Addition of gentamicin for antibiotic prophylaxis in hip hemiarthroplasty does not decrease the rate of surgical site infection.

BACKGROUND: The addition of Gram-negative coverage to antibiotic prophylaxis protocols prior to elective total hip arthroplasty (THA) has been reported to reduce periprosthetic joint infection (PJI). However, it is unknown whether adding a Gram-negative-targeted antibiotic agent improves outcomes in the trauma population. This study aimed to investigate whether the addition of a single, pre-operative dose of Gentamicin is associated with lower rates of PJI in patients undergoing hemiarthroplasty (HA) as treatment for a hip fracture. METHODS: We retrospectively reviewed cases of patients who underwent HA as treatment for a hip fracture from January 2011 to January 2022, and had a minimum 1-year of follow-up. Patients were divided into two groups based on the antibiotic prophylaxis they received during surgery: cefazolin (control group) or cefazolin with addition of Gentamicin (case group). The primary outcome was the rate of surgical site infections (SSI), and secondary outcomes included rates of prosthetic joint infection (PJI) and superficial SSIs. RESULTS: The final study population consisted of 1521 patients. 336 patients (22.1%) were in the case group and 1185 (77.9%) patients were in the control group. Rates of SSI were comparable between the groups (3.8% for the case group vs. 2.8% in the control group, p = 0.34). This held true for both PJIs (3.5 vs. 2.5%, p = 0.3) and superficial SSIs (0.29 vs. 0.33%, p = 0.91). The distribution of the causing pathogen was similar between the groups (p = 0.84). Gentamicin susceptibility rates of the Gram-negative bacteria associated with PJI were similar between the cohorts (p = 0.51). CONCLUSIONS: The addition of a single, pre-operative dose of Gentamicin to the antibiotic prophylaxis protocol of patients undergoing HA as treatment for a hip fracture was not associated with lower rates of SSI, PJI or superficial SSI. The findings of this study indicate that the prophylactic benefits of Gentamicin may not apply to HA as they do to THA.

Reduced cutout for reverse oblique intertrochanteric hip fractures treated with trochanteric fixation advanced (TFN-A) nail compared to the short gamma-3 nail.

BACKGROUND: Reverse oblique fractures (AO/OTA 31-A3) account for 5-23% of all intertrochanteric fractures and are challenging to manage. The Gamma 3-Proximal Femoral Nail (GPFN) and the Trochanteric Fixation Nail Advanced (TFNA) are two common cephalomedullary systems used to treat this fracture. No study has reported on outcomes with the TFN-A for reverse oblique fractures. This study aimed to compare outcomes and complication rates in patients with reverse oblique fractures, treated with either TFNA or GPFN. PATIENTS AND METHODS: A total of 203 patients with reverse oblique fractures (137 in the GPFN group and 66 in the TFNA group), were treated in our institution between June 2010 and May 2019. Data was collected on postoperative radiological variables including screw or blade location, and tip-apex distance (TAD). Data were also collected for non-orthopaedic complication rates and orthopaedic complications. A sub-group analysis was additionally performed for different nail lengths. RESULTS: We found no significant difference in the overall rate of complications and revisions between the two groups. Patients treated with the 235 mm TFN-A nail sustained lower rates of cutout, compared to 180 mm GPFN (GPFN: 6% TFN-A: 0%, p = 0.043). The frequency of revision surgeries and malunions/non-unions did not differ significantly between the two groups and additionally showed no difference in the subgroup analysis. CONCLUSION: The 235 mm TFN-A was associated with lower rates of cut-out compared to the short GPFN for reverse oblique intertrochanteric fractures. Future well-designed prospective studies are warranted to investigate the role of the TFN-A in improving outcomes for such fractures.

Increased postoperative glycemic variability is associated with increased mortality in diabetic patients undergoing hip arthroplasty for hip fracture.

BACKGROUND: Increased glycemic variability (GV) during hospitalization has been associated with increased rates of surgical site and periprosthetic joint infections (PJI) following elective total joint arthroplasty. Uncertainty exists surrounding GV as a predictor for complications in urgent arthroplasty cases following hip fractures. In this study, we evaluated the association between GV and postoperative complications in diabetic patients undergoing total hip arthroplasty (THA) and hemiarthroplasty (HA) for hip fractures. METHODS: We analyzed data on 2421 consecutive patients who underwent THA or HA at our institution from 2011 to 2020. Patients with a known diagnosis of diabetes mellitus who had a minimum of three postoperative glucose values taken within the first week after surgery were included. GV was assessed using a coefficient of variation. Outcomes included short- and long-term mortality, reoperations, prosthetic joint infection (PJI) requiring revision and readmissions for any cause. RESULTS: The final cohort consisted of 482 patients (294 females, 188 males). Higher GV was associated with an increased 90-day mortality (p = 0.017). GV was not associated with 30-day mortality (p = 0.45), readmissions of any cause at 30 or 90 days (p = 0.99, p = 0.91, respectively), reoperation of any cause (p = 0.91) or PJI requiring revision surgery (p = 0.42). CONCLUSIONS: Higher GV in the postoperative period is associated with increased rates of mortality in diabetic patients following THA and HA for hip fractures. Efforts should be made to monitor and control glucose variability in the postoperative period.

Would giving priority in surgery timing to the oldest patients result in lower mortality?

PURPOSE: Early hip fracture surgery in elderly patients is recognized as a positive prognostic factor. When applied as an intervention, it does not always reduce overall patient mortality. A plausible explanation for this is that not all patients equally benefit from early surgery. The purpose of the study is to investigate the effect of early surgery on mortality in patients ages 80 and older. METHODS: This is a retrospective cohort of 3463 patients with hip fractures, operated upon within seven days of admission in a tertiary medical center between 2010 and 2018. Patients were divided into five groups: ages 80-84, 85-89, 90-94, 95-99, and 100 or above. Baseline characteristics were compared between groups. Mortality at one year post-operatively as a function of surgery delay was visualized for each group, using restricted spline curve analysis. RESULTS: Patients with increasing age were operated on earlier, had increased co-morbidities with a higher ASA score and experienced higher mortality. Spline curve analysis in younger patients, ages 80 to 94, demonstrated an inflection point at 48 hours after admission, prior to which mortality was rising rapidly and after which it continued rising slowly. In the two oldest age cohorts, there was no increased mortality with an increasing surgical delay. CONCLUSIONS: In patients ages 80-94 surgery on day one may be preferable to surgery on day two. In patients ages 95 and older, surgery time did not influence mortality. Pursuit of better patient outcomes may include prioritizing early surgery in younger patients.

Efficacy of Oral Nutritional Supplements in Patients Undergoing Surgical Intervention for Hip Fracture.

Introduction: Malnutrition is considered a risk factor among geriatric individuals with hip fracture, affecting functional healing and recovery, increasing healthcare spending, and associated with high mortality. In this study, we sought to evaluate the clinical efficacy of oral nutritional supplements in geriatric patients undergoing surgery for hip fracture. Material and Methods: We retrospectively analyzed data of 1625 consecutive patients who underwent fixation or arthroplasty for hip fracture in a tertiary medical center between 2017 and 2020. Patients who had no available albumin or body mass index levels were excluded. The study group is of patients who received an advanced formula in the form of an oral nutritional supplement (ONS), and the control group of patients that received no ONS. Peri- and postoperative complications, readmissions, short-term mortality, and albumin levels were compared between the 2 groups. Results: The final cohort included 1123 patients, 298 in the study group and 825 controls, with a follow-up of at least 1-year. Provision of the advanced enriched formula was not associated with 30-day, 90-day, or 1-year mortality (P = .62, P = .52, and P = .72, respectively) or any perioperative complications, such as 30-day or 90-day readmission (P = .37 and P = .1, respectively), revision surgery of any cause (P = .35), and postoperative infection rates (P = .73). Albumin levels on admission and the minimum albumin levels during hospitalization were similar between the groups, but they were significantly higher in the study group before discharge (33.42 g/L vs. 32.79 g/L, P = .01). Discussion: The use of an ONS was not associated with reduced perioperative complications or mortality, although it did affect nutritional status, as indicated by increased albumin levels, a known marker of nutritional status. Conclusions. While current findings do not support ONS use to minimize major postoperative complication after hip fracture surgery, further long-term study is warranted to evaluate subjective and functional outcomes associated with improved nutritional status.

Trends in Distribution and Antibiotic Resistance of Bacteria Isolated from Urine Cultures of Children in Northern Israel Between 2010 and 2017.

Objectives: To identify the changing trends of uropathogens over the years 2010-2017 and examine the incidence of both antibiotic resistance and extended spectrum beta lactamases (ESBL)-producing Enterobacteriaceae in urine cultures from pediatric patients. Study Design: Electronic medical records of 1,056 children, admitted to the Poriya Medical Center in Israel, between 2010 and 2017 with positive urine cultures, were reviewed for bacterial species and antibiotics resistance. Results: The leading pathogen was Escherichia coli (76%), followed by Klebsiella (7%), Enterococcus (5.8%), and Proteus (4%). Statistically significant gender-specific and ethnicity-specific differences in the distribution of uropathogens were found. E. coli was more common in females compared to males. Escherichia coli constituted most (92.3%) of the ESBL-positive cultures, while only 4.6% isolates carried Klebsiella, 1.5% carried Enterobacter spp., and 1.5% carried Morganella. Prevalence of ESBL-producing E. coli increased throughout the study period. Increasing prevalence over time was noted for ceftriaxone, cefuroxime, amoxicillin/clavulanate, and ampicillin resistance. Conclusions: Gender and ethnic background should be taken into consideration when choosing empiric antibiotic therapy for urinary tract infections in children. Similarly, the continuous increase in resistance to cefuroxime and amoxicillin/clavulanate should be considered when prescribing therapy in Israel. Ceftriaxone and gentamicin are still the antibiotics of choice for inpatient parenteral empiric treatment.