JAAOS, Volume 26, No. 2

Blood-loss Management in Spine Surgery

Substantial blood loss during spine surgery can result in increased patient morbidity and mortality. Proper preoperative planning and communication with the patient, anesthesia team, and operating room staff can lessen perioperative blood loss. Advances in intraoperative antifibrinolytic agents and modified anesthesia techniques have shown promising results in safely reducing blood loss. The surgeon’s attention to intraoperative hemostasis and the concurrent use of local hemostatic agents also can lessen intraoperative bleeding. Conversely, the use of intraoperative blood salvage has come into question, both for its potential inability to reduce the need for allogeneic transfusions as well as its cost-effectiveness. Allogeneic blood transfusion is associated with elevated risks, including surgical site infection. Thus, desirable transfusion thresholds should remain restrictive.

      • Subspecialty:
      • Spine

      • Spine

    Bearing Surfaces for Total Hip Arthroplasty

    Metal-on–highly cross-linked polyethylene is considered the preferred bearing surface for conventional total hip arthroplasty because of its safety profile and excellent results in the first 10 to 15 years of use. However, with younger patient age, activity expectations increase, and the life expectancy of patients with total hip arthroplasty also has increased, so interest remains in other bearing couples. These other options include the use of various ceramic composites for the femoral head on highly cross-linked polyethylene, the so-called second-generation antioxidant polyethylenes, and ceramic acetabular liners. Several of these bearing couples have shown excellent wear rates in vitro, and short-term clinical studies have demonstrated favorable wear and safety results. It is uncertain whether any of these bearing couples should be adopted at present. Understanding the unique properties and possible complications of these bearing couples is critical for appropriate implant selection.

        • Subspecialty:
        • Hip

        • Adult Reconstruction

      Integrative Medicine as an Adjunct to Orthopaedic Surgery

      Patients often seek nontraditional forms of treatment, including alternative/complementary medical options, such as chiropractic care and acupuncture, to meet their personal needs. In the United States, interest has grown in methods to reduce pain and improve function through Ayurvedic medicine, which uses plant-based supplements, such as turmeric. Traditional allopathic medicine attempts to provide patients with evidence-based therapeutic regimens for their musculoskeletal conditions. Integrative medicine often is used to prevent and manage the sequelae associated with injuries and illnesses; however, competitive athletes and military personnel use complementary medicine for performance enhancement. Thus, physicians should be aware of the evolving field of integrative medicine, including the reported benefits as well as any potential drawbacks, to facilitate an educated discussion with their patients.

          • Subspecialty:
          • General Orthpaedics

        Flexor Tendon Injuries

        Flexor tendon injuries of the hand are uncommon, and they are among the most challenging orthopaedic injuries to manage. Proper management is essential to ensure optimal outcomes. Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics and repair of tendons in the different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions, including tissue engineering and biologic modification of the repair site.

            • Subspecialty:
            • Hand and Wrist

            • Hand

          Prolonged Preoperative Weakness Affects Recovery of Motor Function After Anterior Cervical Diskectomy and Fusion

          Introduction: Some patients who undergo anterior cervical diskectomy and fusion for radiculopathy or myelopathy demonstrate preoperative weakness. The purpose of this study was to determine which factors predict motor recovery in patients undergoing anterior cervical diskectomy and fusion.

          Methods: A retrospective review of our institutional database identified patients undergoing anterior cervical diskectomy and fusion between 2010 and 2013 with 2 years of clinical follow-up. Patients with substantial weakness, defined as preoperative grade ≤3 (on a scale from 0 to 5) in one or more upper extremity muscle groups, were identified. Regression analysis was used to determine risk factors associated with persistent postoperative weakness.

          Results: Of the 1,001 patients who were included, 54 (5.4%) demonstrated substantial weakness. By 2 years postoperatively, 47 of 54 patients (87%) demonstrated motor recovery. The duration of preoperative weakness was an independent predictor of recovery (median, 4 months of preoperative weakness among patients with recovery versus 10 months in patients with persistent weakness; P = 0.012).

          Discussion: Duration of preoperative motor weakness is an independent predictor of motor recovery after anterior cervical diskectomy and fusion in patients with substantial motor weakness.

          Conclusion: Patients being considered for anterior cervical diskectomy and fusion who have substantial preoperative motor deficits may benefit from earlier surgical intervention.

              • Subspecialty:
              • Spine

              • Spine

            No Clear Benefit of Chlorhexidine Use at Home Before Surgical Preparation

            Introduction: Several studies have evaluated the efficacy of home use of chlorhexidine before surgery to reduce bacterial colonization. However, these studies have provided conflicting evidence about the potential efficacy of this strategy in decreasing bacterial loads and infection rates across surgical populations, and no prior study has analyzed the benefit of this intervention before spine surgery. We prospectively analyzed the effectiveness of chlorhexidine gluconate wipes for decreasing bacterial counts on the posterior neck.

            Methods: Sixteen healthy adults participated in this prospective study. The right side of each participant’s neck was wiped twice (the night before and the morning of the experiment) with chlorhexidine gluconate wipes. The left side was used as the control region. Bacterial swabs were obtained as a baseline upon enrollment in the study, then upon arrival at the hospital, and, finally, after both sides of the neck had received standard preoperative scrubbing.

            Results: All patients had positive baseline bacterial growth (median >1,000 colonies/mL). When chlorhexidine gluconate wipes were used, decreased bacterial counts were noted before the preoperative scrub, but this finding was not statistically significant (P = 0.059). All patients had zero bacteria identified on either side of their neck after completion of the preoperative scrub.

            Conclusion: At-home use of chlorhexidine gluconate wipes did not decrease the topical bacterial burden. Therefore, using chlorhexidine gluconate wipes at home before surgery may offer no added benefit.

                • Subspecialty:
                • General Orthopaedics