Periprosthetic infections after total hip and knee arthroplasty--a review.

Periprosthetic joint infections (PJI) in orthopedic surgery are considered to be very serious and dangerous complications of total joint arthroplasty. PJI becomes a long-lasting medical problem and a heavy burden on patient and his family. Patients with such a complication are a significant financial burden for the health care system. Recognizing this issue, investing in scientific research and simultaneously developing technologies in medicine are efforts taken to increase successfulness in preventing and treating PJI. Each year the number of total joint arthroplasties increases which entails a rise in the number of complications among which infections are the leading ones. Sometimes, in the worst case scenarios, infections can endanger patients' lives. New procedural algorithms and new diagnostic possibilities help us make accurate and early diagnoses of postoperative PJI with a great degree of certainty. These diagnostic methods include laboratory tests, imaging, histopathology and microbiological analyses. Treatment options depend on many factors which include the onset of symptoms, patients'general physical condition and type of pathogen. The approach to treating PJI is complex and it requires a multidisciplinary approach in order to ensure the most successful treatment possible. For adequate and successful treatment we need to take into account antibiotic therapy, one-stage or two-stage revision, Girdlestone operation, athrodesis and amputation. In this review we will try to sum up all relevant findings and suggest further steps in management of PJI.

Deposition of heavy metals in biological tissues of workers in metal workshops.

Welding and cutting of metals produce large amounts of particulate matter (PM), which poses a significant health risk to exposed workers. Appropriate biological markers to estimate exposure are of great interest for occupational health and safety. Here, hair and nail samples from metal workers were analyzed, which appear to be more suitable than blood or urine samples for assessing long-term exposure. Four workshops working with steel components were included in the study. The hair and nail samples were analyzed by inductively coupled plasma mass spectrometry (ICP-MS) to measure the concentrations of 12 elements. At the workplaces, the concentrations of 15 elements in particulate matter were determined using X-ray fluorescence (XRF) and particle-induced X-ray emission (PIXE) techniques. The hair and nail samples of the workers contained significantly higher metal concentrations than the analytical results of a nonexposed control group. The most significant difference between the groups was found for Ti, Mn, Fe, and Co.

Treatment of infected tibial nonunion with bone defect using central bone grafting technique.

Treatment of infected tibial nonunion with bone defect represents a challenge for every orthopaedic surgeon. Various methods of treatment have been described for nonunions with infection, bone loss or both. One of them is the central bone grafting technique, which is a safe and effective treatment for nonunions of the tibia. The technique involves placement of autogenous cancellous bone from the iliac crest on the anterior surface of the interosseous membrane with the aim of creating a tibiofibular synostosis. We present the results of uncontrolled, retrospective and continuous series of ten patients treated by a central bone grafting technique for infected tibial nonunion with bone loss. Mean follow-up period was 12 (10-15) years. Most injuries were a result of war injuries. Clinically and radiologically confirmed bony healing with total consolidation of the graft was achieved in all patients within a period of 10-12 months without further bone grafting. The newly-formed bone mass was able to fulfil the mechanical and functional demands of everyday life activities. Once again, the central bone grafting technique has shown to be a safe, reliable and effective method of treatment for infected tibial nonunion with bone defect.

The Correlation between Enrolment Criteria and Students' Success in the Study of Medicine: a Five-Year Retrospective Study.

OBJECTIVE: To investigate whether the students' study-success correlates with the achievements evaluated in the enrolment process based on the State Graduation Exam. METHODS: The retrospective study included a total of 637 students enrolled in the study of Medicine at the Faculty of Medicine from the academic year 2010-11 to 2014-15. We analysed the structure of students enrolled on the basis of the State Graduation Exam, examined their success in two courses of the study programme and then correlated this study-success with individual admission parameters. In particular, we investigated whether the success in the study was influenced by the changes made in the enrolment requirements during this period. Pearson's correlation coefficient was used to measure strenght of correlation between two variables. RESULTS: The changes in the admission parameters, i.e., the inclusion of STEM subjects as obligatory enrolment requirements, made in 2012-13 enabled a better selection of students with high average secondary education grades and with significantly better results in Biology, Physics and particularly in Chemistry. This resulted in a higher success in the study, especially in the last two new-criteria generations. The Pearson correlation coefficient between students' success in Physiology and Pathophysiology II and the achievements valuated in enrolment procedure as total cumulative score were statistically significant (r=0.27, P<0.001). Total points achieved in enrolment procedure was also correlated with students' success in Medical Physics and Biophysics and correlation was even stronger (r=0.52, P<0.001). CONCLUSION: Our results proved that a well-designed combination of the relevant admission parameters is a crucial prerequisite for a better success in the study.

Rapid recurrence of a giant popliteal cyst in a patient with rheumatoid arthritis.

Despite increasing knowledge of etiopathogenesis, therapy, and recurrence rate of popliteal cysts, they nevertheless occasionally represent clinical problems. We report the case of a 58-year-old rheumatoid arthritis patient in whom a giant recurrent cyst developed very shortly after primary excision. Reports of such large popliteal cysts are rare and very few cases were reported in rheumatoid arthritis patients. Moreover, no such giant recurrent cysts formed so shortly after primary excision. Thus, its occurrence may be partially ascribed to the specific dynamics of fluid flows caused by the absence of a valve-like mechanism. With regard to treatment, it appears that synovectomy may reduce the production of synovial fluid, but reinforcement of the thin tissue with capsuloplasty may also be important. Immobilization is necessary so that initiation of the healing process is not disturbed.

Open total talar dislocation with extrusion (missing talus).

Open total dislocation of a talus with extrusion (missing talus) is an extremely rare injury. We present a case of a 63-year-old male who sustained an open total lateral dislocation of the right talus with extrusion and without a concomitant fracture after a fall from a small height. Tibiocalcaneonavicular arthrodesis was performed. Arthrodesis failed, and due to painful and unstable ankle, rearthrodesis was performed two years later, successefully. Because of rarity of this kind of injury, hers importance for foot function, previously described various treatment options and absence of guidelines, herewith we propose, according to our experience and review of literature, the algorithm for the treatment of this rare injury.

Arthroscopic removal of metal foreign bodies from the knee joint after explosive war injuries.

The results of arthroscopic removal of metallic fragments from knee joint due to explosive war injuries are presented. In period from 1991-1995 during war in Croatia we have operated 25 knee joints. Indications for arthroscopy were based on radiographic and clinical findings. The foreign bodies in the joint were found in 19 patients while additional 6 had foreign bodies in the periarticular soft tissues. Arthroscopies were performed on average one month after wounding. The foreign bodies were placed in different parts of the joint with no prediction sites. In 8 knees foreign bodies were freely mobile, and in 11 were anchored to different intraarticular structures. There were no complications during early postoperative period as well as in follow up period.

Keller's arthroplasty with proximal metatarsal opening wedge osteotomy in treating severe Hallux valgus deformity--surgical techniques and case report.

The paper presents an operative technique proposed for treating severe Hallux Valgus deformity with arthrosis of the first metatarsal joint in elderly people. The procedure consists of the Keller's arthroplasty in combination with basal osteotomy of the first metatarsal bone, whereby the head of the metatarsal is displaced laterally and plantarward. The osteotomy is fixed with a reconstructive plate. The results show a significant improvement in the hallux valgus angle, the first metatarsal angle, as well as in the plantar pressure distribution.

Balance index score as a predictive factor for lower sports results or anterior cruciate ligament knee injuries in Croatian female athletes--preliminary study.

Female athletes participating in high-risk sports suffer anterior cruciate ligament (ACL) knee injury at a 4- to 6-fold greater rate than do male athletes. ACL injuries result either from contact mechanisms or from certain unexplained non-contact mechanisms occurring during daily professional sports activities. The occurrence of non-contact injuries points to the existence of certain factors intrinsic to the knee that can lead to ACL rupture. When knee joint movement overcomes the static and the dynamic constraint systems, non-contact ACL injury may occur. Certain recent results suggest that balance and neuromuscular control play a central role in knee joint stability, protection and prevention of ACL injuries. The purpose of this study is to evaluate balance neuromuscular skills in healthy Croatian female athletes by measuring their balance index score, as well as to estimate a possible correlation between their balance index score and balance effectiveness. This study is conducted in an effort to reduce the risk of future injuries and thus prevent female athletes from withdrawing from sports prematurely. We analysed fifty-two female athletes in the high-risk sports of handball and volleyball, measuring for their static and dynamic balance index scores, using the Sport KAT 2000 testing system. This method may be used to monitor balance and coordination systems and may help to develop simpler measurements of neuromuscular control, which can be used to estimate risk predictors in athletes who withdraw from sports due to lower sports results or ruptured anterior cruciate ligament and to direct female athletes to more effective, targeted preventive interventions. The tested Croatian female athletes with lower sports results and ACL knee injury incurred after the testing were found to have a higher balance index score compared to healthy athletes. We therefore suggest that a higher balance index score can be used as an effective risk predictor for lower sports results and lesser sports motivation, anterior cruciate ligament injury and the ultimate decision to withdraw from active participation in sports. If the balance testing results prove to be effective in predicting the occurrence of ligament injuries during future sports activities, we suggest that prophylactic training programs be introduced during athlete training, since the prevention of an initial injury will be more effective than prevention of injury recurrence.

A comparison of lymphocyte subpopulations simultaneously on local and systemic levels in acute rheumatoid arthritis patients.

Rheumatoid arthritis (RA) is one of the most destructive inflammatory and autoimmune joint diseases, most frequently accompanied by extraarticular complications. The pathophysiologic mechanism and the importance of cell subpopulations in the initiation and perpetuation of synovitis are not sufficiently understood. In this study the frequency of lymphocyte subpopulations simultaneously in the synovial fluid (SF), the synovial membrane (SM) and peripheral blood (PB) of acute RA patients is determined, using flow cytometry procedures. The changes in the distribution of T lymphocyte subpopulations were significant on local levels in acute RA patients, resulting in a decreased CD4/CD8 ratio in SF, but an increased CD4/CD8 ratio in SM, compared to the ratio found in PB. The differences observed in the frequency of cells positive on natural killer (NK) cell markers suggest the role of CD16-CD56+ NK cell population in SF of RA patients. Significant differences in the observed frequency of lymphatic subpopulations suggest certain specificities of local immunological events in SM and SF in acute RA. These results confirm the T-lymphocyte hypothesis in initial pathogenic events in RA.

Salmonella typhimurium osteomyelitis of the femur in patient with Crohn's disease.

Osteomyelitis is an inflammation of the bone caused by infecting organisms. We present here the first case of osteomyelitis of the distal femur caused by Salmonella typhimurium in a patient with Crohn's disease. The infection was successfully treated with a combination of antibiotics and surgical treatment.

Cardiovascular risk factors and diseases strongly predict hemodialysis treatment outcome in maintenance hemodialysis patients.

AIM: To identify independent predictors of hemodialysis treatment outcome among major cardiovascular risk factors and pre-existent cardiovascular diseases in maintenance hemodialysis patients with the end-stage renal disease. METHODS: A total of 144 prevalent patients on maintenance hemodialysis at Rijeka University Hospital between 1998 and 2003 were included in the prospective clinical study. Pre-existent cardiovascular risk factors and diseases were identified, as well as their relation to hemodialysis treatment outcome. Primary outcome measure was death, and secondary outcome measure was the length of time from the beginning of patient's hemodialysis treatment to the end of follow-up, ie, end of the study or patient's death. The independent variables on hemodialysis treatment outcome were identified with the multiple linear regressions. RESULTS: Cardiovascular diseases were the major cause of death in 40 (60.6%) patients. Acute myocardial infarction in 15 (22.7%) patients was the major single cause of death. Among risk factors, hyperglycemia (P<0.001), low delivered dialysis dose (P<0.001), use of semi-synthetic dialysis membrane (P<0.001), and anemia (P=0.041) were independent predictors of hemodialysis treatment outcome. Hypertensive heart disease (P<0.001), ischemic heart disease (P<0.001), and dilated cardiomyopathy (P=0.016) were independent predictors of the hemodialysis treatment outcome. CONCLUSIONS: Cardiovascular diseases were the leading cause of death in hemodialysis patients. There was also high prevalence of cardiovascular risk factors and pre-existent cardiovascular diseases. Several of them were independent predictors of the hemodialysis treatment outcome.

Systemic and local expression of perforin in lymphocyte subsets in acute and chronic rheumatoid arthritis.

OBJECTIVE: To investigate the role of the cytolytic action mediated by perforin in the course of rheumatoid arthritis (RA), we studied the immunophenotypic characteristics of lymphocytes containing perforin in peripheral blood (systemic level), in synovial fluid (SF), and in the synovial membrane (local level) in patients during the acute or chronic phase of RA. Cells from patients with osteoarthritis were used as controls. METHODS: Flow cytometry was used for simultaneous detection of intracellular (perforin) and cell surface antigens. Mean fluorescence intensity (MFI) was a measure of the mean perforin content per cell. Immunocytochemical staining was used to visualize perforin in the cytoplasmic compartment of cells. RESULTS: In acute RA highly significant changes in perforin expression were found in all compartments (peripheral blood, SF, and synovial membrane): (1) increase of percentage of total perforin positive cells; (2) increase of both subsets of cytolytic cells, T (CD8+P+) and NK (CD56+P+) cells; (3) increase in the frequency of perforin positive cells in CD8+ and CD56+ cell populations; and (4) the highest content of perforin/cell (MFI values) in all compartments, except in the synovial membrane. CONCLUSION: Perforin positive cells may participate in the acute phase of RA by maintaining and perpetuating inflammation and contributing to tissue destruction.