Carlo Gamba

Preoperative antibiotic prophylaxis in prosthetic joint infections: not a concern for intraoperative cultures

BACKGROUND Culture negative prosthetic joint infections (PJI) still remain an issue even with the advantages of the new diagnostic tools for PJI. This is why some orthopedic surgeons have reservations relative to the use of preoperative antibiotic prophylaxis when a PJI is suspected. The purpose of the present study was to evaluate the influence of preoperative antibiotic prophylaxis on intraoperative cultures. MATERIAL AND METHODS An enhanced diagnostic protocol for PJI (Zimmerli criteria) was used for the inclusion criteria in order to collect all PJI that were seen in a university hospital. Patients were prospectively randomized into two groups. The control group received the classical preoperative antibiotic prophylaxis. The study group did not receive prophylaxis prior to surgery. RESULTS There were 14 patients in each group. They correspond to 13 total hip arthroplasty infections, 12 total knee arthroplasty infections and 3 reverse shoulder prosthesis infections. There were 10 patients in the study group and 10 patients in the control group with at least one positive microbiological criterion (P > 0.05). There were 4 patients in each group with a culture negative PJI (P > 0.05). CONCLUSIONS Preoperative antibiotic prophylaxis does not affect intraoperative cultures in suspected or confirmed PJI. Therefore it is essential to deliver antibiotic prophylaxis in any patient in which a prosthesis is to be implanted in order to protect the prosthesis from infection.

Reverse shoulder arthroplasty for the treatment of acute complex proximal humeral fractures: Influence of greater tuberosity healing on the functional outcomes:

Purpose: To investigate the influence of greater tuberosity healing on the functional outcomes of reverse shoulder arthroplasty (RSA) for the treatment of acute complex proximal humeral fractures (PHFs), and to investigate the influence of patient- and surgery-related factors in the healing of the greater tuberosity. Methods: Retrospective study including 41 consecutive PHFs treated using RSA with minimum 2-year follow-up. In all the cases, tuberosities were reattached with a standardized technique. All the patients were assessed at the last follow-up with constant score. Body mass index, surgery delay, comorbidities, polyethylene size, glenosphere size, overhanging of glenosphere, and scapular notch were recorded, and their influence in final constant score and in greater tuberosity healing was analyzed. Results: Mean final constant score was of 60.7 points (standard deviation (SD) = 9.9). Greater tuberosity healed in proper position in 68% of the cases. There were no significant differences in constant score between patients with (mean = 61; SD = 9.5) and without (mean = 61; SD = 11.3) the healing of greater tuberosity. All patients scored above 90° in forward elevation. Scapular notch was reported in 14.6% of the cases. Age significantly affected the constant score (p = 0.008). Comorbidities significantly interfered with greater tuberosity healing (p = 0.03). There was one reoperation after dislocation. Conclusion: In spite of expecting good functional outcome with low complication rate after RSA for acute PHFs, the influence of greater tuberosity healing on shoulder function could not be demonstrated. The presence of comorbidities, but not age or gender, negatively influenced the healing of the greater tuberosity.

In regard to the letter by Li and Yang on the article “Which immobilization is better for distal radius fracture? A prospective randomized trial”

Dear Editor, Recently, some doubts relative to the methodological aspects of the article BWhich immobilization is better for distal radius fracture? A prospective randomized trial^ have been expressed [1, 2]. In a letter to the Editor, Li and Yang cast doubt on the way in which immobilization was changed from the aboveelbow to the below-elbow cast at the third week, at which time a radiological follow-up was carried out. Due to the importance and incidence of such fractures (distal radius fractures—DRF), it is very important to explain every aspect of this trial and provide all the necessary information to understand the conclusions drawn at the end of the research better. As stated by Li, the clinical and radiological follow-ups were made at weeks one, three, and six. Every visit consisted of first carrying out proper radiological explorations and then checking the clinical situation of the patient. The subjects included in the above-elbow group (B group) had their radiological control first. As was done with all the patients and during the clinical visit, their cast was just cut with a saw and converted in a below-elbow type. Therefore, we think that this could not have interfered with loss of reduction because the cast was not removed and fracture was not manipulated. Moreover, the fact that the most important loss of reduction occurred during first three weeks supports the idea of not needing further elbow immobilization after that time. We appreciate the thought given to those issues in this article and hope this letter can help to clarify the results reported with the end of having more data when treating DRF.

Relationship of Plantar Fascia Thickness and Preoperative Pain, Function, and Quality of Life in Recalcitrant Plantar Fasciitis:

Background: The measurement of plantar fascia thickness has been advocated as a diagnostic and prognostic instrument in patients with plantar fasciitis, but there are no data relative to it in recalcitrant plantar fasciitis. The aim of the study is to evaluate the correlation between plantar fascia thickness and pain, functional score, and health perception in patients with this condition. Methods: Thirty-eight feet were studied with ultrasound and magnetic resonance imaging to measure plantar fascia thickness. The visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society Hindfoot Score (AOFAS), and SF-36 were then recorded for each patient. The relationship between the fascia and these scores was analyzed to evaluate the correlation of thickness with pain, functional level, and health perception of patients. Results: In patients with recalcitrant plantar fasciitis, plantar fascia thickness did not correlate with pain (VAS), AOFAS, or any item of the SF-36. Conclusion: The thickness of the plantar fascia in patients with recalcitrant plantar fasciitis did not correlate with its clinical impact, and thus, we believe it should not be used in treatment planning. Level of Evidence: Level IV, case series.

Corticosteroid Injection for the Treatment of Morton’s Neuroma: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial

Background: The effectiveness of corticosteroid injection for the treatment of Morton’s neuroma is unclear. In addition, most of the studies related to it are case-control or retrospective case series. The purpose of this study was to compare the effectiveness between corticosteroid injection associated with local anesthetic and local anesthetic alone (placebo control group) for the treatment of Morton’s neuroma. Methods: Forty-one patients with a diagnosis of Morton’s neuroma were randomized to receive 3 injections of either a corticosteroid plus a local anesthetic or a local anesthetic alone. The patients and the researcher who collected data were blinded to the treatment groups. The visual analog scale for pain and the American Orthopaedic Foot & Ankle Score (metatarsophalangeal/interphalangeal score) were obtained at baseline, after each injection, and at 3 and 6 months after the last injection. Results: There were no significant between-group differences in terms of pain and function improvement at 3 and 6 months after treatment completion in comparison with baseline values. At the end of the study, 17 (48.5%) patients requested surgical excision of the neuroma: 7 (44%) in the experimental group and 10 (53%) in the control group (P = 1.0). Conclusion: The injection of a corticosteroid plus a local anesthetic was not superior to a local anesthetic alone in terms of pain and function improvement in patients with Morton’s neuroma. Level of Evidence: Level I, randomized controlled trial.