Peri-operative Morbidity Associated with Bilateral Hip Arthroplasty for Inflammatory Arthritis: Results from a Consecutive Series of 168 Hips.

AIM: This study aims to assess the risks and peri-operative morbidity associated with a single-stage sequential bilateral hip arthroplasty (SBHA) when performed in patients with arthritis secondary to inflammatory arthropathy. METHODS: Data of patients who underwent SBHA between 2012 and 2018 for inflammatory arthritis were extracted from a database, for peri-operative complications and functional improvement. SBHA for other causes was excluded. RESULTS: Data of 84 consecutive patients with a mean age of 34.5 years were analyzed. The mean follow-up was 2.4 years. 66% had ankylosing spondylitis, while 14% had rheumatoid arthritis. 50% of the patients had bilateral fusion of the hips, and 34% had flexion deformity > 30°.None of the patients had peri-operative cardiac or pulmonary complications. 2.4% had per-operative hypotension (MAP < 50 mmHg) and 1.2% had desaturation (SpO2 < 90%). The mean drop in hematocrit was 9.3%. While 31% did not require blood transfusion, 35% required more than 1 unit of blood. Patients with pre-operative PCV of > 36% had a significantly lower risk of being transfused > 1 unit of blood (p = 0.02). ICU admission was 6%-mostly for post-operative monitoring. While one patient had a local hematoma that needed a wash-out, there were no infections, dislocations, or mortality in these patients. The modified Harris hip score improved from a mean of 26.5-85. The mean hip flexion improved post-operatively from 32° to 92°. CONCLUSIONS: SBHA for inflammatory arthritis can be performed with minimum complications in a multidisciplinary setting. Pre-operatively, PCV of > 36 is advised to reduce transfusion rates.

Subtrochanteric femoral shortening for hip centre restoration in complex total hip arthroplasty with functional outcome.

AIMS: Complex total hip arthroplasty (THA) with subtrochanteric shortening osteotomy is necessary in conditions other than developmental dysplasia of the hip (DDH) and septic arthritis sequelae with significant proximal femur migration. Our aim was to evaluate the hip centre restoration with THAs in these hips. METHODS: In all, 27 THAs in 25 patients requiring THA with femoral shortening between 2012 and 2019 were assessed. Bilateral shortening was required in two patients. Subtrochanteric shortening was required in 14 out of 27 hips (51.9%) with aetiology other than DDH or septic arthritis. Vertical centre of rotation (VCOR), horizontal centre of rotation, offset, and functional outcome was calculated. The mean followup was 24.4 months (5 to 92 months). RESULTS: The mean VCOR was 17.43 mm (9.5 to 27 mm) and horizontal centre of rotation (HCOR) was 24.79 mm (17.2 to 37.6 mm). Dislocation at three months following acetabulum reconstruction required femoral shortening for offset correction and hip centre restoration in one hip. Mean horizontal offset was 39.72 (32.7 to 48.2 mm) compared to 42.89 (26.7 to 50.6 mm) on the normal side. Mean Harris Hip Score (HHS) of 22.64 (14 to 35) improved to 79.43 (68 to 92). Mean pre-operative shortening was 3.95 cm (2 to 8 cm). Residual limb length discrepancy was 1.5 cm (0 to 2 cm). Sciatic neuropraxia in two patients recovered by six months, and femoral neuropraxia in one hip recovered by 12 months. Mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was 13.92 (9 to 19). Mean 12-item short form survey (SF-12) physical scores of 50.6 and mental of 60.12 were obtained. CONCLUSION: THA with subtrochanteric shortening is valuable in complex hips with high dislocation. The restoration of the hip centre of rotation and offset is important in these hips. LEVEL OF EVIDENCE IV: Femoral shortening useful in conditions other than DDH and septic sequelae.Restoration of hip centre combined with offset to be planned and ensured.

Early outcome of culture-negative infection in open fractures of the lower limb: A prospective study.

Background: Culture-negative infections in open long bone fractures are frequently encountered in clinical practice. We aimed to identify the rate and outcome of culture-negative infections in open long bone fractures of lower limb. Methodology: A prospective cohort study was conducted from November 2015 to May 2017 on Gustilo and Anderson Grade III open long bone fractures of the lower limb. Demographic data, injury details, time from injury to receiving antibiotics and index surgical procedure were noted. Length of hospital stay, number of additional surgeries and occurrence of complications were also noted. Patients with infected open fractures were grouped as culture positive or culture negative depending on the isolation of infecting microorganisms in deep intraoperative specimen. The clinical outcome of these two groups was statistically analysed. Results: A total of 231 patients with 275 open fractures involving the femur, tibia or fibula were studied. There was clinical signs of infection in 84 patients (36.4%) with 99 fractures (36%). Forty-three patients (51.2%) had positive cultures and remaining 41 patients had negative cultures (48.8%). The rate of culture-negative infection in open type III long bone fractures in our study was 17.7%. There was no statistical difference in the clinical outcome between culture-negative and culture-positive infections. Conclusion: Failure to identify an infective microorganism in the presence of clinical signs of infection is routinely seen in open fractures and needs to be treated aggressively.

Microbiological profile of septic arthritis in adults: Lessons learnt and treatment strategies.

Objective: The aim of this study is to characterise the clinical and microbiological profile of adult patients treated at our orthopaedic unit with septic arthritic between 2006 and 2017. Materials and Methods: A total of 70 patients who were admitted with a diagnosis of septic arthritis between 2006 and 2017 were included in the study. The patients' clinical and epidemiological characteristics were surveyed; microbiological profile and the complications relating to the patients' treatment were identified. Results: Septic arthritis was more common among males (83%). About 75% of the patients presented with a history of fever. The knee was the most commonly affected joint (71%), followed by the hip. While C-reactive protein was found to be consistently >75, total blood white blood cell (WBC) counts were found not to be reflective of the presence of infection with a mean WBC count of only 13,561/cu.mm, and Gram stain examination had a poor sensitivity of 47%. Among the co-morbidities, the most prevalent association was with diabetes mellitus. The infectious agent most frequently isolated was Staphylococcus aureus(42.85%). The antibiotic sensitivity pattern has evolved since the early years, with resistant strains becoming increasingly prevalent. Unusually, high incidence of streptococci was noted (30%), contrary to the published literature. One-third of the patients had multi-resistant organisms. Septic arthritis left 70% of the patients with a significant residual disability at 6 months follow-up and had 4.25% mortality. Conclusion: Changing sensitivity patterns of microbes in septic arthritis point to a need for reconsidering empirical antibiotic therapy. Joint damage following infection can lead to significant disability.

Microbiological profile and outcomes of two-stage revision hip arthroplasty.

Background: Prosthetic joint infection (PJI) is one of the most challenging cases that confront modern orthopaedics. Two-stage revision, which is the standard of care for PJI, is the preferred mode of treatment for these infections. Aims and Objectives: To study the microbiological profile of prosthetic joint infections (PJI) in the hip and to assess the efficacy of a two stage revision surgery for PJI. We also aimed to study the sensitivity and specificity of ESR and CRP in the diagnosis of PJI. Materials and Methods: The microbiological profile, clinical and radiological outcomes of 22 patients who had a two-stage revision for PJI of the hip between 2013 and 2017 were retrospectively analysed. PJI was defined using the criteria provided by the International Consensus Statement on PJI 2013. Results: Staphylococcus aureus was found to be the most common organism in PJI. Debridement was successful in removing the organism in 74% of PJI. At the time of re-implantation (second stage), six joints grew organisms that were different from that isolated at the index debridement - coagulase-negative staphylococci (3cases) and enterococci (3cases). Other infection parameters for these patients were negative. None of the patients who had two-stage revision surgery had clinical evidence of reinfection or radiological evidence of loosening at a mean of 2-year follow-up. An ESR cut off of >30mm/hr had a sensitivity of 75% and specificity of 88% in predicting PJI. A CRP >10mg/L had a sensitivity of 75% and specificity of 69%. The sensitivity and specificity of using both ESR and CRP cut-offs in the diagnosis of infection were 57% and 94%, respectively. The positive predictive value was 94% and negative predictive value was 56%. Conclusion: The outcomes of the study justify a two-stage revision arthroplasty for PJI of the hip. The use of ESR and CRP as screening tests for the success of debridement has value - but should be interpreted with caution.

Microbiological profile of infections of the hip joint: An Indian perspective.

Background: Knowledge of the local microbiological epidemiology helps in formulating protocols for appropriate treatment of hip infections. The aim of this study was to profile the organisms cultured from infected hips. Methods: The microbiological profile and sensitivity pattern of organisms in eighty infected hips were reviewed. Results: Infection was secondary to arthroplasty in 35, fracture surgery in 34 and primary septic arthritis in 11. Twenty percent of the infections were polymicrobial, whereas the rest were monomicrobial. Fifty-five percent were Gram-positive, of which 45% were Staphylococcus species (36% methicillin-sensitive Staphylococcus aureus, 20% methicillin-resistant S. aureus, and 44% coagulase sensitive Staphylococcal species). All Staphylococcus species were sensitive to vancomycin, but 20% of Enterococcus species were resistant to vancomycin. One-third of the Enterococcus species and 2% of Staphylococcus species were resistant to teicoplanin. Escherichia coli (n = 10) and Pseudomonas sp. (n = 13) were the most common Gram-negative organism. Although 18% of the Gram-negative organisms were carbapenem resistant, all were sensitive to colistin. Conclusion: Staphylococcus sp. was the most common pathogen found in hip infections. However, the high incidence of Gram-negative infection requires that prophylactic antibiotics cover these organisms as well. The high resistance to first-line antibiotics should be taken into consideration while making protocols. The knowledge of the microbial profile is especially important when considering arthroplasty for arthritis secondary to hip infections.

Is it safe to do a single-stage implant exit and primary hip replacement? clinical and microbiological profiling.

Background: A single-stage implant revision for failed fixation of proximal femoral fractures is performed only when there is no evidence of infection. Else, a two-staged revision is preferred - where the definitive revision surgery is done a few months after the implant exit. This study aims to audit the safety and incidence of culture positivity in single-stage revisions. Materials and Methods: Forty one of 284 patients that presented over the last 12 years for implant exchange of the hip, had a single stage revision surgery for failed fixation of a fracture of the hip, as there was no obvious evidence of infection at the time of implant exit. Results: Micro-organisms were grown in 51% of the 41 hips. 76% were gram positive, of which 63% were Coagulase negative staphylococci (CoNS). 50% of CoNS and 75% of S. aureus were resistant to oxacillin, but susceptible to Vancomycin. Of the gram negative organisms, 2 (Enterobacter sp) were resistant to carbapenam, while others were susceptible. Preoperative ESR and CRP, individually, had low specificity - 50% for ESR >30mm at 1 hour and 62% for CRP>10. The combined use of ESR > 30mm and CRP>10 increased the specificity to 90%. 12% of the patients had immediate postoperative complications that required a wash out in theatre. The long term clinical follow up of these patients is limited. Conclusion: This study suggests that implant exit and simultaneous arthroplasty for failed fracture fixation should be done with caution due to the high possibility of infection. It may be prudent to opt for a 2 stage revision.

Dominance of international high-risk clones in carbapenemase-producing Pseudomonas aeruginosa: Multicentric molecular epidemiology report from India.

BACKGROUND: Pseudomonas aeruginosa is one of the most common opportunistic pathogens that cause severe infections in humans. The burden of carbapenem resistance is particularly high and is on the rise. Very little information is available on the molecular mechanisms and its clonal types of carbapenem-resistant P. aeruginosa seen in Indian hospitals. This study was undertaken to monitor the ß-lactamase profile and to investigate the genetic relatedness of the carbapenemase-producing (CP) P. aeruginosa collected across different hospitals from India. MATERIALS AND METHODS: A total of 507 non-duplicate, carbapenem-resistant P. aeruginosa isolated from various clinical specimens collected during 2014-2017 across seven Indian hospitals were included. Conventional multiplex polymerase chain reaction for the genes encoding beta-lactamases such as extended-spectrum beta-lactamase (ESBL) and carbapenemase were screened. A subset of isolates (n = 133) of CP P. aeruginosa were genotyped by multilocus sequence typing (MLST) scheme. RESULTS: Of the total 507 isolates, 15%, 40% and 20% were positive for genes encoding ESBLs, carbapenemases and ESBLs + carbapenemases, respectively, whilst 25% were negative for the ß-lactamases screened. Amongst the ESBL genes, blaVEB is the most predominant, followed by blaPER and blaTEM, whilst blaVIM and blaNDM were the most predominant carbapenemases seen. However, regional differences were noted in the ß-lactamases profile across the study sites. Genotyping by MLST revealed 54 different sequence types (STs). The most common are ST357, ST235, ST233 and ST244. Six clonal complexes were found (CC357, CC235, CC244, CC1047, CC664 and CC308). About 24% of total STs are of novel types and these were found to emerge from the high-risk clones. CONCLUSION: This is the first large study from India to report the baseline data on the molecular resistance mechanisms and its association with genetic relatedness of CP P. aeruginosa circulating in Indian hospitals. blaVIM- and blaNDM-producing P. aeruginosa is the most prevalent carbapenemase seen in India. Majority of the isolates belongs to the high-risk international clones ST235, ST357 and ST664 which is a concern.