The edition · Orthopaedics
Compliance with partial weight-bearing was 21% until the crutches started talking
Fifty years of periprosthetic joint infection management reviewed; manipulation beats mobilisation for neck pain by less than a point; quadriceps grafts outperform bone-patellar-tendon-bone on the bench; and a small randomised pilot exposes how little partial weight-bearing instruction achieves on its own.
The edition in brief
A review in JBJS traces periprosthetic joint infection management from empirical, procedure-led practice to a diagnostic framework built on validated criteria, serological and synovial biomarkers and molecular techniques, with surgical strategy individualised by host, organism and disease - debridement with implant retention, one-stage or two-stage revision, or salvage - and with biofilm and the microbiome reshaping the underlying microbiology. A randomised mechanistic crossover trial in 89 people with chronic mechanical neck pain, each receiving both cervical manipulation and mobilisation 72 hours apart, found range of motion improved equally after both, while pain fell slightly more after manipulation (mean decrease 0.786 against 0.373 points on an 11-point scale; β 0.413, 95% CI 0.160-0.665, P=0.002) and muscular responses on electromyography were larger; the authors state plainly that the statistically significant findings did not reach clinical significance. A controlled laboratory study of 30 grafts from 15 cadaveric knees found quadriceps tendon autografts larger and stronger than bone-patellar-tendon-bone, with full-thickness double-blade harvest giving the greatest cross-sectional area (0.97 cm² against 0.64 for a cylindrical harvester and 0.44 for bone-patellar-tendon-bone) and the highest load to failure - but stress and strain were equivalent once normalised for area, so the advantage is size rather than tissue quality. A Level IV series of 27 reverse shoulder arthroplasties with allograft-prosthetic composite and lower trapezius transfer raised the proportion with active external rotation past neutral from 15% to 80%, at a 15% rate of revision or reoperation for humeral complications. And in a randomised pilot of 20 patients, real-time feedback crutch tips raised adherence to prescribed partial weight-bearing from 21.1% to 73.6% (P<0.01).
Fifty years of periprosthetic joint infection, and what actually changed
Audit your own periprosthetic joint infection pathway against the modern framework - validated criteria rather than impression, multiple held cultures rather than one, and a surgical choice made on host and organism rather than habit.
Manipulation beat mobilisation for neck pain, by less than the patient would notice
Manipulation and mobilisation are effectively equivalent for chronic neck pain in the short term - choose on safety and patient preference, not on a 0.4-point pain difference.
Quadriceps grafts were bigger and stronger than bone-patellar-tendon-bone, and the harvester mattered
The quadriceps tendon's advantage is size, not tissue quality - so harvest technique determines graft strength, and measuring the cross-sectional area is worth more than choosing a graft type.
Adding a tendon transfer to a reverse shoulder restored external rotation in four of five shoulders
In a salvage shoulder with bone loss and cuff deficiency, adding a lower trapezius transfer restored external rotation past neutral in 80% - consent for rotation, not elevation, and expect a 15% reoperation rate.
Ask the patient to show you the weight-bearing, not tell you
Have the patient reproduce the target load on bathroom scales before they leave and again at follow-up - asking whether they have complied tells you nothing.
Without feedback, patients kept to partial weight-bearing one step in five
Treat a partial weight-bearing prescription as unlikely to be followed - compliance without feedback was 21% of steps, which is the number your fixation decision is actually resting on.
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