Foot and ankle infections: Debridement, early fixation and rifampicin provide earlier recovery of function and quality of life.

BACKGROUND: Infection after foot and ankle fractures is a major concern for orthopedic surgeons. It is widely believed that final osteosynthesis should be delayed until the infection is cured. However, there is no literature that supports this practice. In addition, the delay impairs patient function and quality of life (QoL). METHODS: In the present study, four cases of ankle infection treated with aggressive debridement, early fixation and antibiofilm antibiotics are described. It is thought that, like other implant related infections, ankle infections can be rapidly treated with the definitive fixation and by curing the infection to make for a fast recovery of QoL and function. RESULTS: The infections were caused by MSSA and Pseudomonas aeruginosa in case 1, MSSA in case 2 and MRSA as well as K. pneumonia in case 3. Case 4 was a culture negative infection. They were susceptible to antibiofilm antibiotics (the gram-negative bacilli susceptible to ciprofloxacin and the gram-positive cocci susceptible to rifampicin). Cases 1, 3 and 4 were treated with a tibio-talo-calcaneal arthrodesis and case 2 was treated with a de-rotational fibular osteotomy and a medial closing wedge supramalleolar osteotomy. All cases improved at a median time of 4 weeks in terms of quality of life (SF-36) and function (AOFAS). At 2-years follow-up, no recurrence of infection was observed in any of the cases. All the cases achieved fusion or osteotomy healing at final follow-up. CONCLUSIONS: Early fixation after debridement combined with antibiofilm antibiotics can be performed in foot and ankle inflections to provide early recovery of QoL and function in patients.

Contamination occurs during ACL graft harvesting and manipulation, but it can be easily eradicated.

PURPOSE: Why anterior cruciate ligament (ACL) autograft soaking in a 5 mg/ml vancomycin solution decreases the rate of infection has not been well-explained. One hypothesis is that grafts can be contaminated during harvesting and vancomycin eradicates the bacteria. The purpose of the present study is to assess how the vancomycin solution acts against ACL graft contamination during graft harvesting and preparation. METHODS: The study was carried out in three university hospitals over a period of 6 months. After sample size calculation, 50 patients were included in the study. Three samples were taken from each ACL graft. Sample 1 was obtained immediately after graft harvesting. After graft manipulation and preparation, the remaining tissue was divided into two parts. The raw sample was denominated sample 2 and sample 3 consisted of the rest of the remaining tissue that had been soaked in the vancomycin solution. All the cultures were incubated at 37 °C with 5% CO2 in agar plates for 7 days (aerobically) or 14 days (anaerobically) and inspected daily for microbial growth. Any bacterial growth and the number of colony forming units were reported. RESULTS: In seven cases (14%), either sample 1 or sample 2 was positive. In five of the cases (10%), only the sample after graft preparation was positive (sample 2). In two cases (4%), sample 1 and sample 2 were positive for the same bacteria. Isolated microorganisms corresponded to coagulase-negative staphylococci (CNS) and Propionibacterium acnes. No bacterial growth was observed in sample 3 (p < 0.001). Thus, none of those seven positive cases (0%) were positive after vancomycin soaking (p < 0.001). CONCLUSION: In the series, ACL graft harvesting and manipulation leads to bacterial contamination in 14% of the cases. This contamination is fully eradicated after soaking in the vancomycin solution in this series. LEVEL OF EVIDENCE: Level II.

C-reactive protein may misdiagnose prosthetic joint infections, particularly chronic and low-grade infections.

BACKGROUND: Periprosthetic tissue cultures, sonication and synovial fluid cultures remain the gold standard for prosthetic joint infection (PJI) diagnosis. However, some 15-20% culture-negative PJI are still reported. Therefore, there is the need for other diagnostic criteria. One point of concern relative to the different definitions of PJI is as to the inclusion of the c-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) as diagnostic criteria for PJI despite them being non-specific inflammatory blood tests. PURPOSE: The purpose of the present study was to determine the relevance of CRP and the ESR in the diagnosis of PJI. METHODS: All PJI with positive cultures over a two-year period in two hospitals were reviewed. The main variables of the present study were the type of prosthesis and the CRP level. More information was recorded in those patients with normal CRP: radiographs, physical examination records and the ESR. RESULTS: Seventy-three patients were included in study. Pre-operative CRP levels were normal (lower than 0.8 mg/dl) in 23 patients, representing 32% of all PJI with positive cultures. Low virulence micro-organisms, 12 coagulase-negative staphylococci and four P. acnes, grew in most of them. They represented 70% of all PJI with normal CRP levels. In addition, 17 patients (23% of all PJI with positive cultures) had a normal ESR, a normal physical examination (they only presented with pain) and no clear loosening was observed in the radiographs. CONCLUSIONS: Per the American Association of Orthopaedic Surgeons (AAOS) guidelines or the Musculoskeletal Infection Society (MSIS), 23% of the patients in the present study with PJI would never have been identified. Blood inflammatory markers such as the CRP level and ESR may not be accurate as diagnostic tools in PJI, particularly to identify low-grade and chronic PJI.

Preoperative antibiotic prophylaxis in prosthetic joint infections: not a concern for intraoperative cultures.

BACKGROUND: Culture negative prosthetic joint infections (PJI) still remain an issue even with the advantages of the new diagnostic tools for PJI. This is why some orthopedic surgeons have reservations relative to the use of preoperative antibiotic prophylaxis when a PJI is suspected. The purpose of the present study was to evaluate the influence of preoperative antibiotic prophylaxis on intraoperative cultures. MATERIAL AND METHODS: An enhanced diagnostic protocol for PJI (Zimmerli criteria) was used for the inclusion criteria in order to collect all PJI that were seen in a university hospital. Patients were prospectively randomized into two groups. The control group received the classical preoperative antibiotic prophylaxis. The study group did not receive prophylaxis prior to surgery. RESULTS: There were 14 patients in each group. They correspond to 13 total hip arthroplasty infections, 12 total knee arthroplasty infections and 3 reverse shoulder prosthesis infections. There were 10 patients in the study group and 10 patients in the control group with at least one positive microbiological criterion (P > 0.05). There were 4 patients in each group with a culture negative PJI (P > 0.05). CONCLUSIONS: Preoperative antibiotic prophylaxis does not affect intraoperative cultures in suspected or confirmed PJI. Therefore it is essential to deliver antibiotic prophylaxis in any patient in which a prosthesis is to be implanted in order to protect the prosthesis from infection.

Epidemiology and new developments in the diagnosis of prosthetic joint infection.

Although prosthetic joint infection (PJI) is a rare event after arthroplasty, it represents a significant complication that is associated with high morbidity, need for complex treatment, and substantial healthcare costs. An accurate and rapid diagnosis of PJI is crucial for treatment success. Current diagnostic methods in PJI are insufficient with 10-30% false-negative cultures. Consequently, there is a need for research and development into new methods aimed at improving diagnostic accuracy and speed of detection. In this article, we review available conventional diagnostic methods for the diagnosis of PJI (laboratory markers, histopathology, synovial fluid and periprosthetic tissue cultures), new diagnostic methods (sonication of implants, specific and multiplex PCR, mass spectrometry) and innovative techniques under development (new laboratory markers, microcalorimetry, electrical method, reverse transcription [RT]-PCR, fluorescence in situ hybridization [FISH], biofilm microscopy, microarray identification, and serological tests). The results of highly sensitive diagnostic techniques with unknown specificity should be interpreted with caution. The organism identified by a new method may represent a real pathogen that was unrecognized by conventional diagnostic methods or contamination during specimen sampling, transportation, or processing. For accurate interpretation, additional studies are needed, which would evaluate the long-term outcome (usually >2 years) with or without antimicrobial treatment. It is expected that new rapid, accurate, and fully automatic diagnostic tests will be developed soon.

Multidrug-resistant tuberculosis presenting as a solitary splenic mass in an immunocompetent patient.

Here, we report a case of multidrug-resistant tuberculosis (TB) presenting as a solitary splenic mass in a 60-year-old immunocompetent patient. Splenic TB is unusual and, when present, is usually associated with disseminated disease in immunocompromised patients. A high level of suspicion is required for diagnosis, and, as occurred in our case, it may be an unexpected finding following surgery. Diagnosis was made by polymerase chain reaction, which showed the presence of Mycobacterium tuberculosis DNA. Interestingly, rifampicin- and isoniazid-resistant genes were detected in our analysis. Splenic TB diagnosis and treatment are reviewed.

Non-O1 Vibrio cholerae inguinal skin and soft tissue infection with bullous skin lesions in a patient with a penis squamous cell carcinoma.

Vibrio spp. is a pathogen rarely isolated in cancer patients, and in most cases it is associated with haematological diseases. Cutaneous manifestations of this organism are even rarer. We report a case of Non-O1 Vibrio cholerae inguinal skin and soft tissue infection presenting bullous skin lesions in a young type II diabetic patient with a penis squamous cell carcinoma having a seawater exposure history.