The 2018 New Definition of Periprosthetic Joint Infection is Valuable for Diagnosis of Persistent Infection at Reimplantation in Patients without Synovial Fluid

BACKGROUND

Diagnosis of persistent infection at reimplantation of 2-stage exchange revision is a challenging problem. The aim of our study is to evaluate the performance of the 2018 new definition and Musculoskeletal Infection Society (MSIS) criteria in determining the persistent infection at reimplantation in patients without synovial fluid.

METHODS

We retrospectively reviewed 150 patients who underwent 2-stage exchange revision from 2014 to 2018. Two models were used to define persistent infection-model 1: identical major criteria of the MSIS criteria and new definition and model 2: identical major criteria of 2 criteria and/or subsequent infection after reimplantation. The predictive accuracy of the new definition and MSIS criteria was compared by using receiver operating characteristic curves.

RESULTS

The receiver operating characteristic curves showed that the new definition had good performance in determining the persistent infection, with the area under the curve (AUC) of 0.871 in model 1 and 0.835 in model 2. The optimal threshold for aggregate scores in new definition was 4. The MSIS criteria had limited diagnostic value in both model 1 (AUC = 0.708) and model 2 (AUC = 0.664). In model 1, the sensitivity and specificity were 86.96% and 84.25% in new definition, and 47.83% and 93.70% in MSIS criteria in patients without synovial fluid. In model 2, the sensitivity and specificity were 78.57% and 85.25% in new definition, and 39.29% and 93.44% in MSIS criteria.

CONCLUSION

The 2018 new definition of PJI is valuable in the diagnosis of persistent infection, which can improve diagnostic accuracy compared with the MSIS criteria in patients without synovial fluid.

[Microsurgical replantation of traumatic amputated lip]

This is a case report of two patients with traumatic amputated lip due to respectively human bite and bicycle head-on-car collision. Both patients were successfully treated by microsurgical replantation within 24 hours and with post-operative leech treatment. Furthermore, a MEDLINE/PubMed search was performed for all scientific English articles of lip amputation and replantation using microsurgery. We want to address the importance of preserving amputated parts and the necessity of 24-hour access to plastic surgery and microsurgery in trauma if needed.

A systematic review and meta-analysis comparing outcomes of laparoscopic extravesical versus trans vesicoscopic ureteric reimplantation

OBJECTIVE

When considering treatment for vesico ureteric reflux via inimally invasive surgery there is a dilemma to choose between laparoscopic extravesical (LEVUR) and transvesicoscopic (TVUR) ureteric reimplantation. In this systematic review and meta-analysis we have analyzed the articles on LEVUR and TVUR and compared the outcomes.

METHODS

We searched the databases to identify all papers pertaining to TVUR and LEVUR in the pediatric population. Duplicate publications, review articles, incomplete articles and robotic assistance were excluded. Systematic review was performed to identify patient data, reflux grades, laterality, duration of surgery, time to discharge, success rate and complications. Meta-analysis of heterogeneity was reported with I 2 statistics. Once heterogeneity was found low, the pooled outcomes were compared with students t test and Fishers exact test, wherever appropriate.

RESULTS

After screening a total of 45 articles, 23 articles were included (13 articles on TVUR and 10 articles on LEVUR). The I 2 statistics for TVUR and LEVUR showed low heterogeneity with I 2 of 0% (95% C.I 0-37%) and 25% (95% C.I 0-64%) respectively. With low heterogeneity both were suitable to be considered to have been conducted under similar conditions with possibility of using fixed effect model. The percentage of Grade 5 VUR was significantly higher (p = 0.001; X 2) in TVUR (11.9%) compared to LEVUR (2.2%). The proportion of bilateral reimplantation was significantly higher (p = 0.001; X 2) in TVUR compared to LEVUR (summary table). The success rate of LEVUR was significantly higher at 96.7% compared to TVUR at 93.7% (p = 0.007 X 2). Unilateral/Bilateral TVUR took significantly longer duration of surgery (155/194 min vs 107/161 min) compared to LEVUR (p = 0.001; Fishers). The mean (s.d) time to discharge was longer at 3.2 (1.6) days for TVUR compared to 1.6 (0.4) days for LEVUR (p = 0.001; Fishers). The complication rate was comparable, 7.35% for TVUR and 5.35% for LEVUR (p = 0.167; X 2).

DISCUSSION

In this meta-analysis we found that LEVUR had shorter operating time, higher success, and shorter hospital stay compared to TVUR. A probable explanation could be higher number unilateral VURs and lower number of grade 5 VUR cases in LEVUR group. Both the techniques had comparable overall complication rate: LEVUR had more post-operative urinary retention while TVUR had more port-related problems.

Robotics in Pediatric Urology: Evolution and the Future

Almost 30 years have passed since the inception of minimally invasive surgery in urology and specifically in pediatric urology. Laparoscopy has now become an essential tool in the pediatric urologic armamentarium. The application of robot-assisted surgery in pediatrics has allowed for widespread utilization for common reconstructive procedures such as pyeloplasty and ureteral reimplantation. Understanding the implementation, technical considerations, and outcomes are critical for continued success and adoption. This has allowed for increased use in more complex urologic procedures such as redo pyeloplasty, dismembered ureteral reimplantation, catheterizable channel creation, and bladder augmentation.

Classification and clinical evaluation of "spare parts" procedures in mutilating hand injuries

Mutilating hand injuries are common, and reconstruction should be tailored to each case. The "spare parts" concept relies on harvesting tissues for reconstruction from amputated or non-salvageable parts that are being discarded. This study sought to evaluate the outcomes of "spare parts" procedures in mutilating hand injuries and to propose a classification of "spare parts" types. This study included 28 patients with mutilating hand injuries undergoing surgery using "spare parts" for tissue reconstruction either at the time of trauma or later on. A total of 31 "spare parts" procedures were performed on the 28 patients. The outcomes were assessed in terms of reconstruction success, Disabilities of the Arm, Shoulder, and Hand (DASH) score, grip strength, and an overall patient satisfaction score that we designed. Reconstruction using "spare parts" was successful in 25 patients (89%). The mean DASH score was 8.45 ± 4.74, the mean grip strength was 24.57 ± 2.73 kg, and overall patient satisfaction was 3.32 ± 0.77 out of 5. Specific outcomes were assessed using case-specific measures. Based on these data, a hand-specific classification of "spare parts" procedures was designed to be taken into consideration when managing mutilating hand injuries. Besides direct digital replantation and tissue harvesting from different donor sites, the "spare parts" concept is an important tool for a hand surgeon. Its different types should always be taken into consideration when managing mutilating hand injuries to avoid additional donor site morbidities and to achieve a high level of overall patient satisfaction. We propose adding a "patient satisfaction with hand appearance" item to the DASH and QuickDASH score.

[Two-debranching Thoracic Endovascular Aortic Repair for Thoracic Aortic Aneurysm Complicated by Idiopathic Thrombocytopenic Purpura;Report of a Case]

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disease in which the number of platelets decreases due to auto-antibodies against platelets. We report that thoracic endovascular aortic repair (TEVAR) was successfully performed for a thoracic aortic aneurysm complicated by ITP. The patient was a man of 77 years of age. He had a history of splenectomy due to ITP. He was admitted to our hospital with an aneurysm of the aortic arch that enlarged to a maximum minor axis of 63 mm. An operation was planned. Because of ITP, it was judged that replacement of the aortic arch using a cardio-pulmonary pump would be associated with a high risk of bleeding. Thus, 2-debranching TEVAR was selected and performed with no hemorrhagic complications. He was discharged from the hospital on the 12th day after surgery. We believe that 2-debranching TEVAR is effective for reducing perioperative bleeding in patients with ITP.

A modified frozen elephant trunk technique for acute Stanford type A aortic dissection

BACKGROUND

Acute Stanford type A aortic dissection is often fatal, with a high mortality rate and requiring emergency intervention. Salvage surgery aims to keep the patient alive by addressing severe aortic regurgitation, tamponade, primary tear, and organ malperfusion and, if possible, prevent the late dissection-related complications in the proximal and downstream aorta. Unfortunately, no optimal standard treatment or technique to treat this disease exists. Total arch replacement with frozen elephant trunk technique plays an important role in treating acute type A aortic dissection. We aim to describe a modified elephant trunk technique and report its short-term outcomes.

METHODS

From February 2018 to August 2019, 16 patients diagnosed with acute Stanford type A aortic dissection underwent surgery with the modified frozen elephant trunk technique at Xiamen Heart Center (male/female: 9/7; average age: 56.1 ± 7.6 years). All perioperative variables were recorded and analyzed. We measured the diameters of the ascending aorta, aortic arch, and descending aorta on the bifurcation of the pulmonary and abdominal aortas and compared the diameters at admission, before discharge, and 3 months after discharge.

RESULTS

Fifteen patients (93.8%) had hypertension. The primary tears were located in the lesser curvature of the aortic arch and ascending aorta in 5 (31.3%) and 9 patients (56.3%), respectively, and no entry was found in 2 patients (12.5%). The dissection extended to the iliac artery and distal descending aorta in 14 (87.6%) and 2 patients (12.5%), respectively. The duration of cardiopulmonary bypass (CPB), cross-clamping, and antegrade cerebral perfusion were 215.8 ± 40.5, 140.8 ± 32.3, and 55.1 ± 15.2 min, respectively. Aortic valve repair was performed in 15 patients (93.8%). Bentall procedure was performed in one patient (6.3%). Another patient received coronary artery repair (6.3%). The diameters at all levels were greater on discharge than those on admission, except the aortic arch. After 3 months, the true lumen diameter distal to the frozen elephant trunk increased, indicating false lumen thrombosis and/or aortic remodeling.

CONCLUSIONS

The modified frozen elephant trunk technique for acute Stanford type A aortic dissection is safe and feasible and could be used for organ malperfusion. Short-term outcomes are encouraging, but long-term outcomes require further investigation.

[Valve-sparing Root Reimplantation for Stanford Type A Acute Aortic Dissection Combined with Aortic Root Dilation and Bicuspid Aortic Valve;Report of a Case]

A 45-year-old male developed Stanford type A acute aortic dissection combined with aortic root dilation and congenital bicuspid aortic valve (BAV). He had a Sieveres type 0 BAV, lateral subtype with right and left cusps. Valve-sparing root reimplantation was performed with decalcification of the cusps. Transthoracic echocardiography(TTE) at discharge revealed no aortic regurgitation, and peak velocity of BAV was 2.15 m/second, mean pressure gradient was 9.6 mmHg and aortic valve area was 2.15 cm2. TTE after 6 months revealed only slight elevation of the peak velocity to 2.78 m/second. To perform successful reimplantation in the case of BAV, anatomic orientation of the cusps should be approximately at 180° and the tissue of the cusps should either be normal or have only minor abnormalities. Valve-sparing root reimplantation for BAV needs a careful follow-up for progression of the aortic valve dysfunction.

[A MULTIFACETED APPROACH FOR TRAUMATIC AURICULAR AVULSION WITH VENOUS CONGESTION]

Choice of operative technique is often a major factor in the success of replantation of traumatic avulsions of the auricle. While microsurgery is considered to produce the best aesthetic results, this approach may not be an option due to vascular damage. We present the case of a 66-year-old Caucasian male with a subtotal traumatic left auricle avulsion. Microsurgical repair was not attempted as vessels amenable to anastomosis could not be found. Instead, the auricle was replanted in a non-microsurgical manner as a composite graft using Monocryl sutures. As a preventative measure for clot formation heparin was injected intradermally throughout the anterior auricular surface and helix. Twenty-four hours postoperatively, as signs of venous congestion were noted, a multimodal therapy was initiated combining mechanical, chemical and biological therapies. Medicinal leech therapy (hirudotherapy) was used to enhance venous drainage and prevent clot formation. Hirudotherapy is an effective and safe treatment modality for venous outflow obstruction in avulsed auricle injuries. However, one must consider the possible complications of leech therapy and the need for close monitoring. An examination conducted two months following the initial injury revealed optimal patient outcomes with excellent aesthetic results and full auricular sensation. Good vascular outflow is integral to the successful salvage of replanted tissues. Venous stasis must be identified and addressed early for good patient outcomes. The current report highlights the importance of a multifaceted approach in cases of traumatic auricular avulsions followed by venous congestion.

The Turkey Digit: A New Training Model for Digit Replantation

PURPOSE

Replant survival rates have reportedly declined over the past decade. Although this problem is multifactorial, 1 potential solution may include the development of a relevant teaching model. The development of an in vivo animal model that can be used for surgical training could enhance surgeon and resident experience and potentially improve outcomes. Here, we present a novel training model for digit replantation using turkey digits.

METHODS

Six mature male Bourbon Red turkeys were included in this study. With the animal under general anesthesia, the third digit on either the left or the right foot was randomly selected and amputated. The medial and lateral digital neurovascular bundles were dissected on both sides and the digit was replanted. Perfusion was confirmed prior to skin closure. The foot was casted prior to extubating the turkeys. Turkeys were then placed in a non-weight-bearing sling. Digit status was evaluated twice daily.

RESULTS

All 6 replanted digits were viable immediately after surgery and for at least 24 hours after surgery. The average digit survival was 6 days with a maximum survival of 15 days. All digits were eventually lost owing to a variety of reasons including infection and arterial thrombosis.

CONCLUSIONS

The turkey digit proved to be a successful short-term animal training model for digit replantation. Future studies are needed to determine optimum standard surgical procedure and postoperative care to maximize the educational benefits of this training model.

CLINICAL RELEVANCE

To establish an animal model that can simulate digital replantation.

Management of Vesicoureteral Reflux in a Patient With Recurrent Febrile Urinary Tract Infections, Neurogenic Bladder, and Ureteral Triplication

Ureteral triplication is a rare anomaly with about 100 total cases reported in the literature. In this case presentation, we present a case of ureteral triplication in a young female with a history of neurogenic bladder secondary to L5 lipomeningocele who presented with recurrent febrile urinary tract infections (UTIs) and vesicoureteral reflux despite antibiotic prophylaxis. Given her high grade reflux, she underwent ureteral reimplantation which ultimately led to resolution of her UTIs and reflux. Later in her clinical course, toilet training unmasked additional bladder dysfunction and she was successfully managed with clean intermittent catheterization and anticholinergics. To the best of our knowledge, this is the first case report to describe ureteral triplication, recurrent febrile UTIs and vesicoureteral reflux in the setting of a concomitant neurogenic bladder with a successful outcome.

Graft Dilatation May Cause Secondary Regurgitation in Aortic Valve-Sparing Operations

Aortic valve-sparing operations are meant to stabilize the root in order to provide stable aortic valve function. The possibility of graft dilatation has been known in other forms of aortic replacement but is largely ignored in valve-preserving surgery. We describe graft dilatation as a cause of failure late after aortic valve reimplantation. It was corrected by applying the concepts of aortic valve repair.

Reliability of S.A.R.A. (sterilization and reimplantation autograft) technique in long bone open fractures

The reimplantation of small or large extruded bone segments is one of the most complex clinical management scenarios in the treatment of open fractures. No consensus exists regarding the efficiency of this technique. The aim of the study was to analyse the clinical and radiological outcomes of Sterilization and Reimplantation Autograft (S.A.R.A.) technique in open fractures. Therefore, fifteen skeletally mature patients with Gustilo-Anderson -IIIB type fractures treated with autograft reimplantation, were included in this study. The sample size was divided in two groups: patients with a loss of small segments (Group A - less than 5 cm) and those with large segments (Group B - greater than 5 cm). Eight patients belonged to Group A and seven to Group B. The treatment of contaminated bone may be performed by the following protocols: saline rinse, povidone-iodine scrub and saline rinse, retain periosteum, immersion in antibiotic solution (clindamycin and gentamicin and metronidazole), washing with physiological solution, acute reimplantation in Group A or reimplantation after 21 days in Group B after a bone freezing at -80°C. The Radiographic Union Score (RUS), pain visual analogic score (VAS), patient satisfaction and return to work were assessed at a mean follow-up of 24 months. No cases of superficial or deep infection were reported at 2-year follow-up. The fractures achieved a complete union in 14 patients; one patient belonging to Group A had a malabsorption of the replanted bone. Furthermore, povidone-iodine scrub, antibiotic solution immersion, and washing with physiological solution preserved the articular surface morphology. This study suggests that reimplantation of extruded short or long segments may represent a reliable alternative to amputation in open long bone fractures. Further studies are needed to define the most efficient technique for sterilizing the bone autograft to reduce the complication rate.

[Three-dimensional Anatomical Anastomosis in Total Arch Replacement]

The ascending aorta and the aortic arch curve 3-dimensionally from the right front of the heart to its left rear. If this curve is replaced or connected with a straight artificial graft, the curve will lose its natural shape. Here, we reconstructed the ascending aorta and the aortic arch with 2 different types of grafts, and devised a 3-dimensional(3D) structure by anastomosis. "3D anastomosis" first involves reconstructing the ascending aorta and the aortic arch with separate grafts. An oblique incision was then made at the proximal stump of the aortic arch graft so that its tip pointed to the right side of the patient. Similarly, an oblique incision was made at the distal stump of the ascending aorta graft so that its tip pointed to the anterior position of the patient. Then, the 2 grafts were anastomosed in a twisted manner of 90 degrees. Therefore, a 3D form was created from the right front of the heart to its left rear. We achieved good results in 14 patients using this method.

Reference function of old electrical stimulation electrode in cochlear-reimplantation in children

OBJECTIVES

To explore the causes of cochlear implantation and reference function of old electrical stimulation electrode in cochlear reimplantation in children.

METHODS

The causes, surgical methods and problems found during the operations of 24 cases of cochlear reimplantation in Henan Children's Hospital from June 2016 to April 2018 were analyzed.

RESULTS

Twenty-three cases successfully completed the surgery of cochlear-reimplantation, and the remaining one case had approximately 1/3 of the anterior end of the residual cochlear electrode due to high resistance at the time of withdrawal of the electrodes. The causes of re-implantation were implant equipment failure (eleven cases), elevated impedance values of all electrodes after head trauma (two cases), and implant prolapse together with the electrode caused by a traffic accident (one case).

CONCLUSION

The old stimulus electrode can provide an important reference to reduce the risk of operation and ensure the success of the reoperation.

Vancomycin-Gentamicin Prefabricated Spacers in 2-Stage Revision Arthroplasty for Chronic Hip and Knee Periprosthetic Joint Infection: Insights Into Reimplantation Microbiology and Outcomes

BACKGROUND

Second-stage positive cultures in 2-stage revision arthroplasty are a matter of concern, as their influence in outcomes is not clearly defined. We sought to study reimplantation microbiology when using vancomycin-gentamicin prefabricated cement spacers in hip and knee periprosthetic joint infection. The associations of second-stage positive cultures with treatment failures and patient-associated factors were analyzed.

METHODS

We conducted a retrospective cohort study, examining patients managed with 2-stage revision arthroplasty due to knee or hip chronic periprosthetic joint infection between 2010 and 2017. Prefabricated vancomycin-gentamicin cement spacers were used during the spacer stage. Intraoperative microbiological culture results after the first and second stages were evaluated. The primary end point was infection eradication or relapse.

RESULTS

A total of 108 cases were included (61 hips and 47 knees). And 22.2% of patients had ≥1 second-stage positive culture, while 9.3% had ≥2 positive samples. Overall success, at an average follow-up of 46.4 months, was 77.8%. Treatment failure was higher among cases with positive cultures (15.5% vs 45.8%, P < .01) regardless of the number of positive samples. Diabetes was identified as a risk factor for second-stage positive cultures (P = .03); use of cement loaded with extra antibiotics for spacer fixation showed a protective effect (P < .01).

CONCLUSION

Second-stage positive cultures were related to a higher failure rate when using vancomycin-gentamicin cement spacers. Diabetes increased the likelihood of second-stage positive cultures. The use of extra-antibiotic-loaded cement for spacer fixation during the first stage showed a protective effect.

Long-term outcome of spiral ileal neobladder with orthotopic ureteral reimplantation

PURPOSE

The purpose of this study was to analyze long-term complications, urodynamics, and quality of life (QoL) of patients after orthotopic ileal neobladder with orthotopic ureteral reimplantation to enrich clinical data and provide a basis for clinical use of this surgery.

METHODS

Between January 2007 and January 2013, 72 consecutive patients who underwent spiral ileal neobladder following radical cystectomy were enrolled. The neobladder was created using a modified Camey-II technique. Complications were reviewed and staged according to Clavien-Dindo classification and evaluated in long-term follow-up. Urodynamics were performed, and QoL was assessed by the Functional Assessment of Cancer Therapy for Bladder Cancer (FACT-BL) instrument.

RESULTS

The total follow-up time was 60 months, and the total survival rates at 3 and 5 years after surgery were 76.4% (55/72) and 65.3% (47/72), respectively. There were 34 (47.2%) early complications in 23 (31.9%) patients and 42 (58.3%) late complications in 35 (48.6%) patients. The total satisfactory control rates were 69.1% and 66.0% at 3 and 5 years after the surgery, respectively. Urodynamic studies were performed in some patients, and the receiver operating characteristic curve analysis showed that pressure at maximum capacity, compliance, and post void residual urine had predictive value for mortality (P < 0.05). The total FACT-BL scores of patients at 1, 3, and 5 years postoperation were 125.0 ± 15.2, 127.0 ± 16.2, and 120.6 ± 13.5, respectively, and it decreased at 5 years postoperation (P < 0.05).

CONCLUSION

Spiral ileal neobladder with orthotopic ureteral reimplantation offers satisfactory long-term results, and urodynamic monitoring might have prognostic value.

The state of microsurgical practice in French forward surgical facilities from 2003 to 2015

Microsurgery is an unusual procedure in the theatres of military operations. We sought to analyze the state of microsurgical practices in the French medical treatment facilities (MTFs) deployed around the world in the 21st century. A retrospective study was conducted among all patients who were operated on in French forward surgical facilities between 2003 and 2015. Those who underwent microsurgical procedures for nerve injury, vascular injury, or extremity reconstruction were included. Only early vascular results were assessed. Among the 2589 patients operated on for an extremity injury during the study period, 56 (2.1%) were included, with the group composed of 29 patients with isolated nerve injuries, 28 patients with nerve and arterial injuries, and two patients with isolated arterial injuries, mostly at the hand level. Nerve procedures predominantly consisted of direct suturing, although autografting and nerve transfers were also performed. Thirteen microvascular repairs were carried out, including nine cases of proximal or digital revascularization; revascularization was successful in six of the nine cases. These procedures were completed by orthopedic surgeons trained in microsurgery, mostly under loupes magnification. Routine nerve repair in the field seems to be specific to French MTFs. Salvage of amputated or devascularized fingers in the combat zone had never been reported before. Such emphasizes the need to train deployed orthopedic surgeons to perform microsurgical procedures and to equip all MTFs with basic microsurgical sets and magnification means.

Timing of device reimplantation and reinfection rates following cardiac implantable electronic device infection: a systematic review and meta-analysis

OBJECTIVES

Initial management of cardiac implantable electronic device (CIED) infection requires removal of the infected CIED system and treatment with systemic antibiotics. However, the optimal timing to device reimplantation is unknown. The aim of this study was to quantify the incidence of reinfection after initial management of CIED infection, and to assess the effect of timing to reimplantation on reinfection rates.

DESIGN

Systematic review and meta-analysis.

INTERVENTIONS

A systematic review and meta-analysis was performed of studies published up to February 2018. Inclusion criteria were: (a) documented CIED infection, (b) studies that reported the timing to device reimplantation and (c) studies that reported the proportion of participants with device reinfection. A meta-analysis of proportions using a random effects model was performed to estimate the pooled device reinfection rate.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the rate of CIED reinfection. The secondary outcome was all-cause mortality.

RESULTS

Of the 280 screened studies, 8 met inclusion criteria with an average of 96 participants per study (range 15-220 participants). The pooled incidence rate of device reinfection was 0.45% (95% CI, 0.02% to 1.23%) per person year. A longer time to device reimplantation >72 hours was associated with a trend towards higher rates of reinfection (unadjusted incident rate ratio 4.8; 95% CI 0.9 to 24.3, p=0.06); however, the meta-regression analysis was unable to adjust for important clinical covariates. There did not appear to be a difference in reinfection rates when time to reimplantation was stratified at 1 week. Heterogeneity was moderate (I²=61%).

CONCLUSIONS

The incident rate of reinfection following initial management of CIED infection is not insignificant. Time to reimplantation may affect subsequent rates of device reinfection. Our findings are considered exploratory and significant heterogeneity limits interpretation.

PROSERO REGISTRATION NUMBER

CRD4201810960.