Effectiveness of patient triage at the orthopedic hospital and the hygiene concept in a professional handball team in the first year of the SARS-CoV-2 pandemic.

The first severe acute respiratory syndrome coronavirus type 2 (SARS-CoV­2) pandemic wave in Germany in spring 2020 challenged the largely unprepared healthcare system. A prevention concept was implemented to protect the vulnerable patient group at our orthopedic department. The patient triage during the pre-admission process included screening for symptoms and obtaining information on travel, occupation, contact and cluster (TOCC) [16].In March 2020, all sporting events were also cancelled or postponed [12]. Mitigation strategies for sport activities were necessary to restart training and competition. For the professional handball team of the Sport Club Magdeburg (SCM), a hygiene concept including strict mitigation measures combined with a polymerase chain reaction (PCR) test regime was implemented.We reviewed 15,739 patient contacts in a 12-month period at orthopedic department during the SARS-CoV­2 pandemic. This epidemiological, retrospective study presents the results of patient triage detecting cases with suspected SARS-CoV­2 infections when entering the clinic. We also considered 2328 inpatient PCR test results and the infection rates among the medical staff. At the same period, professional athletes underwent 1428 PCR tests as a part of the hygiene concept.During the triage process, 333 cases (2.12%) with suspected SARS-CoV­2 infections were detected at the orthopedic outpatient department. Three patients had a positive PCR test result after triage. Another four positive PCR tests were found among the inpatient group and one positive result among the medical staff. In the athletes' cohort, none of the 1428 PCR tests was positive.Patient triage as a part of the preadmission process is an effective tool to protect the maximum-care hospital from a SARS-CoV­2 mass outbreak. A hygiene concept with a defined PCR test regime protects a professional athlete team from SARS-CoV­2 infections during international competition and training.

C9 immunostaining as a tissue biomarker for periprosthetic joint infection diagnosis.

Background: Culture-negative periprosthetic joint infections (PJI) are often false diagnosed as aseptic implant failure leading to unnecessary revision surgeries due to repeated infections. A marker to increase the security of e PJI diagnosis is therefore of great importance. The aim of this study was to test C9 immunostaining of periprosthetic tissue as a novel tissue-biomarker for a more reliable identification of PJI, as well as potential cross-reactivity. Method: We included 98 patients in this study undergoing septic or aseptic revision surgeries. Standard microbiological diagnosis was performed in all cases for classification of patients. Serum parameters including C-reactive protein (CRP) serum levels and white blood cell (WBC) count were included, and the periprosthetic tissue was immunostained for C9 presence. The amount of C9 tissue staining was evaluated in septic versus aseptic tissue and the amount of C9 staining was correlated with the different pathogens causing the infection. To exclude cross-reactions between C9 immunostaining and other inflammatory joint conditions, we included tissue samples of a separate cohort with rheumatoid arthritis, wear particles and chondrocalcinosis. Results: The microbiological diagnosis detected PJI in 58 patients; the remaining 40 patients were classified as aseptic. Serum CRP values were significantly increased in the PJI cohort. Serum WBC was not different between septic and aseptic cases. We found a significant increase in C9 immunostaining in the PJI periprosthetic tissue. To test the predictive value of C9 as biomarker for PJI we performed a ROC analyses. According to the Youden's criteria C9 is a very good biomarker for PJI detection with a sensitivity of 89% and a specificity of 75% and an AUC of 0.84. We did not observe a correlation of C9 staining with the pathogen causing the PJI. However, we observed a cross reactivity with the inflammatory joint disease like rheumatoid arthritis and different metal wear types. In addition, we did not observe a cross reactivity with chondrocalcinosis. Conclusion: Our study identifies C9 as a potential tissue-biomarker for the identification of PJI using immunohistological staining of tissue biopsies. The use of C9 staining could help to reduce the number of false negative diagnoses of PJI.

The use of antibiotic-loaded bone cement does not increase antibiotic resistance after primary total joint arthroplasty.

PURPOSE: One of the preventive strategies for periprosthetic joint infection (PJI) is the use of antibiotic-loaded bone cement (ALBC) in primary total joint arthroplasty (TJA). Even though it is widely used, there are concerns about the development of antibacterial resistance. The aim of the study was to investigate whether using ALBC in primary TJA increases the antibiotic-resistant PJI. The hypothesis was that the regular use of ALBC does not increase the rate of resistant PJI. METHODS: Patients with confirmed PJI who had revision surgery from year 2010 to 2019 were included in this international multicenter study. The ALBC group was compared to the non-ALBC TJA group from the same time period. Medical records were used to collect clinical (age, gender, body mass index, comorbidities), TJA-related (type of operation, implant type and survival) and PJI-related (cultured microorganism, antibiogram) data. Resistance to gentamicin, clindamycin and vancomycin were recorded from the antibiograms. Multiple logistic regression model was used to identify risk factors and account for the potential confounders. RESULTS: 218 patients with PJI were included in the study: 142 with gentamicin-loaded bone cement and 76 in the non-ALBC group. The average age in the ALBC group was 71 ± 10 years and 62 ± 12 years in the comparison group (p < 0.001). Coagulase negative Staphylococci (CONS) were the most common (49%) isolated pathogens. The use of ALBC did not increase the rate of any resistant bacteria significantly (OR = 0.79 (0.42-1.48), p = 0.469). The presence of CONS was associated with higher risk of antibiotic resistance. CONCLUSIONS: The current study demonstrates no increase in antibiotic resistance due to ALBC after primary TJA. Thus, the use of ALBC during primary TJA should not be feared in the context of antimicrobial resistance. LEVEL OF EVIDENCE: III.

[Postoperative Dissociation after Knee Replacement and its Influence on the Course of Pain]. / Postoperative Dissoziation nach Totalem Kniegelenkersatz und ihr Einfluss auf den Schmerzverlauf.

OBJECTIVE: Even after successful knee replacement, one in 5 patients complains of chronic pain. Previous studies suggest that surgical interventions trigger postoperative traumatic stress in some patients. The aim of this explorative study is to investigate whether postoperative dissociation occurs as a manifestation of postoperative traumatic stress after total knee replacement. In addition, it should be investigated whether these patients have more chronic postoperative pain 1 year postoperatively and to what extent the course of pain differs from the other patients. METHODS: 201 Patients who underwent primary knee TEP were studied. They answered questionnaires on knee pain (WOMAC) and dissociation (FDS-20) at 3 measurement points: 1 day preoperatively (T1), 10 weeks postoperatively (T2) and 1 year postoperatively (T3). RESULTS: Data from 145 patients could be analyzed. The incidence for postoperative dissociation is 8.3%. Not only do patients with postoperative dissociation report more chronic postoperative pain after 1 year (p=0,016), but also their postoperative pain levels decreases less than in the patients without postoperative dissociation (p=0,025). DISCUSSION: The findings provide evidence that postoperative dissociation occurs as a manifestation of postoperative traumatic stress after total knee replacement. Even if dissociation seems to be a defense mechanism for the regulation of overstraining affects in the short term, it is associated with more chronic postoperative pain in the long term. Furthermore, the patients with postoperative dissociation benefit less in a 1-year follow-up from total knee replacement in terms of pain reduction. CONCLUSION: Strategies to reduce dissociation could lead to better results after knee TEP implementation and should be investigated in future intervention studies.

The Pain Paradox of Borderline Personality and Total Knee Arthroplasty (TKA): Recruiting Borderline Personality Organization to Predict the One-Year Postoperative Outcome.

BACKGROUND: TKA is a common treatment for arthropathies of the knee; however, its results are compromised by psychosocial equivalents of pain: prior research suggests persistent pain and dysfunction after TKA not only to be linked to psychological symptoms such as depression or anxiety but also to psychodynamic determinants of borderline personality, namely borderline personality organization. Osteoarthritis (OA) and Rheumatoid arthritis (RA), the main indications for TKA, are themselves linked to personality factors and disorders, e.g. borderline. The present study investigates the influence of borderline personality organization (BPO) on the outcomes of TKA one year postoperatively. METHODS: We studied 144 patients scheduled for primary TKA before and after the operation using the IPO-16 and the WOMAC for the assessment of knee pain and function. RESULTS: Non-parametric correlations were found between primitive defenses and knee-pain, not function. Linear regression showed prediction of knee pain and knee function by the preoperative WOMAC scores (p<0.01), whereas there was additional prediction of knee-pain by gender (p=0.03) and primitive defenses (p=0.04). DISCUSSION: The results suggest a psychodynamic mechanism of maladaptation after TKA apparently representing the bodily manifestations of fundamental psychic defenses.

Dissociation and Pain-Catastrophizing: Absorptive Detachment as a Higher-Order Factor in Control of Pain-Related Fearful Anticipations Prior to Total Knee Arthroplasty (TKA).

Total Knee Arthroplasty (TKA) is the ultima-ratio therapy for knee-osteoarthritis (OA), which is a paradigmatic condition of chronic pain. A hierarchical organization may explain the reported covariation of pain-catastrophizing (PC) and dissociation, which is a trauma-related psychopathology. This study tests the hypotheses of an overlap and hierarchical organization of the two constructs, PC and dissociation, respectively, using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Childhood Trauma Screener (CTS), a shortened version of the Dissociative Experiences Scale (FDS-20), the Brief Symptom Inventory (BSI-18), the Pain-Catastrophizing Scale (PCS), and the Tampa Scale of Kinesiophobia (TSK) in 93 participants with knee-OA and TKA. Non-parametric correlation, linear regression, and an exploratory factor analysis comprising the PCS and the FDS-20 in aggregate were run. The three factors: 1) PC factor, 2) absorptive detachment, and 3) conversion altogether explained 60% of the variance of the two scales. Dissociative factors were related to childhood trauma, and the PC-factor to knee-pain. The latter was predicted by absorptive detachment, i.e., disrupted perception interfering with the integration of trauma-related experiences possibly including invasive surgery. Absorptive detachment represents negative affectivity and is in control of pain-related anxieties (including PC). The clinical associations of trauma, psychopathology, and maladaptation after TKA may be reflections of this latent hierarchical organization of trauma-related dissociation and PC.

Negative Affect, Type D Personality, Quality of Life, and Dysfunctional Outcomes of Total Knee Arthroplasty.

Background: Type D personality (TDP) is a sign of tapered stress and compromises treatment outcomes including those of hip arthroplasty. The common dissatisfaction with total knee arthroplasty (TKA) is predicted by fear avoidance, pain catastrophizing and emotional lability, with poor quality of life (QoL) reflecting these strains. This study is the first to investigate the influence of TDP on TKA assuming (1) negative affect (NA) to be linked to fear avoidance and to increased dissatisfaction with TKA and (2) the expression of NA and social inhibition (SI) to not be stable over time. Method: We studied 79 participants using the brief symptom inventory-18, the pain-catastrophizing scale, the Tampa scale of kinesiophobia, the SF-36, and the WOMAC preoperatively and 12 months postoperatively. T-test and regression were used to compare the variables of interest between groups built based upon outcome severity. Result: NA at follow-up predicted knee pain (p=0.02) and knee function (p < 0.01) at follow-up. Contrarily, increased expressions of NA/SI at follow-up were predicted by NA (p=0.04) and rumination (p=0.05) at the baseline. Conclusion: The present results suggest the postoperative increase of NA to be linked to dysfunctional outcomes of TKA due to an interaction with pain catastrophizing. Baseline self-rated physical health did not connect to the dissatisfaction with TKA 1-year postoperatively.

[A review on psychosomatic factors affecting the outcome after total knee-arthroplasty (TKA)]. / Übersicht zu psychosomatischen Aspekten des Kniegelenksersatzes (TKA).

A review on psychosomatic factors affecting the outcome after total knee-arthroplasty (TKA) Objectives: In today's ageing Western societies, arthroplasty is a common treatment for endstage osteoarthritis. Despite highly developed implants and surgery, however, this treatment does not always succeed in relieving pain and restoring joint function, i.e., in restoring satisfactory algofunction. Clinicians partly blame psychological factors for this discrepancy, especially in the absence of objective medical complications. METHODS: The present review summarizes previous studies on the role of psychosomatic interactions affecting the course after total knee arthroplasty (TKA). RESULTS: During the perioperative period, patients with TKA suffer from marked psychic distress that is also linked to the postoperative algofunction. CONCLUSIONS: We discuss the theoretical and clinical implications of the findings reviewed.

Management of a cluster of Clostridium difficile infections among patients with osteoarticular infections.

BACKGROUND: Here we describe a cluster of hospital-acquired Clostridium difficile infections (CDI) among 26 patients with osteoarticular infections. The aim of the study was to define the source of C. difficile and to evaluate the impact of general infection control measures and antibiotic stewardship on the incidence of CDI. METHODS: Epidemiological analysis included typing of C. difficile strains and analysis of possible patient to patient transmission. Infection control measures comprised strict isolation of CDI patients, additional hand washings, and intensified environmental cleaning with sporicidal disinfection. In addition an antibiotic stewardship program was implemented in order to prevent the use of CDI high risk antimicrobials such as fluoroquinolones, clindamycin, and cephalosporins. RESULTS: The majority of CDI (n = 15) were caused by C. difficile ribotype 027 (RT027). Most RT027 isolates (n = 9) showed high minimal inhibitory concentrations (MIC) for levofloxacin, clindamycin, and remarkably to rifampicin, which were all used for the treatment of osteoarticular infections. Epidemiological analysis, however, revealed no closer genetic relationship among the majority of RT027 isolates. The incidence of CDI was reduced only when a significant reduction in the use of fluoroquinolones (p = 0.006), third generation cephalosporins (p = 0.015), and clindamycin (p = 0.001) was achieved after implementation of an intensified antibiotic stewardship program which included a systematic review of all antibiotic prescriptions. CONCLUSION: The successful reduction of the CDI incidence demonstrates the importance of antibiotic stewardship programs focused on patients treated for osteoarticular infections.