Irrigation and debridement with chronic antibiotic suppression for the management of infected total knee arthroplasty: A Contemporary Analysis.

AIMS: The results of irrigation and debridement with component retention (IDCR) in the treatment of acutely infected total knee arthroplasties (TKAs) have been variable. The aim of this study was to assess the outcome after IDCR when combined with chronic antibiotic suppression. We also evaluated survivorship free from subsequent infection, removal of the components, and death, as well as the risk factors for failure. PATIENTS AND METHODS: This was a single-centre retrospective review of 134 infected primary TKAs that were treated with IDCR. Infections within four weeks of the procedure were defined as acute postoperative infections, and those occurring more than four weeks after the procedure with symptoms for less than three weeks were defined as acute haematogenous infections. Patients were treated with intravenous antibiotics for four to six weeks, followed by chronic oral antibiotic suppression. Estimates of survival were made using a competing risk analysis. The mean follow-up was five years (2.1 to 13). RESULTS: The infection was an acute postoperative infection in 23 TKAs and an acute haematogenous infection in 111 TKAs. The incidence of subsequent infection was 36% in those with an acute postoperative infection and 33% in those with a haematogenous infection, five years postoperatively (p = 0.40). Age < 60 years increased the risk of subsequent infection (hazard ratio (HR) 2.4; p = 0.009) and removal of the components (HR 2.8; p = 0.007). Infection with a staphylococcal species increased the risk of subsequent infection (HR 3.6; p < 0.001), and removal of the components (HR 3.2; p = 0.002). Musculoskeletal Infection Society host type and local extremity grade, body mass index (BMI), the duration of symptoms, gender, and the presence of a monoblock tibial component had no significant effect on the outcome. CONCLUSION: In a rigorously defined group of acute periprosthetic infections after TKA treated with IDCR and chronic antibiotic suppression, the infection-free survival at five years was 66%. The greatest risk factor for failure was an infection with a staphylococcal species, followed by age of < 60 years. Cite this article: Bone Joint J 2018;100-B:1471-76.

Prior bariatric surgery may decrease the rate of re-operation and revision following total hip arthroplasty.

AIMS: We compared the outcome of total hip arthroplasty (THA) in obese patients who previously underwent bariatric surgery and those who did not, in a matched cohort study. PATIENTS AND METHODS: There were 47 THAs in the bariatric group (42 patients), and 94 THAs in the comparison group (92 patients). The mean age of the patients was 57 years in both groups (24 to 79) and 57% of the patients in both groups were women. The mean time between bariatric surgery and THA was five years (four months to 12 years) in the bariatric group. The mean follow-up after THA was three years (2 to 9). RESULTS: The mean BMI improved from 49.7 kg/m(2) (35 to 75) prior to bariatric surgery to 35.3 kg/m(2) (21 to 49) at the time of THA (p < 0.001). Patients in the comparison group had an increased risk of re-operation (Hazard Ratio (HR) 3.2; 95% confidence intervals (CI) 1.3 to 9.5, p = 0.01) and revision (HR 5.4; 95% CI 1.5 to 34.5, p = 0.01) when compared with the bariatric group. CONCLUSION: Patients had a dramatic improvement in BMI after bariatric surgery and those with prior bariatric surgery had a lower risk of re-operation and revision in the short- and mid-term after a subsequent THA. Larger prospective studies are required before it can be concluded that this extra surgery should be advised in these patients. Cite this article: Bone Joint J 2016;98-B:1180-4.

Epidemiology of periprosthetic femoral fractures in 5417 revision total hip arthroplasties: a 40-year experience.

AIMS: The goals of this study were to define the risk factors, characteristics, and chronology of fractures in 5417 revision total hip arthroplasties (THAs). PATIENTS AND METHODS: From our hospital's prospectively collected database we identified all patients who had undergone a revision THA between 1969 and 2011 which involved the femoral stem. The patients' medical records and radiographs were examined and the relevant data extracted. Post-operative periprosthetic fractures were classified using the Vancouver system. A total of 5417 revision THAs were identified. RESULTS: There were 668 intra-operative fractures, giving an incidence of 12%. Fractures were three times more common with uncemented stems (19%) than with cemented stems (6%) (p < 0.001). The incidence of intra-operative femoral fracture varied by uncemented stem type: fully-coated (20%); proximally-coated (19%); modular fluted tapered (16%) (p < 0.05). Most fractures occurred during the insertion of the femoral component (35%). One-third involved the diaphysis and 26% were of the calcar: 69% were undisplaced. There were 281 post-operative fractures of the femur (20-year probability = 11%). There was no difference in risk for cemented and uncemented stems. Post-operative fractures were more common in men < 70 years (p = 0.02). Periprosthetic fractures occurred earlier after uncemented revision of the femoral component, but later after a cemented revision. The most common fracture type was a Vancouver B1 (31%). Of all post-operative fractures, 24% underwent open reduction and internal fixation and 15% revision arthroplasty. CONCLUSION: In revision THA, intra-operative fractures occurred three times more often with an uncemented stem. Many were undisplaced diaphyseal fractures treated with cerclage fixation. While the risk of post-operative fracture is similar between uncemented and cemented components, they occur at notably different times depending on the type of stem fixation. TAKE HOME MESSAGE: In revision THA, intra-operative periprosthetic femoral fractures occur three times more often with uncemented stems. Many are non-displaced diaphyseal fractures treated with cerclage fixation. While postoperative fracture risks are equivalent between uncemented and cemented components, they occur at notably different time periods based on stem fixation type.

Epidemiology of periprosthetic fracture of the femur in 32 644 primary total hip arthroplasties: a 40-year experience.

AIM AND METHODS: The goals of this study were to define the risk factors, nature, chronology, and treatment strategies adopted for periprosthetic femoral fractures in 32 644 primary total hip arthroplasties (THAs). RESULTS: There were 564 intra-operative fractures (1.7%); 529 during uncemented stem placement (3.0%) and 35 during cemented stem placement (0.23%). Intra-operative fractures were more common in females and patients over 65 years (p < 0.001). The majority occurred during placement of the femoral component (60%), and involved the calcar (69%). There were 557 post-operative fractures (20-year probability: 3.5%; 95% confidence interval (CI) 3.2 to 3.9); 335 fractures after placement of an uncemented stem (20-year probability: 7.7%; 95% CI 6.2 to 9.1) and 222 after placement of a cemented stem (20-year probability: 2.1%; 95% CI 1.8 to 2.5). The probability of a post-operative fracture within 30 days after an uncemented stem was ten times higher than a cemented stem. The most common post-operative fracture type was a Vancouver AG (32%; n = 135), with 67% occurring after a fall. In all, 36% (n = 152) were treated with revision arthroplasty. CONCLUSION: In summary, intra-operative fractures occur 14 times more often with uncemented stems. Female patients over 65 years of age are at highest risk. Post-operative fractures are also most common with uncemented stems, but are independent of age or gender. Cumulative risk of post-operative periprosthetic femur fracture was 3.5% at 20 years. TAKE HOME MESSAGE: Intra-operative fractures occur 14 times more often with uncemented stems, particularly with female patients over 65 years of age, while post-operative fracture risk is independent of age or gender, but still increased with uncemented stems.

Does quality of life impact the decision to pursue stem cell transplantation for elderly patients with advanced MDS?

The factors that influence utilization of reduced-intensity conditioning (RIC) allogeneic hematopoietic stem cell transplantation (HCT) among medically fit older patients with advanced myelodysplastic syndromes (MDS) are largely unknown. The MDS Transplant-Associated Outcomes (MDS-TAO) study is an ongoing prospective observational study at the Dana-Farber Cancer Institute and Massachusetts General Hospital that enrolls transplant-eligible fit patients aged 60-75 years with advanced MDS and follows them through RIC HCT vs non-HCT treatment. In this analysis of 127 patients enrolled from May 2011 to June 2014, we examined the influence of age, gender, cytogenetics, International Prognostic Scoring System (IPSS) category, performance status, distance from HCT center and baseline patient-reported quality of life (QOL) from the EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire) on the likelihood of receiving RIC HCT using competing risk regression modeling. With a median follow-up of 16 months, 44 patients (35%) had undergone RIC HCT. In multivariable analyses, age (hazard ratio (HR) 0.87 per year, 95% confidence interval (CI): 0.81-0.92, P<0.001) and higher IPSS (intermediate-2/high; HR 2.29, 95% CI: 1.25-4.19, P=0.007) were significantly predictive of receipt of RIC HCT; neither global QOL score nor any QOL subscales scores were predictive. These data suggest that baseline patient-reported QOL has little influence on the decision to undergo RIC HCT for older patients with advanced MDS.

Bariatric surgery does not improve outcomes in patients undergoing primary total knee arthroplasty.

Bariatric surgery has been advocated as a means of reducing body mass index (BMI) and the risks associated with total knee arthroplasty (TKA). However, this has not been proved clinically. In order to determine the impact of bariatric surgery on the outcome of TKA, we identified a cohort of 91 TKAs that were performed in patients who had undergone bariatric surgery (bariatric cohort). These were matched with two separate cohorts of patients who had not undergone bariatric surgery. One was matched 1:1 with those with a higher pre-bariatric BMI (high BMI group), and the other was matched 1:2 based on those with a lower pre-TKA BMI (low BMI group). In the bariatric group, the mean BMI before bariatric surgery was 51.1 kg/m(2) (37 to 72), which improved to 37.3 kg/m(2) (24 to 59) at the time of TKA. Patients in the bariatric group had a higher risk of, and worse survival free of, re-operation (hazard ratio (HR) 2.6; 95% confidence interval (CI) 1.2 to 6.2; p = 0.02) compared with the high BMI group. Furthermore, the bariatric group had a higher risk of, and worse survival free of re-operation (HR 2.4; 95% CI 1.2 to 3.3; p = 0.2) and revision (HR 2.2; 95% CI 1.1 to 6.5; p = 0.04) compared with the low BMI group. While bariatric surgery reduced the BMI in our patients, more analysis is needed before recommending bariatric surgery before TKA in obese patients.

Minimising blood loss and transfusion in contemporary hip and knee arthroplasty.

Despite advances in contemporary hip and knee arthroplasty, blood loss continues to be an issue. Though blood transfusion has long been used to treat post-operative anemia, the associated risks are well established. The objective of this article is to present two practical and effective approaches to minimising blood loss and transfusion rates in hip and knee arthroplasty: the use of antifibrinolytic medications such as tranexamic acid and the adoption of more conservative transfusion indications.

Partitioning of marine antifoulants in the marine environment.

The partitioning behaviour of the organic biocides, Irgarol 1051 and diuron and two inorganic biocides (copper and zinc) was investigated using six sediments of differing physico-chemical properties collected from unimpacted sites along the south coast of England. The kinetics of sorption and equilibrium partitioning between the sediments and seawater were investigated over a period of 20 days. Resulting organic carbon/water partition coefficients (log Koc) were related to suspended sediment concentration and ranged from 2.28 to 5.20 for diuron; and from 2.41 to 4.89 for Irgarol 1051. Sediment/water partition coefficients (log Kp) for copper and zinc varied from 2.46 to 5.08 l/kg and from 2.49 to 4.97 l/kg, respectively. Kinetic data indicated that there were significant interactions between the dissolved and particulate phases at the start of the experiments, just after mixing. This is thought to be a result of redistribution of organic carbon between the two phases.

Long term variation in water colour from Yorkshire catchments.

Water colour is a problem in the upland water-gathering grounds of the UK. It has shown considerable variation over recent years and this needs to be put into the longer-term context. In order to do this, factors to convert water colour measured in absorbance units per metre (Au/m) to Hazen units are presented for ten sites in the Yorkshire region using data from August 1997 to June 1998. The conversion factors are site-specific and there is some evidence that they may show seasonal variation. There is also a short-term upward trend in the conversion factor for a number of catchments, which may be related to their recovery following the 1995 drought. Time series of water colour in Hazen from 1980 to 1998 are shown for selected sites. The seasonal variation in colour levels is disrupted at all sites during and following drought periods, notably 1990-1992 and 1995-1998 and, in the case of two sites with long-term colour measurements, the 1975-1976 drought. These periods are followed by enhanced levels of colour and, since the end of the 1995 drought, unprecedented high values have been recorded at some catchments.

Water quality of Scottish rivers: spatial and temporal trends.

The Harmonised Monitoring Scheme (HMS) was initiated in 1974 and represents the best-organised source of temporal and spatial data describing water quality for the major mainland rivers of Scotland, England and Wales. This paper presents the first detailed analysis of HMS data for Scotland, and identifies temporal changes in water quality from 1974 to 1995. From a concomitant analysis of catchment land cover characteristics, water quality indices have been linked with potential 'drivers' of change, influencing both point and diffuse sources. Nitrate concentrations between rivers are highly correlated with the amount of arable land, and relationships exist between grassland cover, orthphosphate-P and suspended solids concentrations. Similarly, urban catchments are highly correlated with ammonium-N, orthophosphate-P and suspended solids. Spatial and temporal trends in water quality for the rivers of Scotland are discussed.

The application of predictive models in the environmental risk assessment of ECONOR.

Environmental risk assessment of products requires information on the physico-chemical properties, persistence and ecotoxicity of the product, its constituents and possible metabolic and degradation products. Experimental investigations are usually required to generate this information and consequently risk assessment can be costly and time consuming. One possible approach to minimising the amount of experimental testing is to supplement experimental data with data predicted using models such as quantitative structure-activity relationships (QSARs). Using these models, information can be generated based primarily on the knowledge of the chemical structure of the substance(s) under investigation. In this study predictive models were used to assess the environmental risk of the veterinary medicine, ECONOR which contains the active ingredient valnemulin. Available experimental data on the properties, degradability and ecotoxicity of valnemulin was supplemented with predicted data. Where possible, experimental data was used to validate the predicted approaches and this indicated that the predictions were accurate. Information on usage, properties and degradability was input to fate models to predict environmental concentrations (PECs) of valnemulin in soil, pore water and groundwater. Comparison of PECs with experimental and predicted ecotoxicity data for valnemulin indicated that that even under 'worst case' scenarios the environmental risk posed by valnemulin was low.

Analytical performance testing of an atrazine immunoassay system.

A rigorous performance evaluation of an enzyme immunoassay (EIA) kit for the determination of atrazine in water samples was undertaken. Eleven individual batches of samples containing standards and spiked drinking waters were analysed and precision, bias and limit of detection were measured using statistical analysis. The technique was shown to be capable of achieving performance criteria (a total standard deviation of less than 5% or 2.5 ng, whichever is the greater) demanded of modern analytical systems and achieved a limit of detection of 9.2 ng l-1. There was no statistically significant bias measured for drinking water samples. Interference tests showed that the atrazine immunoassay was not significantly affected in the pH range 4.0-8.0 or by drinking water matrix components (anions, cations and chlorination by-products), even at their maximum allowable concentrations. There was a small extent of cross-reaction with simazine and atrazine degradation products, but given the persistence of atrazine, through its resistance to hydrolysis, breakdown products are likely to be present at much lower concentrations than the parent compound in drinking water. Simazine may potentially be more problematic, so it would be prudent to monitor a proportion of samples for simazine to determine the extent to which this may be contributing to the 'atrazine' measured in drinking water samples using the EIA kit.

A survey of smoking and quitting patterns among black Americans.

A sample of adult Black policyholders of the nation's largest Black-owned life insurance company was surveyed in 1986 to add to limited data on smoking and quitting patterns among Black Americans, and to provide direction for cessation initiatives targeted to Black smokers. Forty per cent of 2,958 age-eligible policyholders for whom current addresses were available returned a completed questionnaire. Population estimates for smoking status agree closely with national estimates for Blacks age 21-60 years: 50 per cent never-smokers; 36 per cent current smokers; 14 per cent ex-smokers. Current and ex-smokers reported a modal low-rate/high nicotine menthol smoking pattern. Current smokers reported a mean of 3.8 serious quit attempts, a strong desire and intention to quit smoking, and limited past use of effective quit smoking treatments and self-help resources. Correlates of motivation to quit smoking were similar to those found among smokers in the general population, including smoking-related illnesses and medical advice to quit smoking, previous quit attempts, beliefs in smoking-related health harms/quitting benefits, and expected social support for quitting. Methodological limitations and implications for the design of needed Black-focused quit smoking initiatives are discussed.

Nonvolatile organic compounds in treated waters.

Over the past decade much information has been published on the analysis of organics extracted from treated water. Certain of these organics have been shown to be by-products of the chlorination disinfection process and to possess harmful effects at high concentrations. This has resulted in increased interest in alternative disinfection processes, particularly ozonation. The data on organics had been largely obtained by using gas chromatography-mass spectrometry, which is only capable of analyzing, at best, 20% of the organics present in treated water. Research in key areas such as mutagenicity testing of water and characterization of chlorination and ozonation by-products has emphasized the need for techniques suitable for analysis of the remaining nonvolatile organics. Several methods for the isolation of nonvolatile organics have been evaluated and, of these, freeze-drying followed by methanol extraction appears the most suitable. Reverse-phase HPLC was used for separation of the methanol extract, but increased resolution for separation of the complex mixtures present is desirable. In this context, high resolution size exclusion chromatography shows promise. Characterization of separated nonvolatiles is possible by the application of state-of-the-art mass spectrometric techniques. Results obtained by these techniques have shown that the nonvolatile organic fraction of chlorinated drinking water consists of many discrete compounds. Among these, some of the chlorinated compounds are almost certainly by-products of disinfection. Studies of the by-products of ozonation of fulvic and humic acids isolated from river waters have indicated a similar proportion of nonvolatile organics. Further, ozonation can result in the release of compounds that are trapped in the macromolecules.