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ABSTRACTS
SHORT FREE PAPER
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Osteo-articular infections in the pediatric age
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SFP01 – (#147) – Short Free Paper
OSTEOARTICULAR INFECTIONS IN CHILDREN: A REVIEW OF 164 CASES FROM SLOVENIA.
M. Pokorn, T. Srovin
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Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
E-mail: [email protected]
Keywords: Osteoarticular Infections, Children
Aim
Osteoarticular infections (OAI) in children provide both diagnostic and therapeutic challenges. Recent data
suggest that management of OAI can be simplified with shorter treatment duration and earlier switch to oral
antibiotics. The aim of the study was to evaluate management and outcome of OAI in children at our center.
Methods
A retrospective review of all cases of osteoarticular infections (OAI) in children <15 years of age treated at our
institution, from May, 2006 to April, 2015 was performed. Treatment duration and outcome in two periods,
2006-2011 and 2012-2015 were compared.
Results
In a 9-year period there were 164 cases (93 cases in 2006-2011 and 71 cases in 2012-2015) of OAI with 12-24
cases annualy. A male preponderance among patients was observed with a male-to-female ratio of 1,88:1.
There were 86 osteomyelitis (OM) cases, 52 septic arthritis (SA) cases and 26 OM and SA cases. The majority of
cases involved lower limbs. One-third of children with OAI were either active in sport and/or had a recent
history of mild trauma. In 13 (8%) cases OAI developed after varicella. There were 74 microbiologically
confirmed infections and the main causative agent was Staphylococcus aureus (47 cases), followed by
Streptococcus pyogenes (8 cases), S. pneumoniae (5), Kingella kingae and Salmonella (3 cases, respectively).
Surgical treatment was required in 46 cases, further 18 required one or multiple joint aspirations. One child
with S. aureus bacteremia had endocarditis. In one child with sepsis and multiorgan failure necrosis of the
femur developed and in two bone abscesses were drained 3 and 12 months after acute episode. All 3 children
had Panton-Valentine leukocidin (PVL)-positive S. aureus infection. All other children recovered without
permanent sequelae.
When comparing treatment duration, average treatment was shorter in 2012-2015 (31,3 days) than in 20062011 (38,1 days, p=0,0003), particularly due to shortening of parenteral treatment (9,0 days vs. 16,1 days,
p<0,0005). The outcome was similar in both periods.
Conclusions
OAI often occur in children who engage in sports or have a history of recent trauma. The majority of infections
are caused by S. aureus, which can be severe and/or complicated if the isolate is PVL-positive. Antimicrobial
treatment can be shortened and early switch to oral treatment seems to be safe. In general, prognosis of OAI
in children is excellent.
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SFP04 – (#124) -Short Free Paper
PYOGENIC SACROILIITIS IN THE INFANCE, IN CONCEPCIÓN CHILE. REVIEW OF 15 YEARS.
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P. Schaufele , A. Ibieta , D. Pineda , P. Schaufele , C. Peirano , C. Figueroa , T. Ramirez
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University of Concepción - Guillermo Grant Benavente´s Hospital, Concepcion, Chile
2
Guillermo Grant Benavente´s Hospital, Concepcion, Chile
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San Sebastian University, Concepcion, Chile
4
University of Concepción, Concepcion, Chile
E-mail: [email protected]
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Keywords: Pyogenic Sacroiliitis , Infance
Aim
Pyogenic sacroiliitis (PS) is one of the less frequent localizations among joint infections, near the 1,5%. A late
diagnosis generally exists. So we decided to analyze its behaviour in our uniit.
Methods
A retrospective study of 39 records was carried out, 32 with diagnosis of entrance of PS and 7 with another
pathology’s diagnosis that turned out to be a PS, among the years 1999 and 2014 in our unit.
Results
27 only fulfilled the requirements to be classified as PS (Clinic features of infection and sacroiliac localization,
laboratory exams and Tc-99 bone scintigraphy alterations). 20 males and 7 females (74% males), 52% right
sacroiliac joint, only 7 had clinically predisposing conditions (trauma), aged between 3 and 14 years (average
9.6 years). The half time of clinical evolution foresaw to diagnosis was of 4,7 days (6,7 days between 1999–
2005 and 3,5 between 2006-2014) (range between 1 and 10 days). The main symptom that motivates the
consultation was fever (96%) accompanied by FABER test positive (70%) by buttock pain (52%) and by limping
(48%). Laboratory exams: WBC count was normal in 11 cases and elevated in 16 cases too and only in 5 cases
with left deviation (PMNs elevated); CRP higher than 55 mg/dl in 23 patients (100% over 20mg/dl), ERS with
value average of 72 mmHg/hour (27-111). Blood cultures were positive in 70% and the Staphylococcus aureus
was the main bacteria founded (89%). No radiological alterations were found initially. The TC-99 bone
scintigraphy was positive in all cases after the third day. All patients had a 5 to 12 days course of intravenous
antibiotics (oxacillin + amikacin in 96% of patients) and then completed 4 weeks with oral oxacillin. All patients
recovered without sequel.
Conclusions
Blood cultures may be obtained prior the antibiotics’ administration. The Staphylococcus aureus is by far the
most frequent germ involved in this process, and it may guide the empiric antibiotic therapy. The precocious
antibiotic treatment solves the case without sequels. The PS is an uncommon pathology in children that makes
it often not recognized initially. Wrong diagnosis such as appendicitis, transient synovitis of the hip, discitis,
etc. can be avoided if PS is sought in a systematic way.
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SFP07 – (#153) – Short Free Paper
EPIDEMIOLOGY OF STAPHYLOCOCCUS R METI IN OSTEOARTICULAR INFECTIONS IN CHILDREN
R. Boussetta, R. Elafram, I. Jerbi, S. Bouchoucha, W. Saied, M. Nessib
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Children Hospital, Tunis, Tunisia
E-mail: [email protected]
Keywords: Staphylococcus, Resistant, Infection, Bone
Aim
The prevalence of Staphylococcus infections do not decrease despite the preventive measures. The methicillinresistant staphylococcus aureus (MRSA) has become a major nosocomial pathogen in community hospitals and
responsible 60% of staph infections.
Through this study we try to study the epidemiology of methicillin-resistant Staphylococcus in the bone and
joint infections.
Methods
We report a 2-year study retrospectipevelly about 25 cases of bone and joint infection staphilococcus
methicillin-resistant . All patients underwent clinical examination, an inflammatory balance and surgical
treatment with sampling and bacteriological study of the removal liquid and regular monitoring in all patients.
Results
The mean age was5 years and a half. The sexe ratio was 1.2. mean follow-up of 3 months. One patient had
dificit G6PD.
The mostaffected area was the capital in 64% of cases.
The most common location was at the knee in 32%. The most frequent diagnosis was arthritis followed by
osteomyelitis.
The antibiotics of the first intention was based on amoxicillin and clavulanic acid associated with an
aminoglycoside.
It was effective in 75%, and modified according to the results of susceptibility testing in 10 cases.
The average duration of antibiotic therapy in IV was ten days.
The duration of treatment by oral route relay varies from 10 to 21 days. The apyrexia on day 1 postoperatively
was obtained in 73%.
Conclusions
The screening of patients at risk of carrying MRSA and isolation should help keep to a minimum cross
transmission of infections and the number of non-colonized patients. Place of antibiotic therapy is
preponderant and meets pharmacodynamic and pharmacokinetic criteria that must be followed in order to
optimize medical treatment.
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SFP08 – (#119) – Short Free Paper
ACUTE OSTEOMYELITIS IN CHILDREN: CASES OF 12 YEARS
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I. Marchán , A. Matamala , D. Haro , L. Gomez , E. Mora , F. Angles , E. Cuchí
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University Hospital Mutua Terrassa, Terrassa, Spain
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Catlab, Terrassa, Spain
E-mail: [email protected]
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Keywords: Acute, Ostomyelitis, Children, Treatment
References
1. Prolonged intravenous therapy versus early transition to oral antimicrobial therapy for acute osteomyelitis
in children.
2. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community
associated methicillin-resistant Staphylococcus aureus.
3. Acute osteomyelitis and septic arthritis in children.
4. Short- versus long-term treatment for acute hematogenous osteomielitis of childhood: prospective,
randomized trial on 131-cultured positive cases.
5. Management of acute hematogenous osteomyelitis in children.
Aim
Acute osteomyelitis is a rare but important infection because of its severity or its complications or sequelae. In
early stages it can be difficult to recognize.
We review the literature and our series of the last 12 years in order to adapt the diagnosis and treatment of
this disease.
Methods
Retrospective January 2003 to March 2015, with a total of 44 patients. Demographic, clinical, diagnostic and
therapeutic variables, as well as monitoring and evolution are collected.
Results
The mean age was 98 months (range 13-164 months); only 5 patients were younger than 5 years (25%). The
male/female ratio resulted 17/7.
Localization, 75% was in the lower extremities and 20% had pelvic disease. There was history of trauma in 33%
of cases and clear skin entrance door in 33% of cases.
As for the clinic, the pain was constant (100% of cases) and fever occurred in 85% of patients (mean time
before the diagnosis 4.3 days).
The complications encountered 4 patients jurisdiction as abscess (16%), and 3 associated with arthritis (12%).
Analytically, the average numbers of leukocytes was 9555/mm3, CRP 68 mg / L and ESR 41 mm / h, noting that
only 20% had leukocytosis. Germ was isolated in 54% of cases, and in all isolated S. aureus (blood culture
positive patients 12/24, 4/5 patients with bone material culture).
Rx was performed at 75% of cases, bone scan and MRI to 83% to 70%.
The average hospital stay was 16 days and mean intravenous and oral treatment were 14 and 30 days
respectively.
Only one patient has consequences in the form of chronic osteomyelitis with functional impairment.
Conclusions
In our series we include a higher average age (8 years in the literature more than 50% are children under 5
years) and pelvic location (20%) and different data to literature.
We note the limited laboratory abnormality of many patients with little apparent clinics in early stages can
delay diagnosis.
We also want to emphasize the importance of trying insulation etiological treatment directed by susceptibility
and secure.
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SFP09 – (#146) – Short Free Paper
BONE ECHINOCOCCOSIS: ABOUT 6 CASES.
R. Elafram, R. Boussetta, I. Jerbi, S. Bouchoucha, W. Saied, M. Nessib
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Children Hospital, Tunis, Tunisia
E-mail: [email protected]
Keywords: Hydatid Cyst, Pediatrics, Echinococciasis, Osteoarticular System
References
ArazI M, MemIk R, Kapicioglu MI. Answer please. Hydatid disease of the spine. Orthopedics 1998
21(8):912,909-910.
Agarwal S, Shah A, Kadhi SKM, Rooney RJ: Hydatid disease of the pelvis. Clin Orthop 1991; 280:251-255.
Szypryt EP, Morris DL, Mulholland RC: Combined chemotherapy and surgery for hydatid bone disease. J Bone
Joint Surg 1987; 69B(1):141-144.
Alldred AJ, Nisbet NW: Hydatid disease of bone in Australasia. J Bone Joint Surg 1964; 46B(2):260-267.
Booz MK: The management of hydatid disease of bone and joint. J Bone Joint Surg 1972; 54B(4):698-709.
Aim
Hydatid disease of the bone and soft tissue of the musculoskeletal system is uncommon.
The dissemination mode leads to local malignancy with severe prognosis.
Tunisia is an endemic area of the disease. Therefore we treated many patients affected the disease.
Methods
We retrosectivelly reviwed 6 cases of bone hydatid cyst from 1990 to 2010.
There were 3 males and 3 females.
The mean age was 13 years.
Results
The localisation were 03 spinal, 2 in the proximal tibia and & localisation in trochanter.
The diagnosis were histoligical in all patient.
the mean delay for the diagnosis was 3 years.One patient with spinal localisation had neurological
complication paraplegia.
All the patient had surgical excision of the hydatid cyst.
Ther ewere 3 cases with local recurrence.
Conclusions
Because of the poor results with medical treatment, osseous hydatidosis must be treated by a radical
operation with wide excision, adapted to each localization. In the main, the prognosis of osseous hydatidosis
remains poor, especially with spinal and pelvic localizations, which are the most frequent ones.
The prognosis and treatment of osseous hydatidosis belong in the same category as a locally malignant lesion.
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Prostethic joint infection
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SFP10 – (#170) – Short Free Paper
SHOULD PREOPERATIVE ANTIBIOTICS BE TAILORED ACCORDING TO PATIENT’S COMORBIDITIES?
T. Tan, M. Gomez, C. Restrepo, A. Shahi, A. Chen
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Rothman Institute, Philadelphia, United States
E-mail: [email protected]
Keywords: Preoperative, Antibiotics, Comorbidities, Periprosthetic Joint Infection
Aim
Preoperative antibiotic prophylaxis remains one of the most important strategies for preventing periprosthetic
joint infection (PJI). Current guidelines recommend giving universal antibiotic prophylaxis to all total joint
arthroplasty (TJA) patients regardless of their medical conditions or immune status. The aims of this study
were to determine if comorbidities influence the organism profile of PJIs and to investigate if the efficacy of
the two most frequently used perioperative antibiotics (cefazolin or vancomycin) are affected by patient
comorbidities.
Methods
Using an institutional database, the influence of comorbidities on the organism profile of 1022 PJIs was
evaluated. To investigate the influence of perioperative antibiotic monotherapy (cefazolin or vancomycin
therapy) on PJI, 8575 primary TJAs were identified and analyzed based on their comorbidities. Patients with
multiple perioperative antibiotics, prior septic arthritis, unavailable perioperative antibiotic information, or
who underwent aseptic revision were excluded. PJI was determined from ICD-9 codes.
Results
While no comorbidities were associated with an increased rate of gram-positive or gram-negative infections,
metastatic disease (odds ratio [OR] 7.54, p=0.006), rheumatologic disease (OR 1.63, p=0.046), and chronic
pulmonary disease (OR 1.46, p=0.030) demonstrated an increased risk of Staphylococcus aureus PJI. In
addition, metastatic disease (OR 5.71, 95% confidence interval [CI] 1.12-26.93, p=0.018), congestive heart
failure (OR 2.2, 95% CI 1.16-4.00, p=0.010), chronic pulmonary disease (OR 1.76; 95% CI 1.09-2.78, p=0.015),
and diabetes (OR 1.66; 95% CI 1.08-2.52, p=0.019) were associated with PJI from antibiotic resistant
organisms. However, there was no difference in the rate of PJI between cefazolin and vancomycin
monotherapy when stratified for the aforementioned comorbidities.
Conclusions
The present study reveals that comorbidities do not significantly alter the organism profile of high-risk
comorbidities and that comorbidities associated with immune deficits do not influence the rate of PJI between
two different antibiotics. The results of this study thus support current guidelines, which provide a universal
recommendation rather than a protocol that is tailored to a patient’s preexisting comorbidities.
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SFP11 – (#199) – Short Free Paper
PATIENT AND SURGICAL PREDISPOSING FACTORS FOR PERIPROSTHETIC SHOULDER INFECTION
L. Nagaya, M. Salles, A. Miyazaki, M. Fregoneze, P. Santos, L. Da Silva, G. Sella, L. Takikawa, S. Checcia
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Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
E-mail: [email protected]
Keywords: Prosthetic Shoulder Infection, Risk Factor, American Society Of Anesthesiologists Score,
Pseudomonas Aeruginosa
Aim
Shoulder arthroplasty has been performed by many years for the treatment of several conditions such as
osteoarthritis, umeral head avascular necrosis and proximal umeral fractures following traumas. Surgical site
infection (SSI) following shoulder arthroplasty remains a challenge, which increases morbidity including
reoperations, implant removal, poor mobility, and raises extra medical costs. Identification of risk factors may
help implementing adequate strategies to prevent infection. We aim to identify pre- and intra-operative risk
factors associated with deep infections in shoulder arthroplasty.
Methods
An age and sex-matched case control study was conducted to describe the prevalence rate, clinical and
microbiological findings and to evaluate patient and surgical risk factors for shoulder arthroplasty-associated
infections (SAIs), among 158 patients who underwent shoulder replacement surgery due to any reason, from
1988 to 2011 at a tertiary public university institution. To evaluate risk factors from SAI we performed uni- and
multivariate analysis by multiple logistic regression.
Results
We analyzed 168 prosthetic shoulder replacement surgeries from 158 patients, with an overall infection rate
of 9.5%, (16/168 cases). Gram-positive cocci and Gran-negative bacilli were equally isolated in 50% of cases,
however the most common bacteria detected (18.8%) was Pseudomonas aeruginosa. Univariate analysis
identified neither specific comorbidity nor pre-operative risk factors, but American Society of Anesthesiologists
(ASA) score higher than 2 (odds ratio [OR] = 5.30, 95% confidence interval [CI] = 1.58 to 17.79; p=0,013) to be
significant preoperative patient-related predisposing factor for SAI. On univariate analysis, the only surgeryrelated factor significantly associated with higher risk of SAIs was the presence of surgical haematoma (OR =
7.1, 95% CI = 1.1 to 46; p=0.04). On multivariate analysis ASA score higher than two (OR = 4.7, 95% CI = 1.3 to
16.9; p=0.01) was the only independent predictor for periprosthetic shoulder infection.
Conclusions
This study identified unusual pathogens and confirmed previously patient-related known factors such as higher
ASA score that predispose to SAIs.
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SFP12 – (#110) – Short Free Paper
ACUTE POSTOPERATIVE PERIPROSTHETIC JOINT INFECTION AFTER POSTTRAUMATIC HIP
HEMIARTHROPLASTY. IS CURRENT ANTIBIOTIC PROPHYLAXIS STILL VALID?
P. Corona, I. Gallardo, T. Larrainzar, D. Rodriguez-Pardo, C. Pigrau, C. Amat, L. Carrera
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Vall d´Hebron University Hospital, Barcelona, Spain
E-mail: [email protected]
Keywords: Periprosthetic Joint Infection, Hip Fracture, Antibiotic Prophylaxis
Aim
Acute postoperative periprosthetic joint infection (PJI) is a serious complication after any hemiarthroplasty
(HHA) implanted due to a proximal hip fracture. The growing number of chronic institutionalized geriatric
patients (CIGP) colonized with multi-drug resistant bacteria (e.g.: MRSA), not covered by usual antibiotic
prophylaxis, has been identified as a risk factor for PJI after HHA. We therefore sought to compare the HHA
infection characteristics between non-institutionalized patients (NIP) with proximal hip fractures and CIGP. We
investigate (1) the rate of compliance with a new proposed protocol, (2) the acute infection rate, 3) the
microbiologic characteristics of the infection, and 4) the success of the new protocol.
Methods
We gathered clinical, operative and infection data on all patients who underwent HHA due to a proximal
femoral fracture in our center, during a 3-year period. We focus in the cases of acute postoperative infection
(Zimmerli´s criteria). The new proposed antibiotic prophylaxis is cefazolin except in CIGP in which cotrimoxazole is used.
Results
During the study period a total of 385 HHA in 385 patients were performed. In all cases the HHA was
performed after a proximal femoral fracture. Overall, 109 patients (28,2%) were CIGP. We found an acute
postoperative PJI in 21 out 385 HHA procedures, that is, a global acute infection rate of 5.43%. Ten out 109
(9.17%) CIGP patients resulted infected compared to 11 out 278 (3.9%) non-institutionalized patients (p:
0.049). One or more causative microorganisms were identified in 20/21 (95%) of PJI. Globally the GramNegative bacilli group accounted for the majority of the infections (60%). Staphylococus aureus was isolated in
3 cases (8.6%) with only a single MRSA infection. The percentage of polymicrobial infections was 47% (10 out
of 21). Co-trimoxazole was used in the prophylaxis in 80.1% of the CIGP. In the infected cases a non-effective
drug against the microorganism was used in the prophylaxis in 17 (81%) of the acute infected HHA.
Conclusions
We confirm that institutionalized patients are more prone to acute infections after a HHA. Our current strategy
of antibiotic prophylaxis has showed to be effective in preventing MRSA PJI in CIGP. However, we found an
increased rate of infection due to gram-negative bacilli non-covered by the current antibiotic prophylaxis.
According our data an extended antibiotic prophylaxis on gram-negative drug will be proposed to be
implemented in CIGP scheduled to a HHA because a proximal femoral fracture.
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SFP13 – (#76) – Short Free Paper
WOUND DRAINAGE IN THE FIRST 12 POSTOPERATIVE HOURS CORRELATES WITH PROSTHETIC JOINT
INFECTIONS, A CASE CONTROL STUDY
K. Kremers-Van De Hei, A. Voss, S. Koëter
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Canisisius Wilhelmina Hospital, Nijmegen, The Netherlands
E-mail: [email protected]
Keywords: Wound Leakage, Periprosthetic Joint Infection,
Aim
A Prosthetic Joint infections (PJI) is an orthopedic disaster. There is a direct correlation between persistent
wound drainage (>72 hours) and the development of a PJI. It is unknown if early wound drainage (<12 hours) is
correlated with PJI.
Methods
We included 753 consecutive patients treated with a Total Hip Arthroplasty (THA) or Total Knee Arthroplasty
(TKA) operated between december 2012 and december 2013. All patients were treated according to our local
fast track joint surgery protocol. We retrospectively analyzed the prospectively collected data on wound
drainage and PJI.
The diagnosis PJI was established according to the definition by the International Consensus Group on
Prosthetic Joint Infections. Per PJI-case, two control-cases were matched on type of surgery (THA or TKA) and
day of surgery. Analysed variables were co-morbidities, medication, use of drains, haematoma, wound
drainage and dressing changes. Statistical analysis was done using Kaplan Meier logistic regression with
statistic significance set at p<0.005.
Results
In 753 included patients, 25 PJI-cases were identified and 50 controls were matched. Cases had significant
more wound drainage (88% vs 36% P=0.001)) and wound dressing changes (56% vs 18% P=0.006) in the direct
postoperative phase (<12 uur postoperative). Cases had more haematoma (44% vs 10% P=0.005). We found
no association between PJI and co-morbidity, medication and use of drains.
Conclusions
We found that wound drainage directly postoperative (<12hr) correlated with PJI. We believe that direct post
operative drainage is of crucial importance in the development of PJI and inhibition of drainage offers
opportunities for prevention of PJI. The use of tranexamic acid, suction drains and critical evaluation of
guidelines for preventing thrombo embolic events all offer reducing the risk on wound drainage and the
development of PJI.
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SFP14- (#278) – Short Free Paper
FAVORABLE RESULTS FOR TREATMENT OF ANAEROBIC PERIPROSTHETIC KNEE INFECTION
S. Chen, Y. Chang
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Chang Gung Memorial Hospital, Linkou, Taiwan
E-mail: [email protected]
Keywords: Anaerobic Infection, Periprosthetic Joint Infection
References
Marculescu CE. Clin Orthop Relat Res 2006;451:55-63.
Brook I. J Orthop Sci 2008;13:160-169.
Aim
Little information is available regarding the demographic characteristics and outcomes of patients with
periprosthetic joint infection (PJI) resulting from anaerobic organisms, especially in the knee joint.
Methods
We performed a retrospective cohort analysis of all cases of knee PJI that were treated at our institution
during the period from 2005 through 2012.
Results
Anaerobes were involved in 11 (13%) of 86 first-time episodes of knee PJI, and peptostreptococcus was the
most commonly isolated pathogen (10 [91%] of the 11 episodes). The average age of patients was 70 years
(range, 62 to 79) and women were more than men (7 vs. 4) to develop anaerobic PJI. Of the 11 episodes of
anaerobic PJI, 8 (73%) were treated with 2-stage revision arthroplasty for chronic latent infection, and 3 (27%)
with parenteral antibiotics for positive intraoperative culture. Those treating with 2-stage revision arthroplasty
had average 21 months prosthetic age (range, 2 to 41), and 10 weeks interim period between stages (range, 7
to 14). The overall successful rate for treating anaerobic knee PJI was 90%, and 88% for chronic latent
infection.
Conclusions
naerobic PJI represents a substantial proportion of all occurrences of knee PJI. Treating with resection of the
prosthesis and subsequent reimplantation is associated with a favorable outcome for chronic latent infection.
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SFP15- (#82) – Short Free Paper
IODINE IMPREGNATED INCISION DRAPES AND BACTERIAL RECOLONIZATION IN SIMULATED TOTAL KNEE
ARTHROPLASTY, AN EXPERIMENTAL RANDOMIZED CONTROLLED TRIAL
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N. Milandt , T. Nymark , H.J. Kolmos , C. Emmeluth , S. Overgaard
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University of Southern Denmark, Odense, Denmark
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Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
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Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
E-mail: [email protected]
Keywords: Incision Drape, Knee, Arthroplasty, Infection
References
1. Webster 2013, Cochrane Database
2. Alexander 1985, Arch Surg
3. Cooper 2013, Int Wound J
4. Ioban 2™, 3M Healthcare, US
5. Williamson 1965, J Invest Dermatol
Aim
We conducted a randomized controlled trial (RCT) to investigate if iodine impregnated incision drapes (IIID)
increases bacterial recolonization rates compared to no drape use under conditions of simulated total knee
arthroplasty (TKA) surgery.
Background: To prevent surgical site infection (SSI), one of the important issues is managing the patient´s own
skin flora. Many prophylactic initiatives have been suggested, including the use of IIID. IIID has been debated
for many years and was deemed ineffective in preventing SSI in a recent systematic review [1], while some
evidence suggests a potential increase in postoperative infection risk, as a result of IIID use [2].
IIID is sparsely investigated in orthopaedic surgery. An increase in the number of viable bacteria in the surgical
field of an arthroplasty operation has a potential to increase the risk of SSI in an otherwise elective and clean
procedure [3].
Methods
20 patients scheduled for TKA were recruited. Each patient had one knee randomized for draping with IIID [4]
while the contralateral knee was left bare, thus the patients acted as their own controls. Operating theater
settings with laminar airflow and standard perioperative procedures were simulated. Sampling was performed
with the cup-scrup technique [5] using appropriate neutralizers. Samples were collected from the skin of each
knee prior to disinfection and on 2 occasions after skin-preparation, 75 minutes apart. Bacterial quantities
were estimated by spread plating with 48-hour aerobic incubation. Outcome was measured as colony forming
units per square centimeter of skin. We used Wilcoxon signed-rank test for comparative analysis within and
between knees.
Results
Following skin-disinfection we found no significant difference in bacterial quantities between the intervention
and the control knee (p = 0.388). Neither did we see any difference in bacterial quantities between the two
groups after 75 minutes of simulated surgery (p = 0.367). When analyzed within the intervention and control
group, bacterial quantities had not significantly increased at the end of surgery when compared to baseline,
thus no recolonization was detected (p = 0.665 and 0.609, respectively).
Conclusions
Iodine impregnated incision drapes did not increase bacterial recolonization rates in simulated TKA surgery.
Thus, the results of this RCT study does not support the hypothesis that iodine impregnated incision drapes
promotes bacterial recolonization and postoperative infection risk.
Acknowledgements
Grete & Sigurd Petersen´s Fund
Grossier LF Foght´s Fund
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SFP16 – (#27) -Short Free Paper
VANCOMYCIN AND CEFTAZIDIME IN BONE CEMENT AS A POTENTIALLY EFFECTIVE TREATMENT FOR
PERIPROSTHETIC JOINT INFECTION
Y. Chang, S. Lee
1
Chang Gung Memorial Hospital, Taoyuan, Taiwan
E-mail: [email protected]
Keywords: Antibiotic Bone Cement, Periprosthetic Joint Infection
References
Liquid gentamicin and vancomycin in bone cement: a potentially more cost-effective regimen. J Arthroplasty.
2009 Jan;24(1):125-30. doi: 10.1016/j.arth.2008.01.131. Epub 2008 Feb 14.
Aim
This study aimed to determine the optimal formulation of antibiotic-loaded bone cement (ALBC) for
periprosthetic joint infection (PJI) using both in vitro and in vivo models incorporating various combinations of
gram-positive and gram-negative antibiotics.
Methods
The in vitro antibiotic release characteristics and antibacterial capacities of ALBCs loaded with either 4 g of
vancomycin or teicoplanin and 4 g of ceftazidime, imipenem, or aztreonam were measured against methicillinsusceptible S. aureus, methicillin-resistant S. aureus, coagulase-negative staphylococci, Pseudomonas
aeruginosa and Escherichia coli. ALBC spacers with superior in vitro antibacterial capacity were then implanted
into ten patients (five females and five males between 29 and 75 years of age) diagnosed with chronic
hip/knee PJIs and antibacterial activities within joint fluid were measured. The average duration of ALBC
spacer implantation was 80 days (range, 36–155 days). Antibiotic concentrations and antibacterial activities of
joint fluid at the site of infection were measured during the initial period as well as several months following
spacer implantation.
Results
Cement samples loaded with vancomycin/ceftazidime or teicoplanin/ceftazidime exhibited equal or longer
antibacterial duration against test bacteria as compared with other ALBCs. Joint fluid samples exhibited
antibacterial activity against the test microorganisms including ATCC strains and clinically isolated strains.
There were no adverse systemic effects, infection at second stage re-implantation, or recurrent infection at
final follow-up.
Conclusions
Vancomycin/ceftazidime ALBC provided broad antibacterial capacity both in vitro and in vivo and was shown
to be an effective and safe therapeutic measure in the treatment of hip/knee PJIs.
Acknowledgements
We thank H.Y. Hsu for performing bioassay.
15
SFP17 – (#175) – Short Free Paper
ADMINISTRATION OF VANCOMYCIN TO PATIENTS WITH A REPORTED PENICILLIN ALLERGY RESULTS IN A
HIGHER RATE OF RESISTANT ORGANISM INFECTIONS
1
2
1
1
T. Tan , B. Springer , J. Parvizi , A. Chen
1
Rothman Institute, Philadelphia, United States
2
OrthoCarolina, Charlotte, United States
E-mail: [email protected]
Keywords: Vancomycin, Penicillin Allergy, Resistant Organisms, Periprosthetic Joint Infection, Total Joint
Arthroplasty
Aim
Perioperative antibiotic prophylaxis remains one of the most important strategies for prevention of
periprosthetic joint infection (PJI) with current guideline recommending a first or second generation
cephalosporin. Penicillin (PCN) allergy is often reported by patients, which often results in avoidance of
administration of cephalosporins due to fear of cross-reactivity. Alternative medications, such as vancomyin,
are often used despite reduced antimicrobial coverage. The purpose of this study was to determine if PCN
allergic patients who received vancomycin alone prior to elective primary total joint arthroplasty were at
increased risk of developing a subsequent PJI.
Methods
A retrospective review of 7,602 primary total joint arthroplasties (TJAs) performed between 2005 and 2013 in
two institutions were identified using a prospective institutional database. Patient reported PCN or
cephalosporin allergy was electronically queried from the anesthesia note. Patients who recieved multiple
prophylactic antibiotics, or had unavailable perioperative antibiotic information, or those who received
medication other than cefazolin and vancomycin were excluded. PJI was determined using a cross-match with
an institutional PJI database constructed from International Classification of Diseases (ICD)-9 codes. Logistic
regression analysis was then performed to evaluate the risk of subsequent PJI.
Results
The rate of PJI was 1.4% (32/2296) in patients with a reported PCN allergy that received vancomycin alone
versus 1.1% (59/5306) in non-PCN allergic patients that received cefazolin alone. The multivariate analysis,
with the given sample size, did not detect a statistically significant increased risk of PJI when vancomycin was
administered alone (adjusted odds ratio: 1.23, 95% CI 0.6-3.1, p=0.35). While there was no significant
differences in the organism profile between PJIs in both groups, the rate of PJI caused by resistant organisms
was higher in patients who received vancomycin alone (11.9%, 7/59) compared to those who received
cefazolin (3.1%, 1/32).
Conclusions
While administration of perioperative prophylactic vancomycin alone during elective primary arthroplasty
does not seem to result in a higher rate of subsequent PJI, patients who received vancomycin alone and
developed a PJI were more likely to develop an infection with an antibiotic resistant organism. Future studies
are needed to determine the most appropriate prophylactic antibiotic for patients who undergo elective
arthroplasty and report PCN allergy.
16
SFP18 – (#96) – Short Free Paper
INFECTION AFTER PRIMARY KNEE REPLACEMENT - INCIDENCE AND PATHOGENS, OUR LOCAL PRACTICE
C. Sá Barros, L. Rodrigues, B. Direito Dos Santos, B. Pereira, M. Vieira Da Silva, J. Martins-Pereira, N. Tavares, R.
Fidalgo
1
Hospital de Braga, Braga, Portugal
E-mail: [email protected]
Keywords: Incidence,Arthroplasty, Knee Prosthesis, Prosthesis-Related Infections/Diagnosis,Prosthesis-Related
Infections/Prevention & Control
References
Parvizi, Journal of AAOS, Journal of Bone and Joint Surgery, AAOS Now
Aim
Infection after total knee replacement, which is a serious and expensive complication, often represent a
diagnostic and therapeutic problem. The current incidence of infection after the primary procedure is 1 to 3%,
depending on the published series. A correct and timely diagnosis, classification between early and delayed
infection, and which microorganisms are involved, are crucial steps in defining prevention and treatment
strategies.
Determination of the annual and three years incidence of infection after primary total knee replacement;
evaluation of the microorganisms involved and its resistance patterns; assessment of treatment – surgical
approach and selection of antibiotics.
Methods
Collection of clinical and laboratorial data of all patients who underwent primary total knee arthroplasty
between 2011 and 2013 in our hospital; definition of periprosthesic infection cases following the
Musculoskeletal Infection Society (MSIS) criteria.
Results
During the study period, 526 primary knee replacements were performed in 521 patients; with 41 patients
having bilateral replacements. The mean follow-up period was 30 months; 5 patients had no follow up and 1
died in the post operatory.
We reported 9 prosthetic infections, of which 2 did not reached the MSIS criteria, but were also considered
based on high clinical suspicion. The majority of the cases (6) were delayed infections. The calculated 3 year
incidence of infection after primary knee replacement was 1,6%, with annual rates of 3,0% (2011), 1,7% (2012)
and 0,9% (2013). The microorganisms isolated were as follows: Staphylococcus aureus and coagulase-negative
staphylococci, resistant to penicillin; Streptococcus agalactiae and one isolate of Serratia marcescens, both
showing multiple antibiotic resistances.
Only one case was treated with surgical debridement and conservation of prosthesis, in the other 8 cases a
two-stage implant revision procedure was performed. The antibiotics selected were vancomycin,
fluoroquinolones and association of gentamicin and clindamycin.
Conclusions
Our local infection rates are in line with the published series from reference surgical centers. The annual
incidence is decreasing, probably because the majority of our infection cases are delayed (recent years, shorter
follow up period) and our preventive measures are improving. The microorganisms identified are also in
agreement with published data, and our antibiotic resistance pattern is a valuable information to consider in a
first empirical approach.
Treatment options suitable to each case, and antibiotic protocols need to be improved in our local practice.
Preventive measures in delayed infections are still under debate, and represent another future challenge.
17
SFP19 – (#102) – Short Free Paper
RETROSPECTIVE ANALYSIS OF SURGICAL SITE INFECTION INCIDENCE AFTER TOTAL KNEE OR HIP
ARTHROPLASTY
M. Gomes, F. Ramalho, M. Oliveira, R. Couto, J. Moura, T. Barbosa, C. Vilela, M. Mendes
1
Centro Hospitalar do Alto Ave, Guimarães, Portugal
E-mail: [email protected]
Keywords: Surgical Site Infection, Total Knee Arthroplasty, Total Hip Arthroplasty
References
Vigilância das infecções do local cirúrgico: HELICS-CIRURGIA 2006-2010 PNCI, 2012
Surgical Site Infection Event, 2015. Centers for Disease Control and Prevention.
Aim
Surgical Site Infection (SSI) is one of the most frequent nosocomial infections and depends on many factors:
patient, microorganism, antiseptic solution use, antibiotic prophylaxis, hand scrubbing, wound care or hospital
stay lenght.
With the present paper the authors aim to study the SSI incidence after Total Knee (TKA) or Hip Arthroplasty
(THA).
Methods
All patients who underwent primary TKA or THA between January 2011 and May 2012 at our institution were
considered. Patients who died within 1 year after the procedure of unrelated causes were excluded. Data
collected included ASA classification, type of procedure, total and post-operative hospital stay, type and
duration of antibiotic prophylaxis.
Data were collected from the consultation at 1 month and 1 year post-operative, clinical registries and
telephone interview. SSI was defined according to the Centers for Disease Control and Prevention criteria.
Suspected cases of SSI included antibiotic administration longer than 5 days or absence of antibiotic
prescription, hospital stay after the procedure longer than 9 days, patient referring infection symptoms, and
clinical data reports of infection or re-intervention.
Results
During the studied period and after exclusion of 5 cases, a total of 251 surgeries (104 TKA, 147 THA) were
performed, of which 2 were urgent.
For both TKA and THA, the average total hospital stay was 9 days (8 days post-operative). The majority were
American Society of Anesthesiologists (ASA) classification 2 and 3.
There were 4 SSI (1,60%), 2 TKA (1,92%) and 2 THA (1,36%), all of them after discharge. Their average total
hospital stay was 10,5 days.
Antibiotic prophylaxis was used in 93% of the patients (97,4% a cephalosporin), with an average length of 5,7
days.
Conclusions
Recommended hospital stay after a TKA or THA is about 5 days. On HELICS-CIRURGIA 2006-2010 report it was
10 days, similar to ours. In infected patients, our total hospital stay was lower (10,5 vs 26).
Recommended duration of antibiotic prophylaxis is 24h. On HELICS-CIRURGIA more than 50% had it for more
than 24h, which also happened with us; our antibiotic coverage was similar.
Comparing to HELICS-CIRURGIA, the predominance of ASA 2 and 3 classifications was similar, but the overall
SSI rate was lower (1,6% vs 2,24%).
We conclude we must reduce hospital stay and antibiotic duration and keep the surveillance of SSI after TKA or
THA.
Acknowledgements
We appreciate our Infection Control Comission colaboration.
18
SFP20 – (#219) – Short Free Paper
PROSTHETIC JOINT INFECTION (PJI) DUE TO ENTEROBACTER CLOACAE
E. Bonnet, B. Dubouil, J. Lourtet, P. Marlin, M. Félicé, A. Bicart-See, G. Giordano
1
Joseph Ducuing Hospital, Toulouse, France
E-mail: [email protected]
Keywords: Prothetic Joint Infection, Enterobacter Cloacae, Resistance To Antibiotics
Aim
PJI du to Enterobacter cloacae are rare and often severe. The aim of our study is to define the history of
patients with such infections and their outcome.
Methods
We conducted a retrospective monocentric study in an orthopedic unit where complex bone and joint
infections are supported. From 2011 to 214 we selected patients with E. cloacae PJI based on data from the
microbiology laboratory. In their files we collected information on their background, their medical and surgical
history, antibiotics they received in the year before infection, the suspected portal of entry, the management
and the outcome.
Results
Twelve patients were included, 7 male and 5 female. PJI was located to the hip in 8 cases, the knee in 3 cases
and the ankle in one case. The average time between the placing of the first prosthesis and infection was 3
years. Eleven patients had one or more surgery for previous PJI. The average time elapsed since the last
surgery was 30 days. Eleven patients had been treated with antibiotic combinations for at least 6 weeks, in the
year before E cloacae infection. A portal of entry was identified only two times: urinary tract infection in one
patient and catheter-related infection in one patient. Antibiotics the more often prescribed were carbapenems
(n = 5) and cefepime (n = 4), each combined with quinolones (n =4) or fosfomycin (n = 3). Two patients
required an additional debridement within an average of 18 days. Infectious outcome was favorable in 8 cases
(67%) with a median duration of follow-up of 26 months. Two patients had a recurrent infection, one due to
Streptococcus oralis and one to Candida albicans. One patient had a relapse of E cloacae infection. One patient
died from unknown cause.
Conclusions
PJI infections due to E.cloacae usually occur early after prosthetic surgery, typically in patients with complex
surgical history. Despite a high rate of multi-resistance to antibiotics, outcome may be favorable in a large
majority of patients.
Acknowledgements
special thanks to the anaesthesists team and the pharmacy department for their involvement in the
managemnt of these patients.
19
Revision surgery in infected joint replacement
20
SFP21 – (#233) – Short Free Paper
MICROBIOLOGICAL SPECTRUM EVOLUTION IN PROSTHETIC JOINT INFECTIONS BETWEEN 2003-2008 AND
2009-2013: RESULTS OF A SINGLE INSTITUTION IN PORTUGAL
P. Neves, P. Barreira, P. Serrano, M. Silva, P. Leite, A. Pinto, P. Pereira, R. Sousa
1
Centro Hospitalar do Porto, Porto, Portugal
E-mail: [email protected]
Keywords: Prosthetic Joint Infection, Empiric Antibiotic Therapy, Comparative Study
References
Although the microbiological spectrum of prosthetic joint infection(PJI) is well established, it is highly variable
among different geographic settings.Countries in southern Europe and Portugal specifically are known to have
a widespread antimicrobial resistance to antibiotics.Empirical antibiotic therapy is often necessary before
definitive results are available and it is therefore essential to know the local microbial flora in order to make
adequate recommendations.
Aim
We aim to describe the microbiological spectrum and relevant antibiotic susceptibility profile of PJI in our
institution over a five-year period(2009-2013) and determine its evolution considering the preceding six
years(2003-2008) thus evaluating the adequacy of our empirical antibiotic regimen.
Methods
We retrospectively reviewed the records of 96 consecutive PJI (51 hips:45 knees) treated from May 2009December 2013. Demographics, microbial species and antibiotic susceptibility were recorded. These results
were then compared to those previously obtained by studying the 2003-2008 time period.
Results
Infections were polymicrobial in 27 cases(28.1%) and only two cases(2.1%) were culture-negative accounting
for a total of 132 different culture results.
S.aureus grew in 37 samples(28.0%) being the most frequently isolated microorganism. Coagulase-negative
staphylococci grew in 32 samples(24.2%) and gram negative bacteria in 35 samples(26.5%). Other Gram
positive species (most commonly enterococci and streptococci) were isolated in 26 samples(19.7%).
Comparing 2009-2013 to 2003-2008, there was a significant increase of polymicrobial infections – 28% vs.
8%(OR=4.6, 95%CI [1.9-11.3]) and a significant decrease of culture-negative cases – 2% vs. 18%(OR=0.1, 95%CI
[0.02-0.4]). It is also noteworthy that the prevalence of gram negative isolates was significantly increased 26.5% vs. 13.3%(OR=1.3, 95%CI [1.1-1.6]).
Antibiotic susceptibilities study showed a 41.4% methicillin resistance among S.aureus and even higher among
coagulase-negative staphylococci isolates(57.7%). This is a not quite significant decrease compared to the
earlier period(p=0.10). We also found a high rate antibiotic resistance among gram negative:
ampiciline(81.8%), amoxicilin/clavulanate(59.1%), ciprofloxacin(19.2%), aminoglycosides(17%), third
generation cephalosporins(14.6%) and even carbapenems(13.6%).
Conclusions
These results show that our sampling protocol has improved considerably as the proportion of culturenegative cases has dramatically decreased. On the other hand this may also help explain the increase in
polymicrobial infections. We have no clear explanation for the increase in gram negative bacteria.
Despite the downward trend we still face a very significant proportion of methicillin-resistant staphylococci
infections. The antibiotic resistance profile among gram negative bacteria is also worrying. As such we believe
a regimen consisting of vancomycin and gram-negative coverage such as aminoglycosides or a third generation
cephalosporin is still warranted in our institution.
21
SFP22 – (#66) – Short Free Paper
PILOT IN VIVO EVALUATION OF A RESORBABLE ANTIBIOTIC-ELUTING BONE VOID FILLER TO PREVENT
PERIPROSTHETIC JOINT INFECTION
1
2
2
K. Sinclair , Z. Ferrell , D. Grainger
1
Elute, Inc., Salt Lake City, United States
2
Univeristy of Utah, Salt Lake City, United States
E-mail: [email protected]
Keywords: Preclinical Sheep Animal Model, Periprosthetic Joint Infection, Controlled Drug Release,
Tobramycin, Bone Void Filler
References
1. Sinclair et al. Orthopaedic Trauma Association annual meeting, Oct.16-18,2014. Tampa, FL.
2. Brooks et al. PLoSOne 2015DOI:10.1371/journal.pone.0118696
3. Brooks et al. J Biomed Mater Res Part B 2013.102,1074-1083.
Aim
A resorbable, antibiotic-eluting bone void filler (AEBVF) was developed to address device-related infections.
The AEBVF provides two functions: osteoconductive matrix for bone restoration, and local antibiotic delivery
to treat device-related infections. In vitro evaluations of this AEBVF demonstrated antimicrobial activity to 7
weeks against Staphylococcus aureus (S. aureus).1 Subsequent rabbit studies demonstrated bactericidal
capacity2 of the AEBVF against 105 CFU S. aureus and osteoconductivity.1 We hypothesized that the AEBVF
would restore bone volume while eliminating 105 CFU S. aureus in a pilot sheep femoral condyle defect model.
Methods
Four groups (n=2/group) were utilized to assess osteoconductivity (Group A-commercial ProOsteon & BAEBVF) and antimicrobial activity (Group C-ProOsteon with 105 CFU S. aureus & D-AEBVF with 105 CFU S.
aureus). AEBVF devices comprised degradable polymers (PCL, PEG, PLGA), ProOsteon (Biomet, USA), CaCl2,
and tobramycin.3 Devices (1.5cc ProOsteon or 6 AEBVF croutons) were implanted into rectangular defects in
the medial face of each sheep femoral condyle. Defects were evaluated using backscatter electron microscopy,
mineral apposition rate (MAR) analysis, and light microscopy with Sanderson’s Rapid Bone Stain (SRBS).
Results
All animals in Groups A, B, and D survived to the 12-week endpoint. In contrast, Group C animals were
euthanized 11 days post-op. MAR and SRBS demonstrated comparable bone remodeling and defect
restoration after 12 weeks in Groups A, B, and D. Notably, implant volumes of Groups A and D were greatly
diminished (0.16±0.1%; 0.35%) after 12 weeks, compared to Group A (13.23±3.2%) and Time “0” (16.8%).
Conclusions
These data show the AEBVF device’s ability to: eliminate 105 CFU S. aureus, promote bone remodeling
comparable to known bone void filler, and degrade at rates that do not interfere with bone remodeling.
22
SFP23 – (#80) – Short Free Paper
HIGHER CONCENTRATION OF VANCOMYCIN AND GENTAMYCIN IN JOINT FLUID FROM IN THEATRE-MADE
HIPSPACERS COMPARED TO COMMERCIALLY AVAILABLE READY-MADE HIPSPACERS
J. Slastad, H. Steen
1
Oslo University Hospital, Oslo, Norway
E-mail: [email protected]
Keywords: Hip ,Spacer,Antibiotic, Elution
Aim
We wanted to study the risk of systemic toxic effect of gentamycin/vancomycin loaded spacers, and to
investigate whether there is any difference in the elution of gentamycin and
vancomycin to the joint fluid between theatre- made and in factory ready-made spacers
Methods
The study consists of 28 patients.
In group one, 14 patients were given a in factory ready-made spacer containing gentamycin 1,1g – 3,2g and
vancomycin 1,1g – 3,2g depending of the size of the spacer.
In group two, 14 patients were given spacers made in the operating theatre. from PMMA containing 0,5 g
gentamycin in each 40 g batch. 4 g vancomycin were added to each batch of 40 g PMMA. .
The concentration of gentamycin and vancomycin was measured from drainfluid and in serum day 1 and 2
after the operation
Results
Group one Group two Significance
Vancomycin drain day 1 10,3 (2,0-23.3) 88,5 (11,7-242,9) p<0,001
Vancomycin drain day 2 6,3 (2,0-17,5) 55,2 (7,5-161,0) p<0,001
Vancomycin serum day 1 2,0 (2,0-2,0) 1,8 (0,7-2.0) ns
Vancomycin serum day 2 2,0 (1,6-2,2) 1,9 (1,0-2,0) ns
Gentamycin drain day 1 23,4 (0,5-68,0) 44,3 (11,0-117,5) p=0,05
Gentamycin drain day 2 8,7 (0,8-16,1) 18,0 (6,8-45,3) p<0,005
Gentamycin serum day 1 0,2 (0,2-0,2) 0,3 (0,2-1,3) ns
Gentamycin serum day 2 0,2 (0,0-0,2) 0,3 (0,2-1,1) ns
In theatre-made spacers had a significant higher concentration of both gentamycin and vancomycin in the joint
fluid. Even with very high consentrations of gentamycin and vancomycin in the joint fluid the concentrations in
serum were far below the toxic limit and no toxic reactions were observed
Conclusions
Gentamycin and vancomycin added to the hip spacers only to a very small degree passes to the circulation
system.
In theatre-made spacers have a significantly higher elution of gentamycin and vancomycin than in factory
ready-made spacers. If a high initial concentration of gentamycin and vancomycin in joint fluid is desired. in
theatre-made spacers should be considered.
23
SFP24 – (#16) – Short Free Paper
DO WE CHECK ON PROSTHETIC JOINT INFECTION CAUSES CORRECTLY AND FOR LONG ENOUGH RELYING
TOO MUCH ON BIOCHEMICAL TESTS?
M. Ferrari, F. Astore, G. Santoro, A. Eusebio, F. Meda, G. Grappiolo
1
Humanitas Research Hospital, Rozzano (Milan), Italy
E-mail: [email protected]
Keywords: PJI, RARE BACTERIA
References
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897476/
http://ijs.sgmjournals.org/content/49/2/663.full.pdf+html
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4015020/;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC298417/;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC473828/
Aim
Almost any kind of bacteria can be involved in prosthetic joint infections (PJI).
Methods
In 2014 we collected data on 3 patients presenting with hip or knee pain and radiological signs of prosthetic
joint mobilization without any other clinical or biochemical suspect of infection.
Results
Interestingly, in all cases we isolated bacteria very rarely involved in human infections: Cupriavidus pauculus,
Ralstonia paucula and Neisseria flavescens. Both Cupriavidus pauculus and Ralstonia paucula are Gram
negative environmental bacteria which can contaminate water (tap, pool and mineral) and have been isolated
from a variety of human clinical sources including blood, wounds, sputum, urine, eye, throat and peritoneal
fluid, as non pathogenic flora. In such two patients we were able to cure the infection with quinolones (both
strains were sensible). Neisseria species are Gram-negative bacteria included among the proteobacteria.
Neisseria flavescens is often found in the upper respiratory tract and oropharynx of humans, rarely associated
with infectious process (necrotizing pneumonia and empyema). In this last patient we successfully used
piperacillin-tazobactam i.v. during hospitalization and shifted to amoxicillin-clavulanate per os at discharge.
Conclusions
In conclusion, any bacteria can induce PJI: in some cases pre-operative blood tests are normal and therefore
useless. We need new tests to overcome this diagnostic problem (such as alpha-defensin) and we must check
on rare bacteria prolonging incubation to a more extended period of time (as in Propionebacterium acnes or
Mycobacterium spp) and/or sending samples to specialized laboratories.
Acknowledgements
We thank all the medical and nurse staff of Prosthetic Joint Replacement Unit of Orthopaedic Center,
Humanitas Research Hospital
24
SFP25 – (#203) – Short Free Paper
ARE STREPTOCOCCAL PJI LESS SUITABLE FOR DEBRIDEMENT AND RETENTION?
M. Krašna, R. Trebše
1
Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
E-mail: [email protected]
Keywords: Streptococcal PJI, Debridement And Retention
Aim
Prosthetic joint infections (PJI) are caused by a variety of microorganisms but most frequently by
staphylococci. The results of treatment of PJI due to organisms other than staphylococci are less known. The
aim of this study is to evaluate the outcomes after streptococcal PJI.
Methods
The data of 26 streptococcal (13 hip and 13 knee PJI from 24 patients) were retrieved from hospital based PJI
register, and analyzed. There were 15 female and 11 male patients (mean age 66 y). Most (13) PJI were
hematogenous. 15 PJI had been treated with debridement and retention (D&R) of the infected joint, 1 with
permanent resection arthroplasty, 9 had two stage revision and 1 patient had one stage partial replacement.
After the microbiological diagnosis was established most patients received 2-3 weeks of penicillin G or
ceftriaxone followed by 2-6 months of oral amoxicillin. All patients had regular follow-ups after the procedure
at least at 1 month, three months and one year. The results were classified as: PJI cure (in absence of clinical
signs and symptoms of infection and with negative CRP), probable failure (in absence of clinical signs and
symptoms of infection but with elevated CRP), definite failure (if a new treatment was necessary), and
mechanical failure (aseptic loosening, periprosthetic fracture, quadriceps rupture).
Results
One foreign patient was lost to follow up. The mean follow up time for the rest was 60 months (from 16 to
167) months. There was probable prosthesis failure in 1 case, definite prosthesis failure in 7 cases and
mechanical failure in 3 cases. The mean survival time of the failed prostheses was 28 (range from 2 to 83)
months. 6 failures (40 %) occurred in group of cases that had undergone D&R, and 1 (6 %) in the two stage
revision group. Among the 7 definite failures in 4 patients antibiotic treatment was empirically started after
the symptoms reappeared resulting in long remission periods.
Conclusions
Comparing to the published results of staphylococcal PJI it seems that D&R of the prosthesis for streptococcal
PJI is considerably less successful. Rifampicin as a proven treatment of choice for staphylococcal infections is
probably the main reason for the difference. An unexpected feature of streptococcal PJI is that definite failures
are easily suppressed for long time with a short course of oral antibiotics.
25
SFP26 – (#167) – Short Free Paper
PROSTHETIC JOINT INFECTIONS: A RETROSPECTIVE STUDY ON THE TIMING OF REIMPLANTATION IN A TWOSTAGE EXCHANGE
1
2
2
A. Fischbacher , U. Furustrand-Tafin , R. Baalbaki , O. Borens
1
University of Lausanne, Lausanne, Switzerland
2
CHUV, Lausanne, Lausanne, Switzerland
E-mail: [email protected]
2
Keywords: 2-Step Exchange, Short Interval, Long Interval
Aim
Different therapeutic options for prosthetic joint infections exist, but surgery remains the key. With a twostage exchange procedure, a success rate above 90% can be expected. Currently, there is no consensus
regarding the optimal duration between explantation and the reimplantation in a two-stage procedure. The
aim of this study was to retrospectively compare treatment outcomes between short-interval and long-interval
two-stage exchanges.
Methods
Patients having a two-stage exchange of a hip or knee prosthetic joint infection at Lausanne University Hospital
(Switzerland) between 1999 and 2013 were included. The satisfaction of the patient, the function of the
articulation and the eradication of infection, were compared between patients having a short (2 to 4 weeks)
versus a long (4 weeks and more) interval during a two-stage procedure. Patient satisfaction was defined as
good if the patient did not have pain and bad if the patient had pain. Functional outcome was defined good if
the patient had a prosthesis in place and could walk, medium if the prosthesis was in place but the patient
could not walk, and bad if the prosthesis was no longer in place. Infection outcome was considered good if
there had been no re-infection and bad if there had been a re-infection of the prosthesis
Results
145 patients (100 hips, 45 knees) were identified with a median age of 68 years (range 19-103). The median
hospital stay was 58 days (range 10-402). The median follow-up was 12.9 months (range 0.5-152). 28 % and 72
% of the patients had a short-interval and long-interval exchange of the prosthesis, respectively. Patient
satisfaction, functional outcome and infection outcome for patients having a short versus a long interval are
reported in the Table.
Conclusions
The patient satisfaction was higher when a long interval was performed whereas the functional and infection
outcomes were higher when a short interval was performed. According to this study a short-interval exchange
appears preferable to a long interval, especially in the view of treatment effectiveness and functional
outcome.
Short interval (2-4 weeks)
Patient satisfaction
Good
70 %
Medium
Bad
30 %
Long interval (4 weeks and more)
Patient satisfaction
Good
78 %
Medium
Bad
22 %
Functional outcome
96 %
4%
0%
Infection outcome
96 %
4%
Functional outcome
87 %
4%
9%
Infection outcome
92 %
8%
26
SFP27 – (#198) – Short Free Paper
MID-TERM SURVIVAL OF CEMENTLESS REVISION STEMS IS INDEPENDANT FROM ONE- OR TWO-STAGE
EXCHANGE AFTER INFECTED THA
1
2
1
1
1
1
P. Born , T. Ilchmann , L. Zwicky , P. Graber , P. Ochsner , W. Zimmerli , M. Clauss
1
Kantonsspital Baselland, Liestal, Switzerland
2
Hirslanden Klinik, Münchenstein, Switzerland
E-mail: [email protected]
1
Keywords: PJI, THA, Cemetless Revision, One-Stage, Mid-Term
References
Treatment of prosthetic joint infections (PJI) after Total Hip Arthroplasty (THA) is complex and strategies are
discussed controversially. In one- & two-stage exchanges, cemented stems are frequently used.
Aim
To report mid-term results of PJI treated with uncemented stems.
Methods
: 80 hips of PJI after THA were treated with uncemented stems from 01/1993 to 12/2012 and followed
prospectively. Selection occurred for one- (n=27) or two-stage (n=53) exchange according to the Liestal
algorithm. Surgical approaches were transfemoral (n=58), transgluteal (n=9) or transtrochanteric (n=13). A
monoblock (Wagner SL, n=58) or modular (Revitan, n=22) revision stem was implanted. On the acetabular side
44 Müller rings, 33 Burch-Schneider cages (combined with a cemented PE-cup) and 3 press-fit cups were used.
Kaplan-Meier survival was calculated for endpoints (a) persistence of infection, (b) septic/aseptic stem
loosening. Radiographs were analysed for (a) subsidence, (b) distal stem integration, (c) changes in cortical
thickness, (d) proximal femur restoration, (e) radiolucency around stem/cup.
Results
Mean FU was 5.2 (2-15) years. PJI was eradicated in 77 of 80 hips (96%). 3 patients (all two-stage) had a
treatment failure. 2 were treated successfully with an additional two-stage exchange. In the 3rd patient we
were not able to control infection and exarticulation was performed. Furthermore, one stem was revised for
aseptic loosening (5 years), 1 for a broken Wagner stem (7 years) and 1 for subsidence (8 months). Stem
survival after 5 years was 93% (SD ±2.5 years). 2 cups were revised for aseptic loosening and 1 for recurrent
dislocations. Subsidence ≥5mm was found in 6 hips and occurred always within 3 months after surgery
independent of stem type (p=0.947) and approach (p=0.691). Proximal femoral remodelling after transfemoral
approach was excellent or good in 71% (32 excellent, 9 good) with no difference between one-/two-stage
exchanges (p=0.288). Initial distal stem integration was 65mm medial and 66mm lateral and increased to 8mm
medial (p=0.716) and 10mm lateral (p<0.001). Cortical thickness was unchanged over the entire FU period
(p=0.493). Radiolucencies were seen around 26 stems, only the stem revised after 5years was rated loose.
Conclusions
Eradication of PJI was high using our established protocol even with uncemented revision stems. Mid-term
survival was independent from one-/two-stage revision and comparable to results for aseptic loosening
revision.
Acknowledgements
no competing interests
27
SFP28 – (#169) – Short Free Paper
POSITIVE CULTURES DURING REIMPLANTATION INCREASE THE RISK OF SUBSEQUENT FAILURE IN TWOSTAGE EXCHANGE ARTHROPLASTY
T. Tan, J. Manrique, M. Gomez, A. Chen, J. Parvizi
1
Rothman Institute, Philadelphia, United States
E-mail: [email protected]
Keywords: Positive Cultures, Reimplantation, Failure, Two-Stage Exchange Arthroplasty
Aim
It is strongly recommended that tissue and synovial fluid culture samples be obtained during reimplantation
performed as part of a two-stage exchange arthroplasty. The incidence of positive cultures during
reimplantation and the influence of positive cultures on subsequent outcome are unknown. This aim of this
study was to determine the incidence of positive cultures during reimplantation and to investigate the
association between positive cultures at reimplantation and the subsequent outcome
Methods
A retrospective review was conducted on 267 patients that met the Musculoskeletal Infection Society (MSIS)
criteria for PJI that completed both stages of two-stage exchange arthroplasty (Table 1). Intraoperative culture
results from tissue and/or synovial fluid were obtained. Cultures were positive in 33 cases (12.4%) undergoing
reimplantation surgery (Figure 1). Treatment failure was assessed based on the Delphi consensus definition.
Logistic regression analysis was performed to assess the predictors of positive culture and risk factors for
failure of two-stage exchange arthroplasty.
Results
Treatment failure was 45.5% for those with a positive intraoperative culture and 20.9% in those with negative
cultures at the time of reimplantation. When controlling for organism virulence, comorbidities, and other
confounding factors, treatment failure was higher (odds ratio [OR]: 3.3; 95% confidence interval [CI]: 1.3-4.5)
and occurred at an earlier time point (hazard ratio: 2.5; 95% CI: 1.3-4.5) in patients with a positive
reimplantation culture. The treatment failure rate was not different between cases with two or more positive
cultures (36.4%) and one positive culture (42.8%).
Conclusions
Positive intraoperative cultures during reimplantation, regardless of the number of positive samples were
independently associated with two times the risk of subsequent infection and earlier treatment failure.
Surgeons should be aware that a positive culture at the time of reimplantation independently increases the
risk of subsequent failure and needs to be taken seriously. Given the significance of these findings, future
studies are needed to evaluate the optimal management of positive cultures during reimplantation surgery.
28
SFP29 – (#141) – Short Free Paper
DEBRIDEMENT AND IMPLANT RETENTION IN 39 CASES OF PERIPROSTHETIC HIP JOINT INFECTION – THE
RELEVANCE OF CHANGING MOBILE PARTS
1
2
1
1
1
P. Lötscher , P. Sendi , B. Kessler , P. Graber , W. Zimmerli , M. Clauss
1
Cantonal Hospital Baselland, Liestal, Switzerland
2
Inselspital Bern, Bern, Switzerland
E-mail: [email protected]
1
Keywords: Debridement, Implant Retention, Periprosthetic Hip Joint Infection
Aim
Debridement, antibiotics and implant retention (DAIR) is an established treatment option for periprosthetic
joint infection (PJI). Success rates of more than 90% cure have been reported with proper patient selection.
While a meticulous debridement of the joint and an appropriate postoperative antibiotic therapy is important
for treatment success, the relevance of changing mobile parts is still a matter of debate. The latter procedure
is only possible with an extensive soft tissue release, potentially destabilizing the joint. Though, it is impossible
with polyethylene-inlays being no longer available. The aim of this study was to evaluate whether cure of PJI
with DAIR is influenced by retaining the mobile parts.
Methods
Between 01/2004 and 12/2012, 36 patients with 39 episodes of THA-associated infections were treated with
DAIR according to our algorithm (NEJM 2004). All patients met the IDSA criteria for DAIR with a stable implant
and either a PJI diagnosed during the first postoperative month or a haematogenous PJI with infectious
symptoms of less than three weeks. Patients were treated either with a complete debridement, including an
exchange of all mobile parts (n=24), or with a complete debridement and retaining mobile parts (n=15).
Postoperatively all patients received standardized antibiotic treatment (NEJM 2004).
Results
The patients’ mean age at the time of infection was 74 (SD 9) years. Average time between onset of symptoms
and DAIR were 3.6 (0-28) days; Five patients died before the 2-year-follow-up unrelated to PJI. Mean follow-up
of the remaining patients was 45.6 (24-119) months. 20 PJI were early postoperative, 15 haematogenously
acquired, and four unclear. The most frequent causative microorganisms were coagulase-negative
staphylococci (n=16), S. aureus (n=8), streptococci (n=5) and E. coli (n=2 ). Ten episodes were polymicrobial,
and nine cases culture-negative. The overall success rate of all 39 episodes treated with DAIR was 95% (37/39).
Two treatment failures were observed, both after haematogenous S. aureus infection and exchange of mobile
parts. One of them refused further surgery and was treated with a suppressive antibiotic therapy. The other
one had a one-stage exchange four months after DAIR showing a loose cup intraoperatively.
Conclusions
Patients treated with DAIR strictly according to our treatment algorithm show a favourable result regarding
overall success rate. From our data it seems debatable, whether the exchange of all mobile parts is mandatory,
or should be individually evaluated in each case.
29
SFP30 – (#24) – Short Free Paper
THE USE OF SPACERS IN TWO-STAGE REVISION ARTHROPLASTY OF THE INFECTED HIP
1
1
2
E. Veltman , D.J. Moojen , M. Glehr , R. Poolman
1
OLVG, Amsterdam, The Netherlands
2
Medical University hospital Graz, Graz, Austria
E-mail: [email protected]
1
Keywords: Two-Stage Revision, Periprosthetic Joint Infection, Total Hip Arthroplasty
References
(1) Ethgen O. J Bone Joint Surg Am 2004 May;86-A(5):963-74.
(2) Parvizi J. J Bone Joint Surg Am 2014 Mar 19;96(6):441.
(3) Ibrahim MS. Bone Joint J 2014 Oct;96-B(10):1312-8.
(4) Anagnostakos K. Acta Orthop 2006 Aug;77(4):628-37.
Aim
Joint replacement is a highly effective intervention to treat osteoarthritis of the hip, relieving pain and
improving mobility and quality of life.(1) Periprosthetic joint infection (PJI) is a devastating complication after
arthroplasty. Debridement, antibiotics and implant retention are treatment of first choice in case of early
infection after total hip arthroplasty (THA).(2) In case of persisting infection, one- or two-stage revision needs
to be performed.(3) The use of different kinds of spacers has been widely debated in the past years.(4)
The aim of this study was to determine which type of spacer should be used during the interval of two-stage
revision of an infected THA.
Methods
A search term with Boolean operators was constructed. We extracted all information regarding study and
patient characteristics and baseline clinical and laboratory findings. Data regarding type of spacer and
antibiotics used, timing of second stage surgery, tissue culture results, postoperative regimen, functional
outcome and patient satisfaction were extracted.
Results
A total of twenty-six studies met our inclusion criteria and were included for data analysis. Ten studies
described various preformed spacers, six studies described functional spacers and eleven studies described
custom made spacers. See Table 1 for results.
Conclusions
Research should focus on finding the preferred type of treatment and type of spacer to combine a high success
rate of infection treatment with a good functional and patient reported outcome. There is a need for a
prospective study evaluating patient satisfaction and functional outcome after two-stage revision THA
comparing various spacers. Secondly, research should focus on the optimal timing of the second stage
procedure.
Functional spacers achieve a comparable rate of infection eradication in the treatment of periprosthetic hip
joint infections as compared to preformed spacers. There is insufficient evidence concerning rehabilitation and
functional outcome after two-stage revisionTHA to advocate or discourage the use of either kind of interval
spacer.
30
Author
L
N of hips Patient
N of hips
Success
FU
Year of
Age M F Type prosthesis
Failure
stage 1
FU (n)
stage 2
(%)
(months)
E
Group 1
Biring G
Leung
Masri
2010 3
2011 4
2007 4
99
50
31
48
38
29
72 52 47
64 20 18
65 21 10
48
38
29
4
9
3
89
76
90
144
58
47
Cherubino
2013 3
30
30
71
29
1
97
72
Magnan
2001 4
10
10
72
8
2
80
35
Neumann
2012 4
44
44
x
42
1
98
67
Pattyn
2010 3
61
61
65
61
2
96
36
Pignatti
2010 4
41
41
59
40
1
98
64
Romano
2011 3
20
20
56
20
1
95
57
Romano
2012 4
183
162
60
183
10
94
60
Etienne
2003 4
32
32
x
31
1
97
20
Fink
2009 4
44
39
69 20 16
39
0
100
35
Hofmann
2005 4
42
27
64 15 12
35
1
96
76
Tsung
2014 4
76
76
72 37 38
42
12
84
80
Wentworth 2002 3
135
135
66 66 69
118
24
83
x
Younger
50
50
67 22 28
48
3
94
43
38
20
42
51
56
125
46
39
56
44
17
38
20
42
49
53
125
46
39
56
44
17
54
70
61
59
62
68
67
X
62
69
62
33
18
40
49
53
125
46
39
48
44
17
4
2
3
4
4
5
4
2
8
5
0
89
90
93
91
89
96
91
96
86
93
100
48
38
55
50
37
103
35
60
32
49
38
Prostalac
Prostalac
Prostalac
Spacer17 13
G/InterSpace
Spacer7 3
G/InterSpace
Spacer25 19
G/InterSpace
30 31
Spacer-G
Spacer16 25
G/InterSpace
Spacer9 11
G/InterSpace
Spacer61 122
G/InterSpace
Group 2
1997 4
Group 3
Cabrita
2007
Durbhakula 2004
Hsieh
2004
Hsieh Gr1
2009
Hsieh Gr2
Ibrahim
2014
Klouche
2012
Oussedik
2010
Schwartzkopf 2014
Whittaker
2009
Yamamoto 2003
1
3
3
4
3
3
4
4
4
4
x x
x
12
32
27
33
x
26
x
27
21
6
x
8
10
19
20
x
20
x
29
22
11
Functional
spacer
Functional
spacer
Functional
spacer
Functional
spacer
Functional
spacer
Functional
spacer
Custom spacer
Custom spacer
Custom spacer
Custom spacer
Custom spacer
Custom spacer
Custom spacer
Custom spacer
Custom spacer
Custom spacer
Custom spacer
Table 1; General characteristics
X = not reported
31
SFP31 – (#98) – Short Free Paper
TWO-STAGE REVISION OF INFECTED HIP REPLACEMENT WITH RETENTION OF THE FEMORAL CEMENT
MANTLE
B. Leijtens, N. Sadeghi, B. Schreurs, W. Rijnen
1
Radboud University Medical Centre, Nijmegen, The Netherlands
E-mail: [email protected]
Keywords: Cement Retention, Two-Stage Revision, Total Hip Arthroplasty
Aim
This retrospective study evaluates the outcome of patients with a late infection of a cemented total hip
arthroplasty (THA) treated with two-stage revision with retention of the original well-fixed femoral cement
mantle.
Methods
Operation reports of all two stage revision performed in our clinic between 2009 and 2013 were reviewed (249
patients). Patients in which femoral cement mantle was retained during surgery were included (10 patients).
The average age at the first stage revision procedure was 61.5 years (range 38-80). The mean follow-up period
was 26 months (range 5 to 54 months). Clinical, laboratory, and radiological outcomes were evaluated.
Results
Successful treatment of periprosthetic joint infection (PJI) was achieved in six out of 10 patients; four patients
showed no signs of infection during follow-up. Two of these patients received three months of antibiotic
treatment after second stage, because of positive cultures at second stage. The other two successfully treated
patients showed recurrence of PJI one week after second stage. Debridement with retention of prosthesis
(DAIR) was performed. Newly cultured microorganisms were successfully treated with 3 months of antibiotics.
The other four patients were considered to be failures; in three patients, the femoral cement mantle was
removed after the first stage due to recurrent infection. The other failure showed a recurrent PJI after second
stage. Despite DAIR and three months of antibiotic treatment, this patient is treated with suppressive
antibiotics until latest follow-up.
Conclusions
Based on this study, results in managing an infected THA with cement-within-cement revision are
disappointing. Therefore, more research is required to determine which patients are appropriate for cementwithin-cement revision.
32
SFP32 – (#252) – Short Free Paper
SHORT CEMENTED STEM AS A TEMPORARY IMPLANT IN THE TREATMENT OF PERIPROSTHETIC JOINT
INFECTION (PJI)
L. Marega, P. Gnagni
1
ospedale san camillo, Trento, Italy
E-mail: [email protected]
Keywords: PJI, SPACER
References
Periprosthetic Joint Infection (PJI) is probably the most devastating complication in joint arthroplasty surgery;
two stage revision is the gold standard for this this complication. In general, the use of a spacer between the
explantation and the reimplantation is considered beneficial. Unfortunately, spacers made of cement can
break or dislocate and the high friction of the cement surface can cause discomfort to the patient and erosion
of the acetabulum.
Aim
The use of a cemented implant instead of a spacer has been proposed due to the improved function in
comparison with a spacer. Unfortunately the removal of a conventional cemented stem can be challenging.
The use of a short cemented stem can overcome this problem.
Methods
Between July 2011 and May 2013, 10 infected hips were treated with a short cemented stem as a spacer. The
infected implants were cemented in 6 cases and cementless in 4 cases. Mean time from index operation was 3
years ( range 0 to 8 years ). It was the first treatment for infection in all cases. Antibiotic loaded cement and an
all-poly cup was used in all cases. The bugs were staph aureus and staph epidermidis in most cases. A Friendly
short cemented stem with specific cement restrictor and standard cementing tecnique was used in all cases.
This stem has been successfully tested in over 200 patients and approved by TUV to be released on the
marked.
Results
In all cases, the infection was successfully cured with antibiotics for a period ranging from 3 to 5 months. 2
patients were revised after the infection was cured for recurrent dislocation. No recurrent infection was found
at the latest follow up.
Conclusions
One stage revision is gaining in popularity for the decreased morbidity and better quality of life of the patients.
Weak points of one-stage revision are slightly inferior results in terms of eradication of the infection and the
fact that it can be done only with cemented implants. Cemented implants show inferior durability than
cementless implants and are difficult to remove if revision is needed. The use of a short cemented stem can
couple the advantages of one stage revision and the fact that it is easily removed if this is needed for various
reasons ( aseptic loosening, recurrent dislocation and periprosthetic fracture ). Contraindications to this
technique are severe bone loss in the acetabulum or in the proximal femur.
33
SFP33 – (#107) – Short Free Paper
THE CLINICAL AND RADIOLOGICAL OUTCOME OF SUPPRESSIVE ANTIBIOTIC THERAPY IN PROSTHETIC JOINT
INFECTION OF HIP ARTHROPLASTIES.
L. Weerwag, B. Schreurs, W. Rijnen
1
Department of Orthopedic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
E-mail: [email protected]
Keywords: Prosthetic Joint Infection, Suppressive Antibiotic Therapy
Aim
Prosthetic joint infection (PJI) is a severe complication of prosthetic joint implantation, with an estimated
incidence of 2.18%. Most frequently used treatment strategy for PJI is a two-stage revision procedure.
However there are specific patients with a new or persisting infection after primary or revision surgery where
further surgical treatment is not attractive. This may be because of medical or local surgical conditions, or
patient’s refusal to undergo (further) surgical therapy. For these patients suppressive antibiotic therapy (SAT)
may be an alternative treatment.
The aim of this study is to describe the clinical and radiological outcome of patients with a PJI of a hip
arthroplasty, treated with SAT.
Methods
Twenty-four patients with a hip arthroplasty treated with suppressive antibiotic therapy for PJI between
January 1, 2008 and December 31, 2013 were included. All patients had a proven prosthetic joint infection,
either by ≥2 intraoperative cultures or joint aspiration. SAT was defined as treatment with antibiotic therapy
for more than three months. Most used antibiotics were doxycycline in 15 patients and cotrimoxazole in six
patients.
Patients were supposed to have a successful outcome when their prosthesis remained in situ and they had no
relapse or new infection.
Results
Suppressive antibiotic therapy was considered successful in 15 (62.5%) patients with a mean follow-up of 20.6
months. Two patients (8.3%) had to stop the antibiotic therapy due to adverse effects.
The mean duration of the SAT was 20.4 months (range 0.92-92.65 months).
Mean modified Oxford hip score of the successfully treated patients at the latest follow up was 35 (range 1649) and mean Harris hip score 71 (range 40-93). The mean visual analogue scale (VAS) was 16 (range 0-70) in
rest, 32 (range 0-85) during exercise and 65 (range 10-100) for satisfaction.
Of the 9 patients with an unsuccessful outcome, there was a radiological loosening of the cup in 4 patients. In
the group of 15 patients that were considered successful, 2 patients had a radiological loosening of the cup
and one patient loosening of the stem.
Conclusions
Suppressive antibiotic therapy can be an attractive alternative treatment in selected patients with a prosthetic
joint infection of a hip arthroplasty who cannot or will not undergo (further) surgical therapy.
Further research with a larger number of patients is required. Also the optimal dosage and duration of
suppressive antibiotic therapy and possible resistance to the antibiotic therapy is unknown.
34
SFP34 – (#171) – Short Free Paper
PATIENTS WITH FAILED PRIOR TWO-STAGE EXCHANGE HAVE POOR OUTCOMES FOLLOWING FURTHER
SURGICAL INTERVENTION
M. Gomez, J. Manrique, T. Tan, A. Chen, J. Parvizi
1
Rothman Institute, Philadelphia, United States
E-mail: [email protected]
Keywords: Failed, Two-Stage Exchange Arthroplasty, Revision, Outcomes
Aim
Failure of a two-stage exchange arthroplasty for management of periprosthetic joint infection (PJI) poses a
major clinical challenge. There is a paucity of information regarding the outcome of further surgical
intervention in these patients. Thus, we aim to report the clinical outcomes of subsequent surgical
intervention following a failed prior two-stage exchange.
Methods
Our institutional database was used to identify 60 patients (42 knees and 18 hips) with a failed prior two-stage
exchange from infection, who underwent further surgical intervention between 1998 and 2012 and had a
minimum of two years follow-up. A retrospective review was performed to extract relevant clinical
information, such as mortality, microbiology, and subsequent surgeries. Musculoskeletal Infection Society
criteria were used to define PJI, and treatment success was defined using the Delphi criteria as previously
reported.
Results
Irrigation and debridement (I&D) was performed after a failed two-stage exchange in 61.7% (37/60) patients.
The failure rate of I&D in this cohort was 51.3% (19/37). Two patients underwent amputation after I&D due to
uncontrolled infection. A total of 40 patients underwent an intended a second two-stage exchange.
Reimplantation occurred in only 65% of cases (26/40), and infection was controlled in 61.6% (16/26) of
patients. An interim spacer exchange was required in 15% (6/40) of the cases. Of the 14 cases that did not
undergo a second stage reimplantation, 5 required amputation, 6 had retained spacers, 1 underwent
arthrodesis, and 2 patients died.
Conclusions
Further surgical intervention after a failed prior two-stage exchange has poor outcomes. I&D has a high failure
rate and many of the patients who are deemed candidates for a second two-stage exchange either do not
undergo reimplantation for various reasons or fail after reimplantation. The management of PJI clearly remains
imperfect, and there is a dire need for further innovations that may improve the care of these PJI patients.
35
SFP35 – (#262) – Short Free Paper
EARLY DEBRIDEMENT AS TREATMENT FOR POSTOPERATIVE WOUND COMPLICATIONS IN TOTAL KNEE
ARTHROPLASTY.
B. Kickinger
1
Department of orthopaedic surgery, University hospital of Umeå, Umeå, Sweden
E-mail: [email protected]
Keywords: DAIR, Postoperative Wound Complication, Debridement, Total Knee Arthroplasty
Aim
Early and/or prolonged wound discharge after total knee arthroplasty often raises the question whether this is
a sign of an early infection or if the prolonged discharge leads to a secondary deep wound infection from
migrating skin bacteria.
Confronted with the dilemma of what to do with early PWC our department implemented a new treatment
protocol in 2002 to deal with early PWC after TKA in order to standardize decision-making.
The aim of this study was to report our long-term results using this protocol on a prospective cohort primary
TKA and revision TKA performed for other reasons than infection. This report focuses on the results of DAIR
(debridement, antibiotics and implant retention) performed for early PPJI and/or early wound complications
without clinical signs of infection.
Methods
After implementing our treatment algorithm regarding postoperative wound complications in early 2002, we
initiated a quality registration including every primary and non infected revision TKA performed.
Between January 2002 and August 2012 1439 consecutive primary knee arthroplasties were performed at our
institution. During the same period a total of 120 knee revisions for reasons not related to infection were
performed.
All patients undergoing DAIR within three months of the index procedure where divided into two groups:
successful and unsuccessful. Successful DAIR didn’t require any more surgery and the implant could be
retained with a minimum follow up time of two years. Unsuccessful DAIR required at least one more surgical
intervention.
Results
Treatment with DAIR was successful in 47 of 62 patients operated with primary and revision TKA as index
operation. Those patients had no signs of infection and no antimicrobial therapy after a minimum of one year
follow up time. The remaining 15 patients were in need of further surgery.
Positive cultures could be obtained in 41 of 62 patients including those operated for aseptic revision
arthroplasty. Staphylococcus aureus was by far the most common isolated organism with 24 isolations and the
sole causative pathogen in 15 cases.
Conclusions
When looking at all patients even including those with aseptic revision TKA we could see that the algorithm
resulted in 57 of 62 patients (91,9%) ending up with a working knee prosthesis at the final follow up. In 47
(75,8%) cases prosthesis retention could be achieved with only a single DAIR procedure. We therefore
conclude that the algorithm applied at our centre leads to satisfactory results.
36
SFP36 – (#59) – Short Free Paper
PATIENT REPORTED OUTCOME IN 50 CASES OF OPEN DEBRIDEMENT AND EXCHANGE OF TIBIAL INSERT DUE
TO POSTOPERATIVE PJI
1
2
2
2
2
A. W-Dahl , A. Stefánsdóttir , M. Sundberg , L. Lidgren , O. Robertsson
1
Dept. of Orthopedics, Clinical Sciences Lund, Lund University, Sweden,The Swedish Knee Arthroplasy Register,
Lund, Sweden
2
Dept. of Orthopedics, Clinical Sciences Lund, Lund University, Sweden, The Swedish Knee Arthroplasy
Register, Lund, Sweden
E-mail: [email protected]
Keywords: Prosthetic Joint Infection, Knee Arthroplasty, Patient Reported Outcome
Aim
To reveal if patient reported knee-related pain, function, quality of life, general health and satisfaction at one
year after primary total knee arthroplasty (TKA) is different between patients not being subject to revision
surgery and those having had early treatment with open debridement and exchange of the tibial insert for
postoperative PJI.
Methods
The Swedish Knee Arthroplasty Register was used to identify 50 patients in the region of Skane that had a
primary TKA during the years 2008 – 2012 and within 6 months were revised with open debridement and
exchange of the tibial insert due to suspected or verified PJI. Only patients without further revisions were
included. Patient reported outcome measurements (PROM) were obtained preoperatively and 1 year
postoperatively and included knee related pain, function, quality of life using the Knee injury and
Osteoarthritis Outcome Score (KOOS), general health using the EQ-VAS as well as satisfaction with the surgery.
The scores were compared to those reported by 3,913 patients having a TKA during the same time but not
revised during the first year. Welch’s t-test and the Chi2-test were used in statistical analysis.
Results
Compared to the controls the infected patients were older (mean age 72 vs 69 years, p = 0.04) and were more
morbid (ASA 3; 14/50 patients vs 14%, p = 0.02). The preoperative PROM data were similar. Complete 1 year
PROM data was available for 31 of the patients. Those patients reported somewhat worse outcome one year
postoperatively than the controls with statistically and clinically significant differences in general health (mean
61 vs 76, p=0.002), KOOS ADL (mean 65 vs 76, p=0.03) and knee related quality of life (mean 51 vs 63, p=0.02)
with large variations on individual level. Just over half of the patients (17/29) treated for PJI were very satisfied
or satisfied with the surgery compared to 79% of the controls.
Conclusions
Patients treated with open debridement and exchange of the tibial insert due to early PJI after primary TKA
reported less beneficial postoperative outcome than those without revision surgery during the first
postoperative year but with large individual variations.
37
SFP37 – (#176) – Short Free Paper
THE USE OF MASSIVE PROSTHESES IN PERIPROSTHETIC INFECTIONS: ONE STAGE AND TWO STAGE
EXPERIENCE OF 33 PATIENTS.
G. Giordano, G. Gracia, J. Lourtet, M.P. Felice, A. Bicart-See, L. Gauthie, P. Marlin, E. Bonnet
1
Joseph Ducuing Hospital, Toulouse, France
E-mail: [email protected]
Keywords: Massive Prosthesis, Knee PJI, One Stage And Two Stages
Aim
To evaluate the value of the use of massive prostheses in periprosthetic infections both in one stage and two
stages procedures
Methods
Between 2008 and 2014, 236 revisions for PJI had been performed in our hospital by the same surgeon. For
the most complex cases, we decided to introduce megaprostheses in our practice in 2011.
We report a prospective series of 33 infected patients treated between 2011 and the end of 2014, 14 male and
19 female with on average 67.9 years old (38-85) Infection involved TKA in 22 cases (17 TKA revisions, 4
primary TKA), THA in 9 cases (6 revisions, 3 primary THA), a femoral pseudo-arthrosis with posttraumatic
gonarthrosis in one case and a septic humeral pseudoarthrosis in one case. We used a total femoral
component for two patients: the first one for a hip PJI with extended diaphyseal bone loss and multiples sinus
tracks, and the second one for a massive infected knee prosthesis used in a knee reconstruction for
liposarcoma.
Results
We used one stage procedures in 20 cases (8 hips, 12 knees, 1 shoulder) and two stages in 13 cases (12 knees
and 1 hip). Additional technics included 3 massive extensor system allografts, two local flaps. Perioperative
hyperbaric treatment was used for 2 patients.
The average follow up is 19.8 months (6-48 months). The most frequent complications were wound swelling
and delayed healing in 8 cases;). In 3 cases of one stage surgery a complementary debridement was necessary
in the three weeks after the surgery with always a good local and infectious evolution. VAC therapy was used
in four cases with good results. We report one early postoperative dead.
Conclusions
In summary, the use of massive prostheses in PJI is a good option for complex cases. It can be a good
alternative to knee arthrodesis. These components must be used preferentially for older patients, in cases of
extreme bone loss or extensive osteomyelitis to secure the bone debridement and the quality of the
reconstruction.
In our series, the one stage procedure is a validated option even by using complementary technics as bone
allografts, extensor system allografts or flaps. We believe the two stages surgery is a secondary option,
particularly when soft tissues status is compromised before or after the debridement, and mostly for the
knees. The longevity of the implantation must be evaluate by a long term follow up.
38
SFP38 – (#214) – Short Free Paper
PERIPROSTHETIC KNEE INFECTIONS TREATED BY COMPUTED ASSISTED GUIDANCE (CAS) REVISIONS IN A ONE
STAGE PROCEDURE: A SERIES OF 41 PATIENTS.
G. Giordano, G. Gracia, J. Remi, G. Krin, J. Lourtet, M.P. Felice, A. Bicart-See, L. Gauthie, P. Marlin, E. Bonnet
1
Joseph Ducuing Hospital, Toulouse, France
E-mail: [email protected]
Keywords: Knee Chronic PJI, One Stage Revision, Computed Assisted Guidance
Aim
To evaluate a innovate one stage procedure of the PJI knee treatment using computed assisted guidance. Our
objectives; to increase the functional results by optimizing the anatomical joint reconstruction and to verifie if
CAS help to simplifie and standardize these complex surgeries
Methods
It’s a prospective, single surgeon study . Since septembre 2011, 41 patients treated for chronic knee PJI in a
one stage revision (one of them had a ipsilateral chronic knee arthritis). For all of them, a computed assisted
guidance, the ExactechGPS® system was used. This system offers the possibility to define specific profiles to
performe primary TKA surgeries. A personnalized profile of revision was created.
All surgeries were performed with the same protocole; independently of the type of germ, with no use of
tourniquet, no drainage by performing the same debridement procedure step by step and by using the same
knee components
Results
27 males, 14 female with 26 PJI of primary TKA, one infected unicompartimental prosthesis and 15 PJI of first
revised TKA has been treated.The average age was 71 years old (55- 87). The time of surgery was on average
135 mn (120 – 195 mn). The average time of hospitalization was 10 days (7- 16). The average follow up was
20,9 months (6- 47 months). The ROM were on average 114,7% (90°-130°), None post operative HKA outliers
were reported.
3 patients presented a failure of the PJI treatment (one after a local open traumatism, one diabetic patient,
one after a early revision for mechanical complication). None specific CAS complications and no failure of the
CAS procedures are reported. As surgeon, CAS simplified the management of the bone loss after debridement
and the control of the differents parameters (HKA, external femoral rotation, ligamentary balancing, lign
joint…) by a real time feedback. we changed our practise by using more constraint condylar component
instead hinge prostheses
Conclusions
With a rate of success of 92,7% at this follow up, the one stage option appears to be valided. Using CAS is a
safe option with no specific complication. It increases the quality of the ROM, a earlier functional recovery and
a better middle term clinical result . Both combined, It should be a optimal medicoeconomical solution.
compared revision using mechanical ancillary.
Acknowledgements
Special thanks: Nicolas Hohl and (Exactech Team), Plasse Christian and Franck Tremoulet (Osmose Company)
for their great and constant support and to all of our multidisciplinary team.
39
SFP39 – (#159) – Short Free Paper
KNEE ARTHRODESIS IN THE MANAGEMENT OF THE INFECTED TOTAL KNEE ARTHROPLASTY: ANALYSIS OF A
CASE-SERIES OF 46 PATIENTS
A. Figueiredo, R. Ferreira, A. Garruço, P. Lopes, M. Caetano, A. Bahute, U. Fontoura, A. Pinto, V. Pinheiro, J.
Cabral, P. Simões, R. Fonseca, C. Alegre, F. Fonseca
1
Coimbra University Hospital, Orthopaedic Surgery Department, Coimbra, Portugal
E-mail: [email protected]
Keywords: Knee Arthrodesis, Periprosthetic Joint Infection, Infected Knee Arthroplasty
References
Lombardi et al. Why knee replacements fail in 2013. Bone Joint J 2014;96-B(11SupplA):101-4.
Wu CH et al. Arthrodesis should be strongly considered after failed two-stage reimplantation TKA. Clin Orthop
Relat Res. 2014;472(11):3295-304.
Wood JH et al. Advanced Concepts in Knee Arthrodesis. World J Orthop 2015;6(2):202-210.
Aim
Periprosthetic infection is a challenging complication of total knee arthroplasty (TKA) which reported incidence
varies from 1 to 2% in primary TKA and 3-5% in revision TKA. Persistent infection of TKA may benefit from knee
arthrodesis when all reconstruction options have failed. Knee arthrodesis also demonstrated better functional
results and pain relief than other salvage procedures such as above-knee amputation.
The purpose of this study was to analyze treatment results in patients who underwent knee arthrodesis
following infected TKA.
Methods
Retrospective study with review of the data of all patients treated in our department with knee arthrodesis for
chronic infection of knee arthroplasty between 2009 and 2014. Clinical and radiographic data were evaluated
as well as several variables: technique used, fusion rate, time to fusion, need for further arthrodesis and
complications. Patients with less than 8 months of follow-up were excluded from this study.
Results
46 patients were treated with knee arthrodesis in our department from 2009 to 2014 for chronic infection of
total knee arthroplasty. The sample included 26 (57%) women and 20 (43%) men, median age of 70 years. In
45 patients, the technique used was compressive external fixation, while an intramedullary modular nail was
used in 1 patient. Mean follow-up of these patients was 35 months (8-57). Primary knee fusion was obtained in
32 (70%) patients with a mean time to fusion of 5,8 months (4-9). 9 (20%) patients needed rearthrodesis and 7
(15%) ultimately achieved fusion. 33 (72%) patients underwent knee arthrodesis in a single surgical procedure,
while 13 (28%) firstly removed knee arthroplasty and used a spacer before arthrodesis. Overall complication
rate was 35%; 7 (15%) patients experienced persistent infection and 4 (9%) of these undergone above knee
amputation.
Conclusions
Treatment of septic total knee replacement is a surgical challenge. Compressive external fixation was the
method of choice to perform knee arthrodesis following chronic infected TKA. Although complication rate was
worrisome, overall fusion rate was satisfactory and this arthrodesis method can be safely performed in one
stage.
Acknowledgements
The authors would like to express sincere gratitude to all the medical and nursing staff who gave their best in
the treatment of the patients studied.
40
SFP40 – (#114) – Short Free Paper
BRIDGING KNEE ARTHRODESIS WITH A MODULAR AND NON- CEMENTED INTRAMEDULLARY NAIL AFTER
SEPTIC FAILURE TOTAL KNEE ARTHROPLASTY
D. Haro Fernàndez, S. Huguet Miguelez, I. Marchán García, S. Quintas Alvarez, A. Matamala Pérez, L. Gómez
García, F. Anglès Crespo
1
University Hospital Mutua Terrassa, Terrassa, Spain
E-mail: [email protected]
Keywords: Knee, Arthrodesis, Infection, Nail
Aim
Knee arthrodesis is a potencial salvage procedure for limb preservation in patients with multiple failures of
Total Knee Arthroplasty ( TKA ) with massive bone loss and extensor mechanism deficiency.
The purpose of the study is to evaluate the outcome of bridging knee arthrodesis using a modular and non
cemented intramedullary nail in patients with septic failure Total Knee Arthroplasty.
Methods
Between 2005 and 2013 ( 9 years ), 15 patients ( 13 female and 2 male ) with mean age 71.1 years ( range 41
to 85 ) were treated at our Institution with septic two- stage knee arthrodesis using a modular and noncemented intramedullary nail after multiple failures of septic Total Knee Arthroplasty.
Mean follow- up was 70.1 months ( 24 to 108 months ) with a minimum follow- up of 24 months.
We evaluated the erradication of infection clinically and with normalization of laboratory parameters ( ESR and
CRP ), limb length discrepancies and complications ( peri- implant fractures, amputation rates, wound healing
disturbances ) and the subjective evaluation of the patients after knee arthrodesis.
Results
We reported 11 cases of resolution of the infection ( 73.3 % ), with good tolerance of the implant and a mean
limb length discrepancies of 15 mm.
Of these, 8 patients had been monitored over 5 years without recurrence of the infection.
The mean number of previous operations was 4.9 ( range 2 to 9 ).
Two patients ( 13.3 % ) required multiples surgical debridements for uncontrolled sepsis and finally underwent
knee amputation.
Coagulase- negative Staphylococci ( SCN ) were the most commom pathogen ( 53.3 % ) followed by
polimicrobian infections ( 26.7 % )
One patient continues suppressive antibiotic treatment and 1 patient was treated with a one- stage custommade arthrodesis nail exchange.
Conclusions
Bridging knee arthrodesis using a modular and non- cemented intramedullary nail is a salvage procedure with
acceptable results in terms of erradication of infection after septic faliure Total Knee Arthroplasty with
restoration of limb length discrepancy.
Despite these satisfactory results it is not without serious complications such as knee amputation.
41
Revision surgery in infected joint replacement /
Diagnostic tools in MSK infections
42
SFP43 – (#162) – Short Free Paper
AMPUTATION OF LOWER LIMB CAUSED BY SEPSIS?
R. Grünther
1
HELIOS Rehazentrum Bad Berleburg, Bad Berleburg, Germany
E-mail: [email protected]
Keywords: Sepsis, Amputation Of Lower Leg – MRSA - MRE
References
Department of Rehabilitation in Orthopaedics, Traumatology, Amputees, diabetic Foot, HELIOS center of
rehabilitation, Bad Berleburg, Germany
Aim
A retrospective case control study of all rehabilitated patients who suffered amputations of the lower
extremity by sepsis was performed in the HELIOS centre of rehabilitation for amputees, Bad Berleburg,
Germany.
Methods
This study examines patients who had undertaken an amputation of the lower extremity caused by severe
sepsis and septic shock.
Methods: Case control study. The clinical reports of 448 patients with amputations of the lower extremity
clinically rehabilitated from 2010 to 2013 were systematically and statistically evaluated. Sepsis is classified in
4 categories: SIRS, sepsis, severe sepsis and septic shock.
Results
Epidemiology: The mean age of the amputees was 61.33 years, with 25 men and 11 women. Marital status: 16
patients are married (44.44%), 7 divorced, 5 widowed, 7 unmarried, 1 unknown. 24 patients are retired
(66.67%). School-leaving qualifications: 22 elementary school (61.11%), 8 secondary school, 1 high school, 5
unknown. Health insurance: AOK 10 patients (27.77%), BEK 7 patients (19.44%), pension insurance 9 patients
(25.0%). The medial time of hospitalization in the clinic for rehabilitation of the amputated patients suffering
sepsis was 27.23 days.
Results: 36 patients, - 8.03 % of all – with 39 amputations, suffered a loss of the lower extremity caused by
severe sepsis and septic shock: 1 patient suffered an exarticulation of both hips, 20 patients suffered a
transfemoral amputation (1 patient had a transfemoral amputation of both legs), 17 patients lost their leg by
transtibial amputation (1 patient had a transtibial amputation of both legs). 13 patients presented a sepsis by
MRSA (multiresistant Staph. aureus 36.11%), 8 patients with MSSA (multisensible Staph. aureus), 4 patients
with multiresistant Acinetobacter (8.33%), 2 patients with MRSE (multiresistant Staph. epidermidis), 13
patients with other multiresistant germs (36.11%) such as Streptococcus B, Enterococcus faecalis,
Enterobacteriaceae, Klebsiella.
Mobility class of amputees at the beginning of hospitalization: class 0 (= non walkers) all 36 patients (100%).
Mobility class of amputees at the end of hospitalization: class 0 (= non walkers) are 5 patients (27.78%), class 1
(= only inside walkers) are 5 patients (13.89%), class 2 (= inside and little outside walkers) are 18 patients
(50.00%), class 3 (= inside and good outside walkers) are 3 patients (8.33%).
Conclusions
Amputation of the lower extremity following severe sepsis and septic shock is not rare - in our group we found
more than 8%.
43
SFP44 – (#164) – Short Free Paper
TRANSFEMORAL AMPUTATION CAUSED BY AN INFECTION OF TOTAL KNEE ARTHROPLASTY
R. Grünther
1
HELIOS Rehazentrum Bad Berleburg, Bad Berleburg, Germany
E-mail: [email protected]
Keywords: Infection, TKA, Amputation Of Lower Leg, MRE
References
Department of Rehabilitation in Orthopaedics, Traumatology, Amputees, Diabetic Foot, Baumrainklinik,
HELIOS Center of Rehabilitation - Center of Rehabilitation for Amputees, Bad Berleburg, Germany
Aim
Observing a decreasing number of transfemoral amputations following infection of Total Knee Arthroplasty
(TKA) we performed a retrospective case control study of all rehabilitated amputees in the HELIOS centre of
rehabilitation for amputees, located in Bad Berleburg, Germany.
Methods
This study examines all patients who had undertaken a transfemoral amputation (TF) after infection of TKA
since 2007.
Methods: retrospective case control study. The clinical reports of 355 patients with transfemoral amputation
rehabilitated from 2007 to 2013 were systematically and statistically evaluated. In this period we rehabilitate
636 amputees.
Results
Results: 9 patients – 2.53% of all TF-amputations suffered a loss of the lower extremity caused by an infection
of TKA. 3 patients presented an infection only by MRSA (multiresistant Staph. aureus 33.33%), 2 patients only
with MSSA (multisensible Staph. aureus); other 4 patients presented mixed infections with MRSE
(multiresistant Staph. epidermidis), multiresistant Acinetobacter baumannii, E. coli, Enterococcus faecalis,
Pseudomonas aeroguinosa.
Epidemiology: The mean age of the patients at time of amputation was 70.07 years, with 4 men and 5 women.
Marital status: 6 patients are married (66.66%), 1 divorced, 1 widowed, 1 unmarried. All patients are retired.
School-leaving qualifications: 7 elementary school (60.87%), 1 secondary school, 1 unknown. Health insurance:
AOK 3 patients (33.33%), BKK 3 patients (33.33%), employers insurance 1 patients (11.11%) and 2 more
patients. The medial time of hospitalization in the clinic for rehabilitation after suffering amputation because
of infection of TKA was 29.22 days.
Mobility class of amputees at the beginning of hospitalization: class 0 (= non walkers) all 9 patients (100%).
Mobility class of amputees at the end of hospitalization: class 0 (= non walkers) are 2 patients (22.22%), class 1
(= walking only inside) are 5 patients (55.55%), class 2 (= walking inside and a little outside) are 2 patients
(22.22%), class 3 (= walking well inside and outside) no patient.
Conclusions
This retrospective case control study shows for the first time that amputation of the lower extremity following
infection in TKA is rare - in our group we found 2.53%. In the national and international literature one does not
find much research about transfemoral amputations caused by infection in TKA. In our clinic we notice a
decreasing number.
44
SFP45 – (#136) – Short Free Paper
SUPERFICIAL VANCOMYCIN COATING (SVC) OF BONE CEMENT IN ORTHOPEDIC REVISION SURGERY
1
1
2
3
4
1
1
M. Glehr , F. Amerstorfer , E. Baumgartner , G. Schwantzer , S. Fischerauer , K. Kühn , A. Leithner
1
Department of Orthopedic Surgery, Medical University of Graz, Graz, Austria
2
AUVA-Unfallkrankenhaus Graz, Graz, Austria
3
Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
4
Department of Trauma Surgery, Medical University of Graz, Graz, Austria
E-mail: [email protected]
Keywords: Superficial Vancomycin Coating, Bone Cement, Revision Surgery
Aim
The use of antibiotic-loaded cement has become a well-accepted method to develop high local antibiotic
concentrations in orthopedic surgery. A new surgical technique has been established in our department in
order to further increase the local antibiotic concentration, when implanting a prosthesis during revision
surgery. By additional superficial vancomycin coating of the bone cement, high local antibiotic concentrations
are generated. They should reach inhibiting and bactericidal concentrations of the respective pathogen during
the first days after surgery.
The aim of this study was to state the safety of this method by analyzing postoperative serum and drain
vancomycin concentrations. Attention was focused on possible systemic side effects. To determine
nephrotoxicity, creatinine levels were also measured.
Methods
In total 32 revision operations (hip n=10, knee n=22) with additional superficial vancomycin coating were
performed between 05/2013 and 04/2015. Procedures with removal of the prosthesis following temporary
spacer implantation were excluded. In nine cases a one-stage procedure was performed, while in the others an
arthroplasty or arthrodesis was performed after temporary spacer explantation. Vancomycin powder (2
grams) was added superficially to the surface of the bone cement and pressed onto manually before curing.
Postoperative Vancomycin levels were measured in serum and the drain on day 1 to 5 or until the drain has
been removed. In total 90 blood serum samples and 100 drain fluid samples were obtained.
Results
The highest median vancomycin level from the drain was documented on postoperative day 1 with a value of
555.3 μg/mL (range 66.1 – 1081.8), continually decreasing until postoperative day 4. The highest value was
documented on the second postoperative day with 2170.0 μg/mL. On the first postoperative day, a median
serum vancomycin level of 3.35 μg/mL was present (range <2.0 – 8.5), while from postoperative day 2 to 5 a
median level less than 2.0 μg/mL (range <2.0 – 7.2) was documented.
Anaphylactic reaction, red man syndrome or fever and chills were not observed after the surgical procedure.
Furthermore, no subjective hearing loss was reported. Only in one case, a creatinine increase of 0.5 mg/dL
from baseline value was detected. In this case the patient suffered preoperatively from a chronic kidney
insufficiency.
In total two reinfections occurred, one after explanting a spacer with subsequent hip total endoprosthesis , the
other one after a one-stage hip revision.
Conclusions
Superficial Vancomycin Coating of bone cement in orthopedic revision surgery represents a safe method to
increase local inhibiting vancomycin concentrations.
45
SFP46 – (#240) – Short Free Paper
SEPTIC FAILURE OF WRIST ARTHROSPLASTY: HOW TO MANAGE?
J. Neves, N. Fachada, M. Batista, M. Vasconcelos, A. Bispo
1
Hospital Ortopédico Sant'Iago do Outão, Setúbal, Portugal
E-mail: [email protected]
Keywords: Septic Failure, Antibiotics, Spacer, Radiocarpal Arthrodesis
References
Gupta A. Total Wrist Arthroplasty. Am J Orthop. 2008; 37 (8): 12-16
Adams B. A multicenter study of the universal total wrist prosthesis. 57th Annual Meeting of the American
Society for Surgery of the Hand; Phoenix, Arizona: 2002.
Ferlic DC, Jolly SN, Clayton ML. Salvage for failed implant arthroplasty of the wrist. J Hand Surg, 1992; 17: 917923.
Beer TA, Tuner RH. Wrist arthrodesis for failed wrist implant arthroplasty. J Hand Surg, 1997, 22: 685-693.
Carlson JR, Simmons BP. Wrist arthrodesis after failed wrist implant arthroplasty. J Hand Surg. 1998; 23: 893898.
Aim
The aim of this work is to present a clinical case of wrist arthroplasty failure due to chronic infection and try to
discuss and draw a therapeutic approach (algorithm) for similar cases taking in consideration the degree of
osteolysis, the presence of detachment and inherent instability and the condition of the soft tissues.
Methods
The authors report a case of an individual, male, 58 years old, manual worker, that appears with pain and
inflammatory signs on right wrist arthroplasty, with fistulous track. The revison procedure was performed in 2
stages: the first stage revision consisted on removal the implant, debridement and interposition of cement
spacer with antibiotics and immobilization, the second stage revision a radio-metacarpal arthrodesis with plate
and interposition of autologous graft harvested.
Results
The improvement of the implants in recent years have contributed to the increasing use of arthroplasty as a
treatment option with good results. Although it presents itself with an attractive option in terms of future
functional capabilities, arthroplasty remains with some risks and have a higher rate of complications in the
medium and long term than fusion, so the selection of patients should be careful. The main problem of wrist
arthroplasty revision is due to bone stock loose to promote fusion and the shortening after implant removal.
At 1,5 years follow-up, we denote a higher patient satisfaction, without pain, radiological fusion and 28 points
in DASH score
Conclusions
The success of wrist arthroplasty depends on careful patient selection, careful preoperative planning, rigorous
technique and an appropriate program of functional rehabilitation. The wrist arthrodesis can always be seen as
an ultimate salvation procedure in the treatment of failure of wrist arthroplasty, either a mechanical or
infectious failure.
Acknowledgements
Patient and all medical and nurse team
46
SFP47 – (#185) – Short Free Paper
PATELLA TENDON INJURIES SECONDARY TO CEMENT SPACERS USED AT FIRST-STAGE REVISION OF INFECTED
TOTAL KNEE REPLACEMENT
R. Williams, R. Kotwal, N. Roberts-Huntley, W. Khan, R. Morgan-Jones
1
University Hospital Llandough, Cardiff, United Kingdom
E-mail: [email protected]
Keywords: Cement Spacer, Arthroplasty, Infection, Revision
Aim
At first-stage revision surgery for infection of total knee arthroplasties, antibiotic-impregnated cement spacers
are frequently implanted. Two types of cement spacers are commonly used, "static" and "articulating" cement
spacers. Advocates of cement spacers state that they deliver high doses of antibiotics locally, increase patient
comfort, allow mobility and provide joint stability. They also minimize contracture of collateral ligaments,
thereby facilitating re-implantation of a definitive prosthesis at a later stage. The use of these cement spacers,
however, are not without significant complications, including patella tendon injuries.
Methods
We describe a series of three patients who sustained patella tendon injuries in infected total knee
arthroplasties following the use of a static cement spacer at first-stage knee revision.
Results
The patella tendon injuries resulted in significant compromise to wound healing and knee stability requiring
multiple surgeries. The mid-term function was poor with an Oxford score at 24 months ranging from 12-20
Conclusions
Based on our experience, we advise caution in the use of static cement spacer blocks. If they are to be used,
we recommend that they should be keyed in the bone to prevent patella tendon injuries.
47
SFP48 – (#265) – Short Free Paper
RETROSPECTIVE STUDY OF LOW GRADE TOTAL HIP ARTHROPLASTY INFECTIONS.
M. Oliveira, F. Ramalho, R. Couto, M. Gomes, J. Moura, V. Caetano, M. Mendes
1
Centro Hospitalar do Alto Ave, Guimarães, Portugal
E-mail: [email protected]
Keywords: Hip, Low-Grade,Infected, Serum PCR, Two-Time Revision.
References
William A. Jiranek, J Arthroplasty (2015)
Kun Yuan,Surgical Infections, Volume 16, Number X, 2015
Maryam Rezapoor, J Arthroplasty (2015)
Parvizi J, Orthopedics 2010;33:659.
Hanssen A, J Bone Jt Surg 1998:910.
Aim
The aim of this study was to assess the incidence of low-grade infections in total hip arthroplasty revisions and
the clinical outcomes after two-time revision surgery.
Methods
Retrospective study of total hip arthroplasty revision surgery between January of 2012 and December of 2013.
Inclusion criteria: two-time revision surgery, PCR (pre and post-op) white blood cells count and microbiological
culture. The diagnosis of low-grade infection was based on the Academy of Orthopedic Surgeons’ (AAOS)
guidelines. All patients were evaluated with the Harris Hip Score (HHS).
Results
Between this period were revised a total of 79 hips, none of them bilateral, of these fourteen full-filled the
inclusion criteria, eight women and six men. The mean time between primary arthroplasty and revision surgery
was 4.5 years. The interface was metal-on-polyethilene in thirteen and metal-on-metal in one. All patients had
at least three episodes at the urgency department with permanent hip pain in the last six months. Ten have
done a course of antibiotics previous to surgery. Intra-articular pus was present in four patients. The agent
isolated was S. Aureus in five and S. Epidermidis in two. An elevated PCR and leucocytosis was present in all
patients. The mean PCR was 18.1 and leucocytes countage 7600 . The HHS was good in four patients, fair in
seven patients and poor in three. These three patients with poor had another surgical intervention due to
recurrent dislocation.
Conclusions
Periprosthetic joint infection is a common complication after total hip arthroplasty (THA). The incidence is
approximately 1% after primary replacement and about 4% revision arthroplasty. As stated by Hanssen
successful treatment outcomes require precise assessment of the infecting organism, the immune status of
the patient, and the condition of the bone and soft tissues around the joint. With this study we tried to
establish a protocol in our service: patient with a THA, interface metal-on-polyethilene ,persistent coxalgia and
elevated PCR will be diagnosed with low-grade infection, however we need further revision of our experience.
48
SFP49 – (#215) – Short Free Paper
ADDRESSING DIFFICULTIES IN DIFFERENTIAL DIAGNOSIS OF PATIENTS PRESENTING WITH JOINT PROBLEMS
AFTER THA AND TKA
1
2
2
1
3
2
2
2
J. Lorenzen , H. Schønheyder , L. Larsen , Y. Xu , L. Arendt-Nielsen , V. Khalid , O. Simonsen , R. Aleksyniene ,
2
S. Rasmussen
1
Danish Technological Institute, Aarhus, Denmark
2
Aalborg University Hospital, Aalborg, Denmark
3
Aalborg University, Aalborg, Denmark
E-mail: [email protected]
Keywords: Infection, Molecular Analysis, Algorithm, Diagnosis, Microorganisms
Aim
Identification of modalities and procedures to improve the differential diagnosis of septic and aseptic cases in
patients with joint-related pain after total hip or knee alloplasty (THA/TKA).
Methods
A prospective cohort of 147 patients presenting with problems related to previous THA or TKA was included
and subjected to a comprehensive diagnostic algorithm. The standard diagnostics were supplemented with
novel or improved methods for sampling of clinical specimens, sonication of retrieved implant parts, prolonged
and effective culture of microorganisms, and dedicated clinical samples for molecular biological detection and
identification of microorganisms. Furthermore, comprehensive pain investigations and nuclear imaging were
employed. For each case the clinical management was decided upon in a clinical conference with participation
of clinical microbiologist, orthopedics and experts in nuclear imaging. The clinical management of patients was
blinded against the molecular biological detection of microorganisms.
Results
Patients grouped as follows: 69 aseptic, 19 acute septic, 19 chronic septic, 40 pain/unresolved. Sonication of
retrieved implant parts resulted in detection of biofilm not detected by standard specimens, i.e. joint fluid and
periprosthetic tissue biopsies. Next generation sequencing detected and identified few infections not detected
by culture. Molecular analyses showed more polymicrobial infections than culture. Nuclear imaging was
inconclusive with respect to recommendation of changed setup. Analysis of blood based biomarkers is
ongoing. Patients with chronic pain are undergoing follow-up.
Conclusions
The special emphasis put on detection of infections resulted in detection of infections in joints that otherwise
would have been categorized as aseptic loosening. Clinical management for these cases was changed
accordingly. The cross-disciplinary clinical conference is considered valuable for clinical management. The
clinical relevance of the polymicrobial nature of infections as diagnosed employing next generation sequencing
is yet to be established. Long-term follow-up is planned.
Acknowledgements
This study was part of the PRIS-project funded by the Danish Council for Research, Technology and Innovation.
The contributions of all members of the PRIS-study-Group is acknowledged.
49
SFP50 – (#23) -Short Free Paper
PROSTHETIC JOINT INFECTION: EVALUATION OF SONICATION FLUID CULTURES IN COMPARISON TO FROZEN
SECTION AND PERIPROSTHETIC TISSUE CULTURES
P. Di Benedetto, V. Cainero, A. Beltrame, R. Gisonni, A. Fiocchi, A. Causero
1
Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
E-mail: [email protected]
Keywords: Sonication, Prosthetic, Joint Infection
References
Prosthetic joint infection (PJI) is the most severe complication in joint arthroplasty. Identification of hidden
septic loosening and causal microbial factors is essential for an appropriate treatment.
Aim
The purpose of this study was to evaluate the accuracy of the sonication fluid cultures (SFC) for the diagnosis
of prosthetic joint infection and compare it with frozen section and periprosthetic tissue cultures.
Methods
108 patients underwent revision or explantation procedure for any reason. Frozen sections of intraoperative
specimen were analized and multiple periprosthetic samples (at least 5) were collected and cultured. All
explanted prosthesis components were subject to sonication and cultured. All cultures were incubated for 14
days.
Results
PJI was diagnosed in 52 patients (48%). Sonication achieved the highest sensivity with 95% and specificity of
98%. Frozen section showed low sensivity (44%) and specificity (80%) and periprosthetic tissue cultures
showed sensivity of 75% and specificity of 98%.
Conclusions
Sonication fluid culture is a cheap, easy, accurate and sensitive diagnostic method and helps to detect about
30% more PJI compared to frozen section and 16% more compared to periprosthetic tissue cultures. It also
detect about 25% more pathogens than periprosthetic tissue cultures
50
SFP51 – (#103) – Short Free Paper
NORMALIZATION CURVE OF C-REACTIVE PROTEIN IN SHOULDER ARTHROPLASTY
C. Gamba, J. Diez, D. Prieto, A. Fabrego, L. Verdie, F. Perez, C. Canovas
1
Parc de Salut Mar, Barcelona, Spain
E-mail: [email protected]
Keywords: Shoulder Arthroplasty Infection, Acute Infection
Aim
Successfully treatment of acute shoulder arthroplasty infections strongly depends on the timing of treatment.
The objective of this study is to determine the normalization curve of C-reactive protein (CRP) after shoulder
arthroplasty
Methods
Prospective study including 63 patients undergoing shoulder arthroplasty (46 reverse shoulder arthroplasty
(RSA) and 17 total shoulder (TSA)). Mean age 74.1 years old. 25 cuff deficient shoulders, 14 acute fractures, 19
primary gleno-humeral arthritis and 5 fracture sequel were included. Blood samples to determine CRP were
obtained before surgery the day of surgery, 24 and 48 hours after surgery and then 6, 8 and 14 days after
surgery (data of blood samples was determined based on a previous limited study). Co-morbidities that could
interfere CRP were also recorded
Results
Normal value of CRP before surgery (mean 1.28) slightly increases 24 hours after surgery (mean 3.92), reach
maximum value at 48 hours after surgery (mean 6.91) and then slowly decreases to normalize at 14 days (6th
day mean 3.80, 8th day 2.33 and 14th day 1.08). Normalization curve is not affected by age, diagnosis or type
of arthroplasty
Conclusions
CRP after shoulder arthroplasty reaches maximum value at 48h and then slowly decreases to become normal
at 14 days. Any deviation from this normalization curve may help in diagnosis and early treatment of acute
shoulder arthroplasty infections
51
SFP52 – (#201) – Short Free Paper
DIAGNOSIS OF CHRONIC INFECTIONS. REMEMBER THE BIOFILM
1
2
3
2
T. Thomsen , Y. Xu , L. Larsen , J. Lorenzen
1
Danish Technological Institute and Aalborg University, Aarhus, Denmark
2
Danish Technological Institute, Aarhus, Denmark
3
Aalborg University and Aalborg University Hospital, Alborga, Denmark
E-mail: [email protected]
Keywords: Biofilm, Diagnosis, Implants, Wounds,Chronic
Aim
Recent evidence suggests that the microbial community, its spatial distribution and activity play an important
role in the prolongation of treatment and healing of chronic infections. Standard bacterial cultures often
underestimate the microbial diversity present in chronic infections. This lack of growth is often due to a
combination of inadequate growth conditions, prior usage of antibiotics and presence of slow-growing,
fastidious, anaerobic or unculturable bacteria living in biofilms. Thus, diagnosis of chronic infections is
challenged by lack of appropriate sampling strategies and by limitations in microbiological testing methods.
The purpose of this study was to improve sampling and diagnosis of prosthetic joint infections (PJI) and chronic
wounds, especially considering the biofilm issue.
Methods
Systematic sampling, sonication of prosthesis and extended culture were applied on patients with chronic
wounds and patients with suspected PJIs. Optimized DNA extraction, quantitative PCR, cloning, next
generation sequencing and PNA FISH were applied on the different types of specimens for optimized
diagnosis. For further investigation of the microbial pathogenesis, in situ transcriptomics and metabolomics
were applied.
Results
In both chronic wounds and PJIs, molecular techniques detected a larger diversity of microorganisms than
culture methods in several patients. Especially in wounds, molecular methods identified more anaerobic
pathogens than culture methods. A heterogeneous distribution of bacteria in various specimens from the
same patient was evident for both patient groups. In chronic wounds, multiple biopsies from the same ulcer
showed large differences in the abundance of S. aureus and P. aeruginosa at different locations.
Transcriptomic and metabolomic analyses indicated the important virulence genes and nutrient acquisition
mechanisms of Staphylococcus aureus in situ. As an example, diagnosis and treatment of a patient with a
chronic biofilm prosthesis infection persisting for 7 years will be presented.
Conclusions
Our studies show that diagnosis of chronic biofilm related infections required multiple specimen types,
standardized sampling, extended culture and molecular analysis. Our results are useful for improvement of
sampling, analysis and treatment in the clinic. It is our ambition to translate studies on bacterial activity into
clinical practice in the future.
Acknowledgements
This study is part of two Danish innovation consortia: ´Prosthetic-Related Infection and Pain´ (Danish acronym
PRIS) and ‘BIOMED' supported by The Danish Council for Technology and Innovation.
52
SFP53 – (#195) – Short Free Paper
ACCURACY OF LABORATORY INVESTIGATIONS ON JOINT FLUID WHEN DIAGNOSING INFECTION
E. Lautenbach
1
Milpark Hospital, Johannesburg, South Africa
E-mail: [email protected]
Keywords: Joint Fluid, Infection, Laboratory Tests
Aim
We studied twelve parameters (physical appearance, mucin clot, fibrin clot, white cell count, differential
count, red blood cell count, gram stain for bacteria, crystal microscopy, aerobic bacterial culture, anaerobic
bacterial culture and ratio between synovial sugar and blood sugar) in over 300 samples of synovial fluid from
patients with a variety of suspected pathologies (e.g. infection, inflammatory disease, infection adjacent to a
joint, aseptic loosening of a prosthesis).
Methods
The diagnosis of infection was further established using clinical signs, radiological features, full blood count, Creactive protein and iron profile. Many of the patients came to surgery. This of course created further
opportunity to establish or rule out the diagnosis of infection with greater certainty. Nine of the features of
synovial fluid were analysed statistically, including turbidity, diminished viscosity, mucin clot, fibrin clot, total
white cell count, polymorphs greater than 60%, bacteria observed on direct microscopy, bacteria yielded by
culture and concentration of synovial sugar less than 40% of the simultaneous blood sugar. The positive or
negative features of infection were determined to be true or false in the light of the cumulative overall
features of infection. The data so obtained was analysed to establish sensitivity, specificity, positive predictive
value, negative predictive value and accuracy.
Results
The mass of data so obtained cannot be meaningfully expressed in such a brief abstract. Important examples
are when culturing synovial fluid there were 44% false negatives or no growth and 56% true positives. Looking
at the ratio between synovial sugar and blood sugar we found that taking 40% as the critical value, this was
62% sensitive, the specificity was 89%, the accuracy was 73%, the positive predictive value was 89%, the
negative predictive value was 62.4%. However we went further and separated those who were definitely
infected or probably infected i.e. Groups 4 & 5 from those who were probably or definitely NOT infected
according to the sum of clinical laboratory and radiological parameters.
Conclusions
When thus separated the predictive value of a positive result was 100% in Group 4 & 5 and 0% in Group 1 & 2.
The predictive value of a negative result in Group 1 & 2 was 98.7% accurate and 22.4% in Group 4 & 5.
53
SFP54 – (#281) –Short Free Paper
PERFORMANCES OF LABELLED LEUKOCYTES SCINTIGRAPHY IN THE DIAGNOSIS OF PROSTHETIC JOINT
INFECTION. A 168-CASE STUDY.
E. Bonnet1, P. Blanc1, J Lourtet-Hascouet2, P. Payoux2, J.Monteil3, E.Denes3, A.Bicart-See1, G. Giordano1
1.Hôpital Joseph Ducuing, Toulouse, France
2.Service de Médecine Nucléaire, CHU Toulouse, Toulouse, France
3.Service de Médecine Nucléaire, Limoges, Limoges, France
E-mail: [email protected]
Keywords: Labelled Leukocytes Scintigraphy, LLS
Aim
Tc 99m labelled leukocytes scintigraphy (LLS) could be useful for the diagnosis of bone and joint infections. The
aim of our study was to evaluate its performances specifically in the diagnosis of prosthetic joint infection (PJI).
Methods
We conducted a multicenter -7 year- retrospective study including 164 patients with suspected PJI who
underwent surgical treatment. In each case, 5 intraoperative samples were taken. Diagnosis of infection was
confirmed if two or more samples yielded the same microbial agent. LLS was considered as « positive » if an
accumulation of leukocytes was observed in early stage and increased in late stage (24 hours). Among these
patients, 123 had also a bone scintigraphy.
Results
A total of 168 PJ were analyzed: 150 by in vitro polymorphonuclear labelled leukocytes scintigraphy (PLLS) and
18 by anti-granulocytes antibodies labelled leukocytes scintigraphy (LeukoScan®). Location of PJ were: hip (n =
63), knee (n = 71), miscellaneous (n = 4). According to microbiological criteria 62 hip prosthesis and 48 knee
prosthesis were considered as infected. Sensitivity (Se), Specificity (Sp), Positive Predictive Value (PPV) and
Negative Predictive Value of PLLS were: 72%, 60%, 80% and 47%. Se of LLS was higher for knee PJI (87%) than
for hip PJI (57%) [p = 0.002]. Although Sp was higher for hip PJI (75%) than for knee PJI (52%) [p = 0.002]. The
lowest Se was found for coagulase negative staphylococci (70%) and the highest for streptococci (87.5%).
However the difference of Se between bacteria was not significant. Regarding bone scintigraphy, Se, Sp, PPV
and NPV were: 94%, 11%, 65% and 50%.
Conclusions
In our study, performances of LLS were rather low and varied according to the location of infection.
Differences of LLS Se between bacteria was not significant. Bone scintigraphy has a high Se but lacks Sp.
54
Septic Non-Union / Trauma
55
SFP55 – (#274) – Short Free Paper
INFECTION-RELATED OUTCOMES OF GRADE 3 OPEN FRACTURES OF THE LIMB MANAGED WITH A CIRCULAR
FRAME
C.B. Chuo, H. Sharma, A. Kilshaw, G. Barlow, J. Bates, A. Platt
1
Hull & East Yorkshire Hospitals NHS Trust, Kingston-Upon-Hull, United Kingdom
E-mail: [email protected]
Keywords: Open Fracture, Outcome
Aim
Open fractures of the long bones of the limbs are associated with an increased risk of osteomyelitis and few
studies investigate this complication in circular frames. We reviewed the incidence of and contributory factors
toward infection-related outcomes in Grade 3 open fractures, managed with a circular frame, at a single
centre.
Methods
We performed a retrospective study of consecutive adult patients presenting with a Grade 3 open fracture,
who required a circular frame for definitive skeletal fixation from 2005 to 2014. Patient case notes,
microbiology results and radiological studies were reviewed for demographic details and surgical
management. Infection-related outcomes were classified as ‘possible’ and ‘definitive’, based on clinical
findings, microbiology and imaging features at follow-up at 6 and 12 months.
Results
74 patients were identified with an average age of 43 years. There were 70 unilateral and 4 bilateral limb
injuries. Most treated limbs had a tibial fracture (97%). There were 24 Gustillo-Anderson grade 3A, 37 grade
3B, 4 grade 3C and 9 not sub-classified. 33% of patients were debrided on the day of injury. Average time to
circular frame installation was 14 days. 27 Ilizarov, 44 Taylor spatial and 3 other circular frames were used. A
variety of plastic surgery reconstruction was used to provide wound coverage: skin grafts, local and free flaps.
Circular frames were in place for 259 days on average. 10 patients (1 bilateral limb fracture) still have their
frames in-situ. Additional bone grafting to the fracture site was carried out in 13 patients and 15 limbs (1
patient had 2 episodes of bone grafting to the same limb). 8 limbs in 8 patients were excluded from infectionrelated outcome analysis: 4 patients lost to follow-up, 2 patients who went on to below knee amputation and
2 patients had <6 months’ follow-up. 13 patients (14 limbs) had only 6 months’ follow-up and 53 patients (56
limbs) had 12 months’ follow-up. There were 5 patients (5 limbs) with ‘possible’ infection (7%): 1 screw
infection and 4 soft tissue infections. 1 patient (1 limb) had a tissue-confirmed ‘definitive’ infected non-union
(1.4%).
Conclusions
Patients managed with circular frames typically have complex fracture configurations less amenable to other
methods of definitive fixation. Our patient cohort has a limb salvage rate (97%) and a soft tissue infection rate
(‘possible’ infection) comparable to other reported series. We report a low rate of osteomyelitis (‘definitive’
infection) in consecutive patients managed using our protocol.
56
SFP56 – (#237) – Short Free Paper
POST-TRAUMATIC SEPTIC NON-UNIONS. THE ROLE OF EXTERNAL FIXATION IN AN AFRICAN CONTEXT.
A. Loro
1
CoRSU Rehabilitation Hospital, Kisubi, Uganda
E-mail: [email protected]
Keywords: Bone Transport, Non-Union, External Fixation
Aim
To present the results achieved with the use of external fixation techniques in treating 52 cases of posttraumatic and post-surgical septic non-union in a low resources setting.
Methods
From 2006 to 2014 52 patients were treated for post-traumatic septic non-union of the lower and upper limb
bones. Clinical records and radiographs were reviewed; telephone interviews were done for patients unable to
reach our institution.
There were 39 males and 13 females, with an average age at the time of admission of 29 years (the youngest
patient was 8 years old, the oldest 81). Tibia was involved in 43 cases (24 right side, 19 left side), femur in 9 (4
right, 5 left) and left humerus in 1. All the patients, except two, had been treated in other institutions before
admission. At presentation, 19 patients had an external fixator in situ, 18 patients had infected osteosynthesis,
15 had exposed necrotic bone, with loss of soft tissues.
In 20 cases hardware removal, debridement and sequestrectomy were followed by application of an external
fixator. In 31 cases bone transport was done; the fixator was monolateral in 27 cases. In 1 case
sequestrectomy and external fixation were followed by a vascularized fibula graft. Bifocal bone transport was
utilized in one patient while the bone transport procedure was associated to limb lengthening in 10 patients.
Plastic surgery was required in 13 patients. Rotational flaps, vascularized free flaps and extensive skin grafts
were all used.
Results
The site of non union was cured in all the patients, in an average time of 11 months (from 4 to 32). Two
patients required an amputation a few months after the end of the treatment. There was need for fixator
adjustment and screws replacement in 21 patients. Non-union at the docking point was observed in 5 patients;
it was septic in two of them. There was need of skin-plasty in 2 cases for skin invagination. In 3 cases an
extensive skin ulcer was observed during the transport procedure.
Limb length discrepancy was corrected in 10 patients. A residual limb shortening was observed in 14 patients.
Ankle fusion, knee fusion, foot drop, sensory loss in the foot, reduced range of joint motion were also
observed.
Conclusions
The external fixator plays a pivotal role in the treatment of septic non unions, especially in low resources
setting. The treatment is long and costly. Strict medical supervision is necessary during the entire process.
57
SFP57 – (#61) – Short Free Paper
CHALLENGES IN OSTEOMYELITIS TREATMENT IN LOW AND MIDDLE INCOME COUNTRIES
1
2
J. Geurts , P. Moh
1
Maastricht University Medical Center, Maastricht, The Netherlands
2
St. John of God Hospital, Duayaw Nkwanta, Ghana
E-mail: [email protected]
Keywords: Osteomyelitis, Bone Defect, Bioglas
Aim
Treatment of osteomyelitis is a challenge for every surgeon, but even more so in low and middle income
countries, because of delay in presentation, lack of resources and troublesome follow-up. We present a series
of fifteen patients, treated for osteomyelitis in 2014 in a rural Ghanean hospital with one-year follow up. All
bony defects were filled using Bonalive®.
Methods
Fifteen consecutive patients with osteomyelitis were included in this study and treated with Bonalive® in
March 2014. The group consisted of twelve men and three women (age 10-46y, mean 26y). All patients
consented and the study was approved by the hospital's ethical committee. Imaging was performed
preoperatively, immediate postoperatively and at various occasions thereafter with final X-rays taken at
follow-up in April 2015. All were treated by extensive debridement of the osteomyelitic bone, sequestrectomy,
saucerisation and filling of the defect with Bonalive® granules (1,0-2,0 mm in size). Primary closure of the
wound was possible in all cases. Fistulae were curetted, not closed. Peroperatively, multiple culture specimens
were taken and all patients received a course of intravenous antibiotics for a week, continued orally thereafter
for another week. Patients were regularly followed up postoperatively and final review took place in April
2015.
Results
Of all fifteen treated patients, only seven were seen back in April 2015, more than one year postoperatively.
The osteomyelitis was located in the femur in seven patients, tibia in seven and the humerus in two.
Microbiology showed growth of St. aureus in six patients, Proteus species in six, St. epidermidis in two and
pseudomonas in one. Of the seven patients presenting at one year follow-up, all had relief of symptoms for at
least three months. Two were completely symptom free, the other five still had one or more draining fistulae.
Initial X-rays showed good filling of all osteomyelitic defects with the bioglas granules.
Conclusions
Treatment of osteomyelitis remains a challenge in low and middle income countries. First, there is almost
always a delay in presentation and most cases have become chronic by the time they are treated. Secondly,
some sequesters were missed and therefore not removed at surgery, due to the lack of good initial x-ray films.
Thirdly, there is often no access to microbiological diagnostics. At last, a lot of patients are lost to follow-up.
In our opinion, the Bonalive® product delivered it’s claims, but the overall circumstances in which we treated
these patients were importantly responsible for the overall suboptimal outcome.
58
SFP60 – (#94) – Short Free Paper
GRACILIS FREE FLAP RECONSTRUCTION IN THE TREATMENT OF OSTEOMYELITIS: A 3 YEAR CASE SERIES FROM
A SINGLE UNIT
G. Williams, R. Khundkar, A. Ramsden, M. Mcnally
1
Nuffield Orthopaedic Centre, Oxford, United Kingdom
E-mail: [email protected]
Keywords: Gracilis Free Flap, Osteomyelitis, Muscle Flap
Aim
Chronic osteomyelitis is a challenging clinical problem. Aggressive debridement, bony fixation, obliteration of
dead space and vascularised soft tissue coverage with appropriate antimicrobial therapy are essential to
successful management of this condition . The gracilis muscle flap is the workhorse flap in our unit for
reconstruction of limb osteomyelitis.
We describe the experience and use of this flap in our unit over a 3 year period.
Methods
Clinical records were reviewed from a prospectively-maintained Oxford Free Flap Database and patient notes.
All patients who received a free gracilis flap reconstruction as part of the treatment of osteomyelitis between
2011 and 2014 were included in the study.
Results
40 patients received free gracilis flaps; 38/40 for lower limb and 2/40 for upper limb osteomyelitis. Two were
myocutaneous flaps, and the remainder were muscle only. The return to theatre rate was 12.5% with a total
flap loss rate of 5%. Other flap-specific complications include partial flap loss (2.5%), flap site haematoma
(2.5%), donor site haematoma (2.5%) and seroma (2.5%). General complications included pulmonary embolism
(2.5%) and death from sepsis (2.5%).
All but 2 patients were treated successfully and remain disease free following their initial surgery, with a mean
follow up of 12.4 months (range 1-23 months).
Conclusions
We have found that the free gracilis muscle flap is effective in the successful treatment of osteomyelitis, with a
low complication rate.
59
SFP61 – (#49) – Short Free Paper
INTRAMEDULLARY NAIL COATED WITH ALAC CONTAINING 5% OF CULTURE SPECIFIC ANTIBIOTIC IN THERAPY
FOR INFECTED LONG BONE NONUNIONS
I. Babiak, M. Kulig, P. Pedzisz, J. Janowicz
1
Department of Orthopedics and Traumatology, Medical University of Warsaw, Warsaw, Poland
E-mail: [email protected]
Keywords: Septic Non-Union, Antibiotic Loaded Acrylic Cement
Aim
Infected nonunion of the femur or tibia diaphysis requires resection of infected bone, stabilization of bone and
reconstruction of bone defect. External fixation of the femur is poorly tolerated by patients. In 2004 authors
introduced in therapy for infected nonunions of tibia and femur diaphysis coating of IMN with a layer of
antibiotic loaded acrylic cement (ALAC) containing 5% of culture specific antibiotic.
Methods
Seven patients with infected nonunion of the diaphysis of femur ( 2 ) and tibia ( 2 ) were treated, aged 20-63
years, followed for 2-9 years ( average 5,5 years). All have been infected with S. aureus (MSSA: 2 and MRSA: 4)
or Staph. epidermidis ( 1) and in one case with MRSA and Pseudomonas aeruginosa. All patients underwent 3
to 6 operations before authors IMN application. Custom-made IMN coated with acrylic cement (Palamed)
loaded fabrically with gentamycin with admixture of 5% of culture-specific antibiotic: vancomycin ( 7 cases)
and meropeneme (1 case) was used for bone stabilization. Static interlocking of IMN was applied in 4 cases
and dynamic in 2 cases. In 1 case the femur was stabilized with IMN without interlocking screws. In 2 cases
IMN was used for fixation of nonunion at docking site after bone transport. In 3 cases ALAC was used as
temporary defect filling and dead space management. In one case after removal of IMN coated with ALAC, a
new custom made Gamma nail and tubular bone allograft ranging 11 cm was used for defect reconstruction.
Results
Infection healing was achieved in all 7 cases, bone union was achieved in 4 from 7 cases. In 1 case of segmental
diaphyseal defect ranging over 12 cm infection was healed, but bone defect was not reconstructed. This
patient is waiting for total femoral replacement. In another case of segmental defect of 11 cm infection is
healed, but allograft substitution and remodeling by host bone is poor. In the 3rd case of lacking bone healing,
the 63 year old patients was noncooperative and not willing to walk in walker with weight bearing. This patient
refused further treatment.
Conclusions
Custom-made intramedullary nail coated with a layer of acrylic cement loaded with 5% of culture specific
antibiotic can provide local infection control, offer comfortable bone stabilization, and replace standard IM nail
in therapy for difficult to treat infected diaphyseal nonunion of femur or tibia.
60
SFP62 – (#25) – Short Free Paper
INFECTION OF THE ACHILLES TENDON AFTER OPERATIVE TREATMENT OF A RUPTURE
U. Gerlach
1
BG-Unfallkrankenhaus Hamburg, Hamburg, Germany
E-mail: [email protected]
Keywords: Infection O The Achilles Tendon, Subtotal Ressection Of The Tendon, Radical Debridement
Aim
The incidence of rupture of an Achilles tendon constitutes 0,01-0,02%. The infection of the Achilles tendon
after operativ repair is a very rare but severe complication. In this study we examined the functional outcome
after radical debridement of the Achilles tendon.
Methods
From 2009 to 2014 we treated 26 patients (22 male, 4 female) with an infection oft he Achilles tendon. In 24
cases the infection was caused after suture of the tendon, in 2 cases the infection was caused by an open
injury. The average age was 46,8 (21 to 75). The number of operations the patient had to undergo before
admitted to our hospital was 23, in average (with an range from 0 to 9 operations). We performed a radical
debridement and the insertion of a local antibiotic carrier. In all cases an at least subtotal resection of the
Achilles tendon was necessary. In 10 cases we found Staphylococcus aureus, in 4 cases atleast 2 different types
of bacteria. In 2 cases we detected E.coli, in 1 case Enterococcus faecalis and 1 case Bacteroides fragiles. In 6
cases we didn´t succeed in identifying a bacteria despite of a hisological report describing a severe infection.
Results
In all cases we achieved a long-lasting stop of the infection. We succeed in 22 cases with just one operation. In
2 cases we had to perform several surgeries(3 Operations and 7 operations) due to extended soft tissue
damage of the lower leg and the necessity of a free flap. 22 patients are mobilized in normal shoes, 2 in
orthopedic shoes. Because of the building of scartissue we didn´t find a serious impairment of the function
despite a subtotal resection of the tendon. The plantar flexion was possible against resistance with reduced
strength. Further operative measure such as replacement with other tendons were not required.
Conclusions
In order o obtain a durable stop of the infection it is decisive to operate radical. All infected tissue has to be
removed. Even a subtotal resection of the Achilles tendon leads to0 a satisfactory functional outcome.
61
Osteomyelitis / Antibiotics
62
SFP63 – (#193) – Short Free Paper
PYOGENIC VERTEBRAL INFECTION.
S. Gonçalves, S. Stefanova, J. Simões
1
Curry Cabral, Lisboa, Portugal
E-mail: [email protected]
Keywords: Pyogenic, Spondylodiscitis, Treatment.
Aim
The goal of this work is to evaluate the epidemiology and treatment employed in the treatment of pyogenic
spondylodiscitis.
Methods
Diagnosis was based on clinical and imaging, it does not include cases of postoperative infection and lesions
contiguous with decubitus ulcers. The clinical records were used to obtain demography, comorbidities,
presenting symptoms, physical examination, laboratorial values, diagnostic procedures, microbiological profile
as well as medical and surgical treatment. Statistical analysis was performed using SPSS 20.
Results
After reviewing 22 patients met the inclusion criteria. The mean age was 60.82(range 22-86), 82 % were
men(n=18). Most prevalent comorbidities were diabetes mellitus 41%(n=9), chronic alcoholism 18% (n=4), CKD
14%(n=3) and HIV in 9%(n=2). Approximately 40.1% had a septic focus in another location, the most common
UTI 30%(n=3) and 20% sepsis(n=2). The most common symptoms were LBP 51%(n=21), weight loss 15%(n=6)
and fever 12%(n=5). Laboratory evaluation revealed an average leukocytosis 11.8(range 4.3-21.8), ESR
averaged 83.9 mm/h (range 10-128), mean CRP 11.6 mg/dl(range 0.4-38.7). The lumbar spine was the most
affected segment 55%(n=12), then the dorsal 36%(n=8) and cervical 9%(n=2). The microbiological diagnosis
was established in 55% of cases (n=12), 8(66.7%) cases were identified in blood cultures and 3(25%) in bone
biopsy. The most common agents identified were MSSA in 18% of cases (n=4) and cogulase negative
staphylococci 18%(n=4). A surgical procedure was performed in 86.4% (n=19), 7 for fusion and in 4 a
transpedicular biopsy. The indications for surgery were crop material, abscess drainage and instability each
with 32%(n=6). In terms of neurological sequelae 23%(n=5) had changes.The average length of stay was 57.4
days(range 19-190), mortality was 9%(n=2). We found no statistically significant differences regarding the
identification of microorganisms using age (p=0.644), ESR(p=0.233), CRP(p=0.166) and leukocytosis(p=0.147)
as variables.
Conclusions
Our series has characteristics common to literature, predominantly male, risk factors as Diabetes, CKD and HIV
are common. Alcoholism is linked with some immunosuppression and appears as a new risk factor. Obtaining
microbiological diagnosis is crucial to avoid the need for prolonged antibiotic therapy and the potential
increased costs and toxicity of broad spectrum. The low number of positive biopsy (25%) is explained by the
early empirical antibiotic therapy before sampling. Surgery plays an important role in crop products for
microbiological analysis and treatment of instability or neurological deficits. A high index of suspicion in
patients with known risk factors and back pain is crucial since delay in diagnosis leads to worse outcomes.
63
SFP64 – (#230) – Short Free Paper
CANDIDA ALBICANS LUMBAR SPONDYLODISCITIS IN A NON IMMUNOCOMPROMISED PATIENT
N. Barbosa, M.J. Gonçalves, P. Araujo, L. Torres, H. Aleixo, L. Carvalho, L. Fernandes, D. Castro, T. Lino
1
Hospital Pedro Hispano, Matosinhos, Portugal
E-mail: [email protected]
Keywords: Candida Albicans, Lumbar Spondylodiscitis, Spine, Vertebral Osteomyelitis, Fungal Infection
References
Arias,F.,Mata-Essayag, S.,Landaeta,M.E.,De Capriles,C.H.,Pérez, C.,Núez,M.J., Silva,M.(2004). Candida albicans
osteomyelitis:Case report and literature review. International Journal of Infectious Diseases,8(5),307–
314.http://doi.org/10.1016/j.ijid.2003.12.006.
Chen,C.,Chen,W.L.,&Yen,H.(2013).Candida albicans lumbar spondylodiscitis in an intravenous drug user : a
case report.
Miller,D.J.,&Mejicano,G.C.(2001).Vertebral osteomyelitis due to Candida species:case report and literature
review.Clinical Infectious Diseases,33(4),523–530.http://doi.org/10.1086/ 322634
Aim
We report the clinical features and treatment on a rare case of Candida albicans lumbar spondylodiscitis in a
non-immunocompromised patient. Its indolent course leads to delayed suspicion and diagnosis. As soon as
fungal infection is suspected investigations with MRI and biopsy should be performed followed by medical
therapy.
Methods
Retrospective data analysis.
Results
A 58-year-old male underwent surgery for adenocarcinoma of the ampula of Vater treatment . Subsequently,
the patient had a prolonged intensive care unit stay due to major complications , during his stay he developed
a septicemia with Candida albicans isolated in the blood work.He received antifungal therapy anidulofungin
,later changed to fluconazole during 2 weeks. Repeated blood work were negative and no vegetations on
echocardiogram were seen. He was discharged from the ICU to a surgery floor.
During the surgical unit stay he presented with lower back pain radiating to the lower limbs. Findings on
neurological examination were normal,radiographs of the lumbar spine revealed L5-S1 antero listhesis. He was
treated with oral non-steroidal anti-inflammatory drugs and an lumbar MRI and orthopaedic consultation was
agended. One month later, after minor trauma he developed myelopathic symptoms with weakness of both
lower limbs and severe back pain. Plain radiograph showed anterolistesis worsening. Magnetic resonance
imaging showed endplate erosion at L5/S1. There also was evidence of paraspinal collection with epidural
compression of the dural sac.
The patient was treated surgicaly with debridement and posterior instrumented fusion from L4 to S1. Disk and
end-plate material collected confirmed Candidal infection. The patient recovered most of his neurological
deficit immediately after surgery. He was subsequently treated during 2 weeks with liposomal amphotericin B,
later changed to fluconazole 400mg per os per day. He maintained antifungal therapy during 15 months. He
remains asymptomatic with no recurrence of infection clinically or radiologically after surgery.
Conclusions
Fungal spondylodiscitis is rare. Sub-acute or chronic low back pain in either immunocompromised or nonimmunocompromised patients cronically ill and malnourished (parental nutrition) there must be high index of
suspicion for fungal infections. Therefore we recommend screening for Candida osteomyelistis in these cases.
Without treatment, involvement of vertebral bodies can lead to compression fractures, deformity of the spine
and neurological impairment.
64
SFP65 - #150 – Short Free Paper
INFLUENCE OF AN ANTIBIOTIC STEWARDSHIP PROGRAM ON DIAGNOSTIC PROCEDURES AND ANTIBIOTIC
THERAPY FOR PATIENTS WITH SPONDYLODISCITIS
S. Petersdorf, N. Kamp, R. Krauspe, M. Konieczny
1
University Clinic Düsseldorf, Düsseldorf, Germany
E-mail: [email protected]
Keywords: Antibiotic Stewardship, Spondylodiscitis, Tissue Samples, Blood Culture, Specific Antibiotic Therapy
Aim
Spondylodiscitis is a severe infectious disease of the vertebral column and the intervertebral disc space and
may be complicated by an epidural abscess. A wide range of pathogens have been described as causative
agents. Since several weeks of antibiotics are necessary for successful therapy detection of the causative
pathogen is essential. Specific antibiotic therapy improves outcome and reduces antibiotic related
complications. Antibiotic Stewardship (ABS) programs are bundled approaches aimed at improving antibiotic
therapy. In 2012 an ABS program including weekly interdisciplinary clinical rounds and development of
algorithms for diagnosis and therapy of patients with spondylodiscitis was established in the Department of
Orthopedic Surgery in a University hospital. We evaluated the effects of ABS with regard to the
appropriateness of specimen and pathogen detection and antibiotic therapy in patients with spondylodiscitis.
Methods
We retrospectively analysed diagnostic procedures and pathogen detection of 100 patients that were
hospitalized with spondylodiscitis and compared the data of patients that were treated before (2004-2011)
and after introduction of ABS measures (2012-2014). After introduction the effect of ABS on antibiotic therapy
was analysed.
Results
100 patients with radiologically confirmed spondylodiscits were enrolled. The pre-ABS group (2004-2011)
contained 58 patients. Of these no samples were taken for microbiological examination from 21 patients (36%)
and from 8 patients (14%) only swabs were submitted for culture. Aspirates or tissue samples were taken from
22 patients (38%) and blood cultures from 18 patients (31%). Pathogen detection was successful in 18 patients
(31%).
After introduction of ABS in the beginning of 2012 aspirates or tissue samples were taken from 34 patients
(81%) and blood cultures were taken from 34 patients (81%). Pathogen detection was successful in 26 patients
(62%). The most commonly detected pathogens were Gram positive cocci (S.aureus, S. epidermidis, and
streptococci) in 31 patients. Less common pathogens were found in 12 patients (Gram negative rods (8), fungi
(3), Moraxella (1) and Propionibacterium (1). After introduction of ABS antibiotic therapy was changed in 18 of
20 patients (90%) after pathogen identification.
In 50 % of cases the inappropriate empiric therapy was changed (MRSA, MRSE and Gram negative rods) and in
50 % broad-spectrum antibiotic therapy could be deescalated.
Conclusions
ABS significantly improved the number and quality of samples, increased the number of blood cultures taken
and doubled the pathogen detection rates in patients with spondylodiscitis leading to an improvement in
antibiotic therapy in almost all patients with pathogen detection.
65
SFP66 – (#204) – Short Free Paper
OPEN VERSUS ARTHROSCOPIC DRAINAGE OF ACUTE SEPTIC ARTHRITIS OF THE KNEE
D. Saraiva, M. Oliveira, T. Torres, F. Santos, M. Frias, R. Pereira, A. Costa, G. Martins, F. Ferreira, D. Sá, P.
Lourenço, P. Carvalho, F. Lebre, R. Freitas
1
CHVNGaia/Espinho, Porto, Portugal
E-mail: [email protected]
Keywords: Knee, Septic, Open, Arthroscopy
Aim
Acute septic arthritis of the knee can lead to joint damage or sepsis, if early diagnosis and treatment fail to
occur, which includes drainage of the joint, adequate antibiotic coverage and resting of the knee. Classically,
drainage of the knee was performed either with multiple aspirations or open arhtrotomy. The arthroscopic
approach has becoming widely accepted, as it allows adequate drainage of the pus and debridement with
partial or total sinovectomy of the joint.
The aim of this study was to evaluate the differences between arthroscopy and open arthrotomy in the clinical
outcomes and rate of recurrence in patients with septic arthritis of the knee joint.
Methods
We reviewed patients with acute septic arthritis of the knee admitted in our center between January 2010 and
December 2014. The criteria for diagnosis was report of purulent material when arhtrotomy or arthroscopy
was performed or a positive culture of the joint fluid. Patients with recent surgery or documented
osteomyelitis of the femur or tíbia were excluded.
We used the Oxford Knee Score (OKS) to classify the clinical outcomes in the end of follow-up, and registered
the rate of recurrence in each group. The statistical evaluation of the results was performed using Student’s ttest.
Results
65 patients were treated during this period, 37 by an open arthrotomy through a lateral supra-patellar
aproach, and 28 by arthroscopy through 2 standard anterior portals. All the patients were imobilized with a
cast or orthosis in the immediate post-operation period for a mean period of 13 days in the arthrotomy group
(8-15) and 9 days in the arthroscopy group (6-12) and received endovenous antibiotics for at least 10 days,
followed by oral antibiotics for a mean total of 36 days in the the arthrotomy group (30-48) and 32 days in the
arthroscopy group (22-36). The mean follow-up was 22 months in the arthrotomy group (8-28 months) and 18
months in the arthroscopy group (14-24). The mean OKS was 31 in the the arthrotomy group (21-39) and 35 in
the arthroscopy group (25-44). There was 1 recurrence in the arthrotomy group and 1 recurrence in the
arthroscopic group, both managed by knee arthrotomy.
Conclusions
Drainage is a key step in treatment of knee pyoarthrosis, either through an open or an arthroscopic approach.
Both seem to be equally effective, with no significant statistical difference in terms of recurrence. The
functional results tend to favour the arthroscopic approach, but with no statistical significance.
66
SFP67 – (#57) – Short Free Paper
DETERMINING THE TISSUE CONCENTRATION OF DICLOXACILLIN USING MICRODIALYSIS
1
2
1
3
3
1
K. Hansen , L. Rasmussen , O. Skov , F. Nielsen , T. Stage , U. Jørgensen
1
Orthopeadic Research unit, department of Orthopedic Surgery and Traumatology, Odense University Hospital,
Odense, Denmark
2
Department of Orthopedic Surgery, Vejle Hospital, Vejle, Denmark
3
Clinical pharmacology, Institute of Public Health, University of Southern Denmark, Odense, Denmark
E-mail: [email protected]
Keywords: Tissue-Penetration, Microdialysis, Dicloxacillin
References
1. Lund B, Klamer F, Johannessen T. Proteseinfektion i knogler og led 2010.
Aim
In Denmark the most common postoperative pathogen is S. aureus (1), sensitive to dicloxacillin. These bacteria
can cause a postoperative infection despite using prophylactic antibiotics. Whether the tissue concentration
reached is above the minimal inhibitory concentration (MIC) for the pathogens is unknown, and if lower than
expected could result in a postoperative infection. Thus a trial was conducted, measuring the actual tissue
concentration of dicloxacillin in human muscle and adipose tissue and compared these to the plasma
concentration.
Methods
MIC for dicloxacillin against S. aureus was determined using the broth macrodilution method. Six healthy male
volunteers aging 25 to 27 years (body-mass-index; 20-28), were recruited. A CMA63 (Mdialysis, Stockholm,
Sweden) catheter was placed in the subcutaneous tissue of the abdomen and in the rectus muscle of the thigh
and the volunteers given 2 g dicloxacillin intravenously over 5 minutes. In 10 min intervals for the following 6
hours, samples from blood and Microdialysis fluid (flowrate 5 ml/min) were collected. Recovery was
determined in vitro. Plasma was isolated from blood samples. The unbound dicloxacillin was isolated from
plasma using filter plates (AcroPrep 30K Omega, Pall Corporation, US) centrifuged for 30 minutes at 1000 x g
and 37°C . All samples were analyzed with High Performance Liquid Chromatography.
Results
MIC was determined to be 0.125 µg/ml. Average recovery was 73,7 % Maximum concentrations were reached
in muscle tissue after a median of 0.5 hours and adipose tissue after 0.8 hours. The geometric mean ration
(GMR) of AUC0-6h for adipose tissue compared to plasma was 0.32 [0.15-0.71]. GMR of AUC0-6h for muscle
tissue compared to plasma and adipose tissue compared to muscle showed no statistically significant
differences. The tissue concentrations were above MIC for 3.4 hours for adipose tissue and 4.1 hours for
muscle tissue.
Conclusions
The administration of prophylactic dicloxacillin should be given at least 30 minutes prior to incision to ensure
maximum tissue concentrations at the onset of surgery. A second dose should be given after 3.4 hours in case
of long surgery time. Since the dicloxacillin concentration reached in the adipose tissue is lower than in
plasma, it should be investigated whether this difference is more prominent in adipose patients or patients
with impaired peripheral circulation, since these patients are at a greater risk of postoperative infections.
Acknowledgements
Johan Boserup og Lise Boserups Legat
Familien Hede Nielsens Fond
Aase og Ejnar Danielsens Fond
67
SFP68 – (#69) – Short Free Paper
ACTIVITY OF ACRYLIC MICROPARTICLES LOADED WITH DAPTOMYCIN AGAINST MATURE S. EPIDERMIDIS
BIOFILMS – A THERMAL AND IMAGING STUDY.
1
1
1
2
2
2
1
3
I. Ferreira , A. Bettencourt , L. Gonçalves , S. Kasper , J. Kikhney , A. Moter , A. Almeida , A. Trampuz
1
Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
2
Biofilmcenter, German Heart Institute Berlin, Berlin, Germany
3
Center for Musculoskeletal Surgery, Charité – Universitätsmedizin Berlin, Berlin, Germany
E-mail: [email protected]
Keywords: Staphylococcal Biofilms, Isothermal Microcalorimetry, Fluorescence In Situ Hybridization, AntibioticLoaded Polymeric Microparticles
Aim
The aim of the present study was to assess the antibiofilm activity of daptomycin- and vancomycin-loaded
poly(methyl methacrylate) (PMMA) and PMMA-Eudragit RL100 (EUD) microparticles against mature biofilms of
polysaccharide intercellular adhesin-positive S. epidermidis.
Methods
The effect of plain, daptomycin- and vancomycin-loaded PMMA and PMMA-EUD microparticles on S.
epidermidis biofilms was assessed by isothermal microcalorimetry (IMC) and fluorescence in situ hybridization
(FISH). Biofilms were grown for 48h onto poly-urethane pieces of fixed dimensions. Each sample was washed
with PBS in order to remove planktonic bacteria and incubated for 24h with different concentrations of acrylic
microparticles (20-1.25 mg/mL). The minimal biofilm inhibitory concentration (MBIC) of the antibiotic-loaded
particles was defined as the lowest concentration of particles that was able to prevent heat flow associated to
the recovery of the biofilms. After incubation with the microparticles, sessile cocci were hybridized with the
pan-bacterial EUB338-FITC and the staphylococci-specific STAPHY-FICT probes and stained with DAPI. Biofilm
structure and metabolic state were characterized by fluorescence microscopy.
Results
According to the IMC results, plain PMMA-particles showed no effect on S. epidermidis biofilms, whereas
PMMA-EUD-microparticles negatively influenced the recovery of the biofilm probably due to the highly
positive charge of these particles. The MBIC of daptomycin-loaded PMMA-microparticles was 20 mg/mL,
whereas vancomycin-loaded PMMA microparticles were not able to inhibit biofilm recovery. Adding EUD to
the formulation reduced the MBIC of daptomycin-loaded microparticles to 1.25 mg/mL, corresponding to a 16fold reduction. Regarding the vancomycin-loaded microparticles, EUD caused a further decrease of their
antibiofilm activity. The FISH micrographs corroborated the IMC results and provided additional insights on the
antibiofilm effect of these carriers. According to FISH, daptomycin-loaded PMMA-EUD microparticles were
responsible for the most pronounced reduction in biofilm mass. In addition, FISH showed that both PMMA and
PMMA-EUD microparticles were able to attach to the biofilms.
Conclusions
Adding EUD to the formulations proved to be a powerful strategy to improve daptomycin-loaded
microparticles antibiofilm activity. In addition, the combination of IMC and FISH was essential in order to fully
assess the effect of polymeric microparticles on sessile S. epidermidis. Although the present study enabled
gaining further insights on this subject, the nature of these interactions remains unclear. However, this may be
a crucial aspect for the enhancement of antibiofilm activity of antibiotic-loaded polymeric microcarriers
against mature biofilms.
Acknowledgements
This work was supported by the Portuguese government (Fundação para a Ciência e a Tecnologia) and FEDER
(grant SFRH/BD/69260/2010 and research project EXCL/CTM-NAN/0166/2012) and strategic project PEstOE/SAU/UI4013/2011.
68
SFP69 – (#67) – Short Free Paper
USE OF A NEW ANTIBIOTIC BONE SUBSTITUTE TO INDUCE HEALING OF OSTEOMYELITIS IN THE DIABETIC
FOOT
C. Whisstock, S. Ninkovic, M. Marin, M. Bruseghin, A. Volpe, M. Manzi, E. Brocco
1
Diabetic Foot Clinic, Foot and Ankle Clinic, Abano Terme, Italy
E-mail: [email protected]
Keywords: Diabetic Foot, Osteomyelitis, Bone Substitute
Aim
Aim of this work was to evaluate the efficacy of a new antibiotic bone substitute (CERAMENTTM|G) in the
treatment of osteomyelitis (OM) in diabetic foot.
Methods
From June 2013 to April 2015 we used a new Calcium Sulphate Hemihydrate + Hydroxyapatite + Gentamicin
Sulfate (CSH + HA + GS) compound to fill resected bone voids following surgical intervention in cases of
diabetic foot OM. The uniqueness of this product is that it induces native bone growth, while the synthetic
bone disappears and antibiotic is released into the surrounding tissues, maintaining high gentamicin
concentrations for some weeks.
In 20 patients, with or without Charcot neuroarthropathy and post-lesional osteomyelitis, after removal of
infected bone we applied 10 to 20 ml CSH + HA + GS, filling the residual spaces and aiming to stabilize the
remaining bone fragments. When needed, these arthrodeses were stabilized by external-internal hybrid
fixators. X-ray evaluations and, when indicated, MRI evaluations were performed before and after surgical
intervention, and 3 months post-op. Revascularization with percutaneous angioplasty was performed when
needed.
20 patients affected by OM were treated, 4 of them having 1st metatarsal head involvement, 4 having heel
involvement, 12 tarsal and hindfoot involvement. After surgical intervention all of them were treated with
standard medication and pressure relief.
Results
The three 1st metatarsal OM cases healed, both in regards to infection and lesions. One of the patients is still
ongoing. One of the patients with heel OM presented with a worsening of the infection and was treated by
major amputation, another one presented with good soft tissue growth and, two months from the
intervention, and in the absence of clinical signs of OM relapse, was treated with a sural fasciocutaneous
pedicled flap; of the remaining two patients one heald and the other is still ongoing; 11 of the 12 patients who
had midfoot or hindfoot partial resections healed, one patient is still ongoing. The healed patients are all
wearing suitable shoes.
Conclusions
The use of a new CSH + HA + GS bone substitute has shown to be efficacious in inducing OM healing and
preserving foot structures in diabetic feet.
69
SFP70 – (#179) – Short Free Paper
ADJUVANT THERAPY IN CHRONIC OSTEOMYELITIS: SELF MADE THREE ANTIBIOTIC CEMENTED SPACER VS
TWO ANTIBIOTIC CUSTOM MADE
1
1
1
2
D. Fenga , D. Ortolà , S. Marcellino , F. Centofanti , M.A. Rosa
1
Policlinico Universitario G.Martino, Messina, Italy
2
Istituto Codivilla Putti, Cortina D'Ampezzo, Italy
E-mail: [email protected]
1
Keywords: Cement, Antibiotics, Spacer, Osteomyelitis
Aim
The use of antibiotic-spacer, it is essential to treat infections in orthopedics. They play a dual role, to fight the
infection directly on the outbreak and keep the length or the articulation of the limbs thus facilitating the
second operation. To date it is not known, the superiority of use of 3 antibiotics compared to two. Authors try
to compare industrial preformed spacers with two antibiotics with custom made spacers with three antibiotics
to assess (a) the control of infection, (b) complications, (c) quality of life, (d) pain and (e) patient satisfaction.
Methods
137 patients treated at the Institute Codivilla-Putti from January 2010 to December 2012 were considered: 68
patients treated with antibiotic preformed spacer (clindamycin + gentamicin) or (Erythromycin + Colistin), 69
patients treated with antibiotic spacer added with 3 antibiotics (clindamycin + gentamicin + vancomycin) or
(Erythromycin Vancomycin + Colistin).
Demographic data were collected:
• type and site of infection (classified by Cerny-Mader)
• microbiological results
• previous surgeries
• years of illness.
Primary outcome of infection control or relapse after at least 12 months of follow-up were assessed.
Complications were recorded. Each patient completed a test on the quality of life and a satisfaction scale selfreferenced.
Results
After a mean follow-up of 33.82 months (SD 14:50),at the end of the treatment, at last follow up 15/133 were
infected. 4 died from other causes not correlated with infection, whit a 11.3% rate of reinfection.
Conclusions
Up to our knowledge, there is only one study using the procedure in two steps comparing the use of spacers
loaded with 2 or 3 antibiotics. Our results show that a revision protocol in two steps with 3 antibiotic loaded
spacers have a high success rate in the treatment of chronic osteomyelitis. We can observe that patients
treated with custom-made cements are 4 percentage points lower than those treated with preformed
cements, but there are no statistically significant differences in the rate of recurrence of infection. Our results
suggest that a two stages procedure with three antibiotic loaded spacers should be considered in selected
patients to avoid rescue procedures, such as amputation and arthrodesis. We think is important to do more
randomized trials, controlled, prospective study with a larger group to detect statistically significant
differences.
70
SFP71 – (#172) – Short Free Paper
IN HOSPITAL MORTALITY IN PATIENTS WITH PERIPROSTHETIC JOINT INFECTION
A. Shahi, T. Tan, A. Chen, M. Maltenfort, J. Parvizi
1
Rothman Institute, Philadelphia, United States
E-mail: [email protected]
Keywords: Mortality, Periprosthetic Joint Infection, Kidney Transplantation, Carotid Surgery
Aim
Periprosthetic joint infection (PJI) is one of the most devastating complications of total joint arthroplasty (TJA).
Only a few studies have investigated PJI’s impact on the most worrisome of all endpoints, mortality. The
purpose of this study was to perform a large-scale study to determine the rates of PJI associated in-hospital
mortality, and compare it to other surgical procedures.
Methods
The Nationwide Inpatient Sample was queried from 2002 to 2010 to assess the risk of mortality for patients
undergoing revision for PJI or aseptic failures. Elixhauser comorbidity index and ICD-9 codes were used to
obtain patients’ medical conditions and identify PJI. Multiple logistic-regression analyses were used to
determine the associated variables with mortality. In-hospital mortality was compared to the followings:
coronary-artery bypass graft, mastectomy, prostatectomy, appendectomy, kidney transplant, carotid surgery,
cholecystectomy, and coronary interventional procedures.
Results
PJI was associated with an increased risk (odds ratio 2.04) of in-hospital mortality (0.77%) compared to aseptic
revisions (0.38%). The in-hospital mortality of revision THAs done for PJI (1.38%, 95%CI, 1.12-1.64%) was
comparable to or higher than interventional coronary procedure (1.22%, 95%CI, 1.20-1.24%), cholecystectomy
(1.13%, 95%CI, 1.11-1.15%), kidney transplantation (0.70%, 95%CI, 0.61%-0.79%) and carotid surgery (0.89%,
95%CI,0.86%-0.93%) (Figure 1). The following comorbidities were independent risk factors for in-hospital
mortality after TJA: liver disease, metastatic disease, fluid and electrolyte disorders, coagulopathy, weight loss
and malnutrition, congestive heart failure, pulmonary circulation disorder, renal failure, and peripheral
vascular disease.
Conclusions
PJI is associated with a two-fold increase in mortality and have mortality rates comparable to kidney
transplantation and carotid surgery. Considering the fact that patients with PJI often require multiple surgical
procedures, the rate of actual in-hospital mortality for patients with PJI may be considerably higher. Surgeons
should be cognizant of the potentially fatal outcome of PJI and must emphasize the importance of infection
control to reduce the risk of mortality.
71
SFP72 – (#223) – Short Free Paper
IN-VIVO GENTAMICIN CONCENTRATIONS IN PLASMA AND DRAIN FLUID AFTER BONE DEFECT
RECONSTRUCTION USING A GENTAMICIN-ELUTING BONE GRAFT SUBSTITUTE
1
1
2
1
P. Horstmann , W. Hettwer , Z. Song , M. Petersen
1
Department of Orthopedic Surgery, Muskuloskeletal Tumor Section, Rigshospitalet, University of
Copenhagen, Copenhagen, Denmark
2
Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
E-mail: [email protected]
Keywords: Antibiotic-Eluting Bone Graft Substitute, Local Gentamicin Administration, Bone Defect
Reconstruction
References
(1) McNally et al. Abstract F093, 33rd EBJIS Annual Meeting, Utrecht, 2014
Aim
To document early in-vivo concentrations of gentamicin in plasma and drain fluid after bone defect
reconstruction using a gentamicin-eluting bone graft substitute.
Introduction
Reconstruction of bone defects after surgical bone tumor resection is associated with an increased risk of
infection and some surgeons therefore prefer extended antibiotic prophylaxis in these patients. A gentamicineluting bone graft substitute consisting of sulphate and apatite has been shown to be effective for treatment
of osteomyelitis(1) and may be a valuable addition to the therapeutic and/or prophylactic antibiotic regime for
this and many other indications.
Methods
We performed a prospective pilot study from December 2014 to February 2015 in 7 patients (M/F: 4/3, mean
age 51 (37-79) years) who underwent bone defect reconstruction with a gentamicin-eluting bone graft
substitute (CERAMENT™|G – BONESUPPORT AB) containing 175 mg gentamicin per 10 mL. Indications for
surgery were metastatic bone disease (n=3, proximal humerus), giant cell tumor (n=2, distal femur), aseptic
prosthetic loosening (n=1, knee) and chondroid tumor (n=1, distal femur). Additional endoprosthetic
reconstruction with a tumor prosthesis was performed in 3 patients (2 proximal humerus and 1 distal femur).
Drain fluid and plasma was collected immediately postoperatively and each postoperative day until the drain
was removed. In 2 cases we were unable to collect drain fluid directly postoperatively due to minimal fluid
production. Gentamicin concentrations were analyzed using an antibody technique (Indiko™ – Thermo
Scientific).
Results
A mean of 14 (10-20) mL gentamicin-eluting bone graft substitute was used, either alone or in combination
with cancellous allograft and/or a bone graft substitute not containing gentamicin (CERAMENT™|BVF –
BONESUPPORT AB). Mean drain fluid concentrations of gentamicin were 1200 (723-2100) mg/L immediately
postoperative (0-2 hours), 1054 (300-1999) mg/L on day 1 (17-23 hours) and 509 (38-1000) mg/L on day 2 (3945 hours). Mean plasma concentrations of gentamicin were 1.26 (1.08-1.42) mg/L immediately postoperative,
0.95 (0.25-2.06) mg/L on day 1 and 0.56 (0.20-0.88) mg/L on day 2.
Discussion
As gentamicin induces a concentration-dependent bacterial killing effect, the obviously high local peak
concentrations of gentamicin found in this study would be expected to deliver a substantial prophylactic effect
after long operations with an increased risk of intraoperative bacterial contamination.
Conclusions
Local implantation of a gentamicin-eluting bone graft substitute for bone defect reconstruction results in high
concentrations of gentamicin in the drain fluid in the first postoperative days and low plasma concentrations.
72
SFP73 – (#143) – Short Free Paper
IN VITRO EFFICACY OF A LINEZOLID ELUTION SYSTEM BY CANCELLOUS BONE ALLOGRAFTS IN A
STAPHYLOCOCCUS EPIDERMIDIS BIOFILM MODEL
A. Pistiki, P. Nikou, E. Giamarellos-Bourboulis, M. Georgitsi, V. Soranoglou, I. Galani, K. Kanellakopoulou, E.
Giannitsioti
1
4th Department of Internal Medicine, ATTIKON University General Hospital, Athens, Greece
E-mail: [email protected]
Keywords: Linezolid, Biofilm, MRSE, Bone Elution,
References
Kanellakopoulou K et al, J Biomed Mater Res A. 2010;92:52-55,
Zalavras CG,et al Clin Orthop Relat Res. 2004;437:86-93.
P. Nikou et al ;53th ICAAC 2013;A-1050:109
Aim
Prosthetic joint infections are difficult to treat due to bacterial biofilm. Our group has developed a linezolid
elution system by human cancellous bone delivering high concentrations the first 48 hours (Giannitsioti et al.
53rd ICAAC, 2013: A-1050). We tested the activity of this system to inhibit growth of one ica expressing isolate
of Staphylococcus epidermidis (MRSE).
Methods
At a first step, sterile mesh cylinders containing bone particles of the femoral head of healthy volunteers
(MCB) were impregnated into 3mg/ml linezolid for 1, 24 and 48 hours. Then log-phase inocula of 103, 105 and
107cfu/ml were exposed to MCB at 370C for 8 days with regular readings of bacterial growth. MCB were
transferred into fresh Muller-Hinton Broth (MHB) every 24h to avoid material corrosion. At a second step, to
simulate the ability of the system against biofilm-coated MCB, MCB without linezolid were incubated with 103
and 105 cfu/ml for 1 and 24h. MCB were daily transferred into fresh MHB containing 100μg/ml on day 1, 15
μg/ml on day 2, 3 μg/ml on day 3 and 0.5 μg/ml on day 4.
Results
24h linezolid impregnated MCB achieved rapid bacterial killing of the 105 cfu/ml bacterial suspension followed
by re-growth (Figure, n= 5). Similar results were observed for 1h and 48h impregnation and for both tested
inocula. When biofilm-coated MCB generated by 24h exposure to 105 cfu/ml were exposed to linezolid, rapid
bacterial killing was achieved followed by re-growth.
Conclusions
Linezolid local elution may inhibit biofilm-producing MRSE only when locally eluted concentrations exceed
10μg/ml.
Acknowledgements
This study was funded by an unrestricted educational grant by Pfizer Hellas SA
73
SFP75 – (#18) – Short Free Paper
DISTRACTION OSTEOGENESIS. A COMPARATIVE STUDY BETWEEN ILIZAROV FRAME, LENGTHENING OVER
STANDARD NAILING AND OVER SAFE NAIL.
N. Craveiro-Lopes, C. Escalda, M. Leão
1
Garcia de Orta Hospital, Almada, Portugal
E-mail: [email protected]
Keywords: Distraction Osteogenesis, Bone Infection, External Fixation, Nailling, Antibiotic Cemment
Aim
The goal of this paper is to compare the results and complication namely infection rates, of the techniques of
Standard Ilizarov lengthening, lengthening over nail (LON) and lengthening then nailing (LTN) utilizing a
standard nail (STD) and a special nail with a core of cement releasing antibiotics (SAFE).
Methods
In a first study done between 1993 and 2008, we have compared 25 patients treated with lengthening with a
Ilizarov frame (LIF) with 26 patients where a standard nail was used to do a lengthening over nail technique
(LON).
From 2009 and 2012 we have utilized the SAFE nail in 17 patients to perform lengthening over nail (SAFE-LON)
and lengthening then nailing (SAFE-LTN) techniques. 7 patients had a pseudarthrosis, 5 a malconsolidation
with shortening and or axial deviation and 5 a bone loss after infection of total knee replacements.
We used a lengthening over nail in 4 cases, a lengthening and axial correction then nailing in three, acute
compression and proximal lengthening then nailing in five patients and knee arthrodesis and femoral or tibial
lengthening then nailing in another 5 cases. We have used a Ilizarov frame in all cases.
Results
We found that with LON technique, the external fixation time was 3 times lower, promoting the recovery of
full range of knee mobility in half the time, comparatively with LIF technique, with statistically very significant
differences.
We found a rate of 30% of intercurrences on the LON group and 24% in the Ilizarov, difference that was not
statistically significant. 3 patients got bone infection after LON technique, a rate of 11.5%. Late consolidation
and fracture of regenerate appeared only in the Ilizarov technique group, whereas in the LON technique we
had 3 cases of premature consolidation of the regenerate.
In the SAFE-LON and SAFE-LTN techniques utilizing the SAFE nail with antibiotics, we found a decrease of the
overall intercurrence rate from 30% to 12% and namely, bone infection was cured or didn’t appeared after
nailing with this new device in all cases.
Conclusions
LON and LTN techniques are somehow more demanding, but much more comfortable for the patient, which
need to carry the frame for less time, It permits an earlier return to activity, about half the time, it controls
better delayed regenerate and its fracture does not increase complication rate and costs of treatment and
prevents infection when converting from external to internal fixation.
74
SFP76 – (#63) – Short Free Paper
PROFESSIONAL LIABILITY CLAIMS DUE TO INFECTION IN ORTHOPAEDIC AND TRAUMATOLOGY: TEN YEARS
ANALYSIS IN CATALONIA
1
2
3
1
4
5
2
2
G. Bori , E.L. Gómez-Durán , A. Dealbert , A. Combalia , A. Trilla , A. Soriano , R. Torné , J. Arimany-Manso
1
Department of Orthopaedic Surgery and Traumatology, Hospital Clinic of Barcelona, Barcelona, Spain
2
Department of Professional Liability, Barcelona’s Official College of Physicians, Catalonian Council of Official
Colleges of Physicians, Barcelona, Spain
3
Department of Traumatology and Orthopaedic Surgery, Hospital Sant Camil-Consorci Sanitari Garraf, Sant
Pere De Ribes, Spain
4
Department of Preventive Medicine and Epidemiology, Hospital Clinic of Barcelona, Barcelona, Spain
5
Department of Infectious Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
E-mail: [email protected]
Keywords: Professional Liability, Claims
Aim
Patient safety is a major concern worldwide, but particularly high rates of adverse events are reported in the
surgery setting. Orthopaedic and Traumatology is the speciality most frequently involved in claims in
Catalonia. The objective of the study is to perform a descriptive study of the claims regarding infection in
Orthopaedic and Traumatology in Catalonia.
Methods
We performed a retrospective study of the claims regarding infection in Orthopaedic and Traumatology from
the prospective claims database of the Service of Professional Liability of The Catalonian Council of Official
Colleges of Physicians. The time frame of data collection was from 2003 to 2013. We analyzed both the clinical
and legal characteristics of the cases.
Results
During the 10-year period, 638 registered claims were related to the practice of Orthopaedic and
Traumatology, and 74 (11,6%) were due to infection. The most frequent surgical procedure involved were
arthroplasty (knee, hip or shoulder) (14, 18,9%), traumatic wounds and cellulitis (12, 16,2%), spine procedures
(10, 13,5%) and arthroscopy (7, 9,4%). The most frequent anatomical site involved were foot and ankle (17,
22,9%), spine (15, 20,3%), knee (14, 18,9%), wrist and hand (11, 14,8%). The 68,92% of claims was solved by
the courts and 29,73% by an “out-of-court” procedure. The average compensation in cases considered to have
professional liability was 145.045€.
Conclusions
Orthopaedic and Traumatology seem to be a specialty with a high risk for claims, and infection is one of the
most important causes. The study of the claims can lead to improvements in prophylaxis, diagnosis and
treatment of infection in Orthopaedic and Traumatology.
75
SFP77 – (#138) – Short Free Paper
RATES OF SEPTIC ARTHRITIS AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH AUTOLOGOUS
AND ALLOGENIC GRAFTS: A META-ANALYSIS
K. Kursumovic, C. Charalambous
1
Blackpool Victoria Hospital, Blackpool, United Kingdom
E-mail: [email protected]
Keywords: Septic Arthritis, Infection Rates, Anterior Cruciate, ACL
Aim
No consensus exists regarding the optimal graft choice between allogenic and autologous graft. Incidence of
septic arthritis following ACL reconstruction is rare but may dependent on the graft type. Our meta-analysis
assesses the difference in incidence of septic arthritis after ACL reconstruction across three groups of grafts:
hamstring autografts, bone patellar tendon bone (BPTB) autografts and allografts of any type.
Methods
A literature search was performed without language restriction on PubMed and EMBASE databases. We
identified 245 infected ACL grafts across 15 included studies that provided a breakdown of infection incidence
by graft type. A meta-analysis was performed using a random-effects model to estimate the overall infection
rates and those for different graft types. Summary risk ratios and 95% confidence intervals (CIs) were
calculated and reported for each outcome. Publication bias with respect to infection rates was estimated using
a funnel plot.
Results
Our meta-analysis shows an overall ACL graft infection rate of 0.6% (CI 0.3% – 1.3%). The incidence was highest
in autologous hamstring grafts at 1.1% at (CI 0.8% – 1.6%). That of allografts and autologous BPTB grafts was
similar at 0.5% (CI 0.2%-1.0%) and 0.4% (CI 0.2% – 0.7%), respectively. Full breakdown of the meta-analysis
results by study and graft type is reported in Figure 1.
Conclusions
Septic arthritis after ACL reconstruction remains a rare (<1%) but a serious complication. Allograft rates of
infection were not higher than those the autografts, contrary to the theoretical concerns. Therefore a higher
infection risk should not be cited as a reason for not using it. The reason for the apparently higher infection
rate with hamstring autografts is unclear and requires further research. The results of our meta-analysis may
aid informed discussions between surgeons and patients about the risk of infection after ACL reconstructive
surgery and graft choice.
76
SFP78 – (#115) – Short Free Paper
NECROTISING FASCIITIS OF THE EXTREMITIES IN ORTHOPAEDIC POPULATION. A 4 YEARS RETROSPECTIVE
STUDY FOCUSED IN NEW THERAPEUTIC TOOLS.
P. Corona, F. Erimeiku, C. Amat, L. Carrera
1
Vall d´Hebron University Hospital., Barcelona, Spain
E-mail: [email protected]
Keywords: Necrotising Fasciitis, Treatment, New Technologies.
Aim
Necrotising fasciitis (NF) of the extremities is a rapidly progressive, potentially life threatening soft tissue
infection. Recent advances in its management, like hidrobisturi-assisted debridement (Versajet®), negative
pressure wound therapy (NPWT), or Intravenous Immunoglobulin (IVIG) have not clearly influenced in
mortality and morbidity rates, still high. We therefore sought to study the necrotising fasciitis of the
extremities diagnosed in the last four year in our hospital. We investigate (1) the morbidity and mortality rates,
(2) the microbiologic characteristics of the infection, and (4) the management focusing on the use of new
treatment technologies.
Methods
This is a 4-year retrospective chart review of all NF of the extremities who presented in our hospital, from 2010
through 2013. We collected data on demographics, comorbidities, diagnostic test, LRINEC score and
microbiological information. We evaluated the therapeutic management of these patients, focusing in the
intensive care necessities, the use of hidrobisturi and NPWT as well the treatment with IVIG
Results
20 patients satisfied our inclusion criteria. Lower extremity was the most common location of infection (60%).
Blood cultures were available in 14 cases, 7 with a negative culture result (50%). The average LRINEC score on
the day of presentation was 6 (range: 0-11). All the patients were treated operatively with 2.5 interventions on
average (range: 1 to 5 operations). In the operative samples, one or more causative microorganisms were
identified in 18/20 (90%) of the NF cases, with two culture negative cases. Overall, type II NF (Group A βhaemolytic streptococci) was found in 11 cases (55%) and Type I (synergistic polymicrobial) in 7 cases (35%).
Versajet® was used in the first debridement in 40% (8 out 20) of the cases and in the second-look in 80% of the
cases. In 5 cases (25%) a direct wound closure was selected and in 75% cases a VAC closure was the technique
of choice. Thirteen patients (65%) were admitted in the intensive care unit, with a medium stay of 12 days. The
overall mortality was 30 % with LRINEC score, glucose level and creatinin level being an independent risk factor
of death (p < .05). Five amputations were identified in this series (25%).
Conclusions
According our data, despite surgical advances, pharmacological new drugs and intensive care improvements,
NF remains a disease with high mortality and morbidity. New technologies have been used widely in the last
four years in our center without appearing to influence the final outcome of the disease.
77
Economical impact of the septic patient
- how to prevent costs? /
The bone defect in septic surgery / Osteomyelitis
78
SFP79 – (#104) – Short Free Paper
MUSCULOSKELETAL INFECTION – EPIDEMIOLOGY AND ECONOMICAL IMPACT OF INTRAHOSPITAL
PRESCRIPTION
A. Grenho, C. Couteiro, J. Jorge, J. Arcângelo, F. Requicha, S. Alves, C. Pedrosa, H. Santos
1
CHLC - Hospital de Curry Cabral, Lisboa, Portugal
E-mail: [email protected]
Keywords: Musculoskeletal Infection, Epidemiology, Intrahospital Prescripton, Economical Impact
Aim
Infection of the musculoskeletal (MSK) system is a dreaded complication that seems to be on the rise. Many
factors, such as resistant bacteria or poor host factors, may influence such rise. This increase leads to greater
resource consumption, especially due to antibiotic (ATB) prescription. Strategies must be created to detect
patients at risk and prevent such infections. Hospital administrators should be made aware of the costs and
impact of MSK infections in order to understand the need to prevent such complications.
Therefore, our goal is to characterize the infected orthopaedic patient and evaluate the cost associated with
ATB prescription in such cases.
Methods
This is a retrospective and descriptive study, based on patient record analysis of all patients treated at our
department, from January 2013 to March 2015.
Results
We identified 177 patients with a MSK infection and an isolated infectious agent.
There was no predominance of either sex. Approximately 50% of patients were aged between 66 and 85 years
old.
Most frequent agents were MSSA (30,2%) and MRSA (21,8%), followed by Streptococcus species (8,9%) and
Pseudomonas aeruginosas (7,1%). Although most patients were infected by a single agent, 18,6% had two or
more causative agents isolated in cultures. Of those, 69,7% had either MSSA or MRSA as one of the isolated
agents.
Most commonly affected area was the hip (39,5%), followed by the knee (23,2%) and ankle (21,5%). Nearly all
patients had had prior surgery, with arthroplasty and osteosynthesis as the most common procedures (52,4%
and 33,3%, respectively).
Infection related admission was responsible for a total of 6.116 hospital bed-days, with the majority of patients
staying in hospital for up to 30 days (77,3%).
Total cost of hospital ATB administration was 61.365,61€, with approximately 346,7€ spent in each patient.
This corresponds to 42,6% of the total cost of medication during hospital stay (144.146,1€ of total cost, with
814,4€ per patient).
Conclusions
The typical infected orthopaedic patient is aged 66 to 85 years old, was operated to his hip or knee, and either
an arthroplasty or osteosynthesis was performed. Staphylococcus aureus remains the most common agent.
MSK infections have significant costs associated with their treatment, and clinical departments should
periodically re-evaluate discharged patients in order to understand what groups are at risk of developing such
a complication.
Only a correct identification of all these factors makes it possible to create a targeted preventive strategy, in
order to reduce costs to the institution.
79
SFP80 – (#145) – Short Free Paper
AN INJECTABLE BONE SUBSTITUTE ELUTING ANTIBIOTIC IN THE TREATMENT OF TRAUMATIC BONE DEFECTS
AND ITS PROPHYLACTIC EFFECT
D. Papadia, A. Musetti, E. Dematte
1
md orthopaedic, Trento, Italy
E-mail: [email protected]
Keywords: Gentamicin, Osteomyelitis, Nonunion, Bone Substitute
Aim
Open fractures carry a high risk of infection. Our objective was to evaluate the effect of a resorbable bone
substitute (BS) (calcium sulphate and hydroxyapatite) eluting Gentamicin (Cerament™| G) in the prevention of
bone infection and nonunion after open fracture and/or skin lesion.
Methods
The data of patients undergoing osteosynthesis augmented with BS and Gentamicin between December 2012
and April 2015 were retrospectively analyzed from a prospectively established database. Patients were treated
for open fractures grade 1 Gustilo or skin lesion with high risk of contamination. Surgical technique included
initial debridement, open reduction and internal fixation (ORIF), implantation of BS and Gentamicin , soft
tissue closure, and systemic antibiotic therapy for 2 weeks in all cases. Clinical outcome and radiographic bone
defect filling were assessed by blinded observers.
Results
From 12/2013 to 4/2015 nine male and six female with mean age 53yrs (24-77) were treated with ORIF and BS
and Gentamicin for open fractures. Fracture locations were tibial plateau (two), tibia (two), proximal humerus
(one), calcaneus (four), talus (one), forearm (three), and elbow (one) distal femur (one). at final follow-up
(mean 11.1 months; range 7-13).
One patient developed a sterile seroma, which was treated conservatively. No post-operative infection
occurred during the follow-up period. The calcium sulphate phase of BGS dissolved within 4-6 weeks in all
cases.
Bone ingrowth was assessed at 1, 2, 3, 6 and 12 months and new bone formation was observed at 6 months.
One patient with an exposed comminuted fracture and large bone defect showed poor bone regeneration and
was treated with a revision surgery (exchange of plate, autologous cancellous bone graft combined with BGS
and Gentamicin . No complications were reported.
Conclusions
The use of this bone substitute is well documented in the literature. The new product containing 175 mg
gentamicin in 10 ml shows a high release of gentamicin in in-vitro testing, comparable to the elution profile of
PMMA beads that some authors suggested to use to reduce the risk of infection.
However, the use of this antibiotic carrier in order to prevent bone infection after open fracture has not been
studied yet. In this case series 15 patients have been treated and good early clinical outcomes were observed
in almost all cases. This material is highly osteoconductive and has a potential for the prophylaxis of infection
in the treatment of open fractures. Further investigations and larger series are necessary to show the
prophylactic effect in detail.
80
SFP81 – (#266) – Short Free Paper
EARLY RESULTS OF SINGLE STAGE CHRONIC OSTEOMYELITIS TREATMENT WITH ANTIBIOTIC IMPREGNATED
CALCIUM SULPHATE BEADS
A. Chaturvedi, G. Barlow, H. Sharma
1
Hull and East Yorkshire Hospitals NHS Trust, Hull, United Kingdom
E-mail: [email protected]
Keywords: Osteomyelitis, Calcium Sulphate Beads, Antibiotic Elution
References
1. Stimulan – Biocomposites
Aim
The management of chronic osteomyelitis is fraught with difficulties; a multi-disciplinary team approach is
recommended for optimum outcome. Thorough debridement, dead space management and organism
targeted antibiotic therapy the gives best clinical results. Calcium sulphate beads impregnated with antibiotic
is an absorbable option for prolonged local antibiotic elution and dead space management.
This study aims to analyse the early results of single stage management of osteomyelitis with antibiotic
impregnated calcium sulphate beads. Following surgical debridement, calcium sulphate impregnated typically
with tobramycin and/or vancomycin is inserted to obliterate the dead space. Intravenous antibiotics – typically
teicoplanin and piperacillin-tazobactam – are administered until culture results permit rationalisation to
narrow spectrum agents. Patients are followed up in Infectious Diseases and Orthopaedic clinics for a period of
12 months and discharged if quiescence is achieved.
Methods
We conducted a retrospective analysis of our prospective database to identify patients treated with our single
stage protocol for chronic osteomyelitis. We excluded patients that had (1) less than 6 months of follow up, (2)
incomplete metal-ware removal, (3) patients lost to follow up. Fourteen patients (9 men, 5 women) with mean
age of 41 (16-73) years and mean follow up of 9 (6-12) months were included in study. Eleven patients had
previous surgeries involving internal fixation; the rest were primary osteomyelitis. Seven patients had
washouts and removal of metal-ware procedures for osteomyelitis prior to referral to the bone infection
service. Clinical, radiographic, and laboratory (microbiological, biochemical and haematological) methods were
used to monitor response to treatment.
Results
Cierney-Mader classification determined that 8 patients were classed as type A (normal hosts); 4 as BS
(systemically compromised); 2 as BLS (locally and systemically compromised). Anatomic analysis suggested 7
were Type 1 (medullary osteomyelitis); the remaining 7 were type 3 (localised disease). Five patients were
staged IA; three each staged IIIA and IIIBS; and one each staged IBs, IBLS, IIIBLS.
Staphylococcus Aureus was the commonest causative organism.
Follow up radiograph monitoring indicated absorption of the beads by 3 months.
There has been no evidence of recurrence based on clinical, radiographic and blood based parameters in all
patients.
Conclusions
Short-term results of single stage osteomyelitis treatment with calcium sulphate beads impregnated with
antibiotics are promising.
Acknowledgements
No acknowledgements or conflict of interests exist for this study.
81
SFP84 – (#139) – Short Free Paper
A BIPHASIC BONE SUBSTITUTE WITH GENTAMYCIN REGENERATES BONE IN OSTEOMYELITIS WITH MUSCLE
ACTING AS AN OSTEOINDUCTIVE NICHE
1
2
3
3
4
1
5
2
D. Raina , A. Gupta , M. Petersen , W. Hettwer , M. Nally , M. Tägil , M. Zheng , A. Kumar , L. Lidgren
1
Lund University Hospital, Lund, Sweden
2
Indian Institute of Technology Kanpur, Kanpur, India
3
Rigshospitalet Copenhagen, Copenhagen, Denmark
4
Oxford University Hospital, Oxford, United Kingdom
5
University of Western Australia, Perth, Australia
E-mail: [email protected]
1
Keywords: Biphasic, Osteoinduction, Muscle, Bone, Infection
Aim
To demonstrate the role of an antibiotic containing bone substitute, native bone active proteins and muscle
transforming into bone.
Methods
1. Recurrent osteomyelitis was eradicated and filled with a gentamycin eluting bone substitute (Cerament™l G)
consisting of sulphate and apatite phases and covered by a muscle flap.
2. C2C12 muscle cells were seeded on the bone substitute in-vitro and their phenotype was studied.
3. Another muscle cell line L6 was seeded with osteoblast conditioned medium containing bone active proteins
and specific markers were studied for bone differentiation.
Results
1. A chronic, longstanding, fistulating osteomyelitis was operated with radical eradication and filling of the
cavity with gentamycin eluting bone substitute. At one year, the patient had no leg pain and a healed wound.
Significant bone was also seen in the overlaying muscle, at one month post-op disappearing after 6-months.
Local delivery of gentamycin had a protective effect on bone formation.
2. C2C12 cells seeded on the gentamycin eluting bone substitute depicted no difference in proliferation when
compared to plain bone substitute and expressed 4 folds higher Alkaline phosphatase (ALP) compared to
controls.
3. C2C12 cells expressed proteins and genes coding for collagen type 1 (Col 1), osteocalcin (OCN), osteopontin
(OPN) and bonesialoprotein (BSP).
4. L6 cells cultured with osteoblast conditioned medium remained uninucleated and expressed osteoblastic
proteins like Col 1, OCN, OPN and BSP.
Conclusions
1. Bone substitute with gentamycin leads to differentiation of mesenchymal cells into bone in-vitro.
2. Native bone active proteins from an osteoblast culture can induce differentiation of muscle cells in-vitro.
3. Clinical observations with rapid bone formed in the bone substitute and in some cases in the muscle are a
consequence of both leakage of bone active proteins and also from osteoprogenitor cells coming from the
overlaying muscle interacting with the osteoinductive bone substitute.
Acknowledgements
Skåne foundation for disabled people and medical faculty Lund University, DBT-TATA fellowship and IITK for
PhD fellowship.
82
83
SFP85 – (#226) – Short Free Paper
MID- AND LONGTERM RESULTS IN THE THERAPY AND RECONSTRUCTION OF OSSEOUS LESIONS WITH
MESENCHYMAL STEM CELLS AFTER CHRONIC OSTEOMYELITIS
M. Borrée, U. Gerlach, C. Grimme, R. Schoop
1
BG-Krankenhaus Hamburg, Hamburg, Germany
E-mail: [email protected]
Keywords: Mesenchymal Stem Cells, Osteomyelitis, Osseous Lesions,
Aim
During the therapy of infected pseudarthrosis and arthrodesis in which multiple autologous bone grafts did not
result in osseous consolidation and in delayed osseous healing of transport stretches after completion of
segmental transport in osteomyelitis patients without acute infection symptoms, mesenchymal stem cells
were added to the treatment. This study demonstrates the mid- and long-term results in different application
possibilities with good and poor results. The aim is to develop an algorithm in treating bone defects regarding
the different biomaterials and implants that exist on the market.
Methods
The indication to apply mesenchymal stem cells was the reconstruction of osseous lesions after chronic
osteomyelitis, the treatment of pseudarthrosis and the support of osseous growth in segmental transports.
Further indications were the absence of adequate amounts of autologous spongiosa, multiple previous
operations, risk factors (diabetes, peripheral vascular disease, alcohol and nicotine abuse,etc.) as well as
chronic wound healing failure. To obtain the mesenchymal stem cells, we employed two different systems
from two companies. Both systems concentrate the mesenchymal stem cells after puncture and aspiration
from the pelvic crest. The concentrated stem cells were either mixed with platelet-rich plasma and added to
the autologous spongiosa or injected into the area of osseous regeneration after completion of segment
transport.
Since 2009, we have applied mesenchymal stem cells to 87patients. The treatment was performed in 73 cases
of persisting pseudarthrosis after multiple bone grafts and in 14 cases of delayed osseous healing after
segmental transport. The results were evaluated by continuous clinical and radiological examinations in our
outpatient clinic.
Results
We found a great variety in our results with a mainly high rate of survival and healing in the autologous bone
grafts with mesenchymal stem cells, resulting predominantly in stabilization of the pseudarthrosis.
Furthermore a good osseous consolidation was documented in several cases with transport stretches of
segmental transports.
However we also had some frustrating results with all the well-known complications of septic surgery.
Conclusions
Our experiences so far, have led to a distinguished therapy-algorithm including all the biomaterials and
additives that are used in our hospital.
Overall, the results demonstrate an advantage in the treatment with mesenchymal stem cells, espe-cially in
problematic and difficult cases in combination with multiple pre-existing conditions.
The use of mesenchymal stemcells must be included in a general concept regarding all treatment possibilities,
it is, however, not a guarantee for successful therapy of osseous lesions after chronic osteomyelitis especially
as a single toll mechanism.
84
SFP86 – (#208) – Short Free Paper
RECONSTRUCTION OF POSTINFLAMMATORY BONE LOSS WITH USE OF S53P4 BIOGLASS AS AN EFFECTIVE
PREVENTION OF INFECTION RECURRENCE
A. Brychcy, J. Bialecki, M. Drózdz, W. Marczynski
1
Orthopedic Clinic of Centre of Postgraduate Medical Education; Professor Gruca Teaching Hospital, Otwock,
Poland
E-mail: [email protected]
Keywords: Bioglass, Osteomyelitis, Bone Loss,
Aim
The aim of the study was to assess an effectiveness of S53P4 bioglass in reconstruction of postinflammatory
bone loss. We have also evaluated wound healing after the surgical dead space management with use of the
bioglass.
Methods
A group of 7 patients with bone loss due to active osteomyelitis and with purulent fistula treated with use of
S53P4 bioglass is presented in the paper. All the treated patients were male with mean of age 40,5 years.
Mean time of an active inflammatory process with purulent discharge from the wound prior the surgery was
587 weeks. Wound healing pattern with an X-ray evaluation of reconstructed void was performed in
postoperative period as well as in 1, 3, 6 and 12 mounth follow-up.
Results
In 6 out of 7 cases we did not observed any signs of infection recurrence in 1-year follow-up. Starting from 1month follow-up inflammatory serum markers remained in their reference values. In all the successfully
treated cases wound healing was assessed by two independent surgeons as excellent or good. Starting from 3month follow-up we have observed gradual blurring of granular bioglass structure on an X-ray scans. In 1
complicated case we observed recurrence of septic inflammatory process with purulent fistula that required
revision procedure with removal of the bioglass and extended debridement of inflammatory focus. In this case
we have faced posttraumatic malunion of the femur that substantially complicated surgical access to the
inflammatory focus during primary procedure.
Conclusions
S53P4 bioactive glass is an effective solution in reconstruction of postinflammatory bone loss. Properties of
this biomaterial efficiently prevent from focal infection recurrence by inhibiting of bacterial bone growth and
reduction of dead space. The product requires however meticulous debridement and the access to a vital bone
as a source of osteoblast cells. Underestimation of surgical debridement will likely result in reopening of the
fistula due to reinfection. The study group requires further evaluation.
85
SFP87 – (#168) – Short Free Paper
TREATMENT OF BONE LOSS AFTER INFECTION WITH AUTOLOGOUS BONE GRAFT OBTAINED WITH THE RIA
SYSTEM.
N. Craveiro-Lopes, C. Escalda, M. Leão
1
Garcia de Orta Hospital, Almada, Portugal
E-mail: [email protected]
Keywords: RIA, Bone Loss, Gone Graft, Bone Infection
References
J.T. Newman, P.F. Stahel, W.R. Smith, et al. “A New Minimally Invasive Technique for Large Volume Bone Graft
Harvest for Treatment of Fracture Nonunions.” Orthopedics,2008, Vol. 31, 257
Aim
The aim of this paper is to describe the technique and evaluate the effectiveness of the RIA system in the first
cases of bone loss treated by the authors with this technique.
Methods
Between January 2010 and January 2011, ten patients were treated with an average age of fourty six years,
with infected bone loss as a result of open fractures in various bone segments, with multiple failed treatment
attempts, including three humeri, four femurs and three tibiae. The average size of the initial bone loss was 4
cm, varying from 1 to 8 cm. In 4 patients it was used simultaneously a Ilizarov apparatus with acute
compression of the focus, in two patients a Ender pin and monolateral external fixator, three other cases with
a SAFE nail with core with antibiotics and in one case an osteosynthesis with a plate and screws. The RIA was
introduced with a percutaneous technique with a one pass drilling. The graft thus collected was mixed with
appropriate antibiotics and aplied at the defect. The volume of the harvested graft, complications of the donor
and recipient and the final results was recorded.
Results
The review showed that the average volume of graft was 60 cc, from 20 to 90 cc. In two female patients older
than 70 years with osteoporosis, insufficient bone of poor quality was obtained. Problems included a case of
iatrogenic fracture of the donor site, due to poor surgical technique and a case of relapse of the nonunion.
Regarding the effectiveness of grafts extracted with the RIA system, 90% of the cases achieved consolidation in
average of 5 months after grafting, range 3-9 months.
Conclusions
This short experience with the RIA system showed that it is an attractive method allowing a rapid removal of a
large volume of bone graft with a minimally invasive approach and a short learning curve. It is not indicated in
elderly patients with osteoporosis and those with a narrow medullar canal less than 11 mm. Special attention
must be done to the need to choose a drill no larger than 1 mm of the diameter of the isthmus, to do a single
entry point and with only one drill passage to prevent the weakening of the donor site.
86
SFP88 – (#28) – Short Free Paper
A POSITIVE BACTERIAL CULTURE FROM ALLOGRAFT BONE AT IMPLANTATION DOES NOT CORRELATE WITH
SUBSEQUENT SURGICAL SITE INFECTION
C.H. Hu
1
Chang Gung Medical Foundation, Taoyuan, Taiwan
E-mail: [email protected]
Keywords: Allograft Bone, Surgical Site Infection
References
Kappe T, Cakir B, Mattes T, Reichel H, Flören M. Infections after bone allograft surgery: a prospective study by
a hospital bone bank using frozen femoral heads from living donors. Cell Tissue Bank 2010;11:253-259.
Aim
Fresh-frozen allograft bone is frequently used in orthopaedic surgery. We investigated the incidence of
allograft-related infection and analysed the outcomes of recipients of bacterial culture-positive allografts from
our single-institute bone bank during bone transplantation.
Methods
The fresh-frozen allografts were harvested in a strict sterile environment during total joint arthroplasty surgery
and immediately stored in a freezer at -78º to -68º C after packing. Between January 2007 and December
2012, 2024 patients received 2083 allografts with a minimum of 12 months of follow-up.
Results
The overall allograft-associated infection rate was 1.2% (24/2024). Swab cultures of 2083 allografts taken
before implantation revealed 21 (1.0%) positive findings. The 21 recipients were given various antibiotics at
the individual orthopaedic surgeon’s discretion. At the latest follow-up, none of these 21 recipients displayed
clinical signs of infection following treatment.
Conclusions
Based on these findings, we conclude that an incidental positive culture finding for allografts does not
correlate with subsequent surgical site infection. Additional prolonged post-operative antibiotic therapy may
not be necessary for recipients of fresh-frozen bone allograft with positive culture findings.
Acknowledgements
Chang Gung Medical Foundation
87
SFP89 – (#91) – Short Free Paper
SQUAMOUS CELL CARCINOMA COMPLICATING CHRONIC OSTEOMYELITIS: CLINICAL FEATURES AND
OUTCOME OF A CASE SERIES
R. Khundkar, G. Williams, N. Fennell, A. Ramsden, M. Mcnally
1
Nuffield Orthopaedic Centre, Oxford, United Kingdom
E-mail: [email protected]
Keywords: Squamous Cell Carcinoma, Osteomyelitis
References
Altay M, Arikan M, Yildiz Y, Saglik Y.Squamous cell carcinoma arising in chronic osteomyelitis in foot and
ankle.Foot Ankle Int. 2004 Nov;25(11):805-9.
Aim
Squamous Cell Carcinoma (SCC) is a rare complication of chronic osteomyelitis (OM), arising in a sinus tract
(Marjolin’s Ulcer). We routinely send samples for histological analysis for all longstanding sinus tracts in
patients with chronic osteomyelitis. We reviewed the clinical features and outcomes of patients with SCC
arising from chronic osteomyellitis.
Methods
A retrospective study was performed of patients with osteomyelitis between January 2004 and December
2014 in a single tertiary referral centre. Clinical notes, microbiology and histo-pathological records were
reviewed for patients who had squamous cell carcinoma associated with OM.
Results
We treated 9 patients with chronic osteomyelitis related squamous cell carcinoma. The mean age at time of
diagnosis was 51 years (range 41-81 years) with 4 females and 5 males. The mean duration of osteomyelitis
was 16.5 years (3-30 years) before diagnosis of SCC. SCC arose in osteomyelitis of the ischium in 5 patients,
sacrum in 1 patient, femur in 1 patient and tibia in 2 patients. Osteomyelitis was due to pressure ulceration in
7 patients and post-traumatic infection in 2 patients. The histology showed well differentiated SCC in 4 cases
and moderately differentiated SCC in 2 cases with invasion. Two patients had SCC with involvement of bone.
One patient had metastatic SCC to bowel. All patients had polymicrobial or Gram-negative cultures from
microbiology samples.
Four patients (57%) in our series died as result of their cancer despite wide resection. The mean survival after
diagnosis of SCC was 1.3 years and mean age at time of death was 44.7 years. Two of these patients had ischial
disease and were treated with hip disarticulation, hemi-pelvectomy and iliac node clearance.
Five patients remain disease free at a mean of 3.4 years (range 0.1 – 7yrs) after excision surgery. One patient
in this group underwent a through-hip amputation, one underwent an above knee amputation and one
underwent excision of ischium and surrounding sinuses. Of note, all these patients had clear staging scans at
time of diagnosis.
Conclusions
This case series demonstrates the consequences of an uncommon complication of osteomyelitis. In our series
only 3 patients underwent biopsy for suspected SCC due to clinical appearances. The other cases were all
identified incidentally after routine histological sampling, demonstrating the importance of this practice.
88
OTHER
#140 - Free Paper
A SERVICE SPECIFICATION FOR HOSPITALS TREATING BONE AND JOINT INFECTION IN ADULTS, IN THE
UNITED KINGDOM
B. Atkins, M. Mcnally
1
The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
E-mail: [email protected]
Keywords: Bone Infection, Service Specification, Specialist Units, Multidisciplinary Teams
References
http://www.england.nhs.uk/wp-content/uploads/2013/06/b07-bone-joint-infec.pdf
Aim
To propose a national specification for hospitals which offer treatment of complex bone and joint infections to
adults.
Methods
Patients with bone and joint infections are treated in a wide variety of hospitals in the UK. A few have
developed services with infection physicians, microbiology laboratory support and dedicated orthopaedic and
plastic surgeons working together to deliver a multidisciplinary care pathway. However, many patients are
treated in non-specialist units leading to multiple, often unsuccessful procedures with long hospital stays, high
costs and additional pain and disability. Inappropriate antibiotic therapy without adequate surgery risks
antibiotic resistance.
A draft specification was written defining the types of patients who should be referred to a specialist unit for
treatment. A description of the components which must be available to treat these cases (staffing, expertise,
diagnostic support, outcome assessment and governance structure) was proposed. This draft was circulated to
infection units in the UK for consideration and agreed with the Health Department in England.
Results
Complex bone and joint infections would be best served nationally by 3-6 networks, each with a single
specialist centre. This is similar to national arrangements for bone sarcoma treatment.
Patients to be referred will include those with:
1) Chronic osteomyelitis (long bone, pelvis, spine)
2) Chronic destructive septic arthritis
3) Complex prosthetic joint infections (multiple co-morbidities, difficult/multi-resistant organisms, multiply
operated or failed revision surgery)
4) Infected fractures and non-unions
Specialist units should have:
1) Orthopaedic surgeons who specialise in infection (joint revision, Ilizarov techniques,etc).
2) Infection physicians who can treat medically unwell patients with complex co-mordidities and multiresistant infections.
3) Plastic surgeons with experience in difficult microsurgical reconstruction techniques.
4) Scheduled (at least weekly) meetings of all of the above, with a radiologist to discuss new referrals and
complex cases.
5) A home IV therapy service.
6) Dedicated in-patient beds staffed by infection trained staff.
7) Multi-disciplinary (one-stop) out-patient clinics.
8) Quality measures assessed, including PROMS, clinical success rates, and functional outcome.
9) Education and research programmes.
Conclusions
This service specification is a tool for developing regional units. It facilitates the creation of designated centres
in a national network (hub and spoke model). This service specification has been agreed and published by NHS
England.
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