Reducing bacterial adhesion to titanium surfaces using low intensity alternating electrical pulses.

BACKGROUND: Orthopedic implant-related infection remains one of the most serious complications after orthopedic surgery. In recent years, there has been an increased scientific interest to improve prevention and treatment strategies. However, many of these strategies have focused on chemical measures. AIM: To analyze the effect of alternating current electrical fields on bacterial adherence to titanium surfaces. METHODS: Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) were exposed to 6.5 V electrical currents at different frequencies: 0.5 Hz, 0.1 Hz, and 0.05 Hz. After exposure, a bacterial count was then performed and compared to the control model. Other variables registered included the presence of electrocoagulation of the medium, electrode oxidation and/or corrosion, and changes in pH of the medium. RESULTS: The most effective electrical model for reducing S. aureus adhesion was 6.5 V alternating current at 0.05 Hz achieving a 90% adhesion reduction rate. For E. coli, the 0.05 Hz frequency model also showed the most effective results with a 53% adhesion reduction rate, although these were significantly lower than S. aureus. Notable adhesion reduction rates were observed for S. aureus and E.coli in the studied conditions. However, the presence of electrode oxidation makes us presume these conditions are not optimal for in vivo use. CONCLUSION: Although our findings suggest electrical currents may be useful in preventing bacterial adhesion to metal surfaces, further research using other electrical conditions must be examined to consider their use for in vivo trials.

Role of joint aspiration before re-implantation in patients with a cement spacer in place.

BACKGROUND: The usefulness of a mandatory joint aspiration before re-implantation in patients with a cement spacer already in place is unclear. AIM: To evaluate the role of culturing synovial fluid obtained by joint aspiration before re-implantation in patients who underwent a two-stage septic revision. METHODS: A retrospective observational study was conducted, including patients that underwent a two-stage septic revision (hip or knee) from 2010 to 2017. After the first stage revision and according to intraoperative culture results, all patients were treated with an antibiotic protocol for 6-8 wk. Following 2 wk without antibiotics, a culture of synovial fluid was obtained. The results of these cultures were recorded and compared with cultures obtained during re-implantation surgery. RESULTS: Forty-one patients (20 hip and 21 knee spacers) were included in the final analysis. In 39 cases, the culture of synovial fluid was negative, while in the remaining 2 cases (knee spacers) no analysis was possible due to dry tap. In 5 of the patients, two or more intraoperative cultures taken during the re-implantation surgery were positive. CONCLUSION: We found no evidence to support mandatory joint aspiration before re-implantation in patients with a cement spacer in place.

"In vitro" evaluation of bacterial biofilm formation on different cerclage systems.

Cerclage wiring may be used for fracture fixation or osteotomy stabilization in revision arthroplasty. There is a lack of evidence regarding the potential risk of bacterial colonization for the different types of cerclages. The objective of our research is to study the adhesion and biofilm formation of S. epidermidis, S. aureus, and P. aeruginosa on two different cerclage cable models, comparing a polymer cable and a stainless steel metal cable. A two-cm cerclage piece of each material was submerged in 2 mL of tryptic soy broth (TSB) inoculated with 10 µL of a 0.5 McFarland bacterial culture, and incubated at 37°C during 2 h for adhesion and 48 h for biofilm formation. The cerclages were washed with 1xPBS and sonicated in a new culture medium. Aliquots of several dilutions of each sonicated culture were spread in TSB agar and incubated at 37°C for 24 h. The number of colonies was counted. The colony-forming units per ml (CFU/mL) and the percentage of reduction were calculated. Experiments were triplicated. For P. aeruginosa, a statistically significant reduction in biofilm formation was found on the polymer cerclage cable, compared to the metal cerclage cable. Reductions of 59% and 88%, after 2 h and 48 h, respectively, were observed. For S. epidermis and S. aureus, there was a trend towards lower bacterial adhesion and biofilm formation for the polymer cerclage cable. In summary, these results demonstrate that the braided polymer cerclage cable may be less prone to bacterial adherence and biofilm formation compared to the braided metal cerclage cable.

Risk Factors of DAIR Failure and Validation of the KLIC Score: A Multicenter Study of Four Hundred Fifty-Five Patients.

Background: Debridement, antibiotic agents, and implant retention (DAIR) is a currently accepted approach for the treatment of early prosthetic joint infections (PJI). The success of a DAIR procedure has shown variable results throughout the published literature. Scoring systems such as the Kidney, Liver, Index surgery, Cemented prosthesis, and C-reactive protein value (KLIC) score for the selection of patients that are likely to benefit from DAIR have proved to be helpful in decision making. Our study aims to further validate the KLIC score using a large external multicentric cohort and to evaluate other risk factors for failure. Patients and Methods: A retrospective analysis of patients with an early acute PJI who were treated with DAIR and recorded in a database of eight Spanish university hospitals was performed. According to pre-operative variables of the KLIC study, patients were categorized into five groups: group A, ≤2 points; group B, 2.5-3.5 points; group C, 4-5 points; group D, 5.5-6.5 points; and group E, ≥7 points. Failure rates were compared between groups at 60 days and after 60 days of DAIR. Further variables for risk of failure were also analyzed. Results: A total of 455 patients with early acute PJI were included in the analyses. At 60 days, patients presenting with pre-operative elevated C-reactive protein serum levels, Staphylococcus aureus, and polymicrobial infections were associated with failure. Failure rates recorded were 12% for group A (n = 210), 18% for group B (n = 83), 26% for group C (n = 89), 24% for group D (n = 66), and 0% for group E (n = 7). Univariable analysis between consecutive groups of the KLIC score showed no differences for failure before 60 days of the DAIR procedure. Scheduled surgery and having the procedure performed by a specialized unit were also identified as important factors for DAIR success. Conclusions: Our results suggest the KLIC score was not useful for predicting failure in our cohort. Furthermore, our results indicate a specialized unit should conduct DAIR procedures.

A 3D-Printed Model of a Titanium Custom-Made Talus for the Treatment of a Chronic Infection of the Ankle.

Osteoarticular infections are challenging and difficult to treat. The use of innovative technologies like 3D printing already employed in other types of surgeries and pathologies can suppose a great asset to tackle the problem and improve functional results. We present a case of an osteoarticular infection of an ankle treated with a custom-made titanium talus made with 3D metal printing technology: A 63-year-old patient, with chronic infection of the ankle. A 2-staged surgery was performed, with a hand-made cement spacer used during the first stage and the implantation of a custom-made titanium talus with an arthrodesis nail in the second stage. After a 2-year follow-up, a good clinical evolution was achieved, with no signs of reactivation of the infection, no pain, good skin condition and optimal functionality: functional gait pattern without pain and any external aids.

Role of bacterial colonisation of vancomycin-gentamicin spacers in two-stage arthroplasty revision surgery: the usefulness of spacer sonication.

PURPOSE: In two-stage replacements for septic loosening, some studies have suggested an association between bacterial colonisation of spacers and a higher number of complications after implantation of the definitive prosthesis. Our study aimed to determine the reoperation rate of patients undergoing two-stage revision surgery according to the culture results of spacer sonication. METHODS: A retrospective observational study was conducted in which hip or knee spacers implanted at our institution with a diagnosis of periprosthetic joint infection from 2010 to 2018 were analysed. Patients were grouped into three categories: A. Patients with positive spacer sonication fluid culture, with or without positive cultures of the rest of the samples. B. Patients with negative spacer sonication culture and negative cultures of the rest of intraoperative samples. C. Patients with negative spacer sonication culture but positive cultures of the rest of intraoperative samples. RESULTS: A total of 45 spacers were analysed: 10 were included in group A, 24 in group B and 11 in group C. The reoperation rate during the first year after the 2-stage revision surgery was 20%, 29.2% and 54.5% for each group, respectively, due to an infection in 10%, 20.8% and 45.5%. Spacers were colonised in all cases by low virulent micro-organisms. CONCLUSION: In our study, bacterial colonisation of the spacer is not associated with a higher rate of reoperation. The group of patients with positive intraoperative cultures during the second-stage had the highest reoperation rate.

Local infiltration analgesia does not have benefits in fast-track hip arthroplasty programmes: a double-blind, randomised, placebo-controlled, clinical trial.

BACKGROUND: Multimodal analgesia regimes including local infiltration analgesia (LIA) have been successfully applied in fast-track hip arthroplasty programmes. LIA's contribution to the analgesic effect in hip arthroplasty has been questioned. Our study sought to determine the analgesic efficacy of LIA in THA surgery in a fast-track programme. METHODS: Patients diagnosed with hip osteoarthritis scheduled for arthroplasty were randomised to receive LIA (120 ml ropivacaine 0.2% plus epinephrine 0.5 µ/ml) or saline as a part of a multimodal analgesia regime. The surgical team, the nursing staff, and patients were all blinded regarding patient allocation throughout the study. The primary outcome was pain assessed as a continuous variable using the visual analogue scale (VAS) at 4, 8, 24 and 48 hours postoperatively. Secondary outcomes included the amount of analgesic rescue consumption, complications and length of hospital stay. RESULTS: A total of 63 patients were interviewed and agreed to participate in the study. No statistically significant differences were found between groups for pain measurements at 4, 8, 12, 24 and 48 hours after surgery. There were also no differences in rescue medication consumption, complications, or length of stay. CONCLUSIONS: Our results suggest LIA (ropivacaine plus epinephrine, single shot) has no effect in pain management and has not shown benefits for early ambulation in primary THA surgery. Further research is needed to establish the optimal multimodal analgesia regime for THA fast-track programmes. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov (NCT03513276).

Early Radiographic Union Score for Hip Is Predictive of Femoral Neck Fracture Complications Within 2 Years.

OBJECTIVES: To determine if the Radiographic Union Score for Hip (RUSH) measured at 3 and 6 months after femoral neck fracture were predictive of reoperation for infection, nonunion, delayed union, avascular necrosis, or implant failure within 24 months of initial surgery. DESIGN: Secondary analysis of a randomized controlled trial. Logistic regression was performed to investigate associations between lower RUSH and reoperation. Results were reported as odds ratios (OR), 95% confidence intervals (CIs), and associated P values. All tests were 2 tailed with alpha = 0.05. SETTING: Eighty-one clinical sites across 8 countries. PATIENTS/PARTICIPANTS: Data from 734 of the clinical trial participants with radiographs at 3 and 6 months after fracture fixation were included. INTERVENTION: A reviewer blinded to patients' outcomes independently assigned a RUSH at each follow-up time point. MAIN OUTCOME MEASURES: Revision surgery rate related to intervention. RESULTS: Lower RUSH at 3 and 6 months were associated with increased odds of reoperation within 24 months of fracture fixation. For every 2-point decrease in RUSH at 3 months, there was a 16% increase in the odds of a patient experiencing a re-operation (OR, 1.16; 95% CI, 1.10-1.22; P < 0.0001). A similar association was observed at the 6-month assessment for every 2-point decrease (OR = 1.05; 95% CI, 1.01-1.09; P = 0.005). CONCLUSIONS: Decreased radiographic healing as early as 3 months post fracture fixation is associated with developing patient important femoral neck fracture reoperations. This relationship may guide early treatment decisions, suggesting that 3- and 6-month RUSH are a useful surrogate measure of reoperations within 24 months of fracture fixation. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Evaluación de las propiedades psicométricas de la Escala de Detección de la Soledad Existencial en pacientes con enfermedades avanzadas / Assessment of the psychometric properties of the Scale of Detection of Existential Loneliness in patients with advanced diseases

Objetivo: Analizar las propiedades psicométricas y la utilidad clínica de la Escala de Soledad Existencial (EDSOL) en enfermos hospitalizados con enfermedad avanzada. Método: Para determinar las propiedades psicométricas de la escala, se administró la escala EDSOL junto con otros instrumentos a 103 pacientes adultos con enfermedades avanzadas ingresados en 5 unidades de cuidados paliativos de hospitales catalanes. Resultados: La escala presenta una excelente fiabilidad medida a través del alfa de Cronbach (0,902) y una adecuada estabilidad temporal (r=0,71). La escala mostró correlaciones positivas y significativas con ansiedad y depresión de la escala HADS y con la suma total de la misma, así como con la valoración clínica psicológica (p<0,01). A través del análisis estadístico de las curvas ROC se determinó que la escala presentaba una sensibilidad del 79,8% y una especificidad del 74,6% y se sugiere que el punto de corte para la detección de la EDSOL sea una puntuación de 5. Conclusiones: La EDSOL presenta unas buenas propiedades psicométricas, es sencilla, breve, fiable y fácil de administrar. Consideramos que es una escala útil para detectar la presencia de soledad existencial en enfermos hospitalizados que padecen enfermedades avanzadas

Aim: To analyze the psychometric properties and the clinical utility of the Scale of Existential Loneliness (EDSOL) in hospitalized patients with advanced disease. Method: To determine the psychometric properties of the scale, the EDSOL scale was administered along with other instruments to 103 adult patients with advanced diseases admitted to 5 palliative care units of Catalan hospitals. Results: The scale presents an excellent reliability measured through Cronbach’s alpha (0.902) and adequate temporal stability (r = 0.71). The scale showed positive and significant correlations with anxiety and depression of the HADS scale and with the overall score of HADS, as well as with the clinical psychological assessment (p <0.01). Through the statistical analysis of the ROC curves, it was determined that the scale had a sensitivity of 79.8% and a specificity of 74.6% and it is suggested that the cut-off point for the detection of EDSOL be a score of 5. Conclusions: The EDSOL scale has good psychometric properties, is simple, brief, reliable and easy to administer. We consider that is an useful scale to detect the presence of existential loneliness in hospitalized patients suffering from advanced diseases

Subcutaneous Radiographic Measurement: A Marker to Evaluate Surgical Site Infection Risk in Elderly Hip Fracture Patients.

Objectives: Obesity is a documented comorbidity that is prevalent in the elderly population and a known predictor for surgical site infection (SSI). Body mass index is a convenient method to classify obesity, but it fails to account for fat distribution. The objective of our study was to evaluate the association between surgical site infection and a subcutaneous radiographic measurement (SRM) in elderly hip fracture patients. Materials and Methods: A retrospective case-control study was conducted to compare SRMs at the hip in patients diagnosed with surgical site infection after hip fracture surgery with patients that were not diagnosed with surgical site infection. Each case was matched to two controls. An SRM was defined as the distance from the tip of the greater trochanter to the skin following a perpendicular line to the femoral diaphysis in anteroposterior hip radiographs. Clinical diagnosis of acute surgical site infection was based on Tsukayama criteria. Results: Patients with an SRM greater than 6.27cm had a 7-fold increase in the odds of surgical site infection (OR=7.42, 95% Confidence Interval (CI)=3.01-18.28, p<0.001) compared to those with smaller measurements. The odds ratio (OR) for infection of patients with an ASA score of 3 was 15.82(95% CI=5.11-48.9, p-value<0.001) A statistically significant difference between cases and controls was also found when SRM at the hip was analyzed as a continuous variable. Patients with an infection had a 2.24cm (95% CI=1.59 - 2.90; p<0.001) greater mean SRM. Conclusion: Results of our study suggest an association between the SRM at the hip and the risk of SSI in elderly patients with surgically treated hip fractures. SRM may be a helpful tool for evaluating the risk of SSI in elderly hip fracture patients.

Cerclage wiring and intramedullary nailing, a helpful and safe option specially in proximal fractures. A multicentric study.

PURPOSE: Antegrade intramedullary nailing is an alternative for humeral shaft fracture treatment. This surgical technique can be especially demanding in some fracture patterns, leading to problems like malunion and non-union. The purpose of our study is to demonstrate that the use of a nail with cerclage wires could be a safe procedure that facilitate reduction, specially in fractures with abduction of the proximal fragment. MATERIALS AND METHODS: Fifty-six patients were included, from January 2007 to March 2016. In this cohort forty-two patients were females and eighteen males; mean age was sixty-seven (32-89). The fractures were reduced using a cerclage wire through a small lateral or anterior approach, then, antegrade intramedullary nailing was performed. Fracture healing was established by clinical and radiographic evaluation. Shoulder function was assessed using the Constant Score. RESULTS: Fifty-three patients healed (94.6%) adequately. Two patients developed a non-union (3.5%). One patient developed an infection (1.8%). Transient radial nerve palsy was observed in two patients (3.5%). The mean Constant Score at the end of the study was 70 points (range from 34 to 98 points). CONCLUSIONS: Surgical treatment of humeral shaft fractures with cerclage wire and intramedullary nailing is a safe technique to improve fracture reduction. The use of cerclage wires leads to better bone contact while minimizing malunions. The rate of non-union in our study is lower than the rate reported in the literature for humeral shaft fractures treated by intramedullary nailing alone.

Acute medullar compression secondary to a septic arthritis of a thoracic facet joint: a case report and review of literature.

INTRODUCTION: Septic arthritis of a facet joint (SAFJ) is a rare entity and frequently underdiagnosed. It is most frequently localised in the lumbar segment. CASE PRESENTATION: A 48-year-old woman presented at our emergency room with a chief complaint of lumbar pain and perineal hypoesthesia. An urgent lumbar Magnetic Resonance Imaging (MRI) was performed showing no signs of compressive pathology. Intravenous painkillers were administered improving her clinical symptoms, so she was discharged from the emergency department to be followed at our out-patient clinic. After 12 h, the patient presented again referring an acute loss of strength in her lower limbs and paresthesias at a T10 sensitive level. Due to the severity of the symptoms, we performed an urgent dorsal MRI that showed a septic arthritis of the left T8-T9 facet joint and an epidural abscess causing a medullar compression. Blood cultures were performed before surgical treatment. An urgent laminectomy of T8 and debridement of the abscess were performed. Intraoperative microbiology and blood cultures were positive for Streptococcus constellatus. After surgery, the patient presented a progressive improvement of her symptomatology. DISCUSSION: Physicians should have in mind and rule out this clinical entity to avoid severe consequences that a misdiagnosed SAFJ could develop.

Desarrollo de la escala "EDSOL" para la detección de la soledad existencial en enfermos al final de la vida / Development of the EDSOL scale for the detection of existential loneliness in patients at end of life

Objetivo: Presentar el desarrollo de la escala de detección de la soledad existencial (EDSOL) en personas con enfermedades avanzadas en tratamiento paliativo. Método: Se describe el proceso de elaboración de la escala Detección de la Soledad Existencial EDSOL. Para ello, 1) se ha revisado la bibliografía existente sobre el tema; 2) se ha establecido un marco teórico de referencia; 3) se han definido los criterios que debía cumplir el instrumento de cribado; y 4) se ha consultado con expertos y enfermos la adecuación de los ítems de la escala. Resultados: Se presenta a la escala EDSOL, que consta de dos partes: 1) tres preguntas dirigidas a los enfermos; y 2) diferentes observaciones realizadas por el personal sanitario acerca de la presencia de signos externos de soledad existencial. La escala final fue revisada por enfermos y profesionales. Conclusión: La escala EDSOL es una herramienta apropiada para identificar la presencia de Soledad Existencial en pacientes al final de la vida. En este caso, se propondrá su uso sistemático en la detección temprana de la Soledad Existencial y la implementación de intervenciones asistenciales específicas (AU)

Aim: This paper presents the development of Detection of Existential Loneliness Scale (EDSOL) of patients with advanced disease/terminal illness that receiving palliative care. Method: The process of preparing the scale is described. For this: 1) the literature on the subject has been revised, 2) theoretical framework has been established, 3) it has been defined the criteria to be met by the screening tool, and 4) the final scale was reviewed by patients and experts. Results: The EDSOL scale consists of two parts: 1) three questions addressed to patients and; 2) several questions addressed to health staff about the observation of external signs of Existential Loneliness. The final scale was reviewed by patients and experts (facie validity) showing good validity. Conclussion: The EDSOL scale will be an appropriate tool for identifying the Existential Loneliness of patients at the end of life or advanced illness. In this case, we will propose the systematic use of EDSOL for early detection and specific interventions on existential loneliness experiences (AU)