First case of periprosthetic joint infection due to Clostridioides difficile in China.

BACKGROUND: Clostridioides difficile usually causes intestinal infections. However, a 75-year-old lady had a periprosthetic joint infection due to this microorganism. We report a C. difficile infection of a prosthetic hip joint. Such an infection is rarely reported around the world. CASE PRESENTATION: The elder female patient presented with a 2-year history of right hip pain with movement restriction. Her right leg was shorter than another. The skin around the right hip joint was red and swollen without sinus. Her lab test result showed elevator ESR and CRP. Her X-ray film showed a massive bone defect. The patient had a total hip arthroplasty 16 years ago and had a revision 5 years ago. During this hospitalization, her cultures of the synovial fluid and tissue repeatedly grew C. difficile. She improved following two-stage revision surgery and antibiotic treatment. The patient has no recurrence of infection after a one-year follow-up. CONCLUSION: A rapid and accurate sample collection is significant for culture results, making an outstanding contribution to the successful treatment.

A rapid response team is associated with reduced overall hospital mortality in a Chinese tertiary hospital: a 9-year cohort study.

BACKGROUND: Although the evidence for its effectiveness remains uncertainty, rapid response systems are implemented across many hospitals across the world. Increasingly, hospitals in China have recently started to adopt a medical emergency or rapid response team (RRT). Hence, we aimed to determine whether the implementation of an RRT in Chinese hospitals also improved outcomes. METHODS: Our hospital is a Joint Commission International (JCI) accredited, tertiary teaching hospital with 1,200 beds. We conducted a retrospective cohort study comparing 60 months after the implementation of the RRT (January 1, 2013, to December 31, 2017) and 36 months before implementation (January 1, 2009, to December 31, 2011). The outcomes included the overall hospital mortality and incidence of codes. RESULTS: We analyzed 144,673 non-obstetric hospital admissions and 1,269,621 patient days in the control period and 348,687 non-obstetric hospital admissions and 2,361,913 patient days after the RRT implementation. The RRT was activated 834 times (2.39 calls per 1,000 patients and 0.35 call per 1,000 patient-days). There was no difference in the code rate (0.23 vs. 0.17 per 1,000 patient days, P=0.379) between the two periods. Although the hospital mortality had remained stable around 3.0 per 1,000 patients from 2009 to 2011, there was a significant 40% decrease of overall hospital mortality from 2.95 to 1.77 per 1,000 non-obstetric patients after the implementation of RRT (P=0.001), and the annual mortality showed a consistent decrease (P=0.037 for the trend). Moreover, the increase of RRT activations was significantly correlated with the decrease of hospital mortality (P=0.025). CONCLUSIONS: RRT implementation was associated with reduced overall hospital mortality in a Chinese tertiary hospital.

Retrospective Cohort Study Comparing Complications, Readmission, Transfusion, and Length of Stay of Patients Undergoing Simultaneous and Staged Bilateral Total Hip Arthroplasty.

OBJECTIVES: To determine whether the rates of postoperative complications, rate of readmission, cumulative transfusion volume, and length of stay (LOS) differ between simultaneous total hip arthroplasty (THA) and staged bilateral THA and to assess whether the length of the interval between staged procedures influences surgery outcome. METHODS: This was a retrospective cohort study comparing the rate of postoperative complications, readmission, cumulative transfusion volume, and LOS between simultaneous THA and staged bilateral THA in our hospital's registration database. The inclusion criteria is listed as follows: patients who underwent bilateral primary THA between January 2011 and January 2015 with minimum 3-month follow-up; simultaneous bilateral THA; staged bilateral THA; postoperative complications, readmission, cumulative transfusion volume, length of stay of the patients and the influence of the interval between stages of bilateral THA on the outcome above; and retrospective cohort study. Finally, a total of 1145 patients, including simultaneous bilateral THA in 863 patients (1726 hips) and staged bilateral THA in 282 patients (564 hips), were eligible for the present study. The patients were divided into three groups according to the interval time (≤30 days, 30-90 days, >90 days) between the two stages of bilateral THA and we compared postoperative complications, readmission rates, cumulative transfusion volume, and LOS for the three groups. All patients' medical records and outpatient notes were reviewed to extract preoperative data, perioperative complications, readmission, cumulative transfusion, and LOS. Preoperative information included patients' age, sex, diagnosis, body mass index, and American Society of Anesthesiologists (ASA) classification. Perioperative complications were sorted into two groups: (i) medical complications included cardiovascular, pulmonary, neurological, digestive, and urologic system complications, along with other miscellaneous issues; and (ii) surgical complications included dislocation, superficial wound infection, hematoma, deep periprosthetic joint infection, and nerve palsy. Patients who failed to come back to visit our hospital in the postoperative 3 months were followed up by telephone, at which point we inquired about any postoperative complications and readmission. RESULTS: Simultaneous THA was performed more often in younger men, and patients in the simultaneous group had fewer major medical complications (excluding venous thromboembolism), fewer surgical complications, and shorter hospital stays; however, patients in the simultaneous group were likelier to have a higher transfusion rate than patients in the staged group. Among patients in the staged group, there were no differences for differing time intervals, except that patients with a between-stage interval of ≤30 days required more blood transfusions. CONCLUSION: With careful patient assessment and selection, simultaneous bilateral THA is a safe procedure, and has lower rates of surgical and major medical complications than staged bilateral THA.

Total Knee Arthroplasty in Patients with Prior Femoral and Tibial Fractures: Outcomes and Risk Factors for Surgical Site Complications and Reoperations.

OBJECTIVE: To investigate the outcomes of total knee arthroplasty (TKA) in patients with a prior femoral or tibial fracture, and identify the risk factors for surgical site complications and reoperations. METHODS: Seventy-one TKAs performed in 71 patients with a prior tibial or femoral fracture between January 2005 and December 2016 were reviewed retrospectively. Forty males (40 knees) and 31 females (31 knees) were included. The mean age at the time of TKA was 59.2 (range, 29-83) years. Outcomes were assessed using the Knee Society score before surgery and at the final follow-up visit. The patients' satisfaction rates were evaluated. Complications and reoperations were recorded by clinical and radiographic assessment. Logistic regression analysis was used to identify the risk factors for surgical site complications and reoperations. RESULTS: The median follow-up period was 4.7 (range, 3.2-7.1) years. The median knee range of motion increased from 90° preoperatively to 110° at the latest follow-up. The Knee Society knee score and function score improved from 35 (30, 40) and 40 (30, 50) to 90 (82, 93) and 90 (65, 100), respectively. The degree of overall satisfaction after TKA surgery was very satisfied in 41 patients, satisfied in 20 patients, neutral in four patients, dissatisfied in four patients, and very dissatisfied in two patients. The overall satisfaction (very satisfied and satisfied) rate was 85.9% (61 knees). Twelve knees (16.9%) had 19 surgical site complications. Six knees (8.3%) underwent reoperations, including one revision due to periprosthetic joint infection, one debridement and implant retention for superficial infection, two debridements for delayed wound healing, one open reduction and internal fixation for supracondylar fracture, and one re-fixation and bone grafting for hardware failure after a combined femoral shaft osteotomy and TKA. Preoperative patella baja was diagnosed in 12 knees, and was identified as a risk factor for surgical site complications and reoperations. CONCLUSIONS: TKA for post-fracture osteoarthritis significantly relieved pain and improved function, but the incidence of surgical site complications and reoperations was high. Preoperative patella baja was a risk factor for surgical site complications and reoperations.

Plasma Fibrinogen Exhibits Better Performance Than Plasma D-Dimer in the Diagnosis of Periprosthetic Joint Infection: A Multicenter Retrospective Study.

BACKGROUND: The search for potential markers for a timely and accurate diagnosis of periprosthetic joint infection (PJI) is ongoing. Previous studies have focused on inflammatory markers and have rarely examined coagulation-related indicators. The purpose of this study was to evaluate the values of plasma fibrinogen, D-dimer, and other blood markers for the diagnosis of PJI through a multicenter retrospective study. METHODS: A total of 565 revision total hip and knee arthroplasty cases were enrolled in this study from January 2016 through December 2017, 126 of which had coagulation-related comorbidities and were analyzed separately. The remaining 439 cases included 76 PJI and 363 non-PJI patients. The definition of PJI was based on the International Consensus Meeting (ICM) on Periprosthetic Infection criteria. The diagnostic values of D-dimer, plasma fibrinogen, the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and white blood-cell (WBC) count were analyzed using receiver operating characteristic (ROC) curves. RESULTS: ROC curves showed that plasma fibrinogen had the highest area under the curve (AUC), 0.852, followed by 2 classical markers, the CRP level and ESR, which had an AUC of 0.810 and 0.808, respectively. D-dimer had an AUC of 0.657, which was the second lowest value and only slightly higher than that of the WBC count, 0.590. The optimal threshold for plasma D-dimer was 1.25 µg/mL, with a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 0.645, 0.650, 0.278, and 0.897, respectively. The optimal threshold for plasma fibrinogen was 4.01 g/L, which showed good sensitivity, specificity, PPV, and NPV, with values of 0.763, 0.862, 0.537, and 0.946, respectively. CONCLUSIONS: Plasma D-dimer may have a very limited diagnostic value for PJI, while plasma fibrinogen, another coagulation-related indicator, exhibits promising performance. Plasma fibrinogen has good sensitivity and specificity for diagnosing PJI, with values similar to those of classical markers, including CRP level and ESR. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Eliminating impingement optimizes patellar biomechanics in high knee flexion.

BACKGROUND: We investigated the impact of eliminating the impingement between extensor mechanism and tibial insert on patellar tracking and patellar ligament tension in high knee flexion. METHODS: Six cadaveric specimens were tested on an Oxford-type testing rig. The Genesis II knee system was implanted into each specimen knee with the traditional tibial insert and high-flex insert successively. Compared to traditional insert, the high-flex insert was characterized with a chambered anterior post and a chambered anterior lip which eliminates patella-post and patellar ligament-anterior lip impingements. The patella was tracked with an NDI Optotrak Certus system. The patellar ligament tension was measured using a NKB S-type tension transducer. RESULTS: There was a decrease of resultant patellar translation relative to the femur with statistically significant (P<0.05) at 90 degrees to 150 degrees of knee flexion and a decrease of patellar ligament tension with statistical significance (P<0.05) at 100 degrees, 120 degrees, 130 degrees, and 140 degrees of flexion using high-flex insert compared to traditional insert. CONCLUSIONS: Eliminating the impingement between extensor mechanism and implant in high knee flexion altered patellar tracking and reduced patellar ligament tension, which would facilitate high knee flexion.

[Clinical results and peri-operative complications of total knee arthroplasty for patients with different ages].

OBJECTIVE: To analyze the clinical results and complications of total knee arthroplasty (TKA) performed for patients with different ages. METHODS: From January 2004 to March 2005,212 patients (300 knees) were followed up, all patients were divided into 6 groups according to the age. All the complications and knee society scores (KSS) were documented and retrieved for analysis. RESULTS: KSS of all groups was significantly improved after TKA. The patients whose age was 70 years or older, and underwent bilateral TKA achieved the best improvement of knee function. The complication rate increased with the patients' age. CONCLUSIONS: TKA predictably alleviates knee pain and restores knee function. Aging itself does not compromise clinical results of TKA. However perioperative complication rate is a little bit higher in aged patient group and simultaneously bilateral TKA patient group.

[Reconstruction of the acetabular in the Crowe III dysplastic hip].

OBJECTIVE: To investigate the method and the outcome of the acetabular reconstruction in the Crowe III dysplastic hip. METHODS: From January 2001 to June 2007, 43 cases (54 hips) were diagnosed osteoarthritis secondary to Crowe III dysplastic hip. Total hip arthroplasty was performed in all cases. The Harris score was 39 pre-operation. The method of the acetabular reconstruction included acetabular deepening (group A), medial-wall osteotomy (group B), femoral head bone grafting (group C). Radiography data and Harris score were taken to evaluate the clinical outcome. RESULTS: The method of the acetabular reconstruction included acetabular deepening in 27 cases (34 hips), medial-wall osteotomy in 12 cases (15 hips), femoral head bone grafting in 4 cases (5 hips). Forty cases were followed up by the mean time of 29 months. The bone union time of the osteotomy and bone grafting were 4 - 5 months postoperation. In the three groups the obliquity angle of the cup were (41.0 +/- 7.5) degrees , (46.0 +/- 7.7) degrees , (39.0 +/- 11.0) degrees ; the anteversion angle of the cup were (10.0 +/- 2.8) degrees , (9.0 +/- 2.5) degrees , (4.0 +/- 1.9) degrees ; the rotation center of the hip was shift superiorly (8.4 +/- 3.6) mm, (7.3 +/- 2.6) mm, (1.2 +/- 0.5) mm; the rotation center of the hip were shift internally (7.0 +/- 1.5) mm, (9.9 +/- 1.7) mm, (-2.7 +/- 1.2) mm, and the Harris score were 89, 91, 86 at the follow up. The complication included deep venous thrombosis in 2 cases, pulmonary embolism in 2 cases, sciatic nerve palsy in 4 cases. CONCLUSION: Acetabular deepening, medial-wall osteotomy, femoral head bone grafting can be used in reconstruction of the acetabular in the Crowe III dysplastic hip.