Background Since 2003 many orthopaedic journals have adopted grading systems for levels of evidence (LOE). It is unclear if the quality of orthopaedic literature has changed since LOE was introduced. Questions/purposes We asked three questions: (1) Have the overall number and proportion of Level I and II studies increased in the orthopaedic literature since the introduction of LOE? (2) Is a similar pattern seen in individual orthopaedic subspecialty journals? (3) What is the interobserver reliability of grading LOE? Methods We assigned LOE to therapeutic studies published in 2000, 2005, and 2010 in eight major orthopaedic subspecialty journals. Number and proportion of Level I and II publications were determined. Data were evaluated using log-linear models. Twenty-six reviewers (13 residents and 13 attendings) graded LOE of 20 blinded therapeutic articles from the Journal of Bone and Joint Surgery for 2009. Interobserver agreement relative to the Journal of Bone and Joint Surgery was assessed using a weighted kappa.

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Background Amphotericin is a highly toxic hydrophobic antifungal. Delivery of amphotericin from antifungalloaded bone cement (ALBC) is much lower than would be expected for an equivalent load of water-soluble antibacterials. Lipid formulations have been developed to decrease amphotericin toxicity. It is unknown how lipid formulations affect amphotericin release and compressive strength of amphotericin ALBC. Questions/purposes We asked if amphotericin release from liposomal amphotericin ALBC (1) changed with amphotericin load; (2) differed from release from amphotericin deoxycholate ALBC; (3) was an active drug; and (4) if liposomal amphotericin affected the bone cement strength.Methods Forty-five standardized test cylinders were fabricated from three formulations of ALBC: Simplex TM P bone cement with 200 mg liposomal amphotericin, 800 mg liposomal amphotericin, or 800 mg amphotericin deoxycholate per batch. For each ALBC formulation, cumulative released amphotericin was determined from five cylinders, and compressive strength was measured for 10 cylinders, five before elution and five after. Activity of released amphotericin was determined by growth inhibition assay. Results Amphotericin release was greater for increased load of liposomal amphotericin: 770 lg for 800 mg versus 118 lg for 200 mg. Amphotericin release was greater from liposomal ALBC than from deoxycholate ALBC: 770 lg versus 23 lg over 7 days for 800 mg amphotericin. Released amphotericin was active. Compressive strength of liposomal ALBC is decreased, 67 MPa and 34 MPa by Day 7 in elution for the 200-mg and 800-mg formulations, respectively. Conclusions Liposomal amphotericin has greater amphotericin release from ALBC than amphotericin deoxycholate. Compressive strength of liposomal amphotericin ALBC decreases to less than recommended for implant fixation. Local toxicity data are needed before liposomal amphotericin ALBC can be used clinically.

Recent studies have shown subjectively worse outcomes associated with 15 to 20 mm of clavicle shortening. As a result, more than 15 mm of shortening has become a relative indication for operative management. Various methods to quantify shortening have been described in the literature. All measurement techniques described assume clavicular symmetry to assess clavicular shortening. The goal of this study was to assess the side-to-side variation in clavicle length in uninjured, skeletally mature adults.Clavicle length in 102 skeletally mature adults (age range, 22-91 years) was measured using computed tomography data. Clavicle length was defined as the distance between the lateral-most point of the clavicle in the acromioclavicular joint and the medial-most point of the clavicle in the sternoclavicular joint. The side-to-side difference in clavicular length was analyzed, and patients were organized into 2 groups: group 1 was symmetric (difference of less than 5 mm), and group 2 was asymmetric (difference of more than 5 mm). Mean difference in clavicle length for all patients was 4.25±3.8 mm (range, 0-23 mm). Clavicular symmetry was found in 73 (71.5%) of 102 patients. The remaining 29 patients had asymmetry greater than 5 mm. Asymmetry greater than 10 mm was found in 7 (7%) of 102 patients. Twenty-eight percent of clavicles were asymmetric, whereas 7% had clinically significant asymmetry that could affect treatment decisions.This finding calls into question previous methods developed to assess clavicular length in the setting of trauma because of the assumption of symmetry. Further studies are needed to evaluate the effect of hand dominance and pediatric trauma on this observation.

The oligochaete Limnodrilus hoffmeisteri Cleparéde was exposed to sediment-amended pyrene (0-1,196 nmol/g dry wt) for 2, 5, and 10 d to investigate sediment particle-size preference, tissue pyrene bioaccumulation (using biota-sediment accumulation factor, BSAF), fecal pyrene concentrations (using fecal-sediment accumulation factor, FSAF), and pyrene biotransformation. In non-pyrene-amended sediment, L. hoffmeisteri preferentially ingested finer sediment particles (< 3.5 microns). However, pyrene concentrations > 199 nmol/g dry weight resulted in a decreased preference for finer particles, presumably reducing pyrene exposure. Particle selectivity also changed with time such that after 10 d, worms showed an increased preference for finer particles. At high pyrene exposure, tissue pyrene concentrations rapidly attained equilibrium (maximum body residue 4.4 mumol/g wet wt, close to values cited for hydrocarbon critical body residues). Levels of biotransformation were low (mean 14%) and independent of time or pyrene concentration. Biota-sediment accumulation factor showed a negative relationship with sediment pyrene concentration; this trend may be due to reduced availability at high sediment pyrene concentrations or due to reductions in both ingestion rate and selectivity for fine, pyrene-rich particles. Fecal pyrene concentrations were depleted compared to sediment levels, suggesting removal of pyrene during gut passage by absorption. Fecal-sediment accumulation factor showed a negative relationship with increasing sediment pyrene levels.