Periprosthetic joint infections in femoral neck fracture patients treated with hemiarthroplasty - should we use antibiotic-loaded bone cement?

BACKGROUND: Hemiarthroplasty is the most common treatment in elderly patients with displaced intra-capsular femoral neck fracture (FNF). Prosthetic joint infection (PJI) is one of the most feared and frequent complications post-surgery because of the frail health status of these patients and the need for fast track surgery. Therefore, priorities should lie in effective preventive strategies to mitigate this burden. AIM: To determine how much the implementation of the routine use of antibiotic-loaded bone cement (ALBC) as a relatively easy-to-apply amendment to the surgical practice reduces the infection rate in our hemiarthroplasty cohort. METHODS: We retrospectively assessed all demographic, health status and treatment-related data of our FNF patients undergoing cemented hemiarthroplasty in the period from 2011 to 2017; 241 patients were further analyzed after exclusion of patients with cancer-related sequelae and those who died before the end of the 1-year observation period. The PJI rate as diagnosed on basis of the Musculoskeletal Infection Society (MSIS) criteria 2011 was determined for each included patient and compared in function of the bone cement used for hip stem fixation. Patients were split into a group receiving a plain bone cement in the period from January 2011 to June 2013 (non-ALBC group) and into a group receiving an ALBC in the period July 2013 to December 2017 (ALBC group). Data analysis was performed with statistical software. We further calculated the cost-efficacy of the implementation of routine use of ALBC in the second group balancing the in-hospital infection related treatment costs with the extra costs of use of ALBC. RESULTS: In total 241 FNF patients who received cemented hemiarthroplasty in the period from January 2011 to January 2017 were eligible for inclusion in this retrospective study. There were 8 PJI cases identified in the ALBC group among n = 94 patients, whereas 28 PJI cases were observed in the non-ALBC group among n = 147 patients. The statistical analysis showed an infection risk reduction of 55.3% (in particular due to the avoidance of chronic delayed infections) in the ALBC group (95%CI: 6.2%-78.7%; P = 0.0025). The cost-evaluation analysis demonstrated a considerable cost saving of 3.500 € per patient, related to the implementation of routine use of ALBC in this group. CONCLUSION: Use of ALBC is a potent infection preventive factor in FNF patients receiving cemented hemiarthroplasties. It was further found to be highly cost-effective.

An Innovative Technique for Intraoperative Radiological Assessment of Pelvic and Spine Fractures in Austere Environment.

INTRODUCTION: Managing pelvic and spine fractures in the austere environment can be challenging even for skilled orthopedic surgeons, largely due to the difficulty of radiological visualization of bone structures. We present a simple alternative to the metallic operating table by placing the patient on a spinal board that will allow for a better radiological assessment of these fractures. MATERIAL AND METHODS: A cross-sectional, descriptive, and retrospective study was carried out in the period between 2015 and 2020. The study population was all patients with pelvic o spine fractures, managed surgically using a spinal board in the Spanish Role 2 or in the Spanish Role 4. RESULTS: Seven patients underwent surgery in total using a spinal board, pelvic fracture being the the main diagnosis (n = 6; 85.71%). The distribution of surgical procedures was as follows: percutaneous pedicle screw fixation (one case), external fixation of the pelvis (two cases), percutaneous screw fixation of the pelvis (two cases), and open reduction and internal fixation of the pelvis (two cases). The mean duration of surgical interventions was 52 minutes, and a successful reduction and synthesis of the fracture was obtained in all the patients, with no complications reported. CONCLUSION: A spinal board can be a useful, simple, and effective device for the orthopedic surgeon in the deployed setting. The described technique is simple, fast, and efficient in getting a complete radiological assessment of complex regions such as the pelvis and the spine, facilitating the surgical management of these injuries.

A Comparative Study Between Two Combat Injury Severity Scores.

INTRODUCTION: In recent years, specific trauma scoring systems have been developed for military casualties. The objective of this study was to examine the discrepancies in severity scores of combat casualties between the Abbreviated Injury Scale 2005-Military (mAIS) and the Military Combat Injury Scale (MCIS) and a review of the current literature on the application of trauma scoring systems in the military setting. METHODS: A cross-sectional, descriptive, and retrospective study was conducted between May 1, 2005, and December 31, 2014. The study population consisted of all combat casualties attended in the Spanish Role 2 deployed in Herat (Afghanistan). We used the New Injury Severity Score (NISS) as reference score. Severity of each injury was calculated according to mAIS and MCIS, respectively. The severity of each casualty was calculated according to the NISS based on the mAIS (Military New Injury Severity Score-mNISS) and MCIS (Military Combat Injury Scale-New Injury Severity Score-MCIS-NISS). Casualty severity were grouped by severity levels (mild-scores: 1-8, moderate-scores: 9-15, severe-scores: 16-24, and critical-scores: 25-75). RESULTS: Nine hundred and eleven casualties were analyzed. Most were male (96.37%) with a median age of 27 years. Afghan patients comprised 71.13%. Air medevac was the main casualty transportation method (80.13). Explosion (64.76%) and gunshot wound (34.68%) mechanisms predominated. Overall mortality was 3.51%. Median mNISS and MCIS-NISS were similar in nonsurvivors (36 [IQR, 25-49] vs. [IQR, 25-48], respectively) but different in survivors, 9 (IQR, 4-17) vs. 5 (IQR, 2-13), respectively (P < .0001). The mNISS and MCIS-NISS were discordant in 34.35% (n = 313). Among cases with discordant severity scores, the median difference between mNISS and MCIS-NISS was 9 (IQR, 4-16); range, 1 to 57. CONCLUSION: Our study findings suggest that discrepancies in injury severity levels may be observed in one in three of the casualties when using mNISS and MCIS-NISS.

Intracapsular hip fractures in the elderly. Do we know what is important?

BACKGROUND: Hip fractures in the elderly are a common reason for admission to the department of orthopaedic surgery, this condition asks an important part of health resources and is associated with high levels of co-morbidity and mortality. Many improvements have been introduced in the treatment of these patients, preoperative regional analgesia, intensive physical therapy, interdisciplinary care program; but still remain unresolved gaps. The aim of this study is to document the natural history of early versus delayed surgical intervention in elderly patients with hip fractures and to establish the prognostic factors of mortality and walking ability after discharge. METHODS: A sample of 499 patients admitted in our Institution was prospectively reviewed between February 2008 and February 2013. Preoperatively characteristics and functional data were assessed in relation with time to surgery (focused on mortality and ability to walk at first year). RESULTS: The ability to walk and activities of daily living (functional results) were not associated with surgical delays (surgery before 24h from admission, surgery among 24h and 72h from admission and surgery later than 72h). However, ASA class, Parkinson disease and age were significantly associated with poor functional results. In the same way, mortality at 1year was not associated with time to surgery, but ASA class was associated with significant risk factor of 1 year-mortality. CONCLUSIONS: ASA class, Parkinson disease and age are independent predictor of poor functional outcomes after intracapsular hip fracture. In addition, ASA class is an independent predictor of mortality. Patients with poor functional status before fracture and older than 75 years would benefit from geriatric and rehabilitation intervention immediately after surgery.

Case report of early aseptic loosening of total hip arthroplasty in monostotic paget disease, a diagnostic challenge.

Paget's disease of bone is a localised chronic osteopathy which produces bone deformities, bone hypervascularity, structural weakness and altered joint biomechanics. Although radiological diagnosis of Paget's disease of bone is usually straightforward, monostotic cases may potentially raise specific problems which require invasive and expensive procedures such as bone biopsies. The pelvis and upper femur are frequently affected, resulting in disabling hip disease that may require total hip arthroplasty. We report a case of Paget disease of bone in an 84-year-old woman, which was initially identified as avascular necrosis of the hip, reason for which she underwent total hip arthroplasty. During follow up, the patient complained about hip pain and in a few months she was not able to walk because of an early loosening with bone destruction. Radiological and laboratory exams were carried out with normal results except for alkaline phosphatase (AP). After treatment with biphosphonates hip pain relieved but hip reconstruction was not possible. In this paper we present an early aseptic loosening of hip arthroplasty due to monostotic Paget's disease of bone, a rare ethiology of loosening which poses particular diagnostic difficulties prompting an excessive use of excisional biopsies.

Stoppa approach, an alternative for total hip arthroplasty in an intra-pelvic cup.

Removal of an acetabular prosthesis that has migrated into the pelvis can be hazardous. We describe the preoperative planning and the surgical procedure for removing a severely displaced acetabular component in one patient and outline our recommendation for the use of Stoppa approach because it has advantages of simple dissection, a low complication rate, and may help in preventing life-threatening problems.