Operating room ventilation and the risk of revision due to infection after total hip arthroplasty: assessment of validated data in the Norwegian Arthroplasty Register.

BACKGROUND: The air in the operating room is considered a risk factor for surgical site infection (SSI) due to airborne bacteria shed from the surgical staff or from patients themselves. AIM: To assess the influence of validated operating room (OR) ventilation data on the risk of revision surgery due to deep infection after primary total hip arthroplasty (THA) reported to the Norwegian Arthroplasty Register (NAR). METHODS: Forty orthopaedic units reporting THAs to the NAR during the period 2005-2015 were included. The true type of OR ventilation in all hospitals at the time of primary THA was confirmed in a previous study. Unidirectional airflow (UDF) systems were subdivided into: small, low-volume, unidirectional vertical flow (lvUDVF) systems; large, high-volume, unidirectional vertical flow (hvUDVF) systems; and unidirectional horizontal flow (UDHF) systems. These three ventilation groups were compared with conventional, turbulent, mixing ventilation (CV). The association between the end-point, time to revision due to infection, and OR ventilation was estimated by calculating relative risks (RRs) in a multivariate Cox regression model, with adjustments for several patient- and surgery-related covariates. FINDINGS: A total of 51,292 primary THAs were eligible for assessment. Of these, 575 had been revised due to infection. A similar risk of revision due to infection after THA performed was found in ORs with lvUDVF and UDHF compared to CV. THAs performed in ORs with hvUDVF had lower risk of revision due to infection compared to CV (RR = 0.8; 95% CI: 0.6-0.9; P = 0.01). CONCLUSION: THAs performed in ORs with hvUDVF systems had lower risk of revision due to infection compared to THAs performed in ORs with CV systems. The perception that all UDF systems are similar and possibly harmful seems erroneous.

Antibiotic prophylaxis is not indicated prior to dental procedures for prevention of periprosthetic joint infections

Background and purpose: To minimize the risk of hematogenous periprosthetic joint infection (HPJI), international and Dutch guidelines recommended antibiotic prophylaxis prior to dental procedures. Unclear definitions and contradictory recommendations in these guidelines have led to unnecessary antibiotic prescriptions. To formulate new guidelines, a joint committee of the Dutch Orthopaedic and Dental Societies conducted a systematic literature review to answer the following question: can antibiotic prophylaxis be recommended for patients (with joint prostheses) undergoing dental procedures in order to prevent dental HPJI? Methods - The Medline, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs), reviews, and observational studies up to July 2015. Studies were included if they involved patients with joint implants undergoing dental procedures, and either considered HPJI as an outcome measure or described a correlation between HPJI and prophylactic antibiotics. A guideline was formulated using the GRADE method and AGREE II guidelines. Results - 9 studies were included in this systematic review. All were rated "very low quality of evidence". Additional literature was therefore consulted to address clinical questions that provide further insight into pathophysiology and risk factors. The 9 studies did not provide evidence that use of antibiotic prophylaxis reduces the incidence of dental HPJI, and the additional literature supported the conclusion that antibiotic prophylaxis should be discouraged in dental procedures. Interpretation - Prophylactic antibiotics in order to prevent dental HPJI should not be prescribed to patients with a normal or an impaired immune system function. Patients are recommended to maintain good oral hygiene and visit the dentist regularly

Empty can and drop arm tests for cuff rupture : Improved specificity after subacromial injection.

Shoulder disorders are common in the general population : they occur in about 25 of every 1000 patients per year. A rather large majority are caused by cuff disorders. Differentiating between impingement and cuff rupture is essential to adequate treatment. Clinical tests have been developed, but their accuracy is limited. This study was performed to improve clinical accuracy by combining single tests and adding a subacromial injection. We postulated that the empty can and drop arm tests would result in higher sensitivity and specificity after subacromial injection. METHOD: We prospectively assessed 49 patients with the empty can and drop arm tests and used ultrasound to compare the individual and combined results. RESULT: The ultrasound found six cuff ruptures. Specificity improved and sensitivity decreased after subacromial injection. CONCLUSION: Only specificity improved after subacromial injection. Combining the test results led to an increase in both sensitivity and specificity without injection.

[Current guidelines for antibiotic prophylaxis in patients with a joint prosthesis are inadequate]. / Huidige richtlijnen voor antibioticaprofylaxe bij patiënten met een gewrichtsprothese niet volmaakt.

A haematogenous infection of a joint prosthesis is rare, but the consequences can be very serious. For that reason, guidelines issued by medical professional organizations for antibiotic prophylaxis in treatments which involve risk have long existed. On the basis of experience in the United States and the Netherlands, it is clear that successive guidelines sometimes contradict each other and are often not appropriately applied in daily practice. This may be due to insufficient clarity concerning the most important patient risk factors. It remains, for example, unclear when there is a question of reduced immunity in the patient and when the oral region has to be considered to be infected. An appeal is made to follow the existing guidelines better, and, if possible, to achieve a more multidisciplinary revision of the guidelines 'Total hip prosthesis, so that they would be more widely adhered to.

The effectiveness of injections of hyaluronic acid or corticosteroid in patients with subacromial impingement: a three-arm randomised controlled trial.

A total of 159 patients (84 women and 75 men, mean age of 53 (20 to 87)) with subacromial impingement were randomised to treatment with subacromial injections using lidocaine with one of hyaluronic acid (51 patients), corticosteroid (53 patients) or placebo (55 patients). Patients were followed up for 26 weeks. The primary outcome was pain on a visual analogue score (VAS), and secondary outcomes included the Constant Murley score, shoulder pain score, functional mobility score, shoulder disability questionnaire and pain-specific disability score. The different outcome measures showed similar results. After three, six and 12 weeks corticosteroid injections were superior to hyaluronic acid injections and only at six weeks significantly better than placebo injections. The mean short-term reduction in pain on the VAS score at 12 weeks was 7% (SD 2.7; 97.5% confidence interval (CI) 0.207 to 1.55; p = 0.084) in the hyaluronic acid group, 28% (SD 2.8; 97.5% CI 1.86 to 3.65; p < 0.001) in the corticosteroid group and 23% (SD 3.23; 97.5% CI 1.25 to 3.26; p < 0.001) in the placebo group. At 26 weeks there was a reduction in pain in 63% (32 of 51) of patients in the hyaluronic acid group, 72% (38 of 53) of those in the corticosteroid group and 69% (38 of 55) of those in the placebo group. We were not able to show a convincing benefit from hyaluronic acid injections compared with corticosteroid or placebo injections. Corticosteroid injections produced a significant reduction in pain in the short term (three to 12 weeks), but in the long term the placebo injection produced the best results.

Bone graft substitutes in active or suspected infection. Contra-indicated or not?

Treatment of infection in clinical orthopaedic and trauma care is a time consuming and costly endeavour. More than once, it will lead to extraction of implant material and additional surgical interventions. Currently, debridement, implantation of PMMA beads impregnated with antibiotics most often with implant exchange are the gold standard for deep infection treatment. Recently bone graft substitute materials such as calcium phosphate, collagen fleeces and bioglasses have appeared for specific use in infection treatment. Although these materials show great potential, their supporting level of evidence is still limited. This review paper provides an overview of current understanding and therapies for infection treatment and provides concepts for the use of new developed biomaterials in infection treatment. Furthermore, the benefits and risks of using biomaterials in infection treatment are discussed and the level of evidence of a number of new materials is presented.

[Indications for antibiotic prophylaxis in patients with a prosthetic joint]. / Indicaties voor antibiotische profylaxe bij patiënten met een gewrichtsprothese.

Under certain circumstances, patients with a prosthetic joint and a focal infection elsewhere in the body may be at risk of developing bacterial infection of the prosthesis. Patients and physicians should actively prevent infections that can spread systemically. Routine antibiotic prophylaxis is not recommended for all patients with a prosthetic joint and suspected bacteraemia. Antibiotic prophylaxis is warranted in three groups of patients with a prosthetic joint who must undergo an invasive procedure that could cause bacteraemia: patients with a predisposing immunocompromising systemic condition or those receiving immunosuppressive therapy, patients with a dermatological infection, and patients with an obvious focal infection, e.g., urosepsis. If the patient is already receiving antibiotics for the infection, additional prophylaxis is usually unnecessary. For patients undergoing dental procedures who require antibiotic prophylaxis, amoxicillin-clavulanic acid or clindamycin are preferred.

The CatWalk method: a detailed analysis of behavioral changes after acute inflammatory pain in the rat.

Experimental pain research is often complicated by the absence of an objective and detailed method to analyze behavioral changes. In the present study, acute pain was induced into the right knee of the rat (n=15) through the injection of 2mg carrageenan (CAR) in saline. A control group received vehicle injection into the knee (n=15). With the use of an automated quantitative gait analysis system, the CatWalk, it was possible to quantitatively analyze behavioral changes at post-injection time 2.5, 4, 24 and 48h. The CatWalk analysis of individual paw parameters like the intensity of the paw print or the time contact with the floor showed a significant effect after CAR injection into the knee. These CatWalk parameters were highly correlated with von Frey data and thus representative for the development of mechanical allodynia. Furthermore, detailed CatWalk analysis of the gait (i.e. coordinated interaction between left and right hindlimb) showed very fine, accurate and significant coordination changes in the experimental rats from 4h post-injection. In conclusion, the CatWalk method allows an objective and detailed detection of both pain-induced gait adaptations as well as the development of mechanical allodynia in an acute inflammatory pain model.

The effects of insole configurations on forefoot plantar pressure and walking convenience in diabetic patients with neuropathic feet.

BACKGROUND: The aim of this study was to evaluate the effects of insole configurations on plantar pressures and on walking convenience in patients with diabetic neuropathy. METHODS: Twelve different insole configurations were constructed for each of 20 patients with diabetic neuropathy. For this, different combinations of a metatarsal dome, varus and valgus wedges and arch supports with different heights were added on a fitted basic insole. Foot orthoses were evaluated while patients walked on a treadmill. Plantar pressure was measured with a Pedar Insole-system. Walking convenience was scored on a 10-point scale. FINDINGS: For the central and medial regions, plantar pressure reductions (up to 36% and 39%, respectively) were found when using a dome, standard and extra supports. The largest reductions were achieved with combination of a dome and extra support. There were no statistically significant pressure reducing effects of the insole configurations in the big toe and lateral regions, except for the effect of the combination extra support/varus wedge (21%), and for a dome (10%), respectively. The basic insole and a standard support received the best ratings for walking convenience and gradually worsened by adding extra support, a varus wedge and a dome. INTERPRETATION: A dome and the supports reduce plantar pressure in the central and medial forefoot. The combination of a dome and extra support seems to be the best choice for the construction of insoles. The results of this study are a step towards developing an evidence-based algorithm for the construction of optimal orthoses in therapeutic shoe design.

Random effect modelling of patient-related risk factors in orthopaedic procedures: results from the Dutch nosocomial infection surveillance network 'PREZIES'.

In the Dutch surveillance for surgical site infections (SSIs), data from 70277 orthopaedic procedures with 1895 SSIs were collected between 1996 and 2003. The aims of this study were: (1) to analyse the trends in SSIs associated with Gram-positive and Gram-negative bacteria; (2) to estimate patient-related risk factors for deep and superficial SSIs after all orthopaedic procedures, with special attention to primary total hip arthroplasty (THA); and (3) to analyse inherent differences in infection risk between hospitals. A random effect model was used to estimate the odds ratios of patient-related risk factors for developing an SSI, and to describe the distribution of the most widespread bacterial species responsible for SSIs among hospitals. Gram-positive organisms, mainly staphylococci, were the main cause of both deep (84.0%) and superficial SSIs (69.1%) after orthopaedic procedures. The percentage of SSIs after THA caused by coagulase-negative staphylococci decreased over the surveillance period, while the contribution of Staphylococcus aureus increased. Temporary elevations in the incidence of the most widespread pathogen species were observed within hospitals. Patient-related factors such as the National Nosocomial Infections Surveillance System risk index or age had little effect on the predictive power of the random effect models. This study underlines the usefulness of a random effect model, which adjusts risk estimates for random variation between hospitals, in a multicentre study on risk factors for SSIs.

[Surgical removal of debilitating neurogenic heterotopic ossifications of the hip]. / Chirurgisch verwijderen van invaliderende neurogene heterotope ossificaties van de heup.

Two men, aged 24 and 52 years, developed neurogenic heterotopic ossifications of the hip, the first following a cervical spinal-cord injury and the second after prolonged artificial ventilation following bowel surgery. The stiffness caused problems when sitting and when performing general daily activities; the second patient who was ambulatory, also had problems walking. CT investigation clearly showed the localisation of the ossifications. After surgical removal of the ossifications both patients were able to sit for longer periods without low-back pain and the ambulatory function of the second patient was much improved. Indomethacin was given postoperatively and no recurrence of the ossification was seen. A number of per- and postoperative complications are associated with the surgical removal of neurogenic heterotopic ossifications of the hip. These include damage to surrounding structures and infection. However taking into account the improved range of movement and increased independence of the patient, it is a useful intervention for this debilitating condition.

[Antibiotic prophylaxis in cases of closed fractures and prostheses]. / Antibiotikaprophylaxe bei geschlossenen Frakturen und Prothesen.

Antibiotic prophylaxis can be administered systemically or locally when bone cement is used for the implantation of prosthesis. In closed fracture surgery parenteral broad spectrum antibiotics are advised with 1 dose (in case of a long halflife) or for at least 12 hours when an antibiotic with a shorter half life is used. With such a prophylaxis a reduction of the infection rate to about 3% can be achieved, and also an important reduction of the postoperative nosocomial infections. Such a prophylaxis is highly cost effective. In primary prosthesis implantation, a 24 hours prophylaxis is needed. The use of antibiotic loaded bone cement, used as prophylaxis in primary prostheses is effective too, and this kind of cement should be used in combination with systemic antibiotics. In prosthesis an infection rate of 0.2% should be achieved.

Management of hardware infections following deep brain stimulation.

OBJECTIVE: To report our experience on hardware-related infections following deep brain stimulation (DBS). METHODS: The present article presents the retrospective clinical notes review of gained in a two-centre, single-surgeon study experience of 108 consecutive DBS cases between 1996 and 2002. In all patients the minimum follow-up was six months. One hundred and eight patients received an intracerebral electrode implantation and 106 underwent internalization. RESULTS: In total 178 electrodes were implanted with a mean follow-up of 42.6 months and a cumulative follow-up of 367.7 patient-years. Four patients (3.8%) developed an infection related to the DBS-hardware and all were initially treated with antibiotics. Two patients eventually required additional surgical treatment. CONCLUSION: Infections due to DBS-hardware can result in considerable levels of morbidity. In certain cases antibiotic therapy may be adequate. In others, surgical intervention to externalise the electrodes may be necessary. In our experience, there was never a need to remove the electrodes.

Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures.

BACKGROUND: Wound infection and other hospital-acquired infections cause significant morbidity after internal fixation of fractures (osteosynthesis). The administration of antimicrobial agents (antibiotics) may reduce the frequency of infections. OBJECTIVES: To determine whether the prophylactic administration of antibiotics in patients undergoing surgical management of hip or other long bone fractures reduces the incidence of wound and other hospital acquired infections. SEARCH STRATEGY: We searched the The Cochrane Library, Issue 3 2000; MEDLINE, EMBASE, LILACS, Current Contents, Dissertation Abstracts, and Index to UK Theses to August 2000. Bibliographies of identified articles were screened for further relevant trials. No language restriction was applied. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials involving - Participants: Any patients with a hip or other closed long bone fracture undergoing surgery for internal fixation or replacement arthroplasty. INTERVENTIONS: Any regimen of systemic antibiotic prophylaxis administered at the time of surgery. OUTCOME MEASURES: Wound infection (deep and superficial), urinary tract infection, respiratory tract infection, adverse effects of prophylaxis, economic evaluations. DATA COLLECTION AND ANALYSIS: Two reviewers independently screened papers for inclusion, assessed trial quality using an eight item scale, and extracted data. Additional information was sought from two trialists. Pooled data are presented graphically. MAIN RESULTS: Data from 8307 participants in 22 studies were analysed. In patients undergoing surgery for closed fracture fixation, single dose antibiotic prophylaxis significantly reduced deep wound infection (relative risk 0.40, 95%CI 0.24, 0.67) superficial wound infections, urinary infections, and respiratory tract infections. Multiple dose prophylaxis had an effect of similar size on deep wound infection (relative risk 0.40, 95%CI 0.24, 0.67), but significant effects on urinary and respiratory infections were not confirmed. Economic modelling using data from one large trial indicates that single dose prophylaxis with ceftriaxone is a cost-effective intervention. There are limited data for the incidence of adverse effects, but as expected they appear to be more common in those receiving antibiotics, compared with placebo or no prophylaxis. REVIEWER'S CONCLUSIONS: Antibiotic prophylaxis should be offered to those undergoing surgery for closed fracture fixation. On ethical grounds, further placebo controlled randomised trials of the effectiveness of antibiotic prophylaxis in closed fracture surgery are unlikely to be justified. Trials addressing the cost-effectiveness of different effective antibiotic regimens would need to be very large.

Gentamicin PMMA beads and other local antibiotic carriers in two-stage revision of total knee infection: a review.

Local antibiotic carriers are available as resorbable carriers (e.g. gentamicin-loaded collagen) and non resorbable carriers, mostly gentamicin-loaded bone cement in the form of beads or spacers. The release of the antibiotic may differ largely, depending on the properties of the carrier. In the use of spacers the release may remain too low, resulting in subinhibitory gentamicin concentrations. Revision of late deep infection of a knee prosthesis includes extraction, debridement and the use of local and systemic antibiotics. Reimplantation can be performed if healing is appropriate and the bone stock reaches. Otherwise arthrodesis is necessary.

Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures.

BACKGROUND: Antibiotic prophylaxis has been established policy for major surgical operations for many years. In fracture fixation, the effectiveness, and the duration of administration, have been a matter of debate. OBJECTIVES: To assess the effects of the prophylactic administration of antibiotics in patients undergoing surgical management of hip or other long bone fractures. SEARCH STRATEGY: We searched MEDLINE, EMBASE, Current Contents, Dissertation Abstracts, and Index to UK Theses, and bibliographies of identified articles. Trials were also obtained from the Cochrane Musculoskeletal Injuries Group trials register. Date of the most recent search: end of 1997. PARTICIPANTS: Any patients with a hip or other closed long bone fracture undergoing surgery for internal fixation or replacement arthroplasty. INTERVENTIONS: Any regimen of systemic antibiotic prophylaxis administered at the time of surgery. OUTCOME MEASURES: Wound infection (deep and superficial), urinary tract infection, respiratory tract infection, adverse effects of prophylaxis, economic evaluations. DATA COLLECTION AND ANALYSIS: Both reviewers independently selected trials for inclusion, and assessed methodological quality and extracted data. Where possible, data were pooled and Peto odds ratios and absolute risk reductions, each with 95% confidence intervals, calculated. MAIN RESULTS: Twenty one randomised trials of only poor or moderate quality were included. The comparisons tested fell within six comparison groups, principally multiple dose or a single dose of antibiotic versus a placebo or no treatment. Antibiotic prophylaxis reduces wound, urinary and respiratory tract infections in patients undergoing surgery for closed fracture fixation. Economic modelling has indicated that this is a cost-effective intervention. There are limited data for the incidence of adverse effects, but as expected they appear to be more common in those receiving antibiotics. REVIEWER'S CONCLUSIONS: Antibiotic prophylaxis should be offered to those undergoing surgery for closed fracture fixation. On ethical grounds, further placebo controlled randomised trials of the effectiveness of antibiotic prophylaxis in closed fracture surgery are unlikely to be justified. Trials addressing the cost-effectiveness of different effective antibiotic regimens would need to be very large and may not be feasible.

Surgical treatment of aspergillus spondylodiscitis.

Four cases of aspergillus spondylodiscitis were treated with operative debridement and fusion. In this rarely encountered mycotic infection of the spine in immunocompromised patients rapid destruction of the intervertebral disc and vertebral bodies can occur. In advanced cases antimycotic drug therapy is thought to be ineffective and a forcing indication for surgery exists when the destruction is progressive and spinal cord compression is imminent or manifest. Spinal instrumentation can be of help in maintaining or restoring spinal stability and maintaining spinal alignment. In our four patients the aspergillus spondylodiscitis was successfully eradicated and fusion achieved. In two of three patients with a neurologic deficit, this deficit disappeared. Two patients died within 6 months after the operative treatment, due to complications related to the underlying illness. One patient was left with a subtotal paraplegia.

Cervical spondylodiscitis after removal of a fishbone. A case report.

STUDY DESIGN: A case report of cervical spondylodiscitis after removal of a lodged fishbone. OBJECTIVES: To present a rare case of cervical spondylodiscitis and to inform the readers that a lodged fishbone can give rise to this complication after its removal. SUMMARY OF BACKGROUND DATA: In the literature, only one mention of this complication was found. METHODS: The literature, clinical presentation, technical examinations, and treatment are reviewed. RESULTS: Prolonged antibiotic treatment and immobilization of the cervical spine resulted in a cure of the spondylodiscitis. CONCLUSIONS: After removal of a lodged fishbone, a cervical spondylodiscitis is possible, but this is a very rare complication. In this patient, conservative treatment resulted in a cure of the infection. Successive magnetic resonance imaging investigations showed the extent of the destruction of the vertebral bodies and disc very well, as well as the curation of the spondylodiscitis after 5 months.

Osteomyelitis treated with gentamicin-PMMA beads: 100 patients followed for 1-12 years.

We treated 100 patients having osteomyelitis with debridement and gentamicin-PMMA beads and followed them for 5 (1-12) years. 66 of the infections were chronic, in 18 cases combined with arthritis and in 3 cases with pseudarthrosis. They underwent 117 "treatment periods", consisting of one or more operations (total 152), in most cases with an interval of 2 weeks. No systemic antibiotics were necessary besides the local antibiotic treatment in 52 of the treatment periods. Healing was achieved in 92 patients, in 78 after a single treatment period which included 1-5 operations, in 14 after two or three treatment periods. Healing was more difficult to achieve when the infection was chronic, especially with a duration of more than 6 years or when caused by elective surgery. Local antibiotic treatment with gentamicin PMMA beads has the advantage that the wound can be closed primarily and that a higher local antibiotic concentration in the tissues can be achieved, often making systemic antibiotic treatment unnecessary.