Deep infection after shoulder arthroplasty is a diagnostic and therapeutic challenge. The current literature on this topic is from single institutions or Medicare samples, lacking generalizability to the larger shoulder arthroplasty population. We sought to identify (1) patient-specific risk factors for deep infection, and (2) the pathogen profile after primary shoulder arthroplasty in a large integrated healthcare system. A retrospective cohort study was conducted. Of 4528 patients identified, 320 had died and 302 were lost to followup. The remaining 3906 patients had a mean followup of 2.7 years (1 day-7 years). The study endpoint was the diagnosis of deep infection, which was defined as revision surgery for infection supported clinically by more than one of the following criteria: purulent drainage from the deep incision, fever, localized pain or tenderness, a positive deep culture, and/or a diagnosis of deep infection made by the operating surgeon based on intraoperative findings. Risk factors evaluated included age, sex, race, BMI, diabetes status, American Society for Anesthesiologists (ASA) score, traumatic versus elective procedure, and type of surgical implant. For patients with deep infections, we reviewed the surgical notes and microbiology records for the pathogen profile. Multivariable Cox regression models were used to evaluate the association of risk factors and deep infection. Adjusted hazard ratios and 95% CI are presented. With every 1-year increase in age, a 5% (95% CI, 2%–8%) lower risk of infection was observed. Male patients had a risk of infection of 2.59 times (95% CI, 1.27–5.31) greater than female patients. Patients undergoing primary reverse total shoulder arthroplasty had a 6.11 times (95% CI, 2.65–14.07) greater risk of infection compared with patients having primary unconstrained total shoulder arthroplasty. Patients having traumatic arthroplasties were 2.98 times (95% CI, 1.15–7.74) more likely to have an infection develop than patients having elective arthroplasties. BMI, race, ASA score, and diabetes status were not associated with infection risk (all p > 0.05). Propionibacterium acnes was the most commonly cultured organism, accounting for 31% of isolates. Younger, male patients are at greater risk for deep infection after primary shoulder arthroplasty. Reverse total shoulder arthroplasty and traumatic shoulder arthroplasties also carry a greater risk for infection. Propionibacterium acnes was the most prevalent pathogen causing infection in our primary shoulder arthroplasty population. Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

A prospective clinical study used joint scintigraphy to investigate conservative treatment of juvenile osteo chondritis dissecans (JOCD) of the femoral condyle. The predictive value of scintigraphic evaluation and various parameters (age at onset, sex, location and size of lesion) were analyzed. Over a 10 year period, the senior author followed 92 knees in 76 patients, 60 of whom were male and 16 female (11 and 5 bilaterals, respectively). All patients were participants in athletics or exercise programs. All patients had orthopaedic assessment, roentgen ographic studies (AP, lateral, and tunnel views), 99m- Technetium phosphate compound joint scintigraphy, and instruction in a symptom-free existence (with all athletic activity proscribed). Patients were reevaluated and scanned every 8 weeks. No casts or braces were used, although crutches were sometimes necessary to maintain symptom-free levels. Based on specific indications for failure of conserva tive treatment, 50% of these patients failed and under went surgery. Of the 92 knees, 52 were successfully treated conservatively, while 40 failed. Average fol lowup was 4.2 years. Average age at onset was 12.5 years; the success group averaged 12.1 years and the failure group 13.0 years. The average lesion size was 363.2 mm ² , with 309.5 mm ² in the success group and 436.0 mm ² in the failure group. Parameters of location, sex, and scan classification were not statistically signif icant as predictive factors.

Displaced patellar fractures are commonly stabilized with a modified anterior tension-band construct. The goal of the current study was to compare the incidence of complications after tension-band fixation of the patella with Kirschner wires as compared with cannulated screws. We performed a retrospective cohort study of consecutive, surgically treated patellar fractures. Patients were divided into two cohorts: fractures fixed with use of Kirschner wires and fractures fixed with use of cannulated screws. The primary outcome measure was early loss of fixation that necessitated revision surgery. Secondary outcomes included early postoperative infection and the need for implant removal. Four hundred and forty-eight patellar fractures were studied. Kirschner wires were used for fixation in 315 (70%), and cannulated screws were used for fixation in 133 (30%). The incidence of fixation failure was 3.5% in the Kirschner-wire group and 7.5% in the screw group (p = 0.065). A postoperative infection occurred in 4.4% of patients in the Kirschner-wire group and 1.5% of patients in the screw group (p = 0.17). One hundred sixteen (37%) patients in the Kirschner-wire group and 30 (23%) in the screw group underwent elective implant removal (p = 0.003). After adjusting for confounding variables, a trend toward increased incidence of fixation failure with screws as compared with Kirschner wires was present (p = 0.083). Patients treated with Kirschner wires were twice as likely to undergo implant removal compared with those treated with screws (p = 0.002). Serious complications are uncommon following treatment of patellar fractures with a modified tension-band technique, with use of either Kirschner wires or cannulated screws. In both groups the rate of fixation failure was low, as was the rate of postoperative infection. Symptomatic implants, the most common complication observed, were twice as frequent in patients treated with Kirschner wires. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study was to evaluate the long-term clinical outcome of operative versus nonoperative treatment of anterior cruciate ligament (ACL) deficiency and to define its relationship with sports activity. Forty-six patients (37 male, 9 female, mean age, 33.6 ± 8.0 years) who underwent open ACL reconstruction using patellar tendon autograft and 25 patients (18 male, 7 female, mean age, 32.3 ± 9.9 years) who were treated nonoperatively were evaluated by the same two examiners at 5 - 7 and 10 - 13 years following injury. The evaluations included objective and subjective scoring (Lysholm, OAK, IKDC), instrumented testing (Cybex, KT 1000), radiographic evaluation, and assessments of sports activity, with respect to type, frequency and associated symptoms. According to Lysholm, OAK and IKDC scores, the operative group performed significantly (p < 0.05) better and was able to maintain increased involvement in sports, although both groups participated less over time. However, risks for degenerative joint changes were similar for both the operative and the nonoperative group. A significant (p < 0.05) correlation between participation in high-risk pivoting sports, such as soccer or basketball and osteoarthritic changes could be found for the nonoperative group, only. Sports activity represents an important variable not only affecting the outcome, but also influencing treatment decisions following ACL injuries.