Orthopedics

If you believe in conspiracies, then I have a plot for you to ponder. The methodical and continuous suppression of the medical delivery system with special emphasis on the provider will and has driven the clinician to seek security in employment. The logical employer is the hospital or large corporate medical provider. They too are under pressure but have far more resources than an individual clinician.

With the individual practitioner becoming an employee, there is only one entity to deal with – the hospital. Now the government can control and ratchet down reimbursement as well as overregulate one entity. It will leave the doctor control to the hospital or corporate entity. When the books do not balance at the hospital, it is obvious who will feel the pressure: the physician, who is the ultimate provider of services. The insurance companies will merely jump on the tails of government regulators and dictate without input from the medical community the type and quality of services that they will pay for. Although there are a number of entities involved, this begins to look like a single-payer system.

Recent resident and fellow graduates are seeking salaried employment at a rate of over 50% of their graduating classes. This number also seems to be growing rapidly, particularly in urban areas. The current graduate continues to look for an entity that will allow him more time with his specialty and family and less with administrative tasks. They also fear the risk of failure and are seeking out the
security of employment, but they do not recognize that there are some inherent risks in employment by a large corporate entity.

When they choose corporate employment, they are working with a group of physicians of all specialties that they have not chosen to work with. What happens when you are forced to make referrals to a particular department or individual that you would not have done so under the private practice situation? What happens when the hospital loses a contract and must cut its workforce by 20%? Will you be in that 20%? If so, you will not have the opportunity to create a practice and bring patients with you, as they will all belong to the institution that you just left. This will usually require being hired by another large institution in the area or relocating geographically.

Business relationships, partnerships, friendships, and marriages start very easily and oftentimes are very uplifting. Separations, divorce, and breakups are very painful and ugly. Recently there appear to be more and more breakups and dissolutions than there were in the past. Much of this arises from the unrealistic expectations at the end of a very lucrative contract that has a 2- or 3-year guarantee on it. The fine print on these contracts is oftentimes shocking.

Many of the hospitals and large medical delivery systems couch themselves as “nonprofit.” That does not deter them from very large corporate salaries for administration. It certainly never appears to reflect itself in physician compensation. A recent report in the San Diego County area listed the salaries of the top 10 not-for-profit executives; 9 of the 10 were in the hospital and medical care delivery sector. Millions of dollars in salary are being paid to these executives, with little attention to physicians and other health care employees. This will eventually lead to physicians being treated as common laborers, requiring continued negotiations between labor and management. This is a significant distraction from our main goal of providing patient care. We should never be put in a position where our Hippocratic Oath is challenged. We have taken our eye off the ball and have relinquished control, and it is unlikely that we will be able to recapture it. One only needs to look at all the remaining developed countries and
realize that we are the last to fall.

In an attempt to raise corporate profits, avoid onerous regulations, and also fight for survival, many CEOs and hospitals have run into significant problems with the Department of Justice and other government agencies. There have been over 100 hospital bankruptcies in California over the last 7 to 10 years. The press is always
reporting on the dismissal, investigation, or indictment of hospital officials. We rely on hospital administrators rather than MDs to run our hospitals, contrary to the Canadian model. When remuneration for services rendered sinks to untenable levels, even good people oftentimes are driven to break the law and deviate from their ethics. What happens when, as a young surgeon, you are part of that organization and building a practice in a hospital that then becomes subject to prolonged investigations and loss of reputation? Our young surgeons need to make these decisions on employment very carefully and look to some of their elders for guidance. ◾

If you believe in conspiracies, then I have a plot for you to ponder. The methodical and continuous suppression of the medical delivery system with special emphasis on the provider will and has driven the clinician to seek security in employment. The logical employer is the hospital or large corporate medical provider. They too are under pressure but have far more resources than an individual clinician.

With the individual practitioner becoming an employee, there is only one entity to deal with – the hospital. Now the government can control and ratchet down reimbursement as well as overregulate one entity. It will leave the doctor control to the hospital or corporate entity. When the books do not balance at the hospital, it is obvious who will feel the pressure: the physician, who is the ultimate provider of services. The insurance companies will merely jump on the tails of government regulators and dictate without input from the medical community the type and quality of services that they will pay for. Although there are a number of entities involved, this begins to look like a single-payer system.

Recent resident and fellow graduates are seeking salaried employment at a rate of over 50% of their graduating classes. This number also seems to be growing rapidly, particularly in urban areas. The current graduate continues to look for an entity that will allow him more time with his specialty and family and less with administrative tasks. They also fear the risk of failure and are seeking out the
security of employment, but they do not recognize that there are some inherent risks in employment by a large corporate entity.

When they choose corporate employment, they are working with a group of physicians of all specialties that they have not chosen to work with. What happens when you are forced to make referrals to a particular department or individual that you would not have done so under the private practice situation? What happens when the hospital loses a contract and must cut its workforce by 20%? Will you be in that 20%? If so, you will not have the opportunity to create a practice and bring patients with you, as they will all belong to the institution that you just left. This will usually require being hired by another large institution in the area or relocating geographically.

Business relationships, partnerships, friendships, and marriages start very easily and oftentimes are very uplifting. Separations, divorce, and breakups are very painful and ugly. Recently there appear to be more and more breakups and dissolutions than there were in the past. Much of this arises from the unrealistic expectations at the end of a very lucrative contract that has a 2- or 3-year guarantee on it. The fine print on these contracts is oftentimes shocking.

Many of the hospitals and large medical delivery systems couch themselves as “nonprofit.” That does not deter them from very large corporate salaries for administration. It certainly never appears to reflect itself in physician compensation. A recent report in the San Diego County area listed the salaries of the top 10 not-for-profit executives; 9 of the 10 were in the hospital and medical care delivery sector. Millions of dollars in salary are being paid to these executives, with little attention to physicians and other health care employees. This will eventually lead to physicians being treated as common laborers, requiring continued negotiations between labor and management. This is a significant distraction from our main goal of providing patient care. We should never be put in a position where our Hippocratic Oath is challenged. We have taken our eye off the ball and have relinquished control, and it is unlikely that we will be able to recapture it. One only needs to look at all the remaining developed countries and
realize that we are the last to fall.

In an attempt to raise corporate profits, avoid onerous regulations, and also fight for survival, many CEOs and hospitals have run into significant problems with the Department of Justice and other government agencies. There have been over 100 hospital bankruptcies in California over the last 7 to 10 years. The press is always
reporting on the dismissal, investigation, or indictment of hospital officials. We rely on hospital administrators rather than MDs to run our hospitals, contrary to the Canadian model. When remuneration for services rendered sinks to untenable levels, even good people oftentimes are driven to break the law and deviate from their ethics. What happens when, as a young surgeon, you are part of that organization and building a practice in a hospital that then becomes subject to prolonged investigations and loss of reputation? Our young surgeons need to make these decisions on employment very carefully and look to some of their elders for guidance. ◾

If you believe in conspiracies, then I have a plot for you to ponder. The methodical and continuous suppression of the medical delivery system with special emphasis on the provider will and has driven the clinician to seek security in employment. The logical employer is the hospital or large corporate medical provider. They too are under pressure but have far more resources than an individual clinician.

With the individual practitioner becoming an employee, there is only one entity to deal with – the hospital. Now the government can control and ratchet down reimbursement as well as overregulate one entity. It will leave the doctor control to the hospital or corporate entity. When the books do not balance at the hospital, it is obvious who will feel the pressure: the physician, who is the ultimate provider of services. The insurance companies will merely jump on the tails of government regulators and dictate without input from the medical community the type and quality of services that they will pay for. Although there are a number of entities involved, this begins to look like a single-payer system.

Recent resident and fellow graduates are seeking salaried employment at a rate of over 50% of their graduating classes. This number also seems to be growing rapidly, particularly in urban areas. The current graduate continues to look for an entity that will allow him more time with his specialty and family and less with administrative tasks. They also fear the risk of failure and are seeking out the
security of employment, but they do not recognize that there are some inherent risks in employment by a large corporate entity.

When they choose corporate employment, they are working with a group of physicians of all specialties that they have not chosen to work with. What happens when you are forced to make referrals to a particular department or individual that you would not have done so under the private practice situation? What happens when the hospital loses a contract and must cut its workforce by 20%? Will you be in that 20%? If so, you will not have the opportunity to create a practice and bring patients with you, as they will all belong to the institution that you just left. This will usually require being hired by another large institution in the area or relocating geographically.

Business relationships, partnerships, friendships, and marriages start very easily and oftentimes are very uplifting. Separations, divorce, and breakups are very painful and ugly. Recently there appear to be more and more breakups and dissolutions than there were in the past. Much of this arises from the unrealistic expectations at the end of a very lucrative contract that has a 2- or 3-year guarantee on it. The fine print on these contracts is oftentimes shocking.

Many of the hospitals and large medical delivery systems couch themselves as “nonprofit.” That does not deter them from very large corporate salaries for administration. It certainly never appears to reflect itself in physician compensation. A recent report in the San Diego County area listed the salaries of the top 10 not-for-profit executives; 9 of the 10 were in the hospital and medical care delivery sector. Millions of dollars in salary are being paid to these executives, with little attention to physicians and other health care employees. This will eventually lead to physicians being treated as common laborers, requiring continued negotiations between labor and management. This is a significant distraction from our main goal of providing patient care. We should never be put in a position where our Hippocratic Oath is challenged. We have taken our eye off the ball and have relinquished control, and it is unlikely that we will be able to recapture it. One only needs to look at all the remaining developed countries and
realize that we are the last to fall.

In an attempt to raise corporate profits, avoid onerous regulations, and also fight for survival, many CEOs and hospitals have run into significant problems with the Department of Justice and other government agencies. There have been over 100 hospital bankruptcies in California over the last 7 to 10 years. The press is always
reporting on the dismissal, investigation, or indictment of hospital officials. We rely on hospital administrators rather than MDs to run our hospitals, contrary to the Canadian model. When remuneration for services rendered sinks to untenable levels, even good people oftentimes are driven to break the law and deviate from their ethics. What happens when, as a young surgeon, you are part of that organization and building a practice in a hospital that then becomes subject to prolonged investigations and loss of reputation? Our young surgeons need to make these decisions on employment very carefully and look to some of their elders for guidance. ◾

Infections in orthopedic patients are among the most frequent postoperative complications and are known to cause significant morbidity, increased healthcare costs, and prolonged hospital stays.¹ Infections of implanted hardware can be especially devastating and difficult to treat, usually requiring removal of the hardware and prolonged courses of antibiotics; in some cases, amputation becomes necessary. In this month’s E-publishing section of The American Journal of Orthopedics focusing on infections in orthopedic practice, several types of these infections are discussed.

Taken together, these papers highlight two distinct concepts that pertain to orthopedic practice:
1. The prevention and management of infections of primary joint arthroplasties and the importance of following evidence-based practice guidelines to minimize the risk of postoperative infections
2. The need to consider underlying risk factors when formulating a differential diagnosis in a patient with an atypical orthopedic presentation; in these cases, a careful history and physical examination by the surgeon can lead to timely diagnosis and may reveal other medical conditions requiring referral.

In “Wichita Fusion Nail for Patients With Failed Total Knee Arthroplasty and Active Infection,” Barsoum and colleagues highlight the management dilemmas of treating failed total knee arthroplasties due to active infection and present their experience using a modular fusion nail. Kuper and Rosenstein review the literature in “Infection Prevention in Total Knee and Total Hip Arthroplasties” and present their experience in reducing the risk of infection after total knee and hip arthroplasties. Rates of infections after joint arthroplasty have declined substantially since the introduction of such prevention measures as antimicrobial
prophylaxis and “ultraclean” air in operating rooms.¹ Data collected from approximately 300 hospitals participating in the National Nosocomial Infection
Surveillance System (NNIS, now the National Healthcare Safety Network) from 1992 to 2004 showed that pooled mean rates of infection for total knee and hip arthroplasties were < 1 per 100 operations for the lowest-risk patients and slightly more than 2 per 100 for the highest-risk patients.² Hospitals performing these procedures can use these aggregated data to evaluate their own rates of infection.

The importance of prevention measures cannot be overemphasized. In a multicenter study involving over 8000 total hip and knee replacements, Lidwell and colleagues³ found that while both ultraclean air and antimicrobial prophylaxis reduced the incidence of surgical site infection (SSI), antimicrobial prophylaxis alone led to a greater reduction (reducing SSI from 3.4% to 0.8%) than ultraclean
air. While data strongly support that the first dose of cefazolin should be given within 1 hour (preferably within 30 minutes) of incision, the optimal duration of prophylaxis remains unclear; current data do not support continuing beyond 24 hours.¹ Following evidence-based guidelines, conducting close surveillance for SSI appropriately stratified by risk and reporting operation-specific, risk-stratified infection rates to surgical team members are critical measures to prevent these devastating complications.⁴

The issue of diagnosing patients with atypical orthopedic presentations is highlighted in “Psoas Abscess: A Diagnostic Dilemma” by Ebraheim and colleagues. Patients with a psoas abscess often present with vague signs and symptoms in the
buttock, hip, or thigh. Psoas abscesses most commonly result from direct extension of an adjacent source of infection, such as an intra-abdominal infection, perinephric abscess, infected retroperitoneal hematoma, or vertebral osteomyelitis, or less commonly by hematogenous seeding.⁵ Close attention to the patient’s history in all the cases presented revealed previous conditions or procedures that may have predisposed them to psoas abscess. The authors point out that computed tomography is the best modality for diagnosing the abscess and often the source of the infection.

In “Atypical Presentation of Soft-Tissue Mass With Gonococcal Infection in the Hand,” Hurst and colleagues present a case of gonococcal infection manifested by an atypical presentation of a soft-tissue mass in the thenar eminence with focal flexor tenosynovitis in an otherwise healthy man. Culture of purulent fluid from incision and drainage revealed Neisseria gonorrhoeae. Further questioning revealed a history of unprotected sex. The diagnosis of one sexually transmitted disease necessitates appropriate workup for other sexually transmitted coinfections, such as HIV and syphilis, as well as education and screening of sexual partners. Although this is typically outside the realm of the orthopedic surgeon’s practice,
the appropriate referral can have a major impact in the life of patients and their contacts.

References
1. ASHP Commission on Therapeutics Task Force. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 1999;56(18):1839-1888.
2. CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485.
3. Lidwell OM, Elson RA, Lowbury EJ, et al. Ultraclean air and antibiotics for prevention of postoperative infection. A multicenter study of 8,052 joint replacement operations. Acta Orthop Scand. 1987;58(1):4-13.
4. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:250-278.
5. Pasternack MS, Swartz MN. Myositis. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases. 6th Ed, Vol. 1. Philadelphia: Churchill
Livingstone, 2005:1200-1201.

Infections in orthopedic patients are among the most frequent postoperative complications and are known to cause significant morbidity, increased healthcare costs, and prolonged hospital stays.¹ Infections of implanted hardware can be especially devastating and difficult to treat, usually requiring removal of the hardware and prolonged courses of antibiotics; in some cases, amputation becomes necessary. In this month’s E-publishing section of The American Journal of Orthopedics focusing on infections in orthopedic practice, several types of these infections are discussed.

Taken together, these papers highlight two distinct concepts that pertain to orthopedic practice:
1. The prevention and management of infections of primary joint arthroplasties and the importance of following evidence-based practice guidelines to minimize the risk of postoperative infections
2. The need to consider underlying risk factors when formulating a differential diagnosis in a patient with an atypical orthopedic presentation; in these cases, a careful history and physical examination by the surgeon can lead to timely diagnosis and may reveal other medical conditions requiring referral.

In “Wichita Fusion Nail for Patients With Failed Total Knee Arthroplasty and Active Infection,” Barsoum and colleagues highlight the management dilemmas of treating failed total knee arthroplasties due to active infection and present their experience using a modular fusion nail. Kuper and Rosenstein review the literature in “Infection Prevention in Total Knee and Total Hip Arthroplasties” and present their experience in reducing the risk of infection after total knee and hip arthroplasties. Rates of infections after joint arthroplasty have declined substantially since the introduction of such prevention measures as antimicrobial
prophylaxis and “ultraclean” air in operating rooms.¹ Data collected from approximately 300 hospitals participating in the National Nosocomial Infection
Surveillance System (NNIS, now the National Healthcare Safety Network) from 1992 to 2004 showed that pooled mean rates of infection for total knee and hip arthroplasties were < 1 per 100 operations for the lowest-risk patients and slightly more than 2 per 100 for the highest-risk patients.² Hospitals performing these procedures can use these aggregated data to evaluate their own rates of infection.

The importance of prevention measures cannot be overemphasized. In a multicenter study involving over 8000 total hip and knee replacements, Lidwell and colleagues³ found that while both ultraclean air and antimicrobial prophylaxis reduced the incidence of surgical site infection (SSI), antimicrobial prophylaxis alone led to a greater reduction (reducing SSI from 3.4% to 0.8%) than ultraclean
air. While data strongly support that the first dose of cefazolin should be given within 1 hour (preferably within 30 minutes) of incision, the optimal duration of prophylaxis remains unclear; current data do not support continuing beyond 24 hours.¹ Following evidence-based guidelines, conducting close surveillance for SSI appropriately stratified by risk and reporting operation-specific, risk-stratified infection rates to surgical team members are critical measures to prevent these devastating complications.⁴

The issue of diagnosing patients with atypical orthopedic presentations is highlighted in “Psoas Abscess: A Diagnostic Dilemma” by Ebraheim and colleagues. Patients with a psoas abscess often present with vague signs and symptoms in the
buttock, hip, or thigh. Psoas abscesses most commonly result from direct extension of an adjacent source of infection, such as an intra-abdominal infection, perinephric abscess, infected retroperitoneal hematoma, or vertebral osteomyelitis, or less commonly by hematogenous seeding.⁵ Close attention to the patient’s history in all the cases presented revealed previous conditions or procedures that may have predisposed them to psoas abscess. The authors point out that computed tomography is the best modality for diagnosing the abscess and often the source of the infection.

In “Atypical Presentation of Soft-Tissue Mass With Gonococcal Infection in the Hand,” Hurst and colleagues present a case of gonococcal infection manifested by an atypical presentation of a soft-tissue mass in the thenar eminence with focal flexor tenosynovitis in an otherwise healthy man. Culture of purulent fluid from incision and drainage revealed Neisseria gonorrhoeae. Further questioning revealed a history of unprotected sex. The diagnosis of one sexually transmitted disease necessitates appropriate workup for other sexually transmitted coinfections, such as HIV and syphilis, as well as education and screening of sexual partners. Although this is typically outside the realm of the orthopedic surgeon’s practice,
the appropriate referral can have a major impact in the life of patients and their contacts.

References
1. ASHP Commission on Therapeutics Task Force. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 1999;56(18):1839-1888.
2. CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485.
3. Lidwell OM, Elson RA, Lowbury EJ, et al. Ultraclean air and antibiotics for prevention of postoperative infection. A multicenter study of 8,052 joint replacement operations. Acta Orthop Scand. 1987;58(1):4-13.
4. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:250-278.
5. Pasternack MS, Swartz MN. Myositis. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases. 6th Ed, Vol. 1. Philadelphia: Churchill
Livingstone, 2005:1200-1201.

Infections in orthopedic patients are among the most frequent postoperative complications and are known to cause significant morbidity, increased healthcare costs, and prolonged hospital stays.¹ Infections of implanted hardware can be especially devastating and difficult to treat, usually requiring removal of the hardware and prolonged courses of antibiotics; in some cases, amputation becomes necessary. In this month’s E-publishing section of The American Journal of Orthopedics focusing on infections in orthopedic practice, several types of these infections are discussed.

Taken together, these papers highlight two distinct concepts that pertain to orthopedic practice:
1. The prevention and management of infections of primary joint arthroplasties and the importance of following evidence-based practice guidelines to minimize the risk of postoperative infections
2. The need to consider underlying risk factors when formulating a differential diagnosis in a patient with an atypical orthopedic presentation; in these cases, a careful history and physical examination by the surgeon can lead to timely diagnosis and may reveal other medical conditions requiring referral.

In “Wichita Fusion Nail for Patients With Failed Total Knee Arthroplasty and Active Infection,” Barsoum and colleagues highlight the management dilemmas of treating failed total knee arthroplasties due to active infection and present their experience using a modular fusion nail. Kuper and Rosenstein review the literature in “Infection Prevention in Total Knee and Total Hip Arthroplasties” and present their experience in reducing the risk of infection after total knee and hip arthroplasties. Rates of infections after joint arthroplasty have declined substantially since the introduction of such prevention measures as antimicrobial
prophylaxis and “ultraclean” air in operating rooms.¹ Data collected from approximately 300 hospitals participating in the National Nosocomial Infection
Surveillance System (NNIS, now the National Healthcare Safety Network) from 1992 to 2004 showed that pooled mean rates of infection for total knee and hip arthroplasties were < 1 per 100 operations for the lowest-risk patients and slightly more than 2 per 100 for the highest-risk patients.² Hospitals performing these procedures can use these aggregated data to evaluate their own rates of infection.

The importance of prevention measures cannot be overemphasized. In a multicenter study involving over 8000 total hip and knee replacements, Lidwell and colleagues³ found that while both ultraclean air and antimicrobial prophylaxis reduced the incidence of surgical site infection (SSI), antimicrobial prophylaxis alone led to a greater reduction (reducing SSI from 3.4% to 0.8%) than ultraclean
air. While data strongly support that the first dose of cefazolin should be given within 1 hour (preferably within 30 minutes) of incision, the optimal duration of prophylaxis remains unclear; current data do not support continuing beyond 24 hours.¹ Following evidence-based guidelines, conducting close surveillance for SSI appropriately stratified by risk and reporting operation-specific, risk-stratified infection rates to surgical team members are critical measures to prevent these devastating complications.⁴

The issue of diagnosing patients with atypical orthopedic presentations is highlighted in “Psoas Abscess: A Diagnostic Dilemma” by Ebraheim and colleagues. Patients with a psoas abscess often present with vague signs and symptoms in the
buttock, hip, or thigh. Psoas abscesses most commonly result from direct extension of an adjacent source of infection, such as an intra-abdominal infection, perinephric abscess, infected retroperitoneal hematoma, or vertebral osteomyelitis, or less commonly by hematogenous seeding.⁵ Close attention to the patient’s history in all the cases presented revealed previous conditions or procedures that may have predisposed them to psoas abscess. The authors point out that computed tomography is the best modality for diagnosing the abscess and often the source of the infection.

In “Atypical Presentation of Soft-Tissue Mass With Gonococcal Infection in the Hand,” Hurst and colleagues present a case of gonococcal infection manifested by an atypical presentation of a soft-tissue mass in the thenar eminence with focal flexor tenosynovitis in an otherwise healthy man. Culture of purulent fluid from incision and drainage revealed Neisseria gonorrhoeae. Further questioning revealed a history of unprotected sex. The diagnosis of one sexually transmitted disease necessitates appropriate workup for other sexually transmitted coinfections, such as HIV and syphilis, as well as education and screening of sexual partners. Although this is typically outside the realm of the orthopedic surgeon’s practice,
the appropriate referral can have a major impact in the life of patients and their contacts.

References
1. ASHP Commission on Therapeutics Task Force. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 1999;56(18):1839-1888.
2. CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485.
3. Lidwell OM, Elson RA, Lowbury EJ, et al. Ultraclean air and antibiotics for prevention of postoperative infection. A multicenter study of 8,052 joint replacement operations. Acta Orthop Scand. 1987;58(1):4-13.
4. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:250-278.
5. Pasternack MS, Swartz MN. Myositis. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases. 6th Ed, Vol. 1. Philadelphia: Churchill
Livingstone, 2005:1200-1201.