Unexpected Positive Cultures in Hip and Knee Periprosthetic Fractures.

BACKGROUND: The purpose of this study was to determine the prevalence of unexpected positive cultures noted at the time of revision surgery for periprosthetic fracture (PPF) after total hip or knee arthroplasty. Moreover, we evaluated whether this finding should be considered clinically significant and what type of treatment, if any, was required. METHODS: This was a single-center retrospective review of 270 patients undergoing surgery for PPFs from December 2010 to December 2021. Exclusion criteria included: open fractures; history of infection at fractured joint; non-operatively treated patients; and intraoperative fractures. The primary end point was the prevalence of unexpected positive cultures noted at the time of revision surgery. This was defined as one or more positive cultures in a PPF that the surgeon had preoperatively classified as aseptic according to the 2018 International Consensus Meeting. Data collection included patient demographics, medical histories, preoperative investigations, postoperative microbiology, and treatment. RESULTS: During the study period, 159 patients were admitted with PPFs of the hip and 61 with PPFs of the knee. The mean age was 70 years (range, 32 to 93 years). Unexpected positive cultures were diagnosed postoperatively in 15 patients (6.8%; 10 hips, 5 knees). The most prevalent organism was Staphylococcus epidermidis (35.0%). Of those 15 patients, 6 required a surgical revision for infection. None of the patient-related risk factors were found to be associated with an increased risk of unexpected positive cultures. The comparison between infected and noninfected patients showed a significant association between preoperative C-reactive protein >10 mg/mL (P = .04), loose implant (P = .07), and infection. CONCLUSIONS: The prevalence of unexpected positive cultures was 6.8% in our study cohort. Although surgical treatment may be required, the majority of patients seem to require no treatment. Larger series are required to investigate the clinical importance of this rare finding. LEVEL OF EVIDENCE: III.

Combined Medial Patellofemoral Ligament and Medial Patellotibial Ligament Reconstruction for Recurrent Lateral Patellar Dislocation in Flexion.

Recurrent lateral patellar dislocation can be a challenging entity to manage. It results from an imbalance between the restraints to lateralization of the patella and the forces applied to the patella within the biomechanical environment of the knee. The medial patellofemoral ligament has been recognized as the most important static soft-tissue restraint. However, the medial patellotibial ligament and medial patellomeniscal ligament are important for patellar stability at higher degrees of knee flexion. Lateral patellar dislocation in flexion poses a particularly challenging clinical entity with a combination of unique characteristics that need to be addressed to achieve optimal patellar tracking and stability. In this technical note, we describe a combined medial patellofemoral ligament and medial patellotibial ligament reconstruction technique to address lateral patellar dislocation in flexion.

Functional Outcome of Kyphoplasty in Osteoporotic Vertebral Fractures in Patients with Severe Disability Above 60 Years of Age: Mid to Long Term Follow up.

BACKGROUND:  Vertebral osteoporotic fractures are a worldwide problem and can cause significant morbidity. MATERIAL AND METHODS: retrospective analysis reviewing functional outcome of 70 patients who underwent balloon-kyphoplasty(BK). Inclusion criteria, a-patients above 60 years of age b-symptomatic patients who failed conservative treatment c-radiological diagnosis of vertebral compression fracture(VCF). Primary outcome was evaluation of functional outcome in mid- (1-3 years) and long term (>3 years). Secondary outcomes a-analysis of the functional outcome of patients with severe disability or worse in mid- and long-term b-comparison of functional outcome between mid-term and long term follow-up c-correlate number of levels operated on with functional outcome. RESULTS: There were 70 patients with average age of 74 years. Lumbar and thoracic VCFs were included. Average follow-up was 2.7 years. Twenty-eight patients had long-term follow-up of ≥ 3 years and the remaining 42 had mid-term follow-up of > 1 year and < 3 years. All patients experienced clinical and statistically significant improvement in their Oswestry Disability Index score. This was the case in mid-term and long-term follow-up. This was also the case for patients presenting with severe disability. There was no correlation between the number of levels and functional outcome. CONCLUSIONS: 1. Osteoporotic vertebral compression fractures are fragility fractures and can be associated with significant morbidity. 2. Surgical treatment can help improve functional outcome on failure of conservative treatment. 3. Balloon kyphoplasty can significantly improve pa-tients' functional outcome in mid-term and long-term follow-up including patients presenting with severe disability or worse. 4. This study is of value in consenting kyphoplasty patients as they can expect an improvement in their disability in the mid-to-long term.

Scoping review of complications associated with epinephrine use in arthroscopy fluid.

Purpose: To identify if addition of epinephrine to irrigation fluid can result in any intra-operative or post-operative complications. It was hypothesized that significant adverse events would be identified with the use of epinephrine in arthroscopic fluid.Methodology: In accordance with PRISMA guidelines (Appendix 2), an electronic database search was conducted, from inception to February 2019 including MEDLINE, EMBASE, Cochrane, CENTRAL, and Scopus (MeSH search). All English-language studies that addressed complications associated with arthroscopic use of epinephrine were included. Defined outcome measures were any reported intra- or post-operative adverse events secondary to epinephrine use. Data collection included: patient demographics, comorbidities, surgical intervention, epinephrine concentration in irrigation fluid, reported complications, and details of the associated clinical prodrome.Results: Three hundred and ninety-three abstracts were screened with 22 studies identified and reviewed in detail. Of these seven case reports and four randomized trials met the inclusion criteria (1999-2017). The case reports encompassed nine patients (seven females and two males) with an average age of 38.8 years (range 19 to 52 y). Five had shoulder arthroscopies, two had knee scopes and two had hip scopes. A pattern of reported complications was noted in all reports in association with epinephrine including hypertension, tachycardia with or without evolving arrhythmia and/or pulmonary edema. One patient died. Of the four randomized trials, three did not report any adverse events in relation to epinephrine with one trial associating epinephrine to the occurrence of hypotensive bradycardic events in the setting of shoulder arthroscopy in the beach-chair position.Conclusion: While a causal association cannot be established, Anesthetists and Orthopedic Surgeons should be aware of the noted pattern of symptoms in patients undergoing epinephrine-assisted arthroscopy.Clinical relevance: While the incidence of epinephrine-related complications is rare, this review raises awareness to the pattern of reported symptoms, as it could help with identification and treatment should this rare complication be encountered.