Rodilla/Knee/Knie: Cierre con suturas con barbas: no gracias

Superficial Wound Closure Complications with Barbed Sutures Following Knee Arthroplasty

Abigail L. Campbell, MS, David A. Patrick Jr., BS, Barthelemy Liabaud, MD, Jeffrey A. Geller, MD

The Journal of Arthroplasty 29 (2014) 966–969

Abstract

As quality measures may be increasingly used in knee surgery reimbursement, an important focus in outcome assessment will shift toward minimizing complications and increasing efficiency in knee arthroplasty reconstruction. The purpose of this study was to evaluate the efficacy of barbed, absorbable sutures in closure of the longitudinal surgical incision following knee arthroplasty, using post-operative complication occurrences. In 416 operations, primary outcomes assessed were deep infection, superficial infection, dehiscence, or stitch abscesses. Secondary outcomes included self-limiting eschar, severe effusion, arthrofibrosis, and keloid formation. Evaluation of overall primary outcomes showed a higher rate of wound complications using barbed sutures (P b 0.001). With increased rates of infection and overall closure related complications, this study shows that barbed suture use for superficial closure after knee arthroplasty should be avoided.

Rodilla/Knee/Knie: Es clínicamente irrelevante respetar o sacrificar el LCP

Retention versus sacrifice of the posterior cruciate ligament in total knee arthroplasty for treating osteoarthritis.

Verra WC1, van den Boom LG, Jacobs W, Clement DJ, Wymenga AA, Nelissen RG.

Cochrane Database Syst Rev. 2013 Oct 11;10:CD004803

Abstract

BACKGROUND:

The functional and clinical basis on which to choose whether or not to retain the posterior cruciate ligament during total knee arthroplasty surgery remained unclear after a Cochrane systematic review and meta-analysis in 2005, which contained eight clinical trials. Several new trials have been conducted since then. Hence, an update of the review was performed.

OBJECTIVES:

Our aim was to assess the benefits and harms of retention compared to sacrifice of the posterior cruciate ligament in total knee arthroplasty in patients with osteoarthritis of the knee.

SEARCH METHODS:

An extensive search was conducted in CENTRAL, MEDLINE (PubMed), EMBASE, Web of Science, CINAHL, Academic Search Premier, Current Contents Connect and Science Direct. All databases were searched, without any limitations, up to 6 December 2012. References of the articles were checked and citation tracking was performed.

SELECTION CRITERIA:

Randomised and quasi-randomised controlled trials comparing retention with sacrifice of the posterior cruciate ligament in primary total knee arthroplasty in patients with osteoarthritis of the knee.

DATA COLLECTION AND ANALYSIS:

Data were collected with a pre-developed form. Risk of bias was assessed independently by two authors (WV, LB). The level of evidence was graded using the GRADE approach. Meta-analysis was performed by pooling the results of the selected studies, when possible. Subgroup analyses were performed for posterior cruciate ligament retention versus sacrifice using the same total knee arthroplasty design, and for studies using a posterior cruciate ligament retaining or posterior stabilised design, and when sufficient studies were available subgroup analyses were performed for the same brand.

MAIN RESULTS:

Seventeen randomised controlled trials (with 1810 patients and 2206 knees) were found, described in 18 articles. Ten of these were new studies compared to the previous Cochrane Review. One study from the original Cochrane review was excluded. Most new studies compared a posterior cruciate ligament retaining design with a posterior stabilised design, in which the posterior cruciate ligament is sacrificed (a posterior stabilised design has an insert with a central post which can engage on a femoral cam during flexion).The quality of evidence (graded with the GRADE approach) and the risk of bias were highly variable, ranging from moderate to low quality evidence and with unclear or low risk of bias for most domains, respectively.The performance outcome 'range of motion' was 2.4 ° higher in favour of posterior cruciate ligament sacrifice (118.3 ° versus 115.9 °; 95% confidence interval (CI) of the difference 0.13 to 4.67; P = 0.04), however the results were heterogeneous. On the item 'knee pain' as experienced by patients, meta-analysis could be performed on the Knee Society knee pain score; this score was 48.3 in both groups, yielding no difference between the groups. Implant survival rate could not be meta-analysed adequately since randomised controlled trials lack the longer term follow-up in order to evaluate implant survival. A total of four revisions in the cruciate-retention and four revisions in the cruciate-sacrifice group were found. The well-validated Western Ontario and McMaster Universities osteoarthritis index (WOMAC) total score was not statistically significantly different between the groups (16.6 points for cruciate-retention versus 15.0 points for cruciate-sacrifice). One study reported a patient satisfaction grade (7.7 points for cruciate-retention versus 7.9 points for cruciate-sacrifice on a scale from 0 to 10, 10 being completely satisfied) which did not differ statistically significantly. Complications were distributed equally between both groups. Only one study reported several re-operations other than revision surgery; that is patella luxations, surgical manipulation because of impaired flexion.The mean functional Knee Society Score was 2.3 points higher (81.2 versus 79.0 points; 95% CI of the difference 0.37 to 4.26; P = 0.02) in the posterior cruciate ligament sacrificing group. Results from the outcome Knee Society functional score were homogeneous. All other outcome measures (extension angle, knee pain, adverse effects, clinical questionnaire scores, Knee Society clinical scores, radiological rollback, radiolucencies, femorotibial angle and tibial slope) showed no statistically significant differences between the groups. In the subgroup analyses that allowed pooling of the results of the different studies, no homogeneous statistically significant differences were identified.

AUTHORS' CONCLUSIONS:

The methodological quality and the quality of reporting of the studies were highly variable. With respect to range of motion, pain, clinical, and radiological outcomes, no clinically relevant differences were found between total knee arthroplasty with retention or sacrifice of the posterior cruciate ligament. Two statistically significant differences were found; range of motion was 2.4 ° higher in the posterior cruciate ligament sacrificing group, however results were heterogeneous; and the mean functional Knee Society Score was 2.3 points higher in the posterior cruciate ligament sacrificing group. These differences are clinically not relevant.

Rodilla/Knee/Ginocchio: Más estudios apuntando al PRP para la gonartrosis inicial

Platelet-rich plasma vs hyaluronic acid to treat knee degenerative pathology: study design and preliminary results of a randomized controlled trial.

Filardo G, Kon E, Di Martino A, Di Matteo B, Merli ML, Cenacchi A, Fornasari PM, Marcacci M

BMC Musculoskelet Disord 2012.:229.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3532098/pdf/

Abstract

BACKGROUND

Platelet rich plasma (PRP), a blood-derived product rich in growth factors, is a promising treatment for cartilage defects but there is still a lack of clinical evidence. The aim of this study is to show, through a randomized double blind prospective trial, the efficacy of this procedure, by comparing PRP to Hyaluronic Acid (HA) injections for the treatment of knee chondropathy or osteoarthritis (OA).

METHODS

109 patients (55 treated with HA and 54 with PRP) were treated and evaluated at 12 months of follow-up. The patients were enrolled according to the following inclusion criteria: age > 18 years, history of chronic (at least 4 months) pain or swelling of the knee and imaging findings of degenerative changes of the joint (Kellgren-Lawrence Score up to 3). A cycle of 3 weekly injections was administered blindly. All patients were prospectively evaluated before and at 2, 6, and 12 months after the treatment by: IKDC, EQ-VAS, TEGNER, and KOOS scores. Range of motion and knee circumference changes were measured over time. Adverse events and patient satisfaction were also recorded.

RESULTS

Only minor adverse events were detected in some patients, such as mild pain and effusion after the injections, in particular in the PRP group, where a significantly higher post-injective pain reaction was observed (p=0.039). At the follow-up evaluations, both groups presented a clinical improvement but the comparison between the two groups showed a not statistically significant difference in all scores evaluated. A trend favorable for the PRP group was only found in patients with low grade articular degeneration (Kellgren-Lawrence score up to 2).

CONCLUSIONS

Results suggest that PRP injections offer a significant clinical improvement up to one year of follow-up. However, conversely to what was shown by the current literature, for middle-aged patients with moderate signs of OA, PRP results were not better than those obtained with HA injections, and thus it should not be considered as first line treatment. More promising results are shown for its use in low grade degeneration, but they still have to be confirmed.

Rodilla/Knee/Knie: infiltraciones de PRP para la gonartrosis incipiente

The effects of repeated intra-articular PRP injections on clinical outcomes of early osteoarthritis of the knee.

Gobbi ALad DKarnatzikos G

Knee Surg Sports Traumatol Arthrosc 2014 Apr 20.

Abstractc

PURPOSE

To assess the outcome of intra-articular platelet-rich plasma (PRP) injections into the knee in patients with early stages of osteoarthritis (OA) and to determine whether cyclical dosing would affect the end result.

METHODS

This is a prospective, randomized study in which 93 patients (119 knees) were followed up for a minimum of 2 years. Fifty knees were randomly selected prior to the first injection, to receive a second cycle at the completion of 1 year. A cycle consisted of three injections, each given at a monthly interval. The outcome was assessed using Knee Injury and Osteoarthritis Outcome Score (KOOS), Visual Analogue Scale (VAS), Tegner and Marx scoring systems, recorded prior to the first injection and then at 12, 18 and 24 months.

RESULTS

There was a significant improvement in all scores over time compared to the pre-treatment value (p < 0.001). At 12 months, both groups showed similar and significant improvement. At 18 months, except for KOOS (Symptoms) and Tegner score, all other parameters showed a significant difference between the two groups in favour of the patients who had received the second cycle (p < 0.001). At 2 years, the scores declined in both groups but remained above the pre-treatment value with no significant difference between the groups despite the patients with two cycles showing higher mean values for all the scores.

CONCLUSION

Intra-articular PRP injections into the knee for symptomatic early stages of OA are a valid treatment option. There is a significant reduction in pain and improvement in function after 12 months, which can be further improved at 18 months by annual repetition of the treatment. Although the beneficial effects are ill sustained at 2 years, the results are encouraging when compared to the pre-treatment function.

LEVEL OF EVIDENCE: II.

General: A la hora de usarlos, hay que sopesar que los preparados de PRP son heterogéneos

Characterization and comparison of 5 platelet-rich plasma preparations in a single-donor model.

Magalon J, Bausset O, Serratrice N, Giraudo L, Aboudou H, Veran J, Magalon G, Dignat-Georges F, Sabatier F.

Journal Arthroscopy. 2014 May;30(5):629-38

Abstract

PURPOSE: 

The purpose of this study was to compare the biological characteristics of platelet-rich plasma (PRP) obtained from 4 medical devices and a preparation developed in our laboratory using a single-donor model.

METHODS: 

Ten healthy persons donated blood that was processed to produce PRP by use of 4 commercial preparation systems and a protocol developed in our laboratory. Volumes and platelet, white blood cell (WBC), and red blood cell concentrations were recorded. The platelet activation status was assessed by flow cytometry. Enzyme-linked immunosorbent assay was used to determine the concentrations of vascular endothelial growth factor, platelet-derived growth factor AB, epidermal growth factor, and transforming growth factor β1. We calculated platelet capture efficiency, relative composition, and increase factors from whole blood in platelets and WBC, as well as platelet and growth factor (GF) doses, provided from each preparation.

RESULTS: 

Leukocyte-rich PRP was obtained with RegenPRP (RegenLab, Le Mont-sur-Lausanne, Switzerland) and the Mini GPS III System (Biomet Biology, Warsaw, IN) and provides PRP with higher proportions of red blood cells, WBCs, and neutrophils than leukocyte-poor PRP obtained with the Selphyl System (Selphyl, Bethlehem, PA), Arthrex ACP (Arthrex, Naples, FL), and the preparation developed in our laboratory. The highest platelet and GF concentrations and doses were obtained with the Mini GPS III System and the preparation developed in our laboratory. Different centrifugation protocols did not show differences in the percentages of activated platelets. Finally, a positive correlation between platelet doses and all the GFs studied was found, whereas a positive correlation between WBC doses and GFs was found only for vascular endothelial growth factor and epidermal growth factor.

CONCLUSIONS: 

In a single-donor model, significant biological variations in PRP obtained from different preparation systems were highlighted. The observed differences suggest different results for treated tissue and could explain the large variability in the clinical benefit of PRP reported in the literature.

CLINICAL RELEVANCE: 

Our findings will help clinicians to choose a system that meets their specific needs for a given indication.

Rodilla/Knee/Knie: No hay que arrojar la toalla ante asas de cubo crónicas

Outcomes After Repair of Chronic Bucket-Handle Tears of Medial Meniscus

Alejandro Espejo Reina, José Miguel Serrano Fernández, Belén Martín Castilla, Francisco Javier Estades Rubio, Karen K. Briggs, Alejandro Espejo Baena

Arthroscopy: The Journal of Arthroscopikc & Related Surgery, Volume 30, Issue 4

Purpose

The purpose of this study was to determine the outcomes after repair of chronic bucket-handle medial meniscal tears by use of magnetic resonance imaging, clinical examination, and patient-reported outcomes.

Methods

A retrospective review of patients with chronic bucket-handle medial meniscal tears that had been repaired with meniscal sutures was undertaken. The following criteria for inclusion were adopted: minimum tear length of 2 cm and chronic medial meniscal tear identified at the time of arthroscopy. The tears were susceptible to dislocation with probing. Data collected included demographic, clinical, radiologic, and surgical data. Postoperative healing was assessed with the clinical criteria of Barrett et al. The International Knee Documentation Committee rating, Lysholm score, and Tegner activity level were determined, and postoperative magnetic resonance imaging was used to evaluate healing in accordance with the criteria of Henning et al.

Results

Twenty-four patients fulfilled the inclusion criteria. The mean time from injury to surgery was 10 months (range, 2 to 60 months). Sixteen patients underwent anterior cruciate ligament reconstruction, 1 patient underwent posterior cruciate ligament reconstruction, and 6 patients underwent meniscus repair only. A median of 5 sutures (range, 3 to 6 sutures) were used for repair. Four cases (all of which had undergone meniscus repair only) required revision. Complete healing was achieved in 83% of cases according to the criteria of Barrett et al. The mean follow-up time was 48 months (range, 24 to 112 months). An International Knee Documentation Committee rating of A or B was achieved in the 20 patients who did not require revision. The median Lysholm score was 95 (range, 92 to 100). The median Tegner activity level before injury was 7, and it remained unchanged after surgery in all cases.

Conclusions

This study showed that repair of chronic bucket-handle meniscal tears can lead to good clinical outcomes and a relatively low (17%) failure rate. In addition, repairs of isolated meniscal tears had a significantly higher risk of failure than repairs performed in conjunction with anterior cruciate ligament reconstruction.

Level of Evidence

Level IV, therapeutic case series.

Rodilla/Knee/Knie: Hay que lavar la rodilla por artroscopia para salvar la plastia

Arthroscopic Irrigation and Debridement in the Treatment of Septic Arthritis After Anterior Cruciate Ligament Reconstruction

Michael Saper, Kyle Stephenson, Meredith Heisey

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Publication date: Available online 27 March 2014

Purpose

To systematically review the literature and characterize the success and failure rates of arthroscopic irrigation and debridement (I & D) in the treatment of septic arthritis after anterior cruciate ligament (ACL) reconstructions. We also aimed to identify which variables affected the failure rate.

Methods

Five databases (MEDLINE, Ovid, Medscape, Web of Science, and Google Scholar) were screened for clinical studies involving the treatment of septic arthritis after ACL reconstruction with arthroscopic I & D. A full-text review of eligible studies was conducted. Inclusion and exclusion criteria were applied to the searched studies. Failure of I & D was defined as the need for graft removal or revision ACL reconstructive surgery because of infection. Data from the selected studies were combined for statistical analyses to elucidate factors associated with the success or failure.

Results

We identified 11 eligible studies involving 90 patients. These studies described the results of 90 arthroscopic I & D procedures with an overall success rate of 85.6%. Repeated I & D was necessary in 34.5% of patients. Removal of the graft with or without subsequent revision ACL reconstruction was reported in 13 (14.4%) cases. Statistical analysis showed that cases involving Staphylococcus aureus (P = .053), 2 or more I & D procedures (P = .029), and allografts (P < .0001) were at greater risk of failure.

Conclusions

Arthroscopic I & D with graft retention is an effective treatment for patients with septic arthritis after ACL reconstruction. Factors affecting the failure rate may include graft choice and organism virulence.

Level of Evidence

Level IV, systematic review of Level IV studies

Hombro/Shoulder/Schulter: La rehabilitación tras PTH, sin prisas y acorde a lo que hemos hecho

Total Shoulder Arthroplasty Rehabilitation

Cahill, Janet B. PT; Cavanaugh, John T.; Craig, Edward V.

Techniques in Shoulder & Elbow Surgery: March 2014 - Volume 15 - Issue 1 - p 13-17

http://journals.lww.com/shoulderelbowsurgery/Fulltext/2014/03000/Total_Shoulder_Arthroplasty_Rehabilitation.4.aspx

Abstract

Total shoulder arthroplasty is the recommended surgical procedure for glenohumeral arthritis once conservative management is exhausted. Meticulous surgical technique and skilled, carefully supervised, progressive rehabilitation is essential to ensure that the range of motion can be maximized, whereas improved strength, functional goals, and pain relief are achieved. It is critical that the rehabilitation program is evaluation based, that any soft tissue repairs performed intraoperatively are protected while healing takes place, and soft tissue stretching is minimized within the first 6 weeks after surgery. The preoperative diagnosis, range of motion, and function frequently correlate with postoperative success and patient satisfaction. Patient compliance is critical to ensure optimal recovery. Rehabilitation after total shoulder arthroplasty may be modified if concomitant soft tissue procedures, such as a rotator cuff repair or subscapularis lengthening is performed, as the protection and optimization of soft tissue rehabilitation correlates highly with the outcome. It is critical for the health care team to communicate important and relevant specifics of the surgical procedure to ensure proper progression, and that, in efforts to efficiently provide guided rehabilitation, the specific exercises are not advanced too rapidly.

Hombro/Shoulder/Schulter: Si no varían los resultados, por qué empeñarse en hacer además acromioplastia

Arthroscopic Repair of Full-Thickness Rotator Cuff Tears With and Without Acromioplasty: Randomized Prospective Trial With 2-Year Follow-up.

Abrams GD Gupta AK, Hussey KE, Tetteh ES, Karas V, Bach BR,  Cole BJ,  Romeo AA, Verma NN

Am J Sports Med 2014 Apr 14.

Abstract

BACKGROUND:Acromioplasty is commonly performed during arthroscopic rotator cuff repair, but its effect on short-term outcomes is debated. 

PURPOSE:To report the short-term clinical outcomes of patients undergoing arthroscopic repair of full-thickness rotator cuff tears with and without acromioplasty. 

STUDY DESIGN:Randomized controlled trial; Level of evidence, 2. 

METHODS:Patients undergoing arthroscopic repair of full-thickness rotator cuff tears were randomized into acromioplasty or nonacromioplasty groups. The Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, Constant score, University of California-Los Angeles (UCLA) score, and Short Form-12 (SF-12) health assessment were collected along with physical examination including range of motion and dynamometer strength testing. Intraoperative data including tear size, repair configuration, and concomitant procedures were recorded. Follow-up examination was performed at regular intervals up to 2 years. Preoperative imaging was reviewed to classify the acromial morphologic type, acromial angle, and lateral acromial angulation. 

RESULTS:A total of 114 patients were initially enrolled in the study, and 95 (83%; 43 nonacromioplasty, 52 acromioplasty) were available for a minimum 2-year follow-up. There were no significant differences in baseline characteristics, including number of tendons torn, repair configuration, concomitant procedures, and acromion type and angles. Within groups, there was a significant (P < .001) improvement in all functional outcome scores from preoperatively to all follow-up time points, including 2 years, for the nonacromioplasty and acromioplasty groups (ASES score: 55.1-91.5, 48.8-89.0; Constant score: 48.3-75.0, 51.9-78.7, respectively). There were no significant differences in functional outcomes between nonacromioplasty and acromioplasty groups or between subjects with different acromial features at any time point. 

CONCLUSION:The results of this study demonstrate no difference in clinical outcomes after rotator cuff repair with or without acromioplasty at 2 years postoperatively.

Hombro / Shoulder / Schulter: Una tirita de poliéster para un gran problema

Treatment of massive rotator-cuff tears with a polyester ligament (LARS) patch.

Petrie MJ, Ismaiel AH

Acta Orthop Belg 2013 Dec; 79(6):620-5.

http://www.actaorthopaedica.be/acta/download/2013-6/04-Petrie%20et%20al.pdf

Abstract

We describe and analyse the results of our technique for repairing chronic massive tears (Goutallier grade 3 or 4) of the rotator cuff using a ligament augmentation and reconstruction system. This prospective, single surgeon series included 29 symptomatic patients (21 male, 8 female) with a mean age of 67.1 years who underwent 31 ligament augmentation and reconstruction system procedures (two bilateral procedures) with a mean follow-up period of 3 years. All patients had clinical, radiographic, magnetic resonance imaging and arthroscopic evidence of a chronic massive rotator cuff tear. The primary outcome measure was assessed using the Oxford Shoulder Score and visual analogue score pre-operatively and at follow-up. Postoperative overall Oxford shoulder score and visual analogue score results demonstrated a statistically significant improvement at follow-up, compared with pre-operative values (p < 0.0001). Post-operative acromio-humeral interval showed a statistically significant increase when compared to pre-operative radiographs (p = 0.0004). Two patients required revision with good postoperative results. We believe that, in the appropriate age group, the ligament augmentation and reconstruction system repair offers a good option for chronic, primary, non-closable rotator cuff defects in terms of pain relief and function.

Hombro / Shoulder / Schulter: Un repaso de las complicaciones de las PTHi

Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: A systematic review

Matthias A. Zumstein, Miguel Pinedo, Jason Old, Pascal Boileau

The use of hemiarthroplasty in patients with an arthritic rotator cuff deficient shoulder has been shown to provide limited function and inconsistent pain relief.

The semiconstrained reverse shoulder prosthesis, designed by Grammont in the late 1980s, was invented based on 2 biomechanical concepts: lowering the humerus and medialization of the center of rotation at the glenoid component. This design has the dual advantage of tensioning the deltoid muscle to increase its functional strength, and decreasing mechanical torque at the glenoid component, thus avoiding glenoid loosening. The first series of reverse shoulder arthroplasty (RSA) with at least 2 years of follow-up confirmed the preliminary results, with excellent functional outcome and stable glenoid fixation. However, these series had a small numbers of patients and reported variable compli-cation and revision rates of 15% to 50% and reoperation rates of 4% to 40%. One reason for the high variability was unclear definitions of complications and revisions, which varied markedly between the series. Furthermore, it is difficult to draw conclusions from small numbers of patients.

The purpose of the present study was to determine the incidence and functional significance of adverse events after RSA, including problems, complications, reopera-tions, and revisions. We established a study design and specific objectives before commencing the literature research. These objectives were (1) to perform a systematic review of the published literature to determine the overall rates of problems, complications, reoperations, and revi-sions after RSA; (2) to compare their influence on the final functional outcome; and, (3) to analyze the different problems, complications, reoperations, and revisions based on the etiology of the RSA

Hombro / Shoulder / Schulter: El subescapular implicado en la inestabilidad de la PTHi

Instability after reverse total shoulder replacement.

Gallo RA, Gamradt SC, Mattern CJ, Cordasco FA, Craig EV, Dines DM, Warren RF

J Shoulder Elbow Surg 2011 Jun; 20(4):584-90.

Abstract

BACKGROUND

Despite advances in technique and implant design, instability after reverse total shoulder arthroplasty remains a challenging postoperative complication.

MATERIALS AND METHODS

We examined our institutions' first 57 reverse total shoulder arthroplasties performed during a 3-year period (2004-2006). There were 9 cases of instability, all occurring within the first 6 months after surgery.

RESULTS

All 9 patients had compromise of the subscapularis tendon at the time of initial reverse total shoulder implantation. With regard to implant positioning, 2 patients had superiorly inclined metaglenes and 3 had metaglenes positioned superior to the inferior glenoid. Each patient with a dislocation had at least 1 revision surgery, and 4 patients had underlying infection. At most recent follow-up, only 3 patients had a concentrically reduced reverse total shoulder arthroplasty in place whereas 3 remained explanted, 2 chronically dislocated, and 1 chronically subluxated.

CONCLUSIONS

Early instability after reverse total shoulder arthroplasty can be related to inadequate soft tissue, inadequate deltoid tension, malpositioned implants, and/or infection, and outcomes of treatment of early instability are generally poor.

Hombro / Shoulder / Schulter: Una epidemia en los hombros

An epidemiological study of rotator cuff pathology using The Health Improvement Network database

J. J. E. White; A. G. Titchener; A. Fakis; A. A. Tambe; R. B. Hubbard; D. I. Clark, B

Bone Joint J 2014;96-B:350–3.

Abstract

Little is known about the incidence of rotator cuff pathology or its demographic associations in the general population. We undertook a large epidemiological study of rotator cuff pathology in the United Kingdom using The Health Improvement Network (THIN) database. The incidence of rotator cuff pathology was 87 per 100 000 person-years. It was more common in women than in men (90 cases per 100 000 person-years in women and 83 per 100 000 person-years in men; p < 0.001). The highest incidence of 198 per 100 000 person-years was found in those aged between 55 and 59 years. The regional distribution of incidence demonstrated an even spread across 13 UK health authorities except Wales, where the incidence was significantly higher (122 per 100 000 person-years; p < 0.001). The lowest socioeconomic group had the highest incidence (98 per 100 000 person-years). The incidence has risen fourfold since 1987 and as of 2006 shows no signs of plateauing.

This study represents the largest general population study of rotator cuff pathology reported to date. The results obtained provide an enhanced appreciation of the epidemiology of rotator cuff pathology and may help to direct future upper limb orthopaedic services.

Rodilla / Knee / Knie: Mosaicoplastia y ligamentoplastia una pareja bien avenida

Comparison of osteochondral autologous transplantation, microfracture, or debridement techniques in articular cartilage lesions associated with anterior cruciate ligament injury: a prospective study with a 3-year follow-up.

Gudas R, Gudaitė A, Mickevičius T, Masiulis N, Simonaitytė R, Cekanauskas E, Skurvydas A

Arthroscopy 2013 Jan; 29(1):89-97.

PURPOSE

To compare the concomitant treatment of articular cartilage damage in the medial femoral condyle with osteochondral autologous transplantation (OAT), microfracture, or debridement procedures at the time of anterior cruciate ligament (ACL) reconstruction.

METHODS

Between 2006 and 2009, 102 patients with a mean age of 34.1 years and with an ACL rupture and articular cartilage damage in the medial femoral condyle of the knee were randomized to undergo OAT, microfractures, or debridement at the time of ACL reconstruction. A matched control group was included, comprising 34 patients with intact articular cartilage at the time of ACL reconstruction. There were 34 patients in the OAT-ACL group, 34 in the microfracture (MF)-ACL group, 34 in the debridement (D)-ACL group, and 34 in the control group with intact articular cartilage (IAC-ACL group). The mean time from ACL injury to operation was 19.32 ± 3.43 months, and the mean follow-up was 36.1 months (range, 34 to 37 months). Patients were evaluated with the International Knee Documentation Committee (IKDC) score, Tegner activity score, and clinical assessment.

RESULTS

Of 102 patients, 97 (95%) were available for the final follow-up. According to the subjective IKDC score, all 4 groups fared significantly better at the 3-year follow-up than preoperatively (P < .005). The OAT-ACL group's IKDC subjective knee evaluation was significantly better than that of the MF-ACL group (P = .024) and D-ACL group (P = .018). However, the IKDC subjective score of the IAC-ACL group was significantly better than the OAT-ACL group's IKDC evaluation (P = .043). There was no significant difference between the MF-ACL and D-ACL groups' IKDC subjective scores (P = .058). Evaluation of manual pivot-shift knee laxity according to the IKDC knee examination form showed similar findings for the 4 groups immediately postoperatively and at 3-year follow-up, and the findings were rated as normal or nearly normal (IKDC grade A or B) in 29 of 33 patients (88%) in the OAT-ACL group, 28 of 32 patients (88%) in the MF-ACL group, 27 of 32 patients (84%) in the D-ACL group, and 31 of 34 patients (91%) in the IAC-ACL group.

CONCLUSIONS

Our study shows that intact articular cartilage during ACL reconstruction yields more favorable IKDC subjective scores compared with any other articular cartilage surgery type. However, if an articular defect is present, the subjective IKDC scores are significantly better for OAT versus microfracture or debridement after a mean period of 3 years. Anterior knee stability results were not significantly affected by the different articular cartilage treatment methods.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Hombro / Shoulder / Schulter: Diagnosticar desde el primer momento la inestabilidad multidireccional atraumática para no meter la pata

Revision Open Capsular Shift for Atraumatic and Multidirectional Instability of the Shoulder

Aaron J. Bois, Michael A. Wirth

J Bone Joint Surg Am, 2012 Apr 18;94(8):748-756

Shoulder stability is critical for proper functioning of the upper extremity and is dependent on the interplay between static and dynamic stabilizers of the glenohumeral joint. Surgical management of patients with atraumatic and multidirectional instability is effective if the capsular redundancy is properly reconstructed to restore glenohumeral joint biomechanics. Residual capsular laxity remains a common cause of recurrent glenohumeral joint dislocation in patients who have had previous stabilization procedures, and surgical results become less predictable in patients who have had multiple revision procedures. This article demonstrates the importance of the detection of capsular laxity at the time of the index surgery and of the use of reliable surgical techniques to obtain optimal results.

Codo / Elbow / Elbogen : Cuando hay que reconstruir, primero el complejo lateral

Medial and Lateral Collateral Ligament Repair or Reconstruction of the Elbow

Duncan McGuire, Gregory Ian Bain

Operative Techniques in Orthopaedics Volume 23, Issue 4, Pages 205-214, December 2013

Abstract

The elbow is a complex hinge joint relying on bony and soft tissue restraints for stability. The primary soft tissue stabilizers are the medial and lateral collateral ligament complexes. Injury to these structures may occur because of an elbow dislocation or due to a severe varus or valgus force. Most injuries are treated conservatively, but when associated with more severe soft tissue and bony injuries around the elbow, surgical repair or reconstruction may be required. Repair should be anatomical and should restore stability to the elbow so that early active range of motion can be initiated. Reconstruction may be required in severe cases and where primary repair is not possible. Knowledge of the normal anatomy and understanding the pathoanatomy is crucial to achieving a good result. Depending on the degree of instability, either one or both of the collateral ligament complexes may need to be repaired or reconstructed. When reconstruction is required, usually only the lateral ulnar collateral and the anterior band of the medial collateral ligament need to be reconstructed, but when severely unstable, the posterolateral capsule and the posterior band of the medial collateral ligament may also require reconstruction. This may be accomplished by 2 separate grafts or as a single circumferential graft. Arthroscopy is a valuable tool to assess the stability as well as to identify and treat associated injuries. This article describes the normal and pathoanatomy of the unstable elbow and outlines the surgical techniques for repair and reconstruction of the collateral ligaments.

Cadera / Hip / Hüfte: Más inflamación y dolor en pacientes obesos tras PTC

Association of Obesity With Inflammation and Pain After Total Hip Arthroplasty

Roja Motaghedi, James J. Bae, Stavros G. Memtsoudis, David H. Kim, Jonathan C. Beathe, Leonardo Paroli, Jacques T. YaDeau, Michael A. Gordon, Daniel B. Maalouf, Yi Lin

Clinical Orthopaedics and Related Research®

May 2014, Volume 472, Issue 5, pp 1442-1448

Abstract

Background

The prevalence of obesity is increasing, and obesity often leads to degenerative joint disease requiring total hip arthroplasty (THA). Obesity is a proinflammatory state associated with an increase in chronic, low-grade inflammatory response. As such, it may augment the postoperative inflammatory response, which has been associated with postoperative pain and complications.

Questions/purposes

We determined whether severity of obesity was associated with (1) severity of inflammatory response, as measured by the in vivo circulating levels of cytokines and ex vivo functional reactivity of mononuclear blood cells, and (2) severity of pain, as measured by verbal pain scores and analgesic consumption, in the first 24 hours after THA.

Methods

We studied 60 patients (20 normal weight, 20 overweight, 20 obese) undergoing elective primary unilateral THA in this prospective cross-sectional study. Blood samples were collected for C-reactive protein and cytokine levels, including IL-1β, IL-2, IL-6, IL-8, and tumor necrosis factor α (TNF-α), from patients before and 24 hours after surgery. Cytokine response of whole blood was evaluated ex vivo with or without two standard activators, phorbol-12-myristate-13-acetate and lipopolysaccharide, using standardized blood sample from patients at 24 hours. These standard immune activators are implicated in the inflammatory response to gram-negative infection, translocation of microbial products, pathophysiology of septic shock syndrome in human, and tumor promotion. Pain response was gauged using verbal pain scores (on a 0- to 10-point scale, where 0 = no pain and 10 = worst pain) at rest and with activity at 24 hours after surgery and analgesic consumption of volume of epidural analgesic solution for the first 24 hours after surgery.

Results

No correlation was found between BMI and postoperative spontaneous circulating cytokine levels. However, after activation of blood leukocytes with lipopolysaccharide, there was a significant positive correlation between the BMI and IL-1β, IL-6, and TNF-α levels (r = 0.26–0.32; p = 0.03, p = 0.03, and p = 0.01, respectively), suggesting priming of the innate immune system in obesity and potential for excessive postoperative inflammatory response. Obesity was not associated with increased pain or analgesic consumption in the first 24 hours after surgery

Conclusions

Obesity is associated with a proinflammatory state after THA as demonstrated by enhanced cytokine reactivity. Larger studies exploring the specific impact of obesity and inflammation on surgical outcomes, including pain, are warranted.

Level of Evidence

Level II, therapeutic study

Hombro / Shoulder /Schulter: Da igual suturar con nudo que sin él

Arthroscopic bankart repair using knot-tying versus knotless suture anchors: is there a difference?

Ng DZ, Kumar VP

Arthroscopy. 2014 Apr;30(4):422-7

PURPOSE:

To compare the clinical outcome between the use of knotless sutures versus knot-tying sutures in arthroscopic Bankart repairs.

METHODS:

Between January 2007 and January 2011, 87 patients who underwent arthroscopic Bankart repair with the use of knot-tying suture anchors or knotless suture anchors were evaluated, with 45 patients in the knot-tying suture group and 42 patients in the knotless group. Patients were assigned to either group, with odd-numbered patients going to the knot-tying suture arm and even-numbered patients assigned to the knotless arm. Outcomes included the Constant score, the visual analog scale (VAS) score, patient satisfaction score, and range of motion in forward flexion and external rotation with the arm in adduction. Redislocations or subluxations with the 2 techniques was also studied.

RESULTS:

Both groups showed a statistically significant improvement between the preoperative and postoperative VAS scores and Constant scores. In the knot-tying suture group, the VAS score improved from 2.5 ± 2.3 to 0.7 ± 0.5 (P < .05) and the Constant score improved from 64 ± 7 to 92 ± 10 (P < .05). In the knotless group, the VAS score improved from 2.8 ± 2.5 to 0.9 ± 0.6 (P < .05), and the Constant score improved from 62 ± 6 to 89 ± 9 (P < .05). The patient satisfaction scores were 6.9 and 7.1 for the knot tying and knotless groups, respectively. No statistically significant differences were found when comparing the outcomes between the 2 groups. The change in the range of forward flexion and external rotation was also similar in the 2 groups. There was also no difference in recurrence or redislocation rates.

CONCLUSIONS:

Both the knot-tying and knotless suture anchors groups showed statistically significant and similar improvement in VAS and Constant scores. Both anchors provided reasonable outcomes. The knotless suture anchor is a good alternative to knot-tying suture anchors so that arthroscopic Bankart repairs can be performed without knot tying.

LEVEL OF EVIDENCE:

Level II, prospective comparative study.

Pie / Foot / Fuss: Las tendinopatías son degenerativas: repaso del tratamiento

Tendinopathies of the Foot and Ankle 

MICHAEL R. SIMPSON, DO, MS, and THOMAS M. HOWARD, MD

Am Fam Physician. 2009;80(10):1107-1114.

Because our understanding of tendinopathy has evolved in recent years, the condition is now considered a degenerative process; this affects the approach to treatment. Initial therapy should always involve relative rest and modification of physical activity, use of rehabilitative exercises, and evaluation of intrinsic and extrinsic causes of injury. The posterior tibial tendon is a dynamic arch stabilizer; injury to this tendon can cause a painful flat-footed deformity with hindfoot valgus and midfoot abduction (characterized by the too many toes sign). Treatment of posterior tibial tendinopathy is determined by its severity and can include immobilization, orthotics, physical therapy, or subspecialty referral. Because peroneal tendinopathy is often misdiagnosed, it can lead to chronic lateral ankle pain and instability and should be suspected in a patient with either of these symptoms. Treatment involves physical therapy and close monitoring for surgical indications. Achilles tendinopathy is often caused by overtraining, use of inappropriate training surfaces, and poor flexibility. It is characterized by pain in the Achilles tendon 4 to 6 cm above the point of insertion into the calcaneus. Evidence from clinical trials shows that eccentric strengthening of the calf muscle can help patients with Achilles tendinopathy. Flexor hallucis longus tendinopathy is most common among ballet dancers. Patients may complain of an insidious onset of pain in the posteromedial aspect of the ankle; treatment involves correcting physical training errors, focusing on body mechanics, and strenghtening the body’s core. Anterior tibial tendinopathy is rare, but is typically seen in patients older than 45 years. It causes weakness in dorsiflexion of the ankle; treatment involves short-term immobilization and physical therapy

Hombro/Shoulder/Schulter: Hay que cuidar el subescapular en la PTHi

Anterior deltoid deficiency in reverse total shoulder replacement: a biomechanical study with cadavers.

Gulotta LV, Choi D, Marinello P, Wright T, Cordasco FA, Craig EV, Warren RF.

J Bone Joint Surg Br. 2012 Dec;94(12):1666-9

Abstract

Reverse total shoulder replacement (RTSR) depends on adequate deltoid function for a successful outcome. However, the anterior deltoid and/or axillary nerve may be damaged due to prior procedures or injury. The purpose of this study was to determine the compensatory muscle forces required for scapular plane elevation following RTSR when the anterior deltoid is deficient. The soft tissues were removed from six cadaver shoulders, except for tendon attachments. After implantation of the RTSR, the shoulders were mounted on a custom-made shoulder simulator to determine the mean force in each muscle required to achieve 30° and 60° of scapular plane elevation. Two conditions were tested: 1) Control with an absent supraspinatus and infraspinatus; and 2) Control with anterior deltoid deficiency. Anterior deltoid deficiency resulted in a mean increase of 195% in subscapularis force at 30° when compared with the control (p = 0.02). At 60°, the subscapularis force increased a mean of 82% (p < 0.001) and the middle deltoid force increased a mean of 26% (p = 0.04). Scapular plane elevation may still be possible following an RTSR in the setting of anterior deltoid deficiency. When the anterior deltoid is deficient, there is a compensatory increase in the force required by the subscapularis and middle deltoid. Attempts to preserve the subscapularis, if present, might maximise post-operative function.

Rodilla/Knee/Knie: implante de colágeno en las meniscectomías antíguas

Comparison of the collagen meniscus implant with partial meniscectomy. A prospective randomized trial.

Rodkey WG, DeHaven KE, Montgomery WH 3rd, Baker CL Jr, Beck CL Jr, Hormel SE, Steadman JR, Cole BJ, Briggs KK.

J Bone Joint Surg Am. 2008 Jul;90(7):1413-26.

BACKGROUND: Loss of meniscal tissue leads to increased pain and decreased clinical function and activity levels. We hypothesized that patients receiving a collagen meniscus implant would have better clinical outcomes than patients treated with partial medial meniscectomy alone.

METHODS: Three hundred and eleven patients with an irreparable injury of the medial meniscus or a previous partial medial meniscectomy, treated by a total of twenty-six surgeon-investigators at sixteen sites, were enrolled in the study. There were two study arms, one consisting of 157 patients who had had no prior surgery on the involved meniscus (the "acute" arm of the study) and one consisting of 154 patients who had had one, two, or three prior meniscal surgical procedures (the "chronic" arm). Patients were randomized either to receive the collagen meniscus implant or to serve as a control subject treated with a partial meniscectomy only. Patients underwent frequent clinical follow-up examinations over two years and completed validated outcomes questionnaires over seven years. The patients who had received a collagen meniscus implant were required by protocol to have second-look arthroscopy at one year to determine the amount of new tissue growth and to perform a biopsy to assess tissue quality. Reoperation and survival rates were determined.

RESULTS: In the acute group, seventy-five patients received a collagen meniscus implant and eighty-two were controls. In the chronic group, eighty-five patients received the implant and sixty-nine were controls. The mean duration of follow-up was fifty-nine months (range, sixteen to ninety-two months). The 141 repeat arthroscopies done at one year showed that the collagen meniscus implants had resulted in significantly (p = 0.001) increased meniscal tissue compared with that seen after the original index partial meniscectomy. The implant supported meniscus-like matrix production and integration as it was assimilated and resorbed. In the chronic group, the patients who had received an implant regained significantly more of their lost activity than did the controls (p = 0.02) and they underwent significantly fewer non-protocol reoperations (p = 0.04). No differences were detected between the two treatment groups in the acute arm of the study.

CONCLUSIONS: New biomechanically competent meniscus-like tissue forms after placement of a collagen meniscus implant, and use of the implant appears safe. The collagen meniscus implant supports new tissue ingrowth that appears to be adequate to enhance meniscal function as evidenced by improved clinical outcomes in patients with a chronic meniscal injury. The collagen meniscus implant has the utility to be used to replace irreparable or lost meniscal tissue in patients with a chronic meniscal injury. The implant was not found to have any benefit for patients with an acute injury.

Cadera/Hip/Hüfte: Choque isquiofemoral, una solución quirúrgica

Ischiofemoral impingement of the hip: a novel approach to treatment.

Safran M, Ryu J.

Knee Surg Sports Traumatol Arthrosc. 2014 Apr;22(4):781-5

Abstract

Ischiofemoral impingement (IFI) is an uncommon source of hip pain recently described in the non-surgical hip, associated with decreased space between the lesser trochanter and the ischium. There are no reports in the English literature of surgical treatment of this problem. We describe a case of IFI in a 19-year-old female who failed conservative management and underwent endoscopic surgical intervention to increase the space between her ischium and proximal femur. More than 2 years later, the patient is doing very well with an improvement of her iHOT score of 53 points to 85.

 Level of evidence IV.

Cadera/Hip/Hüfte: para los peques PTC no cementada cerámica/cerámica

The results of uncemented total hip replacement in children with juvenile idiopathic arthritis at ten years.

Daurka JS, Malik AK, Robin DA, Witt JD.

J Bone Joint Surg Br. 2012 Dec;94(12):1618-24

Abstract

The inherent challenges of total hip replacement (THR) in children include the choice of implant for the often atypical anatomical morphology, its fixation to an immature growing skeleton and the bearing surface employed to achieve a successful long-term result. 

We report the medium-term results of 52 consecutive uncemented THRs undertaken in 35 paediatric patients with juvenile idiopathic arthritis.

The mean age at the time of surgery was 14.4 years (10 to 16). The median follow-up was 10.5 years (6 to 15). 

During the study period 13 THRs underwent revision surgery. With revision as an endpoint, subgroup analysis revealed 100% survival of the 23 ceramic-on-ceramic THRs and 55% (16 of 29) of the metal- or ceramic-on-polyethylene. This resulted in 94% (95% CI 77.8 to 98.4) survivorship of the femoral component and 62% (95% CI 41.0 to 78.0) of the acetabular component. 

Revision of the acetabular component for wear and osteolysis were the most common reasons for failure accounting for 11 of the 13 revisions. The success seen in patients with a ceramic-on-ceramic articulation seems to indicate that this implant strategy has the potential to make a major difference to the long-term outcome in this difficult group of patients.

Hombro/Shoulder/Schulter: no parece mejor añadir L-PRP al reparar el manguito rotador

Does autologous leukocyte-platelet-rich plasma improve tendon healing in arthroscopic repair of large or massive rotator cuff tears?

Charousset C, Zaoui A, Bellaïche L, Piterman M

Arthroscopy 2014 Apr; 30(4):428-35.

Abstract

PURPOSE

To evaluate the clinical and magnetic resonance imaging (MRI) outcome of arthroscopic rotator cuff repair with the use of leukocyte-platelet-rich plasma (L-PRP) in patients with large or massive rotator cuff tears.

METHODS

A comparative cohort of patients with large or massive rotator cuff tears undergoing arthroscopic repair was studied. Two consecutive groups of patients were included: rotator cuff repairs with L-PRP injection (group 1, n = 35) and rotator cuff repairs without L-PRP injection (group 2, n = 35). A double-row cross-suture cuff repair was performed by a single surgeon with the same rehabilitation protocol. Patients were clinically evaluated with the Constant score; Simple Shoulder Test score; University of California, Los Angeles (UCLA) score; and strength measurements by use of a handheld dynamometer. Rotator cuff healing was evaluated by postoperative MRI using the Sugaya classification (type 1 to type 5).

RESULTS

We prospectively evaluated the 2 groups at a minimum 2-year follow-up. The results did not show differences in cuff healing between the 2 groups (P = .16). The size of recurrent tears (type 4 v type 5), however, was significantly smaller in group 1 (P = .008). There was no statistically significant difference in the recurrent tear rate (types 4 and 5) between the 2 groups (P = .65). There was no significant difference between group 1 and group 2 in terms of University of California, Los Angeles score (29.1 and 30.3, respectively; P = .90); Simple Shoulder Test score (9.9 and 10.2, respectively; P = .94); Constant score (77.3 and 78.1, respectively; P = .82); and strength (7.5 and 7.0, respectively; P = .51).

CONCLUSIONS

In our study the use of autologous L-PRP did not improve the quality of tendon healing in patients undergoing arthroscopic repair of large or massive rotator cuff tears based on postoperative MRI evaluation. The only significant advantage was that the L-PRP patients had smaller iterative tears. However, the functional outcome was similar in the 2 groups of patients.

LEVEL OF EVIDENCE

Level III, case-control study

Ciencia/Science/Wissenshaft: ¿robots especialistas que nos manden al paro?

¿Paraíso perdido? ¿Paraíso recuperado? Nanotecnología, el hombre y la máquina

Sandip Tiwari

https://www.bbvaopenmind.com/articulo/paraiso-perdido-paraiso-recuperado-nanotecnologia-el-hombre-y-la-maquina/?fullscreen=true

Con las capacidades de aprendizaje que adquirirán, las máquinas se convertirán, en un primer momento, en ayudantes expertos de los médicos para convertirse, más tarde, en sustitutos para las tareas más habituales y, finalmente, en especialistas. Estos son ejemplos en los que la máquina está adquiriendo cada vez más capacidades según van apareciendo elementos de menor tamaño que ofrecen la posibilidad de adquirir, asimilar y formar dicho conjunto de datos clasificados así como los patrones relevantes que integran.

(Os recomiendo la lectura completa del artículo)

Rodilla/Knee/Knie: indicación clara de la meniscectomía parcial

Does Arthroscopic Knee Surgery Work?

Krych AJ, Carey JL, Marx RG, Dahm DL, Sennett BJ, Stuart MJ, Levy BA

Arthroscopy. 2014 Mar 15. [Epub ahead of print]

Abstract

A recent randomized trial from the Finnish Degenerative Meniscal Lesion Study Group was published in the New England Journal of Medicine and attempted to determine the efficacy of partial meniscectomy without osteoarthritis. Patients were randomized to either arthroscopic partial meniscectomy or sham surgery. The authors concluded that the clinical outcomes after arthroscopic partial meniscectomy were no better than those after the sham surgical procedure. However, there are several important limitations of this trial that make it difficult to generalize to the 700,000 arthroscopic partial meniscectomies performed in the United States each year. In this small sample of 146 patients, patients with traumatic meniscal tears and locking symptoms-those most likely to benefit from a partial meniscectomy-were excluded. In addition, although patients with radiographic arthritis were excluded, most of the patients in the study had degenerative changes at the time of arthroscopy. Therefore it is difficult to determine whether the patients were symptomatic from their chondral degeneration or their degenerative meniscal tear. In our opinion this study does not change the role of surgery in current clinical practice. The primary indication for arthroscopic partial meniscectomy remains symptoms of well-localized joint line pain with acute onset and mechanical symptoms such as catching or locking that have failed comprehensive nonoperative management.

Hombro/Shoulder/Schulter: Propionibacterium muy difícil de demostrar

Origin of Propionibacterium in Surgical Wounds and Evidence-Based Approach for Culturing Propionibacterium from Surgical Sites

Frederick A. Matsen, III; Susan Butler-Wu; Bradley C. Carofino; Jocelyn L. Jette; Alexander Bertelsen; Roger Bumgarner

J Bone Joint Surg Am, 2013 Dec 04;95(23)

Abstract

Background: 

To explore the origin of Propionibacterium in surgical wounds and to suggest an optimized strategy for culturing this organism at the time of revision surgery, we studied the presence of this organism on the skin and in the surgical wounds of patients who underwent revision arthroplasty for reasons other than apparent infection.

Methods: 

Specimens were cultured in broth and on aerobic and anaerobic media. The presence and degree of positivity of Propionibacterium cultures were correlated with sex. The results of dermal and deep cultures were correlated. Times to positivity and the yields of each media type and specimen source were investigated.

Results: 

Propionibacterium grew in twenty-three of thirty cultures of specimens obtained preoperatively from the unprepared epidermis over the area where a skin incision was going to be made for a shoulder arthroplasty; males had a greater average degree of positivity than females (p < 0.002). Twelve of twenty-one male subjects and zero of twenty female subjects who had cultures of dermal specimens obtained during revision shoulder arthroplasty had positive findings for Propionibacterium (p = 0.0001). Twelve of twenty male subjects and only one of twenty female subjects had positive deep cultures (p = 0.0004). The positivity of dermal cultures for Propionibacterium was significantly associated with the positivity of deep cultures for this organism (p = 0.0001). If Propionibacterium was present in deep tissues, it was likely that it would be recovered by culture if four different specimens were obtained and cultured for a minimum of seventeen days on three different media: aerobic, anaerobic, and broth.

Conclusions: 

Because the surgical incision of dermal sebaceous glands may be a source of Propionibacterium in deep wounds, strategies for minimizing the risk of Propionibacterium infections may need to be directed at minimizing the contamination of surgical wounds from these bacteria residing in rather than on the skin. Obtaining at least four specimens, observing them for seventeen days, and using three types of culture media optimize the recovery of Propionibacterium at the time of revision surgery.

Topics

propionibacterium ; wounds and injuries ; evidence-based practice ; epidermis ; shoulder region