Surgical and patient-reported outcomes after total knee arthroplasty requiring soft tissue flap reconstruction – A 12-year experience from high-volume arthroplasty hospital

Publisher Copyright: © 2022 Elsevier LtdBackground: This study investigates the outcomes of complex knee joint reconstructions performed by an orthoplastic surgery team at a tertiary referral hospital. Methods: Retrospective review of all the total knee arthroplasty (TKA)/revision TKA (rTKA) procedures with soft tissue flap reconstruction performed between 2008 and 2019 was conducted. Patients were stratified into two groups according to the urgency of surgery: scheduled non-complicated (SNC) and emergent complicated (EC). The whole study cohort was also categorized into non-infected and infected groups. Results: Of 20,184 TKAs operated, 58 patients required flap reconstruction (SNC group n = 27; EC group n = 31). The most common reconstruction was medial gastrocnemius flap (74%). Mean follow-up time was 31.9 months. Functional knee joint salvage was achieved in 96.3% the SNC group and in 80.6% the EC group patients (p = 0.07). Transfemoral amputation rates were 3.7% in the SNC group vs. 6.5% in the EC group (p = 0.36). Oxford Knee Score was 34.5 vs. 25.5 (p = 0.21), and range of motion was 100⁰ vs. 93⁰ (p = 0.37) in the SNC and EC groups, respectively. Superior functional knee joint salvage rates were achieved in the non-infected group compared to the infected group (97.1% vs. 75.0%, p = 0.004). However, the transfemoral amputation rate was nearly three-fold in the infected group (8.3% vs. 2.9%, p = 0.36). Estimated five-year survival with functional knee joint was higher in the non-infected group (p = 0.03). Conclusions: Both the SNC and EC groups had similar acceptable limb salvage rates, and functional and PROM outcomes. Infection reduces the probability of a functional knee joint after TKA and flap reconstruction.Peer reviewe

Clinical Outcomes After Revision Hip Arthroplasty due to Prosthetic Joint Infection - A Single-Center Study of 369 Hips at a High-Volume Center with a Minimum of One Year Follow-up

BACKGROUND: Prosthetic joint infection (PJI) treatment decisions are traditionally based on treatment algorithms. There is, however, a lack of evidence to support the choice of these treatment algorithms. Therefore, we aimed to assess the one-year survival after PJI revision and compared different surgical strategies in a single-center setting. METHODS: Revisions of the hip due to PJI performed at our institution between January 2008 and September 2021 with at least one-year of follow-up were identified. In total, 134 debridement, antibiotics, and implant retentions (DAIRs), 114 one-stage revisions, and 121 two-stage revisions were performed. Infections were classified as early, acute hematogenous, and chronic. Survival was calculated using the Kaplan-Meier method and cumulative incidence function. Predictors of outcomes were examined with Fine-Gray regressions and Cox proportional hazards regressions. Subdistribution hazard ratios and hazard ratios (HR) with 95% confidence intervals (CIs) were calculated. RESULTS: At one-year follow-up, 26.6% (CI 22.2-31.2%) of the patients had undergone reoperation and 7.9% (CI 5.4-10.9%) had died. The risk for reoperation was highest after DAIR (36.6%, CI 28.5-44.7%) and lowest after one-stage revision (20.2%, CI 13.4-28%). Within the early infections, the one-stage revision almost halved the risk of reoperation (HR 0.51, CI 0.31-0.84) with no added mortality risk (HR 1.05, CI 0.5-2.2), when compared to DAIR. CONCLUSION: By utilizing 1-stage revision over DAIR in early infections, it might be possible to improve the prognosis by decreasing the risk of reoperation without increasing mortality. However, as the patient selection is undeniably difficult, more research is warranted.Peer reviewe

Trends in Revision Knee Arthroplasty for Prosthetic Joint Infection : A Single-Center Study of 384 Knees at a High-Volume Center between 2008 and 2021

BACKGROUND: Prosthetic joint infection (PJI) is one of the most devastating complications after total knee arthroplasty (TKA), and comorbidities increase the risk. We examined whether a temporal change has occurred in the demographics, especially regarding comorbidities, of patients who have PJI and were treated at our institution over a 13-year study period. In addition, we assessed the surgical methods used and the microbiology of the PJIs. METHODS: Revisions (n=384, 377 patients) due to PJI of the knee performed at our institution between 2008 and September 2021 were identified. All included PJIs fulfilled the 2013 International Consensus Meeting diagnostic criteria. The surgeries were categorized into one of the following categories: debridement, antibiotics, and retention (DAIR), one-stage revision, and two-stage revision. Infections were classified as early, acute hematogenous, and chronic. RESULTS: No changes in the median age of the patients nor comorbidity burden were observed during the study period. However, the proportion of two-stage revisions decreased remarkably from 57.6% in 2008 to 2009 to 6.3% in 2020 to 2021. A DAIR was the most used treatment strategy, but the proportion of one-stage revisions increased the most. In 2008 to 2009, 12.1% of the revisions were one-stage, but in 2020 to 2021, the proportion was 43.8%. The most common pathogen was Staphylococcus aureus (27.8%). CONCLUSIONS: The comorbidity burden remained at the same level with no trends. A DAIR was the most used strategy, but the proportion of one-stage revisions rose to almost the same level. The incidence of PJI varied between the years, but remained relatively low.Peer reviewe

Fungemia and other Fungal Infections Associated with Use of Saccharomyces boulardii Probiotic Supplements

Because of widespread use of probiotics, their safety must be guaranteed. We assessed use of Saccharomyces boulardii probiotic yeast from medical records for patients who had Saccharomyces fungemia or other clinical Saccharomyces culture findings. We evaluated all Saccharomyces sp. findings at 5 university hospitals in Finland during 2009-2018. We found 46 patients who had Saccharomyces fungemia; at least 20 (43%) were using S. boulardii probiotic. Compared with a control group that had bacteremia or candidemia, the odds ratio for use of an S. boulardii probiotic was 14 (95% CI 4-44). Of 1,153 nonblood culture findings, the history for 125 patients was checked; at least 24 (19%) were using the probiotic (odds ratio 10, 95% CI 3-32). This study adds to published fungemia cases linked to use of S. boulardii probiotic and sheds light on the scale of nonblood Saccharomyces culture findings that are also linked to use of this probiotic.Peer reviewe

Fungemia and Other Fungal Infections Associated with Use of Saccharomyces boulardii Probiotic Supplements

Because of widespread use of probiotics, their safety must be guaranteed. We assessed use of Saccharomyces boulardii probiotic yeast from medical records for patients who had Saccharomyces fungemia or other clinical Saccharomyces culture findings. We evaluated all Saccharomyces sp. findings at 5 university hospitals in Finland during 2009–2018. We found 46 patients who had Saccharomyces fungemia; at least 20 (43%) were using S. boulardii probiotic. Compared with a control group that had bacteremia or candidemia, the odds ratio for use of an S. boulardii probiotic was 14 (95% CI 4–44). Of 1,153 nonblood culture findings, the history for 125 patients was checked; at least 24 (19%) were using the probiotic (odds ratio 10, 95% CI 3–32). This study adds to published fungemia cases linked to use of S. boulardii probiotic and sheds light on the scale of nonblood Saccharomyces culture findings that are also linked to use of this probiotic.</p

Genetic Susceptibility to Non-Necrotizing Erysipelas/Cellulitis

Peer reviewe

An outbreak of Streptococcus equi subspecies zooepidemicus associated with consumption of fresh goat cheese

BACKGROUND: Streptococcus equi subspecies zooepidemicus is a rare infection in humans associated with contact with horses or consumption of unpasteurized milk products. On October 23, 2003, the National Public Health Institute was alerted that within one week three persons had been admitted to Tampere University Central Hospital (TaYS) because of S. equi subsp. zooepidemicus septicaemia. All had consumed fresh goat cheese produced in a small-scale dairy located on a farm. We conducted an investigation to determine the source and the extent of the outbreak. METHODS: Cases were identified from the National Infectious Disease Register. Cases were persons with S. equi subsp. zooepidemicus isolated from a normally sterile site who had illness onset 15.9-31.10.2003. All cases were telephone interviewed by using a standard questionnaire and clinical information was extracted from patient charts. Environmental and food specimens included throat swabs from two persons working in the dairy, milk from goats and raw milk tank, cheeses made of unpasteurized milk, vaginal samples of goats, and borehole well water. The isolates were characterized by ribotyping and pulsed-field gel electrophoresis (PFGE). RESULTS: Seven persons met the case definition; six had septicaemia and one had purulent arthritis. Five were women; the median age was 70 years (range 54–93). None of the cases were immunocompromized and none died. Six cases were identified in TaYS, and one in another university hospital in southern Finland. All had eaten goat cheese produced on the implicated farm. S. equi subsp. zooepidemicus was isolated from throat swabs, fresh goat cheese, milk tank, and vaginal samples of one goat. All human and environmental strains were indistinguishable by ribotyping and PFGE. CONCLUSION: The outbreak was caused by goat cheese produced from unpasteurized milk. Outbreaks caused by S. equi subsp. zooepidemicus may not be detected if streptococcal strains are only typed to the group level. S. equi subsp. zooepidemicus may be a re-emerging disease if unpasteurized milk is increasingly used for food production. Facilities using unpasteurized milk should be carefully monitored to prevent this type of outbreaks

Akuutti ja uusiutuva ruusutulehdus

Akuutti ja uusiutuva ruusutulehdus Ruusutulehdus on akuutti ihon ja ihonalaiskudosten bakteeri-infektio. Siitä käytetään myös nimityksiä erysipelas, selluliitti tai, kuten Suomessa yleisesti on tapana, ruusu. Ruusutulehdus sijaitsee tyypillisesti alaraajassa, yleensä sääressä. Se voi tulla myös yläraajaan, kasvoihin tai muulle ihoalueelle. β-hemolyyttisiä streptokokkeja, erityisesti A-ryhmän streptokokkeja (GAS), on pidetty pääasiallisina taudinaiheuttajina. Stafylokokkien merkitys ruusutulehduksessa on epäselvä. Streptokokkitaudeissa penisilliini on ensisijainen antibioottivalinta, mutta stafylokokit ovat nykyisin pääsääntöisesti resistenttejä tavalliselle penisilliinille. Ruusutulehdukselle on tyypillistä sen uusiutuminen. Aiemmissa tutkimuksissa uusiutumisriski on ollut noin 10 % vuodessa. Uusiutumiseen vaikuttavia tekijöitä ei tunneta tarkasti. Todennäköisesti kuitenkin samat tekijät, jotka liittyvät akuuttiin ruusutulehdukseen, altistavat myös sen uusiutumiselle. Tutkimuksen tarkoituksena oli selvittää ruusutulehdukseen ja sen uusiutumiseen liittyviä tekijöitä, ns. kliinisiä riskitekijöitä. Bakteeriviljelyillä etsittiin streptokokkeja ja stafylokokkeja ja vasta-ainemäärityksillä tutkittiin näiden osuutta ruusutulehduksen aiheuttajina. Lisäksi selvitettiin tulehdusmerkkiaineiden merkitystä ruusutulehduksen uusiutumisriskin arvioimisessa. Tutkimuksen ensimmäisessä osassa tutkittiin akuuttiin ruusutulehdukseen liittyviä riskitekijöitä ja bakteereja 90:llä akuutin ruusutulehduksen vuoksi sairaalahoitoon otetulla potilaalla ja 90:llä väestörekisteristä poimitulla verrokilla. Krooninen turvotus ylä- tai alaraajoissa, ihorikot ja ylipaino liittyivät ruusutulehdukseen. Potilaiden iholta eristettiin sekä streptokokkeja että stafylokokkeja, mutta vasta-ainemääritysten perusteella streptokokki oli todennäköisin taudinaiheuttaja ainakin 69 %:ssa tapauksista. G-ryhmän streptokokki (GGS) oli selvästi yleisempi löydös kuin GAS. Kun havainnot bakteeriviljelyistä, vasta-ainetutkimuksista ja penisilliinihoidon onnistumisesta yhdistettiin, streptokokit näyttivät olevan todennäköisin taudinaiheuttaja 84 %:ssa tapauksista. Tutkimuksen toisessa osassa em. potilaisiin otettiin yhteyttä viiden vuoden kuluttua alkuperäisestä tutkimustilanteesta. Puhelinhaastattelun ja potilaskertomusten perusteella todettiin, että ruusutulehdus oli uusiutunut seuranta-aikana ainakin kerran 41 %:lla potilaista. Jos tutkimukseen alun perin johtanut ruusutulehdusepisodi oli potilaan ensimmäinen, uusiutumisen riski viidessä vuodessa oli 26 %. Jos potilas oli sairastanut ruusutulehduksen ainakin kerran ennen tutkimusjaksoa, riski oli 57 %. Mikään muu tutkituista kliinisistä riskitekijöistä ei ennustanut uusiutumista. Tulehdusreaktion voimakkuutta sairaalahoidon aikana arvioitiin C-reaktiivisen proteiinin ja pentraksiini-3:n pitoisuuksien sekä kuumeen ja sairaalahoidon keston perusteella. Niillä, joilla tutkimukseen tullessa oli jo uusiutunut ruusutulehdus, oli voimakkaampi tulehdusreaktio kuin niillä joilla ruusutulehdus oli ensimmäinen. Tulehdusreaktion voimakkuus ei kuitenkaan ennustanut ruusutulehduksen uusiutumista viiden vuoden seuranta-aikana. Kolmannessa osassa selvitettiin uusiutuvan ruusutulehduksen riskitekijöitä kyselylomakkeella 398 potilaalta, jotka saivat penisilliiniestohoitoa uusiutuvan ruusutulehduksen vuoksi. Näitä verrattiin 8005 suomalaisen tietoihin, jotka oli kerätty Kansanterveyslaitoksen (nyk. THL) Terveys 2000 – tutkimuksessa. Tilastollisen monimuuttuja-analyysin perusteella riskitekijöitä olivat krooniset ihosairaudet ja erityisesti psoriasis, diabetes, iän karttuminen ja painoindeksin kohoaminen sekä nielurisojen poisto. Yhteenvetona voidaan todeta, että streptokokit ja erityisesti GGS ovat todennäköisimmät taudinaiheuttajat valtaosassa ruusutulehduksista. On kuitenkin huomattava, että märkäiset tulehdukset kuten paiseet ja haavainfektiot oli suljettu pois tutkimuksesta. Näissä stafylokokit ovat tunnetusti yleisimmät taudinaiheuttajat. Krooninen turvotus, ihorikkoumat ja ylipaino ovat akuutin ruusutulehduksen riskitekijöitä. On todennäköistä, että nämä riskitekijät altistavat myös ruusutulehduksen uusiutumiselle samoin kuin diabetes, psoriasis ja iän karttuminen. Uusiutumisriski on kuitenkin yli kaksinkertainen jo uusiutuneen ruusutulehduksen jälkeen verrattuna ensimmäiseen episodiin. Tulehdusreaktion voimakkuus akuutin ruusutulehduksen yhteydessä ei ennusta ruusutulehduksen uusiutumista. Tutkimuksen ensimmäisessä ja toisessa osassa potilaat olivat sairaalan vuodeosastolle hoitoon otettuja potilaita. Täten tutkimus ei kattanut kaikkein lievimpiä ja toisaalta vakavimpia, esimerkiksi tehohoitoon johtaneita taudintapauksia. Tuloksia ei siis voi suoraan yleistää näihin potilasryhmiin.Acute bacterial non-necrotising cellulitis, or erysipelas, is an acute infection of the dermis and subcutaneous tissue with a tendency to recur. Erysipelas is mentioned already in ancient medical writings. There is considerable variation in the terminology regarding erysipelas and cellulitis. In the present study, cellulitis denotes acute, non- suppurative, superficial skin infection of presumed bacterial origin. This definition excludes abscesses, suppurative wound infections, and necrotising infections. Cellulitis most typically occurs in in the leg, and less often in the upper extremity, in the face, or other parts of the body. β-haemolytic streptococci (BHS) are considered the main causative bacteria associated with cellulitis. Penicillin is the treatment of choice in most cases. The majority of cellulitis patients are probably treated as outpatients. The aim of the present study was to assess clinical risk factors for acute and recurrent cellulitis, to study the bacterial aetiology of cellulitis and characterize BHS associated with cellulitis. Also, the value of clinical features and inflammatory markers in predicting further recurrence was investigated. A case control study was conducted comprising 90 patients hospitalized due to cellulitis and 90 population controls, matched by age and sex. Demographical data and data concerning the suspected clinical risk factors were collected. Bacterial cultures for isolation of BHS were obtained from the affected sites of the skin or skin breaks in the ipsilateral site. Also, pharyngeal swabs and blood cultures were collected on admission to hospital. In addition, sera were collected from patients in acute phase and in convalescent phase 1 month after the admission for subsequent analyses. The median age of the patients was 58 years, 64% were male. The median body mass index (BMI) for patients and controls was 29.1 and 26.5, respectively. Cellulitis was located in the leg in 84%, in the upper extremity in 8%, and in the face in 8% of the cases. In the statistical analysis, chronic oedema, disruption of the cutaneous barriers (toe web maceration, ulcer, wound, or chronic dermatosis), and obesity were independently associated with cellulitis. BHS were isolated from skin swabs or blood cultures in 29% of the cases and group G BHS (GGS) was the most common streptococcal skin isolate. GGS were also isolated from throat swabs in 7% and 13% of the patients and their household members, respectively. No GGS was found in pharyngeal swabs in control subjects. Molecular typing revealed no distinct BHS strain associated with cellulitis. On the basis of the bacteriological and serological findings, BHS were associated with cellulitis in 73% of the cases. Patients were contacted and interviewed by telephone five years after the initial recruitment and patient charts were reviewed. Eleven patients had died during the follow-up. On the basis of telephone interview and review of medical records 87 patients could be evaluated and a recurrence was verified in 36 (41%) and reliably excluded in 51 cases. The mean follow-up time was 4.7 years. The risk for recurrence in five years was 26% after the primary cellulitis episode, and 57% in those who had a recurrent attack at the baseline study. A history of previous cellulitis at baseline was the only risk factor associated with recurrence in five years. At the baseline study, patients with a history of previous cellulitis showed a stronger inflammatory response, reflected by higher c-reactive protein (CRP) level and leukocyte counts, and longer hospital stay, than those with a primary episode. Based on this finding, it was hypothesized, that acute phase reactants CRP and pentraxin-3 (PTX3) could predict recurrence of cellulitis. However, the hypothesis could not be proved in the five year follow-up study. Risk factors for recurrent cellulitis were assessed in another clinical material comprising 398 patients with prophylactic benzathine penicillin treatment for recurrent cellulitis and 8005 controls derived from a national population-based health survey (Health 2000). The median age of the patients was 65 years. The mean BMI was 31.5 for male and 32.5 for female patients. In multivariable analysis psoriasis, other chronic dermatoses, diabetes, increasing BMI, increasing age, and a history of previous tonsillectomy were independently associated with recurrent cellulitis. In conclusion, BHS were associated in the majority of the cellulitis cases. GGS was the most common streptococcal isolate in patients and their household members, but it was not found in the control population. Oedema, skin breaks, and obesity are risk factors for acute cellulitis. Same clinical risk factors probably predispose to acute and recurrent cellulitis, but the risk for further recurrence is higher after a recurrence than after the primary attack. Also, diabetes, psoriasis, and increasing age are risk factors for recurrent cellulitis with benzathine penicillin prophylaxis. High CRP or PTX3 do not predict recurrence of cellulitis. The findings of the present study contribute to the understanding of factors behind the individual risk for cellulitis and especially the recurrence of cellulitis, and may influence the clinical use of antibiotics and non-pharmacological measures in treatment and prevention of cellulitis

Epäsuora ja myy-capture entsyymi-immuunianalyysi myco-plasma pneumoniae-infektion diagnostiikassa.

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Epäsuora ja myy-capture entsyymi-immuunianalyysi myco-plasma pneumoniae-infektion diagnostiikassa.

Syventävä työ ei kirjastoss