Cefazolin remains the linchpin for preventing acute periprosthetic joint infection following primary total knee arthroplasty

Aims

Despite recent literature questioning their use, vancomycin and clindamycin often substitute cefazolin as the preoperative antibiotic prophylaxis in primary total knee arthroplasty (TKA), especially in the setting of documented allergy to penicillin. Topical povidone-iodine lavage and vancomycin powder (VIP) are adjuncts that may further broaden antimicrobial coverage, and have shown some promise in recent investigations. The purpose of this study, therefore, is to compare the risk of acute periprosthetic joint infection (PJI) in primary TKA patients who received cefazolin and VIP to those who received a non-cephalosporin alternative and VIP.

Methods

This was a retrospective cohort study of 11,550 primary TKAs performed at an orthopaedic hospital between 2013 and 2019. The primary outcome was PJI occurring within 90 days of surgery. Patients were stratified into two groups (cefazolin vs non-cephalosporin) based on their preoperative antibiotic. All patients also received the VIP protocol at wound closure. Bivariate and multiple logistic regression analyses were performed to control for potential confounders and identify the odds ratio of PJI.

Results

In all, 10,484 knees (90.8%) received cefazolin, while 1,066 knees (9.2%) received a non-cephalosporin agent (either vancomycin or clindamycin) as preoperative prophylaxis. The rate of PJI in the cefazolin group (0.5%; 48/10,484) was significantly lower than the rate of PJI in the non-cephalosporin group (1.0%; 11/1,066) (p = 0.012). After controlling for confounding variables, the odds ratio (OR) of developing a PJI was increased in the non-cephalosporin cohort compared to the cefazolin cohort (OR 2.389; 1.2 to 4.6); p = 0.01).

Conclusion

Despite the use of topical irrigant solutions and addition of local antimicrobial agents, the use of a non-cephalosporin perioperative antibiotic continues to be associated with a greater risk of TKA PJI compared to cefazolin. Strategies that increase the proportion of patients receiving cefazolin rather than non-cephalosporin alternatives must be emphasized.

Cite this article: Bone Jt Open 2022;3(1):35–41.

A Matched Comparison of Postoperative Complications Between Smokers and Nonsmokers Following Open Reduction Internal Fixation of Distal Radius Fractures

PURPOSE

The purpose of the present study was to identify differences in 30-day adverse events, reoperations, readmissions, and mortality for smokers and nonsmokers who undergo operative treatment for a distal radius fracture.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients who had operatively treated distal radius fractures between 2005 and 2017. Patient characteristics and surgical variables were assessed. Thirty-day outcome data were collected on serious (SAEs) and minor adverse events (MAEs), as well as on infection, return to the operating room, readmission, and mortality. Multivariable logistic analyses with and without propensity-score matching was used to compare outcome measures between the smoker and the nonsmoker cohorts.

RESULTS

In total, 16,158 cases were identified, of whom 3,062 were smokers. After 1:1 propensity-score matching, the smoking and nonsmoking cohorts had similar demographic characteristics. Based on the multivariable propensity-matched logistic regression, cases in the smoking group had a significantly higher rate of any adverse event (AAE) (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.28-2.38), serious adverse event (SAE) (OR, 1.75; 95% CI, 1.22-2.50), and minor adverse event (MAE) (OR, 1.84; 95% CI, 1.04-3.23). Smokers also had higher rates of infection (OR, 1.73; 95% CI, 1.26-2.39), reoperation (OR, 2.07; 95% CI, 1.13-3.78), and readmission (OR, 1.83; 95% CI, 1.20-2.79). There was no difference in 30-day mortality rate.

CONCLUSIONS

Smokers who undergo open reduction internal fixation of distal radius fractures had an increased risk of 30-day perioperative adverse events, even with matching and controlling for demographic characteristics and comorbidity status. This information can be used for patient counseling and may be helpful for treatment/management planning.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Risk Factors for Concomitant Collateral Ligament Injuries in Children and Adolescents With Anterior Cruciate Ligament Tears

Background:

Risk factors for concomitant ligament injuries (CLIs) of the lateral collateral ligament (LCL) and medial collateral ligament (MCL) in children and adolescents with anterior cruciate ligament (ACL) tears are unknown.

Purpose:

To determine whether body mass index (BMI), sex, age, and injury mechanism are associated with CLIs in children and adolescents with ACL tears and whether CLIs are associated with meniscal and chondral injuries and a delay to surgery.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We reviewed the records of patients aged ≤18 years with ACL tears from 2009 through 2013 for sex, age, height, weight, CLI, injury mechanism, intra-articular injury, and time to surgery. Patients were assigned to groups according to the presence of a CLI (CLI group) compared with the presence of an isolated ACL tear (ACL group). BMI was categorized as underweight, normal weight, or overweight/obese. The older group was defined as age ≥14 years for girls and ≥16 years for boys. Logistic regression, Mann-Whitney U tests, and chi-square tests were performed (alpha = 0.05).

Results:

We included 509 patients (267 girls) with a mean age of 15 years (range, 6-18 years) at the time of injury. There were 396 patients (78%) in the ACL group and 113 patients (22%) in the CLI group (90 with MCL, 11 with LCL, and 12 with both MCL and LCL injuries). Groups had similar proportions of overweight/obese patients (P = .619) and girls (P = .104). Older age (odds ratio [OR], 2.0 [95% CI, 1.3-3.3]) and contact injuries (OR, 2.2 [95% CI, 1.4-3.4]) were associated with CLIs. The CLI group had a higher proportion of chondral injuries (P = .001) but not meniscal injuries (P = .295) and presented to surgery earlier than the ACL group (P = .002).

Conclusion:

Older age and contact injuries were associated with CLIs in children and adolescents with ACL tears, whereas BMI category and sex were not. CLIs were associated with a higher proportion of chondral injuries but not meniscal injuries and were not associated with a delay to surgery.

Deficiencies in the availability of essential musculoskeletal surgical services at 883 health facilities in 24 low- and lower-middle-income countries

BACKGROUND

The sequelae of acute musculoskeletal conditions, especially injuries and infections, are responsible for significant disability in low- and middle-income countries. This study characterizes the availability of selected musculoskeletal surgical services at different tiers of the health system in a convenience sample of 883 health facilities from 24 low- and lower-middle-income countries.

METHODS

Selected data points from the World Health Organization's (WHO) tool of situational analysis of surgical availability were extracted from the WHO's database in December, 2013. These included infrastructure, physical resources and supplies, interventions, and human resources. For a descriptive analysis, facilities were divided into two groups based on number of beds (<100, 100-300, and >300) and level of facility (primary referral, secondary/tertiary, and Private/NGO/Mission). Statistical comparison was made between public and Private/NGO/Mission facilities based on number of beds (≤100, 100-300, and >300) using a Chi-Square analysis, with statistical significance at p < 0.05.

FINDINGS

Significant deficiencies were noted in infrastructure, physical resources and supplies, and human resources for the provision of essential orthopedic surgical services at all tiers of the health system. Availability was significantly lower in public versus Private/NGO/Mission facilities for nearly all categories in facilities with ≤100 beds, and in a subset of measures in facilities with between 100 and 300 beds.

INTERPRETATION

Deficiencies in the availability of orthopedic surgical services were observed at all levels of health facility and were most pronounced at facilities with ≤100 beds in the public sector. Strengthening the delivery of essential surgical services, including orthopedics, at the primary referral level must be prioritized if we are to reduce the burden of death and disability from a variety of emergent health conditions.

FUNDING

There were no sources of funding.

Ilfeld abduction orthosis is an effective second-line treatment after failure of Pavlik harness for infants with developmental dysplasia of the hip

BACKGROUND

Closed reduction and spica casting is the most commonly recommended choice for infants with developmental dysplasia of the hip (DDH) for whom Pavlik harness treatment has failed, but it requires general anesthesia in addition to the challenges of spica cast care. The purposes of this study were to evaluate the effectiveness of Ilfeld bracing for infants for whom Pavlik harness treatment is unsuccessful and to compare these results with those for a similar cohort of patients directly undergoing closed reduction and spica casting.

METHODS

We reviewed the cases of a consecutive series of children with DDH who had failure of Pavlik harness treatment and were subsequently managed with Ilfeld bracing (the BR cohort) and compared this cohort with a similar historical group of infants who had failure of Pavlik harness treatment but had standard closed reduction and spica casting (the CR cohort). The cohorts were compared with respect to clinical and ultrasonographic data at the time of Pavlik discontinuation. At one year, the hip stability and acetabular index were assessed; the presence of osteonecrosis was graded according to the criteria described by Salter et al.

RESULTS

Twenty-eight hips (nineteen infants) made up the BR cohort and twenty-two hips (sixteen infants) made up the CR cohort. Ultrasonographic indices (including the alpha angle and the percentage of femoral head coverage) were comparable between the two cohorts (p=0.66 and 0.19, respectively). Following treatment, a stable reduction was achieved in twenty-three (82%) of twenty-eight hips in the BR cohort compared with twenty (91%) of twenty-two hips in the CR cohort. At one year, acetabular indices were similar between both cohorts (mean and standard deviation, 27°±6° for the BR cohort versus 27°±5° for the CR cohort; p=0.62); however, osteonecrosis developed in three hips in the CR cohort compared with none in the BR cohort.

CONCLUSIONS

In our series of infants with DDH for whom Pavlik harness treatment had failed, Ilfeld bracing had success rates comparable with those for closed reduction and spica cast treatment. With the added advantages of avoiding general anesthesia and spica casting as well as a potentially lower rate of osteonecrosis, rigid abduction bracing should be considered as the next step for infants who have had failed Pavlik harness treatment prior to proceeding with closed reduction and spica casting.

Diabetes mellitus is associated with the presence of metastatic spread at disease presentation in hepatocellular carcinoma

PURPOSE

Diabetes mellitus (DM) is identified as a negative prognostic indicator in hepatocellular carcinoma (HCC).

METHODS

A retrospective review of HCC patients was conducted to assess the effect of DM on clinical variables.

RESULTS

Ninety-seven of 265 (34%) patients had DM at the time of diagnosis. Distant metastasis was found in 33% (30/91) of patients with DM compared with only 9.7% (17/174) of those without DM (OR: 4.5, 95% CI: 2.3-8.8, p < .0001). This difference remained significant when adjusting for other clinical variables (OR: 10.0, 95% CI: 3.9-25.7, p < .0001).

CONCLUSIONS

DM is associated with the presence of metastatic disease among a single institution cohort of HCC patients.

Mutational profiling reveals PIK3CA mutations in gallbladder carcinoma

Background

The genetics of advanced biliary tract cancers (BTC), which encompass intra- and extra-hepatic cholangiocarcinomas as well as gallbladder carcinomas, are heterogeneous and remain to be fully defined.

Methods

To better characterize mutations in established known oncogenes and tumor suppressor genes we tested a mass spectrometric based platform to interrogate common cancer associated mutations across a panel of 77 formalin fixed paraffin embedded archived BTC cases.

Results

Mutations among three genes, KRAS, NRAS and PIK3CA were confirmed in this cohort. Activating mutations in PIK3CA were identified exclusively in GBC (4/32, 12.5%). KRAS mutations were identified in 3 (13%) intra-hepatic cholangiocarcinomas and 1 (33%) perihillar cholangiocarcinoma but were not identified in gallbladder carcinomas and extra-hepatic cholangiocarcinoma.

Conclusions

The presence of activating mutations in PIK3CA specifically in GBC has clinical implications in both the diagnosis of this cancer type, as well as the potential utility of targeted therapies such as PI3 kinase inhibitors.