What Factors Influence the Success of Medial Gastrocnemius Flaps in the Treatment of Infected TKAs?

BACKGROUND: Soft tissue defects after TKA are a potentially devastating complication. Medial gastrocnemius flaps occasionally are used to provide soft tissue coverage, most commonly with a periprosthetic joint infection. QUESTIONS/PURPOSES: We asked: (1) What were the rates of persistent or recurrent infection, implant survivorship, flap-related complications, and reoperation for patients who underwent medial gastrocnemius flap reconstruction for soft tissue coverage after TKA? (2) What were the Knee Society clinical and functional scores for patients who underwent medial gastrocnemius flap reconstruction for soft tissue defects after TKA? (3) What were the risk factors for failure of medial gastrocnemius flap reconstruction after TKA, with failure defined as recurrent or new periprosthetic joint infection or inability to reimplant the TKA prosthesis? METHODS: Between 2003 and 2011, four surgeons at one institution performed 31 medial gastrocnemius flaps for soft tissue coverage over an infected TKA. Of those, 27 (87%) were available for followup at a minimum of 2 years (mean, 4 years; range, 2-6 years), although patients experiencing complications or treatment failures before two years were included. The study group consisted of 15 men and 12 women with a mean age of 61 years at the time of surgery (range, 36-86 years). The general indication for using a gastrocnemius flap in this setting was full-thickness soft tissue deficiency over the anterior knee during the course of treatment for concomitant deep infection. Six flaps were performed at prosthetic explantation and antibiotic spacer placement, eight at a spacer exchange, eight at second-stage TKA prosthesis reimplantation, and five at débridement with polyethylene exchange. The decision regarding when during staged treatment to place the flap was based solely on when the soft tissues were deemed insufficient, and not based on a belief that placement at one stage versus another was advantageous. Failure was defined as inability to undergo reimplantation of a TKA prosthesis or recurrence of periprosthetic joint infection. Patient and procedural characteristics were tested for association with failure. Survivorship was calculated by Cox proportional hazards modeling. Outcomes scores were drawn from a longitudinal institutional registry. RESULTS: Fourteen of 27 (52%) patients had a persistent or recurrent infection; survivorship of the TKA prosthesis at 4 years was 48% (95% CI, 31%-66%). Although there were no flap-related complications, 12 patients had a total of 19 reoperations during the study period. Overall, the mean (± SD) Knee Society knee (38 ± 18 vs 65 ± 20; p < 0.001) and function (20 ± 22 vs 37 ± 25; p = 0.002) scores were improved at most recent followup. No factors were identified as associated with failure when a Bonferroni correction was applied. CONCLUSIONS: Gastrocnemius flaps were used to address difficult soft tissue defects in this series, in the presence of deep infections; the high proportion of patients experiencing persistent or recurrent infections reflects the case complexity and not necessarily a problem with the flaps. However, this series highlights the need to continue to explore alternative approaches to managing this difficult clinical problem. Future studies should aim to establish an evidence-based reconstructive algorithm, focusing on host, wound, and timing characteristics that may maximize outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Acute infection with Propionibacterium acnes after a Latarjet coracoid transfer procedure: a case report.

Coracoid transfer procedures are highly effective at improving glenohumeral stability in patients with recurrent shoulder instability; complication rates from this procedure are generally low. We present the first case in the literature of a Propionibacterium acnes (P. acnes) infection following a coracoid transfer. The case stresses the importance of proper antibiotic prophylaxis for patients undergoing Latarjet procedures, as well as the workup for a painful postoperative shoulder, and the need to maintain cultures from the shoulder for up to 21 days to isolate P. acnes.

Local and regional flaps for hand coverage.

Hand surgeons are frequently challenged by the unique requirements of soft tissue coverage of the hand. Whereas many smaller soft tissue defects without involvement of deep structures are amenable to healing by secondary intention or skin grafting, larger lesions and those with exposed tendon, bone, or joint often require vascularized coverage that allows rapid healing without wound contraction. The purpose of this review was to present an overview of local and regional flaps commonly used for soft tissue reconstruction within the hand.

Fracture of a dual-modular femoral component at the stem-sleeve junction in a metal-on-metal total hip arthroplasty.

Innovations in the design of dual-modular femoral components have afforded surgeons several intraoperative advantages during both primary and revision total hip arthroplasty (THA). Although use of these implants has become more popular, the long-term outcomes and potential complications of introducing a second modular junction are still to be determined. In addition, concerns about corrosion potentiation at modular junctions in metal-on-metal (MOM) THA have arisen in recent studies. In this article, we present a unique case of fracture at the modular junction of the stem and modular sleeve of a dual-modular femoral component implanted with a MOM articulation. The proposed mechanisms of failure, including crevice and fretting corrosion as well as the potential effect of metal debris generated by MOM articulations, are reviewed. This case report is the first to describe component fracture at the stem-sleeve junction of this modern-generation dual-modular femoral component. Surgeons who encounter a painful dual-modular femoral stem must entertain this mode of failure and consider junctional failure as a potential diagnosis for such a patient, particularly in the setting of a MOM articulation.

Surgical Management of Symptomatic Olecranon Traction Spurs.

BACKGROUND: There is a paucity of information pertaining to the pathoanatomy and treatment of symptomatic olecranon traction spurs. PURPOSE: To describe the pathoanatomy of olecranon traction spur formation, a technique for spur resection, and a series of patients who failed conservative care and underwent operative treatment. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eleven patients (12 elbows) with a mean age of 42 years (range, 27-62 years) underwent excision of a painful olecranon traction spur after failing conservative care. Charts and imaging studies were reviewed. All patients returned for evaluation and new elbow radiographs at an average of 34 months (range, 10-78 months). Outcome measures included the Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire; the Mayo Elbow Performance Score (MEPS); visual analog scales (VAS) for pain and patient satisfaction; elbow motion; elbow strength; and elbow stability. RESULTS: The traction spur was found in the superficial fibers of the distal triceps tendon in all cases. The mean QuickDASH score was 3 (range, 0-23), the mean MEPS score was 96 (range, 80-100), the mean VAS pain score was 0.8 (range, 0-3), and the mean VAS satisfaction score was 9.6 (range, 7-10). Average elbow motion measured 3° to 138° (preoperative average, 5°-139°). All patients exhibited normal elbow flexion and extension strength, and all elbows were deemed stable. Early postoperative complications involved a wound seroma in 1 case and olecranon bursitis in 1 case: both problems resolved without additional surgery. Two patients eventually developed a recurrent traction spur, 1 of whom underwent successful repeat spur excision 48 months after the index operation. CONCLUSION: Short- to mid-term patient and examiner-determined outcomes after olecranon traction spur resection were acceptable in our experience. Early postoperative complications and recurrent enthesophyte formation were uncommon. CLINICAL RELEVANCE: This study provides the treating physician with an improved understanding of the pathoanatomy of olecranon traction spur formation, a technique for spur resection, and information to review with patients regarding the outcome of surgical management.

Medial unicompartmental knee arthroplasty in patients less than 55 years old: minimum of two years of follow-up.

Eighty-five fixed bearing medial unicompartmental arthroplasties were performed in 42 men and 33 women with a mean age of 49 years (range, thirty-three to fifty-five years old) at the time of surgery. At a mean of 4.0 years (range two to twelve years), the mean pre-operative Knee Society score improved from 49 to 95.1 points (P<0.0001) and the mean UCLA activity score was 7.5 (range 5 to 9). Three knees underwent revision to a total knee arthroplasty; two for arthritic progression in the lateral compartment and one for pain. At the time of final follow-up, two knees (2.4%) demonstrated progressive Grade 4 arthritis of the patellofemoral compartment but were asymptomatic. There was no radiographic evidence of loosening, osteolysis, or premature polyethylene wear. Estimated survivorship was 96.5% at 10 years. UKA offered excellent early outcomes in this cohort of younger, active patients.

Primary and posttraumatic arthritis of the elbow.

Whether degenerative joint disease of the elbow may be the result of primary or posttraumatic etiologies, arthritis of the elbow commonly leads to pain, loss of motion, and functional disability. A detailed history and focused physical examination, in combination with imaging modalities, can help localize the origin of symptoms and help direct treatment. Although nonoperative treatment is the initial therapy for arthritis of the elbow, surgical interventions may provide substantial relief to the appropriately selected patient.

Radioscapholunate arthrodesis with compression screws and local autograft.

Radioscapholunate arthrodesis is performed for patients who experience pain and disability from radiocarpal arthritis. Initial reports from the 1980s demonstrated high nonunion rates and marginal clinical outcomes. Improvements in surgical technique and clearly defined indications have reduced nonunion rates and improved patient satisfaction. We present a technique using headless compression screws inserted through a dorsal approach, which optimizes hardware placement and incorporates local bone graft harvested from the insertion site to supplement the arthrodesis.

Case report: Failure of rotating-hinge total knee prosthesis by disengagement of the hinge-post extension.

BACKGROUND: Although modern-generation rotating-hinge knee implants have been modified to mitigate earlier complications related to aseptic loosening with these devices in revision TKAs, there are few, if any, reports of failure related to the hinge mechanism in these prostheses. CASE DESCRIPTION: We present a case of disengagement of the hinge-post extension in a contemporary rotating-hinge knee prosthesis originally implanted during revision surgery for instability and extensor mechanism insufficiency. We hypothesize the screw home kinematics of the knee resulted in a counterclockwise torque, contributing to the hinge post locking screw disengagement in this case. LITERATURE REVIEW: Although some authors have reported complications and failures related to aseptic loosening with rotating-hinge knee prostheses, there have been no reports regarding complications related to the hinge mechanism, which simultaneously links and permits rotation between the femoral and tibial components. CLINICAL RELEVANCE: Arthroplasty surgeons who use rotating-hinge knee prostheses need to be aware of this potential mode of failure. Design modifications, including more secure locking mechanisms and side-specific implants, may avoid this complication.

The efficacies of 2 ceramic bone graft extenders for promoting spinal fusion in a rabbit bone paucity model.

STUDY DESIGN: Prospective, randomized, controlled animal study. OBJECTIVE: To determine the efficacies of 2 ceramic composite bone graft extenders for promoting spinal fusion. SUMMARY OF BACKGROUND DATA: Although autogenous bone is still considered the "gold standard" graft material for fusion procedures, its use is associated with a number of limitations. Synthetic ceramic composites represent a class of osteoconductive materials that may be employed as supplements or even alternatives to autograft. In this study, we compared the fusion rates generated by 2 ceramic composite bone graft extenders (MasterGraft and Mozaik Strips) with that obtained with autograft in a rabbit bone paucity model. METHODS: Thirty-two New Zealand white rabbits undergoing noninstrumented posterolateral lumbar fusion were randomized to 1 of the following 4 groups: 100% autograft, 50% autograft, 50% autograft with Mozaik Strip, and 50% autograft with MasterGraft Strip. The rabbits were followed postoperatively for 8 weeks at which time the spinal segments were explanted and assessed for the presence of a solid fusion. RESULTS: The arthrodesis rates by manual palpation of the 100% and 50% autograft controls were 75% (6 of 8 animals) and 12.5% (1 of 8), respectively (P < 0.01). In the 50% autograft/Mozaik and 50% autograft/MasterGraft groups, 3/8 and 1/8 of the rabbits were determined to have fused successfully, respectively (P = 0.569). However, there were no significant differences between the fusion rate of the 50% autograft cohort and those exhibited by the Mozaik or MasterGraft animals (P = 0.569 and 1.00, respectively). CONCLUSION: This study provides further evidence that the quantity of autograft may influence the process of spinal fusion such that the arthrodesis rate was significantly lower when less bone was implanted. Neither of the ceramic composite scaffolds seemed to enhance the fusion response compared to an equivalent amount of autograft alone, suggesting that these substances may need to be combined with other osteogenic materials to optimize bone production.

The incidence of noncontiguous spinal fractures and other traumatic injuries associated with cervical spine fractures: a 10-year experience at an academic medical center.

STUDY DESIGN: Retrospective medical record review. OBJECTIVE: The purpose of this study was to describe the incidence of other injuries that commonly occur in conjunction with cervical spine fractures and dislocations. SUMMARY OF BACKGROUND DATA: Cervical spine fractures are often associated with other significant traumatic conditions, which may also require prompt diagnosis and management. However, the relative incidences of the injuries that occur in conjunction with various cervical spine fractures have not been well documented. METHODS: The radiographic reports of all patients who underwent CT scans of the cervical spine at a single level 1 trauma center over a 10-year period were reviewed. The medical records of individuals with acute, nonpenetrating fractures of the cervical spine were further assessed for any associated traumatic pathology including noncontiguous spine injuries and those affecting other organ systems (i.e., head and neck, intrathoracic, intra-abdominal/pelvic, and nonspinal orthopedic disorders). RESULTS: A total of 13,896 CT scans of the cervical spine were performed during this 10-year period of which 492 revealed acute fractures and/or dislocations. Of these subjects, 60% had sustained at least one additional injury. Overall, 57% were noted to have extraspinal injuries (34% head and neck, 17% intrathoracic, 10% intra-abdominal/pelvic, and 30% nonspinal orthopedic conditions) and noncontiguous spinal trauma was present in 19% of these cases (8% cervical injuries, 8% thoracic, and 6% lumbar). In general, the rates of associated injuries observed with occipital condyle and C7 fractures were significantly higher than those recorded for other cervical segments. CONCLUSION: For patients with a known history of cervical spine trauma, the frequencies of associated injuries were similar across all levels of the cervical spine with the exception of the injuries to the craniocervical junctions. In practice, this means that injuries to the cervical spine can likely be grouped together when considering other possible associated injuries. Further elucidation of these injury patterns will likely be useful for facilitating the expedient evaluation and proper management of these individuals.

Postoperative infections of the spine.

The incidence of postoperative infections after spinal surgery ranges from less than 1% to 15%. This rate can vary based on several surgical- and patient-related risk factors, such as the type and duration of the procedure, nutritional status, immunosuppression, and comorbidities of the patient. Most surgeons routinely administer intravenous antibiotics prophylactically, and may employ other measures in an effort to prevent postoperative infection. Multiple diagnostic modalities, in conjunction with examination findings, should be utilized in the assessment of possible postoperative spinal infections. In particular, wound discharge or erythema, and an elevation in the erythrocyte sedimentation rate and C-reactive protein beyond expected postoperative values should raise a clinician's level of suspicion for an infection. The diagnosis of a postoperative spine infection can be difficult to confirm with diagnostic imaging, given findings are not all that different from normal postoperative changes. When suspected, the preferred treatment for a postoperative spinal infection is open irrigation and aggressive debridement of all necrotic tissue and bone, followed by antibiotic treatment based on culture sensitivity.

Normal functional range of motion of the cervical spine during 15 activities of daily living.

STUDY DESIGN: Prospective clinical study. OBJECTIVE: The purpose of this investigation was to quantify normal cervical range of motion (ROM) and compare these results to those used to perform 15 simulated activities of daily living (ADLs) in asymptomatic subjects. SUMMARY OF BACKGROUND DATA: Previous studies looking at cervical ROM during ADLs have been limited and used measuring devices that do not record continuous motion. The purpose of this investigation was to quantify normal cervical ROM and compare these results with those used to perform 15 simulated ADLs in asymptomatic subjects. METHODS: A noninvasive electrogoniometer and torsiometer were used to measure the ROM of the cervical spine. The accuracy and reliability of the devices were confirmed by comparing the ROM values acquired from dynamic flexion/extension and lateral bending radiographs to those provided by the device, which was activated while the radiographs were obtained. Intraobserver reliability was established by calculating the intraclass correlation coefficient for repeated measurements on the same subjects by 1 investigator on consecutive days. These tools were employed in a clinical laboratory setting to evaluate the full active ROM of the cervical spines (ie, flexion/extension, lateral bending, and axial rotation) of 60 asymptomatic subjects (30 females and 30 males; age, 20 to 75 y) as well as to assess the functional ROM required to complete 15 simulated ADLs. RESULTS: When compared with radiographic measurements, the electrogoniometer was found to be accurate within 2.3+/-2.2 degrees (mean+/-SD) and the intraobserver reliabilities for measuring the full active and functional ROM were both excellent (intraclass correlation coefficient of 0.96 and 0.92, respectively). The absolute ROM and percentage of full active cervical spinal ROM used during the 15 ADLs was 13 to 32 degrees and 15% to 32% (median, 20 degrees/19%) for flexion/extension, 9 to 21 degrees and 11% to 27% (14 degrees/18%) for lateral bending, and 13 to 57 degrees and 12% to 92% (18 degrees/19%) for rotation. Backing up a car required the most ROM of all the ADLs, involving 32% of sagittal, 26% of lateral, and 92% of rotational motion. In general, personal hygiene ADLs such as washing hands and hair, shaving, and applying make-up entailed a significantly greater ROM relative to locomotive ADLs including walking and traveling up and down a set of stairs (P<0.0001); in addition, compared with climbing up these steps, significantly more sagittal and rotational motion was used when descending stairs (P=0.003 and P=0.016, respectively). When picking up an object from the ground, a squatting technique required a lower percentage of lateral and rotational ROM than bending at the waist (P=0.002 and P<0.0001). CONCLUSIONS: By quantifying the amounts of cervical motion required to execute a series of simulated ADLs, this study indicates that most individuals use a relatively small percentage of their full active ROM when performing such activities. These findings provide baseline data which may allow clinicians to accurately assess preoperative impairment and postsurgical outcomes.

Normal functional range of motion of the lumbar spine during 15 activities of daily living.

STUDY DESIGN: Prospective clinical study. OBJECTIVE: The purpose of this investigation was to quantify normal lumbar range of motion (ROM) and compare these results with those used to perform 15 simulated activities of daily living (ADLs) in asymptomatic subjects. SUMMARY OF BACKGROUND DATA: Previous studies reporting the ROM of the lumbar spine during ADLs have been limited, only focusing on 4 ADLs. The purpose of this investigation was to quantify the extent of normal lumbar ROM and determine how much motion is necessary to perform 15 simulated ADLs. METHODS: A noninvasive electrogoniometer and torsiometer were used to measure the ROM of the lumbar spine. The accuracy and reliability of the devices were confirmed by comparing the ROM values acquired from dynamic flexion/extension and lateral bending radiographs with those provided by the device that was activated while the radiographs were obtained. Intraobserver reliability was established by calculating the intraclass correlation coefficient for repeated measurements on the same subjects by 1 investigator on consecutive days. These tools were employed in a clinical laboratory setting to evaluate the full active ROM of the lumbar spines (ie, flexion/extension, lateral bending, and axial rotation) of 60 asymptomatic subjects (30 women and 30 men; age 20 to 75 y) and to assess the functional ROM required to complete 15 simulated ADLs. RESULTS: When compared with radiographic measurements, the electrogoniometer was found to be accurate within 2.3+/-2.6 degrees (mean+/-SD). The intraobserver reliabilities for assessing full and functional ROM were both excellent (intraclass correlation coefficient of 0.96 and 0.88, respectively). The absolute ROM and percentage of full active lumbar spinal ROM used during the 15 ADLs was 3 to 49 degrees and 4% to 59% (median: 9 degrees/11%) for flexion/extension, 2 to 11 degrees and 6% to 31% (6 degrees/17%) for lateral bending, and 2 to 7 degrees and 6% to 20% (5 degrees/13%) for rotation. Picking up an object from the ground, either using a bending or squatting technique, required the most ROM of all the ADLs. Squatting required a significantly less amount of sagittal motion compared with bending at the waist (42 vs. 48 degrees, P=0.003). No difference was seen in both lateral and rotation motion between these 2 techniques (11 vs. 11 degrees and 6 vs. 6 degrees, respectively). Both ascending and descending stairs required equivalent amounts of total motion in all 3 motion planes. As a whole, personal hygiene ADLs (hand washing, washing hair, shaving, and make-up application) required a similar amount of motion compared with the 3 locomotive ADLs (walking, up and down stairs). CONCLUSIONS: By quantifying the amounts of lumbar motion required to execute a series of simulated ADLs, this study indicates that most individuals use a relatively small percentage of their full active ROM when performing such activities. These findings provide baseline data that may allow clinicians to accurately assess preoperative impairment and postsurgical outcomes.

Augmented demineralized bone matrix: a potential alternative for posterolateral lumbar spinal fusion.

Variable osteoinductive potential has been reported between and within production lots of different demineralized bone matrix (DBM) products. This study compared fusion rates of different manufactured lots and augmented formulations of DBM with a dose-response curve of recombinant human bone morphogenetic protein 2 (rhBMP-2) on inactivated DBM carrier in a posterolateral fusion rat model. Lumbar fusions were performed in 145 rats. In the control rats, we implanted autograft, graft alternative, including inactivated DBM, or nothing (ie, no graft). In the study rats, we implanted 1 of 2 BioSETR (RTI Biologics, Alachua, Florida) DBM lots, growth factor-enriched DBM, and inactivated DBM plus rhBMP-2 in different concentrations. Manual palpation revealed fusion rates of 25% (autograft), 0% (inactivated DBM), 17% (DBM donor A), and 36% (DBM donor B). The fusion rate of the most enhanced donor B graft (83%) was higher (P<.05) than that of autograft or unenhanced DBM. Inactivated DBM plus rhBMP-2 fused between 45% and 100%. There was no significant difference between DBM plus rhBPM-2 and the highest enrichment group of donor B. Differences between 2 DBM lots in an athymic rat ectopic bone formation model also were found in the spine fusion model. Enhanced DBM formulations were comparable with inactivated DBM plus rhBMP-2 with respect to performance and could represent a bone graft alternative in spine fusion.

Radiation exposure from musculoskeletal computerized tomographic scans.

BACKGROUND: Computerized tomographic scans are routinely obtained to evaluate a number of musculoskeletal conditions. However, since computerized tomographic scans expose patients to the greatest amounts of radiation of all imaging modalities, the physician must be cognizant of the effective doses of radiation that are administered. This investigation was performed to quantify the effective doses of computerized tomographic scans that are performed for various musculoskeletal applications. METHODS: The digital imaging archive of a single institution was retrospectively reviewed to identify helical computerized tomographic scans that were completed to visualize the extremities or spine. Imaging parameters were recorded for each examination, and dosimetry calculator software was used to calculate the effective dose values according to a modified protocol derived from publication SR250 of the National Radiological Protection Board of the United Kingdom. Computerized tomographic scans of the chest, abdomen, and pelvis were also collected, and the effective doses were compared with those reported by prior groups in order to validate the results of the current study. RESULTS: The mean effective doses for computerized tomographic scans of the chest, abdomen, and pelvis (5.27, 4.95, and 4.85 mSv, respectively) were consistent with those of previous investigations. The highest mean effective doses were recorded for studies evaluating the spine (4.36, 17.99, and 19.15 mSv for the cervical, thoracic, and lumbar spines, respectively). In the upper extremity, the effective dose of a computerized tomographic scan of the shoulder (2.06 mSv) was higher than those of the elbow (0.14 mSv) and wrist (0.03 mSv). Similarly, the effective dose of a hip scan (3.09 mSv) was significantly higher than those observed with knee (0.16 mSv) and ankle (0.07 mSv) scans. CONCLUSIONS: Computerized tomographic scans of the axial and appendicular skeleton are associated with substantially elevated radiation exposures, but the effective dose declines substantially for anatomic structures that are further away from the torso.

Survey of spine surgeons on attitudes regarding osteoporosis and osteomalacia screening and treatment for fractures, fusion surgery, and pseudoarthrosis.

BACKGROUND CONTEXT: Osteoporosis and osteomalacia are significant risk factors for fracture and spine instrumentation failure. Low-energy fractures are becoming increasingly more common because of an increase in life expectancy and age of the population. Decreased bone density is an independent risk factor for instrumentation failure in spinal fusion operations. PURPOSE: To assess the awareness and practice patterns of spine surgeons regarding metabolic bone disorders and osteoporosis with emphasis on fracture care and arthrodesis. STUDY DESIGN/SETTING: Questionnaire study. PATIENT SAMPLE: Spine surgeons attending the "Disorders of the Spine" conference (January 2007, Whistler, British Columbia, Canada). OUTCOME MEASURES: Respondent reported frequencies of diagnostics, screening, and treatment methods for patients with low-energy spine fractures, pseudoarthrosis, and those undergoing spinal arthrodesis. METHODS: A ten-question survey was administered to orthopedic surgeons and neurosurgeons who treated spine fractures and degenerative spine conditions in their practice. The survey was given to those who were attending a continuing medical education spinal disorders conference. The survey asked about treatment patterns with respect to osteoporosis and osteomalacia workup and treatment for patients with low-energy spine fractures, pseudoarthrosis, and those undergoing spinal arthrodesis. RESULTS: Of the 133 surgeons to whom the questionnaire was distributed at this meeting, 114 questionnaires were returned that corresponds to a response rate of 86%. Twenty-one surveys were excluded because of incomplete biographical information, resulting in a total of 93 completed questionnaires that were available for analysis. When treating patients with low-energy spine fractures, 60% checked dual-energy X-ray absorptiometry (DEXA) and 39% checked metabolic laboratories (of those who did not order laboratories and DEXA about 63% refer for treatment). Before instrumented fusion, 44% of those queried checked DEXA and 12% checked metabolic laboratories (vitamin D, parathyroid hormone [PTH], and calcium [Ca]). Before noninstrumented fusion, 22% checked DEXA and 11% checked metabolic laboratories. Before addressing pseudoarthrosis, 19% checked DEXA and 20% checked metabolic laboratories. CONCLUSIONS: Despite of the large number of elderly patients undergoing spine care and the high incidence of osteoporosis and/or osteomalacia in this population, a large portion of the spine surgeons who responded to the survey reported that they do not perform routine osteoporosis/osteomalacia workups. Of those who do perform workups, some commented that it will change their surgical plan or preoperative treatment. It appears that there is a need for increased awareness among spine specialists regarding osteoporosis screening and treatment. Osteoporosis practice patterns may also be affected with newly evolving government quality reporting regulations.

Actual knee motion during continuous passive motion protocols is less than expected.

Investigations of the usefulness of continuous passive motion (CPM) after TKA have yielded mixed results, with evidence suggesting its efficacy is contingent on the presence of larger motion arcs. Surprisingly, the range of motion (ROM) the knee actually experiences while in a CPM machine has not been elucidated. In this study, the ability of a CPM apparatus to bring about a desired knee ROM was assessed with an electrogoniometer. The knee experienced only 68% to 76% of the programmed CPM arc, with the higher percentages generated by elevating the head of the patient's bed. This disparity between true knee motion and CPM should be accounted for when designing CPM protocols for patients or investigations evaluating efficacy of CPM.

Postoperative bracing after spine surgery for degenerative conditions: a questionnaire study.

BACKGROUND CONTEXT: A variety of orthoses are routinely applied after spinal procedures but there are limited data regarding their efficacy, especially with the increasing use of internal fixation. At this time, the proper indications for postoperative bracing are not well established. PURPOSE: To assess the postoperative bracing patterns of spine surgeons. STUDY DESIGN/SETTING: Questionnaire study. PATIENT SAMPLE: Spine surgeons attending the "Disorders of the Spine" conference (January 2008, Whistler, Canada). OUTCOME MEASURES: Frequencies of bracing after specific surgical procedures. METHODS: A single-page questionnaire was distributed to all spine surgeons attending the "Disorders of the Spine" conference (January 2008). The questionnaire focused on whether surgeons typically immobilize patients after specific spinal procedures, the type of orthosis used, the duration of treatment, and the rationale for bracing. RESULTS: Ninety-eight of 118 surgeons completed the survey (response rate: 83%). The frequency of bracing was similar between academic and private as well as orthopedic and neurosurgical practices. The difference in the bracing tendencies of fellowship and non-fellowship trained surgeons was found to be statistically significant (61% vs. 46%, p<.0001). The duration of clinical experience did not appear to influence the propensity of surgeons to use orthoses. Bracing was employed more regularly after cervical spine procedures than surgeries involving the lumbar spine (63% vs. 49%, p<.0001). In the anterior cervical spine, orthoses were used more often as the complexity of the procedure increased from single to multilevel constructs (55% vs. 76%, p<.0001). The frequencies of bracing were not significantly different between noninstrumented and instrumented lumbar fusions. In most cases, bracing was continued for a total of 3-8 weeks and the restriction of patient activity was the most common reason cited by surgeons who use orthoses. CONCLUSIONS: Although most of the respondents brace their patients postoperatively, there is an obvious lack of consensus regarding the most appropriate type, duration, and indications for immobilization. Further prospective, clinical studies may play a helpful role in evaluating the efficacy of postoperative bracing protocols.

Which regions of the operating gown should be considered most sterile?

Various guidelines have been proposed regarding which portions of a surgical gown may be considered sterile. Unfortunately, the validity of these recommendations has not been definitively established. We therefore evaluated gown sterility after major spinal surgery to assess the legitimacy of these guidelines. We used sterile culture swabs to obtain samples of gown fronts at 6-inch increments and at the elbow creases of 50 gowns at the end of 29 spinal operations. Another 50 gowns were swabbed immediately after they were applied to serve as negative controls. Bacterial growth was assessed using semiquantitative plating techniques on a nonselective, broad-spectrum media. Contamination was observed at all locations of the gown with rates ranging from 6% to 48%. Compared with the negative controls, the contamination rates were greater at levels 24 inches or less and 48 inches or more relative to the ground and at the elbow creases. The section between the chest and operative field had the lowest contamination rates. Based on these results, we consider the region between the chest and operative field to be the most sterile and any contact with the gown outside this area, including the elbow creases, should be avoided to reduce the risk of infection.