The purpose of this article is to provide the
reader with a seven-step checklist that could help in minimising
the risk of PJI. The check list includes strategies that can be
implemented pre-operatively such as medical optimisation, and reduction
of the bioburden by effective skin preparation or actions taking
during surgery such as administration of timely and appropriate
antibiotics or blood conservation, and finally implementation of
post-operative protocols such as efforts to minimise wound drainage
and haematoma formation. Cite this article:
The primary aim of this study was to investigate the effect of
an enhanced recovery program (ERP) on the short-term functional
outcome after total hip arthroplasty (THA). Secondary outcomes included
its effect on rates of dislocation and mortality. Data were gathered on 1161 patients undergoing primary THA which
included 611 patients treated with traditional rehabilitation and
550 treated with an ERP. Aims
Patients and Methods
Hips with metal-on-metal total hip arthroplasty (MoM THA) have a high rate of adverse local tissue reactions (ALTR), often associated with hypersensitivity reactions. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) measures tissue perfusion with the parameter Ktrans (volume transfer constant of contrast agent). Our purpose was 1) to evaluate the feasibility of DCE-MRI in patients with THA and 2) to compare DCE-MRI in patients with MoM bearings with metal-on-polyethylene (MoP) bearings, hypothesising that the perfusion index Ktrans in hips with MoM THA is higher than in hips with MoP THA. In this pilot study, 16 patients with primary THA were recruited (eight MoM, eight MoP). DCE-MRI of the hip was performed at 1.5 Tesla (T). For each patient, Ktrans was computed voxel-by-voxel in all tissue lateral to the bladder. The mean Ktrans for all voxels was then calculated. These values were compared with respect to implant type and gender, and further correlated with clinical parameters.Objectives
Methods
The objective of this study was to determine if combining variations in mixing technique of antibiotic-impregnated polymethylmethacrylate (PMMA) cement with low frequency ultrasound (LFUS) improves antibiotic elution during the initial high phase (Phase I) and subsequent low phase (Phase II) while not diminishing mechanical strength. Three batches of vancomycin-loaded PMMA were prepared with different mixing techniques: a standard technique; a delayed technique; and a control without antibiotic. Daily elution samples were analysed using flow injection analysis (FIA). Beginning in Phase II, samples from each mix group were selected randomly to undergo either five, 15, 45, or 0 minutes of LFUS treatment. Elution amounts between LFUS treatments were analysed. Following Phase II, compression testing was done to quantify strength. Objectives
Methods
Little information is available about several
important aspects of the treatment of melioidosis osteomyelitis
and septic arthritis. We undertook a retrospective review of 50 patients with these
conditions in an attempt to determine the effect of location of
the disease, type of surgical intervention and duration of antibiotic
treatment on outcome, particularly complications and relapse. We found that there was a 27.5% risk of osteomyelitis of the
adjacent bone in patients with septic arthritis in the lower limb.
Patients with septic arthritis and osteomyelitis of an adjacent
bone were in hospital significantly longer (p = 0.001), needed more
operations (p = 0.031) and had a significantly higher rate of complications
and re-presentation (p = 0.048). More than half the patients (61%), most particularly those with
multifocal bone and joint involvement, and those with septic arthritis
and osteomyelitis of an adjacent bone who were treated operatively,
needed more visits to theatre. Cite this article:
We have investigated the effect of using tranexamic
acid (TXA) during peri-acetabular osteotomy (PAO) on peri-operative
blood loss and blood transfusion requirements. In addition we analysed
whether the use of TXA was associated with an increased risk of
venous thromboembolism (VTE) following this procedure. A consecutive series of 96 PAOs, performed by a single surgeon,
were reviewed. A total of 48 patients received TXA and 48 did not.
The TXA group received a continuous infusion of TXA at a rate of
10 mg/kg/h. The primary outcome measure was the requirement for
blood transfusion. Secondary outcomes included total blood loss,
the decrease in the level of haemoglobin in the blood, the length
of hospital stay, and the complications of this treatment. The mean rate of transfusion was significantly lower in the TXA
group (62.5% The use of TXA reduced the blood loss and the rate of transfusion
after PAO significantly, without adverse effects such as an increased
rate of VTE. Cite this article:
Intramedullary infection in long bones represents
a complex clinical challenge, with an increasing incidence due to the
increasing use of intramedullary fixation. We report a prospective
case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator
(RIA) system, in association with antibiotic cement rods for the
treatment of lower limb long bone infections. A total of 24 such
patients, 16 men and eight women, with a mean age of 44.5 years
(17 to 75), 14 with femoral and 10 with tibial infection, were treated
in a staged manner over a period of 2.5 years in a single referral
centre. Of these, 21 patients had had previous surgery, usually
for fixation of a fracture (seven had sustained an open fracture
originally and one had undergone fasciotomies). According to the
Cierny–Mader classification system, 18 patients were classified
as type 1A, four as 3A (discharging sinus tract), one as type 4A
and one as type 1B. Cite this article:
Necrotising soft-tissue infections (NSTIs) of
the upper limb are uncommon, but potentially life-threatening. We
used a national database to investigate the risk factors for amputation
of the limb and death. We extracted data from the Japanese Diagnosis Procedure Combination
database on 116 patients (79 men and 37 women) who had a NSTI of
the upper extremity between 2007 and 2010. The overall in-hospital mortality was 15.5%. Univariate analysis
of in-hospital mortality showed that the significant variables were
age (p = 0.015), liver dysfunction (p = 0.005), renal dysfunction
(P <
0.001), altered consciousness (p = 0.049), and sepsis (p
= 0.021). Logistic regression analysis showed that the factors associated with
death in hospital were age over 70 years (Odds Ratio (OR) 6.6; 95%
confidence interval (CI) 1.5 to 28.2; p = 0.011) and renal dysfunction
(OR 15.4; 95% CI 3.8 to 62.8; p <
0.001). Univariate analysis of limb amputation showed that the significant
variables were diabetes (p = 0.017) mellitus and sepsis (p = 0.001).
Multivariable logistic regression analysis showed that the factors
related to limb amputation were sepsis (OR 1.8; 95% CI 1.5 to 24.0;
p = 0.013) and diabetes mellitus (OR 1.6; 95% CI 1.1 to 21.1; p
= 0.038). For NSTIs of the upper extremity, advanced age and renal dysfunction
are both associated with a higher rate of in-hospital mortality.
Sepsis and diabetes mellitus are both associated with a higher rate
of amputation. Cite this article:
Clinical and radiological data were reviewed for all patients
with mucopolysaccharidoses (MPS) with thoracolumbar kyphosis managed
non-operatively or operatively in our institution. In all 16 patients were included (eight female: eight male; 50%
male), of whom nine had Hurler, five Morquio and two Hunter syndrome.
Six patients were treated non-operatively (mean age at presentation
of 6.3 years; 0.4 to 12.9); mean kyphotic progression +1.5o/year;
mean follow-up of 3.1 years (1 to 5.1) and ten patients operatively (mean
age at presentation of 4.7 years; 0.9 to 14.4); mean kyphotic progression
10.8o/year; mean follow-up of 8.2 years; 4.8 to 11.8)
by circumferential arthrodesis with posterior instrumentation in
patients with flexible deformities (n = 6).Aims
Methods
Although patients with a history of venous thromboembolism
(VTE) who undergo lower limb joint replacement are thought to be
at high risk of further VTE, the actual rate of recurrence has not
been reported. The purpose of this study was to identify the recurrence rate
of VTE in patients who had undergone lower limb joint replacement,
and to compare it with that of patients who had undergone a joint
replacement without a history of VTE. From a pool of 6646 arthroplasty procedures (3344 TKR, 2907 THR,
243 revision THR, 152 revision TKR) in 5967 patients (68% female,
mean age 67.7; 21 to 96) carried out between 2009 and 2011, we retrospectively
identified 118 consecutive treatment episodes in 106 patients (65%
female, mean age 70; 51 to 88,) who had suffered a previous VTE.
Despite mechanical prophylaxis and anticoagulation with warfarin,
we had four recurrences by three months (3.4% of 118) and six by
one year (5.1% of 118). In comparison, in all our other joint replacements
the rate of VTE was 0.54% (35/6528). The relative risk of a VTE by 90 days in patients who had undergone
a joint replacement with a history of VTE compared with those with
a joint replacement and no history of VTE was 6.3 (95% confidence
interval, 2.3 to 17.5). There were five complications in the previous
VTE group related to bleeding or over-anticoagulation. Cite this article:
Total knee arthroplasty (TKA) is a major orthopaedic
intervention. The length of a patient's stay has been progressively
reduced with the introduction of enhanced recovery protocols: day-case
surgery has become the ultimate challenge. This narrative review shows the potential limitations of day-case
TKA. These constraints may be social, linked to patient’s comorbidities,
or due to surgery-related adverse events (e.g. pain, post-operative
nausea and vomiting, etc.). Using patient stratification, tailored surgical techniques and
multimodal opioid-sparing analgesia, day-case TKA might be achievable
in a limited group of patients. The younger, male patient without
comorbidities and with an excellent social network around him might
be a candidate. Demographic changes, effective recovery programmes and less invasive
surgical techniques such as unicondylar knee arthroplasty, may increase
the size of the group of potential day-case patients. The cost reduction achieved by day-case TKA needs to be balanced
against any increase in morbidity and mortality and the cost of
advanced follow-up at a distance with new technology. These factors
need to be evaluated before adopting this ultimate ‘fast-track’
approach. Cite this article:
The October 2015 Trauma Roundup360 looks at: PCA not the best in resuscitation; Impact of trauma centre care; Quality of life after a hip fracture; Recovery and severity of injury: open tibial fractures in the spotlight; Assessment of the triplane fractures; Signs of an unstable paediatric pelvis; Safe insertion of SI screws: are two views required?; Post-operative delirium under the spotlight; Psychological effects of fractures; K-wires cost effective in DRAFFT
We report the five year outcomes of a two-stage
approach for infected total hip replacement. This is a single-surgeon
experience at a tertiary centre where the more straightforward cases
are treated using single-stage exchange. This study highlights the
vital role of the multidisciplinary team in managing these cases. A total of 125 patients (51 male, 74 female) with a mean age
of 68 years (42 to 78) were reviewed prospectively. Functional status
was assessed using the Harris hip score (HHS). The mean HHS improved
from 38 (6 to 78.5) pre-operatively to 81.2 (33 to 98) post-operatively.
Staphylococcus species were isolated in 85 patients (68%). The rate of control of infection was 96% at five years. In all,
19 patients died during the period of the study. This represented
a one year mortality of 0.8% and an overall mortality of 15.2% at
five years. No patients were lost to follow-up. We report excellent control of infection in a series of complex
patients and infections using a two-stage revision protocol supported
by a multidisciplinary approach. The reason for the high rate of
mortality in these patients is not known. Cite this article:
There have been only a few small studies of patients
with an infected shoulder replacement treated with a single-stage
exchange procedure. We retrospectively reviewed 35 patients (19 men
and 16 women) with a peri-prosthetic infection of the shoulder who
were treated in this way. A total of 26 were available for clinical
examination; three had died, two were lost to follow-up and four
patients had undergone revision surgery. The mean follow-up time was
4.7 years (1.1 to 13.25), with an infection-free survival of 94%. The organisms most commonly isolated intra-operatively were Single-stage exchange is a successful and practical treatment
for patients with peri-prosthetic infection of the shoulder. Cite this article:
The aim of this experimental study on New Zealand’s white rabbits
was to investigate the transplantation of autogenous growth plate
cells in order to treat the injured growth plate. They were assessed
in terms of measurements of radiological tibial varus and histological
characteristics. An experimental model of plate growth medial partial resection
of the tibia in 14 New Zealand white rabbits was created. During
this surgical procedure the plate growth cells were collected and
cultured. While the second surgery was being performed, the autologous
cultured growth plate cells were grafted at the right tibia, whereas
the left tibia was used as a control group. Objectives
Methods
Periprosthetic joint infection (PJI) is a devastating
complication for patients and results in greatly increased costs
of care for both healthcare providers and patients. More than 15
500 revision hip and knee procedures were recorded in England, Wales
and Northern Ireland in 2013, with infection accounting for 13%
of revision hip and 23% of revision knee procedures. We report our experience of using antibiotic eluting absorbable
calcium sulphate beads in 15 patients (eight men and seven women
with a mean age of 64.8 years; 41 to 83) as part of a treatment
protocol for PJI in revision arthroplasty. The mean follow-up was 16 months (12 to 22). We report the outcomes
and complications, highlighting the risk of hypercalcaemia which
occurred in three patients. We recommend that serum levels of calcium be routinely sought
following the implantation of absorbable calcium sulphate beads
in orthopaedic surgery. Cite this article:
The August 2015 Knee Roundup360 looks at: Two days as good as three in TKA; Bilateral TKA: minimising the risks; Tranexamic acid in knee arthroplasty: everyone should be using it, but how?; Initial follow-up for knee arthroplasty?; Navigation finds its niche?; Another take on navigation?; Multimodal care for early knee osteoarthritis; ACL graft fixation methods under the spotlight
In an initial randomised controlled trial (RCT)
we segregated 180 patients to one of two knee positions following total
knee replacement (TKR): six hours of knee flexion using either a
jig or knee extension. Outcome measures included post-operative
blood loss, fall in haemoglobin, blood transfusion requirements,
knee range of movement, limb swelling and functional scores. A second
RCT consisted of 420 TKR patients randomised to one of three post-operative
knee positions: flexion for three or six hours post-operatively,
or knee extension. Positioning of the knee in flexion for six hours immediately
after surgery significantly reduced blood loss (p = 0.002). There
were no significant differences in post-operative range of movement,
swelling, pain or outcome scores between the various knee positions
in either study. Post-operative knee flexion may offer a simple
and cost-effective way to reduce blood loss and transfusion requirements
following TKR. We also report a cautionary note regarding the potential risks
of prolonged knee flexion for more than six hours observed during
clinical practice in the intervening period between the two trials,
with 14 of 289 patients (4.7%) reporting lower limb sensory neuropathy
at their three-month review. Cite this article:
Older patients with multiple medical co-morbidities
are increasingly being offered and undergoing total joint arthroplasty
(TJA). These patients are more likely to require intensive care
support, following surgery. We prospectively evaluated the need
for intensive care admission and intervention in a consecutive series
of 738 patients undergoing elective hip and knee arthroplasty procedures.
The mean age was 60.6 years (18 to 91; 440 women, 298 men. Risk
factors, correlating with the need for critical care intervention,
according to published guidelines, were analysed to identify high-risk
patients who would benefit from post-operative critical care monitoring.
A total of 50 patients (6.7%) in our series required critical care
level interventions during their hospital stay. Six independent
multivariate clinical predictors were identified (p <
0.001)
including a history of congestive heart failure (odds ratio (OR)
24.26, 95% confidence interval (CI) 9.51 to 61.91), estimated blood
loss >
1000 mL (OR 17.36, 95% CI 5.36 to 56.19), chronic obstructive
pulmonary disease (13.90, 95% CI 4.78 to 40.36), intra-operative
use of vasopressors (OR 8.10, 95% CI 3.23 to 20.27), revision hip
arthroplasty (OR 2.71, 95% CI 1.04 to 7.04) and body mass index
>
35 kg/m2 (OR 2.70, 95% CI 123 to 5.94). The model was
then validated against an independent, previously published data
set of 1594 consecutive patients. The use of this risk stratification
model can be helpful in predicting which high-risk patients would
benefit from a higher level of monitoring and care after elective
TJA and aid hospitals in allocating precious critical care resources. Cite this article:
Dysphagia is a common complication of anterior
surgery of the cervical spine. The incidence of post-operative dysphagia
may be as high as 71% within the first two weeks after surgery,
but gradually decreases during the following months. However, 12%
to 14% of patients may have some persistent dysphagia one year after
the procedure. It has been shown that female gender, advanced age,
multilevel surgery, longer operating time and severe pre-operative
neck pain may be risk factors. Although the aetiology remains unclear
and is probably multifactorial, proposed causes include oesophageal
retraction, prominence of the cervical plate and prevertebral swelling.
Recently, pre-operative tracheal traction exercises and the use
of retropharyngeal steroids have been proposed as methods of reducing
post-operative dysphagia. We performed a systematic review to assess the incidence, aetiology,
risk factors, methods of assessment and management of dysphagia
following anterior cervical spinal surgery. Cite this article:
