Evaluating the microbial pattern of periprosthetic joint infections of the hip and knee.

PURPOSE: Periprosthetic joint infection (PJI) is a devastating complication that leads to enormous economic and health care complaints from affected patients. The aim of this study is to identify the causative pathogens responsible for PJI, evaluate temporal trends concerning the pathogen pattern and identify potential risk factors for PJI. METHODOLOGY: This was a retrospective study analysing a total of 937 patients suffering PJI of the hip or knee joint between 2003 and 2011. RESULTS: In total, 394 patients (42.0 %) with total knee arthroplasty (TKA), 477 patients (50.9 %) with total hip arthroplasty (THA) and 64 patients (6.8 %) receiving a dual-head prosthesis had to be hospitalised due to PJI. In two cases (0.2 %), a simultaneous infection of TKA and THA occurred. The mean age of the study cohort was 70.85±11.68 years. The mean body mass index (BMI) was 28.53±5.7. According to the Charlson comorbidity index, 2.99 % of the patients were classified as severity Grade 1, 13.98 % Grade 2, 40.02 % Grade 3 and 43.0 % Grade 4. Staphylococcus aureus (MSSA), methicillin-resistant Staphylococcus epidermidis (MRSE), methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative Staphylococcus (CoNS), Streptococcus, and Enterococcus were the pathogens mainly responsible. An increase in high-resistance pathogens, such as MRSE, extended-spectrum beta-lactamase bacteria (ESBL), ampicillin-resistant Enterococcus, Acinetobacter spp. and vancomycin-resistant Enterococcus (VRE), was found during the study period. Only MRSA showed a declining tendency in a regression model. CONCLUSION: Patients suffering PJI present a certain risk profile with many comorbidities, e.g. high age and obesity. The observed microbiological pattern demonstrates the rise of high-resistance pathogens.

Success rates for initial eradication of peri-prosthetic knee infection treated with a two-stage procedure.

BACKGROUND: In Germany, rates of primary total knee arthroplasty procedures and exchange arthroplasty procedures continue to rise. Late-onset peri-prosthetic infection constitutes a serious complication whose management may be dependent upon the spectrum of micro-organisms involved. The aim of this study was to provide a retrospective analysis of the effectiveness of initial eradication measures performed as part of a two-stage procedure. MATERIAL AND METHODS: Between 2002 and 2008, a total of 328 patients who had received a first-time diagnosis of chronic peri-prosthetic knee infection following total knee arthroplasty (TKA) subsequently underwent surgery at our clinic. The surgical approach consisted of a two-stage procedure, with the initial procedure consisting of the removal of the prosthesis and radical debridement, followed by insertion of an antibiotic-loaded static spacer. The effectiveness of the procedure was assessed after six weeks, with each patient undergoing a number of clinical and laboratory-based tests, including knee joint aspiration. RESULTS: Staphylococcus aureus strains were responsible for 68% (n=223) of the total number of cases of peri-prosthetic knee infection. 19% of cases (n=62) showed evidence of gram-negative bacteria, while MRSA accounted for 15% (n=49) of cases. Six weeks after completion of the above-named treatment regimen, eradication of infection was considered successful in 289 patients (88.1%). Eradication was unsuccessful in 22% of MRSA infections (n=11) and 7% of MSSA infections (n=23). CONCLUSION: The treatment regimen outlined in this report is capable of achieving satisfactory results in the management of late-onset peri-prosthetic knee infection, with one exception: patients with infections caused by MRSA showed high failure rates.

The Posttraumatic Proximal Cross-union of the Forearm in Childhood: What is Recommended?

The posttraumatic proximal cross-union of the forearm in childhood is a rare complication after radial head, neck or proximal forearm fractures and elbow dislocations. There is no standardized treatment. Several surgical procedures with or without interposition techniques are described in the literature. The aim of this study was to analyze all children with cross-unions who underwent surgery over the last 15 years. From 1998 to 2013, 8 children with a posttraumatic proximal cross-union of the forearm (Type 3 according to Vince and Miller) received surgical treatment with resection of the cross-union or radial head. Mean age at the time of initial trauma was 9.0±2.56 years (range 6-14 years), age at the time of surgery was 11.9±3.09 years (range 7-16 years). Mean time of resection of the crossunion was 23.2 months. Follow-up time was 10.6 months (range 1-36 months). Five patients had a resection of the cross-union without any interposition techniques, in 2 cases with an additional arthrolysis of the elbow. One patient had an interposition of a local fascia flap. In 2 cases, a primary excision of the radial head, six and seven years, respectively, after trauma, was performed. All patients, except one, had non-steroidal antiinflammatory drugs therapy after surgery. A post-operative irradiation was performed in 3 cases. The mean postoperative range of motion for pronation/supination was 36/0/53°. Controversy remains about the best procedure to adopt for posttraumatic cross-union in childhood. After analysis of our data and the literature, we recommend the resection of the crossunion within 6-24 months of occurrence without necessarily using any interposition techniques. All patients reported an improvement with regard to ordinary activities. In cases of long-term cross-union for several years with ankylosis of the elbow and bony deformities of the proximal radius, an excision of the radial head as salvage procedure is recommended.

Ilizarov external frame technique for pirogoff amputations with ankle disarticulation and tibiocalcaneal fusion.

BACKGROUND: The high rates of wound failure, persisting infection, and nonunion of the tibiocalcaneal arthrodesis are the main reasons why the Pirogoff ankle disarticulation is rarely used for limb salvage. Use of the Ilizarov external frame has increased our fusion rate. The purpose of this study was to review our experience with the use of the Ilizarov external frame as a technique for Pirogoff amputations with ankle disarticulation and tibiocalcaneal fusion. METHODS: Twenty-four patients (median age, 57.4 years; range, 29-76 years) underwent a Pirogoff amputation with Ilizarov external frame use between January 2004 and June 2011. The most common indications were gangrene with uncontrollable infection due to Charcot arthropathy or chronic osteomyelitis. Four patients had sustained crush injuries of the foot. All patients were clinically and radiographically followed for a minimum of 12 months. Additionally, 15 patients were evaluated using the Taniguchi rating scale for Pirogoff amputations after a mean follow-up of 44.9 months (range, 12-86 months). RESULTS: In 21 patients (87.5%), a well-healed Pirogoff stump was achieved after a mean external fixation time of 18.1 weeks (range, 12.7-26.6 weeks). Impaired vascular perfusion was found to be the limiting factor for successful wound healing and an overall successful Pirogoff amputation. According to the Taniguchi scale, 67% of the patients achieved good or excellent functional results. Fair (27%) and poor (6%) results were observed only in the diabetic patients. CONCLUSION: Using the Ilizarov external frame allowed safe fixation and a high success rate, even in neuropathic feet. The frame allowed for immediate weight-bearing and soft tissue control; however, frame-associated complications were common and could result in revision surgery. LEVEL OF EVIDENCE: Level IV, case series.

Thoracic vertebral body fracture after total hip replacement in diffuse idiopathic skeletal hyperostosis.

This article describes the critical clinical sequelae of a patient with diffuse idiopathic skeletal hyperostosis who sustained an acute iatrogenic thoracic vertebral body fracture with subsequent spinal cord injury after a total hip replacement, with a final lethal course.A 57-year-old woman was referred to the authors' institution after undergoing a total hip replacement in the supine position for secondary osteoarthritis. Postoperatively, the patient had symptoms of an incomplete paraplegia. Computed tomography scan and magnetic resonance imaging revealed diffuse idiopathic skeletal hyperostosis and an acute unstable fracture of T11 with spinal contusion. A posterior spinal fusion of T10-L1 with laminectomy of T11 was performed immediately on admission. Postoperatively, no improvement of the neurological deficit was observed. After developing multiorgan failure while in intensive care, the patient died 2 months after the total hip replacement.The morphological and functional symptoms of diffuse idiopathic skeletal hyperostosis with the typical ossification of the longitudinal ligaments and the associated loss of bending forces of the spine were detected postoperatively. This severe case demonstrates that the surgeon must be alert to possible complications due to intraoperative maneuvers in patients with stiffened spinal disorders undergoing total hip replacement.

Two-stage revision of infected total knee arthroplasty using a distraction spacer.

BACKGROUND: The infection of a total knee arthroplasty (TKA) has remained as one of the most devastating potential complications. In this context we developed a new technique that keeps the spacer in distraction during the cementation process to achieve better weight-bearing stability. METHODS: We present a case of a 75-year-old male patient, who was treated in our hospital with an infected total knee replacement (TKR) using the distraction spacer. The operative technique includes the removal of the infected prosthesis after radical debridement. Then two carbon rods were inserted overlapping 2-3 cm in the medulla of the tibia and femur. Afterwards an external fixateur with distraction module is attached with two Schanz screws into the distal femur and the proximal tibia. The cementation process was performed under distraction. After hardening of the cement the external fixateur and the Schanz screws are then removed. RESULTS: Postoperatively the patient was mobilized with full weight-bearing using an extension splint. The antibiotic therapy was continued for five weeks. After sterile puncture, the reimplantation was performed using a Zimmer-Rotating-Hinge-Knee without any complications. CONCLUSIONS: This method allows cement hardening without micromovements and early mobilization with partial full weight bearing and prevents the contraction of the capsule and the ligaments during the prosthesis-free period, preparing the knee for a secondary TKA or an intramedullary arthrodesis with a titanium stem.

Necrotizing fasciitis in patients with spinal cord injury: an analysis of 25 patients.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: The aim of this study was to analyze the correlation between necrotizing fasciitis (NF) and pressure ulcers, as well as the mortality, and complication rate, in patients with spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA: Pressure ulcers represent a challenging problem, especially in immobilized patients. Necrotizing soft tissue infections arising from decubitus ulcers in patients with SCIs have been reported. METHODS: Twenty-five SCI patients with NF treated between April 2000 and December 2009 were included in the study. All patients were analyzed in regard to the number of surgical debridements, length of hospital stay, and laboratory, microbiological, and histological assessments. Information about age, sex, preexisting conditions, anatomical localization, and etiology of the NF were acquired from the patients' medical records. RESULTS: There were 19 paraplegic and 6 tetraplegic patients with a median age of 47 years. In 18 cases, NF developed in the setting of pressure sores. Grade 4 pressure sores were identified in 15 cases and grade 3 pressure sores in 3 cases. The incidence of developing NF is significantly higher in patients with fourth-grade pressure sores than in those with a lower-grade lesion (odds ratio = 2.91; 95% confidence interval, 1.29-6.56). The mean laboratory risk indicator for NF score was 6.6 upon admission. The most common bacteria were streptococci. During the hospital stay, six patients developed sepsis and two died because of septic multiorgan failure. CONCLUSION: Patients with grade 3 and 4 pressure sores had a significantly increased risk of developing NF. The current investigators recommend that close clinical and laboratory monitoring of all patients with grade 3 or 4 pressure sores is appropriate so that any early clinical signs of NF can be recognized and evaluated for early and aggressive treatment.

Rare complication after VAC-therapy in the treatment of deep sore ulcers in a paraplegic patient.

The VAC-therapy is a safe, easy, and effective therapy for the management of chronic wounds. Known advantages of the VAC technique are the quicker wound healing by stimulating the blood flow, the formation of granulation tissue, angiogenesis, and cell proliferation. The use of negative pressure treatment can decrease the number of dressing changes and length of hospital stay. However, some related complications after and during VAC therapy have been described. We here describe a rare complication during the treatment of severe os ischium sore with VAC therapy, which has not been reported in the literature yet. We report about a 43-year-old paraplegic patient, referred to our clinic from a regional hospital where he had been admitted 2 months earlier, presenting with a necrotizing fasciitis after VAC therapy during the treatment of fourth grade os ischium sore. After operative debridement and long-term antibiotics with Ciprofloxacin soft tissue closure was performed using a myocutaneous tensor fascia lata flap. Temporary stabilization was achieved by a triangle external fixateur attached to the right femur and the pelvis. After 1 week the tapping point of the muscle flap could be covered with local skin mesh-graft from the right calf as a donor site. The patient was mobilized in a wheelchair and was discharged home 3 months after admission. The VAC technique is a safe, easy, and effective means in chronic wound care management. However, the described rare complication should be kept in mind. The clinical management of VAC therapy requires a distinct indication and close clinical monitoring by experienced medical professionals. The use of VAC therapy in fourth grade sores may have deleterious consequences for the patient.