Prevalence and Impact of Unexpected Positive Intraoperative Cultures in Total Hip or Knee Revision Surgery.

BACKGROUND: Our aim was to evaluate the prevalence and impact of unexpected positive intraoperative cultures (UPICs) on the outcome of presumed aseptic total knee and hip revision surgery. METHODS: Data regarding patients who underwent elective total hip or knee revision surgery from January 2003 to July 2017 due to preoperatively presumed aseptic reasons was retrospectively reviewed. Partial revisions and patients who had follow-ups below 60 months were excluded from the study. In all surgeries, at least three intraoperative samples were taken for microbial culture. Failure was defined as the need for re-revision due to any cause at 5 years and/or the need for antibiotic suppressive therapy. Overall, 123 total hip and 431 total knee revisions were eligible for the study. All cases had at least a 5 year follow-up. RESULTS: There were 420 cases (75.8%) that had all cultures negative, 108 (19.5%) had a single UPIC, and 26 (4.7%) had either ≥ 2 UPICs for the same microorganism or 1 UPIC for a virulent microorganism. This latter group was not associated with a significantly higher failure rate (2 of 26, 7.7%) compared to those in the aseptic group (54 of 528, 10.2%). Revisions performed within the first 24 months after primary implantation had a higher 5-year re-revision rate (19.3 versus 8.4%, P = 0.01), mainly attributable to aseptic causes. CONCLUSION: Total hip and knee revisions with UPICs were not significantly associated with a higher re-revision risk at 5 years. Those revisions performed within the first 24 months after primary arthroplasty had a higher rate of any-cause failure.

Wound closure after knee and hip replacement (TKA and THA): Survey results on the clinical practice in Spain. / Cierre de herida en cirugía protésica de rodilla y cadera (PTR y PTC): Resultados de una encuesta sobre la práctica clínica en España.

BACKGROUND AND OBJECTIVE: In orthopedic surgery, it is clear that an optimal standardized closure technique has not yet been developed. Locally, there are no objective data describing the standard surgical practice in wound closure. The aim of this study is to analyze the clinical practice of surgical wound closure in orthopedic surgery by means of a survey of a representative local sample and thus obtain information on the context of closure in Spain. METHOD: an ad hoc group of specialists in orthopedic surgery and traumatology was formed. The group of experts, after analyzing the literature, developed a questionnaire of 32 closed multiple-choice questions divided into the following blocks: hemostasis, surgical wound closure (deep, superficial, and cutaneous), and dressings. RESULTS: A total of 471 surgeons responded to the survey completely and with sufficient information to perform the descriptive analysis. 79% believe that ATX can influence the decrease in surgical site infection rate. 96% believe that the type of deep closure at the level of the arthrotomy could influence outcomes and complications after hip and/or knee replacements. 85% believe that the type of shallow closure at the subcutaneous level may influence outcomes and complications after hip and/or knee replacement. 64% of surgeons use single-use incisional negative pressure therapy for the treatment of surgical wound complications (seroma, prolonged drainage, dehiscence). CONCLUSIONS: There is a high level of variability in wound closure in our setting and a low level of training on the subject. The authors recommend that the different scientific societies invest resources to improve training in this field and reduce the percentage of surgeons who are considered inadequately trained, as well as adapting closure techniques to those considered gold standard according to the evidence.

[Translated article] Wound closure after knee and hip replacement (TKA and THA): Survey results on the clinical practice in Spain.

BACKGROUND AND OBJECTIVE: In orthopaedic surgery, it is clear that an optimal standardised closure technique has not yet been developed. Locally, there are no objective data describing the standard surgical practice in wound closure. The aim of this study is to analyse the clinical practice of surgical wound closure in orthopaedic surgery by means of a survey of a representative local sample and thus obtain information on the context of closure in Spain. MATERIAL AND METHOD: An ad hoc group of specialists in orthopaedic surgery and traumatology was formed. The group of experts, after analyzing the literature, developed a questionnaire of 32 closed multiple-choice questions divided into the following blocks: hemostasis, surgical wound closure (deep, superficial, and cutaneous), and dressings. RESULTS: A total of 471 surgeons responded to the survey completely and with sufficient information to perform the descriptive analysis. 79% believe that ATX can influence the decrease in surgical site infection rate. 96% believe that the type of deep closure at the level of the arthrotomy could influence outcomes and complications after hip and/or knee replacements. 85% believe that the type of shallow closure at the subcutaneous level may influence outcomes and complications after hip and/or knee replacement. 64% of surgeons use single-use incisional negative pressure therapy for the treatment of surgical wound complications (seroma, prolonged drainage, dehiscence). CONCLUSIONS: There is a high level of variability in wound closure in our setting and a low level of training on the subject. The authors recommend that the different scientific societies invest resources to improve training in this field and reduce the percentage of surgeons who are considered inadequately trained, as well as adapting closure techniques to those considered gold standard according to the evidence.

Reporting serious incidents in medical devices used in intraocular surgery: Proposing ideas.

The entry into force of the regulation on medical devices obliges clinicians to identify and report to the Health Authorities possible serious incidents arising from their use. In view of the doubts that may arise as to whether or not it may be considered a serious incident, a working group, set up by members of the Spanish Society of Retina and Vitreo and the cluster of ophthalmology and vision sciences (Cluster4Eye) have prepared a document that aims to guide ophthalmologists about some of the incidents that, in the experience of the work team, are not common or can cause serious damage to the patient's function.

[Translated article] Overview of systematic reviews of risk factors for prosthetic joint infection.

BACKGROUND: Prosthetic joint infection is one of the most serious complications in orthopedics. Prognostic systematic reviews (SRs) detecting and assessing factors related to prosthetic joint infection, allow better prediction of risk and implementation of preventive measures. Although prognostic SRs are increasingly frequent, their methodological field presents some knowledge gaps. PURPOSE: To carry out an overview of SR assessing risk factors for prosthetic joint infection, describing and synthesizing their evidence. Secondarily, to assess the risk of bias and methodological quality. MATERIAL AND METHODS: We conducted a bibliographic search in 4 databases (May 2021) to identify prognostic SR evaluating any risk factor for prosthetic joint infection. We evaluated risk of bias with the ROBIS tool, and methodological quality with a modified AMSTAR-2 tool. We computed the overlap degree study between included SR. RESULTS: Twenty-three SRs were included, studying 15 factors for prosthetic joint infection, of which, 13 had significant association. The most frequently studied risk factors were obesity, intra-articular corticosteroids, smoking and uncontrolled diabetes. Overlapping between SR was high for obesity and very high for intra-articular corticoid injection, smoking and uncontrolled diabetes. Risk of bias was considered low in 8 SRs (34.7%). The modified AMSTAR-2 tool showed important methodological gaps. CONCLUSIONS: Identification of procedural-modifiable factors, such as intra-articular corticoids use, can give patients better results. Overlapping between SR was very high, meaning that some SRs are redundant. The evidence on risk factors for prosthetic joint infection is weak due to high risk of bias and limited methodological quality.

Overview of systematic reviews of risk factors for prosthetic joint infection. / Revisión de revisiones sistemáticas de factores pronóstico para infección protésica.

BACKGROUND: Prosthetic joint infection is one of the most serious complications in orthopedics. Prognostic systematic reviews (SR) detecting and assessing factors related to prosthetic joint infection, allow better prediction of risk and implementation of preventive measures. Although prognostic SR are increasingly frequent, their methodological field presents some knowledge gaps. PURPOSE: To carry out an overview of SR assessing risk factors for prosthetic joint infection, describing and synthesizing their evidence. Secondarily, to assess the risk of bias and methodological quality. MATERIAL AND METHODS: We conducted a bibliographic search in 4databases (May 2021) to identify prognostic SR evaluating any risk factor for prosthetic joint infection. We evaluated risk of bias with the ROBIS tool, and methodological quality with a modified AMSTAR-2 tool. We computed the overlap degree study between included SR. RESULTS: Twenty-three SR were included, studying 15 factors for prosthetic joint infection, of which, 13 had significant association. The most frequently studied risk factors were obesity, intra-articular corticosteroids, smoking and uncontrolled diabetes. Overlapping between SR was high for obesity and very high for intra-articular corticoid injection, smoking and uncontrolled diabetes. Risk of bias was considered low in 8SRs (34.7%). The modified AMSTAR-2 tool showed important methodological gaps. CONCLUSIONS: Identification of procedural-modifiable factors, such as intra-articular corticoids use, can give patients better results. Overlapping between SR was very high, meaning that some SR are redundant. The evidence on risk factors for prosthetic joint infection is weak due to high risk of bias and limited methodological quality.

[Translated article] Current situation of robotics in knee prosthetic surgery: A technology that has come to stay?

Robotic surgery is a surgical technique that is on the rise. The goal of robotic-assisted total knee arthroplasty (RA-TKA) is to provide the surgeon with a tool to accurately execute bone cuts according to previous surgical planning to restore knee kinematics and balance of soft tissue, being able to precisely apply the type of alignment that we choose. In addition, RA-TKA is a very useful tool for training. Within the limitations, there is the learning curve, the need for specific equipment, the high cost of the devices, the increase in radiation in some systems and that each robot is linked to a specific type of implant. Current studies show, with RA-TKA, variations in the alignment of the mechanical axis are reduced, postoperative pain is improved and earlier discharge is facilitated. On the other hand, there are no differences in terms of range of motion, alignment, gap balance, complications, surgical time or functional results.

Oncological monitoring after transanal total mesorectal excision (TaTME) for rectal neoplasia.

BACKGROUND: The surgical treatment of choice for rectal neoplasia is total mesorectal excision (TME). The transanal approach enables a better approach in male and obese patients and/or those with a narrow pelvis and in patients with small tumors. Short-term results are comparable with those for laparoscopy or the open approach, but the medium- and long-term oncological data are sparse. The aim of the present study was to evaluate our early experience with transanal TME (TaTME). METHODS: This was a retrospective study conducted on patients who underwent TaTME at our center between August 2013 and April 2017 with a follow-up ≥ 3 years. Histopathology, complications, mortality, neoplastic recurrence and disease-free survival were analyzed. RESULTS: One hundred patients (68 men and 32 women,, median age 66.8 years [range 29.6-91.2 years]) were included. There were 67 T3 cases (67%) with 74 N0 cases (74%), the mesorectal quality was graded optimal for 87.6% and only 2 cases of radial margin involvement were detected (2%). The median follow-up period was 47.6 months (range 11.8-78.9 months). Eighteen cases of recurrence were diagnosed, of which 3 (3%) recurred locally with an average disease-free period of 43.1 months. Overall survival was 80% and mortality due to progression of disease was 13%. CONCLUSIONS: TaTME is a safe surgical procedure with surgical, anatomopathological and oncological results at 3 years (medium-term) comparable with those for the laparoscopic and open approaches. Better monitoring is required with studies of the long-term functional and quality of life outcomes, i.e., at 5 or 10 years.

Current situation of robotics in knee prosthetic surgery, a technology that has come to stay? / Situación actual de la robótica en cirugía protésica de rodilla, ¿una tecnología que ha venido para quedarse?

Robotic surgery is a surgical technique that is on the rise. The goal of robotic-assisted total knee arthroplasty (RA-TKA) is to provide the surgeon with a tool to accurately execute bone cuts according to previous surgical planning to restore knee kinematics and balance of soft tissue, being able to precisely apply the type of alignment that we choose. In addition, RA-TKA is a very useful tool for training. Within the limitations, there is the learning curve, the need for specific equipment, the high cost of the devices, the increase in radiation in some systems and that each robot is linked to a specific type of implant. Current studies show, with RA-TKA, variations in the alignment of the mechanical axis are reduced, postoperative pain is improved and earlier discharge is facilitated. On the other hand, there are no differences in terms of range of motion, alignment, gap balance, complications, surgical time or functional results.

Perioperative medicine role in painful knee prosthesis prevention.

Total knee arthroplasty is one of the most frequently performed orthopaedic surgeries. However, up to 20% of patients develop persistent postoperative pain. Persistent postoperative pain may be an extension of acute postoperative pain, but can also occur after more than 3 months without symptoms. Risk factors associated with persistent postoperative pain after arthroplasty have now been characterised within the patient's perioperative context (preoperative, intraoperative and postoperative), and can be grouped under genetic, demographic, clinical, surgical, analgesic, inflammatory and psychological factors. Identification and prevention of persistent postoperative pain through a multimodal and biopsychosocial approach is essential in the context of perioperative medicine, and has been shown to prevent or ameliorate postoperative pain.

PREVENCOT project: Do we follow international guidelines to prevent surgical site infection in orthopedic elective surgery? / Proyecto PREVENCOT: ¿Seguimos las recomendaciones internacionales para la prevención de la infección del sitio quirúrgico en cirugía ortopédica programada?

BACKGROUND AND OBJECTIVE: Prevention of postoperative surgical site infections is indeed feasible. The aim of this work is to analyses adherence to international guidelines for the prevention of infections in elective orthopedic prosthetic surgery by means of a survey of a representative sample of Spanish orthopedic surgeons, with the purpose to establish general recommendations. MATERIAL AND METHOD: A population survey was conducted in online format consisting of 78 questions to analyze the usual clinical practice of Spanish orthopedic surgeons in the face of periprosthetic infections of the hip and knee, and their adherence to international guidelines. RESULTS: The results of the survey (n=138) show in clinical practice of Spanish orthopedic surgeons a high adherence to most of the international recommendations. CONCLUSIONS: The integration high adherence of individual clinical practice with the best available scientific evidence based on the recommendations of international guidelines is the best way to adequately manage the prevention of periprosthetic infection in elective surgery.

Hair cortisol level as a molecular biomarker in retinitis pigmentosa patients.

PURPOSE: Retinitis pigmentosa (RP) patients commonly experience negative psychological states due to their progressive and unpredictable loss of vision and visual variations related to stress. The aim of this study was to examine hair cortisol concentrations (HCCs), which is usually associated with chronic stress, pretending to unveil possible associations between underlying psychological factors and disease severity in RP patients. METHODS: Seventy-eight RP patients and 148 healthy controls were included in this study. A complete ophthalmological exam was performed in all patients to grade into severity disease groups. Perceived stress and trait-anxiety were measured by the State-Trait Anxiety Inventory (STAI) questionnaire. RESULTS: Fifty-two (67%) patients had severe RP and 26 (33%) mild-moderate RP. Fifty-eight (58,9%) patients reported severely levels of stress and 18 (23.,1%) highly levels assessed by STAI questionnaire. RP patients exhibited higher HCCs (500.04 ± 120.99 pg/mg) than in controls (136.17 ± 60.51 pg/mg; p < 0.001). Severe RP patients had significant higher HCCs than mild-moderate patients differing in 274.27 pg/mg (p < 0.001). RP severity grade and perceived anxiety levels in the questionaries were not associated. Group differences were not affected by relevant covariates (age, grade of severity, stress status, and gender). CONCLUSIONS: HCC seems an effective biomarker associated with chronic stress in RP patients. This study shows that HCC in patients with RP are elevated compared to population-based controls, and association between HCC and RP severity was found. Future research is needed to characterize the effect of untreated negative psychological states on progression of the disease if any.

[Prevalence of SARS-CoV-2 infection during the first wave of the pandemic among health and non-health personnel of the General Hospital of Segovia, Castilla y León]. / Prevalencia de infección por SARS-CoV-2 durante la primera oleada de la pandemia entre personal sanitario y no sanitario del Hospital General de Segovia, Castilla y León.

OBJECTIVE: Health and non-health workers (HNH-W) in a hospital are more exposed to SARS-CoV-2 infection than the general population. We studied the prevalence of this infection in these workers of Segovia´s Hospital after the first epidemic wave. METHODS: Monocentric, observational, cross-sectional study, carried out between April 29 and May 14, 2020. The infection was diagnosed by capillary immunochromatography test for IgG and / or IgM antibodies, or PCR. Work, health, and exposure variables were studied. RESULTS: A total of 1,335 HNH-W participated in the study out of a total of 1,667 (80.1%), 79.3% women, with a mean age of 47.3 years, and 47.1 for men. The prevalence of infected was 21.95%, 24.7% asymptomatic. Age presented a significant OR of 1.02/year. Exposure outside of work increased the prevalence by 16.8%. The continued use of Personal Protective Equipment (PPE) and the administration of nebulizations presented an OR of 0.54 and 0.46 respectively. The symptoms associated with the highest prevalence were anosmia (OR 9.31), ageusia (OR 3.05), and fever (OR 1.94). Today, about 75% of HNH-W were infected in the first wave. CONCLUSIONS: The prevalence is higher among healthcare workers than the population they serve. Age is associated with a higher prevalence of infection. Almost a quarter of those infected were asymptomatic. The continuous use of PPE was associated with a lower prevalence, for that the administration of nebulisations could be safe. The symptoms with the greatest association were fever, anosmia, and ageusia.

Usefulness of histology for predicting infection at the time of hip and knee revision in patients with rheumatoid arthritis.

INTRODUCTION: It remains unclear whether rheumatoid arthritis might be a cause of false positive of the histology for the diagnosis of prosthetic joint infection. Our aim was to evaluate the usefulness of the histology for the diagnosis of infection during hip and knee prosthesis revision in patients with rheumatoid arthritis. MATERIALS AND METHODS: All patients with the diagnosis of rheumatoid arthritis (RA) undergoing hip or knee revision surgery (total or partial) were retrospectively reviewed. Positive histology was considered when ≥ 5 neutrophils per high-power field (400×) were found in at least five separate microscopic fields. Patients who presented ≥ 2 positive cultures for the same microorganism or the presence of fistula were considered as "true positives". RESULTS: Thirty-two hip (n = 12) and knee (n = 20) revision procedures were performed. Sensitivity, specificity, positive and negative predictive value of the histology were 50%, 78.6%, 25% and 91.7%, respectively. Six out of the eight patients presenting with positive histology had negative cultures (75.0% of false positives). CONCLUSIONS: Our results suggest that, in the context of RA, negative histological results have a very high negative predictive value. RA poses false positive histology results for the diagnosis of infection during hip and knee revision when conventional cultures are used for diagnosis of infection.

Perioperative medicine role in painful knee prosthesis prevention. / Papel de la medicina perioperatoria en la prevención de la prótesis de rodilla dolorosa.

Total knee arthroplasty is one of the most frequently performed orthopaedic surgeries. However, up to 20% of patients develop persistent postoperative pain. Persistent postoperative pain may be an extension of acute postoperative pain, but can also occur after more than 3 months without symptoms. Risk factors associated with persistent postoperative pain after arthroplasty have now been characterised within the patient's perioperative context (preoperative, intraoperative and postoperative), and can be grouped under genetic, demographic, clinical, surgical, analgesic, inflammatory and psychological factors. Identification and prevention of persistent postoperative pain through a multimodal and biopsychosocial approach is essential in the context of perioperative medicine, and has been shown to prevent or ameliorate postoperative pain.

Arthrotomy debridement of arthrostic septic arthritis of the knee is more effective than arthroscopic debridement and delays the need for prosthesis despite progression. / El desbridamiento por artrotomía de la artritis séptica de rodilla artrósica es más eficaz que el artroscópico y retrasa la necesidad de prótesis a pesar de la progresión de la artrosis.

BACKGROUND AND OBJECTIVE: 40%-50% of this septic arthritis occurs in the knee, despite rapid medical surgical treatment, 24%-50% will have a poor clinical outcome. It is not clear which debridement technique, by arthrotomy or arthroscopy, is more effective in controlling infection, or whether or not previous osteoarthritis worsens the outcome. The objective of this study on septic arthritis of the osteoarthritic knee was to analyse which surgical debridement technique, arthroscopy or arthrotomy, is more effective, the clinical and radiographic outcomes of the patients, and how many go on to require a TKR after the infection has healed. MATERIAL AND METHODS: A retrospective study was performed in 27 patients with native septic arthritis of the knee. Eighteen were men and the mean age was 64.8 years (30-89years). Fifteen patients were debrided by arthrotomy and 12 by arthroscopy. The effectiveness of debridement in controlling infection, the radiographic progression of the osteoarthritis on the Ahlbäch scale, the need for subsequent replacement, and pain and functional status were analysed using the VAS and WOMAC scales at 52.8±11.2-month follow-up. RESULTS: The infection was controlled in 93% and 92% of the patients, 13% and 42% required 2 or more surgeries for infection control, 18% and 44.4% showed progression of arthritis in the arthrotomy and arthroscopy groups, respectively. One patient in each group required a knee replacement. The VAS score was superior in the arthrotomy group and there were no differences in WOMAC score. CONCLUSION: Debridement by arthrotomy in the emergency department by non-sub-specialist knee surgeons is more effective than arthroscopic debridement in controlling septic arthritis of the knee. Surgical debridement of septic arthritis in knees with previous osteoarthritis enabled control of the infection with no pain despite the progression of the osteoarthritis.

Validity of the KLIC and CRIME80 scores in predicting failure in late acute infection treated by debridement and implant retention. / Validez de las escalas KLIC y CRIME80 en la predicción del fracaso en la infección aguda tardía tratada mediante desbridamiento y retención de implantes.

It is very important to treat prosthetic infections correctly in order to ensure a higher success rate. Debridement with implant retention (DAIR) is widely used in acute and late infections, however patients who fail after this surgery are known to have a higher risk of failure in subsequent surgeries. Therefore, it is important to find a scale that enables us to predict the risk of DAIR failure. Hence the KLIC and CRIME80 scores for acute and late acute infections, respectively. This study analysed the validity of both scores in acute late periprosthetic knee infections. We observed that the KLIC score has no predictive value for this type of infection, but the CRIME80 score does.

[Septic arthritis of the knee by Staphylococcus warneri]. / Artritis séptica de rodilla por Staphylococcus warneri.

Septic arthritis usually occurs as an acute joint process that can cause a rapid destruction of the cartilage, if the necessary therapeutic measures were not taken. Rarely, Staphylococcus warneri may be the cause of this pathology although due to its diagnostic difficulty we can make mistakes in its treatment. We present the case of a patient with septic arthritis of the knee by this germ and we intend to remark what are the diagnostic measures and recommendations to consider for this osteoarticular infection.

La artritis séptica suele presentarse como un proceso articular agudo que puede provocar una rápida destrucción del cartílago, si no se toman las medidas terapéuticas necesarias. De manera poco frecuente, el Staphylococcus warneri puede ser la causa de esta patología aunque por su dificultad diagnóstica podemos cometer errores en su tratamiento. Presentamos el caso de un paciente con artritis séptica de rodilla por este germen y pretendemos remarcar cuáles son las medidas diagnósticas y recomendaciones a tener en cuenta para esta infección osteoarticular.