The use of synthetic mesh in contaminated and infected abdominal wall repairs: challenging the dogma-A long-term prospective clinical trial.

BACKGROUND: Abdominal wall reconstruction in patients presenting with enteric fistulas and mesh infection is challenging. There is a consensus that synthetic mesh must be avoided in infected operations, and the alternatives to using synthetic mesh, such as component separation techniques and biologic mesh, present disappointing results with expressive wound infection and hernia recurrence rates. METHODS: A prospective clinical trial designed to evaluate the short- and long-term outcomes of 40 patients submitted to elective abdominal wall repair with synthetic mesh in the dirty-infected setting, and compared to a cohort of 40 patients submitted to clean ventral hernia repairs. Patients in both groups were submitted to a single-staged repair using onlay polypropylene mesh reinforcement. RESULTS: Groups' characteristics were similar. There were 13 (32.5%) surgical site occurrences in the infected mesh (IM) group, compared to 11 (27.5%) in the clean-control (CC) group, p = 0.626. The 30-day surgical site infection rate was 15% for the IM group vs. 10% for the CC cases, p = 0.499. One patient required a complete mesh removal in each group. The mean overall follow-up was 50.2 ± 14.8 months, with 36 patients in the IM group and 38 clean-controls completing a follow-up of 36 months. There was one hernia recurrence (4.2%) in the IM group and no recurrences in the CC group. CONCLUSION: We demonstrated that using polypropylene mesh in the infected setting presented similar outcomes to clean repairs. The use of synthetic mesh in the onlay position resulted in a safe and durable abdominal wall reconstruction. TRIAL REGISTRATION: Study registered at Plataforma Brasil (plataformabrasil.saude.gov.br), CAAE 30836614.7.0000.0068. Study registered at Clinical Trials (clinicaltrials.gov), Identifier NCT03702153.

Role of Imaging, Tissue Sampling, and Biomarkers for Diagnosis of SSI in Spine Surgery.

In July 2018, the Second International Consensus Meeting on Musculoskeletal Infection convened in Philadelphia, PA to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 15 focused on the use of imaging, tissue sampling, and biomarkers in spine surgery, for which this article provides the recommendations, voting results, and rationales.

How Does Body Mass Index Influence Outcomes in Patients After Lumbar Fusion?

STUDY DESIGN: Retrospective study. OBJECTIVE: The purpose of the present study is to determine how body mass index (BMI) affects patient-reported outcome measurements (PROMs) after lumbar fusions. SUMMARY OF BACKGROUND DATA: Although greater preoperative BMI is known to increase the rates of adverse events after surgery, there is a paucity of literature assessing the influence of BMI on PROMs after lumbar fusion. METHODS: Patients undergoing lumbar fusion surgery between 1 and 3 levels were retrospectively identified. PROMs analyzed were the Short Form-12 Physical Component Score, Mental Component Score, Oswestry Disability Index (ODI), and Visual Analog Scale Back and Leg pain scores. Patients were divided into groups based on preoperative BMI: class 1, BMI <25.0; class 2, BMI 25.0 to 29.9; class 3, BMI 30.0 to 34.9; and class 4, BMI ≥35.0. Absolute PROM scores, the recovery ratio, and the percentage of patients achieving minimum clinically important difference between groups were compared. RESULTS: A total of 54 (14.8%) patients in class 1, 140 (38.2%) in class 2, 109 (29.8%) in class 3, and 63 (17.2%) in class 4 were included. All patients improved after surgery across all outcome measures (P < 0.001) except for class 4 patients, who did not improve in terms of Short Form-12 Mental Component Score scores after surgery (P = 0.276). Preoperative Short Form-12 Physical Component Score (P = 0.002) and Oswestry Disability Index (P < 0.0001) scores were significantly different between BMI groups-with class 4 having worse disability than class 1 and 2. BMI was not a significant predictor for any outcome domain. Overall 30- and 90-day readmission rates were similar between groups, with a higher revision rate in the class 4 group (P = 0.036), due to a higher incidence of postoperative surgical site infections (P = 0.014). CONCLUSION: All patients undergoing short-segment lumbar fusion for degenerative disease improved to a similar degree with respect to PROMs. Those in the highest class of obesity (BMI ≥35.0) were, however, at a greater risk for postoperative surgical site infection. LEVEL OF EVIDENCE: 3.

Gastric duplication cyst in the adult. A case report.

Gastric duplication cyst is a very rare congenital anomaly accounting up to 4-9% of all gastrointestinal tract duplications. It is a quite rare anomaly in adults, the majority of cases are diagnosed in the neonatal period. Gastric duplication cysts are usually asymptomatic in the adult. They are usually discovered incidentally in TAC or RMN, although the best specificity diagnostic test is the echoendoscopy. The best election treatment is the surgical complete extirpation. We describe a case of an adult patient who is diagnosed of the incidentally gastric cyst duplication.

El quiste de duplicación gástrico es una anomalía congénita muy rara que representa entre 4 y 9% de todas las duplicaciones del aparato digestivo. Es una alteración bastante rara en el adulto y la mayoría de los casos se diagnostica en el periodo neonatal. En el adulto suele cursar de forma asintomática y la TC o RMN la descubren de forma incidental, aunque la prueba que la diagnóstica con mayor eficacia es la ecoendoscopia. La extirpación quirúrgica completa de la lesión se considera el tratamiento de elección. Se presenta el caso clínico de una paciente con un quiste de duplicación gástrico diagnosticado de forma incidental.

Strategies for the Prevention and Treatment of Surgical Site Infection in the Lumbar Spine.

Surgical site infection (SSI) following spine surgery can be devastating for both the patient and the surgeon. It leads to significant morbidity and associated health care costs, from readmissions, reoperations, and subsequent poor clinical outcomes. Complications associated with SSI following spine surgery include pseudarthrosis, neurological deterioration, sepsis, and death. Its management can be very challenging. The diagnosis of SSI involves the interpretation of combined clinical, laboratory, and occasionally radiologic findings. Most infections can be treated with an appropriate course of antibiotics and bracing if required. Surgical intervention is usually reserved for infections resistant to medical management, the need for open biopsy/culture, evolving spinal instability or deformity, and neurologic deficit or deterioration. A thorough knowledge of associated risk factors is required and patients should be stratified for risk preoperatively. The multifaceted approach of risk stratification, early diagnosis and effective treatment, is essential for successful prevention and effective treatment and crucial for a satisfactory outcome.

Osteomielitis crónica por Corynebacterium striatum en una adolescente / Chronic osteomyelitis due to Corynebacterium striatum in a female adolescent

A case of a girl with chronic posttraumatic osteomyelitis of the right tibia with microbiological isolation of Bacillus spp. by conventional methods and confirmation by mass spectrometry MALDI-TOF (matrix-assisted laser desorption/ionization time-of-flight mass) of Corynebacterium striatum is presented. Diagnostic methods, clinical manifestations, and resistance pattern of these infections are described.

Se presenta el caso de una adolescente con osteomielitis crónica postraumática de la tibia derecha con aislamiento microbiológico por métodos convencionales de Bacillus spp. y confirmación por espectrometría de masas MALDI-TOF de Corynebacterium striatum, microorganismo considerado generalmente saprófito. Se describen las presentaciones clínicas de estas infecciones descritas en la literatura científica, la necesidad del diagnóstico etiológico por técnicas no convencionales y el patrón de resistencia comúnmente expresado.

[Chronic osteomyelitis due to Corynebacterium striatum in a female adolescent]. / Osteomielitis crónica por Corynebacterium striatum en una adolescente.

A case of a girl with chronic posttraumatic osteomyelitis of the right tibia with microbiological isolation of Bacillus spp. by conventional methods and confirmation by mass spectrometry MALDI-TOF (matrix-assisted laser desorption/ionization time-of-flight mass) of Corynebacterium striatum is presented. Diagnostic methods, clinical manifestations, and resistance pattern of these infections are described.

What Are the Risk Factors and Management Options for Infection After Reconstruction With Massive Bone Allografts?

BACKGROUND: Massive bone allografts have been used for limb salvage of bone tumor resections as an alternative to endoprosthesis, although they have different outcomes and risks. The use of massive bone allografts has been thought to be associated with a high risk for infection, and there is no general consensus on the management of this complication and final outcome. Because infection is such a devastating complication of limb salvage, at times leading to loss of a limb, recognizing the risk factors for infection and the results of treatment is important. QUESTIONS/PURPOSES: The purposes of this study were (1) to analyze the frequency of infection in a group of patients treated with massive bone allografts; (2) to analyze risk factors such as age, sex, affected bone, type of reconstruction, operative room used, primary or revision procedure, length of postoperative antibiotic administration, and use of chemotherapy; and (3) to determine the likelihood that treatment of an infected allograft will result in a successful reconstruction. METHODS: We retrospectively analyzed the records of patients treated with massive bone allografts for a benign or malignant bone tumor or as a revision for a previous limb salvage procedure between 1985 and 2011. During this period, 673 patients were reconstructed with massive bone allografts in long bones, which included 272 osteoarticular, 246 intercalary, and 155 allograft-prosthetic composite reconstructions. Using a chart review, we ascertained the frequency of infection and reoperations after the treatment of infected allografts. Minimum followup was 2 years unless death occurred earlier (mean, 106 months; range, 6-360 months), and no patient was lost to followup. The selected variables were analyzed using multivariate logistic regression to identify risk factors for infection. We analyzed survivorship free of infection as the endpoint. RESULTS: During followup, 60 patients (9%) had a bacterial infection of the allograft with a survivorship free from infection of 92% at 5 years (95% confidence interval [CI], 90%-94%) and 91% at 10 years (95% CI, 89%-93%). We found that tibia allografts (p < 0.001; odds ratio [OR], 3.17; 95% CI, 1.80-5.60), male patients (p < 0.029; OR, 1.92; 95% CI, 1.08-3.49), procedures performed in a conventional operating room (p < 0.002; OR, 3.15; 95% CI, 1.58-6.62), and the use of longer periods of postoperative antibiotics (p < 0.041; OR, 2.25; 95% CI, 1.02-4.88) were patient factors associated with a greater risk of infection. In 11 patients (18%, 11 of 60 infections) the infection was controlled with antibiotics and surgical débridement; however, in 49 patients (82%, 49 of 60 infections), this approach failed, so the allograft was removed and a temporary cement spacer with antibiotic was implanted to control the infection. Forty-one patients subsequently had the spacer removed and were reconstructed after infection control with another bone allograft in 24 and an endoprostheses in 17. Four patients underwent an amputation for infection and four died of disease with the spacer in place. When we analyzed the 41 patients with a second reconstruction, 14 failed with a new infection (34%, 14 of 41 secondary reconstructed) of whom 12 had been reconstructed with bone allograft (29%) and two had endoprostheses (5%). CONCLUSIONS: Management of infections of massive bone allografts with antibiotics and surgical débridement usually resulted in failure. Infections could be treated with resection of the allograft, antibiotics, a temporary cement spacer with antibiotics, and a repeat reconstruction; however, this approach is unlikely to be successful if a second bone allograft is used. Infections are difficult to treat, and more studies are needed, but we propose that it might be preferable to use endoprosthesis reconstruction for salvage of an infected allograft. LEVEL OF EVIDENCE: Level III, therapeutic study.

Osteomielitis por Yokenella regensburgei después de una craneotomía en una paciente inmunocompetente / Osteomyelitis due to Yokenella regensburgei following craniotomy in an immunocompetent patient

Yokenella regensburgei es un bacilo Gram negativo de la familia Enterobacteriaceae, que puede encontrarse en agua de pozos, alimentos y en el tubo digestivo de insectos y reptiles. Aunque se ha aislado de muestras provenientes de seres humanos, pocas veces se ha reportado como causante de infección y, en tales casos, especialmente en pacientes inmunosuprimidos. Se presenta aquí el primer caso de osteomielitis secundaria a una infección por Y. regensburgei en una paciente inmunocompetente después de un procedimiento quirúrgico.

The gram-negative bacillus Yokenella regensburgei (of the Enterobacteriaceae family) can be found in groundwater and foodstuffs, as well as the digestive tracts of insects and reptiles. Although it has been isolated from humans since its original description, it has rarely been reported as a cause of infection, and then, only in immunosuppressed patients. We report the first case of post-surgical secondary osteomyelitis due to Y. regensburgei in an immunocompetent woman who had undergone a craniotomy.

Scintigraphic imaging with technetium-99M-labelled ceftizoxime is a reliable technique for the diagnosis of deep sternal wound infection in rats.

PURPOSE: To evaluate whether scintigraphy with technetium-99m-labeled ceftizoxime ((99m)Tc-CFT) can differentiate mediastinitis from aseptic inflammation associated with sternotomy. METHODS: Twenty female Wistar rats were randomly distributed into four groups: S (control) -partial upper median sternotomy with no treatment; SW (control) - sternotomy and treatment of sternal wounds with bone wax; SB - sternotomy and infection with Staphylococcus aureus; SWB - sternotomy with bone wax treatment and bacterial infection. Scintigraphy with (99m)Tc-CFT was performed eight days after surgery and images were collected 210 and 360 min after infusion of the radiopharmaceutical. RESULTS: No animals exhibited clinical signs of wound infection at the end of the experiment, although histological data verified acute inflammatory response in those experimentally infected with bacteria. Scintigraphic images revealed that tropism of (99m)Tc-CFT to infected sternums was greater than to their non-infected counterparts. Mean counts of radioactivity in bacteria-infected sternal regions (SB and SWB) were significantly higher (p = 0.0007) than those of the respective controls (S and SW). CONCLUSION: Scintigraphy with technetium-99m-labeled ceftizoxime is a method that can potentially detect infection post sternotomy and differentiate from aseptic inflammation in animals experimentally inoculated with S. aureus.

[Osteomyelitis due to Yokenella regensburgei following craniotomy in an immunocompetent patient]. / Osteomielitis por Yokenella regensburgei después de una craneotomía en una paciente inmunocompetente.

The gram-negative bacillus Yokenella regensburgei (of the Enterobacteriaceae family) can be found in groundwater and foodstuffs, as well as the digestive tracts of insects and reptiles. Although it has been isolated from humans since its original description, it has rarely been reported as a cause of infection, and then, only in immunosuppressed patients. We report the first case of post-surgical secondary osteomyelitis due to Y. regensburgei in an immunocompetent woman who had undergone a craniotomy.

Guías para el diagnóstico por imágenes del foco inflamatorio/séptico en pacientes críticos / Diagnostic imaging in intensive care patients

Propósito. Definir, según niveles de evidencia, el rol de los Métodos de Diagnóstico por Imágenes en la localización del foco causante de una infección de origen desconocido, en el paciente. Material y métodos. Se realizó una revisión exhaustiva de la literatura médica disponible. Se elaboraron recomendaciones fundamentales para el diagnóstico por imágenes del foco séptico en pacientes críticos en cada situación causal, analizándolas según el nivel de evidencia. La gradación de la evidencia utilizada es la del Oxford Centre for Evidence-based Medicine. Resultados. La infección nosocomial es la complicación más frecuente del paciente internado en una unidad de cuidados críticos (25 a 33 por ciento), con alta probabilidad de desarrollar sepsis. Son causas muy comunes de infección en estos pacientes: neumonía asociada a ventilación mecánica, sinusitis, colecciones intraabdominales y colecistitis alitiásica. En cada una de estas causas se demuestra la efectividad diagnóstica de la Radiología simple, Ecografía, Tomografía computada y Medicina nuclear y el valor del uso de procedimientos intervensionistas guiados por imágenes. Conclusión: Hay evidencia científica, con diferentes grados de recomendación, sobre el importante papel que juegan los métodos de diagnóstico por imágenes en la detección y terapéutica de focos infecciosos, en el paciente gravemente enfermo. Los estudios deben ser seleccionados por su exactitud diagnóstica, por la capacidad del equipo médico, y por la disponibilidad del recurso, considerando el concepto de riesgo beneficio con la mayor seguridad para el paciente. Evaluados los métodos de elección para cada una de las patologías se proponen algoritmos para examinar al paciente séptico, de acuerdo a la sospecha clínica (AU)

Utilidad del ultrasonido de la pared abdominal en la evaluación de pacientes en diálisis peritoneal ambulatoria contínua / Ultrasonographic evaluation of the catheter tunnel infection in patients urdergoing CAPD

La Diálisis Peritoneal Ambulatoria Contínua (DPAC) representa actualmente un método alternativo para el tratamiento de la IRC. Las complicaciones más frecuentes que pueden surgir durante el tratamiento son las peritonitis de origen primario o asociadas a infecciones del catéter. La principal indicación de la ecografía es la infección del sitio de salida del catéter para determinar la extensión en profundidad del proceso infeccioso. Nuestro objetivo es demostrar la utilidad del ultrasonido (US) en el manejo de pacientes con DPAC. Se efectuaron 42 ecografías en 22 pacientes (11 varones y 11 mujeres) entre noviembre de 1996 y mayo de 2000. Se utilizó un transductor lineal de 7,5 MHz. Una ecografía positiva se considera a la presencia de una colección líquida a lo largo de cualquier segmento del catéter mayor a 2 mm de espesor. Los hallazgos se localizaron en segmentos de acuerdo con la ubicación del proceso, clasificándolos en: a) colecciones superficiales, b) profundas y c) vinculadas con la incisión quirúrgica. Concluimos en que la ecografía es una valiosa herramienta para el manejo de pacientes con infecciones relacionadas con el catéter, ya que en las infecciones superficiales del túnel se realiza tratamiento conservador, mientras que las infecciones profundas, sin respuesta al tratamiento médico, pueden requerir la extracción del catéter (AU)

Use of a bone block graft from the iliac crest with rigid fixation to correct diaphyseal defects of the radius and ulna.

We report our experience with the use of a bone block graft from the iliac crest to correct diaphyseal defects of the forearm bones. The technique was used in 12 patients (ten men and two women, average age 29 years) for defects resulting mainly from either closed or compound fractures, which later developed infection and bone tissue loss. The average dimensions of the graft required to correct the defect was 3.5 x 1.8 cm. The graft application was combined with rigid fixation with an AO 3.5 mm DCP plate, permitting early active motion. The graft incorporated without any additional grafting procedure in ten cases within 17.2 weeks on average. The most frequent complication was infection (four cases), controlled by means of debridement, cleansing and antibiotics. A comparative analysis of the immediate and final radiographs of the graft showed an average 30% loss of bone mass despite integration. We conclude that the technique of bone block grafting to correct diaphyseal defects of the radius or ulna is relatively easy to carry out and has a high success rate.

[Long-term follow-up of 166 surgically treated patients with congenital hip dislocation]. / Langfristige Beobachtung von 166 operierten Patienten mit angeborener Hüftverrenkung.

UNLABELLED: 166 patients with congenital dislocation of the hip, ranging from 10 months to 5 years old, were operated between 1958 and 1971. 140 patients were women (84%) and 26 patients were men (16%). 96 patients had unilateral and 70 patients had bilateral dislocation; that makes a total of 236 dislocated hips. 61 patients with bilateral hip dislocation were operated simultaneously on both hips. All the patients were treated with adductor tenotomy and open reduction through Smith Petersen incision with section or elongation of the psoas tendon. The postoperative immobilization consisted in a period of one month pelvic toecast followed by 2 plaster casts with abduction rod during 3 to 5 months. The postoperatory follow-up ranged from 9 years to 26 years, 2 months; average 14 years, 5 months. The clinical evaluation comprises pain, hip mobility, gait and muscle power. RESULTS: excellent 138 (59%); good 66 (28%); fair 29 (12%); and poor 3 (1%). The radiological evaluation considered: Mose; acetabular femoral head index; Wiberg's CD-angle; cervico-diaphysiary angle and radial quotient. RESULTS: normal 5 (2%); excellent 44 (19%); good 78 (33%); subtotal 54%; fair 90 (38%), and poor 19 (8%). Complications (hips); infections 12 (5%); 3 of them deep ones (1%); residual subluxation 19 (8%); reluxation 1 (0.5%). Isquemic necrosis Grade II of Tönnis 31 (13%); Grade III 2 (1%) and Grade IV 1 (0.5%).