What's new in pediatric orthopaedics

Changing practice patterns: the impact of a randomized clinical trial on surgeons preference for treatment of type 3 supracondylar humerus fractures

BACKGROUND

A recent prospective randomized clinical trial (RCT) for comparison of medial and lateral entry pins with lateral entry pins for treatment of Gartland type 3 supracondylar humerus fractures (SCHF) was published, validating the national trend toward treatment of this injury with only lateral entry pins. But have surgeons actually changed their practice as a result of these recent data? The purpose of this study was to compare pin configuration, loss of reduction and rate of nerve injuries before and after the RCT.

METHODS

This was a retrospective review of patients with Gartland type 3 SCHF who were treated before the RCT (April 2000 to April 2003: 141 patients) and after the trial (April 2006 to April 2009: 126 patients). Eight surgeons were included. Patient demographic data, pin configuration, neurovascular status, and radiographic results were compared. Comparisons between the pretrial cohort and the posttrial cohort as a group as well as for each individual surgeon were performed. Comparisons included the choice of pin configuration, incidence of loss of radiographic reduction, iatrogenic nerve injuries, return to the operating room, and infection before and after the clinical trial.

RESULTS

There was a statistically different pin configuration in the pretrial group compared with the posttrial group (P<0.0001) with the posttrial group having a much higher percentage of bicolumnar lateral entry only pins. Five out of 8 surgeons individually had a statistically significant change in their practice pattern for pin configuration. There was no difference from pretrial to posttrial in loss of radiographic reduction, infection rate, iatrogenic nerve injuries, or return to the operating room.

CONCLUSIONS

Data showing change in surgeon practice have been relatively sparse. In this group of surgeons who participated in an RCT, there was a statistically significant change in pin configuration for treatment of Gartland type 3 SCHF after the results of the RCT were known. The change in clinical practice did not have an effect on outcomes.

LEVEL OF EVIDENCE

Level III.

Quantitative analysis of biofilm formation of methicillin-resistant Staphylococcus aureus (MRSA) strains from patients with orthopaedic device-related infections

Biofilms play a pivotal role in medical device-related infections. However, epidemiological analysis of biofilm formation and genotyping among clinical methicillin-resistant Staphylococcus aureus (MRSA) isolates from patients with orthopaedic infections has rarely been reported. A total of 168 MRSA strains were examined: 23 strains from patients with device-related infection (the device group); 55 from patients with device-non-related infection (the nondevice group); and 90 from asymptomatic nasal carriers (the colonization group). Pulsed-field gel electrophoresis analysis and five genotyping methods including agr typing were performed. Biofilm formation was quantified using a microtitre plate assay. The device group had a significantly higher incidence of agr-2 than the colonization group (78.3% vs. 34.4%, P=0.001). The biofilm index of the agr-2 (0.523 ± 0.572) strains was significantly higher than those of agr-1 (0.260 ± 0.418, P<0.0001) and agr-3 (0.379 ± 0.557, P=0.045). The prevalence of strong biofilm formers in the device group (43.5%) was significantly higher than that in the nondevice group (12.7%, P=0.003) and the colonization group (20.0%, P=0.020). agr-2 MRSA strains may be more likely to cause orthopaedic device infection because of their strong biofilm formation ability.