To determine risk factors of infection in total knee arthroplasty. This descriptive study was conducted in the Department of Orthopedics for a duration of three years from January 2016 to January 2019. All patients undergoing primary total knee replacement were included in the study. Exclusion criteria were all patients operated in another hospital and revision total knee replacement. All patients were followed up at 2, 4, 8, 12 and 24 weeks post-operatively. Signs of inflammation and inflammatory markers such as total leukocyte count (TLC), C-reactive protein (CRP) and ESR were measured. Risk factors like age, body mass index (BMI), ASA, co-morbid conditions were also noted. A total of 78 patients underwent primary unilateral Total Knee Replacement (TKR) during the study period. Of these, 30 (34.09%) were male and 48 (61.54%) female patients. Mean age of patients was 68.32 ± 8.54 years. Average BMI 25.89 Kg/m2 .Osteoarthritis was the pre-dominant cause of total knee replacement (94.87%). Among co-morbid factors 33.33% were diabetic, 28.20% having ischemic heart disease and 12.82% with chronic lung disease. Upon anaesthesia fitness pre-operatively, 91.02% patients had an American society of anaesthesiologist score (ASA) between 0–2 while 07 (8.97%) between 3- 5. Average duration of surgery was 85.62± 4.11 minutes. 6.41% cases got infected. In majority of the infected cases (60%), Staphylococcus aureus was the infective organism. Diabetes Mellitus (p=0.01) and Obesity (p=0.02) had a significant relation to post-operative infection. Pre-operative risk evaluation and prevention strategies along with early recognition of infection and control can greatly reduce the risk of joint infection post-TKR which will not only improve the mobility of patient but also its morbidity and mortality as well. Key Words:. C-reactive protein (CRP), Erythrocyte Sedimentation Rate (ESR), Staphylococcus aureus, Total Knee Arthroplasty (TKA)

Summary. There is little consensus regarding the regime for treatment of tuberculosis of spine, although WHO has laid down guidelines couple of years back classifying spinal tuberculosis in Category 1. This study proves the efficacy of WHO regime in spinal tuberculosis by clinico-radiological evaluation. Introduction. The medical fraternity is divided over the duration of chemotherapy in cases spinal tuberculosis. WHO clearly recommend spinal tuberculosis under Category I, but not accepted by most clinicians. Patient and Methods. In this prospective study during the period between August 2005 and July 2012, a total of 76 cases were diagnosed and evaluated clinico-radiologically to test the efficacy of WHO protocol (2HRZE+4HR) in our hospital with a mean follow up of 50 months (30 – 80 months). Results. Spinal tuberculosis was seen in 56% of all osteoarticular tuberculosis. Maximum population was between 11–50 years, females were involved more than males (66%), and regional distribution was different in males (Lumbar) and females (Thoracic). Skip and multifocal lesions were seen in 13% (6 cases), more common in immune compromised cases. Pain was the most common symptom (95%) followed by constitutional symptoms. Radiographic changes were nonspecific, appear late and suggestive of tuberculosis in 53%case, MRI is very useful in diagnosing in 95% cases especially when X ray is contributory. ESR is useful tool for follow up of patients, elevated in 94%cases. Results were evaluated on clinical, hematological and radiological basis. Of the total 64cases (after dropouts, lost in follow up, mortality), 50 patients (78%) received treatment for 6 months and14 cases for more than 6months (P value<0.001). No MDR cases were present. In 50 patients fall in ESR at the end of 2 months was found to be statistically significant (P value<0.05) and hence were given a treatment for 6 months, the fall at the end of 6 months was highly significant (P value<0.001). In rest of the 14 cases the duration of treatment was given for more than 6 months as the trend of fall of ESR was not significant. MRI changes were assessed in the form of osteitis, osteitis with discitis, abscess formation and granulation tissue on initiation of treatment, completion of treatment and 6 months after completion of treatment. Conclusion and Discussion. The experience shows that spinal tuberculosis is common in a tertiary health care centre in India with diagnosis possible by combination of clinical evaluation and radiological evaluation. Statistical significance was found in clinical symptoms, ESR trends and MRI evaluation in cases receiving 6 months of chemotherapy. With this study, WHO short course chemotherapy was found to be effective in spinal tuberculosis, with no relapse over a period of 6 years

Low back pain admission to orthopaedics, aged >55, routinely received a myeloma screen (protein electrophoresis and urinary Bence Jones proteins). Myeloma association guidelines outline the symptoms that should trigger investigation. Acute admissions for back pain alone do not form part of this. We aimed to establish the number of emergency back pain admissions, >55, in our unit over two years. We wished to identify all patients who had protein electrophoresis and/or urinary Bence Jones proteins taken, the number of positive results and diagnoses of myeloma. From our database all patients >55 admitted with back pain in 2009 and 2010 were identified. Using the electronic laboratory reporting system we recorded FBC/ESR/Electrophoresis/Urinary Bence-Jones Proteins. There were 7682 admissions from January 2009–December 2010. 87 were for back pain (1.4%). 55 patients were aged >55 years. Within this group – 22 had protein electrophoresis and 23 had Bence-Jones Proteins. All were negative. 36 patients had an ESR taken, 9 were elevated. None were subsequently found to have haematological malignancy. 53 patients had an FBC taken (5 were anaemic, 8 had leucocytosis and 3 had thrombocytopenia). 20 patients had a vertebral fracture (36.4%). There were no documented cases of myeloma. The Information & Statistics Division of NHS Scotland published figures that demonstrate in 2006–2010, in patients > 55, there were 716 new cases of myeloma in the West of Scotland. Extrapolating this to our unit, on average, we would expect 24 new cases / year in this age group from all presentations. Performing myeloma screens on all back pains does not fulfil recognised screening criteria. We propose myeloma screens are not performed routinely in patients >55 admitted with back pain. It would be reasonable to do so where there is evidence of bone marrow failure, or plasmocytoma on Xray, associated with non-mechanical back pain

Background. The discussion over the duration, type of therapy and regimen to be used in osteoarticular tuberculosis is losing importance in all orthopaedic gathering. Still little consensus is there over the universality of a treatment regime for osteoarticular tuberculosis. Material and Method. 340 new cases of osteoarticular tuberculosis were included in the study that were medically treated in the department of orthopaedics in a tertiary care center between 2001 and 2011. Out of which 202 cases were of spinal tuberculosis and 138 cases of extraspinal tuberculosis. 88 cases of spinal tuberculosis were treated by conventional method and 114 cases by short course chemotherapy. 60 cases of extraarticular tuberculosis were treated by conventional chemotherapy and 78 cases by short course and intermittent therapy. Results. All cases were evaluated on clinical, radiological and haematological basis. Cases who received conventional therapy received 18–24 months of treatment irrespective to the clinical, radiological and haematological parameters. Whereas those who received short course (2HRZE+4 HR) and intermittent therapy (DOTS) were evaluated for clinical improvement. Maximum follow up was of 12.8 years (conventional) minimum follow of 8 years (intermittent). The trend of fall in ESR, clinical and radiological parameters showed improvement beyond 2 years of initiation of treatment in cases that had stopped treatment at 6 months. But the improvement was slow after six months even in cases who received 24 months of chemotherapy. There were no relapses in all the three groups. Conclusion. This study reinforces that chemotherapy tailored to the response of treatment (6-9months) is the rational therapy. This study gives an insight over the evolution of different regimes as well as gives an understanding of the clinical treatment. Level of Evidence. Level 1. No relevant financial disclosures or conflicts of interest from any of the authors

Infection remains among the first reasons for failure of joint prosthesis. Currently, the golden standard for treating prosthetic joint infections (PJIs) is two-stage revision. However, two-stage procedures have been reported to be associated with higher costs and possible higher morbidity and mortality, compared to one-stage. Furthermore, recent studies showed the ability of a fast-resorbable, antibacterial-loaded hydrogel coating to reduce surgical site infections after joint replacement, by preventing bacterial colonization of implants. Aim of this study was then to compare the infection recurrence rate after a one-stage, cemenless exchange, performed with an antibacterial coated implant versus a standardized two-stage revision procedure. In this two-center prospective study, 22 patients, candidate to revision surgery for PJI, were enrolled to undergo a one-stage revision surgery with cementless implants, coated intra-operatively with a fast-resorbable, antibiotic-loaded hyaluronan and poly-D,L-lactide based hydrogel coating (“Defensive Antibacterial Coating”, DAC, Novagenit, Italy). DAC was reconstructed according to manufacturer indications and loaded with Vancomycin or Vancomycin + Meropenem, according to cultural examinations, and directly spread onto the implant before insertion. This prospective cohort was compared with a retrospective series of 22 consecutive patients, matched for age, sex, host type, site of surgery, that underwent a two stage procedure, using a preformed, antibiotic-loaded spacer (Tecres, Italy) and a cementless implant. The second surgery, for definitive implant placing, was performed only after CRP normalization and no clinical sign of infection. Clinical, laboratory and radiographic evaluation were performed at 3, 6 and 12 months, and every 6 months thereafter. Infection recurrence was defined by the presence of a sinus tract communicating with the joint, or at least two among the following criteria: clinical signs of infections; elevated CRP and ESR; elevated synovial fluid WBC count; elevated synovial fluid leukocyte esterase; a positive cultural examination from synovial fluid; radiographic signs of stem loosening. The two groups did not differ significantly for age, sex, host type and site of surgery (18 knees and 4 hips, respectively). The DAC hydrogel was loaded intra-operatively, according to cultural examination, with vancomycin (14 patients) or vancomycin and meropenem (8 cases). At a mean follow-up of 20.2 ± 6.3 months, 2 patients (9.1%) in the DAC group showed an infection recurrence, compared to 3 patients (13.6%) in the two-stage group. No adverse events associated with the use of DAC or radiographic loosening of the stem were observed at the latest follow-up months. This is the first report on one-stage cementless revision surgery for PJI, performed with a fast-resorbable antibacterial hydrogel coating. Our data, although in a limited series of patients and at a relatively short follow-up, show similar infection recurrence rate after one-stage exchange with cementless, coated implants, compared to two-stage revision. These findings warrant further studies in the possible applications of antibacterial coating technologies to treat implant-related infections

Deep surgical infections are a serious complication of total knee arthroplasty (TKA). Various protocols exist for treating these infections, each with its own advocates. In this series we report the one to five year follow-up of infected TKA that were treated with a two-stage revision knee replacement at the Glasgow Royal Infirmary between December 2003 and March 2009. 48 patients were identified from the hospital database. 6 of these were excluded as they did not meet the stipulated infection criteria. Another patient was excluded as no notes were available thereby the infection status could not be determined. Another 8 patients were excluded as these only had a first stage. 33 patients (16 male) average age 67y (49–88) met the inclusion criteria. Mean BMI was of 31.62 (19–47) and 8 patients suffered from rheumatoid arthritis. At presentation, the median for the ESR, CRP and WCC were 70.5, 133 and 8.5 respectively. The infective organism was identified in 22 patients. Following the first stage, the patients were treated with antibiotics (initially intravenous followed by oral) for an average of 11.8 weeks (4–52 weeks). This procedure failed to eliminate the infection in 6 patients (18.18%) who had further re-admissions for infection of the affected prosthesis. The resultant success rate is of over 80% which is comparable to literature data (success rates of 41% to 96% quoted). For these patients, the average time to review was 25.13 months (12–67months). At review these patients had a mean extension of 2.17° (0–10°) and a mean flexion of 98.26 (70–120°). These patients were all satisfied with their outcome. Our results show a high successful rate of elimination of infection when a two-stage revision is used for infected knee prosthesis with over 80% of patients free of infection

Discitis in childhood is rare. It can be difficult to diagnose, particularly in the younger child, often leading to a delay in initiation of appropriate treatment. It is not known whether it represents an infective or an inflammatory process. Our aim was to review all cases treated at a regional children's hospital since the introduction of the departmental database. A retrospective review (64,058 cases), for the period 1990-2008 was performed. 12 cases were identified (3 male/9 female), with a biphasic age distribution; eight [mean 22 months old (12-32)] and four [mean 12 years old (11-13)]. Mean time to diagnosis from onset was 22 days, (5-49). Symptoms varied with age, no one less than 28 months complained of back pain, while all over 28 months did, to a varying degree. All the younger children presented primarily with a gait abnormality. 92% (11/12) were apyrexial on admission. WBC and CRP were normal in 83% (10/12). Venous blood cultures were negative in 89% (8/9). Only ESR was mildly raised, mean 30 (10-65). Radiographs showed loss of intervertebral disc height in 91% (10/11), earliest by 10 days following onset symptoms, mean 28 days. A technetium bone scan was performed in 42% (5/12) and an MRI of the lumbar spine, in 58% (7/12). All were positive for discitis. All occurred in the lumbar spine, 50% at L3/4. Antibiotics were used in 11/12 (92%), flucloxacillin alone in the majority 9/11. One had non-steroidal medication alone. No form of brace was used. Mean follow-up was 13.3 months (2-36). In all, symptoms had resolved by mean 6.5 weeks (2-12). No recurrence was noted. The common features of childhood discitis are presented; knowledge of these may aid the physician to come to a more rapid diagnosis of this uncommon paediatric condition

Background. Establishing the diagnosis in a child presenting with an atraumatic limp can be challenging. There is particular difficulty distinguishing septic arthritis (SA) from transient synovitis (TS) and consequently clinical prediction algorithms have been devised to differentiate the conditions using the presence of fever, raised erythrocyte sedimentation rate (ESR), raised white cell count (WCC) and inability to weight bear. Within Europe measurement of the ESR has largely been replaced with assessment of C-reactive protein (CRP) as an acute phase protein. We have evaluated the utility of including CRP in a clinical prediction algorithm to distinguish TS from SA. Method. All children with a presentation of ‘atraumatic limp’ and a proven effusion on hip ultrasound between 2004 and 2009 were included. Patient demographics, details of the clinical presentation and laboratory investigations were documented to identify a response to each of four variables (Weight bearing status, WCC >12,000 cells/m3, CRP >20mg/L and Temperature >38.5 degrees C. The definition of SA was based upon microscopy and culture of the joint fluid collected at arthrotomy. Results. 311 hips were included within the study. Of these 282 were considered to have transient synovitis. 29 patients met criteria to be classified as SA based upon laboratory assessment of the synovial fluid. The introduction of CRP eliminated the need for a four variable model as the use of two variables (CRP and weight bearing status) had similar efficacy. An algorithm that indicated a diagnosis of SA in individuals who could not weight-bear and who had a CRP >20mg/L correctly classified SA in 94.8% individuals, with a sensitivity of 75.9%, specificity of 96.8%, positive predictive value of 71.0%, and negative predictive value of 97.5%. CRP was a significant independent predictor of septic arthritis. Conclusions. CRP was a strong independent risk factor of septic arthritis, and its inclusion within a regression model simplifies the diagnostic algorithm, such that a two-variable model correctly classified 95% individuals with SA. Nevertheless, this and similar algorithms are generally more reliable in excluding SA, than confirming SA, and therefore a clinician's acumen remains important in identifying SA in those individuals with a single abnormal variable

Summary. Pyogenic spondylodiscitis is an uncommon but severe spinal infection. In majority of cases treatment is based on intravenous antibiotics and rigid brace immobilization. Posterior percutaneous spinal instrumentation is a safe alternative procedure in relieving pain, preventing deformity and neurological compromise. Introduction. Pyogenic spondylodiscitis (PS) is an uncommon but severe spinal infection. Patients affected by a non-complicated PS and treatment is based on intravenous antibiotics and rigid brace immobilization with a thoracolumbosacral orthosis (TLSO) suffices in most cases in relieving pain, preventing deformity and neurological compromise. Since January 2010 we started offering patients percutaneous posterior screw-rod instrumentation as alternative approach to TLSO immobilization. The aim of this study was to evaluate safety and effectiveness of posterior percutaneous spinal instrumentation for single level lower thoracic (T9-T12) or lumbar pyogenic spondylodiscitis. Materials and Methods. Retrospective cohort analysis on 27 patients diagnosed with PS who were offered to choose between 24/7 TLSO rigid bracing for 3 to 4 months and posterior percutaneous screw-rod instrumentation bridging the infection level followed by soft bracing for 4 weeks after surgery. All patients underwent antibiotic therapy. Fifteen patients chose conservative treatment, 12 patients chose surgical treatment. Patients were seen at 1, 3, 6, 9 months after diagnosis. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and complete blood count were measured at each follow-up visit. Segmental kyphosis was measured at diagnosis and at 9 months. VAS, SF-12, and EQ-5D questionnaires were recorded at each follow-up visit. Baseline groups’ demographic characteristics were assessed using independent sample t-tests for continuous variables and χ2 tests for frequency variables. Results. Complete healing was achieved in all patients, no difference was observed in healing time between the two groups (77.3±7.2 days vs 80.2±4.4). Instrumentation failure and screw loosening was not observed in any patient. In both group CRP and ESR decreased accordingly with response to antibiotic therapy. Surgically treated patients had significantly lower VAS scores at 1 month (3.05±0.57 in surgery group vs 5.20±1.21 in TLSO group) and 3 months (2.31±0.54 in surgery group vs 2.85±0.55 in TLSO group) post-diagnosis. Both groups had similar trends toward fast recovery in both mental (MCS) and physical components (PCS) of SF-12 questionnaire, surgically treated patients showed steeper and statistically significative improvement at 1 month (37.83±4.57 MCS in surgery group vs 24.52±3.03 MCS in TLSO group and 35.46±4.43 PCS in surgery group vs 27.07±4.45 PCS in TLSO group, p<0.001), 3 months (52.94±3.82 MCS in surgery group vs 39.45±4.92 MCS in TLSO group and 44.93±3.73 PCS in surgery group vs 35.33±6.44 PCS in TLSO group, p<0.001), and 6 months (54.93±3.56 MCS in surgery group vs 49.99±5.82 MCS in TLSO group) post-diagnosis, no statistically significant differences were detected at the other time points (9 months post-diagnosis). EQ-5D index was significantly higher in surgery patients at 1 month (0.764±0.043 in surgery group vs 0.458±0.197 in TLSO group) and 3 months (0.890±0.116 in surgery group vs 0.688±0.142 in TLSO group); no statistically significant changes were observed in segmental kyphosis between the two groups. Conclusion. Posterior percutaneous spinal instrumentation is a safe, feasible, and effective procedure in relieving pain, preventing deformity and neurological compromise. Surgical stabilization was associated with faster recovery, lower pain scores, and improved quality of life compared with TLSO conservative treatment at 1 and 3 months after diagnosis

The treatment of chronic osteomyelitis often includes surgical debridement and filling the resultant void with antibiotic-loaded polymethylmethacrylate cement, bone grafts or bone substitutes. Recently, the use of bioactive glass to treat bone defects in infections has been reported in a limited series of patients. However, no direct comparison between this biomaterial and antibiotic-loaded bone substitute has been performed.

In this retrospective study, we compared the safety and efficacy of surgical debridement and local application of the bioactive glass S53P4 in a series of 27 patients affected by chronic osteomyelitis of the long bones (Group A) with two other series, treated respectively with an antibiotic-loaded hydroxyapatite and calcium sulphate compound (Group B; n = 27) or a mixture of tricalcium phosphate and an antibiotic-loaded demineralised bone matrix (Group C; n = 22). Systemic antibiotics were also used in all groups.

After comparable periods of follow-up, the control of infection was similar in the three groups. In particular, 25 out of 27 (92.6%) patients of Group A, 24 out of 27 (88.9%) in Group B and 19 out of 22 (86.3%) in Group C showed no infection recurrence at means of 21.8 (12 to 36), 22.1 (12 to 36) and 21.5 (12 to 36) months follow-up, respectively, while Group A showed a reduced wound complication rate.

Our results show that patients treated with a bioactive glass without local antibiotics achieved similar eradication of infection and less drainage than those treated with two different antibiotic-loaded calcium-based bone substitutes.

Cite this article: Bone Joint J 2014; 96-B:845–50.

Objectives

To determine the pattern of mutations of the WISP3 gene in clinically identified progressive pseudorheumatoid dysplasia (PPD) in an Indian population.

Platelet-leucocyte gel (PLG), a new biotechnological blood product, has hitherto been used primarily to treat chronic ulcers and to promote soft-tissue and bone regeneration in a wide range of medical fields. In this study, the antimicrobial efficacy of PLG against Staphylococcus aureus (ATCC 25923) was investigated in a rabbit model of osteomyelitis. Autologous PLG was injected into the tibial canal after inoculation with Staph. aureus. The prophylactic efficacy of PLG was evaluated by microbiological, radiological and histological examination. Animal groups included a treatment group that received systemic cefazolin and a control group that received no treatment.

Treatment with PLG or cefazolin significantly reduced radiological and histological severity scores compared to the control group. This result was confirmed by a significant reduction in the infection rate and the number of viable bacteria. Although not comparable to cefazolin, PLG exhibited antimicrobial efficacy in vivo and therefore represents a novel strategy to prevent bone infection in humans.

We studied 51 patients with osteo-articular tuberculosis who were divided into two groups. Group I comprised 31 newly-diagnosed patients who were given first-line antituberculous treatment consisting of isoniazid, rifampicin, ethambutol and pyrazinamide. Group II (non-responders) consisted of 20 patients with a history of clinical non-responsiveness to supervised uninterrupted antituberculous treatment for a minimum of three months or a recurrence of a previous lesion which on clinical observation had healed. No patient in either group was HIV-positive. Group II were treated with an immunomodulation regime of intradermal BCG, oral levamisole and intramuscular diphtheria and tetanus vaccines as an adjunct for eight weeks in addition to antituberculous treatment. We gave antituberculous treatment for a total of 12 to 18 months in both groups and they were followed up for a mean of 30.2 months (24 to 49). A series of 20 healthy blood donors served as a control group.

Twenty-nine (93.6%) of the 31 patients in group I and 14 of the 20 (70%) in group II had a clinicoradiological healing response to treatment by five months.

The CD4 cell count in both groups was depressed at the time of enrolment, with a greater degree of depression in the group-II patients (686 cells/mm³ (sd 261) and 545 cells/mm³ (sd 137), respectively; p < 0.05). After treatment for three months both groups showed significant elevation of the CD4 cell count, reaching a level comparable with the control group. However, the mean CD4 cell count of group II (945 cells/mm³ (sd 343)) still remained lower than that of group I (1071 cells/mm³ (sd 290)), but the difference was not significant. Our study has shown encouraging results after immunomodulation and antituberculous treatment in non-responsive patients. The pattern of change in the CD4 cell count in response to treatment may be a reliable clinical indicator.

Ciprofloxacin hydrochloride-loaded microspheres were prepared by a spray-drying method using pectin and chitosan. The effects of different polymers and drug ratios were investigated.

The most appropriate carriers were selected by in vitro testing. A rat methicillin-resistant Staphylococcus aureus osteomyelitis model was used to evaluate the effects of the loaded microspheres.

The drug was released rapidly from the pectin carrier but this was more sustained in the chitosan formulation.

Chitosan microspheres loaded with ciprofloxacin hydrochloride were more effective for the treatment of osteomyelitis than equivalent intramuscular antibiotics.