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Volume 3 - Issue 6, December 2010
Current Orthopaedic Practice E-News
Welcome Orthopaedics in Brief Clinical Pearls Article of the Month Practice Management
Editor: Nanci Kulig

Happy holidays and welcome to Current Orthopaedic Practice eNews. Read Orthopaedics in Brief to keep up to date on clinical news. In this issue, learn which method best restores hip geometry during total hip arthroplasty, discover the long-term outcomes of shoulder resurfacing, find out how well vancomycin-modified bone allografts resist bacterial colonization, and more.

Read Practice Management to build your business know-how. In this issue, discover why your practice needs a policy manual, what components it should have, and how it could help prevent problems with staff.

In Article of the Month, enjoy free access to an article that offers a technical trick from the Journal of Orthopaedic Trauma.

Have a comment or suggestion? Contact me at editor@c-orthopaedicpractice.com.

Nanci Kulig
Editor, COP eNews

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Comparing 2 implant systems for restoring hip geometry

Femoral components with a modular junction at the base of the neck (two modular junction components) have increased the options for restoring femoral offset and leg length during total hip arthroplasty (THA). Investigators evaluated whether a femoral component with 2 modular junctions would predict by templating more frequent restoration of preoperative offset and leg length abnormalities than a component with a single modular junction.
     Investigators reviewed the preoperative templating data for 100 primary THAs that were performed using single modular junction implants with a neutral version stem and 100 THAs with 2 modular junction implants. They compared the frequency with which the desired leg length and offset were restored completely in both groups.
     Offset and leg lengths were restored to within 1 mm in 85% of cases with 2 modular junction implants and in 60% of cases with single modular junction implants. An anteverted or a retroverted neck was used in 25% of the procedures that were performed with 2 modular junction stems.
     Femoral components with 2 modular junctions resulted in more frequent ability to restore femoral offset and leg length than those with a single modular junction. Investigators caution that the advantage of clinical flexibility conferred by 2 modular junctions is somewhat offset by the potential for prosthetic mechanical failure and increased third-body wear, corrosive debris, and prosthetic cost.

Source: Archibeck MJ, Cummins T, Carothers J, Junick DW, White RE Jr. A comparison of two implant systems in restoration of hip geometry in arthroplasty. Clin Orthop Relat Res. 2010 Nov 17. [Epub ahead of print]

Quadriceps strength: How important after ACL?

Quadriceps strength and activation may improve recovery after anterior cruciate ligament (ACL) revision. In a recent study, researchers documented deficits in bilateral quadriceps central activation and osteoarthritis in patients who underwent revision ACL reconstruction.
     The study involved 21 patients assessed 14 to 85 months after revision ACL reconstruction. Bilateral quadriceps strength testing consisted of maximal voluntary isometric contractions (MVICs) with the knee bent 90 degrees. Researchers calculated quadriceps central activation ratio (CAR) using the superimposed burst technique. A fellowship-trained orthopaedic surgeon used the International Knee Documentation Committee (IKDC) grading system to rate the severity of degeneration on bilateral standing anteroposterior radiographic views with the knees flexed and lateral views with the knees fully extended.
     Average CARs were lower in reconstructed limbs than in contralateral limbs (83.9 ± 12.0% vs. 85.5 ± 9.5%, respectively). Average normalized MVIC torque also was lower in reconstructed limbs than in contralateral limbs (2.5 ± 1.0 Nm/kg vs. 2.7 ± 1.0 Nm/kg, respectively).
     Patient age at the follow-up assessment was related to the severity of knee joint degeneration, especially the medial, anterior, and patellofemoral compartments. More severe degeneration in the patellofemoral joint was correlated with lower CARs in younger patients and lower normalized MVIC torque values in older patients.

Source: Hart JM, Turman KA, Diduch DR, Hart JA, Miller MD. Quadriceps muscle activation and radiographic osteoarthritis following ACL revision. Knee Surg Sports Traumatol Arthrosc. 2010 Nov 26. [Epub ahead of print]

Ankle sprains by the numbers

Much is known about ankle sprains among athletes, but until now, researchers have paid scant attention to sprains in the general population.
     Investigators used the National Electronic Injury Surveillance System (NEISS) to analyze demographic data relating to all patients presenting to emergency departments with ankle sprain injuries between 2002 and 2006. During the study period, an estimated 3,140,132 ankle sprains occurred--a rate of 2.15 sprains per 1000 person-years in the United States.
     The data indicate that ankle sprains are most common among people 10 to 19 years of age. The peak incidence of ankle sprains is among teenagers of both sexes, ages 15 to 19 (7.2 per 1000 person-years). Males between 15 and 24 years of age have substantially higher rates of ankle sprain than females in the same age range, but women older than 30 have higher rates than their male counterparts.
     Half of all ankle sprains occur during athletic activity. Sports that account for the highest percentage of ankle sprains are basketball (41.1%), football (9.3%), and soccer (7.9%).

Source: Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ Jr. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):2279-2284.

Gauging long-term results after shoulder resurfacing

Shoulder resurfacing has regained popularity in recent years, but what are its long-term results in terms of patient satisfaction and implant survival?
     Recent study results indicate that shoulder resurfacing is successful for most patients. The procedure is associated with high rates of patient satisfaction, long-term survival of the humeral prosthesis, and few complications.
     The study involved 61 patients who underwent shoulder resurfacing procedures (74 shoulders). Patients were followed for a minimum of 20 years or until death. Average patient age at surgery was 58 years.
     There were 41 total resurfacing procedures and 33 hemi-resurfacing procedures. The humeral component involved a cup with a short central peg that was affixed with or without cement. The glenoid was resurfaced with a cemented polyethylene or polyurethane component.
     Patient satisfaction was 95%, and survival of the humeral prostheses was 96%. There were no periprosthetic fractures, dislocations, or infections. Two humeral components were revised to stemmed prostheses (1 for loosening and 1 for unexplained pain). One was revised from a cementless to a cemented resurfacing prosthesis. Twelve cemented polyethylene glenoid prostheses had radiolucencies, but only 3 produced symptoms requiring revision surgery. Three polyurethane glenoid prostheses showed severe wear radiographically, but none was loose or required revision surgery. There were 7 revision procedures, 6 of which produced good results.

Source: Pritchett JW. Long-term results and patient satisfaction after shoulder resurfacing. J Shoulder Elbow Surg. 2010 Nov 22. [Epub ahead of print]

Decreasing bone-graft infection

Do vancomycin-modified bone allografts resist bacterial colonization and biofilm formation? To find out, investigators coupled the antibiotic to allografts and challenged them with S. aureus.
     Investigators noted a uniform distribution of antibiotic on the allograft. After challenges with S. aureus for 6 hours, the covalently bonded vancomycin decreased colonization as a function of inoculum. The vancomycin-coated surface resisted biofilm formation, even in niches that are conducive to bacterial adhesion.
     The antibiotic attachment to the allograft surface was robust, and the vancomycin was stable whether incubated in aqueous media or in air. Vancomycin levels remained at 75-100% of initial levels for 60 days.
     Although the vancomycin-allograft combination inhibited gram-positive S. aureus colonization, which is in keeping with vancomycin's spectrum of activity, the vancomycin-modified allograft was readily colonized by gram-negative E. coli.
     Initial toxicity measurements indicate that the vancomycin-modified allograft had no influence on osteoblast colonization or viability. Researchers conclude that vancomycin-modified allografts have great potential for decreasing bone graft-associated infections because the covalently tethered antibiotic is stable, active, retains its specificity, and doesn't exhibit toxicity.

Source: Ketonis C, Barr S, Adams CS, Shapiro IM, Parvizi J, et al. Vancomycin bonded to bone grafts prevents bacterial colonization. Antimicrob Agents Chemother. 2010 Nov 22. [Epub ahead of print]

Taking the measure of new imaging technology

Is it safe to exclude peripheral skeletal injuries on the basis of screening with the new Lodox Statscan (LS)? Also, can LS imaging provide adequate information for preoperative planning?
     The LS is a digital low-radiation imaging device that provides full-body anterior and lateral views using enhanced linear slot-scanning technology.
     Investigators conducted a study involving 245 consecutive patients age 16 years or older who sustained polytrauma and underwent LS imaging. The LS scans were reviewed and compared with plain radiographs or computed tomography scans, when they were available.
     The sensitivity and specificity of LS were 73% and 100%, respectively, for peripheral skeletal injuries. Additional plain radiographs were obtained in 50% of cases, for reasons that included more precise resolution of the affected body part, an additional second or third plane, additional information regarding the fracture type and planning of the surgical approach, and preoperative planning of implant size and positioning on calibrated digitized films.
     Investigators concluded that the high sensitivity and specificity of LS make it an efficient tool for patient screening in the emergency room. For diagnostic or preoperative uses, however, additional radiographic imaging often is required.

Source: Evangelopoulos DS, Deyle S, Brehmer T, Benneker LM, Hasler R, et al. The efficiency of full body radiography 'Lodox Statscan' in the detection of peripheral skeletal fractures in adult trauma patients. Injury Extra. 2010;41(12):132.

Improving shoulder function in patients with RA

Reverse shoulder arthroplasty could potentially restore biomechanical balance to patients with rheumatoid arthritis (RA) who develop superior migration of the humeral head after massive rotator cuff tears, but does the high incidence of reported glenoid failure apply to patients with RA?
     Investigators analyzed pain relief and shoulder function after reverse arthroplasty in patients with RA. They compared results between primary and revision procedures, determined the incidence of scapular notching, and determined the complication rate.
     Twenty-three patients (27 shoulders) who had reverse arthroplasty, including 18 primary and 9 revision arthroplasties, were assessed after a minimum follow-up period of 18 months. All patients were assessed preoperatively and postoperatively. Level of pain, range of motion, and Constant-Murley score were recorded, and new radiographs were obtained.
     Reverse arthroplasty in patients with RA decreased pain and improved shoulder function with few complications. Visual analog scale scores for pain decreased from 8 to 1. Constant-Murley scores increased from 13 to 52; patients who underwent primary procedures had higher scores than those who had revisions. Three patients required revision surgery. Notching occurred in 52% of shoulders, but no loosening was observed.
     Investigators suggest that this procedure should be considered for elderly patients with RA who have pain and poor active range of motion resulting from massive rotator cuff tears.

Source: Ekelund A, Nyberg R. Can reverse shoulder arthroplasty be used with few complications in rheumatoid arthritis? Clin Orthop Relat Res. 2010 Nov 12. [Epub ahead of print]

Artificial total disc replacement vs. fusion for the cervical spine

Cervical total disc replacement (CTDR) is no better than fusion in alleviating symptoms related to disc degeneration in the cervical spine, according to results from a systematic literature review. CTDR, however, is used increasingly as an alternative to fusion in patients who have pain or neurological symptoms in the cervical spine that don't respond to nonsurgical treatment.
     According to the literature review, pain, disability, and quality of life improve about equally after each procedure. Both procedures have similar success alleviating symptoms related to disc degeneration in the cervical spine. Both procedures have similar complication rates. No evidence is available to compare CTDR and nonsurgical treatment.
     Long-term improvement of health outcomes seems to be similar after CTDR and fusion; however, the quality of the studies reviewed was often severely limited. After either intervention, many patients still face problems.
     Investigators don't recommend CTDR for routine use, but they note that many trials are ongoing and recommend future re-evaluation. They also note the need for research that compares the effectiveness of CTDR and conservative treatment.

Source: Zechmeister I, Winkler R, Mad P. Artificial total disc replacement versus fusion for the cervical spine: a systematic review. Eur Spine J. 2010 Oct 10. [Epub ahead of print]

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Writing a valuable practice manual

Don't you love it when an employee stops you in the hall and asks if she can leave early to attend a personal event? How about the industrious staff member who mentions that he is going to come in extra early for the next few days to get caught up on some work?
     The experienced manager or owner knows that his or her response to these seemingly innocuous questions can have far-reaching effects. A good manager will consider many factors and anticipate problems that may be created, possibly bringing them to the employee's attention.
     Consider using a 2-step guide for employee issues. First, look to your office policy manual on the matter. Second, consider whether your response will be fair to other employees. If you aren't sure how to respond to an employee's request, delay answering until you have time to think about it.

Fairness is one of the most important characteristics employees seek in an employer, and never doubt that they're looking. Part of the challenge in managing a staff is knowing the policies that have been set. Having office policies in writing is a big advantage because there's no doubt about the rules, and 90% of the fairness test is met if the employee knows a policy in advance.

Writing your manual
If you don't already have an office policy manual, below is a list of topics it should cover. If you already have a manual, it's a good idea to review it every year to ensure it adequately reflects your office policies. Read the list here and make sure you have a policy or statement for every topic.
     There are 2 kinds of employment manuals: policy manuals and procedural manuals. Both are important for every practice. A policy manual describes, for example, how an employee requests a vacation, whereas the procedure manual describes matters such as how an employee adjusts a patient's bill. The next issue of Practice Management will cover how to write procedure manuals.

Giving just enough details
It's important to give details about the rules of the office, but too much detail can cause problems. One set of rules doesn't fit every situation, and you may not think of something when you devise a policy.
     If your policies are very specific, you may lose flexibility to handle unexpected situations. For example, if you list the steps that are supposed to occur if an employee is disciplined or discharged, you're bound to follow them in every case. If you give a job description that is very detailed, it may be difficult to ask an employee to do something not listed. An office manual could be treated as an employment contract by a court of law or by a state department of employment.

Topics to include
     Here are some topics that your office policy manual should cover:

  1. General philosophy of the office
  2. Vision statement
  3. Practice motto
  4. History of the practice
  5. Practice ownership
  6. Employee benefits
  7. Health insurance
  8. Uniforms and personal appearance
  9. Continuing education and travel
  10. Financial incentives from suppliers
  11. Work schedule
  12. Paychecks
  13. Vacation days
  14. Personal days (sick days)
  15. Personal time off
  16. Overtime
  17. Employee parking
  18. Confidential patient information
  19. Confidential proprietary information
  20. Alcohol and drug use
  21. Personal telephone calls and internet use
  22. Chewing gum
  23. Smoking

Adapted from Neil B. Gailmard, OD, MBA, FAAO, editor, Optometric Management Tip of the Week.

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Please submit any clinical questions you have or any solutions you've found to clinical problems at clinicalpearls@c-orthopaedicpractice.com. We'll do our best to answer your questions and share solutions.

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Enjoy free access to "Stabilization of Displaced Articular Fragments in Calcaneal Fractures Using Bioabsorbable Pin Fixation: A Technique Guide," from the Journal of Orthopaedic Trauma. Access the abstract here: http://journals.lww.com/jorthotrauma/Abstract/2010/12000/Stabilization_of_Displaced_Articular_Fragments_in.9.aspx. Free access to this article lasts until your next issue of COP eNews arrives, when you'll receive free access to a new article.

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