The February 2024 Research Roundup³⁶⁰ looks at: If you use a surgical helmet, you should seal your gown-glove interface; The use of iodophor-impregnated drapes in patients with iodine-related allergies: a case series and review of the literature; Location of the ovaries in children and efficacy of gonadal shielding in hip and pelvis radiography; Prehospital tranexamic acid administration does not improve outcomes in severe trauma patients; Silver-coated distal femur megaprosthesis in chronic infections with severe bone loss: a multicentre case series.

Aims. Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA. Methods. A prospective cohort study was performed. Patients were excluded if they had poor renal function, known allergic reaction to vancomycin or tobramycin, received intravenous vancomycin, or were scheduled for same-day discharge. All patients received 600 mg tobramycin and 1 g of vancomycin powder suspended in 25 cc of normal saline and injected into the joint after closure of the arthrotomy. Serum from peripheral venous blood and drain fluid samples were collected at one, four, and 24 hours postoperatively. All concentrations are reported in µg per ml. Results. A total of 22 patients were included in final analysis. At one, four, and 24 hours postoperatively, mean (95% confidence interval (CI)) serum concentrations were 2.4 (0.7 to 4.1), 5.0 (3.1 to 6.9), and 4.8 (2.8 to 6.9) for vancomycin and 4.9 (3.4 to 6.3), 7.0 (5.8 to 8.2), and 1.3 (0.8 to 1.8) for tobramycin; intra-articular concentrations were 1,900.6 (1,492.5 to 2,308.8), 717.9 (485.5 to 950.3), and 162.2 (20.5 to 304.0) for vancomycin and 2,105.3 (1,389.9 to 2,820.6), 403.2 (266.6 to 539.7), and 98.8 (0 to 206.5) for tobramycin. Conclusion. Intra-articular administration of 1 g of vancomycin and 600 mg of tobramycin as a solution after closure of the arthrotomy in primary cementless TKA achieves therapeutic intra-articular concentrations over the first 24 hours postoperatively and does not reach sustained toxic levels in peripheral blood. Cite this article: Bone Joint J 2021;103-B(11):1702–1708

Periprosthetic infection after total joint replacement is a catastrophic complication. Current rates of infection have been decreasing and in most centers now are in the range of 0.1–1%. Peri-operative intravenous antibiotic therapy is used routinely in total hip arthroplasty patients at this time. With rates this low and mixed evidence that antibiotics in bone cement for routine total hip replacement are beneficial at reducing joint infection, routine use of this practice seems unnecessary and has potential disadvantages. Cost of antibiotics being added to cement on a routine basis will increase the cost of the arthroplasty $300–$500. Although small addition of bone cement also has a negative effect on the mechanical properties of the cement. The major disadvantage remains the danger of resistant bacterial strains from excessive use of antibiotics particularly vancomycin resistant organisms when it is used routinely. Although rare with the aminoglycosides, allergic reactions may occur if cephalosporins are used as prophylaxis. Use of antibiotics in bone cement should be considered in high risk patients for infection undergoing total hip replacement but not routinely because of cost, emergence of resistant organism and possible allergic reaction

Apart from the inflammatory reaction upon surgery itself, the immunological biocompatibility of a given material varies with factors like the site of implantation, the immunogenicity of implant constituents and the individual reactivity of the patient. Most investigations have focused on cytotoxic, osteolytic or proinflammatory effects of wear debris and corrosion products. In some patients specific immune response, e.g. allergic reactions, to the implant components may develop and lead to localized or generalized eczema, local swelling, recurrent urticaria or even implant loosening. However the number of these patients seems to be much lower than the sensitisation rates to cobalt, chromium or nickel ranging between 2–10% in the general population. To identify implant associated allergic reactions the diagnostic approach should encompass both epicutaneous patch testing and in vitro methods, e.g. analysis of T-cell reactivity in peripheral blood and perimplantar tissue. Several patients with allergy-mediated implant intolerance under the picture of eczema, swelling, seroma formation or implant loosening will be presented. Based on these cases, a new panel of patch test substances (developed by the German Contact Dermatitis Group), immunohistology and molecular biology approach to characterize the periimplantar immune response will be exemplified. As the author is actually establishing a nationwide register for implant-associated allergic reactions, more information about incidence and clinical picture of these reactions will be available in the future. Certainly, these patients profit from an interdisciplinary problem solving approach

Aim. Patients reporting penicillin allergy do often receive clindamycin as systemic antibiotic prophylaxis. The effect of clindamycin has however not been compared to antibiotics with proven effect in joint arthroplasty surgery. The aim of the study was to reveal if there were differences in the rate of revision due to infection after total knee arthroplasty (TKA) depending on which antibiotic was used as systemic prophylaxis. Method. Patients reported to the Swedish Knee Arthroplasty Register having a TKA performed due to osteoarthritis (OA) during the years 2009 – 2015 were included in the study. The type of prophylactic antibiotic is individually registered. For 80,018 operations survival statistics were used to calculate the rate of revision due to infection until the end of 2015, comparing the group of patients receiving the beta-lactam cloxacillin with those receiving clindamycin as systemic prophylaxis. Results. Cloxacillin was used in 90% of the cases, clindamycin in 7% and cephalosporins in 2%. The risk of becoming revised due to infection was higher when using clindamycin than cloxacillin, RR 1.51 (95% CI: 1.18–1.95, p=0.001). There was no significant difference in revision rate due to other causes, (p=0.21). Conclusions. We advise that patients reporting allergic reaction to penicillin have their allergic history explored. In the absence of clear history of type 1 allergic reaction we suggest the use of a cephalosporin instead of clindamycin as a perioperative prophylaxis when undergoing a TKR. No recommendation can be given regarding patients with type 1 allergy

The purpose of this study was to evaluate the safety of liquid collagen and cross-linked collagen in treating bone defects. In a prospective trial, the use of liquid collagen and a stiffer, slightly more rigid cross-linked collagen allograft was evaluated. Bone cavities resulting from curettage of cysts or tumours were filled with either liquid or cross-linked collagen. The collagen was extracted from donor allograft and mixed with minute particles of crushed cortical bone. Patients were monitored clinically, radiologically and haematologically for complications, including infection, rejection or allergic reactions. There were five patients with osteoid osteoma, five with chondrosarcoma, two with bone cysts, five with osteitis and three with chondroblastoma. One patient each had enchondroma, ossifying fibroma, osteosarcoma, aneurysmal bone cyst, fibrous dysplasia, thickening of the tibial cortex, avascular necrosis, Ewing’s sarcoma, a luxstacortical ganglion and a tumour of the pubic symphysis. Eleven patients received liquid collagen and 32 cross-linked collagen. The use of liquid collagen was abandoned because it was too fluid to keep in the cavity. The cross-linked collagen, though more solid, could be introduced even through small holes in a bone or spinal cages. No allergic reactions occurred and the bone graft behaved similarly to a combination of allograft/autogenous graft. Cross-linked collagen is as effective as any other allogenic bone product in bone cavities. In this series there were no complications attributable to the graft

Aims: Palacos cement is one of the commonest types of bone cements used in joint replacement surgery. It contains peanut oil which is used as a diluent for Chlorophyll to give the green colour. The manufacturer’s instruction states that it is a contra-indication to use Palacos cement in patients allergic to peanut. The aim of our study was to check the awareness among the orthopaedic surgeons of this contra-indication and find their views on using Palacos cement in patients allergic to peanuts. Methods: We conducted a postal questionnaire survey among all the orthopaedic surgeons and trainees in Wales, enquiring about their prior knowledge of the contra-indication and their views on what should be done if the patient undergoing arthroplasty has peanut allergy. Results: There was a response rate of 71%. Only 20% of the consultants and only 40% of the trainees were aware of the contraindication. There were widely conflicting views on what should be done if the patient has peanut allergy. Those views included using different cement, using uncemented implant, seeking second opinion and some suggested they would still continue to use Palacos cement despite history of peanut allergy. Conclusions: Majority of the orthopaedic surgeons in our study were not aware of the contraindication. This is surprising as peanut allergy could be life threatening. But we are unaware of any reported case of allergic reaction in peanut allergic patients. Review of the literature also suggests that as the peanut oil in Palacos cement is highly refined peanut oil, it is very unlikely to produce allergic reaction in peanut allergic patients. There is no evidence-based reason to support the manufacturer’s advice that Palacos cement should not be used in patients allergic to peanuts

Despite the demonstrated success in revision total joint arthroplasties, the utilization of antibiotic-loaded bone cement in primary total joint arthroplasty remains controversial. Multiple studies have demonstrated several risks associated with the routine use of this technique including: allergic reactions, changing the mechanical properties of the cement, emergence of resistant bacterial strains, systemic toxicity, and the added cost. In addition, evidence shows a currently low rate of periprosthetic joint infections in primary total joint arthroplasty (around 1%) and the theoretical benefit of marginally reducing this rate by using antibiotic-cement may not necessarily justify the associated risks and the added cost. Moreover, most of the primary total hip and an increasing number of primary total knee arthroplasties are cementless, which further raises questions about the routine use of antibiotic-loaded bone cement in primary total joint arthroplasty

Introduction. Cardiac events have been found to occur with increased frequency in total joint arthroplasty (TJA) patients >65 y/o without known coronary artery disease (CAD). Avoidance of readmissions for cardiac events is paramount with bundled payment programs. It has been thought that many of these patients may have undiagnosed CAD because of sedentary life styles brought on by chronic osteoarthritis. The purpose of this study is to assess with Coronary Computed Tomographic Angiography (CCTA) the prevalence and severity of CAD in patients >65 y/o for elective TJA. Methods. 126 elective patients that were part of a total hip and knee bundled payment program were referred for cardiac evaluation with CCTA if they were >65 but <70 y/o with a history of heart disease or 2 risk factors or were >70 y/o. CCTA was acquired on all patients unless they had a history of a severe allergic reaction to contrast, GFR <50 ml/min., the presence of atrial fibrillation, or declined the test. All images were evaluated by an experienced reader. Arterial narrowing of 70% diameter or greater was classified as significant CAD. Intermediate lesions <70% were reclassified as significant if CT-FFR (Functional flow reserve) was < or = 0.80. Results. Excluding the 12 patients with known CAD who had stents or coronary artery bypass graft (CABG), the remaining 114 patients were classified into three groups. 34/114 (29.8%) had no CAD (Group A). 75/114 (65.8%) had (Group B). 5/114 (4.4%) had > or = 70% stenosis. Group C included one patient who had <70% stenosis but had CT-FFR <80%. Of 17 patients with known CAD with >70% or heart CT-FFR <80%, or prior stents/CABG, one patient was predicted to be high risk of a cardiac event because of a complex plaque with an ulcer, history of suppressed paroxysmal atrial fibrillation, and withdrawal from apixaban. He was nurse navigated throughout his hospital course and post discharge only to be recalled to the hospital to be rescued with cardiac stenting. Conclusion. Patients >65 y/o having TJA without a cardiac history were found to have a 4.4% prevalence of significant CAD. When added to the patients with known CAD, the overall prevalence was 13.5%. One patient had complex plaque predictive of a cardiac event. As the US population ages and TJA becomes more prevalent with greater pressure to reduce costs by bundling and shifting to outpatient surgery, further data needs to be collected to better understand CAD in TJA patients >65 y/o

Despite the prophylactic use of antibiotics and hygienic strategies, surgical site infection following total joint arthroplasty (TJA) is still a severe and unsolved complication. Since antibiotic-loaded bone cement (ALBC) was introduced by Buchholz in the 1970s, the use of ALBC has been increasingly used for the prevention and treatment of periprosthetic infection (PPI). However, the routine use of ALBC during primary TJA remains controversial. Recent clinical studies have found that ALBC is effective in reducing the risk of PJI following primary TJA. Although ALBC having the advantage of reducing the risk of PJI, the main disadvantages are the possible development of toxicity, antibiotic resistance, allergic reaction, and possible reduction of the mechanical properties of bone cement. Nevertheless, a recent published article demonstrated, that the use of high dose dual-antibiotic impregnated cement reduce significantly the rate of surgical site infections compared to standard low dose single ALBC in the setting of a hip fracture treating with hemiarthroplasty. Furthermore, Sanz-Ruiz et al. presented that the use of ALBC in TJA has favorable cost-efficiency profile. In this context, reasons why surgeons should use antibiotic-loaded bone cement during primary TJA are demonstrated

Background. Revision hip arthroplasty for excessive bone loss because of osteolysis or infection is difficult theme. Bone grafting is essential technique for bone loss and need of allograft is increasing. Recently, many hospital bone banks are established in Japan. The aim of this study is investigate efficacy and safety of allograft in our hospital bone bank. Material and method. We evaluated management, result and complication of allografts retrieved from living donors in our institute. Result. All donors meet the criteria of Japanese Orthopaedic Association (JOA) guideline and gave fully informed written consent. We obtained 75 femoral head grafts that were retrieved during primary total hip arthroplasty under sterile operating theatre conditions. No donor had hepatitis B and C, human immunodeficiency (HIV), Human T-cell leukemia (HTLV-1) and Syphilis. After heat treatment, allograft was swabbed for cultures and stored in freezer at −80□. All cultures ware negative and proved before implantation. We used allograft in 27 revision hip arthroplasty. Six cases were femoral side and 21cases were acetabular side. At the minimum of 3 months follow-up, 1 fracture of acetablar and 1 superficial infection occurred. No allergic reaction happened. Conclusion. Our bone bank thoroughly managed based on JOA guideline was effective and safe. Careful follow-up is needed for long-term implant fixation and osteoinduction

Modern metal-on-metal bearings were reintroduced on the market by Prof. B.G. Weber in 1988. Since this date, more than 500,000 bearings have been implanted world-wide with excellent clinical results. The goals of this presentation are to review critically the long-term published clinical results for metal-on-metal bearings (small and large diameter) and to investigate the current concerns (ions release, allergic reactions, pseudo-tumours…) about metal-on-metal bearings. Based on this review, the benefice-risk ratio of metal-on-metal bearings will be discussed

Surgery for pelvic or acetabular fractures carries a high risk of deep-vein thrombosis (DVT). Reports indicate that fondaparinux is a more effective thromboprophylactic agent than low molecular weight heparin (LMWH) after major orthopaedic surgery. We prospectively evaluated a new protocol for DVT prophylaxis using fondaparinux. Patients and methods. One hundred and eight patients with pelvic or acetabular fractures were randomised to receive either fondaparinux or enoxaparin. Specific review points included the primary end-point of clinical deep vein thrombosis (DVT) or pulmonary embolism (PE) and any evidence of adverse effects such as bleeding or allergic reactions. Results. Two patients that received enoxaparin were found to have a DVT (3%) and one patient died from a PE (1%). There was no documented DVT or PE in patients that received fondaparinux. The mean number of units of blood transfused was significantly higher in the enoxaparin group and this was significant post-operatively (p<0.05). The current study supports that post-operative fondaparinux, in patients with pelvic and acetabular fractures, is more effective and equally safe to enoxaparin

Biodegradable implants made from polyglycolic and polylactic acid co-polymers undergo degradation by hydrolysis which results in loss of their mechanical strength. The degradation of 1.5 mm polyglycolide rods (Biofix) was studied after intramedullary and subcutaneous implantation in rabbits. Two weeks after implantation there was a 73% reduction in strength of the intramedullary implants and a 64% reduction in the subcutaneous implants. Polyglycolide implants were compared with Kirschner wires for intramedullary fixation of extra-articular fractures in the hand. In one group of patients fractures were fixed with a 1.5 mm intramedullary rod and in a similar group a Kirschner wire was used. In both a wire loop was added for extra fixation. At six months there was no significant difference between the two groups. There were no allergic reactions to the polyglycolide implants

Introduction: Digital nerve lesions with nerve gaps require reconstruction with the use of some form of graft or guide. Neurotube, a bioabsorbable polyglycolic acid (PGA) conduit, has been proposed as an effective solution for this kind of defect in emergency and planned surgery. Methods: Nineteen posttraumatic lesions of common (5 cases) or proper (14 cases) palmar digital nerves were repaired by means of Neurotube from January 2003 till January 2006. The nerve gap size averaged 22 mm (range 15–35 mm). Thirteen lesions had associated vascular, tendon or osseous injury. Results: Nerve regeneration was evaluated at a mean of 17 months postoperative interval. Positive results in recovery of sensibility were noticed in 73 % of the cases; static and moving two point discrimination was excellent (less than 6mm and 4mm respectively) in 9 cases and fair in 5 (7–15mm and 5–7mm respectively). Dysesthesia was present in 6 patients, cold intolerance in two, delayed wound healing in one and one patient complained for painful scar. There was no infection, conduit extrusion or allergic reaction. Discussion and Conclusion: Bioabsorbable polyglycolic acid conduit presents an attractive and useful alternative for the reconstruction of digital nerve lesions with a small nerve gap, especially when a direct anastomosis of the two stumps is not possible, or when the suture appears to be in tension. Its use is simple, safe and also eliminates the donorsite morbidity associated with nerve-graft harvesting

Introduction. The correction of paediatric scoliosis is a surgical procedure in which substantial bleeding occurs, and which historically has been associated with high levels of blood transfusion. Transfusions are associated with risks of infection, allergic reactions, volume overload and immunosuppression. The purpose of our study was to evaluate the efficacy of a care pathway implemented at St Thomas' hospital over ten years with a focus on minimising the need for blood transfusions. A Spinal Surgery Care Pathway was developed including: nurse-led clinics facilitating pre-operative haemoglobin optimisation; intra operative cell-salvage, the use of tranexamic acid, and a transfusion criteria awareness programme. Methods. We reviewed the records of all patients 18 years of age or younger undergoing spinal corrective surgery between 2000 and 2010. Collating data from the surgical records and haematology laboratory, we identified the proportion of patients requiring transfusion and the respective volume of blood or blood products transfused. Results. 534 spinal procedures were undertaken on patients over the decade of interest. Over this time, the proportion of patients requiring transfusion reduced from 83.3% in 2000, to 6.4% in 2010 (p < 0.001); a consistent year on year reduction was witnessed between 2005 and 2010. In those requiring transfusion, the volume of packed red cells transfused fell from a mean of 7.7 units in 2000, to 1.5 units in 2010 (p < 0.001). These results were despite an increase in posterior fusions, associated with higher bleeding, from 50.0% to 79.4% over the same time period. Conclusion. Over ten years, we have demonstrated that the implementation of a multifaceted, multidisciplinary pathway together with challenging cultural attitudes to blood transfusion, can dramatically and sustainably reduce the need for blood transfusion and the risks associated therewith. These data lends weight to the adoption of such a care pathway in paediatric scoliosis surgery

The purpose of this paper is to present the results of the comparative study about the use of autologous transfusion system for drainage of surgical trauma after total knee arthroplasty, aiming to decrease the p.o. homologous blood transfusion need. During the period between Nov 2001 and Apr 2003 we studied 110 patients (80 women and 15 men, mean age 70,5 years) who underwent TKR. We used autologous transfusion system in 55 patients (group A) and for the rest 55 (group B) a plain negative pressure drainage system. From the group B patients, 35 (63,63%) were transfused with 2–4 blood units, while only 17 (30,9%) patients from group A had the need for homologous blood transfusion (2–5 units). But, we should mark that in 8 patients autologous transfusion system failed and 7 of them were transfused (2 units each). This means that from group A patients to whom autologous transfusion system was used successfully (47) only for 10 (21,27%) there was need for homologous blood transfusion. The autologous transfusion system gave 200–1650cc (mean 619cc) of blood. None of group A patients and 2 of group B had allergic reaction. In conclusion, the autologous transfusion system contributes to decreasing the homologous blood transfusion after TKR and in addition it decreases the transfusion’s complications

Reconstruction of the lateral ligaments of the ankle has been performed for many years, but few reports are available regarding the outcome after 10 years or longer, and there are no such reports on reconstruction with the more recently developed artificial ligaments. I report the clinical outcome and radiological findings. Materials and results: The subjects are 62 feet in 57 patients (male 28 feet, female 34 feet). All patients were followed up by direct examination and stress roentgenography for 10 years or longer. Mean follow-up period is 11 years and 9 months. On stress X-ray taken at the final examination, TTA improved preoperatively 19 degrees to 4 degrees postoperatively, and ADT improved from 12 to 5 mm. There was no marked development or progression of arthropathic changes. No allergic reaction to the artificial ligament material occurred in any patient. postoperatively and no patient had instability that became severe enough for reoperation to be required. As for arthropathic changes, in 3 patients with a TTA of 10 degrees or more postoperatively, progression of mild osteoarthritic changes was observed. Discussion: There have been few studies involving long-term follow-up for 10 years or more. This procedure is not happened OA changes and ADL limitation because reconstruction at anatomical position of ATFL and CFL. It has not been happened pathological rupture of artificial ligament because lateral ligaments are not intra-articular ligament but periarticular ligament. Conclusion: Reconstruction with artificial ligament is anatomical procedure and can be expected the prolonged effectiveness

Introduction: It is very common in spine surgery to transfuse substantial amounts of homologous blood. The danger of spreading infectious diseases (HIV, HBV etc.) as well as possible side- effects of multiple transfusions (haemolysis, anaphylaxia, etc.) has created the necessity of finding methods to minimize the amount of homologous blood transfusions. One of these methods is the use of systems for autotransfusion of the patient’s drained blood. Purpose: Evaluation of the advantages of the use of postoperative autotransfusion systems is spine surgery. Methods: 26 patients were evaluated, from November 2002 until May 2003, who underwent posterior spinal fusion and to whom postoperative autotransfusion was used. The patients’ group consisted of 19 women and 7 men aged from 14–75 years old (aver.23.8 years of age). We recorded the preoperative haematocrit value, the amount of homologous blood transfused intra- and postoperatively, the amount of autologous blood transfused as well as the haematocrit values at the 1st, 2nd, and 5th postoperative day. Moreover all the patients were observed postoperatively for possible complications relevant to autotransfusion. Results: 70% of the patients did not require postoperative transfusion with homologous blood. We observed allergic reactions in 4 patients and fever in 3 patients. These findings were not directly correlated to autotrans-fusion, however the autotransfusion was interrupted. There were no major complications. The above mentioned results are considered to be encouraging for further us and study of postoperative autotransfusion systems in spine surgery

In a randomized study of 60 patients allergic reactions are evaluated in three joint prosthesis groups, a resurfacing arthroplasty (ReCap), a non-cemented, large metal-on-metal head (Bimetric Magnum) and a non-cemented, alumina ceramic-on-ceramic bearing in a titanium shell (Bimetric C2a). The inclusion criteria were osteoarthritis, ASA I–II, MRI-scan without caput necrosis, DXA-scan without osteoporosis. The exclusion criteria were short neck (<2cm.), large cysts (>1cm.), medical treatment affecting the bone metabolism, severe deformity of the femoral head, impaired kidney function and inability to co-operate. Blood samples were drawn prior to and 6 weeks, 6 months, 1 year, and 3 years after surgery; two tubes from which plasma was prepared, and two tubes for serum. From the last included 20 patients in each group was also taken blood one and three years after surgery for an in vitro lymphocyte assay for scoring of possible hypersensitivity to prosthesis metals. The isolated lymphocytes were subjected to measurement of proliferation and expression of CD69 by flow cytometry and measurement of the Migration Inhibitory Factor (MIF) by ELISA. Plasma concentrations of the cytokines IL-1, IL-4, IL-6, IL-8, IL-12p70, IL-15, interferon-and osteoprotegerin were determined by multiplex-immunoassay. Serum concentrations of chromium and cobalt were determined by graphite furnace atomic absorption spectrometry. The serum concentrations of chromium and cobalt were lowest in patients with the C2a implant and highest with Magnum, some of these differences were significant at 6 weeks, 6 months, and 1 year after surgery. No patient had a very high serum metal concentration. The values of the variables measured in the in vitro lymphocyte assay mainly changed in the expected direction depending on the concentration of the same metal in the serum sample drawn at the same time, but no significant correlation was seen. One patient had uncertain symptoms of metal hypersensitivity and relatively high serum metal concentrations 3 years after arthroplasty with a Magnum prosthesis and was assessed extraordinarily, and elicited the marginally highest MIF responses in the lymphocyte assay. A strong correlation was found between the plasma concentrations of most cytokines, but the cytokine concentrations were not correlated to contemporary metal concentrations