Thursday, January 5, 2012

Registries, Shoulder arthroplasty, periprosthetic infection in December JBJS

After a winter solstice steelhead, some spectacular views from a remote mountain cabin, and slogging through a heavy snowfall, it's time to get back to work and blogging.

The December 21 JBJS has some articles of interest.
Bill Maloney wrote an editorial on the role of orthopaedic device registries in improving patient outcomes. In it he points to the difficulties in keeping track of which patients have which results with which implants performed by which surgeons. He uses the recent example of the failure of metal-on-metal hips, but there are many other examples of defective implants that might have been recognized earlier had their been a central registry of implants and their clinical performance. Yet the implant is only one of the potential causes of failure of a joint replacement.  Others include poor selection of patients, poor surgical technique, complications and poor rehabilitation. We live in a world where millions of joint replacements are done every year, yet the results of over 95% these arthroplasties are not analyzed so that the knowledge that could potentially be gained from what works and what doesn't work in different circumstances is lost. Since neither industry, nor the government, nor organized medicine can make followup happen, maybe some young person will save the day by designing an "app" called "MyJoint" that will ask the patient to enter the specifics about themself and their arthroplasty and remind them to complete a self assessment each year and post it to a central database.

Javad Parvizi et al reported on the novel idea of using a simple colorimetric strip test to look for the enzyme leukocyte esterase in the joint fluid of knees with a possible joint infection. The test correlated well with the number of neutrophils and with systemic inflammatory markers. It is exciting to see how well this works for knees; however for those of us in the shoulder world most of our infections engender less of an inflammatory response so that the effectiveness of this approach remains to be evaluated.

Sunny Kim et al reported the increasing incidence of shoulder replacements in the US. They found relatively constant growth in the number of hemiarthroplasties from 12,000 in 2000 to 20,000 in 2008, many of these being performed for fracture. The number of total shoulders grew from 8,000 in 2000 to 11,000 in 2003 and then took a sudden leap to over 27,000 in 2008, perhaps in part due to the introduction of the reverse total shoulder in the US in 2003. Unfortunately, this article contains no information on functional outcomes or revision rates.


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