ABSTRACT
BACKGROUND: Evidence for the management of periprosthetic joint infection (PJI) after total elbow arthroplasty is sparse, particularly in regard to débridement, antibiotics, and implant retention (DAIR). This study explored the outcomes of DAIR and analyzed risk factors for failure. METHODS: A retrospective cohort study of patients 18 years or older diagnosed with elbow PJI and managed with DAIR between January 1, 2003, and December 31, 2018, at a single institution was performed. Twenty-six elbows met the inclusion criteria during the study period. All DAIR procedures included in this study represented an attempt to manage an acute PJI with surgical irrigation and débridement without removal of the elbow arthroplasty components, followed by long-term systemic antimicrobial therapy. DAIR failure was defined as recurrence of PJI, unplanned re-operation for infection, or death secondary to infection. A Cox proportional hazards model was used to identify possible risk factors for failure. RESULTS: DAIR failed in 17 cases of elbow PJI with a failure rate of 65% at 2 years (95% confidence interval: 41.3%-79.6%). The median time to failure from DAIR was 43 days (interquartile range: 27-114). We found that DAIR failed in all cases with sinus tracts or negative cultures. The group with favorable outcomes had a shorter median duration of symptoms (5 vs. 18 days, P = .65) and a higher proportion of monomicrobial infections (58.8% vs. 88.9%, P = .19) compared to those with unfavorable outcomes. However, with the numbers available, none of the possible risk factors analyzed for association with failure reached statistical significance. CONCLUSION: DAIR for elbow PJI was associated with high rates of failure. Possible risk factors for failure may include the presence of sinus tract, longer duration of symptoms, and culture-negative infection. Although the relatively low morbidity of DAIR compared with total elbow arthroplasty implant resection for a one-stage or two-stage reimplantation is attractive, patients considered for DAIR must know that the chance of success is limited to approximately 35%.
Subject(s)
Arthritis, Infectious , Prosthesis-Related Infections , Humans , Retrospective Studies , Debridement/methods , Prosthesis-Related Infections/etiology , Prosthesis-Related Infections/surgery , Anti-Bacterial Agents/therapeutic use , Elbow , Treatment Outcome , Arthritis, Infectious/surgery , Risk FactorsABSTRACT
BACKGROUND: The objective of this study was to retrospectively review clinical and radiographic outcomes of patients who underwent corrective osteotomies for clavicle malunion and internal fixation for nonunion using a combination of virtual surgical planning, patient-specific 3-dimensional (3D)-printed clavicles, and 3D-printed cutting guides manufactured at the point of care. METHODS: Between 2015 and 2021, 18 patients underwent corrective osteotomy for a clavicle malunion (7 shoulders) or internal fixation for a clavicle nonunion (11 shoulders). There were 11 male and 7 female individuals with an average patient age of 43.9 (range 19-76) years. All patients underwent computed tomography evaluation of both clavicles. The DICOM files were manually segmented, virtual surgical planning was performed selectively using commercially available software, and a mirrored version of the normal clavicle was 3D printed along with a 3D-printed replica of the affected clavicle. Three-dimensionally printed mirrored clavicles were used in all cases to ensure adequate restoration of the shape and length of the clavicle and to precontour fixation plates. Virtual surgical planning and 3D-printed cutting guides for osteotomy were used in 4 of 18 (22%) patients. Either cancellous or structural intercalary bone grafting was used in 15 of 18 (83%) cases. Patients were contacted postoperatively to determine clinical outcome scores. Preoperative, early postoperative, and late postoperative radiographs were reviewed to assess for union and complications. The average follow-up time was 24.9 months. RESULTS: Radiographic evaluation at the most recent follow-up demonstrated adequate restoration of length and successful union for all shoulders. There were no complications or reoperations. Postoperative patient-reported outcomes could be obtained in 16 of 18 (88.9%) patients. At the most recent follow-up, the mean visual analog scale for pain was 2.38 points (range, 1-7), the mean shoulder American Shoulder and Elbow Surgeons score was 73.2 points (range, 25-100), and the mean Patient-Reported Outcome Measurement Information System Upper Extremity score was 26 points (range, 7-35). All (100%) the patients were satisfied with their outcome (9 very satisfied, 7 satisfied), and their mean subjective shoulder value was 73% (range, 10%-100%). However, 2 patients complained of hardware-related symptoms, and 1 patient had return of preoperative symptoms after an interim 2 years of pain relief. CONCLUSION: The use of mirrored 3D-printed clavicles combined with virtual surgical planning and patient-specific 3D guides provides a reliable technique for restoring native anatomy when performing corrective osteotomies for clavicle malunion or internal fixation for clavicle nonunion, with a high rate of satisfactory clinical and radiographic outcomes.
Subject(s)
Clavicle , Fractures, Malunited , Humans , Male , Female , Young Adult , Adult , Middle Aged , Aged , Clavicle/diagnostic imaging , Clavicle/surgery , Fractures, Malunited/diagnostic imaging , Fractures, Malunited/surgery , Retrospective Studies , Osteotomy/methods , Pain , Treatment OutcomeABSTRACT
PURPOSE: The term "pectoralis minor syndrome" refers to this constellation of symptoms that can occur when the pectoralis minor (Pm) is shortened and contracted. Release of the tendon of the Pm from the coracoid has been reported to provide substantial clinical improvement to patients presenting with pectoralis minor syndrome. The purpose of this study was (1) to describe the technique for endoscopic release of pectoralis minor tendon at the subdeltoid space, (2) to classify the pectoralis minor syndrome according to its severity and (3) and to report the short-term outcomes of this procedure in a consecutive series of patients diagnosed with pectoralis minor syndrome. METHODS: Endoscopic release of the pectoralis minor tendon was performed in a series of 10 patients presenting with pectoralis minor syndrome. There were six females and four males with a median age at the time of surgery of 42 (range from 20 to 58) years. Four shoulders were categorized as grade I (scapular dyskinesis), and six as grade II (intermittent brachial plexopathy). Shoulders were evaluated for pain, motion, satisfaction, subjective shoulder value (SSV), quick-DASH, ASES score, and complications. The mean follow-up time was 19 (range, 6 to 49) months. RESULTS: Arthroscopic release of the tendon of the Pm led to substantial resolution of pectoralis minor syndrome symptoms in all but one shoulder, which was considered a failure. Preoperatively, the median VAS for pain was 8.5 (range, 7-10) and the mean SSV was 20% (range, 10% - 50%). At most recent follow-up the mean VAS for pain was 1 (range, 0-6) and the mean SSV 80% (range, 50% - 90%). Before surgery, mean ASES and quick-DASH scores were 19.1 (range, 10-41.6) and 83.1 (range, 71 and 95.5) points respectively. At most recent follow-up, mean ASES and quick-DASH scores were 80.1 (range, 40-100) and 19.3 (range, 2.3-68) points respectively. No surgical complications occurred in any of the shoulder included in this study. CONCLUSIONS: Endoscopic release of the tendon of the pectoralis minor from the coracoid improves pain, function and patient reported outcomes in the majority of patients presenting with the diagnosis of isolated pectoralis minor syndrome.
ABSTRACT
BACKGROUND: Periprosthetic joint infection (PJI) is a relatively frequent and oftentimes devastating complication after total elbow arthroplasty (TEA). Its microbiologic diagnosis is usually based on periprosthetic tissue culture (hereafter referred to as tissue culture), but the sensitivity of tissue culture is variable. Although implant sonication culture has been shown to be superior to tissue culture for the diagnosis of hip and knee PJI, only a single small study (of fewer than 10 infected implants) has assessed sonication for PJI diagnosis after elbow arthroplasty. METHODS: We retrospectively analyzed 112 sonicate fluid cultures from patients who underwent revision of a TEA at a single institution between 2007 and 2019, comparing results to those of tissue cultures. We excluded patients who had fewer than 2 tissues submitted for culture. Using the Infectious Diseases Society of America guidelines to define PJI, there were 49 infected and 63 non-infected cases. Median ages in the PJI and non-infected groups were 66 and 61 years, respectively. In the non-infected group, 65% were female vs. 63% in the PJI group. We reviewed clinical characteristics and calculated the sensitivity and specificity of tissue compared with sonicate fluid culture. In addition, we compared the sensitivity of tissue culture to the combination of tissue and sonicate fluid culture. RESULTS: The most common pathogens were coagulase-negative Staphylococcus sp (49%), followed by Staphylococcus aureus (12%). Sensitivity of tissue culture was 63%, and sensitivity of sonicate fluid culture was 76% (P = .109). Specificity of tissue culture was 94% and specificity of sonicate fluid culture was 100%. Sensitivity of sonicate fluid culture in combination with tissue culture was 84% (P = .002 compared to tissue culture alone). CONCLUSION: In this study, we found that the combination of sonicate fluid and tissue culture had a greater sensitivity than tissue culture alone for microbiologic diagnosis of PJI after TEA.