased risk of OPAT-related complications. We used a retrospective cohort design that assessed 337 adult patients treated with OPAT for orthopedic and neurosurgical infections between August 1, 2008 and May 30, 2010. Independent variables included demographics, infection characteristics, lead time factors, OPAT treatment factors, and comorbid conditions. Multivariable log-binomial regression was used to estimate the risk of OPAT complications. The mean patient age was 55 years (range 19-87), 86% had an orthopedic infection, and 44% were treated with intravenous vancomycin. OPAT complications were seen in 45% (152/337) of the cohort. Risk ratios for OPAT complications were 1.9 (95% confidence interval 1.4-2.5) in patients having no primary care provider, 1.7 (95% confidence interval 1.3-2.1) for those treated with vancomycin. Identifying specific patient characteristics and OPAT treatment factors could facilitate OPAT process improvements to reduce the risk of OPAT complications for vulnerable patients.

Title: Orthopaedic Physical Therapy: Update to the Description of Specialty Practice. Citation: The Journal of orthopaedic and sports physical therapy, Jan 2016, vol. 46, no. 1, p. 9-18 Author(s): Johanson, Marie A, Miller, Michael B, Coe, Jean Bryan, Campo, Marc Abstract: Study Design Descriptive, cross-sectional observational study. Background In the physical therapist profession, the outcomes of specialty practice analyses are used to

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determine content areas for specialty board examinations and for American Physical Therapy Association (APTA)-accredited residency curricula. To maintain currency for specialty practices, the American Board of Physical Therapy Specialties (ABPTS) requires any approved specialty area to revalidate its Description of Specialty Practice (DSP) a minimum of every 10 years. Objectives The purpose of this article was to describe the most recent practice analysis process and to report revisions to the DSP for orthopaedic physical therapists. Methods A survey instrument was developed by a group of subject matter experts, following guidelines established by the ABPTS. The survey was sent electronically to a random sample of 800 orthopaedic certified specialists (OCSs). The survey contained 5 sections: (1) knowledge areas (eg, human anatomy and physiology); (2) professional roles, responsibilities, and values (eg, consultation); (3) patient/client management model (eg, examination); (4) percentage of body regions treated; and (5) demographic information. Results A total of 224 completed surveys and 43 partially completed surveys were submitted, for a response rate of 33.4%. Based on a priori decision rules regarding survey data, consensus of the group of subject matter experts, and ABPTS suggestions, the DSP for orthopaedic physical therapy was revised. Conclusion The revised DSP will be used to reconstruct the blueprint for future OCS examinations, APTA-accredited orthopaedic residency program curricula, as well as professional development activities related to recertification in orthopaedic

Title: Barriers and Facilitators Associated with Non-Surgical Treatment Use for Osteoarthritis Patients in Orthopaedic Practice. Citation: PloS one, Jan 2016, vol. 11, no. 1, p. e0147406. (2016) Author(s): Hofstede, Stefanie N, Marang-van de Mheen, Perla J, Vliet Vlieland, Thea P M, van den Ende, Cornelia H M, Nelissen, Rob G H H, van Bodegom-Vos, Leti Abstract: International evidence-based guidelines for the management of patients with hip and knee osteoarthritis (OA) recommend to start with (a combination of) non-surgical treatments, and using surgical intervention only if a patient does not respond sufficiently to non-surgical treatment options. Despite these recommendations, there are strong indications that non-surgical treatments are not optimally used in orthopaedic practice. To improve the adoption of non-surgical treatments, more insight is needed into barriers and facilitators of these treatments. Therefore, this study assessed which barriers and facilitators are associated with the use and prescription of different non-surgical treatments before hip and knee OA in orthopaedic practice among patients and orthopaedic surgeons in the Netherlands. We performed two internet-based surveys among 172 orthopaedic surgeons and 174 OA patients. Univariate association and multivariable regression techniques are used to identify barriers and facilitators associated with the use of non-surgical treatments. Most barriers and facilitators among patients were associated with the use of physical therapy, lifestyle advice and dietary therapy. Among orthopaedic surgeons, most were associated with prescription of acetaminophen, dietary therapy and physical therapy. Examples of barriers and facilitators among patients included "People in my environment had positive experiences with a surgery" (facilitator for education about OA), and "Advice of people in my environment to keep on moving" (facilitator for lifestyle and dietary advice). For orthopaedic surgeons, examples were "Lack of knowledge about

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guideline" (barrier for lifestyle advice), "Agreements/ deliberations with primary care" and "Easy communication with a dietician" (facilitators for dietary therapy). Also the belief in the efficacy of these treatments was associated with increased prescription. Strategies to improve non-surgical treatment use in orthopaedic practice should be targeted at changing the beliefs of orthopedic surgeons, communication with other OA care providers and involving patient's environment in OA treatment.

Title: Recent Orthopedic Surgeries Aiming to Improve Quality of Life for Patients with Rheumatoid Arthritis. Citation: The Journal of rheumatology, Jan 2016, vol. 43, no. 1, p. 245-246, 0315-162X Author(s): Momohara, Shigeki, Yano, Koichiro, Sakuma, Y U, Ikari, Katsunori

Title: Application of Tranexamic Acid in Trauma and Orthopedic Surgery. Citation: The Orthopedic clinics of North America, Jan 2016, vol. 47, no. 1, p. 137-143 Author(s): Jennings, John D, Solarz, Mark K, Haydel, Christopher Abstract: Tranexamic acid has gained recent interest in orthopedics and trauma surgery because of its demonstrated benefit in several clinical trials. It is inexpensive and effective at reducing blood loss and blood transfusion requirements without a significant increase in morbidity or mortality. The optimal timing, dosing, and route of administration in orthopedics are yet to be elucidated. Significant investigation of tranexamic acid use in joint replacement and spine surgery has promoted its incorporation into the everyday practice of many of these surgeons. The paucity of studies regarding its use in orthopedic trauma has limited its integration into a field that may stand to benefit most from the drug.

Title: Mechanical compatibility of sol-gel annealing with titanium for orthopaedic prostheses. Citation: Journal of materials science. Materials in medicine, Jan 2016, vol. 27, no. 1, p. 21. Author(s): Greer, Andrew I M, Lim, Teoh S, Brydone, Alistair S, Gadegaard, Nikolaj Abstract: Sol-gel processing is an attractive method for large-scale surface coating due to its facile and inexpensive preparation, even with the inclusion of precision nanotopographies. These are desirable traits for metal orthopaedic prostheses where ceramic coatings are known to be osteoinductive and the effects may be amplified through nanotexturing. However there are a few concerns associated with the application of sol-gel technology to orthopaedics. Primarily, the annealing stage required to transform the sol-gel into a ceramic may compromise the physical integrity of the underlying metal. Secondly, loose particles on medical implants can be carcinogenic and cause inflammation so the coating needs to be strongly bonded to the implant. These concerns are addressed in this paper. Titanium, the dominant material for orthopaedics at present, is examined before and after sol-gel processing for changes in hardness and flexural modulus. Wear resistance, bending and pull

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tests are also performed to evaluate the ceramic coating. The findings suggest that sol-gel coatings will be compatible with titanium implants for an optimum temperature of 500 °C.

Title: A pilot study of orthopaedic resident self-assessment using a milestones' survey just prior to milestones implementation. Citation: International journal of medical education, Jan 2016, vol. 7, p. 11-18 (2016) Author(s): Bradley, Kendall E, Andolsek, Kathryn M Abstract: To pilot test if Orthopaedic Surgery residents could self-assess their performance using newly created milestones, as defined by the Accreditation Council on Graduate Medical Education. In June 2012, an email was sent to Program Directors and administrative coordinators of the154 accredited Orthopaedic Surgery Programs, asking them to send their residents a link to an online survey. The survey was adapted from the Orthopaedic Surgery Milestone Project. Completed surveys were aggregated in an anonymous, confidential database. SAS 9.3 was used to perform the analyses. Responses from 71 residents were analyzed. First and second year residents indicated through self-assessment that they had substantially achieved Level 1 and Level 2 milestones. Third year residents reported they had substantially achieved 30/41, and fourth year residents, all Level 3 milestones. Fifth year, graduating residents, reported they had substantially achieved 17 Level 4 milestones, and were extremely close on another 15. No milestone was rated at Level 5, the maximum possible. Earlier in training, Patient Care and Medical Knowledge milestones were rated lower than the milestones reflecting the other four competencies of Practice Based Learning and Improvement, Systems Based Practice, Professionalism, and Interpersonal Communication. The gap was closed by the fourth year. Residents were able to successfully self-assess using the 41 Orthopaedic Surgery milestones. Respondents' rate improved proficiency over time. Graduating residents report they have substantially, or close to substantially, achieved all Level 4 milestones. Milestone self-assessment may be a useful tool as one component of a program's overall performance assessment strategy.

Title: Risk factors for surgical site infection and delayed wound healing after orthopedic surgery in rheumatoid arthritis patients. Citation: Modern rheumatology / the Japan Rheumatism Association, Jan 2016, vol. 26, no. 1, p. 68-74 Author(s): Kadota, Yasutaka, Nishida, Keiichiro, Hashizume, Kenzo, Nasu, Yoshihisa, Abstract: To investigate the prevalence and the risk factors of surgical-site infection (SSI) and delayed wound healing (DWH) in patients with rheumatoid arthritis (RA) underwent orthopedic surgery. We reviewed the records of 1036 elective orthopedic procedures undertaken in RA patients. Risk factors for SSI and DWH were assessed by logistic regression analysis using age, body mass index, disease duration, pre-operative laboratory data, surgical procedure, corticosteroid use, co-morbidity, and use of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and biological DMARDs (bDMARDs) as variables. SSI and DWH were identified in 19 cases and 15 cases, respectively. One case of

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SSI and three cases of DWH were recorded among 196 procedures in patients using bDMARDs. Foot and ankle surgery was associated with an increased risk of SSI (odds ratio (OR), 3.167; 95% confidence interval (CI), 1.256-7.986; p = 0.015). Total knee arthroplasty (TKA; OR, 4.044; 95% CI, 1.436-11.389; p = 0.008) and disease duration (OR, 1.004; 95% CI, 1.000-1.007; p = 0.029) were associated with an increased risk of DWH. Our results indicated foot and ankle surgery, and TKA and disease duration as risk factors for SSI and DWH, respectively. bDMARDs was not associated with an increased risk of SSI and DWH.

Other

Title: Short-Form Mini Nutritional Assessment as a useful method of predicting the development of postoperative delirium in elderly patients undergoing orthopedic surgery. Citation: General hospital psychiatry, Jan 2016, vol. 38, p. 15-20 (2016 Jan-Feb) Author(s): Chu, Che-Sheng, Liang, Chih-Kuang, Chou, Ming-Yueh, Lin, Yu-Te, Hsu, Chien-Jen, Abstract: Postoperative delirium (POD) is a major cause for concern among elderly patients undergoing surgery, often resulting in poor outcome. It is therefore important to predict and prevent POD. The aim of this study was to evaluate the Mini Nutritional Assessment Short-Form (MNA-SF) as a predictor of POD after orthopedic surgery. Elderly patients undergoing orthopedic surgery between April 2011 and March 2013 were included in the study (n=544; mean age, 74.24±7.92 years). The MNA-SF was used to evaluate preoperative nutritional status. Delirium was assessed daily after surgery using the confusion assessment method. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria were used to confirm delirium diagnosis. Univariate and multivariate logistic regression analyses were performed to identify key factors associated with POD. POD occurred in 52 patients (9.6%). According to the MNA-SF, 17.5% of subjects were at risk of undernutrition. Adjusting for all potential factors in the final model, age, male gender and lower Mini-Mental State Examination and higher Charlson Comorbidity Index scores were associated with significantly increased likelihood of POD. Subjects who were identified preoperatively as at risk of undernutrition were 2.85 times more likely to develop POD compared to normally nourished subjects (odds ratio: 2.85, 95% confidence interval: 1.19-6.87). These results suggest that the MNA-SF is a simple and effective tool that can be used to predict incident delirium in elderly patients after orthopedic surgery.

Title: An evaluation of orthopaedic nurses' participation in an educational intervention promoting research usage – a triangulation convergence model. Citation: Journal of Clinical Nursing, Jan 2016, (Jan 14, 2016), 0962-1067 (Jan 14, 2016) Author(s): Berthelsen, Connie Bøttcher, Hølge‐Hazelton, Bibi

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Abstract: Aims and objectives To describe the orthopaedic nurses' experiences regarding the relevance of an educational intervention and their personal and contextual barriers to participation in the intervention. Background One of the largest barriers against nurses' research usage in clinical practice is the lack of participation. A previous survey identified 32 orthopaedic nurses as interested in participating in nursing research. An educational intervention was conducted to increase the orthopaedic nurses' research knowledge and competencies. However, only an average of six nurses participated. Design A triangulation convergence model was applied through a mixed methods design to combine quantitative results and qualitative findings for evaluation. Methods Data were collected from 2013–2014 from 32 orthopaedic nurses in a Danish regional hospital through a newly developed 21‐item questionnaire and two focus group sessions. Data were first analysed using descriptive statistics (stata 12.0) and qualitative manifest content analysis. Second, the results were compared, contrasted and interpreted using international literature. Results The nurses experienced the intervention as a new way to focus on nursing research in practice. However, some nurses were not able to see the relevance of research usage in clinical practice. Nursing research was not a top priority for the nurses and their personal barriers for research usage during their working day were prioritising patients’ and colleagues’ well‐being. Their colleagues’ and head section nurses' lack of acceptance regarding participation in the teaching session was a contextual barrier for the nurses. Conclusion The nurses were interested in participating in the intervention. However, some felt restricted by the research‐practice gap and by diverse personal and contextual barriers. Relevance to clinical practice The knowledge derived from this study has high clinical and

Title: Understanding Orthopaedic Registry Studies: A Comparison with Clinical Studies. Citation: The Journal of bone and joint surgery. American volume, Jan 2016, vol. 98, no. 1, p. e3. (January 6, 2016) Author(s): Inacio, Maria C S, Paxton, Elizabeth W, Dillon, Mark T Abstract: Orthopaedic registries are valuable for monitoring patient outcomes in real-world settings. Registries are useful for identifying procedure incidence and device utilization, evaluating outcomes, determining patients at risk for complications and reoperations, identifying devices in recall situations, assessing comparative effectiveness of procedures and devices, and providing data for research studies. In the present report, we describe how orthopaedic registries can be used to conduct research and how they compare with randomized controlled trials (RCTs) in regard to methodology. Using an example, a comparison of the performance of mobile and fixed bearings in total knee arthroplasty, we evaluate the differences between, and the similarities of, RCTs and registry cohort studies with regard to how they are conducted and how their findings are reported. Orthopaedic registry studies differ from RCTs in many ways and offer certain advantages. The strengths and limitations of registry cohort studies and RCTs must be understood to properly evaluate the literature.

Title: The Evolving Role of Clinical Registries: Existing Practices and Opportunities for Orthopaedic Surgeons.

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Citation: The Journal of bone and joint surgery. American volume, Jan 2016, vol. 98, no. 2, p. e7. (January 20, 2016) Author(s): Dy, Christopher J, Bumpass, David B, Makhni, Eric C, Bozic, Kevin J, AAOS Washington Health Policy Fellowship

Title: Effectiveness of Virtual Reality Training in Orthopaedic Surgery. Citation: Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, Jan 2016, vol. 32, no. 1, p. 224-232 (January 2016) Author(s): Aïm, Florence, Lonjon, Guillaume, Hannouche, Didier, Nizard, Rémy Abstract: The purpose of this study was to conduct a systematic review to determine the effectiveness of virtual reality (VR) training in orthopaedic surgery. A comprehensive systematic review was performed of articles of VR training in orthopaedic surgery published up to November 2014 from MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases. We included 10 relevant trials of 91 identified articles, which all reported on training in arthroscopic surgery (shoulder, n = 5; knee, n = 4; undefined, n = 1). A total of 303 participants were involved. Assessment after training was made on a simulator in 9 of the 10 studies, and in one study it took place in the operating room (OR) on a real patient. A total of 32 different outcomes were extracted; 29 of them were about skills assessment. None involved a patient-related outcome. One study focused on anatomic learning, and the other evaluated technical task performance before and after training on a VR simulator. Five studies established construct validity. Three studies reported a statistically significant improvement in technical skills after training on a VR simulator. VR training leads to an improvement of technical skills in orthopaedic surgery. Before its widespread use, additional trials are needed to clarify the transfer of VR training to the OR. Systematic review of Level I through Level IV studies.

Title: Socioeconomic deprivation and age are barriers to the online collection of patient reported outcome measures in orthopaedic patients. Citation: Annals of the Royal College of Surgeons of England, Jan 2016, vol. 98, no. 1, p. 40-44 (January 2016) Author(s): Jenkins, P J, Sng, S, Brooksbank, K, Brooksbank, A J Abstract: Introduction Questionnaires are used commonly to assess functional outcome and satisfaction in surgical patients. Although these have in the past been administered through written forms, there is increasing interest in the use of new technology to improve the efficiency of collection. The aim of this study was to assess the availability of internet access for a group of orthopaedic patients and the acceptability of online survey completion. Methods A total of 497 patients attending orthopaedic outpatient clinics were surveyed to assess access to the internet and their preferred means for completing follow-up questionnaires. Results Overall, 358 patients (72%) reported having internet access. Lack of

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access was associated with socioeconomic deprivation and older age. Multivariable regression confirmed increased age and greater deprivation to be independently associated with lack of internet access. Out of the total group, 198 (40%) indicated a preference for assessment of outcomes via email and the internet. Conclusions Internet access was not universal among the patients in our orthopaedic clinic. Reliance on internet collection of PROMs may introduce bias by not including results from patients in older age groups and those from the more deprived socioeconomic groups.

Title: Value of a Dedicated Saturday Orthopaedic Trauma Operating Room. Citation: Journal of orthopaedic trauma, Jan 2016, vol. 30, no. 1, p. e24. (January 2016) Author(s): Runner, Robert, Moore, Thomas, Reisman, William Abstract: To determine the effect of an additional scheduled operative day on length of stay, distribution of caseload, waiting time to surgery, and direct variable hospital costs. Retrospective chart review. Urban level 1 trauma center. Consecutive operative tibia and femur fractures admitted from November 1, 2009, to October 31, 2011. Addition of a dedicated Saturday orthopaedic trauma operating room. Length of stay, distribution of caseload, and waiting time to surgery. The overall length of stay for all trauma patients admitted with femur or tibia fractures was significantly reduced by 2.7 days from a mean of 14.0-11.3 days (P value 0.018). Additionally, there was a trend toward shorter waiting time to surgery (average reduction of 25.1 hours) for patients admitted on a Friday (48.6 vs. 23.5 hours, P value 0.06). Furthermore, there was an increase in the number of cases performed on Saturdays by 59% (6.2% of the total caseload), whereas the originally disproportionally high number of cases on Mondays was appropriately reduced by 33% (6.7% of the total caseload). The estimated direct variable cost savings per year for the hospital was $1.13 million. Overall, these findings support the continuation of a dedicated Saturday orthopaedic trauma operating room and can provide the foundation for other departments with similar circumstances to negotiate for more dedicated operative time on weekends to improve efficiency. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Title: Mobile Device Trends in Orthopedic Surgery: Rapid Change and Future Implications. Citation: Orthopedics, Jan 2016, vol. 39, no. 1, p. e51. (January 1, 2016) Author(s): Andrawis, John P, Muzykewicz, David A, Franko, Orrin I Abstract: Mobile devices are increasingly becoming integral communication and clinical tools. Monitoring the prevalence and utilization characteristics of surgeons and trainees is critical to understanding how these new technologies can be best used in practice. The authors conducted a prospective Internet-based survey over 7 time points from August 2010 to August 2014 at all nationwide American Council for Graduate Medical Education-accredited orthopedic programs. The survey questionnaire was designed to evaluate the use of devices and mobile applications (apps) among trainees and physicians in the clinical

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setting. Results were analyzed and summarized for orthopedic surgeons and trainees. During the 48-month period, there were 7 time points with 467, 622, 329, 223, 237, 111, and 134 responses. Mobile device use in the clinical setting increased across all fields and levels of training during the study period. Orthopedic trainees increased their use of Smartphone apps in the clinical setting from 60% to 84%, whereas attending use increased from 41% to 61%. During this time frame, use of Apple/Android platforms increased from 45%/13% to 85%/15%, respectively. At all time points, 70% of orthopedic surgeons believed their institution/hospital should support mobile device use. As measured over a 48-month period, mobile devices have become an ubiquitous tool in the clinical setting among orthopedic surgeons and trainees. The authors expect these trends to continue and encourage providers and trainees to be aware of the limitations and risks inherent with new technology. [Orthopedics. 2016; 39(1):e51-e56.

Journal Tables of Contents

The most recent issues of the following journals:

Journal of Bone and Joint Surgery

Journal of Orthopaedic Trauma

Injury

Strategies in Trauma and Limb Construction

Clinical Orthopaedics and Related Research

Click on the links for abstracts. If you would like any of these papers in full text then get in touch: library@uhbristol.nhs.uk

Journal of Bone and Joint Surgery

February 2016; volume 98, issue 3

http://journals.lww.com/jorthotrauma/pages/currenttoc.aspx

Journal of Orthopaedic Trauma

February 2016; volume 30, issue 2

http://journals.lww.com/jorthotrauma/pages/currenttoc.aspx

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Injury

January 2016; volume 47, issue 1

http://www.injuryjournal.com/current

Strategies in Trauma and Limb Construction

November 2015; volume 10, issue 3

http://link.springer.com/journal/11751/10/3/page/1

Clinical Orthopaedics and Related Research

March 2016; volume 474, issue 3

http://www.clinorthop.org/volume/474/issue/3

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