Periprosthetic Infection in Patients With Multiple Joint Arthroplasties.

The number of total joint arthroplasties performed in the United States is increasing every year. Owing to the aging population and excellent long-term prosthesis survival, 45% of patients who undergo joint arthroplasty will receive two or more joint arthroplasties during their lifetimes. Periprosthetic joint infection (PJI) is among the most common complications after arthroplasty. Evaluation and treatment of PJI in patients with multiple joint arthroplasties is challenging, and no consensus exists for the optimal management. Multiple PJI can occur simultaneously, synchronous, or separated by extended time, metachronous. Patient risk factors for both scenarios have been reported and may guide evaluation and long-term management. Whether to perform joint aspiration for asymptomatic prosthesis in the presence of suspected PJI in patients with multiple joint arthroplasties is controversial. Furthermore, no consensus exists regarding whether patients who have multiple joint arthroplasties and develop PJI in a single joint should be considered for prolonged antibiotic prophylaxis to reduce the risk of future infections. Finally, the optimal treatment of synchronous joint infections whether by débridement, antibiotics and implant retention, and one-stage or two-stage revision has not been defined. This review will summarize the best information available and provide pragmatic management strategies.

Risk Factors in Patients Who Had Prior Renal or Liver Transplant Undergoing Primary Total Knee Arthroplasty.

BACKGROUND: More solid organ transplant (SOT) patients are undergoing total knee arthroplasty (TKA). This study identifies risk factors for complications, implant survivorship, and mortality in TKA patients who had prior SOT. METHODS: We identified 176 TKAs in patients who had prior SOT. Of these, 77 had a prior renal (RT), 77 had a prior liver (LT) transplant, and 22 had multiple prior transplants (MT). Median survival was estimated using Kaplan-Meier. Univariate analyses were assessed with mixed-effects logistic regressions for complications and Cox-regressions for mortality. Median follow-up was 63 months (range, 24 to 109). RESULTS: At least one acute medical complication occurred in 25, 13, and 27% of cases with prior RT, LT, and MT, respectively (P = .12). None of the variables were significantly associated with acute medical complications. At least one surgical complication occurred in 14, 13 and 14% of cases with prior RT, LT, and MT, respectively (P = 1). Vitamin D supplementation (Odds Ratio [OR] = 0.38, P < .03) was associated with lower risk of surgical complications. Reoperation and revision rates were 5 and 3%, respectively. Older age at time of transplantation and greater level of serum creatinine at time of TKA were associated with lower risk (OR = 0.96, P = .01), and higher risk of reoperation (OR = 4.9, P = .01), respectively. Coronary artery disease was associated with higher mortality (Hazard Ratio = 2.35, P = .01). CONCLUSIONS: Vitamin D was associated with lower surgical complications, whereas a younger age at time of transplantation increased the risk of reoperation. Additionally, SOT patients with coronary artery disease demonstrated higher mortality after TKA.

Combining acetabular and femoral morphology improves our understanding of the down syndrome hip.

BACKGROUND: Hip instability is frequent in patients with Down syndrome. Recent studies have suggested that skeletal hip alterations are responsible for this instability; however, there are currently no studies simultaneously assessing femoral and acetabular anatomy in subjects with Down syndrome in the standing position. The aim was to analyze the three-dimensional anatomy of the Down syndrome hip in standing position. METHODS: Down syndrome subjects were age and sex-matched to asymptomatic controls. All subjects underwent full body biplanar X-rays with three-dimensional reconstructions of their pelvises and lower limbs. Parameter means and distributions were compared between the two groups. FINDINGS: Forty-one Down syndrome and 41 control subjects were recruited. Acetabular abduction (mean = 52° [SD = 9°] vs. mean = 56° [SD = 8°]) and anteversion (mean = 14° [SD = 8°] vs. mean = 17.5° [SD = 5°]) as well as posterior acetabular sector angle (mean = 91° [SD = 7°] vs. mean = 94° [SD = 7°]) were significantly lower in Down syndrome subjects compared to controls (P < 0.01). Anterior acetabular sector angle (mean = 62° [SD = 10°] vs. mean = 59° [SD = 7°]; P < 0.01) was significantly higher in Down syndrome compared to controls. The distributions of acetabular anteversion (P = 0.002;V = 0.325), femoral anteversion (P = 0.004;V = 0.309) and the instability index (P < 0.001;V = 0.383) were significantly different between the two groups, with subjects with Down syndrome having both increased anteversion and retroversion for each of these parameters. INTERPRETATION: Subjects with Down syndrome were found to have a significantly altered and more heterogeneous anatomy of their proximal hips compared to controls. This heterogeneity suggests that treatment strategies of hip instability in Down syndrome should be subject-specific and should rely on the understanding of the underlying three-dimensional anatomy of each patient.

Spinopelvic Alignment in Subjects With Down Syndrome.

STUDY DESIGN: This was a cross-sectional study. OBJECTIVE: The aim of this study was to describe the spinopelvic alignment of subjects with Down syndrome (DS). SUMMARY OF BACKGROUND DATA: Subjects with DS are known to suffer from a large prevalence of scoliosis. While scoliosis is known to significantly affect postural alignment, there are currently no studies on the spinopelvic alignment of subjects with DS. MATERIALS AND METHODS: In total, 41 subjects (28 female subjects and 13 male subjects) with DS, age and sex-matched to 41 asymptomatic subjects, underwent biplanar x-rays with 3-dimensional reconstructions of their spines and pelvises, followed by measurement of commonly used spinopelvic sagittal and coronal alignment parameters. Subjects were then classified into one of Roussouly's 4 types of sagittal alignment. Alignment parameters and prevalence of alignment patterns were compared between the 2 groups. RESULTS: Subjects with DS were found to be relatively hypokyphotic (T4-T12=-29.0 vs. -37.5 degrees; P<0.001) and hyperlordotic (L1-L5=53.8 vs. 44.3 degrees; P<0.001) with larger pelvic incidence (53.2 vs. 45.1 degrees; P<0.001), sacral slope (47.7 vs. 36.8 degrees; P<0.001), Cobb angle (10.2 vs. 8.0 degrees; P=0.005), and axial rotation of the apical vertebra (6.6 vs. 3.7 degrees; P<0.001) but had smaller pelvic tilt (4.9 vs. 8.1 degrees; P<0.001) compared with control subjects. Roussouly's type 4 was found to be the most frequent pattern in DS subjects (68.3% vs. 14.6%; P<0.001). CONCLUSIONS: Subjects with DS were found to have a peculiar pattern of hypokyphosis, hyperlordosis, large pelvic incidence, and small pelvic tilt. The altered spinopelvic alignment found in DS could predispose these subjects to hip instability and osteoarthritis. LEVEL OF EVIDENCE: Level III.

Effect of a Quality Improvement Project to Reduce Noise in a Pediatric Unit.

PURPOSE: Noise levels remain high in clinical settings, which may result in stress and sleep disruption, and can lead to immunosuppression, delayed healing, confusion, disorientation, delusions, and increased length of hospital stay. The purpose of this quality improvement project was to assess effects of a multidisciplinary noise reduction program on a pediatric unit in an acute care hospital in a developing country. METHODS: A quality improvement project was carried out over 15 months in a pediatric unit. A three-phase study was conducted where the first phase included obtaining patient satisfaction ratings and recording sound levels, the second phase included implementing a noise reduction program and designing a noise detector machine, and the third phase included obtaining patient satisfaction data and recording noise levels over a 1-year period. RESULTS: There was a significant decrease in noise of 8 A-weighted decibels when comparing the values before and after implementing the quality improvement project at t = 6.44, p < 0.000. There was no significant difference in patient satisfaction ratings. CLINICAL IMPLICATIONS: Noise in the pediatric unit exceeded recommended guidelines; however, decreasing the levels was possible and sustainable, which can improve the psychological and physiological wellbeing of hospitalized children.

The management of residual acetabular dysplasia: updates and controversies.

Residual acetabular dysplasia is a frequent cause of secondary osteoarthritis of the hip and its management is still controversial. The aim of this review is to describe residual acetabular dysplasia, to estimate the age limit above which surgical management is needed, and to emphasize the role of assistive imaging in evaluating predictive parameters for future acetabular development. A decision-making algorithm is presented.

Bilateral Salmonella Septic Arthritis of the Hip in a Patient with Crohn Disease: A Case Report.

CASE: A 27-year-old immunocompromised man with Crohn disease presented with bilateral septic hip arthritis due to Salmonella enterica serotype Typhi. The diagnosis was confirmed by synovial membrane and effusion culture specimens that were obtained during arthroscopic debridement of both hips. CONCLUSION: Prolonged antimicrobial therapy, bilateral femoral head resection, and placement of cement spacers for 5 months, followed by bilateral total hip arthroplasty, was a radical and effective treatment for a patient with Crohn disease and bilateral Salmonella septic arthritis of the hip.

Icatibant, an inhibitor of bradykinin receptor 2, for hereditary angioedema attacks: prospective experimental single-cohort study / Icatibanto, um inibidor de receptor 2 de bradicinina, para ataques de angioedema hereditário: estudo experimental prospectivo de coorte sem grupo controle

CONTEXT AND OBJECTIVE: Hereditary angioedema (HAE) with C1 inhibitor deficiency manifests as recurrent episodes of edema involving the skin, upper respiratory tract and gastrointestinal tract. It can be lethal due to asphyxia. The aim here was to evaluate the response to therapy for these attacks using icatibant, an inhibitor of the bradykinin receptor, which was recently introduced into Brazil. DESIGN AND SETTING: Prospective experimental single-cohort study on the efficacy and safety of icatibant for HAE patients. METHODS: Patients with a confirmed HAE diagnosis were enrolled according to symptoms and regardless of the time since onset of the attack. Icatibant was administered in accordance with the protocol that has been approved in Brazil. Symptom severity was assessed continuously and adverse events were monitored. RESULTS: 24 attacks in 20 HAE patients were treated (female/male 19:1; 19-55 years; median 29 years of age). The symptoms were: subcutaneous edema (22/24); abdominal pain (15/24) and upper airway obstruction (10/24). The time taken until onset of relief was: 5-10 minutes (5/24; 20.8%); 10-20 (5/24; 20.8%); 20-30 (8/24; 33.4%); 30-60 (5/24; 20.8%); and 2 hours (1/24; 4.3%). The time taken for complete resolution of symptoms ranged from 4.3 to 33.4 hours. Adverse effects were only reported at injection sites. Mild to moderate erythema and/or feelings of burning were reported by 15/24 patients, itching by 3 and no adverse effects in 6. CONCLUSION: HAE type I patients who received icatibant responded promptly; most achieved improved symptom severity within 30 minutes. Local adverse events occurred in 75% of the patients. .

CONTEXTO E OBJETIVO: O angioedema hereditário (AEH) com deficiência de inibidor de C1 manifesta-se por episódios recorrentes de edema envolvendo pele, trato respiratório superior e gastrointestinal. Pode ser letal por asfixia. O objetivo foi avaliar a resposta à terapia dos ataques com icatibanto, inibidor do receptor de bradicinina, recentemente introduzido no Brasil. TIPO DE ESTUDO E LOCAL: Estudo experimental prospectivo de coorte, sem grupo controle, da eficácia e segurança do icatibanto em paciente com AEH. MÉTODOS: Pacientes com diagnóstico confirmado de AEH foram incluídos de acordo com os sintomas, independentemente do tempo de início do ataque. Icatibanto foi administrado segundo protocolo aprovado no Brasil. A gravidade do sintoma foi estabelecida continuamente e os eventos adversos foram monitorados. RESULTADOS: 24 ataques em 20 pacientes com AEH foram tratados (19 F:1 M; 19-55 anos; mediana 29 anos). Os sintomas foram: edema subcutâneo (22/24), dor abdominal (15/24) e obstrução de vias aéreas superiores (10/24). O tempo para o início do alívio foi: 5-10 minutos, 5/24 (20,8%); 10-20, 5/24 (20,8%); 20-30, 8/24 (33,4%); 30-60, 5/24 (20,8%) e 2 horas, 1/24 (4,3%). O tempo para a resolução completa variou de 4,3-33,4 horas. Somente efeitos adversos nos locais das injeções foram relatados. Eritema leve a moderado e/ou sensação de ardor foram relatados por 15/24 pacientes, prurido em 3, e 6 não tiveram efeitos adversos. CONCLUSÃO: Pacientes com AEH tipo I receberam icatibanto com pronta resposta; a maioria teve melhora na gravidade dos sintomas em 30 minutos. Eventos adversos locais ocorreram em 75% dos pacientes. .

Icatibant, an inhibitor of bradykinin receptor 2, for hereditary angioedema attacks: prospective experimental single-cohort study.

CONTEXT AND OBJECTIVE: Hereditary angioedema (HAE) with C1 inhibitor deficiency manifests as recurrent episodes of edema involving the skin, upper respiratory tract and gastrointestinal tract. It can be lethal due to asphyxia. The aim here was to evaluate the response to therapy for these attacks using icatibant, an inhibitor of the bradykinin receptor, which was recently introduced into Brazil. DESIGN AND SETTING: Prospective experimental single-cohort study on the efficacy and safety of icatibant for HAE patients. METHODS: Patients with a confirmed HAE diagnosis were enrolled according to symptoms and regardless of the time since onset of the attack. Icatibant was administered in accordance with the protocol that has been approved in Brazil. Symptom severity was assessed continuously and adverse events were monitored. RESULTS: 24 attacks in 20 HAE patients were treated (female/male 19:1; 19-55 years; median 29 years of age). The symptoms were: subcutaneous edema (22/24); abdominal pain (15/24) and upper airway obstruction (10/24). The time taken until onset of relief was: 5-10 minutes (5/24; 20.8%); 10-20 (5/24; 20.8%); 20-30 (8/24; 33.4%); 30-60 (5/24; 20.8%); and 2 hours (1/24; 4.3%). The time taken for complete resolution of symptoms ranged from 4.3 to 33.4 hours. Adverse effects were only reported at injection sites. Mild to moderate erythema and/or feelings of burning were reported by 15/24 patients, itching by 3 and no adverse effects in 6. CONCLUSION: HAE type I patients who received icatibant responded promptly; most achieved improved symptom severity within 30 minutes. Local adverse events occurred in 75% of the patients.

Is progressive lengthening of the distal phalanx of a child's index finger possible and safe?

Progressive lengthening using an external fixator has only recently been applied to the phalanges of the hand. A number of technical challenges exist, especially in pediatric cases, such as the size of the bone involved, the existence of the physis, and the risk of infection and neurovascular compromise. Here, we report a case of lengthening of a short distal phalanx following osteomyelitis in a 7-year-old child with a uniplanar mini-external fixator. Elongation of 63% was obtained, reaching 80% of the contralateral phalanx, with complete resolution of the preoperative functional impairment, and an acceptable cosmetic result for the patient. A mild limitation of the distal interphalangeal joint flexion as well as mild effort-related discomfort was still present at the last follow-up. No complications were recorded. Gradual lengthening of the phalanges using uniplanar minifixators can be performed safely in children with good results as long as appropriate indications and technical limitations are respected.