Reconstruction of mechanical leg axis using non-modular cemented hinged prosthesis in complex primary total knee arthroplasty

PURPOSE

Modular cementless knee arthroplasty systems are capable of precise reconstruction of the mechanical axis. However, they are considered more susceptible to complications. In contrast, non-modular cemented systems are said to be more forgiving and show good long-term results. The aim of this study was to investigate the resulting leg axis after implantation of a non-modular cemented rotating hinged knee prosthesis. Furthermore, potential risk factors for the occurrence of malalignment and complications should be identified.

METHODS

Between 2005 and 2015, 115 patients could be included in this monocentric retrospective cohort study. All patients underwent primary hinged non-modular cemented total knee arthroplasty. Preoperative and postoperative standardized long radiographs were analysed to determine resulting leg axis. Furthermore, epidemiological and intraoperative data as well as perioperative complications were surveyed.

RESULTS

Average leg axis was 5.8° varus preoperatively and 0.6° valgus postoperatively. Considering an axis deviation of 3° as the target corridor, 27% of all cases examined were outside the desired range. 21% cases showed a femoral deviation from the target corridor and 15% showed a tibial deviation. There was a significant relationship between the preoperative mLDFA and the mechanical alignment of the femoral component (R = 0.396, p < 0.001) as well as between the preoperative mMPTA and the mechanical alignment of the tibial component (R = 0.187, p = 0.045). The mean operative duration was 96 min. No periprosthetic fractures were observed within the study cohort.

CONCLUSION

The main result of the present work is that a non-modular cemented rotating hinged knee arthroplasty system can reconstruct the mechanical leg axis precisely and comparable to modular cementless and unconstrained total knee prostheses. Component malalignment is primarily dependent upon extraarticular deformity preoperatively. Periprosthetic fracture rates and duration of surgery were lower compared with current literature.

LEVEL OF EVIDENCE

Level III: Retrospective cohort study.

What-if nature-based storm buffers on mitigating coastal erosion

Creating ecosystem buffers in intertidal zones, such as seagrass meadows, has gained increasing attention as a nature-based solution for mitigating storm-driven coastal erosion. This study presents what-if scenarios using an integrated model framework to determine the effectiveness and strategies for planting seagrass to reduce coastal erosion. The framework comprises two levels of simulation packages. The first level is a regional-scale coupled hydrodynamic model that simulates the processes of a specific storm and provides boundary forces for the morphodynamic model XBeach to apply at the next level, which simulates nearshore morphological evolution. The framework is applied to the open coast of Norderney in the German Bight of the North Sea. We demonstrate that optimising the location and size of seagrass meadows is crucial to increase the efficiency of onshore sediment erosion mitigation. For a specific depth range, depending on the storm's intensity, the most significant reduction in erosion may not be achieved by starting the meadow at the depth that permits the largest meadow size. To maintain a significant coastal protection effect, seagrass density and stem height should be considered together, ensuring erosion reduction by at least 80 % compared to the unprotected coast. This study provides valuable insights for the design and implementation of seagrass transplantation as a nature-based solution, highlighting the importance of considering location, size, density, and stem height when using seagrass meadows for coastal protection.

Genetic Testing for Supravalvar Aortic Stenosis: What to Do When It Is Not Williams Syndrome

BACKGROUND

We aimed to describe the frequency and yield of genetic testing in supravalvar aortic stenosis (SVAS) following negative evaluation for Williams-Beuren syndrome (WS).

METHODS AND RESULTS

This retrospective cohort study included patients with SVAS at our institution who had a negative evaluation for WS from May 1991 to September 2021. SVAS was defined as (1) peak supravalvar velocity of ≥2 meters/second, (2) sinotubular junction or ascending aortic Z score <-2.0, or (3) sinotubular junction Z score <-1.5 with family history of SVAS. Patients with complex congenital heart disease, aortic valve disease as the primary condition, or only postoperative SVAS were excluded. Genetic testing and diagnoses were reported. Of 162 patients who were WS negative meeting inclusion criteria, 61 had genetic testing results available (38%). Chromosomal microarray had been performed in 44 of 61 and was nondiagnostic for non-WS causes of SVAS. Sequencing of 1 or more genes was performed in 47 of 61. Of these, 39 of 47 underwent ELN sequencing, 20 of 39 (51%) of whom had a diagnostic variant. Other diagnoses made by gene sequencing were Noonan syndrome (3 PTPN11, 1 RIT1), Alagille syndrome (3 JAG1), neurofibromatosis (1 NF1), and homozygous familial hypercholesterolemia (1 LDLR1). Overall, sequencing was diagnostic in 29 of 47 (62%).

CONCLUSIONS

When WS is excluded, gene sequencing for SVAS is high yield, with the highest yield for the ELN gene. Therefore, we recommend gene sequencing using a multigene panel or exome analysis. Hypercholesterolemia can also be considered in individuals bearing the stigmata of this disease.

Community-Directed Vector Control to Accelerate Onchocerciasis Elimination

Onchocerciasis, or river blindness, has historically been one of the most important causes of blindness worldwide, and a major cause of socio-economic disruption, particularly in sub-Saharan Africa. Its importance as a cause of morbidity and an impediment to economic development in some of the poorest countries in the world motivated the international community to implement several programs to control or eliminate this scourge. Initially, these involved reducing transmission of the causative agent Onchocerca volvulus through controlling the vector population. When ivermectin was found to be a very effective drug for treating onchocerciasis, the strategy shifted to mass drug administration (MDA) of endemic communities. In some countries, both vector control and ivermectin MDA have been used together. However, traditional vector control methods involve treating rivers in which the black fly vectors breed with insecticides, a process which is expensive, requires trained personnel to administer, and can be ecologically harmful. In this review, we discuss recent research into alternatives to riverine insecticide treatment, which are inexpensive, ecologically less harmful, and can be implemented by the affected communities themselves. These can dramatically reduce vector densities and, when combined with ivermectin MDA, can accelerate the time to elimination when compared to MDA alone.

Significant reduction of blackfly densities in persistent onchocerciasis area following pilot implementation of an environment friendly approach (Slash and Clear)

The effectiveness of the "Slash and Clear" method in reducing blackfly populations in low transmission areas is established, but its impact in high transmission settings with large rivers and dense vectors is yet to be proven. A community-based intervention study was conducted in the Mbam Valley, Centre Cameroon, involving two sites: Bayomen (control) and Biatsota (intervention). In each arm, baseline blackfly densities were collected over one year using the human landing method. The intervention consisted of destroying the trailing vegetation where blackflies breed. Blackfly densities were collected post-intervention to assess the impact of the intervention. Post-intervention data showed a 50.8% reduction in blackfly density in Biatsota (mean number of collected blackflies from 1936 to 953), while a reduction of 26.7% was observed in Bayomen (mean number of collected blackflies from 2418 to 1774). The reduction rate attributable to the intervention was 32.9%. Statistical analysis confirmed that the reduction in blackfly density was significantly greater in the intervention site. This study demonstrates the feasibility and significant impact of the "Slash and Clear" method in high transmission areas. However, further research is required to assess its long-term effects and determine how this strategy can be scaled up and sustained until onchocerciasis elimination is achieved.

Validity of leg length measurement in the supine and standing position compared with pelvic survey X-ray after total hip arthroplasty

INTRODUCTION

The correct adjustment of leg length is a major goal in the implantation of total hip replacements (THRs). Differences in leg length can lead to functional impairment and patient dissatisfaction. By determining leg length at an early stage, before the patient is discharged from hospital, compensatory measures such as the production of special insoles or orthopaedic footwear can be initiated promptly if there is a difference in leg length. Due to shortening of the period of time spent in hospital, the traditional measurement of leg length in a standing position may be increasingly subject to error. A protective posture immediately after surgery or the presence of a twisted pelvis, for example, due to scoliotic spinal misalignments, falsifies the measurement result in the standing position. Here, the measurement of leg length in the supine position may prove to be accurate immediately postoperatively, regardless of potential sources of error, and is to be compared with measurement in the standing position versus radiological measurement on the AP pelvic survey.

MATERIAL AND METHODS

The present retrospective study included 190 patients who had undergone primary total hip arthroplasty. The leg length difference (LLD) of the patients was determined pre- and postoperatively both in the supine and standing position and compared with the postoperative radiological pelvic survey image.

RESULTS

Postoperatively, it was shown that the mean length measured was 0.35 mm too long in the supine position and 0.68 mm too short in the standing position (p value < 0.001). Determination of the average absolute measurement error produces a deviation of 4.06 mm in the standing and 4.51 mm in the supine position (p value 0.126).

CONCLUSIONS

It is shown that the postoperative measurement of LLD in the supine and standing position is equally valid and sufficiently accurate, compared with the gold standard of measurement on a radiograph.

Plain radiographic indices are reliable indicators for quantitative bone mineral density in male and female patients before total hip arthroplasty

Osteoporosis is underdiagnosed in patients undergoing total hip arthroplasty (THA). Bone mineral density measurement by dual-energy X-ray absorptiometry (DXA) is the gold standard, but indices on plain hip radiographs also seemed to be reliable screening tools in female or Asian ethnicities in previous studies. Given the lack of knowledge about male patients and Caucasian ethnicities, this study was conducted to evaluate plane hip radiographic indices as a screening tool for osteopenia and osteoporosis in Caucasian female and also male patients before undergoing THA. A retrospective analysis of 216 elderly patients with pre-existing DXA before hip arthroplasty was performed and four indices were calculated on plain hip radiographs: Canal-Flare-Index (CFI), Canal-Calcar-Ratio (CCR), Canal-Bone-Ratio (CBR) 7 and 10 cm below the lesser trochanter. They were correlated with femoral neck DXA T-scores by Pearson's correlation and intraclass correlation coefficient, and a ROC analysis was performed. A total of 216 patients (49.5% male) were included. CBR-7 and -10 were highly correlated (p < 0.001) with femoral neck T-score in males (Pearson's correlation CBR-7 r = - 0.60, CBR-10 r = - 0.55) and females (r = - 0.74, r = - 0.77). CBR-7 and -10 also showed good diagnostic accuracy for osteoporosis in the ROC analysis in males (CBR-7: AUC = 0.75, threshold = 0.51; CBR-10: 0.63; 0.50) and females (CBR-7: AUC = 0.87, threshold = 0.55; CBR-10: 0.90; 0.54). Indices such as the Canal Bone Ratio (CBR) 7 or 10 cm below the lesser trochanter on plain hip radiographs are a good screening tool for osteopenia and osteoporosis on plain hip radiographs and can be used to initiate further diagnostics like the gold standard DXA. They differ between male and female patients.

Clinical Outcomes and Associations With Radial to Femoral Crossover in ST-Elevation Myocardial Infarction

Radial access during primary percutaneous coronary intervention is associated with reduced mortality and major bleeding compared with femoral access and is the recommended access site. Nevertheless, failure to secure radial access may necessitate crossover to femoral access. This study aimed to identify the associations with crossover from radial to femoral access in all comers with ST-elevation myocardial infarction and to compare the clinical outcomes with those patients who did not require crossover. From 2016 to 2021, a total of 1,202 patients presented to our institute with ST-elevation myocardial infarction. Associations, clinical outcomes, and independent predictors of crossover from radial to femoral access were identified. From 1,202 patients, radial access was used in 1,138 patients (94.7%) and crossover to femoral access occurred in 64 patients (5.3%). Patients who required crossover to femoral access had higher rates of access site complications and longer length of stay in the hospital. Inpatient mortality was higher in the group requiring a crossover. This study identified 3 independent predictors of crossover from radial to femoral access in primary percutaneous coronary intervention: cardiogenic shock, cardiac arrest before arrival at the catheterization laboratory, and previous coronary artery bypass grafting. Biochemical infarct size and peak creatinine was also found to be higher in those requiring crossover. In conclusion, crossover in this study portended an increased rate of access site complications, greatly prolonged length of stay, and a significantly higher risk of death.

Less soft tissue release in total knee arthroplasty for anteromedial compared to posteromedial knee osteoarthritis

In total knee arthroplasty (TKA), the aim of achieving a mechanically straight leg axis as well as symmetrical and equally wide gaps has become established as the gold standard in terms of surgical technique. In contrast to TKA unicompartmental knee arthroplasty (UKA) is performed in anteromedial osteoarthritis (AMOA) and does not normally require releases. This raises the hypothesis whether the type of osteoarthritis (AMOA vs. posteromedial osteoarthritis (PMOA)) determines the requirement for soft tissue releases in TKA.In this retrospective study, 114 patients with medial osteoarthritis of the knee who had been treated with a navigated total knee replacement were consecutively included. On the basis of the preoperative lateral radiographs, the patients were divided into two groups: AMOA and PMOA. The incidence and the extent of releases performed were recorded using the navigation records.Patient-specific data (gender, age) did not differ between the groups (NS). Knees with AMOA presented an overall varus alignment of 5.3 ± 3.5°, knees with PMOA 8.0 ± 4.0° (p < 0.001). 30 cases (44%) had to be released in the AMOA group, compared with 33 cases (72%) in the PMOA group (p = 0.004). In the case of medial release, the extension gap increased 3.3 ± 2.4 mm in the AMOA compared to 5.3 ± 3.7 mm in the PMOA group (p = 0.006). The medial flexion gap was released 2.2 ± 2.6 mm in the AMOA and 2.9 ± 3.0 mm in the PMOA group (p = 0.008).To achieve a neutral mechanical alignment, a release has to be performed due to asymmetry of the extension gap more often if PMOA is present than in AMOA. Surgeons should be prepared to perform more frequent and extensive medial releases in PMOA. Higher constrained implants should be available in case of unintended over release in PMOA.

Topical vancomycin powder does not affect patella cartilage degeneration in primary total knee arthroplasty and conversion rate for secondary patella resurfacing

INTRODUCTION

Vancomycin powder (VP) is an antibiotic first introduced in pediatric spinal surgery to prevent surgical site infections (SSI). Recently its topical application was expanded to total hip and knee arthroplasty (THA, TKA) and anterior cruciate ligament reconstruction (ACLR). Toxicity to cartilage is the subject of current research. The aim of this study was to prove the hypothesis that topical application of VP in TKA does not result in a degeneration of patella cartilage. We propagate that the conversion rate for secondary patella resurfacing is not influenced by its use.

MATERIALS AND METHODS

Between 2014 and 2021, 4292 joints were included in this monocentric retrospective cohort study. All patients underwent TKA without primary patella resurfacing. After a change of the procedure in the hospital, one group (VPG) was administered VP intraoperatively. The other group (nVPG) received no VP during surgery (nVPG). The remaining perioperative procedure was constant over the investigation period. Conversion rates for secondary patella resurfacing for both groups were determined without making distinctions in the indication. A second cohort was composed of patients presenting for follow-up examination 12 months after TKA and included 210 joints. Retrospective radiographic evaluations were performed preoperatively, before discharge and at follow-up examination. Patella axial radiographs were analyzed for patella tracking (lateral patellar tilt, patellar displacement) and patella degeneration (Sperner classification, patellofemoral joint space).

RESULTS

There was no significant difference in the conversion rate for secondary patella resurfacing (4.24% VPG, 4.97% nVPG). Patella tracking and patella degeneration did not differ significantly between both groups.

CONCLUSIONS

The topical application of VP does not influence the conversion rate for secondary patella resurfacing. Moreover, it does not result in a degeneration of patella cartilage in TK.

LEVEL OF EVIDENCE

Retrospective case series, Level III.

C-reactive protein during the first 6 postoperative days after total hip arthroplasty cannot predict early periprosthetic infection

INTRODUCTION

Periprosthetic joint infection (PJI) after total hip arthroplasty (THA) remains a serious complication in orthopaedic surgery. C-reactive protein (CRP) is widely used as a marker to screen for inflammatory complications. The early postoperative course is well known, but knowledge about the predictive value of CRP in the first 6 postoperative days for detecting an acute postoperative PJI is lacking.

METHODS

We retrospectively analyzed the inpatient course of CRP of all primary THA and THA with acute PJI within 28 days in our hospital from 2013 to 2021. A receiver-operating curve (ROC) analysis was performed and the best CRP threshold for detecting an acute PJI based on Youden's-index was calculated and an area-under-the curve (AUC) analysis of the threshold was performed.

RESULTS

33 of 7042 patients included had an acute PJI within 28 days. Patients with acute PJI were older, had a higher BMI and longer operation time and suffered more often from diabetes mellitus. A preoperatively elevated CRP was a risk factor for PJI. CRP was significantly higher in the PJI group on postoperative days 3 and 5. Threshold values were calculated to be 152 mg/l on day 3 and 73 mg/l on day 5. However, these values had a low sensitivity (75%, 76%) and specificity (67%, 61%).

CONCLUSION

Especially considering the decreasing length of stay after THA, the question of the usefulness of regular inpatient CRP checks arises. AUC analysis of the ROC showed a poor diagnostic accuracy in almost all cases. Only the dynamic analysis of the maximum CRP value to the lowest CRP value with a decrease of 102.7 mg/l showed a fair accuracy. This calls into question the clinical relevance of CRP in the first postoperative week for detection of acute postoperative PJI.

An exploratory analysis of patient factors influencing acceptance of extended criteria liver grafts

INTRODUCTION AND OBJECTIVES

There is a shortage of ideal donor organs with consequential increasing waitlist times, drop-off, and mortality. Teams have thus extended the donor criteria. Little is known about patients' actual choices and what factors may influence their decisions regarding different extended criteria liver grafts.

PATIENTS AND METHODS

The documented acceptance or refusal of seven extended criteria liver graft types of patients consented for transplant in a single institution over a 2-year period was reviewed. Patient factors including sex, age, indication, aetiology, and model for end-stage liver disease (MELD) score were analysed using logistic regression.

RESULTS

Most patients were willing to accept most graft types. MELD score did not impact the acceptance or refusal of any graft type. Older patients and those with hepatocellular carcinoma (HCC) or ascites had significantly higher rates of acceptance. Hepatitis B or C disease aetiology was predictive of willingness to accept a similarly infected graft, respectively. HCC was predictive of acceptance of grafts from donors with a cancer history.

CONCLUSIONS

In general, patients embrace the available extended criteria donors. Our analysis suggests that consent should be revisited as patients deteriorate or ameliorate on the waitlist, especially if in the form of ascites or HCC but not necessarily MELD score.

In vitro additive effects of dalbavancin and rifampicin against biofilm of Staphylococcus aureus

Dalbavancin is a novel glycopeptide antibiotic approved for the treatment of acute bacterial skin and skin structure infections (ABSSSIs). It is characterized by a potent activity against numerous Gram-positive pathogens, a long elimination half-life and a favorable safety profile. Most recently, its application for the treatment of periprosthetic joint infections (PJIs) was introduced. The aim of this study was to proof our hypothesis, that dalbavancin shows superior efficacy against staphylococcal biofilms on polyethylene (PE) disk devices compared with vancomycin and additive behavior in combination with rifampicin. Staphylococcus aureus biofilms were formed on PE disk devices for 96 h and subsequently treated with dalbavancin, vancomycin, rifampicin and dalbavancin-rifampicin combination at different concentrations. Quantification of antibacterial activity was determined by counting colony forming units (CFU/ml) after sonification of the PE, serial dilution of the bacterial suspension and plating on agar-plates. Biofilms were additionally life/dead-stained and visualized using fluorescence microscopy. Dalbavancin presented superior anti-biofilm activity compared to vancomycin. Additive effects of the combination dalbavancin and rifampicin were registered. Dalbavancin combined with rifampicin presents promising anti-biofilm activity characteristics in vitro. Further in vivo studies are necessary to establish recommendations for the general use of dalbavancin in the treatment of PJIs.

An Isoelastic Monoblock Cup Retains More Acetabular and Femoral Bone Than a Modular Press-Fit Cup: A Prospective Randomized Controlled Trial

BACKGROUND

For cup revision after total hip arthroplasty, sufficiently good periacetabular bone stock is a prerequisite for fixation of the revision implant. Cementless cups can lead to a relevant reduction of peri-implant bone mineral density (BMD) through stress-shielding.

METHODS

Fifty patients were included in this prospective randomized controlled trial. Group 1 (RM group) received an isoelastic monoblock cup (RM Pressfit vitamys; Mathys). Group 2 (IT group) received a modular titanium cup (Allofit-S IT Alloclassic with a polyethylene liner; Zimmer). Periacetabular BMD was determined and subdivided into 4 regions of interest by dual x-ray absorptiometry at 1 week (baseline) and at 4 years postoperatively. Our primary outcome was reduction in periacetabular BMD.

RESULTS

Periacetabular BMD was reduced by an average of 15.1% in the RM group and 16.5% in the IT group at 4 years postoperatively. No significant difference was found between the 2 groups over the periacetabular structure as a whole. However, the decrease of BMD in the polar region was significantly different in the RM group (4.9% ± 10.0%) compared with the IT group (15.9% ± 14.9%, p = 0.005). Use of the isoelastic RM cup showed significantly less bone loss than the modular IT cup.

CONCLUSIONS

Relevant loss of BMD at 4 years after surgery was identified in the periacetabular region in both groups. No differences between the 2 cup systems were found when looking at the overall periacetabular region. As a secondary outcome, less postoperative periacetabular bone loss occurred in the polar region when an isoelastic cup was used. Longer follow-up is required to allow for conclusions to be drawn about the long-term course of the 2 cup systems.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Exploring diastolic pressure ratio to fractional flow reserve discordance and a hypothesis on tailoring diastolic pressure ratio cut-off values to improve diagnostic accuracy in the mid- and distal-LAD

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This study assessed diastolic pressure ratio to FFR discordance.

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12.7% of LAD lesions in this study had discordant result.

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2.4% of non-LAD lesions had discordant results.

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This represents a statistically significant difference in discordance rate.

Previous studies have identified a higher rate of discordance between non-hyperaemic pressure ratios and FFR in the LAD when compared to the other two coronary arteries. We hypothesised that in keeping with recently published data, we would identify a higher discordance rate between diastolic pressure ratio (DPR) and FFR in the LAD compared to the RCA or LCx. In our study, 12.7% of LAD lesions had discordant results compared with 2.4% of non-LAD lesions. This represents a statistically significant increased rate of discordance in LAD lesions compared to non-LAD lesions (p = 0.04986). Note was made of a tendency for non-proximal LAD lesions to be associated with false-positive DPR results in the borderline range (0.88 and 0.89). In a speculative, hypothesis generating post-hoc analysis, we found an improved diagnostic accuracy of DPR when the cut-off value for a positive DPR in the non-proximal LAD was changed to ≤0.87. It is fathomable that improvements in the diagnostic accuracy of DPR for FFR may be improved by tailoring DPR cut-offs to the location of the lesion assessed.

Cytotoxic effect of sodium hypochlorite (Lavanox 0.08%) and chlorhexidine gluconate (Irrisept 0.05%) on human osteoblasts

Purpose

Soft tissue, bone and joint infections are severe complications in orthopedic and traumatological surgery. Lavanox (0.08% NaOCl) and Irrisept (0.05% chlorhexidine gluconate, CHG) are industrially produced antiseptic solutions commonly used in infection treatment. Regarding this clinical indication, the microbicidal effect is often investigated, but toxicity to osteoblasts has rarely been examined. This is important to decide whether these solutions should be used in septic situations in which bone healing must take place. The hypothesis of the present study is that NaOCl and CHG are cytotoxic to osteoblasts even after a short exposure time.

Methods

Human osteoblasts were isolated from donors with osteoarthritis during total knee and hip arthroplasty. Cells were cultivated and treated with both antiseptic solutions for 2, 5 and 10 min in different dilutions. Toxicity was quantified by counting cells, lactate dehydrogenase (LDH) expression, spectrophotometric quantification via XTT assay and FDA/PI fluorescence microscopy.

Results

Analyzing viable cells after treatment with both antiseptics showed a significant decrease in viable cells through LDH expression test, XTT assay, fluorescence microscopy and light microscopy, depending on concentration. The time dependence showed a trend to more cell death at longer exposure times, without significance.

Conclusion

Toxic effects on osteoblasts were shown after treatment with 0.08% NaOCl and 0.05% CHG after an exposure time of 2 min which also was concentration dependent. There was no difference in cytotoxicity between both antiseptics. In conclusion, these antiseptic solutions may be used with caution in situations requiring bone healing.

Trial registration number

Local ethics committee registration number: 5176–07/16

Supplementary Information

The online version contains supplementary material available at 10.1007/s00590-021-02907-3.

Vancomycin is toxic to human chondrocytes in vitro

INTRODUCTION

Vancomycin powder (VP) is a well-established topical antibiotic used in spinal surgery to prevent surgical site infections. More recently its extension to hip and knee arthroplasty was introduced. The aim of this study was to examine toxic effects of VP on the viability of human chondrocytes. Our hypothesis was that VP damages human chondrocytes in vitro with increasing concentration and length of exposure.

MATERIAL AND METHODS

Primary human chondrocytes were isolated and cultured from donated human knee joints. VP was added to these cultures with increasing concentrations (0-50 mg/ml) and length of exposure (0-336 h). Toxicity and viability were analyzed using LDH und XTT Elisa assays. Cell structure and determination of vital versus dead cells were visualized using light microscopy and fluorescence microscopy.

RESULTS

Light microscopy and fluorescence microscopy visualized defect cell structures and cell death proportional to increasing dose and length of exposure to VP. The analysis of LDH activity data showed toxic effects on chondrocytes as early as 2,5 min after exposure to VP. XTT activity data revealed a significant toxic threshold of a VP concentration above 12.5 mg/ml.

CONCLUSIONS

These results show that exposure to high VP concentrations yields to a damage of human chondrocytes in vitro. Chondrotoxicity is an immediate effect that is proportional to VP concentration. Therefore, the intraarticular use of high concentrations of vancomycin powder in the presence of native cartilage tissue must be considered critically.

Perioperative Outcomes After Tracheostomy Placement Among Complex Pediatric Patients

OBJECTIVES/HYPOTHESIS

To compare perioperative outcomes after pediatric tracheostomy placement based on patient complexity.

STUDY DESIGN

Retrospective case series.

METHODS

All patients that underwent tracheostomy placement at a tertiary children's hospital between 2015 and 2019 were followed. Children with a history of major cardiac surgery, sepsis, or total parental nutrition (TPN) were grouped as complex. Admission length, tracheostomy-related complications, in-hospital mortality, and 30-day readmissions were recorded among complex and non-complex patients.

RESULTS

A total of 238 children were included. Mean age at tracheostomy was 39.9 months (SD: 61.3), 51% were male and 51% were complex. Complex patients were younger at admission (29.9 vs. 46.8 months, P = .03), more likely to have respiratory failure (81% vs. 53%, P < .001) and more often required mechanical ventilation at discharge (86% vs. 67%, P < .001). An additional 33 days after placement was required for complex children (95% CI: 14-51, P = .001) and this group had more deaths (8% vs. 1%, P = .02); however, both groups had similar complication and readmission rates (P > .05). Total charges were higher among complex patients ($700,267 vs. $338,937, P < .001). Parametric survival analysis identified mechanical ventilation and patient complexity interacting to predict post-tracheostomy admission length.

CONCLUSIONS

Hospital discharge after pediatric tracheostomy was associated with patient complexity and further influenced by mechanical ventilation. Recognition that cardiac surgery, sepsis, or TPN can predict poorer perioperative outcomes can provide quality improvement strategies for these vulnerable children.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2469-E2474, 2021.

Optimization of Slash and Clear Community-Directed Control of Simulium damnosum Sensu Stricto in Northern Uganda

Onchocerciasis, caused by infection with Onchocerca volvulus, has been targeted for elimination by 2030. Currently, onchocerciasis elimination programs rely primarily on mass distribution of ivermectin. However, ivermectin alone may not be sufficient to achieve elimination in some circumstances, and additional tools may be needed. Vector control has been used as a tool to control onchocerciasis, but vector control using insecticides is expensive and ecologically detrimental. Community-directed removal of the trailing vegetation blackfly larval attachment sites (slash and clear) has been shown to dramatically reduce vector biting densities. Here, we report studies to optimize the slash and clear process. Conducting slash and clear interventions at Simulium damnosum sensu stricto breeding sites located within 2 km of afflicted communities resulted in a 95% reduction in vector biting. Extending slash and clear further than 2 km resulted in no further decrease. A single intervention conducted at the first half of the rainy season resulted in a 97% reduction in biting rate, whereas an intervention conducted at the end of the rainy season resulted in a 94% reduction. Vector numbers in any of the intervention villages did not fully recover by the start of the following rainy season. These results suggest that slash and clear may offer an inexpensive and effective way to augment ivermectin distribution in the effort to eliminate onchocerciasis in Africa.

Sodium hypochlorite is more effective than chlorhexidine for eradication of bacterial biofilm of staphylococci and Pseudomonas aeruginosa

PURPOSE

Periprosthetic infection is a common reason for surgical revision. Given the increasing resistance of bacteria to antibiotics (e.g., VRE, 4-MRGN) local antiseptic treatment is gaining in importance. However, no standard guideline-based treatment recommendation is yet available. The aim of this study was to investigate the effectiveness of sodium hypochlorite and chlorhexidine against bacterial biofilms. Furthermore, the toxicity of both antiseptics towards human chondrocytes was examined.

METHODS

Human chondrocytes were isolated, cultivated and treated with sodium hypochlorite and chlorhexidine. The viability of cultures was assessed by determination of cell count, XTT and MTT ELISAs, and fluorescent staining with propidium iodide. Bacterial strains of Staphylococcus aureus, Staphylococcus epidermidis and Pseudomonas aeruginosa were added to liquid media and incubated overnight. After determination of bacterial concentrations polyethylene (PE) devices were inoculated with bacteria for 48 h until biofilms formed. The devices were then washed, treated with antiseptics for 2 and 5 min and subsequently spread on agar plates.

RESULTS

Sodium hypochlorite is more effective than chlorhexidine in penetrating biofilms of S. aureus, S. epidermidis and P. aeruginosa. Both antiseptics are chondrotoxic, but sodium hypochlorite damages human chondrocytes less than chlorhexidine in vitro.

CONCLUSIONS

The findings confirm the effectiveness of sodium hypochlorite and chlorhexidine against bacterial biofilms. Both antiseptics can be recommended for the treatment of periprosthetic infections. The toxic effects of sodium hypochlorite and chlorhexidine towards chondrocytes may mean there is a risk of damage to cartilage tissue.

LEVEL OF EVIDENCE

Controlled experimental study.

Clinical, serological and DNA testing in Bengo Province, Angola further reveals low filarial endemicity and opportunities for disease elimination

The prevalence of Loa loa, Onchocerca volvulus and Wuchereria bancrofti infections in an under-surveyed area of Bengo Province, Angola, was determined by surveying 22 communities with a combination of clinical, serological and DNA diagnostics. Additional information was collected on participants' duration of residency, access to mass drug administration, knowledge of insect vectors and use of bednets. A total of 1616 individuals (38.1% male: 61.9% female), with an average age of 43 years, were examined. For L. loa, 6.2% (n = 100/16616) individuals were found to have eyeworm, based on the rapid assessment procedure for loiasis (RAPLOA) surveys, and 11.5% (n =178/1543) based on nested PCR analyses of venous blood. L. loa prevalences in long-term residents (>10 years) and older individuals (>60 years) were significantly higher, and older men with eyeworm were better informed about Chrysops vectors. For O. volvulus, 4.7% (n = 74/1567) individuals were found to be positive by enzyme-linked immunosorbent assay (Ov 16 ELISA), with only three individuals reporting to have ever taken ivermectin. For W. bancrofti, no infections were found using the antigen-based immunochromatographic test (ICT) and real-time PCR analysis; however, 27 individuals presented with lymphatic filariasis (LF) related clinical conditions (lymphoedema = 11, hydrocoele = 14, both = 2). Just under half (45.5%) of the participants owned a bednet, with the majority (71.1%) sleeping under it the night before. Our approach of using combination diagnostics reveals the age-prevalence of loiasis alongside low endemicity of onchocerciasis and LF. Future research foci should be on identifying opportunities for more cost-effective ways to eliminate onchocerciasis and to develop innovative surveillance modalities for clinical LF for individual disease management and disability prevention.

Identification of Human-Derived Attractants to Simulium damnosum Sensu Stricto in the Madi-Mid North Onchocerciasis Focus of Uganda

Human landing collections (HLCs) have been the standard method for the collection of black flies that serve as vectors for Onchocerca volvulus, the causative agent of onchocerciasis or river blindness. However, HLCs are inefficient and may expose collectors to vector-borne pathogens. The Esperanza window trap (EWT) has been shown to be a potential alternative to HLCs for the collection of Simulium damnosum, the principal vector of O. volvulus in Africa. To improve the performance of the EWT, sweat from individuals highly attractive or less attractive to S. damnosum sensu stricto was examined by gas chromatography and mass spectroscopy. Twelve compounds were identified which were solely present or present in increased amounts in the sweat of the highly attractive individuals. Two of these compounds (naphthalene and tert-hexadecyl mercaptan) were found to be attractive to S. damnosum s.s. in behavioral assays. Traps baited with these compounds outperformed those baited with the current standard bait of worn socks. Using these newly identified compounds as baits will make the EWT more efficient in collecting vector black flies and may enhance the potential utility of the EWT as a local vector control measure.

Tranexamic acid is toxic on human chondrocytes, in vitro

The aim of this study was to examine toxic effects of tranexamic acid (TXA) on the viability of human chondrocytes. Our hypothesis was that TXA damages human chondrocytes. Chondrocytes were cultured from donated human knee joints. TXA was added to these cultures. Toxicity were analyzed by using LDH und XTT Elisa assays, light microscopy and fluorescence microscopy. The results show that TXA damages human chondrocytes in vitro. We cannot recommend the use of TXA in hemiarthroplasty of the hip or unicompartmental knee arthroplasty in higher concentrations.