In 2013, we introduced a specialized, centralized, and interdisciplinary team in our institution that applied a standardized diagnostic and treatment algorithm for the management of prosthetic joint infections (PJIs). The hypothesis for this study was that the outcome of treatment would be improved using this approach. In a retrospective analysis with a standard postoperative follow-up, 95 patients with a PJI of the hip and knee who were treated with a two-stage exchange between 2013 and 2017 formed the study group. A historical cohort of 86 patients treated between 2009 and 2011 not according to the standardized protocol served as a control group. The success of treatment was defined according to the Delphi criteria in a two-year follow-up.Aims
Patients and Methods
Periprosthetic joint infection following joint arthroplasty surgery is one of the most feared complications. The key to successful revision surgery for periprosthetic joint infections, regardless of treatment strategy, is a thorough deep debridement. In an attempt to limit antimicrobial and disinfectant use, there has been increasing interest in the use of acetic acid as an adjunct to debridement in the management of periprosthetic joint infections. However, its effectiveness in the eradication of established biofilms following clinically relevant treatment times has not been established. Using an Using a methicillin-sensitive Objectives
Materials and Methods
The aim of this study was to compare the results of 16S/28S rRNA sequencing with the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and synovial fluid analysis in the diagnosis of prosthetic joint infection (PJI). Between September 2015 and August 2016, 214 consecutive patients were enrolled. In the study population, there were 25 patients with a PJI and 189 controls. Of the PJI patients, 14 (56%) were women, and the mean age at the time of diagnosis was 65 years (38 to 83). The ESR and CRP levels were measured, and synovial fluid specimens were collected prospectively. Synovial fluid was subjected to reverse transcription polymerase chain reaction (RT-PCR)/sequence analysis targeting the 16S/28S rRNA, and to conventional culture. Laboratory personnel who were blind to the clinical information performed all tests. The diagnosis of PJI was based on the criteria of the Musculoskeletal Infection Society.Aims
Patients and Methods
External fixation is widely used in orthopaedic
and trauma surgery. Infections around pin or wire sites, which are usually
localised, non-invasive, and are easily managed, are common. Occasionally,
more serious invasive complications such as necrotising fasciitis
(NF) and toxic shock syndrome (TSS) may occur. We retrospectively reviewed all patients who underwent external
fixation between 1997 and 2012 in our limb lengthening and reconstruction
programme. A total of eight patients (seven female and one male)
with a mean age of 20 years (5 to 45) in which pin/wire track infections
became limb- or life-threatening were identified. Of these, four
were due to TSS and four to NF. Their management is described. A
satisfactory outcome was obtained with early diagnosis and aggressive
medical and surgical treatment. Clinicians caring for patients who have external fixation and
in whom infection has developed should be aware of the possibility
of these more serious complications. Early diagnosis and aggressive
treatment are required in order to obtain a satisfactory outcome. Cite this article:
Nasal carriers of Paired nasal swabs for polymerase chain reaction (PCR) assay and culture of Objectives
Methods
The aim of this study was to assess the effects of transferring patients to a specialized arthroplasty centre between the first and second stages (interstage) of prosthetic joint infection (PJI) of the knee. A search of our institutional database was performed to identify patients having undergone two-stage revision total knee arthroplasty (TKA) for PJI. Two cohorts were created: continuous care (CC) and transferred care (TC). Baseline characteristics and outcomes were collected and compared between cohorts.Aims
Patients and Methods
Periprosthetic infection following total hip replacement can be a catastrophic complication for the patient. The treatments available include single-stage exchange, and two-stage exchange. We present a series of 50 consecutive patients with a diagnosis of infected total hip replacement who were assessed according to a standardised protocol. Of these, 11 underwent single-stage revision arthroplasty with no recurrence of infection at a mean of 6.8 years follow-up (5.5 to 8.8). The remaining 39 underwent two-stage revision, with two recurrences of infection successfully treated by a second two-stage procedure. At five years, significant differences were found in the mean Harris Hip Scores (single-stage 87.8; two-stage 75.5; p = 0.0003) and in a visual analogue score for satisfaction (8.6; 6.9; p = 0.001) between the single- and two-stage groups. Single-stage exchange is successful in eradicating periprosthetic infection and results in excellent functional and satisfaction scores. Identification of patients suitable for the single-stage procedure allows individualisation of care and provides as many as possible with the correct strategy in successfully tackling their periprosthetic infection
A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion. Causes of the nonunion were divided into four categories: mechanical; infection; dead bone with a gap; and host. Prospective and retrospective data of 100 consecutive patients who had undergone surgery for long bone fracture nonunion were analysed.Objectives
Methods
We evaluated the cost and consequences of proximal femoral fractures requiring further surgery because of complications. The data were collected prospectively in a standard manner from all patients with a proximal femoral fracture presenting to the trauma unit at the John Radcliffe Hospital over a five-year period. The total cost of treatment for each patient was calculated by separating it into its various components. The risk factors for the complications that arose, the location of their discharge and the mortality rates for these patients were compared to those of a matched control group. There were 2360 proximal femoral fractures in 2257 patients, of which 144 (6.1%) required further surgery. The mean cost of treatment in patients with complications was £18 709 (£2606.30 to £60.827.10), compared with £8610 (£918.54 to £45 601.30) for uncomplicated cases (p <
0.01), with a mean length of stay of 62.8 (44.5 to 79.3) and 32.7 (23.8 to 35.0) days, respectively. The probability of mortality after one month in these cases was significantly higher than in the control group, with a mean survival of 209 days, compared with 496 days for the controls. Patients with complications were statistically less likely to return to their own home (p <
0.01). Greater awareness and understanding are required to minimise the complications of proximal femoral fractures and consequently their cost.
We compared the use of broth culture medium for
samples taken in theatre with the standard practice of placing tissue
samples in universal containers. A total of 67 consecutive patients
had standard multiple samples of deep tissue harvested at surgery
and distributed equally in theatre either to standard universal
containers or to broth culture medium. These samples were cultured
by direct and enrichment methods. The addition of broth in theatre to
standard practice led to an increase in sensitivity from 83% to
95% and an increase in negative predictive value from 77% to 91%.
Placing tissue samples directly into broth in the operating theatre
is a simple, inexpensive way to increase the sensitivity of cultures
from infected patients, and does not appear to compromise the specificity
of these cultures. Cite this article:
Fresh-frozen allograft bone is frequently used
in orthopaedic surgery. We investigated the incidence of allograft-related
infection and analysed the outcomes of recipients of bacterial culture-positive
allografts from our single-institute bone bank during bone transplantation.
The fresh-frozen allografts were harvested in a strict sterile environment
during total joint arthroplasty surgery and immediately stored in
a freezer at -78º to -68º C after packing. Between January 2007
and December 2012, 2024 patients received 2083 allografts with a
minimum of 12 months of follow-up. The overall allograft-associated
infection rate was 1.2% (24/2024). Swab cultures of 2083 allografts
taken before implantation revealed 21 (1.0%) positive findings.
The 21 recipients were given various antibiotics at the individual
orthopaedic surgeon’s discretion. At the latest follow-up, none
of these 21 recipients displayed clinical signs of infection following
treatment. Based on these findings, we conclude that an incidental positive
culture finding for allografts does not correlate with subsequent
surgical site infection. Additional prolonged post-operative antibiotic
therapy may not be necessary for recipients of fresh-frozen bone
allograft with positive culture findings. Cite this article:
Clinical studies of patients with bone sarcomas have been challenged
by insufficient numbers at individual centres to draw valid conclusions.
Our objective was to assess the feasibility of conducting a definitive
multi-centre randomised controlled trial (RCT) to determine whether
a five-day regimen of post-operative antibiotics, in comparison
to a
24-hour regimen, decreases surgical site infections in patients
undergoing endoprosthetic reconstruction for lower extremity primary
bone tumours. We performed a pilot international multi-centre RCT. We used
central randomisation to conceal treatment allocation and sham antibiotics
to blind participants, surgeons, and data collectors. We determined
feasibility by measuring patient enrolment, completeness of follow-up,
and protocol deviations for the antibiotic regimens. Objective
Methods
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:
The treatment of infected nonunions is difficult.
Antibiotic cement-coated (ACC) rods provide stability as well as delivering
antibiotics. We conducted a review of 110 infected nonunions treated
with ACC rods. Patients were divided into two groups: group A (67
patients) with an infected arthrodesis, and group B (43 patients)
with an infected nonunion in a long bone. In group A, infected arthrodesis,
the success rate after the first procedure was 38/67 (57%), 29/67
(43%) required further surgery for either control of infection or
non-union. At last follow-up, five patients required amputation,
representing a limb salvage rate of 62/67 (93%) overall. In all,
29/67 (43%) presented with a bone defect with a mean size of 6.78
cm (2 to 25). Of those with a bone defect, 13/29 (45%) required
further surgery and had a mean size of defect of 7.2 cm (3.5 to
25). The cultures were negative in 17/67 (26%) and the most common
organism cultured was methicillin-resistant Cite this article:
Fractures of the proximal femur are one of the
greatest challenges facing the medical community, constituting a
heavy socioeconomic burden worldwide. Controversy exists regarding
the optimal treatment for independent patients with displaced intracapsular fractures
of the proximal femur. The recognised alternatives are hemiarthroplasty
and total hip replacement. At present there is no established standard
of care, with both types of arthroplasty being used in many centres.
The principal advantages of total hip replacement are a functional
benefit over hemiarthroplasty and a reduced risk of revision surgery.
The principal criticism is the increased risk of dislocation. We
believe that an alternative acetabular component may reduce the
risk of dislocation but still provide the functional benefit of
total hip replacement in these patients. We therefore propose to
investigate the dislocation risk of a dual-mobility acetabular component
compared with standard polyethylene component in total hip replacement
for independent patients with displaced intracapsular fractures
of the proximal femur within the framework of the larger WHiTE (Warwick
Hip Trauma Evaluation) Comprehensive Cohort Study. 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:
The December 2013 Research Roundup360 looks at: Inflammation implicated in FAI; Ponseti and effective teaching; Unicompartmental knee design and tibial strain; Bisphosphonates and fracture healing; Antibiosis in cement; Zoledronic acid improves primary stability in revision?; Osteoporotic fractures revisited; and electroarthrography for monitoring of cartilage degeneration