Two-stage treatment of chronic staphylococcal orthopaedic implant-related infections using vancomycin impregnated PMMA spacer and rifampin containing antibiotic protocol.

To determine the clinical role of rifampin containing antibiotic combination and modified two-stage exchange arthroplasty with a vancomycin loaded polymethylmethacrylate (PMMA) spacer for the treatment of orthopaedic implant related Staphylococcus epidermidis infections, a prospective study was initiated. A total of 10 patients, with a mean age of 59 years (range: 32 to 78 years) were included in the study. The mean follow up was 23.4 months (range: 16 to 36 months). Six patients had an infected hemiarthroplasty of the hip, three had infected total hip arthroplasty, and one had an infected femoral neck fracture with implant failure and pseudoarthrosis. All had culture-proven Staphylococcus epidermidis infections, six of the isolates were methicillin resistant. Following debridement and implantation of a PMMA spacer, a rifampin-vancomycin antibiotic protocol was initiated until the erythrocyte sedimentation rate and C-reactive protein levels were within normal limits. After reimplantation and discharge from the hospital, oral antibiotics with rifampin-ciprofloxacin were continued for three to six months. At the final follow-up none of the patients had any clinical or laboratory signs of infection. Although this study includes a limited number of patients and relatively short-term follow-up the results indicate that in the presence of orthopaedic implant infection with Staphylococcus epidermidis, modified two-stage exchange arthroplasty using a vancomycin-loaded PMMA spacer and a rifampin-containing antibiotic protocol may be beneficial.

Calcific myonecrosis.

Calcific myonecrosis is a rare and late sequela of compartment syndrome, which becomes symptomatic years after the initial trauma. We diagnosed this condition in a 64-year old man, 42 years after he sustained a shot-gun wound to the right lower leg. Total excision of a peripherally calcified, cystic mass, continuous with the anterior tibial muscle belly resulted in complete resolution of symptoms. Consideration of the diagnosis is warranted in patients with a history of major injury who develop a soft tissue mass in the traumatized compartment. The treatment of choice is marginal excision.

Gunshot wounds to the spine.

In the USA, low velocity gunshot injuries (GSI) account for 13% of all urban spinal injuries, and they have become the second leading cause of all spinal cord injuries. The initial clinical evaluation should assess vascular, visceral, and/or neurological injury. Early imaging studies are required with computerized tomography in addition to plain radiographs to assess accurately the location and extent of the bone injury. The role of steroids is unclear, and if given, should be administered to GSI patients with complete or partial neurological deficit who present within eight hours of injury. The indications for prophylactic antibiotics have not been well established and although recommended, these are deemed essential only in patients with associated visceral perforation. Early surgical exploration is most appropriate to address associated vascular or visceral injury, while spinal decompression does not appear to influence neurological recovery. The majority of GSI spine fractures are stable; instability is usually due to ill-advised decompression of cervical spine GSI. Retained bullet fragments are rarely problematic; lead toxicity can occur due to missile contact with the synovial fluid, disc space, or contact with a pseudocyst.

Low-velocity civilian gunshot wounds of the spine.

This article describes a retrospective study on patients admitted to a level I trauma center between 1989 and 1993 with low-velocity gunshot wounds to the spine. Medical records and imaging studies were reviewed to determine patient demographics, neurologic deficit, prophylactic antibiotic administration, and rate of infection, spine stability, and principle associated injuries. A total of 37 patients with low-velocity gunshot wounds to the spine were identified and comprised 34% of all spinal injury patients. Neurologic outcome of the low-velocity gunshot wound to the spine depended on the level of the injury and the presenting neurologic deficit, as improvement of one or two Frankel grades occurred in only seven patients. Prophylactic antibiotics were given to 20 patients, and one infection occurred and was associated with colon perforation. In the absence of hollow viscus perforation, antibiotic prophylaxis did not appear beneficial. Spinal instability was noted in three patients with cervical injury and one patient with lumbar injury, and neurologic deficit was variable despite the presence of instability. The major associated injury was vascular occlusion or disruption in 8 of 12 (66%) cervical low-velocity gunshot wounds to the spine.

Treatment of scaphoid nonunions with a vascularized bone graft based on the first dorsal metacarpal artery.

Four patients with chronic nonunion of the scaphoid were treated by a vascularized bone graft based on first dorsal metacarpal artery. The mean duration of the nonunion was 28.5 months (range 12-48 months). There was avascular necrosis in all patients confirmed by magnetic resonance imaging (MRI). None of the patients had previous attempts at surgical reconstruction. Two fractures were localized at the waist one in the distal part and one at the proximal pole. Osseous union of the scaphoid was confirmed by X-ray in all patients in an average of 2.1 months. We recommend this technique for the treatment of established scaphoid pseudoarthrosis with avascular necrosis since it is associated with minimal morbidity and predictable good results.

Efficacy of antibiotics alone for orthopaedic device related infections.

Treatment of orthopaedic device related infections with antibiotics alone generally has been thought to be inadequate. A rabbit model was used to compare the efficacy of 4 different antibiotic regimens for treating orthopaedic device related infection caused by slime producing Staphylococcus epidermidis. After bacterial inoculation of a hole drilled through the intercondylar notch, a stainless steel screw was placed into the femur. Two weeks later, rabbits were randomized to receive a 2-week course of antibiotics: (1) 9 rabbits received vancomycin alone; (2) 10 rabbits received minocycline alone; (3) 10 rabbits received vancomycin plus rifampin; and (4) 10 rabbits received minocycline plus rifampin. Quantitative bone cultures were performed, and antibiotic levels in serum, bone, and biofilm were determined. Despite high levels of vancomycin in biofilm, infection was never cured by vancomycin alone and was eradicated in only 20% of rabbits that received minocycline alone. The highest cure rate (90%) was achieved with the combination of vancomycin and rifampin, whereas the combination of minocycline and rifampin yielded a cure rate of 70%. These results encourage the clinical evaluation of the combination of vancomycin and rifampin in patients in whom infected orthopaedic device cannot be removed.

Ureteral injury after anterior lumbar interbody fusion. A case report.

STUDY DESIGN: This case report presents a patient with ureter injury after anterior spinal fusion and its management. OBJECTIVES: To present possible causes, symptoms, diagnostic approach, and management of this rare complication. SUMMARY OF BACKGROUND DATA: The reported complications of anterior surgical approaches to the lumber spine have been predominantly vascular or neurologic. The susceptibility of the ureter to injury is emphasized by the description of an as-yet-unreported case of ureter laceration after anterior lumbar fusion. METHODS: Ureter injury was diagnosed using computed axial tomography, ultrasonography-guided aspiration, and chemical analysis of the aspirate after anterior spinal fusion. RESULTS: Early diagnosis of this injury prompted a ureter stent placement and prevented additional deterioration of renal function and infection. CONCLUSIONS: The ureter is prone to injury if not identified and protected when sharp and pointed instruments are used for retraction. Abdominal mass, low-grade fever, and leukocytosis should prompt use of computed tomography or ultrasonography-guided aspiration.

Late reconstruction of patellar ligament ruptures using Ilizarov external fixation.

Chronic patellar ligament ruptures, on which failed reconstruction attempts have been made, cause structural changes in the quadriceps mechanisms with marked fixed proximal migration of the patella. Before reconstruction, the position of the patella must be normalized. When using Ilizarov principles and an Ilizarov external fixator to treat these ruptures, full weightbearing and range of motion can be maintained throughout the pre- and postreconstruction period. This previously unreported technique has been used in 2 patients with chronic patellar ligament ruptures in whom reconstruction attempts had failed. Successful results obtained with this procedure warrant its consideration for this rare but disabling problem.

Amputation after failed total knee arthroplasty.

From 1983 to 1992, nine above-knee amputations were performed in eight patients for complications after total knee arthroplasty. The mean time from the initial knee replacement to amputation was 9.7 years. The average age of the four men and four women was 72 years. Eight knees had chronic infection and one had intractable pain after four revision attempts for aseptic loosening. Most patients had two revision arthroplasties after the original implant. In this series, the common factors that lead to amputation were multiple revision attempts in the presence of chronic infection, severe bone loss, and intractable pain. Earlier consideration of arthrodesis rather than multiple revision attempts is recommended to avoid such a poor outcome.

Leiomyosarcoma of the great saphenous vein.

Primary malignant tumours of the great saphenous vein are extremely rare with only 15 cases reported in the English literature since 1919. We report a patient who survived 5.5 years after treatment with surgery and chemotherapy before dying from lung metastases.

Pott's disease and extrapleural anterior decompression. Results of 108 consecutive cases.

Between 1973 and 1988, 108 patients with a preoperative diagnosis of spinal tuberculosis were treated by anterior extirpation and interbody fusion at Ankara University Medical Faculty, Orthopedic Surgery and Traumatology Department. In 96 cases the operations were performed intrapleurally, as Hogston described. For 12 patients who had spinal involvement at lower thoracic and upper lumbar segments an extrapleural and extraperitoneal approach was used. The extrapleural approach is strongly recommended for patients who have compromised pulmonary reserve. When this approach is used adequate exposure can be obtained and postoperative rehabilitation of patients is facilitated. Advantages and disadvantages of the extrapleural approach and the results obtained from 108 patients are presented.