Bone and Joint Surgery

Comparison of Surgical Site Infection Risk Between Warfarin, LMWH, and Aspirin for Venous Thromboprophylaxis in TKA or THA: A Systematic Review and Meta-Analysis Background: Infection following arthroplasty can have devastating effects for the patient and necessitate further surgery. Venous thromboembolism (VTE) prophylaxis is required to minimize the risk of deep venous thrombosis and pulmonary embolism. Anticoagulation has been demonstrated to interfere with wound-healing and increase the risk of infection. We hypothesized that different anticoagulation regimes will have differing effects on rates of periprosthetic joint infection. The aim of this study was to compare the surgical site infection risk between the use of warfarin, low-molecular-weight heparin (LMWH), and aspirin for VTE prophylaxis following total knee or hip arthroplasty. Methods: A systematic literature search was conducted in November 2018 using the PubMed, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify studies that compared warfarin, LMWH, and/or aspirin with regard to surgical site infection rates following hip or knee arthroplasty. Meta-analyses were performed to compare the infection and VTE risks between groups. Results: Nine articles involving 184,037 patients met the inclusion criteria. Meta-analysis showed that warfarin prophylaxis was associated with a higher risk of deep infection (or infection requiring reoperation) (odds ratio [OR] = 1.929, 95% confidence interval [CI] = 1.197 to 3.109, p = 0.007) and surgical site infection overall (OR = 1.610, 95% CI = 1.028 to 2.522, p = 0.038) compared with aspirin in primary total joint arthroplasty, with similar findings also seen when primary and revision procedures were combined. There was no significant difference in infection risk between warfarin and LMWH and between LMWH and aspirin. There was a nonsignificant trend for VTE risk to be higher with warfarin compared with aspirin therapy for primary procedures (OR = 1.600, 95% CI = 0.875 to 2.926, p = 0.127), and this was significant when both primary and revision cases were included (OR = 2.674, 95% CI = 1.143 to 6.255, p = 0.023). Conclusions: These findings caution against the use of warfarin for VTE prophylaxis for hip and knee arthroplasty. Further randomized head-to-head trials and mechanistic studies are warranted to determine how specific anticoagulants impact infection risk. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Complications and Controversies in the Management of 5 Common Pediatric Sports Injuries »Growing participation in sports among children, along with increasingly intense training regimens, has contributed to an increasing rate of sports-related injuries.»Despite the similarities to adult sports injuries, pediatric patients have distinctive injury patterns because of the growing physis and therefore necessitate unique treatment algorithms.»Caring for these injured children requires in-depth knowledge of not only pediatric injury patterns, but also the scope of age-specific treatments, the associated complications, and the controversies.»When treating motivated pediatric athletes, one must be able to strike a delicate balance between patients' eagerness to return to sport and the need to ensure their long-term health and function.»Knowledge of controversies and complications will help both patients and physicians make informed decisions about how best to restore pediatric athletes back to health.

Return-to-Driving Recommendations After Lower-Extremity Orthopaedic Procedures »Following lower-extremity orthopaedic surgery, recommendations for safe return to driving include at least 6 to 12 weeks for a right ankle fracture, 2 days to 2 weeks for a right ankle arthroscopy, 6 to 9 weeks for a total ankle arthroplasty, 6 to 7 weeks for a right Achilles tendon rupture repair, 1 to 4 weeks for a right total knee arthroplasty, 2 weeks for a left total knee arthroplasty, 3 to 6 weeks for a right anterior cruciate ligament repair, and 1 to 4 weeks for a total hip arthroplasty.»Important individual factors such as extent of injury, laterality of injury, current driving habits, type of vehicle transmission (manual or automatic), and medical comorbidities must be taken into consideration.»State laws vary widely and often use vague language to describe the legal responsibilities that orthopaedic surgeons have when providing return-to-driving recommendations.

Treatment Algorithm for Surgical Site Infections Following Extensor Mechanism Repair »Despite general agreement regarding techniques for extensor mechanism repair, there is very limited guidance in the literature for the management of surgical site infections (SSIs) that may occur after these procedures.»Early or mild superficial SSIs, such as cellulitis, can be managed on an outpatient basis while monitoring for improvement, with escalated intervention if the symptoms do not resolve within 1 week.»Deep SSIs should be managed more aggressively with surgical irrigation and debridement (I&D), including the knee joint, depending on the results of the aspiration, removal of all braided nonabsorbable suture (if necessary) with immediate or delayed exchange with monofilament suture, and the administration of parenteral antibiotics based on culture results and an infectious disease consult.»Arthrocentesis should be performed early to monitor for the spread of infection to the joint space, and diagnosis of a septic knee joint should be immediately followed by arthroscopic or open I&D.»For refractory cases (i.e., wound coverage issues or persistent infections despite multiple attempts at debridement), a consult with a plastic surgeon for consideration of a gastrocnemius flap is recommended, and surgeons should remain suspicious of the possibility of the contiguous spread of osteomyelitis.

Optimizing Return to Play for Common and Controversial Foot and Ankle Sports Injuries »Surgical decision-making should consider factors to help optimize return to play for athletes with foot and ankle injuries, including injuries to the syndesmosis, the Achilles tendon, the fifth metatarsal, and the Lisfranc complex. Understanding influential factors on return to play may help orthopaedic surgeons counsel athletes and coaches on expectations for a timeline to return to play and performance metrics.»Outcomes after rigid and flexible fixation for syndesmotic injuries are generally favorable. Some data support an earlier return to sport and higher functional scores with flexible fixation, in addition to lower rates of reoperation and a decreased incidence of malreduction, particularly with deltoid repair, if indicated.»Minimally invasive techniques for Achilles tendon repair have been shown to have a decreased risk of wound complications. Athletes undergoing Achilles repair should expect to miss a full season of play to recover.»Athletes with fifth metatarsal fractures have better return-to-play outcomes with surgical management and can expect a high return-to-play rate within approximately 3 months of surgery.»Percutaneous treatment of Lisfranc injuries may expedite return to play relative to open procedures.

Erratum: The Use of Dual Mobility Implants in Patients Who Are at High Risk for Dislocation After Primary Total Hip Arthroplasty No abstract available

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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