BackgroundIn the context of an increase number of primary and revision total hip and total knee arthroplasty performed yearly, an increased risk of complication is expected. Prosthetic joint infection (PJI) remains the most common and feared arthroplasty complication. Ralstonia pickettii is a Gram-negative bacterium, that has also been identified in biofilms. It remains an extremely rare cause of PJI. There is no report of an identification of R. pickettii on an extracted spacer loaded with antibiotic.Case presentationWe present the case of an 83-years-old Caucasian male patient, that underwent a right cemented total hip replacement surgery. The patient is diagnosed with an early PJI with no isolated microorganism. A debridement and change of mobile parts is performed. At the beginning of 2016, the patient in readmitted into the Orthopedic Department for sever, right abdominal and groin pain and elevated serum erythrocyte sedimentation rate and C-reactive protein. A joint aspiration is performed with a negative microbiological examination. A two-stage exchange with long interval management is adopted, and a preformed spacer loaded with gentamicin was implanted. In July 2016, based on the proinflammatory markers evolution, a shift a three-stage exchange strategy is decided. In September 2016, a debridement, and changing of the preformed spacer loaded with gentamicin with another was carried out. Bacteriological examination of the tissues sampled intraoperatively was positive for Pseudomonas aeruginosa. From the sonication fluid, no bacteria were isolated on culture or identified using the bbFISH assay. During the hospitalization period, the patient received i.v. ceftazidime 3x2g/day and p.o. ciprofloxacin 2x750mg/day, antibiotic therapy that was continued after discharge with p.o. ciprofloxacin 2x750mg/day for 6 weeks. In February 2017, a reimplantation of a revision prosthesis is performed. The retrieved spacer is sonicated, and after 4 days of incubation of the sonication fluid, R. pickettii is isolated. A long term antibiotic therapy with cotrimoxazole being prescribed.ConclusionsBacteria culture of sonication fluid remains the gold standard in diagnosing prosthetic joint infections. R. pickettii remains an extremely rare cause of prosthetic joint infection. Optimal management of R. pickettii prosthetic joint infections of has not been established.
By 2030, the annual number of combined total hip and knee arthroplasty is estimated to reach 3.5 to 4 million in the US alone. In the context of a constant increase of the number of primary and revision total hip and knee arthroplasty, an increased risk of complication is expected. Prosthetic joint infections (PJIs) represent major cause of healthcare expenditure and morbidity. PJI still remain the most common and feared arthroplasty complication. A rapid and correct diagnosis of infection is decisive for a correct therapeutical management. In this setting, the Academic Emergency Hospital Sibiu adopted and implemented, with the beginning of September 2016, a new strategy for the diagnosis of PJIs strategy that uses sonication and beacon-based fluorescent in situ hybridization (bbFISH) technology. Until November 2017, 40 patients (40 retrieved implants) were enrolled in the study. Sonication fluid (SF) was collected after sonication of the implants, and samples were harvested on aerobic and anaerobic culture media. A bbFISH was used as a rapid method of bacteria detection. 16 patients were diagnosed with PJIs (all 16 patients presented a positive culture of the SF). Comparing bbFISH with culture, 11 samples tested true-positive. As the kit doesn’t contain probes for Pseudomonas fluorescens or Ralstonia pickettii , 4 strains of R pickettii and 1 strain of P fluorescens that was associated with Staphylococcus epidermidis were not detected. Bacteria culture of SF remains the gold standard. bbFISH holds promise to be a diagnostic tool for rapid identifying of PJIs. The bbFISH assay needs to be optimized for the detection of bacterial strains that are relevant for the PJIs field.
Background: There is no clear distinction in the literature regarding the positivity trends of bacterial cultures in acute and chronic prosthetic joint infections. Methods: We prospectively included in this study all consecutive patients, aged over 18 years, that were hospitalized from September 2016 through December 2019, that underwent a joint arthroplasty revision surgery. Results: Forty patients were included in our analysis, 11 acute/acute hematogenous and 29 chronic PJIs. We were able to identify all strains of acute/acute hematogenous PJIs within 3 days, whereas this took 8 days for chronic PJIs. Sonication fluid cultures increased the positivity rate and helped in identifying rare pathogens such as Ralstonia pickettii from chronic PJIs, but also increased the number of identified strains from acute PJIs. Culturing synovial fluid in our study did not seem to have a clear benefit compared to sonication fluid and periprosthetic tissue cultures. Conclusion: There was a different positivity trend in bacterial cultures. Empiric broad-spectrum antibiotic therapy can be re-evaluated after 3 days for acute PJIs. A prolonged incubation time, especially in the case of chronic PJIs, is mandatory; however, extending the incubation period beyond 14 days would not further improve the ability to identify microorganisms.
Background Periprosthetic joint infections (PJIs) represent one of the most serious complications associated with joint replacement surgeries, a complication also of modern orthopedic surgery despite the efforts that occurred in this field. Frequently PJIs lead to prolonged morbidity, increased costs and mortality. Methods We are conducting a single-center observational cohort ongoing study in the Academic Emergency Hospital Sibiu, Romania, study in which sonication of the retrieved and as a rapid method of bacteria detection, molecular identification of bacteria by 16S rRNA beacon-based fluorescent in situ hybridization (bbFISH) are used. Results A total of 61 patients were enrolled in this study. The diagnosis of aseptic loosening was established in 30 cases (49.1%) and the diagnosis of periprosthetic joint infection was established at 31 patients (50.8%). The mean follow-up period in the subgroup of patients diagnosed with periprosthetic joint infections was 36.06 ± 12.59 months (range: 1–54). The 25-months Kaplan-Meier survival rate as the end point, as a consequence of the period of enrollment and a different follow-up period for each type of surgical procedure, was 75% after debridement and implant retention, 91.7% after one-stage exchange, 92.3% after two-stage exchange, and 100% after three-stage exchange. There were no significant differences in survival percentage. Conclusions Our study has good results similar to previously published data. We cannot recommend one strategy of managing prosthetic joint infections over the other. Definitely, there is a need for prospective randomized controlled trials.
Shockwaves can be defi ned as transient pressure oscillations which propagate in three dimensions and offer an increased pressure in a very short period of time. Biological effects of shockwave therapy have been proven to stimulate the release of angiogenic growth factors, and contribute to the improvement of blood supply which leads to the repair of bone and soft tissue. The role of ESWT in the treatment of chronic calcifying tendinitis of the rotator cuff has been evaluated in many studies. ESWT has been gaining attention as an alternative option to surgical excision of calcifi cation or when other conservative options have not proven effi cient. The main purpose for using ESWT in heel spur is to increase the local blood supply by inducing neovascularisation. This action influences the inflammatory process and furthermore stimulates the local metabolism. Also, shockwaves have been proposed as a possible treatment in early phases of femoral head necrosis in adults. In case of patellar tendinopathy in vitro studies have shown biological effects, while clinical effects remain unclear. Data suggests that ESWT associated with other physical modalities achieve realiable clinical importance of pain reduction in lateral epycondylitis. However there is still a lack of standardisation and a consensus is needed regarding frequency and intensity.
Intralesional tumoral procedures in giant cell tumor (GCT) are quoted as having a recurrence rate of up to 60%. Thus, a number of studies suggest that broad resection is associated with a lower local recurrence risk compared to intralesional curettage, increasing the free recurrence interval from 84% to 100%. The TCG involvement of the proximal tibia occupies a particular place through the relationship with the articular line, but especially through the frequent, direct, or indirect interest of the extensor mechanism of the knee. Purpose of the paper. Based on the unique tumor registry of "Foişor" Orthopedic Clinic, we proposed to follow all the cases of TCG with proximal tibial localized operation, beneficiaries of an "en bloc" resection and modular tumor prosthesis reconstructions -registering a number of 5 cases between 2009 and 2017. Material and method. The initial evaluation was performed by radiography, CT-scan and MRI investigations and recurrence cases in which histopathological reassessment became mandatory after post-intralesional techniques were also included in the study. The surgical technique followed tumor resection, tumor reconstruction, and the reconstruction procedure of the extensor of the knee, which involved the modulation of the modular tumor prosthesis with a rotary reversible flap of the medial gastrocnemius with the ankle of the patellar tendon to the prosthesis and flap. Quantification of functional outcomes required the use of the revised Muscle-Skeletal Society Score (rMTS) and postoperative complications were centralized; the most commonly reported being the peroneal nerve palsy. Results and discussions. The results obtained were compared to the orthopedic oncology literature data for such a procedure, following their superposition and discrepancy. The challenge of such an orthopedic oncology intervention is the reconstruction of the extensor, with definite functional implications of limiting the knee extension, as well as avoiding the peroneal nerve palsy. However, the results can be reproducible, with an absent relapse rate.
Oncological resection and articular reconstruction through modular tumor prosthesis is a challenge for the surgeon, but at the same time gives the patient the certainty of keeping the function and hope for healing. Due to technical evolution, the recovery of osteoarticular post-resection tumor is today much more versatile and permissive, providing the comfort of the orthopedic oncologist surgeon during reconstruction and at the same time the patient satisfaction. Purpose of the paper. Short-term and medium-term evaluation of surgical treatment outcome of bone oncological pathogenesis of the knee with modular tumor prosthesis. Material and method. Recording based on the unique tumor registry of the Clinic in a monocentric, retrospective continuously study between 2009 and 2017, of all orthopedic oncology patients with malignant/ borderline tumors with metaphyso-epiphyseal knee periarticular involvement, beneficiaries of the resection-reconstruction with prosthesis modular tumor - a total of 21 cases. Case analysis included details of histopathological types of tumors, followed by Enneking staging, which was performed, alongside classical demographics. The Malaware oncological resection technique was followed and the learning curve and results of the prostatic modular prosthetic reconstruction were registered, considering failure for any of the following reasons: revision, necessity exhaustion of the prosthesis - infection, relapse, or amputation. The functional evaluation was based on the revised Muscular-skeletal Tumor Society Score (rMSTS). Results and discussions. Only one case of failure was registered - a periprosthetic infection. The overall rate of apparently postoperative complications followed the literature data for this type of intervention - 40-50%. Compared to amputation, the lower limb salvage process in the knee malignant tumors has proven to be cost-effective and has contributed to improving the quality of life, becoming one of the sustainable options for onco-surgical management in good cases selected. The limits of the study are determined by the relatively short duration of follow-up, and the apparently large number of complications is nevertheless included in the international statistics related to such interventions.
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