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Background and objective The impact of prosthetic joint infection (PJI) stretches far beyond the physical nature of the disease. It can result in psychological and social consequences, with significant morbidity and mortality for patients. Calcium sulphate-based delivery agents are effective in the management of PJI, yet with associated risks of systemic adverse events. This study aims to evaluate the risk of systemic adverse events when using calcium-sulphate-based local antibiotic delivery agents in the management of PJIs. Methodology We identified 43 patients who underwent debridement, antibiotics and implant retention (DAIR) for infected total knee arthroplasty (TKA) between 2008 and 2014. Patients in the control groupunderwent conventional intravenous and then oral antibiotic administration, while those in the intervention groupunderwent additional local antibiotic therapy via a calcium sulphate alpha hemihydrate matrix. Case notes and laboratory results data were compiled to establish the safety and efficacy of local glycopeptide delivery. Results Serum vancomycin levels were within the safe therapeutic range for all patients in the intervention group with no difference in serum assays between treatment groups (intervention 7.7 mg/L; control 8.0 mg/L; P = 0.85). Renal function for the study cohort improved at every time point post-operatively when referenced against pre-operative renal function (P < 0.05). There was no difference in renal function between intervention and control groups on day 1, one week, six weeks or 12 weeks post-operatively (P = 0.78, 0.89, 0.20 and 0.50). Conclusions Local glycopeptide delivery via a calcium sulphate alpha hemihydrate matrix did not result in systemic adverse consequences specifically not raising the systemic level of glycopeptide, nor reducing renal function. Implications for future research Although demonstrates a safety profile and potential therapeutic benefit, the long-term efficacy of this approach needs to be established. Importantly, selection bias may contribute to masking clinically significant differences in post-operative outcomes.
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The falciform ligament is a double peritoneal fold that separates the left and right hepatic lobes anatomically. Fatty-falciform ligament appendage torsion (F-FLAT) is defined as torsion of the extraperitoneal fat within the falciform ligament causing fat infarction, which is an uncommon surgical presentation, scarcely documented within the current literature. The objective of presenting this case report and reviewing the literature on F-FLAT is to discuss the clinical presentation, possible associated factors and management strategies in regard to this rare pathology. A 72-year-old female patient presented to the emergency department with a seven-day history of epigastric pain, reduced appetite and nausea. On admission, the patient was stable and apyrexial with abdominal examination highlighting she was tender in her right upper quadrant and epigastric region. Due to the patient's unremitting abdominal pain despite appropriate analgesia, CT of the abdomen and pelvis (CTAP) with intravenous contrast was done and a diagnosis of F-FLAT was made. The patient was treated with antibiotics and analgesia, had a negative abdominal ultrasound (US) result and due to her symptoms settling by the second day of admission, she was discharged the same afternoon. A literature review into falciform ligament infarction was conducted by two independent reviewers across four different databases: PubMed, Medline, Embase and the Cochrane Library. Search terms included "falciform ligament" OR "falciform" AND "infarction" (likewise with Medical Subject Headings, or MeSH, terms in the Cochrane Library). Eligibility criteria and our subsequent inclusion criteria were based on studies specifically discussing falciform ligament infarction and published in English. Study types were by majority case reports, but also included one literature review and a book source as well as two pictorial radiological reviews. All 13 patients presented with abdominal pain, but only 53% presented with raised infective/inflammatory markers. The majority of patients had abdominal US as a first-line investigation with 9 of 13 patients also having a CTAP with contrast, which classically showed fat stranding in the falciform ligament. Two patients had no evidence of any radiological investigation. Initially all cases were managed conservatively with non-steroidal anti-inflammatory drugs and analgesia, but in 62% of the cases (8/13), surgical intervention was needed due to unresolving abdominal pain. All eight of the excised falciform ligaments showed evidence of infarction and necrosis histologically. In conclusion, F-FLAT is a relatively rare condition making it difficult to build higher level evidence studies. The current literature has revealed some evidence of incomplete and inconsistent data, for example, in the biochemical results and management techniques presented, yet contrast-enhanced CT seems moderately sensitive for detection in the reviewed literature. Though F-FLAT is rare and unfamiliar, it is vital we exclude common acute surgical pathologies that F-FLAT mimics and monitor for unsettling symptoms that could change the management trajectory.
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BACKGROUND: We conducted a systematic review and meta-analysis of contemporary RCTs to determine the clinical effectiveness of spinal vs general anaesthesia (SA vs GA) in patients undergoing hip fracture surgery using a consensus-based core outcome set, and outcomes defined as important by patient and public involvement (PPI) initiatives. METHODS: RCTs comparing any of the core outcomes (mortality, time from injury to surgery, acute coronary syndrome, hypotension, acute kidney injury, delirium, pneumonia, orthogeriatric input, being out of bed at day 1 postoperatively, and pain) or PPI-defined outcomes (return to preoperative residence, quality of life, and mobility status) between SA and GA were identified from MEDLINE, Embase, Cochrane Library, and Web of Science (2000 to February 2022). Pooled relative risks (RRs) and mean differences (95% confidence intervals [CIs]) were estimated. RESULTS: There was no significant difference in the risk of delirium comparing SA vs GA (RR=1.07; 95% CI, 0.90-1.29). Comparing SA vs GA, the RR for mortality was 0.56 (95% CI, 0.22-1.44) in-hospital, 1.07 (95% CI, 0.52-2.23) at 30 days, and 1.08 (95% CI, 0.55-2.12) at 90 days. Spinal anaesthesia reduced the risk of acute kidney injury compared with GA: RR=0.59 (95% CI, 0.39-0.89). There were no significant differences in the risk of other outcomes. Few studies reported PPI-defined outcomes, with most studies reporting on one to three core outcomes. CONCLUSIONS: Except for acute kidney injury, there were no differences between SA and GA in hip fracture surgery when using a consensus-based core outcome set and patient and public involvement-defined outcomes. Most studies reported limited outcomes from the core outcome set, and few reported outcomes important to patients, which should be considered when designing future RCTs. PROSPERO REGISTRATION: CRD42021275206.