Intraoperative culture positive allograft bone and subsequent postoperative infections: a retrospective review.

BACKGROUND: Obtaining intraoperative cultures of allograft bone just before use in orthopedic procedures is standard practice in many centres; however, the association between positive cultures and subsequent surgical infections is unknown. Our study had 3 goals: to determine the prevalence of positive intraoperative allograft culture and subsequent infection; to determine if, in cases of subsequent infection, organisms isolated at reoperation were the same as those cultured from the allograft at the time of the index procedure; and to assess the costs associated with performing intraoperative allograft cultures. METHODS: In this retrospective case series, we obtained data on patients receiving allograft bone between 2009 and 2012. Patients receiving allograft with positive cultures were reviewed to identify cases of significant infection. Organisms isolated at reoperation were compared with the allograft culture taken at the time of implantation, and we performed a cost assessment. RESULTS: Of the 996 allograft bone grafts used, 43 (4.3%) had positive intraoperative cultures and significant postoperative infections developed in 2, requiring reoperation. Antibiotics based on culture results were prescribed in 24% of cases. Organisms cultured at the time of reoperation differed from those isolated initially. The cost of performing 996 allograft cultures was $169 320. CONCLUSION: This series suggests that rates of positive intraoperative bone allograft culture are low, and subsequent infection is rare. In cases of postoperative infection, primary allograft culture and secondary tissue cultures isolated different organisms. Costs associated with performing cultures are high. Eliminating initial culture testing could save $42 500 per year in our health region.

CONTEXTE: L'obtention de cultures d'allogreffes osseuses peropératoires juste avant une intervention orthopédique est une pratique standard dans de nombreux centres. Or, on ignore s'il y a un lien entre des résultats de cultures positifs et les infections chirurgicales subséquentes. Notre étude avait 3 objectifs : déterminer la prévalence des cultures d'allogreffes peropératoires positives et des infections subséquentes; déterminer si, dans les cas d'infections subséquentes, les agents pathogènes isolés lors d'une réintervention étaient les mêmes que dans les spécimens prélevés sur les allogreffes au moment des interventions initiales; évaluer les coûts associés à l'obtention des cultures d'allogreffes peropératoires. MÉTHODES: Dans cette série de cas rétrospectifs, nous avons réuni des données sur des patients receveurs d'allogreffes osseuses entre 2009 et 2012. Nous avons passé en revue les cas d'allogreffes dont les résultats de culture étaient positifs pour recenser ceux qui étaient porteurs d'une infection significative. Nous avons comparé les agents pathogènes isolés lors de la réintervention à ceux de la culture de l'allogreffe effectuée lors de l'implantation, et nous avons procédé à une évaluation des coûts. RÉSULTATS: Parmi les 996 allogreffes osseuses effectuées, 43 (4,3 %) avaient des résultats positifs aux cultures peropératoires; des infections postopératoires significatives se sont déclarées dans 2 de ces cas et ont nécessité une réintervention. Des antibiotiques ont été prescrits en fonction des résultats des cultures dans 24 % des cas. Les agents pathogènes isolés en culture au moment de la réintervention étaient différents de ceux qui avaient été initialement isolés. Le coût des 996 cultures d'allogreffes s'est élevé à 169 320 $. CONCLUSION: Cette série donne à penser que les taux de résultats de cultures d'allogreffes osseuses peropératoires positifs sont bas et que les infections subséquentes sont rares. Dans les cas d'infections postopératoires, les cultures des allogreffes primaires et les cultures tissulaires secondaires ont révélé la présence d'organismes pathogènes différents. Les coûts associés à la réalisation des cultures sont élevés. Éliminer les cultures initiales permettrait à notre région de santé d'économiser 42 500 $ par année.

In vivo assessment of a multicomponent and nanostructural polymeric matrix as a delivery system for antimicrobials and bone morphogenetic protein-2 in a unicortical tibial defect in goats.

OBJECTIVE: To determine the response of cortical bone to a multicomponent and nanostructural polymeric matrix as a drug delivery system for enhancing bone healing. ANIMALS: 20 healthy adult crossbred goats. PROCEDURES: A 3.5-mm-diameter unicortical defect was created in each tibia (day 0), and goats (4 goats/group) were treated as follows: not treated (control group), grafted with the matrix, grafted with antimicrobial (tigecycline and tobramycin)-impregnated matrix, grafted with recombinant human bone morphogenetic protein type 2 (rhBMP-2)-impregnated matrix, or grafted with antimicrobial- and rhBMP-2-impregnated matrix. Elution kinetics of antimicrobials was monitored through plasma concentrations. Bone response was assessed with radiographic scoring (days 1 and 30) and dual-energy x-ray absorptiometry (days 1, 14, and 30). Goats were euthanized on day 30, and histomorphologic analysis was performed. Categorical variables were analyzed with a generalized linear model, and continuous variables were analyzed with an ANOVA. RESULTS: Plasma antimicrobial concentrations indicated continued release throughout the study. Radiography and dual-energy x-ray absorptiometry did not reveal significant differences among treatments on day 30. Periosteal reactions were significantly greater surrounding bone defects grafted with rhBMP-2-impregnated matrix than those not treated or grafted with matrix or with antimicrobial-impregnated matrix; periosteal reactions were similar in bone defects grafted with rhBMP-2-impregnated matrix and antimicrobial- and rhBMP-2-impregnated matrix. CONCLUSIONS AND CLINICAL RELEVANCE: The matrix served as an antimicrobial delivery system and stimulated bone proliferation when rhBMP-2 was present. Antimicrobial and rhBMP-2 can be used concurrently, but the presence of antimicrobials may affect the performance of rhBMP-2.

The Clinical Standards Advisory Group (CSAG) Cleft Lip and Palate Study.

A national study of care and outcomes in children born with a unilateral cleft lip and palate (UCLP) was performed over a 15-month period. Two cohorts of children ('5-year-olds' and '12-year-olds') were examined. There were 57 active cleft teams in the U.K. with 105 consultant orthodontists involved in the care of these children. Only 36 teams could provide basic data such as patients names. Of the patients, 47-51 per cent had neonatal appliances. The dental arch relationships were measured with the Goslon Index and a Five-Year-Old Index, 37-39 per cent of both age groups were either 'poor' or 'very poor'. Seventy per cent of the 12-year-old patients had a Skeletal III relation and 42 per cent of bone grafts were seriously deficient or failed. Dental treatment for active caries was needed by 40 per cent of 5-year-olds and 20 per cent of 12-year-olds. In addition, the training of recently appointed consultant orthodontists involved in the care of these children was scrutinized. As a whole, the results were disappointing with standards of care not significantly raised in the last decade. Recommendations have been made to the Department of Health and the implications for the orthodontic profession are explored. Overall, it seems that fewer orthodontists will need to be involved in a centralized care model for these children.

The salvage of open grade IIIB ankle and talus fractures.

Between 1983 and 1989, 11 open grade IIIB ankle or talus fractures were treated according to protocol including debridement, temporary placement of antibiotic beads, soft tissue coverage (including seven free vascular tissue transfers), intravenous antibiotics and fusion using an anterior plate, and bone graft. All patients had a minimum of three separate hospitalizations. Each had at least five operative procedures performed with an average of 8.2/patient (range: 5-12). The total in-patient hospital stay averaged 61.6 days (20-107 days) and in patient costs averaged $62,174.43/patient (range: $33,535.06-$143,847.45). Overall hospital cost averaged $1,009.32/day. Follow-up averaged 47.8 months (range 32-85 months), with an average time to union of 4.4 months. Fusion rate and muscle flap success was 100%. Although fusion and eradication of infection in this specific group of patients was possible, significant functional and psychosocial disability remained. Eight of eleven patients had significant pain, difficulty with stairs, and limited ambulation. All changed jobs or were unemployed. Patients with open grade IIIB tibiotalar injuries with significant bone loss may therefore benefit from early amputation. A multicenter randomized clinical outcome study is needed.