Eric B. Smith

Reliability of a novel classification system for thoracolumbar injuries: the Thoracolumbar Injury Severity Score.

Study Design. Prospective study of 5 spine surgeons rating 71 clinical cases of thoracolumbar spinal injuries using the Thoracolumbar Injury Severity Score (TLISS) and then re-rating the cases in a different order 1 month later. Objective. To determine the reliability of the TLISS system. Summary of Background Data. The TLISS is a recently introduced classification system for thoracolumbar spinal column injures designed to simplify injury classification and facilitate treatment decision making. Before being widely adopted, the reliability of the TLISS must be studied. Methods. A total of 71 cases of thoracolumbar spinal trauma were distributed on CD-ROM to 5 attending spine surgeons, including clinical/radiographic data, details of the TLISS, and a scoring sheet in which cases would be scored using the system. The surgeons were later assigned the task with the cases reordered. Intraobserver and interobserver reliability was calculated for TLISS components, total score, and surgeons treatment decision using the Cohen unweighted kappa coefficients and Spearman rank-order correlation. Results. Interrater reliability assessed by generalized kappa coefficients was 0.33 ± 0.03 for injury mechanism, 0.91 ± 0.02 for neurologic status, 0.35 ± 0.03 for posterior ligamentous complex status, 0.29 ± 0.02 for TLISS total, and 0.52 ± 0.03 for treatment recommendation. Respective results using the Spearman correlation were 0.35 ± 0.04, 0.94 ± 0.01, 0.48 ± 0.04, 0.65 ± 0.03, and 0.51 ± 0.04. Surgeons agreed with the TLISS recommendation 96.4% of the time. Intrarater kappa coefficients were 0.57 ± 0.04 for injury mechanism, 0.93 ± 0.02 for neurologic status, 0.48 ± 0.04 for posterior ligamentous complex status, 0.46 ± 0.03 for TLISS total, and 0.62 ± 0.04 for treatment recommendation. Respective results using the Spearman correlation were 0.70 ± 0.04, 0.95 ± 0.02, 0.59 ± 0.05, 0.77 ± 0.04, and 0.59 ± 0.05. Conclusions. The TLISS has good reliability and compares favorably to other contemporary thoracolumbar fracture classification systems.

The rise in the incidence of pulmonary embolus after joint arthroplasty: is modern imaging to blame?

In recent years, there has been an apparent increase in the incidence of pulmonary embolus after joint arthroplasty at our institution. We hypothesized the use of sophisticated imaging modalities such as the multidetector computed tomography scan, with better sensitivity, resulted in an apparent increase in the incidence of pulmonary embolus. We studied all patients with pulmonary embolus after joint arthroplasty between 2000 and 2005. The incidence of pulmonary embolus increased from 0.21% (six of 2859) when VQ scan was the modality of choice to 0.98% (50 of 5095) during the time spiral computed tomography was used to 1.72% (89 of 5179) in recent years when multidetector computed tomography was used. Despite the apparent increase in pulmonary embolus, we observed no change in mortality during the study period. Surgeons should be aware of the challenges sophisticated imaging modalities in general and modern imaging introduce for pulmonary embolus in particular. Extremely sensitive imaging tests with unknown specificity have resulted in an increase in diagnosed pulmonary embolus. However, diagnosing pulmonary embolus generates implications for further treatment such as prolonged anticoagulation and/or inferior vena cava filter insertion with potential for catastrophic complications. The challenge is to distinguish which require treatment and which do not.Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Aquacel surgical dressing reduces the rate of acute PJI following total joint arthroplasty: a case-control study.

An effort to prevent PJI has led to the development of antimicrobial dressings that support wound healing. We sought to determine whether Aquacel Surgical dressing independently reduces the rate of acute PJI following TJA. A single institution retrospective chart review of 903 consecutive cases who received the Aquacel Surgical dressing and 875 consecutive cases who received standard gauze dressing was conducted to determine the incidence of acute PJI (within 3 months). The incidence of acute PJI is 0.44% in the Aquacel dressing group compared to 1.7% in the standard gauze dressing group (P = 0.005). Multivariate analysis revealed that use of Aquacel dressing was an independent risk factor for reduction of PJI (odds ratio of 0.165, 95% confidence interval: 0.051-0.533). Aquacel Surgical dressing significantly reduces the incidence of acute PJI.

Is it Time to Include Vancomycin for Routine Perioperative Antibiotic Prophylaxis in Total Joint Arthroplasty Patients

In an effort to reduce methicillin-resistant Staphylococcus aureus (MRSA) and overall periprosthetic joint infections (PJI), we switched the perioperative prophylactic antibiotic during total knee arthroplasty and total hip arthroplasty from cefazolin to vancomycin in June 2008. We retrospectively reviewed the total and MRSA PJI in 5036 primary total joint arthroplasties, as well as the cure rate of PJI from January 2006 to June 2008 (Ancef Period) and June 2008 to December 2010 (Vanco Period). With vancomycin, total PJI was significantly reduced (1.0%-0.5%) and MRSA PJI (0.23%-0.07%). Periprosthetic joint infections that occurred were more successfully treated with irrigation and debridement only, not requiring spacer (76.9% vs 22.2%). The use of vancomycin as the perioperative prophylactic antibiotic for primary total joint arthroplasties appeared to be effective in decreasing the rate of PJI and may result, when they occur, in infections with less virulent organisms.

Delayed surgery for patients with femur and hip fractures-risk of deep venous thrombosis.

BACKGROUND This prospective study explores the incidence of preoperative deep venous thrombosis (DVT) in a group of patients with hip and femur fracture who for various reasons experienced a delay of >24 hours from the time of injury until time of surgery. We also evaluated the results of preoperative treatment with inferior vena cava (IVC) filter. METHODS There were 101 consecutive patients with a mean age of 75.8 years. The mean time to surgery from injury was 3.5 days. All patients were evaluated for signs and symptoms of DVT and underwent Doppler ultrasound before surgery. All patients received preoperative prophylactic anticoagulation. Those patients with DVT underwent IVC filter insertion before surgical intervention. RESULTS No patient exhibited signs or symptoms of DVT; however, preoperative ultrasound detected DVT in 10 patients. Despite negative ultrasound, two additional patients developed pulmonary embolus preoperatively for an overall incidence of thromboembolic disease of 11.9%. The average delay in surgery was 5.7 days for patients with DVT versus 3.2 days for those without (p = 0.021). The incidence increased each day from 14.5% if surgery was delayed >1 day to 33.3% if surgery was delayed >7 days. Relative risk increased from 2.32 to 3.71 over the same period. There were no postoperative thromboembolic complications or complications related to IVC filter placement in these patients. DISCUSSION In this prospective study, we observed that patients experiencing a delay in surgical care for an acute hip or femur fracture are at a relatively high risk for development of thromboembolic disease despite prophylactic anticoagulation. There was a direct correlation between the period of delay and the incidence of thromboembolism. Clinical examination in this setting is unreliable as none of these patients had signs or symptoms suggestive of DVT. We suggest that all patients with delayed (>24 hours) surgical intervention undergo preoperative Doppler ultrasound to rule out DVT. Appropriate measures such as placement of an IVC filter and aggressive postoperative anticoagulation should then be implemented for those with DVT and/or pulmonary embolus.

The Effect of Implementing a Multimodal Approach on the Rates of Periprosthetic Joint Infection After Total Joint Arthroplasty.

INTRODUCTION We examined the efficacy of implementing a multimodal program aimed at reducing the incidence of periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) in a mid-size community hospital. METHODS An infection reduction committee (IRC) was formed at our hospital in November 2010. The IRC consisted of two orthopaedic surgeons, an infectious disease specialist, an internist with extensive experience in perioperative medical management of TJA patients, an anesthesiologist, the hospital infection control nurse, and two additional nurses. Their goals were to 1) evaluate the current incidence of PJI at our institution, compare it with the reported national data, and consider measures already in place directed at preventing PJI; 2) review and routinely evaluate recently published studies or information obtained from continuing medical education events related to PJI to determine if practice changes were warranted (based on intervention efficacy, cost, and safety) and then develop a plan to implement appropriate alterations in perioperative protocols using a multimodal strategy; and 3) evaluate the effect and safety of newly-introduced infection reduction strategies on the incidence of PJI. RESULTS In 2008, the incidence of PJI at our hospital was 1.0%. By 2013, this rate had reduced to 0.4%. In absolute numbers, in 2009, 20 of 1,150 TJAs developed a PJI in the 12-month period following partial, primary, or revision TJA. In 2013, PJI occurred in only 4 of 1,053 TJA patients. CONCLUSION We found that formation of an IRC focused on evaluating and implementing strategies to reduce PJI following TJA can be effective.

Septic Sacroiliitis in a 53-year-old Adult: A Case Report

A 53‐year‐old woman with no significant medical history presented with 10/10 right buttock pain that radiated to the right groin. With no reported recent injury, the absence of fever, and no identifiable risk factors, an infectious etiology, including septic sacroiliitis (SSI), is at the end spectrum of the differential. SSI is a rare condition with nonspecific findings that can lead to major complications, including death. To our knowledge, there are only 4 recent major literature reviews on SSI, with most cases reported to have at least 1 risk factor or clinical sign indicating the possibility of an infectious etiology. The patient reported in this case had no identifiable risk factors; therefore, high clinical suspicion is needed to prevent debilitating consequences from prolonged infection.