[Evaluation of the importance of a ready-made, gentamicin-impregnated spacer in relation to bacteriological findings in patients with periprosthetic joint infections]. / Zhodnocení významu ready-made spaceru s gentamicinem ve vztahu k bakteriologickým nálezum u pacientu s infekcí kloubní náhrady.

BACKGROUND: Periprosthetic infection is a serious complication in total hip and knee arthroplasty. The complex therapeutic approach within two-stage reimplantation includes the use of antibiotic-impregnated spacers (temporary joint replacements). The aim of this paper was to evaluate bacteriological findings in selected patients with periprosthetic infection in whom a ready-made gentamicin-impregnated spacer was used to treat the infection. MATERIALS AND METHODS: Between 2008 and 2012, a ready-made, gentamicin-impregnated cement spacer was used in 24 patients to treat periprosthetic hip or knee infection within two-stage reimplantation. All components of the prosthesis and periprosthetic tissue samples were sent for microbiological examination at the first revision surgery, while at the second revision surgery, the spacer and surrounding tissue samples were sent in. In six patients with an inserted knee spacer, the level of gentamicin in the joint fluid was measured. Subsequently, the patients were regularly monitored. RESULTS: Twenty-two (92%) of 24 patients were bacteriologically positive by culture. The most commonly detected causative agents were coagulase-negative staphylococci. Other isolates were Staphylococcus aureus, Corynebacterium, anaerobic bacteria, and Salmonella serotype Enteritidis. Nineteen (76%) of 25 primary pathogens were gentamicin sensitive. Spacers from two patients were culture positive for coagulase-negative staphylococci that tested resistant to gentamicin. During the follow-up of at least two years, none of the patients developed another periprosthetic infection. CONCLUSION: The success rate of two-stage-reimplantation total hip and knee arthroplasty using ready-made, gentamicin-impregnated spacers was 100 % in our cohort of patients; no other periprosthetic infection was reported during the follow-up of at least two years. From the bacteriological results, it appears that the ready-made, gentamicin-impregnated spacer only covers 76 % of the range of the causative agents. The solution would be to use a spacer impregnated with a combination of vancomycin and gentamicin that would be effective against all cultured species.

[Leukocyte esterase testing for examination of exudate associated with skeletal system diseases. Comparison with cytological and microbiological examinations]. / Porovnání vysetrení výpotku pohybového aparátu pomocí leukocytární esterázy s jejich cytologickým a kultivacním vysetrením.

PURPOSE OF THE STUDY: Leukocyte esterase is an enzyme in neutrophils from which it is released into exudate; its detection by colorimetric test strips indicates the presence of neutrophils. This is a rapid method to find whether exudate is of infectious or non-infectious aetiology. The aim of the study was to determine the sensitivity and specificity of leukocyte esterase testing with use of AUTION Sticks (Arkray) for examination of exudates obtained in inflammatory diseases of the skeletal system. MATERIAL AND METHODS: Exudates associated with skeletal system diseases were collected from 45 patients in the period from July 1st to December 31 st , 2012. Aspirates obtained under sterile conditions were examined for leukocyte esterase; cytological and microbiological examinations were also carried out. For the detection of leukocyte esterase, a drop of aspirate was placed on the reagent zone of a test strip and the resulting colour reaction was read after 90 minutes. Changes in colour were compared with a reference strip provided by the manufacturer. The results were assessed on a five-shade scale as follows: 0, no colour change; 1 to 4, gradual change from light pink to deep purple. The results were compared with those of cytological and microbiological examinations. Shade 4 on the strip corresponded to a positive cytological finding of bacterial infection, and shades 3 and 4 correlated with a positive microbial finding. The sensitivity and specificity of leukocyte esterase testing were statistically evaluated for both comparisons. RESULTS: Based on the results of cytological and microbiological examinations, an infectious aetiology of exudate was diagnosed in 21 (44.4%) and non-infectious aetiology in 24 (63.6%) patients. With leukocyte esterase reagent strips when shade 4 was taken as a positive result, the sensitivity and specificity of examination was assessed as 0.6190 and 0.9583, respectively. When taking both shade 3 and shade 4 for a positive result, sensitivity and specificity were 0.8571 and 0.8750, respectively. Shades 0 and 1 corresponded to the number of leukocytes in exudate that was no higher than 2 x 109/ml. DISCUSSION: The detection of leukocyte esterase is a quick and easy examination. It is useful for readily excluding or confirming an infectious aetiology of exudate and can, to some extent, substitute a cytological examination. It can also help to make a quick decision whether one- or two-stage joint reimplantation should be performed and thus eliminate the need of intra-operative histological examination of frozen tissue samples. A drawback of the method was that exudate samples contaminated with blood interfered with an assessment of colour shades. However, this can be avoided by centrifugation of the sample and use of a supernatant free from erythrocytes. CONCLUSIONS: Diagnosing infectious aetiology of joint exudate or exudate from an abscess using leukocyte esterase reagent strips appears, according to our results, to be a promising, semi-quantitative method with high specificity and sensitivity which is rapid, simple and affordable. It can be useful particularly in out-patient institutions for a quick diagnosis of arthritis; intraoperatively, it can serve as an additional method to other exudate examinations.

[Total hip arthroplasty after femoral neck fracture in patients with acquired neurological deficit]. / Implantace totální endoprotézy kycelního kloubu pro zlomeninu krcku femuru u pacientu se získaným neurologickým deficitem.

PURPOSE OF THE STUDY: To evaluate the outcome of total hip arthroplasty (THA) performed for femoral neck fracture in patients with a paralytic hip. MATERIAL AND METHODS: Between 1997 and 2004, total hip arthroplasty was performed in 301 patients with a medio-cervical or sub-capital fracture of the femoral neck. In 17 of them there was also neurological deficit due to a stroke in 11, multiple sclerosis in four, and conditions following cranial injury in two. The degree of neurological deficit was assessed pre-operatively and its effect on the outcome was evaluated, in particular that on the overall results of THA, implant stability and post-operative complications. RESULTS: At an average follow-up of 61 months, 15 out of the 17 patients were examined, because one died and one failed to turn up. Four patients had a dislocation and two had a post-operative infection and para-articular ossification. Seven patients could walk with the use of walking aids, eight had serious difficulties or were in a wheelchair. DISCUSSION: The incidence of post-operative complications is much more frequent in patients with neurological deficit than in the other THA patients. Some possibilities to improve the prospects of neurologically affected patients are discussed, such as fall prevention, rational drug therapy, etc. Options for operative techniques and implant use are also dealt with as well as post-operative care to prevent complications. CONCLUSIONS: In patients with medio-cervical or sub-capital fracture of the femoral neck and co-existent neurological deficit, operative considerations should also involve further surgical techniques, such as osteosynthesis or Girdlestone arthroplasty. To achieve a good outcome it is necessary to choose a correct operative procedure with an optimal combination of acetabular and femoral components, to perform additional periarticular surgery and to indicate post-operative comprehensive rehabilitation.