In vivo pharmacokinetics of a gentamicin-loaded collagen sponge in acute periprosthetic infection - Serum values in 19 patients

Background The in vivo pharmacokinetics of gentamycin- loaded collagen fleeces in humans have not been described in the current literature. We therefore analyzed in vivo pharmacokinetics of these fleeces when used in the treatment of periprosthetic infections. Patients and methods Gentamycin concentrations were measured in 19 consecutive patients with an acute periprosthetic infection. Each patient received 2-5 fleeces (130 mg gentamycin/fleece). Results Initially, the blood concentration increased to 3.2-7.2 mg/L, depending on the number of fleeces that were applied. The serum peak concentrations resulted in peak/MIC ratios of 2.5-36 for P. aeruginosa, S. aureus, and Klebsiella spp. Subsequently, the serum values decreased almost linearly below 0.3 mg/L in 18 to 62 hours. After 24 hours, the serum levels of gentamicin dropped below 2 mg/L, the toxicity threshold. Interpretation The application of 2 to 5 130-mg gentamycin-loaded collagen fleeces may be useful as an adjuvant treatment for implant-related infections, since no toxic concentrations were measured 24 hours postoperatively

Minimally Invasive versus Classic Procedures in Total Hip Arthroplasty: A Double-blind Randomized Controlled Trial

BACKGROUND: For total hip arthroplasty (THA), minimally invasive surgery (MIS) uses a smaller incision and less muscle dissection than the classic approach (CLASS), and may lead to faster rehabilitation. QUESTIONS/PURPOSES: Does minimally invasive hip arthroplasty result in superior clinical outcomes? PATIENTS AND METHODS: In this double-blind randomized controlled trial, 120 consecutive primary noncemented THAs in 120 patients were assigned to one of two groups (MIS or CLASS). The randomization sequence was stratified for two groups of surgeons, ie, those using a posterolateral approach (PL-CLASS or PL-MIS) and those using an anterolateral approach (AL-CLASS or AL-MIS). Length of the incisions was 18 cm for the CLASS procedures. MIS incisions were extended at the skin level to 18 cm at the end of the procedure. The primary end point was the Harris hip score (HHS) at 6 weeks postoperatively. Patient-centered questionnaires were obtained preoperatively and after 6 weeks and 1 year. RESULTS: For the patients in the MIS group (average 7.8 cm incision length), statistically significant increased mean HHSs were seen compared with the CLASS group at 6 weeks and 1 year. This difference was small and mainly caused by the favorable results of the PL-MIS. In the MIS group, surgical time was longer. A learning curve was observed based on operation time and complication rate. Although not statistically significant, the perioperative complication rate was rather high in the (anterolateral) MIS group. CONCLUSIONS: The minimal invasive approach in THA did not show a clinically relevant superior outcome in the first postoperative year. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidenc

Effectiveness of multidisciplinary nutritional care on nutritional intake, nutritional status and quality of life in patients with hip fractures: a controlled prospective cohort study

The purpose of this study was to determine the effectiveness of a multidisciplinary intervention program on nutritional intake and of nutritional intake on nutritional status and quality of life in older patients treated for a hip fracture. A controlled prospective cohort study included 66 patients in the control group and 61 patients in the intervention group, aged over 65 and sustaining a hip fracture with subsequent operative intervention. Postoperatively, the control group received standard nutritional care and the intervention group multidisciplinary nutritional care that focused on nutritional support during hospitalisation and a transfer of nutritional care after discharge. Nutrient intakes were monitored with food records. Nutritional status was determined by the Mini Nutritional Assessment (MNA), and bioelectrical impedance analysis was used to assess body cell mass (BCM). The EuroQol (EQ-5D) was used to assess quality of life. Patients were evaluated at admission and three months postoperatively. There was a significant difference in the daily energy intake of patients between both groups during the first seven days postoperatively: 1127 kcal (±309) in the control group and 1292 kcal (±280) (P = 0.002) in the intervention group. Mean protein intake in the intervention group (57 g (±12)) was significantly higher than in the control group (48 g (±14), P = 0.000). The intervention group demonstrated a significantly lower reduction of EQ-5D index scores compared with the control group (P = 0.004) after three months. At three months, significantly fewer patients in the intervention group were classified as malnourished or at risk of malnutrition. Among elderly patients with a hip fracture, a multidisciplinary postoperative approach of nutritional care was associated with an increase of energy and protein intake during hospitalisation. After three months follow-up there were fewer malnourished patients in the intervention group, and the decline in quality of life was lower than in the control group. There were no advantages of multidisciplinary nutritional care on body cell mas

Long-term outcomes of the Bi-Metric proximally hydroxyapatite-coated femoral stem

Purpose: Promising clinical results and survival rates have been reported for the Bi-Metric proximally hydroxyapatite(HA)-coated femoral stem in short-and mid-term studies. In this study we evaluated the long-term survival as well as clinical and radiological results of this stem. Methods: From 1992 to 1998 we prospectively included 112 consecutive patients who received a total hip arthroplasty (THA) with an uncemented proximally HA-coated Bi-Metric femoral component (Biomet). At 3 months, 1 year and thereafter every 2 to 3 years, patients were clinically and radiologically monitored. Primary endpoint was revision of the stem for any reason. Secondary endpoints were survival of the cup and THA, radiological characteristics and clinical scores (HHS, HOOS, SF-36 and VAS). Results: Median follow-up was 20 (16-22.25) years. Median age at surgery was 52 (22-63) years. At final follow-up, survival analysis showed an all-cause stem survival of 96.8% (95% CI, 93.3-100). Median HHS scores improved from 57 preoperatively to 94 at final follow-up (p Conclusions: In this prospective cohort study the 20-year survival rate of the Bi-Metric proximally HA-coated femoral stem was excellent

No difference in bacterial contamination of hip capsule sutures and control sutures in hip arthroplasty surgery

Abstract Background Perioperative preventive measures are important to further reduce the rate of periprosthetic joint infections (PJI) in patients undergoing total hip arthroplasty (THA). During THA surgery, joint capsule sutures are commonly placed to optimize exposure and reinsertion of the capsule. Bacterial contamination of these sutures during the procedure poses a potential risk for postoperative infection. In this exploratory study, we assessed the contamination rate of capsule sutures compared to the contamination of the remains of exchanged control sutures at the time of closure. Methods In 100 consecutive patients undergoing primary THA capsule sutures were exchanged by sterile sutures at the time of capsule closure. Both the original sutures and the remainder of the newly placed (control) sutures were retrieved, collected and cultured for ten days. Types of bacterial growth and contamination rates of both sutures were assessed. Results Sutures from 98 patients were successfully collected and analyzed. Bacterial growth was observed in 7/98 (7.1%) of the capsule sutures versus 6/98 (6.1%) of the control sutures, with a difference of 1% [CI -6–8]. There was no clear pattern in differences in subtypes of bacteria between groups. Conclusions This study showed that around 7% of capsule sutures used in primary THA were contaminated with bacteria and as such exchange by new sutures at the time of capsule closure could be an appealing PJI preventive measure. However, since similar contamination rates were encountered with mainly non-virulent bacteria for both suture groups, the PJI preventive effect of this measure appears to be minimal

Efficacy of different preoperative skin antiseptics on the incidence of surgical site infections: a systematic review, GRADE assessment, and network meta-analysis

Background: Surgical site infection (SSI) is the most common postoperative complication and substantially increases health-care costs. Published meta-analyses and international guidelines differ with regard to which preoperative skin antiseptic solution and concentration has the highest efficacy. We aimed to compare the efficacy of different skin preparation solutions and concentrations for the prevention of SSIs, and to provide an overview of current guidelines. Methods: This systematic review and network meta-analysis compared different preoperative skin antiseptics in the prevention of SSIs in adult patients undergoing surgery of any wound classification. We searched for randomised controlled trials (RCTs) in MEDLINE, Embase, and Cochrane CENTRAL, published up to Nov 23, 2021, that directly compared two or more antiseptic agents (ie, chlorhexidine, iodine, or olanexidine) or concentrations in aqueous and alcohol-based solutions. We excluded paediatric, animal, and non-randomised studies, and studies not providing standard preoperative intravenous antibiotic prophylaxis. Studies with no SSIs in both groups were excluded from the quantitative analysis. Two reviewers screened and reviewed eligible full texts and extracted data. The primary outcome was the occurrence of SSI (ie, superficial, deep, and organ space). We conducted a frequentist random effects network meta-analysis to estimate the network effects of the skin preparation solutions on the prevention of SSIs. A risk-of-bias and Grading of Recommendations, Assessment, Development, and Evaluation assessment were done to determine the certainty of the evidence. This study is registered with PROSPERO, CRD42021293554. Findings: Overall, 2326 articles were identified, 33 studies were eligible for the systematic review, and 27 studies with 17 735 patients reporting 2144 SSIs (overall incidence of 12·1%) were included in the quantitative analysis. Only 2·0–2·5% chlorhexidine in alcohol (relative risk 0·75, 95% CI 0·61–0·92) and 1·5% olanexidine (0·49, 0·26–0·92) significantly reduced the rate of SSIs compared with aqueous iodine. For clean surgery, we found no difference in efficacy between different concentrations of chlorhexidine in alcohol. Seven RCTs were at high risk of bias, 24 had some concerns, and two had low risk of bias. Heterogeneity across the studies was moderate (I2=27·5%), and netsplitting did not show inconsistencies between direct and indirect comparisons. Five of ten studies that mentioned adverse events related to the skin preparation solutions reported no adverse events, and five reported a total of 56 mild events (mainly erythema, pruritus, dermatitis, skin irritation, or mild allergic symptoms); none reported a substantial difference in adverse events between groups. Interpretation: For adult patients undergoing a surgical procedure of any wound classification, skin preparation using either 2·0–2·5% chlorhexidine in alcohol or 1·5% olanexidine is most effective in the prevention of SSIs. For clean surgery, no specific concentration of chlorhexidine in alcohol can be recommended. The efficacy of olanexidine was established by a single randomised trial and further investigation is needed. Funding: Dutch Association for Quality Funds Medical Specialists