Recommendations for the management of septic arthritis after ACL reconstruction

Purpose

To evaluate the current evidence for the management of septic arthritis after anterior cruciate ligament (ACL) reconstruction, the factors that affect the outcome after treatment and the retention of graft and implants.

Methods

A systematic literature search of the PubMed database was performed on septic arthritis after ACL reconstruction. A total of 301 publications were initially identified, and 17 papers were found to fulfil the criteria to be included in the review.

Results

There were 196 cases of septic arthritis after ACL reconstruction in over 30,000 ACL reconstructions, making the proportion of infection 0.6 %. Most patients (114/123, 92.6 %) had an acute or subacute infection at an average of 16.8 ± 10.5 days after ACL reconstruction. Coagulase-negative Staphylococci (CNS) was the most common organism (67/147, 45.6 %) followed by Staphylococcus aureus (SA) (35/147, 23.8 %); 86.9 % underwent surgical treatment of which 92.8 % had an average of 1.54 (up to 4) arthroscopic debridements. The group with SA infection had a higher graft removal rate (33.3 %, p = 0.019), a longer antibiotic duration (35.4 days, p = 0.047) and a worse range of flexion (111.5°, p = 0.036) than the CNS group.

Conclusions

CNS was the most common organism in septic arthritis after ACL reconstruction followed by SA. For most authors, arthroscopic debridement combined with intravenous antibiotic therapy was the initial treatment of choice. Antibiotic therapy with or without multiple irrigations of the joint is not recommended based on the high failure rates. Delayed diagnosis of more than 7 days or SA infection required a longer duration of antibiotic therapy and increased the likelihood for graft removal and restricted range of motion. Fungal infection and tubercular infection had a high prevalence of late diagnosis and open debridement.

Level of evidence

Systematic review, Level IV.     

In Vitro Evaluation of the Dual‐Diffuser Design for a Reversible Rotary Intra‐Aortic Ventricular Assist Device

The intra‐aortic ventricular assist device (IntraVAD) is a miniature intra‐aortic axial‐flow ventricular assist device (VAD) that works in series with the left ventricle (LV) to assist the compromised heart. Previous in vitro results have shown that the IntraVAD can successfully increase coronary perfusion and offload ventricular volume by operating in reverse‐rotation control (RRc) mode. The RRc mode includes forward rotation in systole and reverse rotation (RR) in diastole. It is necessary to derive a new diffuser design that can be used for the bi‐directional rotation of the IntraVAD. In this work, a dual‐diffuser set (DDS) was proposed to replace the conventional inducer and diffuser upstream and downstream of the pump. The DDS comprised two diffusers, located on both sides of the impeller, omitting the conventional inducer and diffuser. Different configurations of the DDS were designed and manufactured with various combinations of curved and straight blades. All configurations were initially tested in continuous flow, then in a pulsatile mock circulatory loop. A weighted normalized scalar (WNS) was proposed to comprehensively evaluate the hemodynamic effect of the DDS with different configurations. The results show that the maximum of WNS occurred when the upstream diffuser had equal numbers of curved and straight blades and the downstream diffuser had only curved blades. This indicates such a dual‐diffuser design for the IntraVAD can give an optimal cardiac assistance potentially improving ventricular contractility, thereby restoring heart function.     

Versatility of Hemisternotomy for Cardiac Surgery

Abstract   Background: Hemisternotomy has been suggested as a way to reduce morbidity by limiting the invasiveness of surgical interventions but it is often limited to aortic valve disease. This study reviews the experience of one center employing hemisternotomy and compares patient outcomes, both in-hospital and post-discharge, with a matched group of full sternotomy patients. Methods: Propensity scores were used to match all hemisternotomy valve cases (Hemi) to full sternotomy valve cases (Full) (1:2). An in-hospital composite outcome (COMP) was defined as mortality, stroke, deep sternal wound infection, sepsis, or return to operating room (OR) for bleeding or valve dysfunction. Provincial administrative health databases were used to determine freedom from mortality and hospital readmission for cardiac cause. Results: During the study period, 70 patients received hemisternotomy for various cardiac surgical interventions with only 38 patients undergoing isolated aortic valve replacement. Examining valve surgery exclusively, 65 Hemi were matched to 130 Full. In-hospital complications were low in both groups, with 1.0% mortality and a non-significant trend toward COMP in the Full group (Hemi = 4.6%; Full = 8.5%; p = 0.39). Ventilation time was significantly decreased in Hemi (median four vs. six hours; p = 0.002). At two years follow-up, survival was excellent for both (Hemi = 95.0%; Full = 93.6%) and freedom from cardiac morbidity (Hemi = 76.8%, Full = 73.2%) was comparable. Conclusion: Hemisternotomy appears to be a safe, effective, and versatile alternative for many cardiac surgical interventions. With a median follow-up of four years, this study represents the longest cardiac morbidity follow-up for hemisternotomy patients. However, we were unable to conclusively show a morbidity benefit with this incision.     

Resection of liver metastases from colorectal cancer: does preoperative chemotherapy affect the accuracy of PET in preoperative planning?

Background: Preoperative scanning for hepatic colorectal metastases surgery remains a challenge, especially in the age of preoperative chemotherapy, which has marked biochemical and physical effects on the liver. Integrated fluoro‐deoxyglucose positron emission tomography and computed tomography (FDG‐PET/CT) has applications for detecting extrahepatic disease. The aim of the present study was to investigate FDG‐PET/CT as a preoperative planning tool for detecting liver lesions in patients with and without preoperative chemotherapy. Methods: Patients who had resection of hepatic colorectal metastases between January 2004 and June 2006 were included. Patients were divided into those who received preoperative chemotherapy and those who did not. Malignant hepatic lesions found on each scan were compared with those found on histopathology, intraoperative examination and/or intraoperative ultrasound. Accurate scans (scan lesions corresponded to true lesions), false positives (scan lesions detected at least one non‐lesion) and false negatives (scan lesions missed at least one true lesions) were recorded. Results were also compared on a per lesion basis. Results: A total of 21 patients had preoperative FDG‐PET/CT scans with preoperative chemotherapy and 53 without. Accurate tests were six (29%) for the chemotherapy group versus 28 (53%) for the non‐chemotherapy group (P= 0.06). Notably, there were 11 (52%) underestimations in the chemotherapy group versus 18 (34%) in the non‐chemotherapy group. A total of 1.7 lesions were missed per patient in the chemotherapy group versus 0.7 in those who did not receive chemotherapy. Conclusion: Preoperative assessment with FDG‐PET/CT is not useful for hepatic colorectal metastases, particularly when preoperative chemotherapy is used, with a trend towards underestimation of lesions.     

Complete worldwide operative experience in laparoscopic diaphragm pacing: results and differences in spinal cord injured patients and amyotrophic lateral sclerosis patients

Background  Diaphragm movement is essential for adequate ventilation, and when the diaphragm is adversely affected patients face lifelong positive-pressure mechanical ventilation or death. This report summarizes the complete worldwide multicenter experience with diaphragm pacing stimulation (DPS) to maintain and provide diaphragm function in ventilator-dependent spinal cord injury (SCI) patients and respiratory-compromised patients with amyotrophic lateral sclerosis (ALS). It will highlight the surgical experiences and the differences in diaphragm function in these two groups of patients. Methods  In prospective Food and Drug Administration (FDA) trials, patients underwent laparoscopic diaphragm motor point mapping with intramuscular electrode implantation. Stimulation of the electrodes ensued to condition and strengthen the diaphragm. Results   From March of 2000 to September of 2007, a total of 88 patients (50 SCI and 38 ALS) were implanted with DPS at five sites. Patient age ranged from 18 to 74 years. Time from SCI to implantation ranged from 3 months to 27 years. In 87 patients the diaphragm motor point was mapped with successful implantation of electrodes with the only failure the second SCI patient who had a false-positive phrenic nerve study. Patients with ALS had much weaker diaphragms identified surgically, requiring trains of stimulation during mapping to identify the motor point at times. There was no perioperative mortality even in ALS patients with forced vital capacity (FVC) below 50% predicted. There was no cardiac involvement from diaphragm pacing even when analyzed in ten patients who had pre-existing cardiac pacemakers. No infections occurred even with simultaneous gastrostomy tube placements for ALS patients. In the SCI patients 96% were able to use DPS to provide ventilation replacing their mechanical ventilators and in the ALS studies patients have been able to delay the need for mechanical ventilation up to 24 months. Conclusion   This multicenter experience has shown that laparoscopic diaphragm motor point mapping, electrode implantation, and pacing can be safely performed both in SCI and in ALS. In SCI patients it allows freedom from ventilator and in ALS patients it delays the need for ventilators, increasing survival. Presented as an oral presentation at the Plenary Session of SAGES 2008 Scientific Session, Philadephia.     

Previous transurethral resection of the prostate is not a contraindication to high‐dose rate brachytherapy for prostate cancer

OBJECTIVE

To analyse retrospectively the morbidity and efficacy of high‐dose rate (HDR) brachytherapy in patients who had a previous transurethral resection of the prostate (TURP).

PATIENTS AND METHODS

Morbidities documented in the records of 32 patients with previous TURP and 106 with no previous TURP, treated with HDR brachytherapy for prostate cancer at our institution, were analysed and compared. All patients received HDR brachytherapy as a boost before conformal external beam radiotherapy. We recorded and analysed genitourinary complications, rectal morbidity, and the biochemical control rate as assessed by the prostate‐specific antigen (PSA) level.

RESULTS

All complications of patients who received HDR brachytherapy were recorded during the follow‐up. All gastrointestinal and genitourinary complications were not significantly different in patients with or without previous TURP. There was little incontinence or severe morbidity associated with HDR brachytherapy. The PSA‐based biochemical control rates were similar in patients with or without previous TURP in each risk group.

CONCLUSIONS

HDR brachytherapy is a reasonable treatment for localized prostate cancer in patients who have had a previous TURP, with the expectation of low morbidity and satisfactory biochemical control.     

Generalized low bone mass of girls with adolescent idiopathic scoliosis is related to inadequate calcium intake and weight bearing physical activity in peripubertal period

Generalized low bone mass has been well documented in patients with adolescent idiopathic scoliosis (AIS). However, studies linking calcium-intake (CA), weight-bearing physical-activity (PA) and bone mass of AIS are lacking. We aimed to study the relationship between CA, PA and bone mass in AIS girls and compared to those of healthy non-AIS controls during the peripubertal period. Newly diagnosed AIS girls (n=596) aged 11–16 years with Cobb angle 10° were recruited to compare with age-matched healthy girls (n=302) in a cross-sectional study. Anthropometric parameters, pubertal status, CA and PA were assessed. Areal bone mass of lumbar spine and femoral neck, and volumetric bone mass of distal radius and tibia were determined by dual-energy X-ray absorptiometry and peripheral quantitative computed tomography, respectively. The results showed that weight and body mass index (BMI) of AIS were lower than the controls (P<0.05). Corrected height and arm span of AIS were longer than those of controls from 13 years onwards (P<0.02). Median CA of AIS was <410 mg/day across the ages and did not differ from the controls (P=0.063). Median PA of AIS (1.6 h/day) was lower than the controls (1.8 h/day) (P=0.025). Bone mass of AIS was on average 6.5% lower than controls across the ages (P<0.05). CA and PA were significantly correlated with bone mass of AIS (P<0.04). Multivariate analysis showed that AIS in girls was associated with lower bone mass, and that both CA and PA were independent predictors of bone mass in AIS. In conclusion, AIS girls were found to have lower body weight and BMI, longer segmental lengths and generalized low bone mass. Inadequate calcium intake and weight-bearing physical activity were significantly associated with low bone mass in AIS girls during the peripubertal period. The importance of preventing generalized osteopenia in the control of AIS progression during the peribubertal period warrants further study.