Transfemoral amputation following total knee arthroplasty: mortality and functional outcomes.

AIMS: The aim of this study was to characterize the factors leading to transfemoral amputation after total knee arthroplasty (TKA), as well as the rates of mortality and functional independence after this procedure in these patients. PATIENTS AND METHODS: This was a multicentre retrospective review with a prospective telephone survey for the assessment of function. All patients with a TKA who subsequently required transfemoral amputation between January 2001 and December 2015 were included. Demographic information, medical comorbidities, and postoperative mortality data were collected. A 19-item survey was used for the assessment of function in surviving patients. RESULTS: A total of 111 patients were included. Their mean age was 61.0 years (42.0 to 88.0) at the time of TKA, with a subsequent mean of 3.7 operations (0 to 15) over a mean period of 6.1 years (0.05 to 30.1) before amputation. The indication for amputation was chronic infection in 97 patients (87.4%). The rate of five-year survival was 51.7%, and advanced age (p = 0.001) and renal failure (p = 0.045) were associated with an increased risk of mortality. Of the 62 surviving patients, 34 completed the survey; 32 (94.1%) owned a prosthesis but only 19 (55.9%) used it; 19 (55.9%) primarily used a wheelchair for mobility; 27 (79.5%) had phantom pain; and 16 (47.1%) required chronic pain medication. Only 18 patients (52.9%) were satisfied with the quality of life. CONCLUSION: Patients with complications after TKA, in whom transfemoral amputation is considered, should be made aware of the high rate of mortality and the poor functional outcome in the survivors. Alternative forms of treatment including arthrodesis of the knee should be investigated.

An unusually long-lasting outbreak of community-acquired Legionnaires' disease, 2005-2008, Italy.

An unusually long-lasting community-acquired outbreak of Legionnaires' disease (LD) occurred in the inhabitants of a town in northern Italy from 2005 to 2008. Overall, 43 cases were diagnosed including five deaths. Hundreds of water samples were collected for Legionella isolation but only two clinical samples were obtained. Clinical strains were ST23 as were environmental isolates detected in most Legionella-positive patients' homes and those from a public fountain. Although no Legionella was found in the municipal water mains, a continuous chlorination was applied in 2008. This action resulted in a halving of cases, although incidence remained tenfold higher than the Italian average incidence until the end of 2013, when it dropped to the expected rate. Retrospective analyses of prevalent wind direction suggested that a hidden cooling tower could have been the main cause of this uncommon outbreak, highlighting the importance of implementation of cooling tower registers in supporting LD investigations.

Robotic systems in orthopaedic surgery.

Robots have been used in surgery since the late 1980s. Orthopaedic surgery began to incorporate robotic technology in 1992, with the introduction of ROBODOC, for the planning and performance of total hip replacement. The use of robotic systems has subsequently increased, with promising short-term radiological outcomes when compared with traditional orthopaedic procedures. Robotic systems can be classified into two categories: autonomous and haptic (or surgeon-guided). Passive surgery systems, which represent a third type of technology, have also been adopted recently by orthopaedic surgeons. While autonomous systems have fallen out of favour, tactile systems with technological improvements have become widely used. Specifically, the use of tactile and passive robotic systems in unicompartmental knee replacement (UKR) has addressed some of the historical mechanisms of failure of non-robotic UKR. These systems assist with increasing the accuracy of the alignment of the components and produce more consistent ligament balance. Short-term improvements in clinical and radiological outcomes have increased the popularity of robot-assisted UKR. Robot-assisted orthopaedic surgery has the potential for improving surgical outcomes. We discuss the different types of robotic systems available for use in orthopaedics and consider the indication, contraindications and limitations of these technologies.

[Kyphectomy in myelomeningocele patients. Longterm results, complications and risk analysis]. / Gibbusresektion bei Myelomeningozelepatienten. Langzeitergebnisse, Komplikationen und Risikoanalyse.

BACKGROUND: The conservative and surgical management of lumbar kyphosis is difficult and is a challenge for the orthopaedic surgeon. A kyphotic deformity of the lumbar spine is present in 8% to 20% of these patients. Most curves have very rigid components, often exceed 80 degrees at birth. The options for conservative management are limited. Bracing is extremely difficult, rarely effective, and in advanced stages impossible. We have been using the Warner and Fackler kyphectomy technique at our institution since 1994 as a standard procedure for treating children with lumbar kyphosis due to myelomeningocele. RESULTS: This study was performed for a better understanding of the cause of the complications and optimizing the surgical technique. AIM: The aim of this study was to evaluate the longterm results, technical problems, early and late complications and the complication associated risk factors.

Estimating the burden of disease and the economic cost attributable to chikungunya, Andhra Pradesh, India, 2005-2006.

To estimate the burden and cost of chikungunya in India, we searched for cases of fever and joint pain in the village of Mallela, Andhra Pradesh, and collected information on the demography, signs, symptoms, healthcare utilization and expenditure associated with the disease. We estimated the burden of the disease using disability-adjusted life years (DALYs). We estimated direct and indirect costs and made projections for the district and state using surveillance data corrected for under-reporting. On average, from December 2005 to April 2006, each of the 242 cases in the village led to a burden of 0.0272 DALYs (95% CI 0.0224-0.0319) and a cost of US$37.50 (95% CI 30.6-44.3). Overall, chikungunya in Mallela led to 6.57 DALYs and a loss of US$9100. Out-of-pocket direct medical costs accounted for 68% of the total. From January to December 2006 the burden for Kadapa district was 160 DALYs (cost: US$290 000). Over the same period the burden for Andhra Pradesh was 6600 DALYs (cost: US$12 400 000). While the burden was moderate, costs were high and mostly out of pocket.

An outbreak of viral gastroenteritis linked to municipal water supply, Lombardy, Italy, June 2009.

We report an outbreak of viral gastroenteritis linked to municipal drinking water in a town in northern Italy in June 2009. Over one month we identified 299 probable cases of whom 30 were confirmed for at least one of the following viruses: norovirus, rotavirus, enterovirus or astrovirus. Water samples and filters from the water system also tested positive for norovirus and enterovirus. Control measures included treating the water system with chlorine dioxide and filters with peracetic acid, while providing temporary alternative sources of drinking water to the population.

The use of a Type-I lyophilisate collagen as an osteoinductive factor in pseudarthroses of the forearm.

The purpose of this study was to assess the use of a novel bone void filler consisting of Type I collagen and various growth factors (VEGF, TGFß-1, TGFß-2, IGF-1, BMP-2, BMP-3, and BMP-7) and surgical fixation to treat diaphyseal forearm pseudarthroses. Eleven patients underwent an osteosynthesis procedure for isolated pseudarthrosis fractures of the forearm (six radial and five ulnar diaphysis). The mean duration between the initial failed surgical fixation and re-operation was 38 weeks. Radiographic signs of fracture healing after the application of the bone void filler were noted at a mean of 5 weeks, and complete fracture consolidation was achieved at a mean of 6 weeks. All patients demonstrated improved range of motion and grip strength. Additionally, all patients were pain-free by 6 weeks. The combination of a novel bovine bone-derived bone void filler and stable internal fixation led to union and rapid healing of forearm pseudarthroses.

[Resurfacing for osteonecrosis of the femoral head]. / Oberflächenersatz bei Hüftkopfnekrose.

Osteonecrosis of the femoral head is a disease of the young patient which eventually destroys the hip joint. In the early stage of the disease, treatment options are aimed at preserving the femoral head. Unfortunately, many patients present with late-stage disease (Ficat III and IV).In late-stage disease the treatment of choice is total hip arthroplasty. The high failure rate of total hip arthroplasty in young patients with osteonecrosis of the femoral head, however, made it an unfavourable treatment option. The results of hemiresurfacing (femoral resurfacing) in this patient population have been very disappointing due to high revision rates and insufficient pain relief. More recently, promising short- and mid-term results were reported with the use of total resurfacing with a survivorship of 90-93% after 3.4-10 years. Our own results in 60 patients show an overall survivorship of 92% after a mean follow-up of 4.8 years (1.6-6.5 years). Total hip resurfacing is a valuable treatment option for late-stage osteonecrosis based on recent study results.

Percutaneous drilling for the treatment of secondary osteonecrosis of the knee.

Osteonecrosis of the knee comprises two separate disorders, primary spontaneous osteonecrosis which is often a self-limiting condition and secondary osteonecrosis which is associated with risk factors and a poor prognosis. In a series of 61 knees (38 patients) we analysed secondary osteonecrosis of the knee treated by a new technique using multiple small percutaneous 3 mm drillings. Total knee replacement was avoided in 59 knees (97%) at a mean follow-up of 3 years (2 to 4). Of the 61 knees, 56 (92%) had a successful clinical outcome, defined as a Knee Society score greater than 80 points. The procedure was successful in all 24 knees with small lesions compared with 32 of 37 knees (86%) with large lesions. All the procedures were performed as day cases and there were no complications. This technique appears to have a low morbidity, relieves symptoms and delays more invasive surgery.

Molecular identification and differentiation of Staphylococcus species and strains of cheese origin.

Amplified Ribosomal-DNA Restriction Analysis (ARDRA) was used to differentiate among 12 species and 4 subspecies of the genus Staphylococcus. With a universal primer pair a 2.4 kbp PCR-product was amplified, including the 16S rDNA, the 16S-23S rDNA interspacer region, and about 500 bp of the 23S rDNA. Species-specific restriction patterns were found using the restriction enzymes HindIII and XmnI separately. Cheese related staphylococci were clearly differentiated. ARDRA results were in good agreement with results of partial sequencing of the 16S rDNA. ARDRA could fully replace the biochemical identification with ID32 Staph (BioMerieux) which was less reliable when staphylococci of cheese origin were analysed. Genomic restriction digests of cheese-related S. equorum strains by SmaI and SacI gave unique strain-specific restriction patterns which can be used to identify starter staphylococci in a complex microbial environment such as the surface of Red-Smear cheeses.

Identification and differentiation of species and strains of Arthrobacter and Microbacterium barkeri isolated from smear cheeses with Amplified Ribosmal DNA Restriction Analysis (ARDRA) and pulsed field gel electrophoresis (PFGE).

ARDRA (Amplified Ribosomal-DNA Restriction Analysis) was used to differentiate among species and genera of Arthrobacter and Microbacteria. Species-specific restriction patterns of PCR-products were obtained with NciI for Arthrobacter citreus (DSM 20133T), A. sulfureus (DSM 20167T), A. globiformis (DSM 20124T) and A. nicotianae strains (DSM 20123T, MGE 10D, CA13, CA14, isolate 95293, 95294, and 95299), A. rhombi CCUG 38813T, and CCUG 38812, and Microbacterium barkeri strains (DSM 30123T, MGE 10D, CA12 and CA15, isolate 95292, and isolate 95207). All yellow pigmented coryneforme bacteria isolated from the smear of surface ripened cheeses were identified as either A. nicotianae or M. barkeri strains. Using pulsed field gel electrophoresis (PFGE) strain specific restriction pattern for all Arthrobacter species and Microbacteria tested were obtained with restriction enzymes AscI and SpeI.