Orthopedic postoperative infection profile and antibiotic sensitivity of 2038 patients across 24 countries - Call for region and institution specific surgical antimicrobial prophylaxis

Purpose

Improper utilization of surgical antimicrobial prophylaxis frequently leads to increased risks of morbidity and mortality.This study aims to understand the common causative organism of postoperative orthopedic infection and document the surgical antimicrobial prophylaxis protocol across various institutions in to order to strengthen surgical antimicrobial prophylaxis practice and provide higher-quality surgical care.

Methods

This multicentric multinational retrospective study, includes 24 countries from five different regions (Asia Pacific, South Eastern Africa, Western Africa, Latin America, and Middle East). Patients who developed orthopedic surgical site infection between January 2021 and December 2022 were included. Demographic details, bacterial profile of surgical site infection, and antibiotic sensitivity pattern were documented.

Results

2038 patients from 24 countries were included. Among them 69.7 % were male patients and 64.1 % were between 20 and 60 years. 70.3 % patients underwent trauma surgery and instrumentation was used in 93.5 %. Ceftriaxone was the most common preferred in 53.4 %. Early SSI was seen in 55.2 % and deep SSI in 59.7 %. Western Africa (76 %) and Asia-Pacific (52.8 %) reported a higher number of gram-negative infections whereas gram-positive organisms were predominant in other regions. Most common gram positive organism was Staphylococcus aureus (35 %) and gram-negative was Klebsiella (17.2 %). Majority of the organisms showed variable sensitivity to broad-spectrum antibiotics.

Conclusion

Our study strongly proves that every institution has to analyse their surgical site infection microbiological profile and antibiotic sensitivity of the organisms and plan their surgical antimicrobial prophylaxis accordingly. This will help to decrease the rate of surgical site infection, prevent the emergence of multidrug resistance and reduce the economic burden of treatment.

Partial atlantooccipital assimilation causing atlantoaxial instability and early myelopathy in an adult treated with occipitocervical fusion: A case report

INTRODUCTION & IMPORTANCE

Atlanto-occipital assimilation is a rare congenital abnormality which can cause atlantoaxial instability. Basilar invagination and instability can lead to cord compression and myelopathy in young individuals.

CASE REPORT & DISCUSSION

A 37-year-old male presented with gradually worsening axial neck pain for four years duration His deep tendon reflexes are exaggerated in all four limbs but there is no weakness or imbalance. Following radiological evaluation, he was diagnosed to have partial atlantooccipital assimilation causing atlantoaxial instability, basilar invagination and early myelopathy. He was treated with occipital-cervical fusion after the closed reduction of the atlantoaxial joint.

CONCLUSION

Atlanto-axial assimilation can lead to atlantoaxial instability and subsequently myelopathy. Dynamic radiographs and computed tomography are helpful in the diagnosis. Reducible atlantoaxial instability can be managed with closed reduction and occipitocervical fusion.

Bilateral fracture-dislocation of the shoulder following a seizure- A case report & review of literature

Introduction

and Importance: Bilateral shoulder dislocations are uncommon and those are usually posterior dislocations. Bilateral anterior fracture-dislocations are rarest of their kind following seizure episodes.

Case presentation

We present a case of bilateral fracture-dislocations of the shoulder following a seizure episode. Bilateral dislocations were relocated to the emergency unit and managed conservatively as he refused to undergo surgery. The patient was followed up at the Orthopaedic clinic and achieved a full range of movements of the bilateral shoulder the one-year post-intervention.

Clinical discussion

A closed reduction is also an option on occasion like this patient.

Conclusion

Careful radiological assessment and follow-up with physiotherapy will help to achieve a good outcome.

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Bilateral anterior fracture-dislocations of the shoulder are rare following seizure due to contraction of stronger trapezius.

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The “triple E syndrome” (Epilepsy, Electroconvulsive therapy & Electrocution) is the frequent causes.

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Radiographs followed by computed tomography will help to identify and plan the management.

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A successful closed reduction and post-post procedure radiograph will help to decide on further management options.

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Failed closed reduction should be treated with open reduction & surgical fixation using plates, screws and wires.

Late-onset pseudoaneurysms of lower limb arteries following late complications of orthopaedic constructs - Two cases and review of literature

INTRODUCTION & IMPORTANCE

Damage to the adventitial layer of an artery leads to pseudoaneurysm formation. Pseudoaneurysms caused by complications of orthopaedic constructs are rare.

CASE PRESENTATION & CLINICAL DISCUSSION

Case report 01. A 27-year-old male presented with acute bleeding from an external fixator pin site. He had defaulted follow-up due to covid pandemic and presented with malunited distal tibia fracture and loosened Schanz pins. CT angiogram revealed a pseudoaneurysm of the peroneal artery over the loosened pin site. The patient underwent exploration and ligation of the peroneal artery. Case report 02. 86-year-old female presented with a gradually enlarging lump on her left anteromedial thigh for three months duration. She underwent open reduction and internal fixation of ipsilateral femur fracture 17 months back. She was found to have a pseudoaneurysm of the superficial femoral artery caused by exposed screws following bony erosion. Exploration and repair of "neck" the pseudoaneurysm was performed and the recovery was uneventful.

CONCLUSION

Pseudoaneurysms are rare but carry devastating complications following various orthopaedic procedures. The common cause for the formation of pseudoaneurysms is trauma during surgery. But loosened Schanz screws and screws are also can be the cause. Early identification of a pseudoaneurysm and proper intervention will reduce morbidities.

Bilateral symmetrical pronation type of Galeazzi fracture following high-speed motor traffic crash: A case report

INTRODUCTION AND IMPORTANCE

Bilateral Galeazzi fracture is a rare occurrence following trauma. Anatomical reduction of the fracture and the distal radioulnar joint is mandatory for a good outcome.

CASE PRESENTATION

We present a 24-year-old patient with bilateral Galeazzi fracture following a high-velocity motorbike accident.

CLINICAL DISCUSSION

A motorcyclist presented with bilateral painful deformed forearms following a motor traffic crash. Radiographs of bilateral forearms showed bilateral symmetrical supination type (Type II) Galeazzi fractures. He has undergone open reduction and internal fixation of the bilateral radii. Bilateral distal radioulnar joints reduced spontaneously when the fracture of the radius reduced anatomically. The reduction of the fracture and the distal radioulnar joints was confirmed by postoperative radiographs.

CONCLUSION

Bilateral Galeazzi fracture is a rare entity following high-velocity injury. Disruption of the distal radial ulnar joint needs to address to achieve a good outcome. An awareness of this entity, early detection, and intervention of this condition may help to regain the full function of the forearm.

Pediatric anterior elbow dislocation due to a rare mechanism of injury: A case report

INTRODUCTION & IMPORTANCE

Elbow dislocations are rare among the pediatric population as their ligaments are stronger than bones. Anterior dislocations of the elbow are even rarer entity usually caused by anteriorly directed force on the hyper-flexed elbow. We present a case of a rotational force on an extended elbow causing anterior dislocation of the shoulder in an 11-year-old boy.

CASE PRESENTATION

An 11-year-old boy presented to the Accident & Trauma unit with pain & swelling of the right elbow following a twisting injury by a spinning washing machine. The child was in pain.

CLINICAL DISCUSSION

His elbow was semi flexed and deformed. Distal neurovascular status was found normal. Radiographs of the right elbow revealed anteromedial dislocation of the elbow with the medial epicondyle avulsion. Emergent relocation of the elbow joint has been performed. A concentric reduction, absence of incarcerated bony fragments and stability has been confirmed by the fluoroscopic examination. Post reduction neurovascular examinations unremarkable. The child was discharged with the above-elbow splint. The range of motion exercises has been commenced after three weeks. The child achieved full range of motion at six weeks of post-injury.

CONCLUSION

Anterior dislocations are a rare entity in pediatric orthopaedic practice. Evaluation of the causative mechanism of injury is the clue. A rare type of mechanism of injury also should be kept in mind to prevent the delay in diagnosis and treatment.

A case report on non-specific synovitis of the knee due to septic foreign body in the Hoffa fat pad causing diagnostic dilemma

INTRODUCTION & IMPORTANCE

Recurrent chronic synovitis due to foreign body is a rare entity and it may progress into chronic septic arthritis. Chronic recurrent synovitis or septic arthritis may leave permanent damage to the articular cartilage and renders the child with permanent disabilities.

CASE PRESENTATION

A 03-year-old girl has been transferred to a tertiary centre with a history of recurrent pain and swelling of the right knee and on and off limping for six weeks duration. These symptoms were preceded by a history of prick injury to the ipsilateral knee.

CLINICAL FINDINGS & INVESTIGATIONS

The knee was warm to the touch, moderately tender and contains effusion. C-Reactive peptide level series were elevated, Erythrocyte sedimentation rate was 83 mm/1 st hour and White cell count was 10,300/mm3. The ultrasonography revealed suprapatellar bursitis, other investigations such as Antinuclear antibody levels, Rheumatoid factor and Bacterial culture of the aspirate were negative.

INTERVENTIONS & OUTCOME

Arthrotomy and synovectomy performed. While performing synovectomy, an organic thorn has been retrieved from the Hoffa fat pad. The child was treated with intravenous antibiotics for ten days (Co-amoxiclav) and discharged. Her recovery was uneventful and in six weeks she has shown marked improvement of the knee function. Histological examination revealed non-specific chronic synovitis.

RELEVANCE & IMPACT

Chronic synovitis due to foreign body mimicking septic arthritis or causing diagnostic difficulty is a rare entity in the paediatric population. Careful clinical evaluation after creating a good rapport with the child is of utmost importance.

Myositis ossificans of the hip joint causing sciatic nerve palsy following Guillain-barré syndrome: A case report

INTRODUCTION AND IMPORTANCE

Myositis ossificans of the hip is a rare entity caused by trauma and neurological conditions which lead to lamellar bone formation around the joint.

CASE PRESENTATION

We present a 47 years old patient with myositis ossificans of the left and the piriformis muscle following Guillain Barré syndrome causing sciatic nerve palsy (Piriformis syndrome).

CLINICAL DISCUSSION

Clinical assessment revealed global limitation of the left hip movements and palpable bony mass on the lateral aspect of the left hip. Radiographs and computed tomography showed extensive myositis ossificans of the left hip and non-bridging calcification noted on the asymptomatic right side. During initial medical management and physiotherapy patient developed sciatic nerve palsy due to piriformis syndrome and ankylosis of the hip on the left side. Surgical exploration of the sciatic nerve and debridement of the hip. The left hip was found ankylosed and not salvageable. Uncemented total hip arthroplasty was carried out in the session. The patient recovered completely from sciatic nerve palsy and regained the range of motion of the hip. He is under follow-up for the recurrence of myositis ossificans.

CONCLUSION

Guillain-barré syndrome causing piriformis syndrome is a rare entity. Extensive myositis ossificans causing sciatic nerve palsy is even rarer. An awareness of this entity, early detection, and intervention of this condition may help to preserve the native hip.

Bilateral irreducible asymmetrical fracture-dislocation of the hip: A case report and literature review

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Bilateral asymmetrical irreducible fracture-dislocation of hips is a rare entity. Different positions of legs during the impact on them causes asymmetrical hip dislocations. A large amount of energy is required to dislocate both hips, this entity usually associated with other injuries.

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Diagnosis can be suspected clinically and confirmed with radiography. Pre-reduction CT may help if it is not delaying the initial management. Irreducible dislocations mandate the CT to find about the impedance, plan approaches and the fixation if indicated.

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Irreducible hip dislocations warrant an immediate open reduction to avoid avascular necrosis of the femoral head. During open reduction positioning of previously reduced dislocation should be cared for to prevent re-dislocation. Common complications of hip dislocations are avascular necrosis of femoral heads, Myositis ossificans and post-traumatic arthrosis.

Introduction and importance

Bilateral hip dislocation is a rare injury. Bilateral asymmetrical fracture-dislocation is an even rarer type of injury. Apart from its rarity, prompt diagnosis of this condition and emergent treatment is necessary to prevent complications.

Case presentation

Here we present a 32 years old patient admitted with bilateral asymmetrical dislocation of hips following high energy motor traffic accident.

Clinical findings and investigations

Computed tomography revealed bilateral asymmetrical hip dislocations (Left hip anterior dislocation and the right hip posterior dislocation) with a small femoral head fracture on the right side and a large Pipkin I fracture on the left side.

Intervention and outcome

Closed reduction of bilateral hips failed under general anaesthesia and rendered immediate open reduction of both hips through different approaches and fixation of the osteochondral fragment. Rehabilitation was challenging as the patient has been recovering from a head injury and bilateral lower limb involvement. The patient is under follow-up for any evidence of avascular necrosis of the femoral heads and myositis ossificans.

Relevance and impact

Bilateral irreducible asymmetrical fracture-dislocations of the hip joint are rarest of its kind. Pre-operative emergent computed tomography is very helpful to identify fracture-dislocations and help in the planning of osteosynthesis. Preparation for open reduction while undergoing a close reduction is essential.