Rifampicin and fluoroquinolone based therapy is generally considered as first-choice targeted oral antimicrobial therapy for staphylococcal prosthetic joint infections (PJI) treated with debridement, antibiotics and implant retention (DAIR). Alternative equally effective antimicrobial strategies are urgently needed due to toxicity and drug-drug interactions that frequently occur with this strategy. Data from recent clinical studies suggests equipoise for other antimicrobial treatment regimens. The objective of the The RiCOTTA-trial is a multicenter, non-inferiority, open-label, randomized controlled trial evaluating clindamycin versus rifampicin/fluoroquinolone combination therapy in the oral treatment phase in patients with staphylococcal PJI managed with DAIR. The trial is performed in 16 hospitals in the Netherlands. Eligible patients are adults with staphylococcal knee or hip PJI managed by DAIR. Patients are included one to six days before antibiotic treatment is switched from intravenous to oral therapy. Patients with a contraindication for rifampicin, with a megaprosthesis or who receive intravenous antibiotics for more than three weeks after initial debridement are excluded. Primary outcome is treatment success one year after finishing antimicrobial treatment. Success is defined as the absence of: i. Infection related re-surgery, ii. New episode of antibiotic treatment for infection of the index joint after the initial treatment phase of 12 weeks, iii. Ongoing use of antibiotics for the index joint at the end of follow-up, iv. Death. The estimated treatment success of rifampicin combination therapy is 85% and the monotherapy strategy is considered not inferior when the difference in treatment success will be less than 10%. Enrolment of 158 patients per group (316 in total) is needed to confirm non-inferiority of monotherapy with a power of 80%. The trial is currently open for enrolment. The study is approved by the Medical Ethics Committee Leiden, the Hague, Delft, the Netherlands and registered under EU trial number 2022-501620-26-00 in Clinical Trial Information System.Aim
Method
The anterior supine intermuscular (ASI) approach enables total hip arthroplasty (THA) without dissection of muscles or insertions. This could be beneficial in patient recovery and satisfaction. Study-aim was to assess the learning-curve for the ASI-approach and show short-term results. Two surgeons performed uncemented THA on 23 (17 and six respectively) consecutive patients. The Taperloc stem, Recap-cup and Magnum head (Biomet, Warsaw, USA) were used. THA was performed without the use of a traction-table. Data was gathered till 3 months follow-up. Average patient age was 61 years (36–74), ASA-classification was two (one-four). There was a decrease in surgical time from 140 at the beginning to 80 minutes at the end of our series. Average blood-loss was 788 ml. Three patients received erythrocyte-transfusion. Minor non-orthopaedic complications all resolved within 48 hours. Average length of stay was five-and-a-half days. Functional score-lists showed improvement comparing pre-operative scores with scores on 12 weeks follow-up: Harris-Hip-Score from 56 to 94, Oxford-Hip-Score from 43 to 19, Hip-disability-and-Osteoarthritis-Outcome-Score from 109 to 18. On six weeks follow-up 65% and on 12 weeks 100% of patients showed unaided mobilisation. At follow-up we saw one superficial wound-infection, one partial non-disabling sartorius-lesion, one paraesthesia and one transient anaesthesia of the lateral femoral cutaneous nerve area. ASI-approach for uncemented THA showed good results and rapid patient-mobilisation. This may in part be due to the non-dissecting of muscles or insertions, thus non-compromising the propriocepsis. Off course tissue-damage occurs, though this is likely to be of a fast reversible nature. There were no serious adverse events. We saw a rapid decline in session-duration suggesting a moderate learning-curve. Further research will have to prove the beneficiality of the ASI-approach.
In the past decades the use of allografts has increased rapidly in the field of orthopaedic surgery. In particular in revision hip arthroplasty allografts are frequently employed. Several reports in the past decades on the transmission of HIV and hepatitis have, however, raised concerns on the safety of allografts. These reports have led to a revision of the standards for tissue banks. The screening of donors’ medical and social history was improved and rigorous testing methods were implemented. Processing methods introduced by tissue banks have further reduced the risk of transmission. Despite these precautions, however, a recent report of the CDC has again caused for concern regarding the safety of allografts. After receiving allografts from a common source one patient died and another developed a serious infectious complication. These cases make it clear that the use of allografts is still not without risks. Orthopaedics should be aware of these risks but should also be familiar with the measures taken by tissue banks to reduce these. Only then can the surgeon decide whether he should use an allograft for a specific indication and more important which graft he should select. This presentation will provide an overview of measures that may be taken by tissue banks to reduce the risk of disease transmission. Also, suggestions are made for orthopaedic surgeons for the selection of an appropriate graft from a safety point of view.
