Prosthetic joint infection and wound leakage after the introduction of intraoperative wound irrigation with a chlorhexidine-cetrimide solution: a large-scale before-after study

Background: Intraoperative chlorhexidine irrigation could be a valuable additive to systemic antibiotics to prevent infections after total joint arthroplasties. However, it may cause cytotoxicity and impair wound healing. This study evaluates the incidence of infection and wound leakage before and after the introduction of intraoperative chlorhexidine lavage.Methods: All 4453 patients receiving a primary hip or knee prosthesis between 2007 and 2013 in our hospital were retrospectively included. They all underwent intraoperative lavage before wound closure. Initially, wound irrigation with 0.9% NaCl was standard care (n = 2271). In 2008, additional irrigation with a chlorhexidine-cetrimide (CC) solution was gradually introduced (n = 2182). Data on the incidence of prosthetic joint infections and wound leakage, as well as relevant baseline and surgical characteristics, were derived from medical charts. Chi-square analysis was used to compare the incidence of infection and wound leakage between patients with and without CC irrigation. Multivariable logistic regression was used to assess robustness of these effects by adjusting for potential confounders.Results: The prosthetic infection rate was 2.2% in the group without CC irrigation vs 1.3% in the group with CC irrigation (P = .021). Wound leakage occurred in 15.6% of the group without CC irrigation and in 18.8% of the group with CC irrigation (P = .004). However, multivariable analyses showed that both findings were likely due to confounding variables, rather than by the change in intraoperative CC irrigation.Conclusions: Intraoperative wound irrigation using a CC solution does not seem to affect the risk of prosthetic joint infection or wound leakage. Observational data easily yield misleading results, so prospective randomized studies are needed to verify causal inference. Level of Evidence: Level IIIduncontrolled before and after the study.(c) 2022 The Authors. Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).Orthopaedics, Trauma Surgery and Rehabilitatio

Digital medical history implementation to triage orthopaedic patients during COVID-19: findings from a rapid cycle, semi-randomised A/B testing quality improvement project

Introduction: The COVID-19 pandemic severely impacted musculoskeletal care. To better triage the notable backlog of patients, we assessed whether a digital medical history (DMH), a summary of health information and concerns completed by the patient prior to a clinic visit, could be routinely collected and utilised.Methods: We analysed 640 patients using a rapid cycle, semi-randomised A/B testing approach. Four rapid cycles of different randomised interventions were conducted across five unique patient groups. Descriptive statistics were used to report DMH completion rates by cycle/patient group and intervention. Multivariable logistic regression was used to determine whether age or anatomic injury location was associated DMH completion.Ethical Approval: N/A (Quality Improvement Project)Results: Across all patients, the DMH completion rate was 48% (307/640). Phone calls were time consuming and resource intensive without an increased completion rate. The highest rate of DMH completion was among patients who were referred and called the clinic themselves (78% of patients [63 out of 81 patients]). Across all patients, increasing age (odds ratio [OR]: 0.985 (95% CI: 0.976-0.995), p = 0.002), patients with back concerns (OR: 0.395 (95% CI: 0.234-0.666), p = 0.001), and patients with non-specific/other musculoskeletal concerns (OR: 0.331 (95% CI: 0.176-0.623), p = 0.001) were associated with decreased odds of DMH completion.Discussion and Conclusion: DMHs can be valuable in helping triage orthopaedic patients in resource-strapped settings, times of crisis, or as we transition towards value-based health care delivery. However, further work is needed to continue to increase the completion rate about 50%.Orthopaedics, Trauma Surgery and Rehabilitatio

Bone regeneration based on growth factor releasing polymer composites

Overall, this thesis clearly highlights the potential of polymeric composites as growth factor delivering scaffolds for bone regeneration. It shows that polymeric microspheres can be used to locally deliver growth factors from the composite while maintaining their bioactivity. The diversity of physicochemical properties of polymers allows tailoring of the growth factor release profile from the delivery vehicle and the creation of a construct capable of releasing two growth factors independent from each other. These features provide the research community with excellent tools to identify the optimal amounts, ratio, timing and release sequence of various growth factors and will help optimizing the bone regeneration process to ensure consistent success for future clinical applications

Bone regeneration based on growth factor releasing polymer composites

Overall, this thesis clearly highlights the potential of polymeric composites as growth factor delivering scaffolds for bone regeneration. It shows that polymeric microspheres can be used to locally deliver growth factors from the composite while maintaining their bioactivity. The diversity of physicochemical properties of polymers allows tailoring of the growth factor release profile from the delivery vehicle and the creation of a construct capable of releasing two growth factors independent from each other. These features provide the research community with excellent tools to identify the optimal amounts, ratio, timing and release sequence of various growth factors and will help optimizing the bone regeneration process to ensure consistent success for future clinical applications

Growth factor interactions in bone regeneration

Growth factor interactions in bone regeneration. Diederik H R Kempen, Laura B Creemers, Jacqueline Alblas, Lichun Lu, Abraham J Verbout, Michael J Yaszemski and Wouter J A Dhert 1 Department of Orthopedics, University Medical Center , Utrecht, The Netherlands . AbstractBuy the PDF Pubmed abstract Get permission Buy the PDF Suppl. info HTML version PMID: 21039299 Bone regeneration is a complex process regulated by a large number of bioactive molecules. Many growth factors and cytokines involved in the natural process of bone healing have been identified and tested as potential therapeutic candidates to enhance the regeneration process. Although many of these studies show an enhancement of the bone regeneration process by a single drug therapy, in vivo bone regeneration is the result of a complex interplay between the applied growth factor and various endogenous produced growth factors. To investigate these growth factor interactions, various studies have investigated the effect of growth factor combinations on bone regeneration. This review provides an overview of the growth factor and cytokine combinations tested in translational bone regeneration studies and shows that their interaction may result in an enhancement or inhibition of bone formation

Effect of Autologous Bone Marrow Stromal Cell Seeding and Bone Morphogenetic Protein-2 Delivery on Ectopic Bone Formation in a Microsphere/Poly(Propylene Fumarate) Composite

A biodegradable microsphere/scaffold composite based on the synthetic polymer poly(propylene fumarate) (PPF) holds promise as a scaffold for cell growth and sustained delivery vehicle for growth factors for bone regeneration. The objective of the current work was to investigate the in vitro release and in vivo bone forming capacity of this microsphere/scaffold composite containing bone morphogenetic protein-2 (BMP-2) in combination with autologous bone marrow stromal cells (BMSCs) in a goat ectopic implantation model. Three composites consisting of 0, 0.08, or 8 μg BMP-2 per mg of poly(lactic-co-glycolic acid) microspheres, embedded in a porous PPF scaffold, were combined with either plasma (no cells) or culture-expanded BMSCs. PPF scaffolds impregnated with a BMP-2 solution and combined with BMSCs as well as empty PPF scaffolds were also tested. The eight different composites were implanted subcutaneously in the dorsal thoracolumbar area of goats. Incorporation of BMP-2–loaded microspheres in the PPF scaffold resulted in a more sustained in vitro release with a lower burst phase, as compared to BMP-2–impregnated scaffolds. Histological analysis after 9 weeks of implantation showed bone formation in the pores of 11/16 composites containing 8 μg/mg BMP-2–loaded microspheres with no significant difference between composites with or without BMSCs (6/8 and 5/8, respectively). Bone formation was also observed in 1/8 of the BMP-2–impregnated scaffolds. No bone formation was observed in the other conditions. Overall, this study shows the feasibility of bone induction by BMP-2 release from microspheres/scaffold composites