Rapidly-growing mycobacterial infection: a recognized cause of early-onset prosthetic joint infection.

BACKGROUND: Prosthetic joint infection (PJI) is a major complication of total hip and total knee arthroplasty (THA, TKA). Although mycobacteria are rarely the causative pathogens, it is important to recognize and treat them differently from non-mycobacterial infections. This study aimed to compare the clinical characteristics, associated factors and long-term outcomes of mycobacterial and non-mycobacterial PJI. METHODS: We conducted a retrospective case-control study of patients aged ≥18 years who were diagnosed with PJI of the hip or knee at Siriraj Hospital from January 2000 to December 2012. Patient characteristics, clinical data, treatments and outcomes were evaluated. RESULTS: A total of 178 patients were included, among whom 162 had non-mycobacterial PJI and 16 had mycobacterial PJI. Rapidly growing mycobacteria (RGM) (11) and M. tuberculosis (MTB) (5) were the causative pathogens of mycobacterial PJI. PJI duration and time until onset were significantly different between mycobacterial and non-mycobacterial PJI. Infection within 90 days of arthroplasty was significantly associated with RGM infection (OR 21.86; 95% CI 4.25-112.30; p < .001). Implant removal was associated with improved favorable outcomes at 6 months (OR 5.96; 95% CI 1.88-18.88; p < .01) and 12 months (OR 3.96; 95% CI 1.15-13.71; p = .03) after the infection. CONCLUSIONS: RGM were the major pathogens of early onset PJI after THA and TKA. Both a high clinical index of suspicion and mycobacterial cultures are recommended when medically managing PJI with negative cultures or non-response to antibiotics. Removal of infected implants was associated with favorable outcomes.

Effectiveness Testing of Combined Innovative Pressurized Carbon Dioxide Lavage and Pulsatile Normal Saline Irrigation to Enhance Bone Cement Penetration in Total Knee Replacement: A Cadaveric Study.

Background: The cementing technique in total knee arthroplasty (TKA) is essential for a successful outcome. Previous studies have shown that deeper cement penetration results in greater tensile and shear strength between the bony part and the prosthetic parts. Objective: Objective: To investigate the effectiveness of combined innovative pressurized carbon dioxide lavage and pulsatile normal saline irrigation for enhancing cement penetration into cancellous bone, as compared with standard pulsatile normal irrigation alone. Material and Method: An intra-individual comparative cadaveric study was conducted at the Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University in April 2015. Ten fresh cadavers underwent TKA via the medial parapatellar approach. The proximal tibia was cut perpendicular to its anatomical axis at a point nine millimeters inferior to the lateral plateau. After randomization of knees, the proximal tibia of one side was prepared with pulsatile normal saline irrigation followed by innovative pressurized carbon dioxide lavage. The contralateral side was then prepared using standard pulsatile normal saline irrigation alone. After completing bilateral cemented TKA, the tibial prostheses were removed from both knees. The proximal tibia was then cut on three planes. The posterior coronal plane cut, the medial sagittal oblique plane cut, and the lateral sagittal oblique plane cut facilitated visualization and measurement of the depth of cement penetration into the posterior, middle, and lateral columns, respectively. A bone sample from each column was measured by digital vernier caliper to evaluate bone cement penetration. Results: Combined innovative pressurized carbon dioxide lavage and pulsatile normal saline irrigation produced significantly deeper cement penetration into cancellous bone, as compared with pulsatile normal irrigation alone (1.90±0.39 mm vs. 1.21±0.21 mm, p = 0.04). Conclusion: Combined innovative pressurized carbon dioxide lavage and pulsatile normal saline irrigation produced significantly deeper bone cement penetration than pulsatile normal saline irrigation alone.

Sterility verification of innovative pressurized carbon dioxide lavage for bone surface preparation in cemented knee arthroplasty.

OBJECTIVE: To verify sterility of innovative pressurized carbon dioxide (CO) lavage for bone surface preparation in cemented knee arthroplasty. MATERIAL AND METHOD: Twenty-five 500 L. air samples from the innovative pressurized CO, lavage were laboratory tested to verify the presence or absence of either bacteria or fungi in microbial air samplings taken in a biological safety cabinet. CO2 gas was delivered though a pressure regulator, a sterile delivery tube, a hand piece, and a microbial air filter with a pressure level of 50 psi, according to the medical standard. Contamination samples for bacteria and fungi were taken by using Tryptic Soy Agar and SabouraudAgar as the culture media and were then analyzed at 48 hours and 10 days, respectively. RESULTS: Twenty-five samples of microbial culture showed no bacterial or fungal growth on either Tryptic Soy Agar or Sabouraud Agar CONCLUSION: The sterility of the innovative pressurized carbon dioxide lavage was confirmed by laboratory test results and was approved for application for bone surface preparation in cemented total knee arthroplasty.

Plasma concentrations of bupivacaine after spinal anesthesia with single shot femoral nerve block and periarticular injection in total knee arthroplasty.

OBJECTIVE: To determine the plasma concentrations of bupivacaine and toxicity after periarticular injection (PAI) combined with spinal anesthesia and femoral nerve block (FNB). MATERIAL AND METHOD: Forty-three patients scheduled for unilateral total knee arthroplasty (TKA) were enrolled in the prospective observational study. The dose of bupivacaine for spinal anesthesia was adjusted by the attending anesthesiologist. The single-shot femoral nerve block (FNB) and periarticular injection (PAI) were performed with 20 ml of 0.5% bupivacaine and 20 ml of 0.25% bupivacaine respectively. Venous blood samples from antecubital vein were collected at 60 minutes after femoral nerve block and at the time before periarticular injection, then at 15, 30, 45, and 60 minutes afterwards. Plasma bupivacaine concentrations were analyzed, using a high performance liquid chromatography with tandem mass spectrometry. RESULTS: Ten males and 32 females, ASA I-II were included. The highest median plasma concentration was 586.22 ng/ml (min = 245.39, max = 1,614.36) at 45 minutes after periarticular injection. The maximum plasma bupivacaine concentration was 1,709.71 ng/ml at 60 minutes after periarticular injection. No clinical toxicity was encountered CONCLUSION: The plasma concentration of bupivacaine in patients performed periarticular injection with 20 ml of 0.25% bupivacaine after spinal anesthesia and single-shot femoral nerve block with 20 ml of 0.5% bupivacaine is below the plasma toxic level.

Efficacy and safety of different bupivacaine concentrations in periarticular infiltration combined with adductor canal block for bilateral total knee arthroplasty: a randomized controlled trial.

BACKGROUND: Pain management for bilateral total knee arthroplasty (BTKA) often combines adductor canal block (ACB) with periarticular infiltration (PAI). However, concerns arise regarding local anesthetic toxicity. This study evaluated the efficacy and safety of different bupivacaine concentrations in simultaneous BTKA. METHODS: Patients undergoing simultaneous BTKA under spinal anesthesia were included in the study. They received ACB with 50 mg bupivacaine for each thigh. The patients were then randomized into two groups. Group A was administered a PAI of 100 mg bupivacaine per knee (totaling 300 mg bupivacaine for ACB and PAI). Group B received a PAI with 50 mg bupivacaine per knee (totaling 200 mg bupivacaine for ACB and PAI). Postoperative pain was assessed using a visual analog scale at 4-h intervals for 48 h after surgery. Plasma bupivacaine concentrations were measured at eight specified times. Postsurgery walking ability was also evaluated. RESULTS: Among the 57 participants analyzed, visual analog scale pain scores revealed no significant differences between the two groups. An interim analysis of plasma bupivacaine concentrations in both groups indicated no significant disparities. In group B, 93.1% managed to walk with assistance within 48 h, as opposed to group A's 71.4% (P = 0.041). CONCLUSIONS: Combining ACB with 100 mg bupivacaine and PAI with another 100 mg bupivacaine provided effective pain relief. This combination also had a better safety profile and led to more patients walking postsurgery than when combining ACB with 100 mg bupivacaine and PAI with 200 mg bupivacaine. Thus, ACB combined with PAI with a total dose of 200 mg bupivacaine appears suitable for simultaneous BTKA. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03249662).

Metabolic and genetic risk factors associated with pre-diabetes and type 2 diabetes in Thai healthcare employees: A long-term study from the Siriraj Health (SIH) cohort study.

BACKGROUND: The study of non-communicable diseases (NCDs) in a developing country like Thailand has rarely been conducted in long-term cohorts, especially among the working-age population. We aim to assess the prevalence and incidence of risk factors and their associations underlying NCDs, especially type-2 diabetes mellitus (T2DM) among healthcare workers enrolled in the Siriraj Health (SIH) study cohort. METHODS: The SIH study was designed as a longitudinal cohort and conducted at Siriraj hospital, Thailand. A total of 5,011 participants (77% women) were recruited and follow-up. Physical examinations, blood biochemical analyses, family history assessments, behavior evaluations, and genetics factors were assessed. RESULTS: The average age was 35.44±8.24 years and 51% of participants were overweight and obese. We observed that men were more likely to have a prevalence of T2DM and dyslipidemia (DLP) compared to women. Aging was significantly associated with pre-diabetes and T2DM (P<0.001). Additionally, aging, metabolic syndrome, and elevated triglycerides were associated with the development of pre-diabetes and T2DM. The minor T allele of the rs7903146(C/T) and rs4506565 (A/T) were associated with a high risk of developing pre-diabetes with odds ratios of 2.74 (95% confidence interval [CI]: 0.32-23.3) and 2.71 (95% CI: 0.32-23.07), respectively; however, these associations were statistically insignificant (P>0.05). CONCLUSION: The findings of the SIH study provide a comprehensive understanding of the health status, risk factors, and genetic factors related to T2DM in a specific working population and highlight areas for further research and intervention to address the growing burden of T2DM and NCDs.

Phase II clinical trial of Ayurved Siriraj Wattana Recipe for symptomatic relief in patients with osteoarthritis of the knee.

BACKGROUND: Osteoarthritis of the knee is one of the most common public health problems in Thailand and throughout the world. It causes disability, with pain and loss of function. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most common treatment modality to relieve pain for OA, but can cause undesirable adverse effects. Effective and safer alternative treatments for OA are urgently needed. Among the many kinds, Ayurved Siriraj Wattana Recipe has been widely used in humans for a long time. The components of the recipe probably were related with many systems of the body such as the immune system and the gastrointestinal system and it may have anti-inflammatory activity as well as anti-oxidative capacity. OBJECTIVE: Determine the efficacy of Ayurved Siriraj Wattana Recipe for knee osteoarthritis in a randomized, open-label, diclofenac-controlled trial for 12 weeks. The trial has been approved from Siriraj Institutional Review Board (SIRB), Faculty of Medicine, Siriraj Hospital, Mahidol University. MATERIAL AND METHOD: Analyze the 12-item Oxford, defined as 5-point Likert scales of pain and functional activity. The secondary assessment included 10-cm VAS pain assessment tool as well as, patients' and physician's global efficacy assessment. RESULTS: "12-Item Oxford" revealed that patients had mild problems in terms of function and pain with an average function score observed between groups (p = 0.6). The average pain score at 12 weeks' follow-up was not significantly different in the Wattana group compared with the diclofenac group (p = 0.3). Responses with no differences included the mean 10-cm VAS that assessed pain at 12 weeks' follow-up in both groups. There were no significant differences in the patients' and physician's global efficacy assessment with patients in both groups. There were no differences in the frequent of adverse events between groups. In addition, there were no significant differences in the patients' and physician's global safety assessment between groups. CONCLUSION: The present, diclofenac-controlled trial concludes that Ayurved Siriraj Wattana Recipe treatment could be an effective treatment of pain in knee OA at 12 weeks.

Tranexamic acid reduces blood loss and blood transfusion after TKA: a prospective randomized controlled trial.

BACKGROUND: TKA may be associated with considerable blood loss, and transfusion carries substantial risk of immunologic reaction and disease transmission. Blood transfusion also involves additional cost, therefore a reduction in its use is important. Several methods reportedly reduce postoperative blood loss and avoid homologous blood transfusion with traditional TKA approaches, but it is unclear these reductions apply to a minimally invasive technique. QUESTIONS/PURPOSES: We asked whether tranexamic acid administration could reduce blood loss and blood transfusion requirements after TKA. PATIENTS AND METHODS: Between March 2008 and May 2008, we enrolled 100 patients with primary osteoarthritis undergoing a unilateral cemented TKA in a prospective, randomized, double-blind study. Patients were randomized into one of two groups: the control group received a placebo and the study group received tranexamic acid intravenously (10 mg/kg) 10 minutes before inflation of the tourniquet and 3 hours postoperatively and orally (250 mg/capsule; two capsules three times daily) for 5 days. We measured volume of drained blood 48 hours postoperatively, decrease in hemoglobin levels 12 hours postoperatively, amount of blood transfused, and number of patients requiring allogenic blood transfusion. The minimum followup was 6 months (mean, 10.4 months; range, 6-12 months). RESULTS: Mean (± SD) postoperative volume of drained blood was lower in the group receiving tranexamic acid (727.50 ± 234 mL) than in control subjects (1208.77 ± 421 mL). The mean hemoglobin decrease 12 hours postoperatively was lower in patients receiving tranexamic acid (2.12 ± 0.64 g/dL) than in control subjects (3.33 ± 0.88 g/dL). The amount of blood transfused and number of patients requiring blood transfusion were lower in patients receiving tranexamic acid than in control subjects. CONCLUSIONS: Tranexamic acid reduced postoperative blood loss after TKA, as reflected in reduction in the number of blood transfusions. We did not observe any change in symptomatic thromboembolic phenomenon. LEVEL OF EVIDENCE: Level 1, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Oxford knee score and SF-36: translation & reliability for use with total knee arthroscopy patients in Thailand.

Evaluation of health-related quality of life is an established criterion for the evaluation of therapeutic outcome. Specifically, while there are a great number of different questionnaires, in English, for this purpose, there is a lack of comparable questionnaires in Thai. The objectives of the present study were two-fold: (1) to translate the original, English-language, 12-item Oxford (Oxford-12) outcome questionnaire and Short Form 36 (SF-36) general health questionnaire into a standard Thai version, and (2) to assess reliability of these two questionnaires and correlation between them among 100 patients having total knee replacement (TKR). Patients' mean age was 63 years and 86% were female. Oxford-12 revealed that patients had mild problems in terms of function and pain with the average function and pain score of 15.0 and 8.8 compared to maximum possible score of 35 and 25 respectively Oxford-12 was very reliable with Cronbach's alpha for function, pain and total score of 0.819, 0.874 and 0.918 respectively. For 8 health domains of SF-36 including physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH), patients had the highest score (i.e., good health)for VT followed by MH, but lowest for PF. This resulted in a higher score for mental component summary (MCS) than physical component summary (PCS). Cronbach's alpha for 8 health domains varied from 0.651 (VT) to 0.996 (RP). Since a low score of Oxford-12 indicates a better state of health compared to high score for SF-36, negative correlation between them was expected PF of SF-36 had the highest negative correlation with both Oxford function and pain with Pearson's correlation coefficient (r) of -0.69 and -0.72 respectively. PCS was correlated well with both Oxford function and pain with r of -0.73 and -0.76 respectively whereas correlation between MCS and Oxford function and pain were only -0.60 and -0.58 respectively. Thai versions of Oxford-12 and SF-36 retain their original characteristics and are reliable for assessing the quality of life after TKR in Thai speaking patients.

Lipid peroxidation, glutathione, vitamin E, and antioxidant enzymes in synovial fluid from patients with osteoarthritis.

AIM: To compare levels of lipid peroxidation and antioxidants in synovial fluid from primary knee osteoarthritis (OA) patients with severe cartilage damage undergoing total knee replacement with those in the synovial fluid from injured knee joint patients with intact cartilage undergoing knee arthroscopy. METHODS: Thirty-two OA patients and 10 injured knee joint patients were recruited. Lipid peroxidation (thiobarbituric acid reactive substances [TBARs]), iron and glutathione (GSH) were measured using a colorimetric method. Vitamin E was measured with high-performance liquid chromatography (HPLC). Activities of antioxidant enzymes (glutathione peroxidase [GPx], superoxide dismutase [SOD]) were analyzed with the use of a kinetic method. RESULTS: TBARs, iron and GSH levels in synovial fluid were not significantly different between OA patients and injured knee joint patients. Antioxidant enzymes such as GPx and SOD activities also indicated no significant difference. Only vitamin E level was significantly lower in the synovial fluid of OA patients than in that of the injured knee joint patients. CONCLUSIONS: Oxidative stress may have a role in pathogenesis of knee osteoarthritis. Vitamin E supplementation may have a role in the management of patients.