Screening of MRSA colonization in patients undergoing total joint arthroplasty.

BACKGROUND: Periprosthetic infection is commonly caused by Staphylococcus aureus and, if resistant to methicillin (MRSA), is associated with increase in severity and costs to patient and healthcare systems. MRSA colonizes 1-5% of the population, therefore using a screening and decolonisation protocol the risk of periprosthetic infection could be reduced. The objective of our study is to report the results of a preoperative MRSA screening and management protocol utilised at our hospital. METHODS: All patients undergoing a total joint arthroplasty at our hospital were preoperatively screened for MRSA colonization with swab samples of five different locations. Exposure to risk factors were investigated in colonised patients and they were treated for 5 days prior surgery with nasal mupirocin, chlorhexidine sponges and oral tablets. RESULTS: During the 48 months of the study, MRSA colonisation was identified in 22 (1.01%) of 2188 patients operated. The culture was positive only in the nasal swab in 55 patients. In five patients the nasal culture was negative, but they had another positive swab culture (three in the groin and two perianal). None of the patients reported a history of recent antibiotic treatment or hospitalization. CONCLUSION: At our institution, the prevalence of MRSA colonisation is 1.01% in patients undergoing hip and knee arthroplasty. Interestingly, our screening protocol included samples from five different anatomic locations, and it is important to highlight that we found patients with negative nares culture and positive cultures in other locations. Therefore, the number of carriers may be underdiagnosed if only nasal samples are obtained. LEVEL OF EVIDENCE: IV.

Resultados de un vástago con cobertura completa de hidroxiapatita con un seguimiento mínimo de 5 años / Outcomes using wedge stem with full hydroxiapatite coverage with a minimum of 5 years' follow-up

Introducción. La artroplastia total de cadera (ATC) con vástagos no cementados es popular en las últimas décadas. La supervivencia de un implante es crítica, con una tasa de revisión menor al 10% a 10años como límite para su aceptación y comercialización. Objetivos. Analizar los resultados clínico-radiográficos con un vástago en forma de cuña no cementado con recubrimiento completo de hidroxiapatita (HA) y con seguimiento mínimo de 5años. Material y métodos. Estudio prospectivo. Utilización de vástago Element (Exactech) y copa no cementada con inserto crosslink pared posterior elevada y cabeza metálica de 32mm. Se realizó un abordaje posterolateral con retención del músculo piriforme. Seguimiento clínico a las 3 semanas, a los 3 y 6 meses, al año y años subsiguientes. Evaluación radiográfica base en el postoperatorio inmediato y comparación con los controles. Se registraron las complicaciones intraoperatorias y en los seguimientos. Resultados. Ciento catorce ATC en 104 pacientes: 54 mujeres y 50 hombres (52/48%), con seguimiento de 5,7años (rango, 5-6,2años) y con 56,8años de promedio de edad (rango, 42-75años). Evaluación inicial score Merle d’Aubigné pobre con mejora postoperatoria de 6,8 puntos. Score de Harris inicial de 47,3 puntos y, a la última consulta, de 93,1 puntos. Evaluación radiográfica: osteointegración de todos los vástagos. Hundimiento: 6 casos (5,3%) a 3meses de cirugía, promedio de 1,4mm (rango, 0-2,6mm) sin repercusión clínica hasta la actualidad. En 3 casos de hundimiento hubo fracturas intraoperatorias: una del trocánter mayor (se realizó un cerclaje tipo mochila) y 2 por fractura proximal en el área del calcar (tratadas con cerclaje circular). Evaluación subjetiva: 86 casos (82,6%) excelente, 9 pacientes (8,6%) buena, 6 casos (5,9%) satisfactoria y 3 casos (2,9%) pobre. Los resultados pobres coincidieron con pacientes que tuvieron las complicaciones mencionadas. No se detectó dolor femoral anterior. No se produjeron luxaciones o aflojamientos sépticos. No hubo pérdida de pacientes en el período de seguimiento. Todos los implantes se encuentran in situ al momento del último seguimiento. Conclusiones. La evaluación y el seguimiento radiográfico confirman buena osteointegración del vástago. Los resultados clínicos y subjetivos son prometedores. Con una buena técnica quirúrgica y sin complicaciones, el riesgo de aflojamiento aséptico impresiona ser mínimo o ausente (AU)

Introduction. Total Hip Arthroplsty (THA) using uncemented stems is a popular practice in the last decades. The implant survivorship is crtitical and a less than 10% revision at 10 years is been propesed for commercialization and use. Objective. To analyse the clinicoradiological results of an uncemented hydroxiapatite covered wedge stem with a 5 years minimum follow up. Material and methods. Prospective study, patients aged from 21-75years were included. All patients received an Element stem (Exactech) and uncemented cup with crosslink poly and 32 mm metal head, and posterior approach with piriformis retention was used. Scheduled clinical and radiographic evaluation at 3 weeks, 3-6 month, year and subsequent years using Harris Hip Score and Merle d’Aubigné Postel. Intraoperative and during follow up complications were recorded. Results. One hundred and fourteen total hip replacements in 104 patients: 54 females and 50 males (52%/48%). Follow-up of 5.7 years (range, 5-6.2years). Average age 56.8years (range, 42-75years). Clinical evaluation the Merle d’Aubigné score improved 6.8 points and from the initianl Harris Hip Score 47.3 to 93.1 points at last follow up. Radiographic evaluation shows osteointegration in all stems. And in 6 cases (5.3% at 3 months subsidence was detected, average 1.4 mm (range 0-2.6 mm) with no clinical manifestation, 3 cases of subsidence were associated to intraoperative fractures (1 greater trochanter and 2 in the calcar area, all resolved with wire cerclaje). Subjective evaluation: 86 cases (82.6%) excellent, 9 patients (8.6%) good, 6 cases (5.9%) satisfactory and 3 cases (2.9%) poor. All poor results linked to the intraoperative complications. No patient lost during follow up period. No femoral pain dislocation or aseptic or loosening detected. All implants were in situ at last follow up. Conclusions. The radiological results confirm the benefits of this type of stem with good osteointegration. The clinical and subjective results are promising. With good surgical technical and without complications the risk of aseptic loosening should be absent or minimal (AU)

Outcomes using wedge stem with full hydroxiapatite coverage with a minimum of 5 years' follow-up. / Resultados de un vástago con cobertura completa de hidroxiapatita con un seguimiento mínimo de 5 años.

INTRODUCTION: Total Hip Arthroplsty (THA) using uncemented stems is a popular practice in the last decades. The implant survivorship is crtitical and a less than 10% revision at 10 years is been propesed for commercialization and use. OBJECTIVE: To analyse the clinicoradiological results of an uncemented hydroxiapatite covered wedge stem with a 5 years minimum follow up. MATERIAL AND METHODS: Prospective study, patients aged from 21-75years were included. All patients received an Element stem (Exactech) and uncemented cup with crosslink poly and 32 mm metal head, and posterior approach with piriformis retention was used. Scheduled clinical and radiographic evaluation at 3 weeks, 3-6 month, year and subsequent years using Harris Hip Score and Merle d'Aubigné Postel. Intraoperative and during follow up complications were recorded. RESULTS: One hundred and fourteen total hip replacements in 104 patients: 54 females and 50 males (52%/48%). Follow-up of 5.7 years (range, 5-6.2years). Average age 56.8years (range, 42-75years). Clinical evaluation the Merle d'Aubigné score improved 6.8 points and from the initianl Harris Hip Score 47.3 to 93.1 points at last follow up. Radiographic evaluation shows osteointegration in all stems. And in 6 cases (5.3% at 3 months subsidence was detected, average 1.4 mm (range 0-2.6 mm) with no clinical manifestation, 3 cases of subsidence were associated to intraoperative fractures (1 greater trochanter and 2 in the calcar area, all resolved with wire cerclaje). Subjective evaluation: 86 cases (82.6%) excellent, 9 patients (8.6%) good, 6 cases (5.9%) satisfactory and 3 cases (2.9%) poor. All poor results linked to the intraoperative complications. No patient lost during follow up period. No femoral pain dislocation or aseptic or loosening detected. All implants were in situ at last follow up. CONCLUSIONS: The radiological results confirm the benefits of this type of stem with good osteointegration. The clinical and subjective results are promising. With good surgical technical and without complications the risk of aseptic loosening should be absent or minimal.

Efectividad y eficiencia de la vía clínica rápida (fast-track) en prótesis total de rodilla y cadera (PTR y PTC): 11 años de experiencia. Validación de la vía clínica. Análisis de la estancia hospitalaria, tasa de revisiones y coste en un hospital público español / Effectiveness and efficiency of the fast-track protocol in total hip and knee arthroplasty (THA and TKA): 11 years of experience. validation of the protocol, analysis of hospital stay, rate of revision surgery and cost in a Spanish public hospital

Objetivo. a) Valorar la efectividad de la implementación del fast-track en PTR-PTC; y b) evaluar la eficiencia en la estancia hospitalaria, las cirugías de revisión y los costes. Material y métodos. Estudio observacional en 2 tiempos: 1) Estudio prospectivo con 200 pacientes (PTR=100, PTC=100) en 2005-2007. Se analizó la edad, el sexo, la estancia hospitalaria, la escala visual analógica (EVA), el balance articular (BA) de rodilla, las complicaciones y la rehabilitación tras el alta. 2) Estudio prospectivo a 3.094 PTR y 1.664 PTC, desde el 2005-2015. Se analizó la estancia hospitalaria, el porcentaje de cirugías de revisión y el ahorro estimado. Resultados. En la validación en PTR el 68% (n=68) eran mujeres y el 32% (n=32) varones. La edad media fue de 71 años y la estancia hospitalaria de 6 días. La EVA preoperatoria/6 meses/año/2 años disminuyó progresivamente (7; 1,8; 1,4 y 1,2). El BA al alta/mes/2 años mejoró progresivamente (82°, 90° y 93°). Complicaciones 3% (n=3; fractura postraumática y 2 inestabilidades). Rehabilitación ambulatoria 8% (n=8). En la validación en PTC el 48% (n=48) eran mujeres y el 52% (n=52) varones, con una edad media de 70 años. La estancia hospitalaria fue de 5 días. Hubo complicaciones en 3 pacientes (3%) (fractura, luxación y TVP). Rehabilitación ambulatoria 3% (n=3). En PTR la estancia media (11 años) fue 5,96 días, las revisiones 5,96% y el ahorro estimado (2013-2015) 117.776 euros. En PTC la estancia media (11 años) fue 6,24 días, las revisiones 10,62% y el ahorro estimado (2013-2015) 116.316 euros. Conclusiones. La implantación/seguimiento del protocolo fast-track en PTR-PTC disminuye el dolor, las complicaciones, la rehabilitación ambulatoria, la estancia hospitalaria, la tasa de revisiones y los costes (AU)

Objective. a) To validate the effectiveness of the implementation of a fast-track protocol for TKA-THA; b) to evaluate efficiency in reducing length of stay, hospital costs and revision surgeries. Material and methods. A two-phase observational study was performed: 1) A prospective study in 200 patients (100 TKA and 100 THA) between 2005 and 2007. Age, sex, length of stay, visual analog scale (VAS) for pain, knee range of movement (ROM), complications and post-discharge rehabilitation were analyzed. 2) A prospective study was conducted in 3094 TKA and 1664 THA patients between 2005 and 2011. Length of stay, revision surgery and estimated savings were analyzed. Results. In the TKA evaluation, 68% of the patients were female (n=68) and 32% were male (n=32). The mean age was 71 years. Length of stay was 6 days. Pain diminished progressively at discharge/6 months/1 year/2 years (7; 1.8; 1.4 and 1.2), respectively. The ROM progressively increased at discharge/1 month/2 years (82°, 90° and 93°), respectively. The complications rate was 3% (n=3) (fracture and instability). Ambulatory rehabilitation was provided in 8% (n=8). In the THA evaluation, 48% of the patients were female (n=48) and 52% were male (n=52). The mean age was 70 years. Length of stay was 5 days. The complications rate was 3% (n=3) (fracture, dislocation and deep vein thrombosis). Ambulatory rehabilitation was provided in 3% (n=3). In TKA (11 years), the length of stay was 5.96 days, revision surgeries were carried out in 5.96%, and the cost saving in 2013-2015 was 117,776 euros. In THA (11 years), the length of stay was 6.24 days, revision surgeries were performed in 10.62%, and the cost saving in 2013-2015 was 116,316 euros. Conclusions. The implementation/follow-up of the fast-track protocol in THA-TKA was effective in decreasing pain, complications, ambulatory rehabilitation, length of stay, the rate of revision surgery, and costs (AU)