Economic advantage of 'self-made' antibiotic-loaded spacer compared to prefabricated antibiotic-loaded spacer and spacer molds in two-staged revision arthroplasty.

Infection after total hip or total knee arthroplasty is a serious complication implying great costs for the health care system. Amongst the different treatment options, the two-step exchange using a spacer in the interval is a valid option. We evaluate the economic impact of our self-made antibiotic-loaded hip and knee cement spacers compared with prefabricated spacers and spacer molds. Costs to prepare self-made cement spacers are detailed for each spacer type. We also assess the intraoperative time spent for fabricating our self-made hip and knee spacers. The price of these self-made knee spacer is 514 CHF (450 EUR / 505 USD) if non-articulated and 535 CHF (470 EUR / 525 USD) if articulated ; the price for the self-made hip spacer is 749 CHF (760 EUR / 735 USD). Our average preparation time is 14 minutes for our self-made knee spacers and 16 minutes for our self-made hip spacers. While the senior surgeon is fabricating the self-spacers, another surgeon of the team continues intensive irrigation and debridement. Thus, no time is lost waiting for the self-spacer to be fabricated. In our hands, self-made hip and knee spacers are at least 40-50% cheaper than prefabricated spacers and spacer-molds. This is a serious economic advantage in this already expensive surgery. When done in teamwork, self-spacer fabrication does not increase the surgery time. The economic advantage is added to the main and most important advantage of self- made spacers, which remains the possibility of patient adapted anatomical reconstruction of the joint.

The potential use of microcalorimetry in rapid differentiation between septic arthritis and other causes of arthritis.

Current diagnostic methods in differentiating septic from non-septic arthritis are time-consuming (culture) or have limited sensitivity (Gram stain). Microcalorimetry is a novel method that can rapidly detect microorganisms by their heat production. We investigated the accuracy and time to detection of septic arthritis by using microcalorimetry. Patients older than 18 years of age with acute arthritis of native joints were prospectively included. Synovial fluid was aspirated and investigated by Gram stain, culture and microcalorimetry. The diagnosis of septic arthritis and non-septic arthritis were made by experienced rheumatologists or orthopaedic surgeons. Septic arthritis was diagnosed by considering the finding of acute arthritis together with findings such as positive Gram stain or positive culture of synovial fluid or positive blood culture. The sensitivity and specificity for diagnosing septic arthritis and the time to positivity of microcalorimetry were determined. Of 90 patients (mean age 64 years), nine had septic arthritis, of whom four (44 %) had positive Gram stain, six (67 %) positive synovial fluid culture and four (44 %) had positive blood culture. The sensitivity of microcalorimetry was 89 %, the specificity was 99 % and the mean detection time was 5.0 h (range, 2.2-8.0 h). Microcalorimetry is an accurate and rapid method for the diagnosis of septic arthritis. It has potential to be used in clinical practice in diagnosing septic arthritis.

[Charcot osteoarthropathy: don't miss it!]. / "Pied de Charcot": un diagnostic à ne pas manquer!

Charcot neuropathic osteoarthropathy (CNO) is a destructive process affecting the bone and joint structure of diabetic patients and resulting from peripheral neuropathy. It is a limb threatening condition resulting in dramatic deformities associated with severe morbi-mortality. The diagnosis is mostly made by the observation of inflammatory signs and higlight the importance of prompt foot evaluation. Imaging studies may help confirm the diagnosis and the severity of the condition but lack of specificity. The goal of the treatment is to maintain or achieve structural stability of the foot and ankle to prevent further deformity and plantar dislocation. The scientific evidences aren't strong enough to recommend bisphosphonates or acute surgical treatment. Surgery is unanimusly recommended to prevent secondary ulceration.

Lower limb reconstruction involving osteosynthesis material: A retrospective study on propeller flaps outcomes.

INTRODUCTION: Reconstruction of soft tissue defects in lower limb fractures requiring internal fixation remains a challenging scenario with the optimal surgical treatment still debated. This study aims to recommend, and eventually redefine, surgical indications for propeller flaps reconstruction in the distal lower limb, with a particular focus on the presence or not of metalwork. METHODS: A retrospective study of lower limb soft tissue reconstructions performed between January 2015 and July 2018 was carried out including all patients treated with a propeller perforator flap (PPF) with at least 6-month follow-up. Patients were further divided in 2 groups depending on the presence of metalwork fixation beneath the flap (F group, propeller on Framework; NF group, propeller with No-Framework). RESULTS: 21 patients were retained (F group, 11 patients; NF group, 10 patients). There were no significant differences between the two groups in age, BMI, ASA scores, comorbidities or defect size. There was a statistically significant difference between the groups (p<0.05) in the cumulative hospital stay with a mean cumulative hospital stay of 22 ± 9 days in the F group and 12 ± 8 days in NF group. Failures were higher where PPF were used to cover hardware material, with 3 patients requiring a major secondary procedure in F group versus 1 patient in NF group. CONCLUSION: The presence of underlying metalwork significantly reduced the margin for small, day-case revision procedures such as flap readvancement or STSG. This study emphasizes clinical intuition that whilst PPF are a useful and elegant tool in lower limb reconstruction, their use should be limited when underlying metalwork is present.

[Antibiotic prophylaxis before dental procedures in arthroplasty patients]. / Utilité de la prophylaxie antibiotique avant un geste dentaire pour tes porteurs de prothèses totales du genou ou de la hanche.

Antibiotic prophylaxis is commonly prescribed to patients with total arthroplasties before a dental intervention. This attitude is not evidence-based for several reasons: 1) the usual pathogens of prosthetic joint infections are not of oral origin; 2) even if given, systemic antibiotic do not completely suppress the occult bacteraemia occurring during dental intervention and 3) humans may have up to twelve episodes of occult bacteraemia of dental origin per day. Routine antibiotic prophylaxis should be clearly distinguished from the antibiotic treatment required in case of established oral cavity infection. A constant optimal oral and dental hygiene is more important in terms of prevention and should be routinely recommended to every patient carrying a joint arthroplasty.

[New methods for the diagnosis of implant-associated infections]. / Nouvelles méthodes pour le diagnostic des infections liées aux implants.

For successful treatment of prosthetic joint infection, the identification of the infecting microorganism is crucial. Cultures of synovial fluid and intraoperative periprosthetic tissue represent the standard method for diagnosing prosthetic joint infection. Rapid and accurate diagnostic tools which can detect a broad range of causing microorganisms and their antimicrobial resistance are increasingly needed. With newer diagnostic techniques, such as sonication of removed implants, microcalorimetry, molecular methods and mass spectrometry, the sensitivity has been significantly increased. In this article, we describe the conventional and newer diagnostic techniques with their advantages and potential future applications.

[Clinical study of movable external fixation for elbow tuberculosis].

OBJECTIVE: To compare clinical effect of movable external fixation and fusion fixation for the treatment of elbow tuberculosis. METHODS: From October 2013 to June 2019, 52 patients with elbow tuberculosis treated with standard antituberculosis therapy were divided into movable external fixation group and fusion fixation group according to treatment methods. In group A, there were 25 patients, including 11 males and 14 females, aged from 24 to 75 years old with an average of (42.81± 9.01) years old; the courses of diseases ranged from 2 to 9 months with an average of (3.96±1.45) months. In group B, there were 27 patients, including 15 males and 12 females, aged from 23 to 77 years old with an averageof (44.08±7.44) years old; the courses of diseases ranged from 2 to 7 months with an average of (3.88±1.67) months. All patients were performed focus debridement. Intraoperative blood loss, operative time were compared between two groups. VAS score before operation, 2 weeks and 12 months after operation were applied to evaluate pain relieve;Mayo elbow performance score (MEPS) before operation, 1 and 12 months after operation were used to evaluate clinical effect;changes of erythrocyte sedimentation rate (ESR) and Creactive protein, CRP) before operation, 3 weeks after antituberculosis therapy, 1 week and 6 months after operation were compared between two groups. RESULTS: All patients were followed up from 12 to 20 months with an average of (13.50±4.85) months. No mixed infection and recurrence of tuberculosis occurred. There were no statistical differences in intraoperative blood loss and operative time(P>0.05). There was difference in postoperative VAS score at 2 weeks between movable external fixation group (5.15±0.95) and fusion fixation group (4.04±0.84)(P<0.01);while no difference in postoperative VAS score at 12 months between two groups (P>0.05). No difference in ESR and CRP level between two groups before and after operation (P>0.05). Postoperative Mayo score at 1 and 12 months in movable external fixation group were (78.15±7.83) and (90.19±7.13);in fusion fixation group were (70.40±7.61) and (82.60±8.38);there were differences in Mayo score at different time points between two groups(P<0.01). CONCLUSION: For elbow tuberculosis, movable external fixation and fusion fixation have equal effect in operative time, amount of bleeding and control of tuberculosis infection indicator. Movable external fixation need earlier functional exercise, not conducive to pain relief at early stage, which may be better than fusion fixation, it is worth clinical promoting.

[Update on implant related infections in orthopaedic surgery. Diagnosis and treatment]. / Diagnostic et traitement des infections d'implants orthopédiques.

Infections associated with implants are increasingly important in modem medicine. Biofilms are the cause that these infections are more difficult to diagnose and to cure. Particularly low-grade infections are difficult to distinguish from aseptic failure, because they often present with early loosening and persisting pain. For an accurate diagnosis, clinical signs and symptoms, laboratory markers of infection, microbiology, histology and imaging examinations are needed. The treatment goal is eradication of infection and an optimal functional result. Successful treatment requires adequate surgical procedure combined with long-term antimicrobial therapy, ideally with an agent acting on biofilms.

Does candidate for plate fixation selection improve the functional outcome after midshaft clavicle fracture? A systematic review of 1348 patients.

INTRODUCTION: The hypothesis of this study was that patient selection for midshaft clavicle fracture (open reduction internal fixation with plate versus conservative) would give better functional outcome than random treatment allocation. METHODS: We performed a systematic literature search for primary studies providing functional score and non-union rate after conservative or surgical management of midshaft clavicle fractures. Six randomized controlled trial and 19 non-randomized controlled trial studies encompassing a total of 1348 patients were included. RESULTS: Patients treated with surgical management were found to have statistically superior Constant scores in non-randomized controlled trials than in randomized controlled trials (94.76 ± 6.4 versus 92.49 ± 6.2; p < 0.0001). For conservative treatment, randomized controlled trials were found to have significantly better functional outcome. The prevalence of non-union (6.1%) did not show significant statistical difference between non-randomized controlled trial and randomized controlled trial studies. The functional outcome after surgical management was significantly higher than after conservative management in both randomized controlled trial and non-randomized controlled trial groups. The non-union rate after surgery (1.1% for both non-randomized controlled trial and randomized controlled trial) was significantly lower than following conservative treatment (9.9% non-randomized controlled trial versus 15.1% randomized controlled trial). DISCUSSION: This review shows that patient selection for surgery may influence functional outcome after midshaft clavicle fracture. Our results also confirm that plate fixation provides better functional outcome and lower non-union rate.

ALT flap with vascularized fascia lata for one-stage functional patellar tendon reconstruction.

INTRODUCTION: Composite anterolateral thigh (ALT) flap with vascularized fascia lata can reconstitute patellar tendon integrity and knee soft tissue coverage in one stage. However, long-term evidence of outcomes is lacking. This work analyzes long-term functional results, compares subtotal and total reconstruction of patellar tendon, and assesses the respective function of the extensor apparatus. PATIENTS AND METHODS: Outcomes of reconstruction using 10 ALT flaps in 9 patients (age range 21-87 years) were analyzed (mean follow-up 30 ±â€¯6 months). Knee Society Scores, isometric knee extensor strength (M1-M5), and sensory recovery were evaluated, together with active range of motion and extensor lag of the reconstructed limb, compared to contralateral. RESULTS: Ten flaps were used for tendon replacement in 9 patients. Eight (80%) free flaps and 2 (20%) propeller distally based flaps were used. Complications requiring the harvest of a second flap were seen in 2 patients. All patients could return to their daily activities without the use of walking supports. Mean active ROM was 94.4° with an extensor lag of 9.4°, without a significant difference between partial and total patellar tendon reconstruction. The mean knee and functional scores of the Knee Society were 81/100 and 77/100, respectively. CONCLUSION: Composite ALT flap with fascia lata can satisfy the twofold needs of functional restoration and soft tissue coverage, thus ensuring stable results in total and subtotal knee extensor mechanism reconstruction. Distally based flaps should be carefully considered, as they lead to higher complication rates.

International survey among orthopaedic trauma surgeons: Lack of a definition of fracture-related infection.

INTRODUCTION: Fracture-related infection (FRI) is one of the most challenging musculoskeletal complications in orthopaedic-trauma surgery. Although the orthopaedic community has developed and adopted a consensus definition of prosthetic joint infections (PJI), it still remains unclear how the trauma surgery community defines FRI in daily clinical practice or in performing clinical research studies. The central aim of this study was to survey the opinions of a global network of trauma surgeons on the definitions and criteria they routinely use, and their opinion on the need for a unified definition of FRI. The secondary aims were to survey their opinion on the utility of currently used definitions that may be at least partially applicable for FRI, and finally their opinion on the important clinical parameters that should be considered as diagnostic criteria for FRI. METHODS: An 11-item questionnaire was developed to cover the above-mentioned aims. The questionnaire was administered by SurveyMonkey and was sent via blast email to all registered users of AO Trauma (Davos, Switzerland). RESULTS: Out of the 26'563 recipients who opened the email, 2'327 (8.8%) completed the questionnaire. Nearly 90% of respondents agreed that a consensus-derived definition for FRI is required and 66% of the surgeons also agreed that PJI and FRI are not equal with respect to diagnosis, treatment and outcome. Furthermore, "positive cultures from microbiology testing", "elevation of CRP", "purulent drainage" and "local clinical signs of infection" were voted the most important diagnostic parameters for FRI. CONCLUSION: This international survey infers the need for a consensus definition of FRI and provides insight into the clinical parameters seen by an international community of trauma surgeons as being critical for defining FRI.

Infection after fracture fixation: Current surgical and microbiological concepts.

One of the most challenging complications in trauma surgery is infection after fracture fixation (IAFF). IAFF may result in permanent functional loss or even amputation of the affected limb in patients who may otherwise be expected to achieve complete, uneventful healing. Over the past decades, the problem of implant related bone infections has garnered increasing attention both in the clinical as well as preclinical arenas; however this has primarily been focused upon prosthetic joint infection (PJI), rather than on IAFF. Although IAFF shares many similarities with PJI, there are numerous critical differences in many facets including prevention, diagnosis and treatment. Admittedly, extrapolating data from PJI research to IAFF has been of value to the trauma surgeon, but we should also be aware of the unique challenges posed by IAFF that may not be accounted for in the PJI literature. This review summarizes the clinical approaches towards the diagnosis and treatment of IAFF with an emphasis on the unique aspects of fracture care that distinguish IAFF from PJI. Finally, recent developments in anti-infective technologies that may be particularly suitable or applicable for trauma patients in the future will be briefly discussed.

Definition of infection after fracture fixation: A systematic review of randomized controlled trials to evaluate current practice.

INTRODUCTION: One of the most challenging musculoskeletal complications in modern trauma surgery is infection after fracture fixation (IAFF). Although infections are clinically obvious in many cases, a clear definition of the term IAFF is crucial, not only for the evaluation of published research data but also for the establishment of uniform treatment concepts. The aim of this systematic review was to identify the definitions used in the scientific literature to describe infectious complications after internal fixation of fractures. The hypothesis of this study was that the majority of fracture-related literature do not define IAFF. MATERIAL AND METHODS: A comprehensive search was performed in Embase, Cochrane, Google Scholar, Medline (OvidSP), PubMed publisher and Web-of-Science for randomized controlled trials (RCTs) on fracture fixation. Data were collected on the definition of infectious complications after fracture fixation used in each study. Study selection was accomplished through two phases. During the first phase, titles and abstracts were reviewed for relevance, and the full texts of relevant articles were obtained. During the second phase, full-text articles were reviewed. All definitions were literally extracted and collected in a database. Then, a classification was designed to rate the quality of the description of IAFF. RESULTS: A total of 100 RCT's were identified in the search. Of 100 studies, only two (2%) cited a validated definition to describe IAFF. In 28 (28%) RCTs, the authors used a self-designed definition. In the other 70 RCTs, (70%) there was no description of a definition in the Methods section, although all of the articles described infections as an outcome parameter in the Results section. CONCLUSION: This systematic review shows that IAFF is not defined in a large majority of the fracture-related literature. To our knowledge, this is the first study conducted with the objective to explore this important issue. The lack of a consensus definition remains a problem in current orthopedic trauma research and treatment and this void should be addressed in the near future.

Fracture-related infection: A consensus on definition from an international expert group.

Fracture-related infection (FRI) is a common and serious complication in trauma surgery. Accurately estimating the impact of this complication has been hampered by the lack of a clear definition. The absence of a working definition of FRI renders existing studies difficult to evaluate or compare. In order to address this issue, an expert group comprised of a number of scientific and medical organizations has been convened, with the support of the AO Foundation, in order to develop a consensus definition. The process that led to this proposed definition started with a systematic literature review, which revealed that the majority of randomized controlled trials in fracture care do not use a standardized definition of FRI. In response to this conclusion, an international survey on the need for and key components of a definition of FRI was distributed amongst all registered AOTrauma users. Approximately 90% of the more than 2000 surgeons who responded suggested that a definition of FRI is required. As a final step, a consensus meeting was held with an expert panel. The outcome of this process led to a consensus definition of FRI. Two levels of certainty around diagnostic features were defined. Criteria could be confirmatory (infection definitely present) or suggestive. Four confirmatory criteria were defined: Fistula, sinus or wound breakdown; Purulent drainage from the wound or presence of pus during surgery; Phenotypically indistinguishable pathogens identified by culture from at least two separate deep tissue/implant specimens; Presence of microorganisms in deep tissue taken during an operative intervention, as confirmed by histopathological examination. Furthermore, a list of suggestive criteria was defined. These require further investigations in order to look for confirmatory criteria. In the current paper, an overview is provided of the proposed definition and a rationale for each component and decision. The intention of establishing this definition of FRI was to offer clinicians the opportunity to standardize clinical reports and improve the quality of published literature. It is important to note that the proposed definition was not designed to guide treatment of FRI and should be validated by prospective data collection in the future.

Transolecranon anterior fracture dislocation.

Between January 1996 and July 2003, 93 consecutive patients operated on with a diagnosis of olecranon fractures were identified from our trauma unit files. Fourteen transolecranon fracture-dislocations were found after a retrospective X-radiographic evaluation. Eight patients were women and six were men, with a mean age of 54 years. There were 4 noncomminuted olecranon fractures, treated with K-wires and single tension-band wiring. The remaining 10 fractures were complex fractures, treated in 3 cases with multiple K-wires and single tension-band wiring, in 2 by use of one-third tubular plates, in 1 with a 3.5-mm dynamic compression plate, and in the remaining 4 with 3.5-mm reconstruction plates. Ligament repair was not performed in any case. Three patients needed reoperation because of early failure of primary fixation. Patients were reviewed at a mean follow-up of 3.6 years. Two reported difficulties in daily activities, none with any symptoms of elbow instability. According to the Broberg and Morrey score, 4 patients had excellent results, 6 had good results, 2 had fair results, and 2 had poor results. Four patients showed signs of degenerative arthritis on the radiographs obtained at follow-up. We conclude that transolecranon fracture-dislocation is an underreported and misdiagnosed injury. Various fixation techniques can restore the anatomic relationships and contour of the trochlear notch; the imperative goal is to obtain a good stable primary fixation and allow early active mobilization.

[Infected osteosynthesis]. / Infizierte Osteosynthese.

BACKGROUND: Infections after osteosynthesis are a feared complication of the surgical treatment of fractures and should be dealt with by a multidisciplinary team. In addition to the surgeon, also included in this multidisciplinary team are a specialist for infectious diseases, a microbiologist, a radiologist and often a plastic surgeon. This review article describes the current knowledge on the pathogenesis, diagnostics, classification and treatment. The aim is to demonstrate some basic rules in the treatment of infections associated with implants and to show potential therpeutic approaches. MATERIAL AND METHODS: The principles of diagnostics and combined surgical and antibiotic treatment are presented based on the current specialist literature. RESULTS: With the help of a team approach the goals of treatment of an infected osteosynthesis, i.e. fracture healing, return to function and eradication of infection can be achieved. While the osteosynthesis material can usually be retained in acute infections, it is better to remove the infected hardware in chronic infections as eradication of the mature biofilm is no longer possible. DISCUSSION: With adequate local wound débridement, the use of local and systemic antibiotics, as indicated by the specialist for infectious diseases and appropriate soft tissue coverage and wound closure, acute as well as chronic infections can be successfully treated. Nowadays, the surgeon has many different options for the management of bone defects. Depending on the anatomical location and the size of the defect a variety of techniques ranging from acute shortening to the Masquelet technique up to the Ilizarov distraction technique are available. These techniques should be combined with local bactericidal treatment.

Identification of Propionibacterium avidum from a breast abscess: an overlooked etiology of clinically significant infections.

We report the case of a 37-year-old previously healthy woman diagnosed with a breast abscess due to Propionibacterium avidum after breast reduction surgery. This case emphasizes the potential pathogenicity and morbidity associated with this commensal skin organism.

BMP signaling components are expressed in human fracture callus.

Of the various growth factors involved in the healing response after a fracture, bone morphogenetic proteins (BMPs) are emerging as key modulators. BMPs exert their effects by binding to a complex of type I and type II receptors leading to the phosphorylation of specific downstream effector proteins called Smads. The current study examined the presence of BMP signaling components in human callus obtained from five nascent malunions undergoing fracture fixation. These callus samples represented various stages of bone healing and a mixture of endochondral and intramembraneous bone healing. We performed immunohistochemistry on the callus, using antibodies for BMP (BMP-2,-3,-4,-7), their receptors (BMPR-IA, -IB, -II), and phosphorylated BMP receptor-regulated Smads (pBMP-R-Smads). Active osteoblasts showed fairly consistent positive staining for all BMPs that were examined, with the immunoreactivity most intense for BMP-7 and BMP-3. Immunostaining for BMPs in osteoblasts appeared to colocalize with the expression of BMPR-IA, -IB, and -II. Positive immunostaining for pBMP-R-Smads suggests that the BMP receptors expressed in these cells are activated. Staining for BMPs in cartilage cells was variable. The immunostaining appeared stronger in more mature cells, whereas staining for BMP receptors in cartilage cells was less ubiquitous. However, the expression of pBMP-R-Smads in cartilage cells suggests active signal transduction. Fibroblast-like cells also had a variable staining pattern. Overall, our findings indicate the presence of BMPs, their various receptors, and activated forms of receptor-regulated Smads in human fracture callus. To the best of our knowledge, this is the first study that documents the expression of these proteins in human fracture tissue. Complete elucidation of the roles of BMP in bone formation will hopefully lead to improved fracture healing care.

Traumatic hernia of the abdominal wall after pelvic and acetabular fracture: a case report.

Traumatic hernia of the abdominal wall is a rare and easily missed injury in the presence of major pelvic and abdominal lesions. We present a radiographically documented case of combined pelvic and acetabular fracture with a major contralateral traumatic hernia with avulsion of the internal oblique, the external oblique and the transverse abdominal muscles diagnosed four months after the initial trauma. To our knowledge no similar case has been described in the current literature.

Septic arthritis of the pubic symphysis caused by Streptococcus mitis.

Septic arthritis of the pubic symphisis is distinguished from osteitis pubis by positive cultures. The symptoms, physical examination and laboratory findings of these two conditions are comparable. We present a case of 57-year-old woman with septic arthritis of pubic symphisis caused by Streptococcus mitis, a commensal oral flora that belongs to viridans group streptococci, which normally reside in the oral cavity, the gastrointestinal and the urogenital tract.