Blood and synovial fluid calprotectin as biomarkers to diagnose chronic hip and knee periprosthetic joint infections.

AIMS: Calprotectin (CLP) is produced in neutrophils and monocytes and released into body fluids as a result of inflammation or infection. The aim of this study was to evaluate the utility of blood and synovial CLP in the diagnosis of chronic periprosthetic joint infection (PJI). METHODS: Blood and synovial fluid samples were collected prospectively from 195 patients undergoing primary or revision hip and knee arthroplasty. Patients were divided into five groups: 1) primary total hip and knee arthroplasty performed due to idiopathic osteoarthritis (OA; n = 60); 2) revision hip and knee arthroplasty performed due to aseptic failure of the implant (AR-TJR; n = 40); 3) patients with a confirmed diagnosis of chronic PJI awaiting surgery (n = 45); 4) patients who have finished the first stage of the PJI treatment with the use of cemented spacer and were qualified for replantation procedure (SR-TJR; n = 25), and 5) patients with rheumatoid arthritis undergoing primary total hip and knee arthroplasty (RA; n = 25). CLP concentrations were measured quantitatively in the blood and synovial fluid using an immunoturbidimetric assay. Additionally, blood and synovial CRP, blood interleukin-6 (IL-6), and ESR were measured, and a leucocyte esterase (LE) strip test was performed. RESULTS: Patients with PJI had higher CLP concentrations than those undergoing aseptic revision in blood (median PJI 2.14 mg/l (interquartile range (IQR) 1.37 to 3.56) vs AR-TJR 0.66 mg/l (IQR 0.3 to 0.83); p < 0.001) and synovial fluid samples (median PJI 20.46 mg/l (IQR 14.3 to 22.36) vs AR-TJR 0.7 mg/l (IQR 0.41 to 0.95); p < 0.001). With a cut-off value of 1.0 mg/l, blood CLP showed a sensitivity, specificity, positive predictive value, and negative predictive value of 93.3%, 87.5%, 89.4%, and 92.1%, respectively. For synovial fluid with a cut-off value of 1.5 mg/l, these were 95.6%, 95%, 95.5%, and 95%, respectively. CONCLUSION: This small study suggests that synovial and blood CLP are useful markers in chronic PJI diagnosis with similar or higher sensitivity and specificity than routinely used markers such as CRP, ESR, IL-6, and LE. CLP was not useful to differentiate patients with PJI from those with rheumatoid arthritis. Cite this article: Bone Joint J 2021;103-B(1):46-55.

Results of the Treatment of Infected Nonunions of the Lower Limbs Using the Ilizarov Method.

BACKGROUND: Infected nonunion is a complex complication of the treatment of long bone fractures. An in creased incidence of injuries, including high energy injuries (often open ones), contributes to a higher incidence of nonunion. These primarily infected injuries cause osteomyelitis, which prevents bone union, resulting in an infected nonunion. The Ilizarov method meets the biological and biomechanical treatment requirements, opti mising the process of inflammation healing and producing bone union. MATERIAL AND METHODS: A total of 54 patients were treated in 2000-2014 for nonunion in the lower limbs with the Ilizarov method, which was used after previous treatment had failed. The subjects underwent intra operative resection of the locus of infection, sequestrectomy and a Judet procedure, followed by the use of the Ilizarov apparatus and bone transport, depending on the defect. RESULTS: Inflammation healed in 52 patients (96%) and bone union was achieved in 46 patients (86%). Good outcomes with healed inflammation and bone union were reported in 76% of the cases, fair outcomes with tem porary elimination of the inflammation and without bone union in 16%, and poor outcomes without inflam ma tion healing and without bone union in 7%. CONCLUSIONS: Treatment of infected nonunion can only be effective after eliminating endogenous inflamma tory foci, covering skin defects, ensuring a good condition of the skin and soft tissues, restoring normal blood supply to the bone fragments, and good biomechanical fixation of the fragments with dynamisation or compression. The Ilizarov method is a method of choice in the treatment of cases of infected nonunion where other treatments have failed.

Analysis of Risk Factors for Periprosthetic Joint Infection in Clinical Data.

BACKGROUND: Progress in orthopaedics has now made it possible to improve the functional status of damaged hip joints with hip arthroplasty and eliminate the associated pain. The constantly growing number of hip replacement procedures is, however, associated with a proportional rise in the number of subsequent surgery-related complications. The most important complication is septic loosening of the implant. The treatment of septic complications is often ineffective and recovery becomes impossible. In that setting, an awareness of the risk factors of septic complications and an ability to prevent periprosthetic joint infection (PJI) are becoming necessary. AIM: The aim of the study was to analyse the risk factors of PJI as an essential element of the prophylaxis of septic complications. MATERIAL AND METHODS: We analysed the data of 142 patients treated for PJI at the Ward of Bone and Joint Infections, Department of Orthopaedics, Medical Centre of Postgraduate Education in Otwock, between 2008 and 2010. Their medical records were analysed retrospectively. The diagnosis was evidence-based, relying on case histories, physical examination and accessory investigations, including imaging studies and biochemical and microbiological testing. RESULTS: The analysis of clinical data served to identify factors that appeared repetitively in the patients with PJI treated at the Ward. Those elements constitute the combination of risk factors for PIJ. CONCLUSIONS: 1. An awareness of risk factors for septic complications and their early elimination are necessary in daily orthopaedic care. 2. The pre-surgery checklist is a very effective tool to eliminate the most common risk factors of PJI.

Stimulation of bone union with dynamic beams of Konzal's "R" external fixator.

BACKGROUND: Treatment of septic long bone non-union remains a complex therapeutic problem. External stabilisation with Konzal's "R" fixator has been used in the Orthopaedic Department of CPME for years and allows for rigid stabilisation of bone fragments and good mutual alignment. Tried and tested in the treatment of osteitis, the fixator, however, offers limited possibilities for dynamisation and interfragmental compression. The following article presents a modernised design of Konzal's "R" with dynamic beams. MATERIAL AND METHODS: The efficacy of dynamisation of the fixator with the modernised design was compared with that of the earlier technique of eccentric shifting of static beams by assessing the time of bone union, the average number of pin restabilisations required, and the percentage of "partial unions" in two groups treated with the different methods. RESULTS: In the dynamic beam group, mean time to bone union was shorter by 5.1 months on average. This group also recorded a significantly lower percentage of "partial unions" (<50% of diaphysial circumference) as well as a lower count of necessary pin restabilisations per patient. There was no correlation between time to bone union and the duration of active inflammation prior to the surgical treatment or the presence of an open fistula. CONCLUSIONS: 1. The modernised design allows for dynamic load bearing by the bone tissue between the fragments rather than by the fixator's static beams. 2. The biomechanical principle of the fixator provides for optimal bone healing and shortens the time to bone union.

The effects of cooperation between orthopaedic surgeons and microbiologists on the effectiveness of diagnosis and treatment of septic hip joint loosening.

BACKGROUND: The objective of this study is to compare the results of microbiological examinations of two types of materials: specimens collected intraoperationally upon removal of prostheses following septic loosening and cultures from sonicated implants. The study was the effect of collaboration between the Clinic of Orthopedics of A. Gruca Hospital in Otwock and the Department of Microbiology in Lublin. MATERIAL AND METHODS: The study population consisted of 24 patients aged 39 to 84 years, average of 68 years, undergoing surgeries at the Department of Bone and Joint Inflammation, Clinic of Orthopedics of A. Gruca Hospital in Otwock in years 2010-2011. All patients were qualified for surgical treatment consisting of removal of hip prosthesis due to inflammation. Sixty percent of the group were women, while the remaining forty percent were men. The methodology of the study was based on intraoperational collection of material for microbiological examinations at the Department of Microbiology of A. Gruca Hospital. The study material was collected from 3 locations: femoral shank, hip acetabulum and gluteal muscle. Explanted implants were placed in sterile containers, frozen at -20°C and transported to the Department of Microbiology in Lublin. There, the implants were sonicated. RESULTS: The obtained results were consistent in both groups in 37% of cases. In 9 patients (37%), standard cultures were negative while the cultures of sonicated material were positive. In 16 patients (67%), the spectrum of perioperative and sequential antibiotic therapy included flora cultured by standard methods as well as flora obtained from sonicated implant cultures. In the remaining patients, cultures obtained from sonicated material were resistant to antibiotics used. CONCLUSIONS: Cultures of sonicated implant materials increase the chance for identification of microbes responsible for inflammation. Limitations of the method include the requirement to either examine the implant shortly after removal or freeze the implant in order to prevent secondary infections of the material.

[Septic complications after multilocal fractures and multiple traumatic injury]. / Powiklania infekcyjne po zlamaniach wielomiejscowych i obrazeniach wielonarzadowych.

INTRODUCTION: The increase of the number of the multiple traumatic injuries is related to social factors, such as: the development of industry, the change of life style and the conditions of work, the manner and the speed of relocation and the biological factors related with the elongation of life time. According to the World Health Organization data the injuries are one of the main health problems in the world. AIM: The clinical analysis of multitrauma patients treated due to the septic complications of the fractures. MATERIAL AND METHODS: The material consists of 34 multitrauma patients treated in The Osteomyelitis and Septic Complications Unit in Prof. A. Gruca Orthopedic and Trauma Hospital in Otwock, Poland between 2005 and 2010. The cause of trauma, the timing of arrival to our unit, the number of the days of treatment, the number and the specificity of bone and internal injuries, the bacteriology of bone infections and operative techniques and pharmacologic treatment were analyzed. RESULTS: The causes of the injuries were: road accident (79%), fall from the height (8.8%), others (12.2%). The first stay in our unit was 21 months after the injury on average (1-129 months), the number of stays in the unit was 2,8 on average (1-6), the length of stay was 25.7 days on average (4-108 days). In analyzed group of 34 patients, we found: 12 opened fractures of single bone, 11 opened fractures of more than one bone, 22 closed fractures of single bone, 12 closed fracture of more than one bone. Central nervous system (55.9%), abdominal organs (35.3%) and thorax (29.4%) were the most common internal organs ocuppied with the injury. Osteomyelitis was the most frequently diagnosed in femur (50%) and tibia (41.2%). The main reasons of bone infection were: Methycylin-Sensitive Staphylococcus Aureus (35,3%), Methycylin-Resistant Staphylococcus Aureus (17,3%), Pseudomonas aeruginosa (23,5%), Escherichia coli, Acinetobacter baumani, Enterococcus faecalis. The following treatment was undertaken: the debridement of septic bone, usually together with the removal of the hardware stabilization (73,5%), the removal of the damaged or improperly fixed stabilization (44%), the conversion of the internal fixation into the external fixation(62%). All the patients were taken intravenous antibiotics according to The Hospital Commission for Preventing of Infections, i.e. 2nd generation cephalosporin and gentamycin. Culture directed antibiotics were started after receiving the bacteriology results. The outcomes. The control of infection in 14 patients (41.3%), 18 patients (52.9%) still remain under the treatment, bad outcome (persistent infection, amputation of a extremity) we had in 2 patients. CONCLUSIONS: Multiple traumatic injury and its immunologic consequences predispose to systemic infections including bone infections. Posttraumatic osteomyelitis is the indication to chronic treatment. Surgical management of the wound and external fixation of the fractures of the long bones according to the control damage surgery is the most important in prevention of posttraumatic osteomyelitis.

[Two-stage revision procedure for septic complicated endoprosthesis of the hip]. / Dwuetapowa replantacja stawu biodrowego w leczeniu powiklan zapalnych endoplastyki.

Total hip arthroplasty is commonly used way for treatment of degenerative changes of a hip joint. Continuous progress of medicine enables use of more and more modern implants, that are supposed to provide to patients comfortable and painless motility. Nevertheless, with increasing number of implanted endoprostheses, rising numer of loosened impants is observed. Proper laboratory dignostics and postoperative proceedings as well as systematic follow up with standard X-ray scans allow for early recognition of loosened prostheses and implementation of surgical procedure. In the article two-stage method for treatment of septic loosened primary total hip arthroplasties applied in CMKP Orthopedic Clinic in Otwock, Poland as well as results of treatment of selected cases are presented.