Acne cream reduces the deep Cutibacterium acnes tissue load before elective open shoulder surgery: a randomized controlled pilot trial

BACKGROUND Cutibacterium acnes is the main pathogen in periprosthetic shoulder infections. In acne vulgaris therapy, benzoyl peroxide-miconazole nitrate cream effectively reduces the superficial C acnes burden of the skin. Its additional potential in the subcutaneous and capsular layers (eg, for prevention of future periprosthetic shoulder infections) is unknown. The aim of this study was to investigate the efficacy of a topical acne vulgaris cream (benzoyl peroxide-miconazole nitrate) to reduce subcutaneous and capsular C acnes in individuals with C acnes skin colonization undergoing open shoulder surgery. METHODS A prospective randomized pilot trial was performed, allocating 60 adult patients (1:1) to either a 7-day preoperative application of a commercial acne cream (benzoyl peroxide-miconazole nitrate) on the preoperative skin (intervention group) or no cream (control group) from November 1, 2018, to May 31, 2020. The superficial skin of the shoulder was sampled at enrollment and before incision, and deep subcutaneous and capsular shoulder samples were taken during surgery. RESULTS Sixty patients (mean age, 59 years; 55% female patients) undergoing primary open shoulder surgery (17 Latarjet procedures and 43 arthroplasties) were included in the study. At baseline, both randomized groups showed the presence of C acnes on the skin at a rate of 60% (18 of 30 patients in intervention group and 19 of 30 patients in control group, P = .79). In patients with C acnes skin colonization, the intervention resulted in a significant reduction in the overall number of intraoperative samples with positive findings compared with the control group (8 of 18 patients vs. 16 of 19 patients, P = .01), especially in capsular samples (0 of 18 patients vs. 4 of 19 patients, P = .04). CONCLUSION The topical 7-day preoperative skin application of acne cream (benzoyl peroxide-miconazole nitrate) significantly reduced the intraoperative C acnes load in 56% of the patients in the intervention group compared with 16% of the control patients

Effectiveness of proximal tibial tubercle transfer in patients with patella baja after total knee arthroplasty

PURPOSE Patella baja after total knee arthroplasty (TKA) is a common problem that is usually treated via proximal transfer of the tibial tubercle. As the long-term outcomes of this procedure are unclarified, this study aimed to investigate the changes in clinical function and radiographic patellar height during five years of follow-up. METHODS Sixty patients with patella baja after TKA who underwent proximalisation of the tibial tubercle were followed up for a mean of 71 months (range 21-153 months). The pre- and postoperative range of motion (ROM) and clinical scores (Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)) were compared. The radiographic patellar height was measured with the Caton-Deschamps index (CDI), Blackburne-Peel ratio (BP), and modified Insall-Salvati index (MIS). RESULTS Proximalisation of the tibial tubercle resulted in a significant improvement in the ROM from 80° to 88°. The KSS and WOMAC did not improve or even worsened after the intervention. The radiographic patellar height immediately after tibial tubercle transfer was not better than prior to the intervention (CDI 0.72 vs. 0.63, p = 0.72; BP 0.66 vs. 0.61, p = 0.72; MIS 1.59 vs. 1.55, p = 1.00) and further decreased significantly so that the mean final values were worse than the values in the native joint (CDI 0.59 vs. 0.78, p = 0.001; BP 0.58 vs. 0.74, p = 0.001; MIS 1.39 vs. 1.81, p < 0.001). CONCLUSION Proximalisation of the tibial tubercle in patients with patella baja after TKA does neither lead to significant improvements in the clinical outcome nor in the radiographic patellar height during long-term follow-up. LEVEL OF EVIDENCE III

Associations of Statin Use with Deep Surgical Site Infections and Late Non-Infectious Revision Surgeries in Patients Undergoing Orthopedic Surgery: A Clinical Cohort Study

Statins have multiple preventive properties. We investigate if a chronic perioperative statin medication for cardiovascular indications reduces deep orthopedic surgical site infections (SSI), and other late non-infectious complications, in adult patients. We performed a single-center cohort of primary orthopedic interventions 2014-2019; with the exclusion of infection surgery and diabetic foot surgery. Group comparisons with Cox regression analyses; with and without propensity-score matching (nearest neighbor approach). We included 20,088 interventions in 20,088 different patients (median age 53 years, 49% females, 5% diabetes mellitus). Among them, 2,486 episodes (12%) revealed a pre-operative statin therapy (222 different brands and doses). After a median follow-up of 11 months, 1,414 episodes needed a surgical revision: 158 (0.8%) due to deep SSI and 1256 (6.3%) for non-infectious reasons. In multivariate Cox regression analyses, statin use was unrelated to both SSI (hazard ratio (HR) 0.9; 95% confidence interval (CI) 0.6-1.4) and non-infectious complications (HR 1.1, 95%CI 0.9-1.3). We equally lacked associations when we associated deep SSIS with statin use for the subgroups of implant-related surgery (HR 0.8, 95%CI 0.4-1.6) or orthroplasties (HR 0.8, 95%CI 0.3-2.6), separately. Likewise, propensity-score matched analyses on the variable “statin” equally failed to alter these outcomes. In our large cohort study with 20,088 orthopedic interventions, we found no protective association of a statin medication on deep SSI risks; or on other late non-infectious complications requiring revision surgery. Keywords statin medication, orthopedic surgery, surgical site infection, revision surgery, epidemiolog

Ulcer occurrence on adjacent toes and hallux valgus deformity after amputation of the second toe in diabetic patients

BACKGROUND Amputation of the second toe is associated with destabilization of the first toe. Possible consequences are hallux valgus deformity and subsequent pressure ulcers on the lateral side of the first or on the medial side of the third toe. The aim of this study was to investigate the incidence and possible influencing factors of interdigital ulcer development and hallux valgus deformity after second toe amputation. METHODS Twenty-four cases of amputation of the second toe between 2004 and 2020 (mean age 68 ± 12 years; 79% males) were included with a mean follow-up of 36 ± 15 months. Ulcer development on the first, third, or fourth toe after amputation, the body mass index (BMI) and the amputation level (toe exarticulation versus transmetatarsal amputation) were recorded. Pre- and postoperative foot radiographs were evaluated for the shape of the first metatarsal head (round, flat, chevron-type), the hallux valgus angle, the first-second intermetatarsal angle, the distal metatarsal articular angle and the hallux valgus interphalangeal angle by two orthopedic surgeons for interobserver reliability. RESULTS After amputation of the second toe, the interdigital ulcer rate on the adjacent toes was 50% and the postoperative hallux valgus rate was 71%. Neither the presence of hallux valgus deformity itself (r = .19, p = .37), nor the BMI (r = .09, p = .68), the shape of the first metatarsal head (r = - .09, p = .67), or the amputation level (r = .09, p = .69) was significantly correlated with ulcer development. The interobserver reliability of radiographic measurements was high, oscillating between 0.978 (p = .01) and 0.999 (p = .01). CONCLUSIONS The interdigital ulcer rate on the first or third toe after second toe amputation was 50% and hallux valgus development was high. To date, evidence on influencing factors is lacking and this study could not identify parameters such as the BMI, the shape of the first metatarsal head or the amputation level as risk factors for the development of either hallux valgus deformity or ulcer occurrence after second toe amputation. TRIAL REGISTRATION BASEC-Nr. 2019-01791

Intraoperative Estimation of the Popeye Sign by Electrical Stimulation of the Musculocutaneous Nerve Following Shoulder Biceps Tenotomy

Younger patients in particular may require biceps tenodesis following tenotomy to avoid the development of a biceps "Popeye deformity." It is, however, difficult to predict whether a tenodesis is cosmetically necessary, since this deformity develops to a very variable degree, as the biceps muscle will retract in the postoperative course to an unknown amount with active contraction. Through the intraoperative electrical stimulation of the musculocutaneous nerve, the maximal contraction of the muscle can intraoperatively be provoked and thus the amount of Popeye deformity becomes apparent. We conclude that this method could be useful for intraoperative decision making if biceps tenodesis is needed and helps to avoid this surgical step and its associated risks, which otherwise often is performed unnecessarily, just in case

Long-term results of Sauvé-Kapandji procedure

The Sauvé-Kapandji procedure is an established treatment option for distal radioulnar joint dysfunction. We retrospectively analysed 36 patients following Sauvé-Kapandji procedure between 1997 and 2013. Fifteen patients were available for a follow-up after a mean of 13 years (range 6 to 23). Six patients needed revision surgery because of ulnar stump instability. Radiographs and sonography were performed to quantify the instability of the proximal ulnar stump. These showed a radioulnar convergence of 8 mm without weight and 2 mm while lifting 1 kg. Sonographically, the proximal ulnar stump dislocated by 8 mm to the volar side while applying pressure to the palm, compared with 4 mm on the contralateral side. Sonographically measured ulnar stump instability showed a positive strong correlation with the Disabilities of the Arm, Shoulder and Hand questionnaire and Patient-Reported Wrist Evaluations and a negative strong correlation with grip strength and supination torque. Because of the high incidence of revision surgery due to instability of the proximal ulnar stump, we restrict the use of the Sauvé-Kapandji procedure only to very selected cases.Level of evidence: IV

Deep surgical site infections following double-dose perioperative antibiotic prophylaxis in adult obese orthopedic patients

BACKGROUND Obesity is a risk factor for surgical site infections (SSI). Based on retrospective comparisons and pharmacology, many orthopedic centers have adopted weight- or body mass index (BMI)-related antibiotic prophylaxis. METHODS Double-dose prophylaxis was introduced in March 2017 for patients weighting >80 kg. The period April 2014 to March 2017 ('before') was compared to the period March 2017 to June 2019 ('after') regarding the impact on deep SSIs. RESULTS A total of 9318 surgeries 'before' were compared to 7455 interventions 'after' the introduction of double-dose prophylaxis. Baseline demographic characteristics (age, sex, BMI, American Society of Anesthesiologists score, and duration of surgery) were similar. In the period 'after', 3088 cases (3088/16 773; 18%) received double-dose prophylaxis. Overall, 82 deep SSIs were observed (0.5%). The pathogens were resistant to the standard cefuroxime prophylaxis in 30 cases (30/82; 37%). Excluding these prophylaxis-resistant cases and all of the five hematogenous SSIs, the remaining 47 SSIs (57%) could have been prevented by the preceding prophylaxis. Double-dosing of parenteral cefuroxime from 1.5 g to 3.0 g in obese patients did not reduce deep SSIs (hazard ratio 0.7, 95% confidence interval 0.3-1.6). In the direct group comparison among obese patients >80 kg, the double-dose prophylaxis equally failed to alter the SSI risk (3088/16 726 non-infections vs 8/47 SSI despite double-dose prophylaxis; Chi-square test, P = 0.78). CONCLUSIONS In this single-center before-and-after study with almost 17 000 orthopedic surgeries in adult patients, systemic doubling of the perioperative antibiotic prophylaxis in obese patients clinically failed to reduce the overall deep SSI risk

Axillary nerve elongation in humeral fracture plating: A cadaveric study for comparison between straight and helical Philos plates

Helical plating is a known concept in humeral fracture treatment. Attention should be paid to the axillary nerve when inserting a plate underneath the deltoid muscle. The purpose of this cadaveric study was to estimate axillary nerve stretching when introducing the plate. METHODS: On 42 fresh frozen human humeri, an 8-, 10- and 12-hole Philos plate in a straight and a helical shape were compared measuring the maximum plate-bone-distance. RESULTS: For all three plate lengths, the helical plates had a significantly lower plate-bone-distance. CONCLUSION: Indirectly, this suggests a lower axillary nerve elongation and hence less chance of nerve damage.status: publishe