Prolonged suppressive antibiotic therapy is successful in the management of prosthetic joint infection

European Journal of Orthopaedic Surgery & Traumatology - Prosthetic joint infection (PJI) remains one of the major challenges facing orthopaedic surgeons. There is a paucity of evidence on...     

Current developments in lantibiotic discovery for treating Clostridium difficile infection

Introduction: Clostridium difficile is a major cause of healthcare-associated diarrhea linked to the misuse of antimicrobials and the corresponding deleterious impact they have on the protective microbiota of the gut. Resistance to agents used to treat C. difficile including metronizadole and vancomycin has been reported highlighting the need for novel agents. Lantibiotics represent a novel class of agents that many studies have highlighted as effective against C. difficile.

Areas covered: In this review lantibiotics including nisin, actagardine, mersacidin, NAI-107 and MU-1140 that exhibit good activity against C.difficile, all of which are currently in the preclinical phase of investigation are discussed. The lantibiotic NVB302, which has completed phase I clinical trials for the treatment of C. difficile, is also described.

Expert opinion: Lantibiotics represent promising candidates for the treatment of C. difficile infections due to their novel mode of action, which is thought to decrease the potential of resistance developing and the fact they often possess a less deleterious effect on the protective gut microbiota when compared to traditional agents. They are also extremely amenable to bioengineering approaches and the incorporation of synthetic biology to produce more potent variants.     

Anterior fracture dislocation of the hip: an unusual presentation and a review of principles of management

Anterior dislocation of the hip occurs in 10–15% of cases (DeLee et al. in J Bone Joint Surg Am 62(6):960–964, 1). It is usually due to high velocity trauma and associated with multiple injuries. We present a case of this unusual injury associated with an acetabular fracture and a Brumback type IV B fracture of the femoral head caused by a low energy mechanism. We discuss the rationale for our management including issues involved in making the diagnosis, the reasons for our delay in diagnosing the injury and we propose strategies to avoid this in the future. The current literature evaluating the aetiology as well as the treatment of anterior fracture dislocation of the hip is also critically evaluated.     

Anomalous origin of left coronary artery from pulmonary artery. Treatment by aorto-left coronary saphenous vein bypass

Definitive surgical therapy is available for the adult or post-infantile form of anomalous origin of the left coronary artery from the pulmonary trunk. Left coronary artery ligation has proved successful because of intercoronary anastomoses; however, more desirable treatment consists of establishing a 2-coronary arterial system, if possible by aorto-left coronary bypass. A 34 year old patient is described in whom aorto-left coronary artery continuity was established using an autogenous saphenous vein bypass graft.     

Direct myocardial revascularisation: experience with 9364 operations.

Between July 1968 and December 1976, 9364 consecutive patients with coronary insufficiency underwent direct myocardial revascularisation using aortocoronary bypass (ACB). Among these patients 8017 had ACB alone, and the remaining 1347 had ACB in addition to correction of other cardiac and vascular lesions. In the series of patients having ACB alone the hospital (early) mortality was 3.9%, but for 2383 surgical patients in 1976 this figure was 2.2%. Operative mortality was higher for women (6.85%) than for men (3.5%), but late survival was about the same for both sexes. Among surviving patients 88% were improved or symptom-free after undergoing ACB. According to our data, at the end of eight years 80% of the patients will be survivors. These results, when compared with other series of patients treated medically, indicate the superiority of surgical treatment both in terms of symptomatic relief and also in increased life expectancy.     

Aortocoronary artery bypass: present indications and risk factors.

From 1969 through 1974, a total of 4,522 patients were operated on for coronary artery occlusive disease. This article is an in-depth analysis of a consecutive series of 275 of these patients, operated on during 1974. The mortality was 1.8% and perioperative myocardial infarction occurred in 3.6%. On analysis of risk factors, it was found that 24% of the patients were over the age of 60; 57% had some degree of left ventricular dysfunction; 9% had generalized hypokinesis; 24% were New York Heart Association functional class IV; 13% had left main coronary artery stenosis; and 11% had preinfarction angina. On analysis of the early mortality, the limiting factor was diffuse coronary arteriosclerosis combined with poor ventricular function. This resulted in inadequate or incomplete myocardial revascularization. Since these two risk factors are usually predictable, coronary artery bypass can be recommended not only for patients with intractable angina, but also for patients with impaired left ventricular function associated with angina, and in patients without angina who have a positive stress electrocardiogram.     

Ascending Aorta-Abdominal Aorta Bypass: Indications,Technique, and Report of 12 Patients

Use of the supraceliac segment of the abdominal aorta for ascending aorta-abdominal aorta bypass (AAAAB) offers a new technique for management of certain difficult surgical problems. Since 1973, we have performed AAAAB in 12 patients: 4 with recurrent coarctation of the thoracic aorta; 4 with coarctation of the thoracic aorta and associated cardiac lesions requiring a concomitant intracardiac procedure; 2 with recurrent aortoiliac occlusive disease (AIOD); 1 with interruption of the aortic arch requiring concomitant pulmonary artery banding; and 1 with coarctation of the abdominal aorta. In 3 of these patients (2 with recurrent AIOD and 1 with coarctation of the abdominal aorta) the distal anastomosis was made to the distal abdominal aorta or femoral arteries. Ten patients (83.3%) experienced satisfactory results; 2 patients (16.6%) died. The technique of AAAAB provides a practical solution to complex situations in which previous procedures preclude a standard operative approach, or when necessary concomitant procedures would otherwise require a two-stage operation.