Management of the infected shoulder prosthesis: a retrospective analysis and review of the literature

Experience with infected shoulder arthroplasty is limited. Treatment options are either one- or two-stage reimplantation, débridement with retention of the prosthesis, resection arthroplasty or arthrodesis. We retrospectively analysed ten patients with an infected shoulder prosthesis and evaluated the diagnostic and therapeutic management as well as the clinical outcome, assessed by the Constant score, Neer’s criteria and the mean abduction ability. We identified an infecting organism before surgery in nine patients. Four patients were treated by two-stage exchange reimplantation, five by resection arthroplasty and one underwent serial débridement combined with vacuum-irrigation therapy. Infection was eradicated in all patients of this series. The mean Constant score in resected patients was 32.7, in patients treated by stage exchange 40.1 (no difference) and we measured 90 points in the patient with retention of the implant. In patients treated by resection arthroplasty, merely the mean abduction yielded a better result (63 vs 31°) than in patients treated by two-stage exchange—with the pain level being identical in both groups. Treatment of infected shoulder implants in patients who often have to deal with concomitant diseases remains unsatisfactory. Two-stage exchange procedures yielded only slightly better functional results than resection arthroplasty, which should be considered in cases of elderly or chronically ill patients because it offers good pain relief. Serial débridement combined with irrigation therapy is a new method which offers good clinical results, however with an unknown risk of persisting infection. The authors recommend isolating the infecting organism prior to surgery to allow the administration of organism-specific antibiotics as early as possible during surgery in order to efficiently eradicate the infection.     

布鲁氏菌致全膝关节置换术后假体周围感染1例报道及文献复习

假体周围感染(prosthetic joint infection,PJI)是关节置换术后严重并发症。不仅增加术后全因死亡率,也导致住院时间延长、患肢畸形、关节功能受限、治疗费用增加、生活质量下降[1]。因此PJI也成为了人工关节外科中的热点和难点。     

Tibial sesamoidectomy: a review of the literature and retrospective study

Tibial sesamoid afflictions have been subject to various methods of treatment. A review of current concepts was challenged by a retrospective study involving patients in whom surgical intervention was performed. Data was collected from pre- and postoperative radiographs to determine if a change in the osseous relationships around the first metatarsophalangeal joint had occurred, thereby necessitating adjunctive procedures to compensate. The results obtained from our patient population substantiate the fact that a need does exist to evaluate these surgical candidates adequately in order to include additional procedures necessary to decrease morbidity.     

Pneumococcal arthritis in a prosthetic knee. A case report and review of the literature

Prosthetic joint infection caused by Streptococcus pneumoniae is a rare condition. An 86-year-old woman with a S. pneumoniae-infected total knee arthroplasty was successfully treated by a combined medical-surgical approach.     

Recurrence of inguinal herniae following removal of infected prosthetic meshes: a review of the literature

Purpose  

Late-onset mesh infection, occurring months to years following hernia repair, is a rare complication of hernia surgery. Its management usually requires removal of the mesh. The aim of this paper was to assess the rate of recurrence of inguinal herniae following removal of the mesh for late onset deep mesh infection.     

Polyethylene-induced pes anserinus bursitis mimicking an infected total knee arthroplasty: a case report and review of the literature

Polyethylene-induced pes anserinus bursitis after total knee arthroplasty (TKA) with the clinical manifestations mimicking an infected TKA is a very rare occurrence. We report such a case in a 74-year-old woman. She developed recurrent draining papules on the anterolateral aspect of the knee because of polyethylene-induced chronic pes anserinus bursitis 8 years after TKA. The diagnosis was established with a sinography study and confirmed by histopathologic examination of the surgical specimen. The symptoms were resolved after surgical excision of the lesion. Pes anserinus bursitis should be included in the differential diagnosis in knees with a draining sinus after TKA, and sinogram is considered the best method to establish the diagnosis.     

Adenocarcinoma of the vermiform appendix: retrospective study and literature review

Adenocarcinoma of the vermiform appendix is a rare clinical entity, fewer than 200 cases having been reported. The authors carried out a retrospective review over a 25-year period and found five patients admitted to the Vancouver General Hospital with primary appendiceal adenocarcinoma. Four other patients, initially reported as having appendiceal adenocarcinoma, were found after critical microscopic review to have had either benign disease or mucinous carcinoid. Primary epithelial neoplasms of the appendix demonstrate a wide variety of histologic types and because of the different clinical behaviour, an accurate diagnosis must be made. For the benign tumours, appendectomy alone will suffice but for adenocarcinoma of the appendix, right hemicolectomy is recommended.     

Pasteurella multocida infected total knee arthroplasty: a case report and review of the literature

Pasteurella multocida is a rare cause of prosthetic joint infection. This infection generally follows significant animal contact, usually licks and scratches. We report a case of P multocida infection that was treated with linezolid with salvage of the implant. Linezolid is generally active against Gram-positive organisms only with the exception of Pasteurella, which is Gram-negative. We extensively review the previous reported cases of implant infection with P multocida.     

Graft vasculopathy of vascularized composite allografts in humans: a literature review and retrospective study

Mechanisms of chronic rejection of vascularized composite allografts (VCA) remain poorly understood and likely present along a spectrum of highly varied clinicopathological findings. Across both animal and human VCA however, graft vasculopathy (GV) has been the most consistent pathological finding resulting clinically in irreversible allograft dysfunction and eventual loss. A literature review of all reported clinical VCA cases with documented GV up to December 2018 was thus performed to elucidate the possible mechanisms involved. Relevant data extracted include C4d deposition, donor‐specific antibody (DSA) formation, extent of human leukocyte antigen (HLA) mismatch, pretransplant panel reactive antibody levels, induction and maintenance immunosuppression used, the number of preceding acute rejection episodes, and time to histological confirmation of GV. Approximately 6% (13 of 205) of all VCA patients reported to date developed GV at a mean of 6 years post‐transplantation. 46% of these patients have either lost or had their VCAs removed. Neither C4d nor DSA alone was predictive of GV development; however, when both are present, VCA loss appears inevitable due to progressive GV. Of utmost concern, GV in VCA does not appear to be abrogated by currently available immunosuppressive treatment and is essentially irreversible by the time of diagnosis with allograft loss a likely eventuality.     

Anesthesia and the HIV infected parturient: a retrospective study

We wished to determine whether immunosuppression and/or acceleration of human immunodeficiency virus (HIV)-associated disease is related to the mode of anesthesia in the HIV infected parturient. Ninety-six known HIV-infected asymptomatic parturients who delivered between January 1990 and January 1992 at Grady Memorial Hospital were reviewed for pre-delivery health status, mode of anesthesia and peripartum/post-partum complications. Statistics used chi2 analysis. There were 36 regional anesthetics (28 epidural, 8 spinal), 11 general anesthetics, 22 local anesthesia/intravenous sedation and 27 patients who did not receive anesthesia. There were no differences in the 24-48 h and 4-6 week complication rates. None of the women studied developed neurologic sequelae for 2 years after anesthesia. Thirty-one of the 96 women had CD4/CD8 T-cell lymphocyte data at second trimester and 24-48 h post partum which showed no worsening of maternal immune status in women receiving regional anesthesia, local anesthesia/intravenous sedation or no anesthesia. We believe that both regional and general anesthesia can be performed safely on the asymptomatic HIV-infected parturient. The choice of anesthesia should be based on the usual obstetric and clinical considerations.     

The value of preoperative knee aspiration and arthroscopic biopsy in revision total knee arthroplasty

AIM: The accurate preoperative diagnosis of occult sepsis in endoprosthetic loosening of total knee arthroplasty is the key to successful management of revision total knee arthroplasties. The aim of this study was to evaluate the results of preoperative aspiration in comparison with preoperative arthroscopic biopsy of the synovial tissue. METHOD: From 2000 to 2004 eighty-six revision total knee arthroplasties in 86 patients were performed. 60 patients had only a knee aspiration, 15 an arthroscopic biopsy and an aspiration, 11 only arthroscopic biopsy. The results of both methods were compared with the intraoperative cultures during revision surgery. RESULTS: 69 aseptic and 17 septic knee exchange arthroplasties were performed. The preoperative aspiration of the prosthetic knee joint had a sensitivity of 68.8 %, specificity of 96.6 %, positive predictive value of 84.5 % and a negative predictive value of 92.2 %. The preoperative arthroscopic biopsy had a sensitivity of 100 %, specificity of 94.7 %, positive predictive value of 87.4 % and a negative predictive value of 100 %. CONCLUSION: Preoperative aspiration of the knee is a very helpful study for the diagnosis or exclusion of infection in a prosthetic knee joint and should be a standard procedure in the diagnosis of prosthetic loosening. If after aspiration a suspicion of infection remains, then the biopsy is an accurate procedure to diagnose or exclude periprosthetic sepsis.     

Role of knee aspiration after resection of the infected total knee arthroplasty

Recognizing persistent infection after resection arthroplasty and implantation of cement spacers in the infected total knee arthroplasty is often difficult. The purpose of this study was to determine whether aspiration of the knee after resection arthroplasty is valuable for determining the presence of ongoing infection. Thirty-four previously infected knees that were aspirated and cultured after resection arthroplasty, implantation of cement spacers, and intravenous antibiotics for an average of 6.3 weeks were identified. There were 8 cases of persistent infection-none identified on preoperative aspiration. Two preoperative cultures were false positive for Staphylococcus epidermidis. Preoperative cultures were negative in 32 knees, with 8 false-negative results. The antibiotic-free interval among all cases averaged 20 days; the cases with false-negative results from aspiration had an antibiotic-free interval averaging 11.5 days, compared with an average of 26 days among all other cases. Aspiration of knees after resection arthroplasty had sensitivity of 0%, positive predictive value of 0%, and accuracy of 71%. Specificity was 92%, and negative predictive value was 75%. A negative result from joint aspiration after resection arthroplasty does not necessarily rule out the presence of ongoing infection. False-negative results may be observed if joint aspiration is not delayed more than 2 to 3 weeks.     

Cement burns: retrospective study of 18 cases and review of the literature

SUBJECT: Cement is increasingly used in the construction industry, but the occurrence of cement burns is rarely reported. This retrospective study concerns patients treated for cement burns in our unit between 1997 and 2002. MATERIALS AND METHODS: Eighteen patients 18-64 years of age, treated previously in our unit for cement burns, were interviewed by telephone for evaluation. RESULTS: The mean time since treatment was 39 months. Burns were predominantly seen on the lower limbs, and a third occurred during an accident on the job. All deep burns were excised, and 16 patients received grafts. Mean hospital stay was 10 days, and mean sick leave 2 months. Our study indicated that all patients were poorly informed about cement-related risks. DISCUSSION: Surgical treatment of full-thickness cement burns at diagnosis enables rapid healing with a minimum of sequelae and reduces the high socioeconomic costs resulting from these lesions. CONCLUSION: This study indicates once again the need to improve preventive measures; which are very often inadequate because of lack of awareness of risks.     

Total knee replacement in the morbidly obese: a literature review

Background: The ‘obesity epidemic’ is expected to result in an increased incidence of knee osteoarthritis and hence total knee replacements (TKRs). Reviews have demonstrated the conflicting results of TKR for all obese (body mass index (BMI) >30). The aim of this literature review was to specifically evaluate outcomes of TKR in patients with morbid obesity (MO; BMI >40). Methods: A systematic review of medical databases (PubMed, Medline, Cochrane Library, ScienceDirect) by use of keywords from January 1990 to September 2009 was undertaken. Results: Clinical and functional Knee Society Scores (KSS) improve after TKR for patients with MO. The post‐operative functional KSS was, in general, less than in controls. Radiographic analysis was inconclusive because of small study populations and short duration of follow‐up. All studies reporting complications noted a greater prevalence in MO patients (10–30%). Of concern was the significantly higher prevalence of deep prosthetic infection (3–9‐times that of controls). The morbidly obese also had a significantly higher incidence of wound complications. TKR did not result in weight loss for MO patients, and therefore has no benefit on weight‐related medical conditions. Bariatric surgery in MO under 65 years of age has been shown to be a cost‐effective and clinically effective method of weight reduction. This surgery also results in significant improvement in weight‐related medical conditions, the KSS and knee pain. Conclusions: Given the increase in complications for MO patients after TKR, these patients should be advised to lose weight before surgery and, if suitable, would probably benefit from bariatric surgery.     

Choledochal cysts: a retrospective review of 28 patients and a review of the literature.

Retained choledochal cysts have been associated with recurrent cholangitis, portal hypertension and malignant lesions of the biliary tract. The authors reviewed the cases of 23 females and 5 males who had congenital cystic dilatation of the biliary tree; 26 were seen primarily and 2 were referred because of complications from previous surgery. Patient age at presentation ranged from 6 weeks to 46 years. The presenting complaints in 25 patients were pain or jaundice, or both; the classic triad of pain, jaundice and an abdominal mass was present in only 3 patients. Primary cyst excision was performed in 11 patients. Internal drainage procedures were performed in 12 patients, external drainage procedures in 3 patients and no direct operative procedure in 2 patients. Follow-up ranged from 1 to 20 years. Nine of 11 patients with primary excision were asymptomatic; 2 had recurrent cholangitis and required treatment for bile duct stricture. Five patients with retained cysts were asymptomatic. Recurrent cholangitis occurred in seven patients. Six patients required at least one reoperation, but only two had secondary cyst excision. The long-term complication rate for patients with retained cysts was 66.7% and for those with primary excision was 18%. The findings of this study support the current recommendation of primary excision of choledochal cysts. Symptomatic patients with retained cysts should have secondary cyst excision. Asymptomatic patients with retained cysts are at risk for malignancy and should undergo lifelong periodic radiologic examinations and liver-function testing.     

Brucellar epididymo-orchitis in Saudi Arabia: a retrospective study of 26 cases and review of the literature.

OBJECTIVE: To review the clinical and laboratory features and response to treatment of patients with acute brucellar epididymo-orchitis reporting to a tertiary care hospital in Riyadh, and to compare these with other cases reported previously. PATIENTS AND METHODS: In this retrospective study, records of all 26 adult patients with brucellosis, who presented with epididymitis or epididymo-orchitis at a tertiary hospital in Riyadh from 1983 to 2000, were reviewed. Positive blood culture or high agglutination titres of > or = 1 : 320 and positive clinical manifestations of brucellosis were the main criteria for diagnosing brucellosis. Among these cases, epididymitis or epididymo-orchitis was diagnosed on the basis of a typical history of gradual onset of scrotal pain and findings of enlarged tender testes and/or epididymis. RESULTS: Epididymo-orchitis occurred in 1.6% of all patients with brucellosis. Most (58%) were 25--44 years old; approximately 77% of the patients presented with acute symptoms of < 2 weeks' duration. All patients complained of swollen painful testicles. Other presenting symptoms included undulant fever (96%), chills (54%) and arthralgia (23%). Four patients had dysuria and one haematuria. Ten patients gave a positive history of ingestion of raw milk and milk products; one patient had laboratory-acquired brucellosis. Six patients had unilateral epididymo-orchitis (two with features of florid presentation); the remaining 20 had only orchitis (bilateral in two, right in 10 and left in eight). Leucocytosis was present in six patients; 25 had initial agglutination titres of > 1 : 320 and the remaining patient had a positive blood culture. All patients received combined therapy with streptomycin for the first 2 weeks (or oral rifampicin for 6 weeks) with doxycycline or tetracycline for 6 weeks. All showed improvement, fever subsided in 2--5 days and the scrotal enlargement and tenderness regressed. Only one patient had a relapse within one year. CONCLUSION: In brucellosis-endemic areas, clinicians encountering epididymo-orchitis should consider the likelihood of brucellosis. A careful history, a meticulous physical examination and a rapid laboratory evaluation help in diagnosis. Clinical and serological data are sufficient for diagnosis. Leucocytosis is not an atypical feature of brucellar epididymo-orchitis and so cannot be used for differentiating it from the nonspecific variety. Conservative management with combination antibiotic therapy is adequate for managing brucellar epididymo-orchitis.     

Infection in total knee replacement: a retrospective review of 6489 total knee replacements.

Six thousand four hundred eighty-nine knee replacements were done in 6120 patients at the authors' institution between 1993 and 1999. Operations were done in a theater with vertical laminar flow and with the surgical team using body exhaust suits. Of these knee replacements, 116 knees became infected and 113 were available for followup. One hundred of the infections occurred in patients undergoing primary knee replacement, whereas the remaining infections occurred in patients undergoing revision knee replacement. Ninety-seven of these knees (86%) had deep periprosthetic infections and the remaining 16 knees had superficial wound infections. One third of the deep infections occurred within the first 3 months after surgery and the remaining 2/3 occurred after 3 months. The overall early deep infection rate for patients undergoing a primary knee replacement was 0.39%, whereas the rate for patients undergoing a revision knee replacement was 0.97%. A cohort of noninfected knee replacements from patients matched for gender, age, and month of surgery was used as a control group. Those comorbidities that were statistically significant in increasing the risk of infection were prior open surgical procedures, immunosuppressive therapy, poor nutrition, hypokalemia, diabetes mellitus, obesity, and a history of smoking. Patients undergoing revision procedures had a statistically higher risk of infection than did patients undergoing primary surgeries. If the surgery took longer than 2.5 hours, the risk of infection was increased significantly. There was no change in the infection rate when the perioperative antibiotic prophylaxis was decreased from 48 to 24 hours after surgery. The predominant infectious organisms were gram-positive (Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus Group B). Twenty percent of the knees that were infected clinically had no organisms that could be identified. In each case, the patient had been treated empirically at another institution with antibiotics before a culture of the joint was obtained.     

The use of posterior vertebral column resection in the management of severe posttuberculous kyphosis: a retrospective study and literature review

Purpose

We present a retrospective study of 15 cases with severe posttuberculous kyphosis of thoracolumbar region that underwent posterior vertebral column resection.

Methods

From 2004 to 2009, 15 consecutive patients with posttubercular kyphotic deformity underwent posterior vertebral resection osteotomy. Six subjects were females and nine were males with an average age of 35.8 years (range 20–60 years) at the time of surgery. None of the patients had neurological deficits. The mean preoperative visual analogue scale was 8.7 (range 3–9), and the average preoperative Oswestry Disability Index was 46.5 (range 40–56).

Results

The average duration of postoperative follow-up was 36.1 ± 10.7 months (range 24–62 months). The number of vertebra resected was 1.3 (range 1–2) on average. There were ten patients with one-level osteotomy and five patients with two-level osteotomy. The average operation time was 446.0 ± 92.5 min (range 300–640 min) with an average blood loss of 1,653.3 ± 777.9 ml (range 800–3000 ml). The focal kyphosis before surgery averaged 92.3 ± 8.9° (range 74–105°), and the kyphotic angle decreased to 34.5 ± 8.7° on average after the surgical correction. The average kyphotic angle at the last follow-up was 36.9 ± 8.5°, loss of correction was 2.4 ± 1.4° on average. All patients postoperatively received bony fusion within 6–9 months.

Conclusions

Our results showed that although posterior vertebral resection is a highly technical procedure, it can be used safely and effectively in the management of severe posttuberculous kyphosis. It is imperative that operations be performed by an experienced surgical team to prevent operation-related complications.