Postinjury multiple organ failure in polytrauma: more frequent and potentially less deadly with less crystalloid.

BACKGROUND: Recently, retrospective registry-based studies have reported the decreasing incidence and increasing mortality of postinjury multiple organ failure (MOF). We aimed to describe the current epidemiology of MOF following the introduction of haemostatic resuscitation. METHODS: A 10-year prospective cohort study was undertaken at a Level-1 Trauma Centre-based ending in December 2015. Inclusion criteria age ≥ 16 years, Injury Severity Score (ISS) > 15, Abbreviated Injury Scale (AIS) Head < 3 and survived > 48 h. Demographics, physiological and shock resuscitation parameters were collected. The primary outcome was MOF defined by a Denver Score > 3. SECONDARY OUTCOMES: intensive care unit length of stay (ICU LOS), ventilation days and mortality. RESULTS: Three hundred and forty-seven patients met inclusion criteria (age 48 ± 20; ISS 30 ± 11, 248 (71%) were males and 23 (6.6%) patients died. The 74 (21%) MOF patients (maximum Denver Score: 5.5 ± 1.8; Duration; 5.6 ± 5.8 days) had higher ISS (32 ± 11 versus 29 ± 11) and were older (54 ± 19 versus 46 ± 20 years) than non-MOF patients. Mean daily Denver scores adjusted for age, sex, MOF and ISS did not change over time. Crystalloid usage decreased over the 10-year period (p value < 0.01) and PRBC increased (p value < 0.01). Baseline cumulative incidence of MOF at 28 days was 9% and competing risk analyses showed that incidence of MOF increased over time (subdistribution hazard ratio 1.14, 95% CI 1.04 to 1.23, p value < 0.01). Mortality risk showed no temporal change. ICU LOS increased over time (subdistribution hazard ratio 0.95, 95% CI 0.92 to 0.98, p value < 0.01). Ventilator days increased over time (subdistribution hazard ratio 0.94, 95% CI 0.9 to 0.97, p value < 0.01). CONCLUSION: The epidemiology of MOF continues to evolve. Our prospective cohort suggests an ageing population with increasing incidence of MOF, particularly in males, with little changes in injury or shock parameters, who are being resuscitated with less crystalloids, stay longer on ICU without improvement in survival.

A desirability of outcome ranking (DOOR) for periprosthetic joint infection - a Delphi analysis.

Background: Treatment outcomes in studies on prosthetic joint infection are generally assessed using a dichotomous outcome relating to treatment success or failure. These outcome measures neither include patient-centred outcome measures including joint function and quality of life, nor do they account for adverse effects of treatment. A desirability of outcome ranking (DOOR) measure can include these factors and has previously been proposed and validated for other serious infections. We aimed to develop a novel DOOR for prosthetic joint infections (PJIs). Methods: The Delphi method was used to develop a DOOR for PJI research. An international working group of 18 clinicians (orthopaedic surgeons and infectious disease specialists) completed the Delphi process. The final DOOR comprised the dimensions established to be most important by consensus with > 75  % of participant agreement. Results: The consensus DOOR comprised four main dimensions. The primary dimension was patient-reported joint function. The secondary dimensions were infection cure and mortality. The final dimension of quality of life was selected as a tie-breaker. Discussion: A desirability of outcome ranking for periprosthetic joint infection has been proposed. It focuses on patient-centric outcome measures of joint function, cure and quality of life. This DOOR provides a multidimensional assessment to comprehensively rank outcomes when comparing treatments for prosthetic joint infection.

Open Debridement is Superior to Arthroscopic Debridement for the Infected Total Knee Arthroplasty.

BACKGROUND: Acutely infected total knee arthroplasty (TKA) is commonly treated with debridement, antibiotics, and implant retention (DAIR). There are no direct comparative studies to determine whether debridement should be performed open or arthroscopically for infected TKA. The aim of this study is to compare the outcomes of open vs arthroscopic debridement of infected TKAs. METHODS: All patients at a university teaching hospital with an infected TKA treated with DAIR between 2002 and 2017 were analyzed. The primary outcome was successful treatment defined using international consensus criteria. Secondary outcomes included antibiotic suppression, prosthesis retention, mortality, postoperative range of motion, and length of stay. Clinical, laboratory, surgical, and antibiotic treatment data were collected. Propensity score matching was performed to control for selection bias. RESULTS: DAIR was used in 141 patients. The initial DAIR procedure was open for 96 patients and arthroscopic for 45 patients. The success rate was 29% greater for open DAIR (45% open vs 16% arthroscopic; P < .001). After propensity score matching, this benefit was estimated to be 36% (95% confidence interval, 22%-50%; P < .0001). When those on antibiotic suppression were also considered successfully treated, open DAIR was still superior by 34% (95% confidence interval, 18%-51%; P < .0001). CONCLUSION: For infected TKA, open DAIR is a more successful index procedure compared with arthroscopic DAIR. Open DAIR remained more successful even when antibiotic suppression is considered successful treatment.

Outcomes of paediatric septic arthritis of the hip and knee at 1-20 years in an Australian urban centre.

BACKGROUND: Septic arthritis in children is a joint threatening condition with potentially severe consequences; however, long-term outcome data is lacking. This study aims to determine 1-20-year outcomes following septic arthritis of hip and knee joints in children in an Australian population. METHODS: All paediatric patients with septic arthritis of the hip or knee from 1995 to 2015 treated at our Australian institution were retrospectively assessed. Clinical features, treatment and investigation results were recorded. Long-term functional and radiological outcomes, infection recurrence and reoperation rate at final follow-up (mean 8.5 years, range 1.0-20.3; hip versus mean 7.7 years, range 1.1-20.3; knee) were recorded. RESULTS: Sixty-four patients (37 hip, 27 knee) met inclusion criteria. Fifty-two patients (81.3%) attended follow-up. No mortalities or late infection recurrence occurred. Three patients (1; hip versus 2; knee) had a later operation. Median Oxford scores were excellent (48; hip versus 48; knee); however, a significant proportion had a degree of impaired function (31.3%; hip versus 42.1%; knee). Radiological outcomes were excellent in knees more commonly than hips (81.3%; hip versus 100%; knee). CONCLUSIONS: Outcomes at 1-20 years for the majority of patients following septic arthritis of the hip and knee are excellent with early joint irrigation and intravenous antibiotics. Our results demonstrate a significant proportion of patients following septic hip arthritis have mild to moderately poor functional and radiological outcomes. Those with septic knee arthritis demonstrated universally excellent radiological outcomes and mild functional impairment in approximately one-third of cases.

Open Compared with Arthroscopic Treatment of Acute Septic Arthritis of the Native Knee.

BACKGROUND: Acute native knee septic arthritis is a joint-threatening emergency. Operative treatments by open or arthroscopic methods are available to surgeons. To our knowledge, the literature to date has primarily consisted of case series and no large study has yet compared these methods. The aim of this study was to compare open and arthroscopic treatment for acute native knee septic arthritis. METHODS: All adult patients with acute native knee septic arthritis treated at our institution with either open or arthroscopic irrigation from 2000 to 2015 were retrospectively evaluated. The clinical findings, laboratory evidence, arthrocentesis and microbiology results, knee radiographs, and outcomes were compared. RESULTS: There were 161 patients (166 knees) with acute native knee septic arthritis treated between 2000 and 2015. Initially, 123 knees were treated by arthroscopic irrigation and 43 knees were treated by open irrigation; however, 71% in the open treatment group required repeat irrigation compared with 50% in the arthroscopic treatment group. The superiority of an arthroscopic procedure persisted after adjustment for potential confounders by multivariable analysis, with an odds ratio of 2.56 (95% confidence interval, 1.1 to 5.9; p = 0.027). After 3 irrigation procedures, the cumulative success rate was 97% in the arthroscopic treatment group and 83% in the open treatment group (p = 0.011). The total number of irrigation procedures required was fewer in the arthroscopic treatment group (p = 0.010). In the arthroscopic treatment group, the mean postoperative range of motion was greater (p = 0.016) and there was a trend toward a shorter median length of stay (p = 0.088). CONCLUSIONS: Arthroscopic treatment for acute native knee septic arthritis was a more successful index procedure and required fewer total irrigation procedures compared with open treatment. Long-term postoperative range of motion was significantly greater following arthroscopic treatment. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of postinjury multiple-organ failure scoring systems: Denver versus Sequential Organ Failure Assessment.

BACKGROUND: The Denver and Sequential Organ Failure Assessment (SOFA) scores have been used widely to describe the epidemiology of postinjury multiple-organ failure; however, differences in these scores make it difficult to compare incidence, duration, and mortality of multiple-organ failure. The study aim was to compare the performance of the Denver and SOFA scores with respect to the outcomes of mortality, intensive care unit length of stay (ICU LOS), and ventilator days. METHODS: A 60-month prospective epidemiologic study was undertaken at an Australian Level I trauma center. Data were collected on trauma patients that met inclusion criteria (ICU admission, Injury Severity Score [ISS] > 15, age > 18 years, head Abbreviated Injury Scale [AIS] score < 3, survival for >48 hours). Demographics, ISS, physiologic parameters, SOFA and Denver scores, and outcome data were prospectively collected. Sensitivity/specificity and receiver operating characteristic curve were calculated for both scores. Analysis was also completed for a Day 3 postinjury SOFA and Denver score. RESULTS: A total of 140 patients met the inclusion criteria (mean [SD] age, 47 [21] years; ISS, 30; male, 69%; mortality rate, 6%; mean [SD] ICU LOS, 9 [7] days; mean [SD] ventilation period, 6 [7] days). There was no difference in the score performance predicting mortality. Day 3 SOFA score of 4 or greater outperformed the Denver score of greater than 3 when predicting ICU LOS and ventilator days (area under the curve, 0.83 vs. 0.69, 0.86 vs. 0.73, respectively). The SOFA score was more sensitive and the Denver score was more specific when predicting mortality, ICU LOS, and ventilator days. CONCLUSION: Both scores had similar performance predicting mortality; however, the Day 3 SOFA score outperforms the Denver score when predicting ICU LOS and ventilator days. Either score could be superior based on whether one is seeking to optimize specificity or sensitivity. It is important to note that these findings are in a non-head-injured population and that there are practical difficulties using the SOFA in head-injured patients. LEVEL OF EVIDENCE: Diagnostic study, level II.

Changes in the epidemiology and prediction of multiple-organ failure after injury.

BACKGROUND: The epidemiology of multiple-organ failure (MOF) after injury has been changing, questioning the validity of previously described prediction models. This study aimed to describe the current epidemiology of MOF. The secondary aim was development of a prediction model that could be used for early identification of patients at risk of MOF. METHODS: A 60-month prospective epidemiologic study was undertaken at an Australian Level I trauma center. Data were collected on trauma patients that met inclusion criteria (intensive care unit [ICU] admission; Injury Severity Score [ISS] > 15; age > 18 years, head Abbreviated Injury Scale [AIS] score < 3; and survival for >48 hours). Demographics, injury severity (ISS), physiologic parameters, MOF status based on the Denver score, and outcome data were prospectively collected. Univariate analysis and multivariate logistic modeling were performed; p < 0.05 was considered significant. Data are presented as percentage or mean (SD). RESULTS: A total of 140 patients met the inclusion criteria (age, 47 [21] years; ISS, 30 [11]; male, 69%), 21 patients (15%) developed MOF, and MOF associated mortality was 24% versus non-MOF mortality rate of 3%. Patients who developed MOF had longer ICU stays (19 [7] vs. 7 [5], p < 0.01) and had more ventilator days (18 [9] vs. 4 [4], p < 0.01). Prediction models were generated at two time points as follows: admission and 24 hours after injury. At admission, age (>65 years) and admission platelet count (<150 × 10(9)/L) were significant predictors of MOF; at 24 hours after injury, MOF was predicted by age more than 65 years, admission platelet count less than 150 × 10(9)/L, maximum creatinine of greater than 150 × 10(9)/L and minimum bilirubin of greater than 10 × 10(9)/L. Shock parameters and injury severity did not predict MOF. CONCLUSION: The incidence of MOF (15%) is lower than reported 15 years ago; MOF remains a major cause of ICU resource use and late mortality after injury. The independent predictors of MOF have fundamentally changed, likely owing to improvements in resuscitation and critical care. Current predictors are universally available at admission and 24 hours. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Epidemiology of post-injury multiple organ failure in an Australian trauma system.

BACKGROUND: The epidemiology of post-injury multiple organ failure (MOF) is reported internationally to have gone through changes over the last 15 years. The purpose of this study is to describe the epidemiology of post-injury MOF in Australia. METHODS: A 12-month prospective epidemiological study was performed at the John Hunter Hospital (Level-1 Trauma Centre). Demographics, injury severity (ISS), physiological parameters, MOF status and outcome data were prospectively collected on all trauma patients who met inclusion criteria (ICU admission; ISS > 15; age > 18, head Abbreviated Injury Scale (AIS) <3 and survival >48 h). MOF was prospectively defined by the Denver MOF score greater than 3 points. Data are presented as % or Mean +/- SEM. Univariate statistical comparison was performed (Student t-test, Chi2 test), P < 0.05 was considered significant. RESULTS: Twenty-nine patients met inclusion criteria (Age 40 +/- 4, ISS 29 +/- 3, Male 62%), five patients developed MOF. The incidence of MOF among trauma patients admitted to ICU was 2% (5/204) and 17% (5/29) in the high-risk cohort. The maximum average MOF score was 6.3 +/- 1, with the average duration of MOF 5 +/- 2 days. Two patients had respiratory and cardiac failure, two patients had failure of respiratory, cardiac and hepatic systems, while one patient had failure of respiratory, hepatic and renal systems. One MOF patient died, all non MOF patients survived. MOF patients had longer ICU stays (20 +/- 4 versus 7 +/- 0.8 P = 0.01), tended to be older (60 +/- 11 versus 35 +/- 4 p = 0.07). None of the previously described independent predictors (ISS, base deficit, lactate, transfusions) were different when the MOF patients were compared with the non-MOF patients. CONCLUSION: The incidence of MOF in Australia is consistent with the international data. In Australia MOF continues to cause significant late mortality and morbidity in trauma patients. MOF patients have longer ICU stay than high-risk non MOF patients, and use significant resources. Our preliminary data challenges the timeliness of the 10-year-old independent predictors of post-injury MOF. The epidemiology, the clinical presentation and the independent predictors of post-injury MOF require larger scale reassessment for the Australian context.