Optimization of the empirical antibiotic choice during the treatment of acute prosthetic joint infections: a retrospective analysis of 91 patients.

Background and purpose - The preferred treatment of an acute prosthetic joint infection (PJI) is debridement, antibiotics, irrigation and retention of the prosthesis (DAIR). The antibiotic treatment consists of an empirical and targeted phase. In the empirical phase, intravenous antibiotics are started after surgery before micro-organisms are determined in microbiological cultures. Which empirical antibiotic is used differs between hospitals, partly reflecting geographic differences in susceptibility spectrums. We investigated whether flucloxacillin should remain the antibiotic of choice in our hospital for empiric treatment of acute PJI with DAIR. Patients and methods - We retrospectively analyzed 91 patients treated for PJI with DAIR between 2012 and 2016. The susceptibility of micro-organisms was determined in multiple cultures of periprosthetic tissue and synovial fluid for 3 antibiotics: amoxicillin/clavulanic acid, cefazolin, and flucloxacillin. Results - Positive microbiological cultures from 68 patients were analyzed. Staphylococcus aureus was the predominant pathogen, cultured in half of the patients. In one-third of patients more than 1 micro-organism was found. On a patient level, the data showed that 65% were responsive to flucloxacillin, 76% to amoxicillin/clavulanic acid, and 79% to cefazolin. Interpretation - Flucloxacillin appeared to be a suboptimal choice in our patient population treated with DAIR. We therefore changed our practice to cefazolin as the preferred antibiotic in the empirical treatment of acute PJI with DAIR.

Single-stage total knee arthroplasty and osteotomy as treatment of secondary osteoarthritis with severe coronal deviation of joint surface due to extra-articular deformity.

PURPOSE: Severe extra-articular deformities can be treated with single-stage total knee replacement (TKA) and osteotomy. Aim of this study was to examine the patient-reported outcome measures (PROMs) and the complications after single-stage TKA and osteotomy. We hypothesized patients achieve good outcome after single-stage TKA and osteotomy, which is comparable to outcome after primary TKA without deformity. METHODS: Twenty-one patients with severe extra-articular deformity who underwent single-stage TKA and deformity-correcting osteotomy were reviewed and invited to fill in PROMs including the Oxford Knee Score, the Short Form-12, a Visual Analogue Scale for pain, and questions about satisfaction and quality of life. RESULTS: The mean follow-up period was 64 months. Ten patients were treated with TKA and supracondylar femoral osteotomy. Although PROMs showed good results (mean quality of life score was 85 out of 100), two patients had a revision of the osteotomy due to non-union. Eleven patients were treated with TKA and high tibial osteotomy. Patients were satisfied with the results (mean quality of life score was 81 out of 100). Two patients developed infection requiring debridement, resulting in one arthrodesis and one gastrocnemius transfer for wound closure. CONCLUSION: In general, patients were satisfied with the postoperative result. Outcome was comparable to patients after primary TKA in the literature. However, serious complications need to be taken into account. LEVEL OF EVIDENCE: III.

Reconstructive osteotomy of fibular malunion: review of the literature.

The treatment of ankle fractures has a primary goal of restoring the full function of the injured extremity. Malunion of the fibula is the most common and most difficult ankle malunion to reconstruct. The most frequent malunions of the fibula are shortening and malrotation resulting in widening of the ankle mortise and talar instability, which may lead to posttraumatic osteoarthritis. The objective of this article is to review the literature concerning the results of osteotomies for correcting fibular malunions and to formulate recommendations for clinical practice. Based on available literature, corrective osteotomies for fibular malunion have good or excellent results in more than 75% of the patients. Reconstructive fibular osteotomy has been recommended to avoid or postpone sequela of posttraumatic degeneration, an ankle arthrodesis or supramalleolar osteotomy. The development of degenerative changes is not fully predictable; therefore, it is advisable to reconstruct a fibular malunion soon after the diagnosis is made and in presence of a good ankle function. Recommendations were made for future research because of the low level of evidence of available literature on reconstructive osteotomies of fibular malunions.

Delirium after emergency/elective open and endovascular aortoiliac surgery at a surgical ward with a high-standard delirium care protocol.

Delirium is a common problem in elderly patients undergoing surgery. Standard delirium care is not available at all surgical wards. We determined the incidence, risk factors, and outcomes of postoperative delirium among patients undergoing elective/emergency aortoiliac surgery at a surgical ward with high-standard delirium care. A prospective descriptive survey in 107 patients was conducted. High-standard delirium care was given to patients above age 65, consisting of an extended focus on risk factors and intensive screening. The Delirium Observation Scale was used as a screening instrument for delirium. Patients were classified as having delirium if they met the DSM-IV criteria. The overall incidence of delirium was 23%. The incidence was 14% after elective surgery. Delirium occurred in 59% after emergency surgery and more often after open than after endovascular aneurysm repair (p < .01). Delirium was associated with age (p < .01) and emergency surgery (p = .01) and is an important and frequent complication after aortoiliac surgery.

[An invasive process in the pancreas: sometimes lymphoma]. / Een ruimte-innemend proces in het pancreas: soms een lymfoom.

An invasive process in the pancreas was found in a 60-year-old woman and a 50-year-old man with abdominal symptoms. Generally, such findings turn out to be adenocarcinoma. However, these patients had lymphoma. Primary pancreatic lymphoma or localization of lymphoma in the pancreas are rare and chemotherapy may be curative. Therefore, obtaining tissue for histopathological confirmation of the diagnosis is very important. Both patients underwent chemotherapy. The first patient was in complete remission one month after the last chemotherapy cycle. In the second, the disease went into remission, but he suddenly died of sepsis after the fourth chemotherapy cycle.

Delirium after abdominal surgery at a surgical ward with a high standard of delirium care: incidence, risk factors and outcomes.

BACKGROUND: Although delirium is a common problem in elderly patients undergoing surgery, standard delirium care is not available in all wards. The object of this study was to determine the incidence, risk factors and outcomes of postoperative delirium among patients aged 65 and above undergoing elective abdominal surgery at a surgical ward with a high standard delirium care. METHODS: Prospective descriptive survey in 71 patients. The Delirium Observation Scale was used to screen for delirium. Patients were classified as having a delirium if they met the DSM IV-criteria. Delirious and nondelirious patients were compared and associated risk factors were calculated using logistic regression analyses. RESULTS: Incidence of postoperative delirium was 24%. Univariate analysis showed that age above 74 years, CST score, ASA score, length of ICU stay, length of hospital stay and number of complications were significant risk factors for delirium. Older age, however, was the only significant risk factor in multivariate analysis (OR 1.16; 95% CI 1.00-1.35; p = 0.05). Lastly, mortality was significantly higher in the delirium group (29.4 vs. 3.7%; p = 0.001). CONCLUSION: At a surgical ward with high standard delirium care, the incidence of delirium was 24% and mortality was higher in delirious patients undergoing elective abdominal surgery.