Necrotizing fasciitis attended in the Emergency Department in a tertiary Hospital: Evaluation of the LRINEC scale. / Infecciones necrosantes de partes blandas atendidas en un servicio de urgencias de tercer nivel: evolución y correlación con la escala laboratory risk indicator for necrotizing fasciitis (LRINEC).

AIM: To describe mortality and complications of patients seen in the emergency room, diagnosed with necrotizing soft tissue infection (NSTI) and the correlation of such complications with the Laboratory Risk Indicator for Necrotizing fasciitis scale (LRINEC). METHODS: Retrospective observational study including patients with a diagnosis of NSTI in the emergency room of a tertiary hospital over 7 years. The results are shown as median, interquartile range and absolute range for quantitative variables. In the case of qualitative variables, the results are shown as absolute and relative frequency. The comparison between the categories of the LRINEC scale was performed through a post-hoc comparison from a non-parametric ANOVA analysis. Comparisons between LRINEC groups in the qualitative variables were performed using Fisher's Exact test. RESULTS: 24 patients with a mean age of 51.9 years were identified. The LRINEC scale was used on 21 patients: in 10, the value indicated low risk (<6), in 4 it indicated intermediate risk (6 or 7) and in 7 it indicated high risk (≥8). The amputation rate in patients with low, intermediate and high risk was 10%, 25% and 66% respectively with a mortality of 4.2%. There was an increase in hospital stay between the low and high level of the scale (p=0,007). CONCLUSIONS: In general, a change in the prognosis between the medium and high levels of the LRINEC scale could not be recorded, but was recorded in hospital stay between the low and the high level, practically tripling the median of days of hospital stay.

KLIC-score for predicting early failure in prosthetic joint infections treated with debridement, implant retention and antibiotics.

Debridement, irrigation and antibiotic treatment form the current approach in early prosthetic joint infection (PJI). Our aim was to design a score to predict patients with a higher risk of failure. From 1999 to 2014 early PJIs were prospectively collected and retrospectively reviewed. The primary end-point was early failure defined as: 1) the need for unscheduled surgery, 2) death-related infection within the first 60 days after debridement or 3) the need for suppressive antibiotic treatment. A score was built-up according to the logistic regression coefficients of variables available before debridement. A total of 222 patients met the inclusion criteria. The most frequently isolated microorganisms were coagulase-negative staphylococci (95 cases, 42.8%) and Staphylococcus aureus (81 cases, 36.5%). Treatment of 52 (23.4%) cases failed. Independent predictors of failure were: chronic renal failure (OR 5.92, 95% CI 1.47-23.85), liver cirrhosis (OR 4.46, 95% CI 1.15-17.24), revision surgery (OR 4.34, 95% CI 1.34-14.04) or femoral neck fracture (OR 4.39, 95% CI1.16-16.62) compared with primary arthroplasty, C reactive protein >11.5 mg/dL (OR 12.308, 95% CI 4.56-33.19), cemented prosthesis (OR 8.71, 95% CI 1.95-38.97) and when all intraoperative cultures were positive (OR 6.30, 95% CI 1.84-21.53). A score for predicting the risk of failure was designed using preoperative factors (KLIC-score: Kidney, Liver, Index surgery, Cemented prosthesis and C-reactive protein value) and it ranged between 0 and 9.5 points. Patients with scores of ≤2, >2-3.5, 4-5, >5-6.5 and ≥7 had failure rates of 4.5%, 19.4%, 55%, 71.4% and 100%, respectively. The KLIC-score was highly predictive of early failure after debridement. In the future, it would be necessary to validate our score using cohorts from other institutions.

Clinical and microbiological findings in prosthetic joint replacement due to aseptic loosening.

OBJECTIVES: A role for microorganisms in aseptic prosthetic loosening (AL) is postulated. We analyse the microbiological and clinical findings of patients with suspected AL, and compare them with patients with chronic prosthetic joint infection (PJI). METHODS: Prospective study (2011-2012) of patients with presumed AL. Evaluation of tissue samples (≥5; TS) at the time of surgery and sonication fluid (SF) of prosthesis. RESULTS: According to positive culture in TS/SF, 89 patients were divided into: Group1: (≥2 positive-TS; n = 12); Group2: single positive-TS and concordant SF (n = 10); Group3: one positive or non-concordant TS or SF (n = 38); and Group4: cultures negative (n = 29). Positive-SF was always concordant with TS in Group 1 (75%); it was positive in 74% in Group 3. Median months (prosthesis-age: implantation to revision arthroplasty) for PJI and Group 1-4 was 21, 46, 65, 63 and 81, respectively (P < 0.001); they also had a different dynamic trend in prosthesis failure (P < 0.001). CONCLUSIONS: Several patients with suspected AL are misdiagnosed PJI. Results from SF correlated well with TS in Group 1, led us to consider single positive-TS as significant (Group 2) and to suggest that microorganisms were on the prosthesis (Group 3). We observed a correlation between microbiology and prosthesis-age, which supports that early loosening is more often caused by hidden PJI than late loosening.

Long-term outcome of acute prosthetic joint infections due to gram-negative bacilli treated with retention of prosthesis.

OBJECTIVE: To update the clinical information of the 47 patients with a prosthetic joint infection due to Gram-negative bacilli included in a previous study and to reassess the predictors of failure after a longer follow-up. METHODS: Using the electronic files of our hospital, all the information regarding readmissions to the hospital, new surgical procedures and the reason for the new surgery (infection, aseptic loosening), and the last visit in the hospital were registered. The medical chart of the 35 patients that were considered in remission in the previous publication was reviewed. RESULTS: In 30 patients no clinical evidence of failure was detected and no additional surgery on the previously infected prosthesis was necessary and they were considered in long-term remission. In 5 cases a late complication was identified. One case had a reinfection due to coagulase-negative staphylococci after 22 months from the open debridement and required a 2-stage revision surgery. The other 4 cases developed an aseptic loosening and it was necessary to perform a 1-stage exchange. Receiving a fluoroquinolone when all the Gram-negatives involved in the infection were susceptible to fluoroquinolones was the only factor associated with remission in the univariate analysis (p=0.002). CONCLUSION: After a long-term follow-up, our results support the importance of using fluoroquinolones in acute PJI due to Gram-negative bacilli.

Usefulness of monitoring linezolid trough serum concentration in prolonged treatments.

Linezolid has proven valuable in musculoskeletal infections, however, failure and resistance have been described and toxicity is worrisome when more than 28 days are necessary. We describe the first 5 cases in whom linezolid trough serum concentrations were weekly measured and its relationship with clinical outcome and toxicity.

[Prosthetic joint infection by Candida spp.]. / Infección por Candida spp. sobre prótesis articulares.

INTRODUCTION: Fungal periprosthetic infectionis a rare entity. The aim of this report was to review our experience in two different educational hospitals. MATERIAL AND METHODS: patients with documented prosthetic joint infection due to Candida spp. from February 2002 to October 2010 were retrospectively reviewed. Demographics, microbiological data, treatment and outcome of each patient was recorded. RESULTS: Ten patients, 8 women and 2 men, with a meanage of 77.7 (range 66-92) years were identified. Nine patients had previous bacterial infection, received antibiotic treatment for more than 15 days and required multiple surgeries. The most frequent species was C. albicans with 6 cases. All patients received fluconazole and surgical treatment consisted of debridement without removing the implant in 3 cases and 2-stage exchange with a spacer in 7. The first surgical and antifungal approach failed in all cases and a second debridement was necessary in one case, a resection arthroplasty in 8 and chronic suppressive treatment with fluconazol in one. After a mean follow-up of 31 (range 2-67) months, two patients were free of infection. CONCLUSION: Prosthetic joint infection was associated with long-term antibiotic treatment and multiples previous surgeries. Treatment with fluconazol and debridement or two stage replacement with a spacer was associated with a high failure rate.

Outcome and predictors of treatment failure in early post-surgical prosthetic joint infections due to Staphylococcus aureus treated with debridement.

Experience with debridement and prosthesis retention in early prosthetic joint infections (PJI) due to Staphylococcus aureus is scarce. The present study aimed to evaluate the outcome and predictors of failure. Patients prospectively registered with an early PJI due to S. aureus and 2 years of follow-up were reviewed. Demographics, co-morbidity, type of implant, clinical manifestations, surgical treatment, antimicrobial therapy and outcome were recorded. Remission was defined when the patient had no symptoms of infection, the prosthesis was retained and C-reactive protein (CRP) was ≤ 1 mg/dL. Univariate and multivariate analysis were performed. Fifty-three patients with a mean ± SD age of 70 ± 10.8 years were reviewed. Thirty-five infections were on knee prosthesis and 18 were on hip prosthesis. The mean ± SD duration of intravenous and oral antibiotics was 10.6 ± 6.7 and 88 ± 45.9 days, respectively. After 2 years of follow-up, 40 (75.5%) patients were in remission. Variables independently associated with failure were the need for a second debridement (OR 20.4, 95% CI 2.3-166.6, p 0.006) and a CRP > 22 mg/dL (OR 9.8, 95% CI 1.5-62.5, p 0.01). The onset of the infection within the 25 days after joint arthroplasty was at the limit of significance (OR 8.3, 95% CI 0.8-85.6, p 0.07). Debridement followed by a short period of antibiotics is a reasonable treatment option in early PJI due to S. aureus. Predictors of failure were the need for a second debridement to control the infection a CRP > 22 mg/dL and the infection onset within the first 25 days after joint arthroplasty.

Total hip arthroplasty in hemodialysis and renal transplant patients.

Osteoarticular complications are common in patients with chronic renal failure and they often require implantation of a hip arthroplasty (total or partial) due to osteoarthritis, femoral neck fracture or ischemic necrosis of multifactor aetiology. Between 1992 and 2005 we operated on eighteen patients (23 hips) with chronic renal failure who were receiving renal replacement therapy (ten haemodialysis and eight renal transplants), and in each case either a total or partial hip arthroplasty was implanted. This group comprised nine women and nine men, with a mean age of 56 years (range: 30-83). Five cases were bilateral. The clinical diagnoses were necrosis (fourteen cases), femoral neck fracture (five cases) and osteoarthritis (three cases). The main early complications were haemorrhage in seventeen cases (74%) and infection in six cases (33%) (two urinary infections and four of the surgical wound). The late complications involved eight cases (35%) of prosthetic loosening (five aseptic and three septic). The surgery-related mortality rate was 17% (three cases). Prosthetic hip surgery in patients receiving renal replacement therapy is associated with high morbidity and mortality, thus highlighting the importance of careful patient selection.

Comminuted intra-articular fractures of the distal end of the radius treated with the Hoffmann external fixator.

In 1985 we began a prospective study of the use of external fixation in the treatment of intra-articular comminuted fractures of the distal end of the radius. A total of 30 patients have been treated by this method, representing 1.3% of the total number of patients treated in the Emergency Unit for a fracture of the distal epiphysis of the radius. The use of external fixation in instable fractures of the distal end of the radius improves the anatomic results. These correlate closely with the overall functional results obtained, which were excellent or good in 82.1% of cases, according to the rating system of Gartland and Werley. The main indications are fractures with a high degree of comminution, displacement, and articular affectation (unstable fractures) in young patients, corresponding to Frykman grades VII and VIII.

Immediate complications and associated lesions in fractures of the pelvis. A review of 447 cases.

The high incidence of pelvic fractures and the frequency of complications and associated lesions encouraged us to conduct a retrospective study with the purpose of evaluating the treatment of these patients. 447 fractures of the pelvis were reviewed. Of these, 84% were characterised by associated lesions either secondary to the fracture or involving other systems. Collaboration between the various disciplines involved is essential in order to guarantee the best possible treatment of these patients.

Traumatic dislocation of the tibialis posterior tendon at the ankle level.

We report one case of traumatic dislocation of the tibialis posterior tendon at the ankle level as a lesion of an exceptional rarity which was successfully treated by performing a flap of inverted periosteum. The pathogenetic mechanisms involved, on the basis of the results of anatomic and electromyographic studies performed, appear to be a combination of exertion of the tibialis posterior and hypoplasia of the sulcus.