Longer Operative Time Results in a Higher Rate of Subsequent Periprosthetic Joint Infection in Patients Undergoing Primary Joint Arthroplasty

Background

Whether prolonged operative time is an independent risk factor for subsequent surgical site infection (SSI) and periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) remains a clinically significant and underexplored issue. The aim of this study is to investigate the association between operative time and the risk of subsequent SSI and PJI in patients undergoing primary TJA.

联合拉力交锁髓内系统治疗股骨转子间骨质疏松性骨折

目的 前瞻性研究联合拉力交锁髓内钉系统(Inter TAN)治疗股骨转子问骨质疏松性骨折的临床效果.方法 设立入组及排除标准后,2008年3月一2010年3月共有24例闭合性骨质疏松性转子间骨折患者人组,男15例,女9例,年龄60～81岁,平均年龄为(68±6)岁.股骨转子间骨折按国际内固定研究学会(AO/ASIF)分型(AO31-):A1型5例,A2型17例,A3型2例.按Evans分型:Ⅰ型3度5例,Ⅰ型4度17例,Ⅱ型2例.对所有患者的Singh指数进行分度:Ⅲ度6例,Ⅱ度14例,Ⅰ度4例.均进行手术治疗,用InterTAN内固定.随访内容包括骨折愈合情况、顶尖距(TAD)值变化情况、术后并发症、髋关节Harris评分.结果 本组病例均获得随访,平均随访时间为(18±3)个月,骨折均牢固愈合,X线片上骨折愈合时间为5～17周,平均为(8.0±1.4)周.末次随访时,患侧髋关节Harris评分平均为(76.0±7.3)分,与健侧髋关节的(80.0±8.5)分的差异无统计学意义(P＞0.05).功能评价优12例(50.0%),良6例(25.0%),中3例(12.5%),差3例(12.5%).结论 Inter-TAN固定股骨转子间骨质疏松性骨折的稳定性好,既有滑动加压效果,又有抗旋转作用,其双钉模式还避免产生"Z-效应",是治疗股骨转子间骨质疏松性骨折安全、有效的方法.     

牙周教学中加强住院医师临床思维能力的探索

住院医师规范化培训中如何提高学员的临床思维能力,培育岗位胜任能力是培训的重点。在牙周住培教学活动中进行探索,入科教育采用思维导图使临床思维可视化、小讲课提倡模块化教学主攻牙周治疗计划、疑难病例讨论采用案例教学法、椅旁教学使用TSDF(tellshow-do-feedback)带教模式并让学员模拟标准病人进行临床思维训练。思维导图强调自我学习,小讲课以传统授课为主,疑难病例讨论学员则参与讨论,TSDF椅旁带教强调实战演练,而临床思维训练更注重一种考核式得训练。通过教学模式的改革期望加强住院医师的临床思维能力,提高诊疗规范水平,达到培育岗位胜任能力的目的。     

The Presence of Sinus Tract Adversely Affects the Outcome of Treatment of Periprosthetic Joint Infections

BackgroundA sinus tract may be encountered in patients with periprosthetic joint infection (PJI) and constitutes a major criterion for diagnosis. The aim of this study is to identify associated factors for the presence of sinus tract and outcome of 2-stage exchange arthroplasty in these patients.MethodsWe retrospectively reviewed all patients with PJI following hip and knee arthroplasty from 2000 to 2017. Of them, 161 patients with a sinus tract had a minimum follow-up of 1 year following 2-stage exchange arthroplasty. These patients were matched 1:2 with those without sinus tract by using propensity score matching. Treatment success was assessed using the modified Delphi criteria. A multiple logistic regression analysis was performed to determine the effect of sinus tract on the outcome and associated factors for the presence of sinus tract.ResultsFactors significantly associated with sinus tract included smoking (odds ratio [OR] = 1.83), hypothyroidism (OR = 1.62), hypoalbuminemia (OR = 1.52), hip joint involvement (OR = 1.43), and prior revision surgery (OR = 1.37). Patients with sinus tract had a significantly higher rate of failure compared to those without sinus tract (OR = 2.94).ConclusionThis study demonstrates that the presence of sinus tract in patients with PJI adversely affects the outcome of treatment of these patients. The presence of sinus tract may be a proxy for other issues such as poor periarticular soft tissue, the poor nutritional status of the host, and multiple prior operations. These findings need to be borne in mind when treating patients with PJI and a concomitant sinus tract.     

机器人辅助下膝关节单髁置换术短期临床疗效

目的评估机器人辅助下膝关节单髁置换术(UKA)的短期临床结果。 方法随访评估2016年9～12月在上海交通大学附属第六人民医院接受机器人辅助下UKA治疗的10例患者,纳入标准：内侧单间隙骨关节炎;不伴严重膝关节内翻畸形;前后交叉韧带完整。其中男2例,女8例,平均年龄(65±6)岁。均采用MAKO RIO机器人手术系统和RESTORIS MCK单髁膝关节假体(STRYKERMAKO Surgical,美国)进行手术。回顾以上10例患者,对其术前及术后影像学资料,日常活动情况,美国膝关节协会评分(KSS)、遗忘关节评分(FJS)等进行记录分析。采用配对样本t检验进行统计学分析。 结果10例患者均获得随访,随访时间平均(22.2±1.5)月。患者KSS的临床评分由术前的(58.8±13.7)分提升至末次随访的(96.0±2.8)分,功能评分由术前的(59.5±19.0)分提升至末次随访的(88.5±15.2)分,膝关节活动度由术前的(90.7±6.1)°提升至末次随访的(127.9±7.2)°(t＝－8.588,P<0.01)。FJS评分为(83±24)分,表示患者对手术膝关节的感受接近本体膝关节。10例患者的影像学评估良好,膝关节内翻畸形角度由术前的(8.8±3.5)°纠正至末次随访时的(4.0±2.0)°(t＝7.294,P<0.01)。患者假体对位对线良好,未见透亮线,未出现假体下沉、假体松动等不良事件,所有患者均未继发外侧间室的骨关节炎,关节间隙正常。 结论机器人辅助下UKA能使假体获得良好的对位对线和软组织平衡,达到功能好、患者主观感受佳的目标,术后短期的临床疗效优异;其远期临床结果及假体生存率需要通过更长期的随访加以证实。     

Intra-articular Application is More Effective Than Intravenous Application of Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

Background

The optimal administration route of tranexamic acid (TXA) in total knee arthroplasty (TKA), and the effect of TXA on hidden blood loss and total blood loss are undetermined. The purpose of this study was to compare the effectiveness of intravenous versus intra-articular application of tranexamic acid in patients undergoing knee arthroplasty.

Comparison of 3 Routes of Administration of Tranexamic Acid on Primary Unilateral Total Knee Arthroplasty: A Prospective,Randomized, Controlled Study

Background

The mode of administration for tranexamic acid (TXA) to significantly reduce the decrease in hemoglobin (Hb), number of transfusions, relevant costs, and side effects in patients undergoing primary unilateral total knee arthroplasty (TKA) has not been resolved.

Sonication of Explanted Prosthesis Combined with Incubation in BD Bactec Bottles for Pathogen-Based Diagnosis of Prosthetic Joint Infection

Prosthetic joint infection (PJI) is a rare but refractory complication of arthroplasty. Accurate identification of pathogens is a key step for successful treatment of PJI, which remains a challenge for clinicians and laboratory workers. We designed a combined culture method with sonication of implants and incubation in a BD Bactec system to improve the effectiveness of pathogen diagnosis in PJI. The aims of this study were to investigate the diagnostic accuracy of sonicate fluid cultures in the BD Bactec system and to compare the results with those of synovial fluid cultures in the BD Bactec system. The prosthetic components removed were sonicated in Ringer''s solution, and then sonicate fluid was incubated in Bactec bottles for 5 days. Synovial fluid was incubated in Bactec bottles for 5 days as a control. Synovial fluid cultures with Bactec bottles and sonicate fluid cultures with Bactec bottles showed sensitivities of 64% and 88%, respectively (P = 0.009), with specificities of 98% and 87% (P = 0.032), respectively. Sonicate fluid cultures with Bactec bottles were more sensitive than synovial fluid cultures with Bactec bottles regardless of whether antimicrobial agents were used within 14 days before surgery (81% versus 52%; P = 0.031) or not (93% versus 72%; P = 0.031). Sonication of explanted prostheses followed by incubation of the resulting sonicate fluid in Bactec bottles detected many more pathogens than did synovial fluid cultures with Bactec bottles. This method is also effective in cases with antibiotic treatment before surgery.     

Intraoperatively-made cement-on-cement antibiotic-loaded articulating spacer for infected total knee arthroplasty

Cement articulating spacers have been used for the treatment of TKA infection. The disadvantages of commercially available pre-made mobile spacers include limitations in implant size and antibiotic dose, often allowing delivery of only a single antibiotic agent. Hand-made mobile spacers fail to provide a well-shaped and congruently articular surface and have difficulties in maintaining stability. We present a method of intraoperatively-made cement-on-cement antibiotic-loaded articulating spacer for infected total knee arthroplasty. A custom mold was made intraoperatively with bone cement and the standard posterior stabilized TKA provisional components which were of the same size as the original prosthesis. Fabrication of the spacers did not increase the overall surgical time. From 2004 to 2007, 17 infected total knee arthroplasties were treated with two-stage reimplantation. The average length of follow-up was 31 months. One patient required an above-knee amputation for persistent infection. A knee arthrodesis was performed in one case. Ten patients received reimplantation with Nexgen LCCK knee implants. Articulating spacers were retained in situ in five patients. This articulating spacer can help improve knee mobility and function during the interval between stages.