Intrawound application of vancomycin reduces wound infection after open release of post-traumatic stiff elbows: a retrospective comparative study

Efficacy of Intrawound Vancomycin in Prevention of Periprosthetic Joint Infection After Primary Total Knee Arthroplasty: A Prospective Double-Blinded Randomized Control Trial

BACKGROUND

Periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a devastating complication. Intrawound vancomycin powder has been shown to reduce infection rates in spine surgery, but its role in arthroplasty remains controversial. This prospective randomized control trial aimed to evaluate the efficacy of intrawound vancomycin in preventing PJI after primary TKA.

METHODS

A total of 1,022 patients were randomized to the study group (n = 507, who received 2 grams intrawound vancomycin powder before arthrotomy closure) or to the control group (n = 515, no local vancomycin) with a minimum follow-up of 12-months. The primary outcome was the incidence of PJI or surgical site infection (SSI). Secondary outcomes included associated minor complications such as stitch abscess, persistent wound drainage, and delayed stitch removal. Other parameters evaluated include reoperation rates and incidences of nephrotoxicity.

RESULTS

The overall infection rate in 1,022 patients was 0.66%. There was no significant difference in PJI rate in the study group (N = 1; 0.2%) versus the control group (N = 3; 0.58%), P = .264. Reoperation rates in the study group (N = 4; 0.78%) and control (N = 5; 0.97%), and SSI rates in the study (N = 1; 0.2%) and control groups (N = 2; 0.38%) were comparable. The Vancomycin cohort, however, demonstrated a significantly higher number of minor wound complications (n = 67; 13.2%) compared to the control group (n = 39; 7.56%, P < .05). Subgroup analysis showed diabetics in the study group to also have a higher incidence of minor wound complications (24 [14.1%] versus 10 [6.2%]; P < 05]. Multivariate analyses found that vancomycin use (odds ratio = 1.64) and smoking (odds ratio = 1.85) were associated with an increased risk of developing minor wound complications. No cases of nephrotoxicity were reported.

CONCLUSIONS

Intrawound vancomycin powder does not appear to reduce PJI/SSI rate in primary total knee arthroplasties, including high-risk groups. Although safe from a renal perspective, intrawound vancomycin was associated with an increase in postoperative aseptic wound complications. Intrawound vancomycin may not be effective in reducing the rate of PJI in primary TKA.

The Effect of Vancomycin and Tobramycin Local Antibiotic Powder on Surgical Site Infections After Open Treatment of Fracture: A Retrospective Propensity-Matched Analysis

OBJECTIVES

The aim of this study was to compare the effect of vancomycin/tobramycin local antibiotic powder (LAP) on surgical site infections (SSIs) after open treatment of fractures.

METHODS

DESIGN

This was a retrospective comparative study with propensity matching.

SETTING

The study was set in an urban level 1 trauma center.

PATIENTS SELECTION CRITERIA

Patients undergoing open procedures for fracture performed by a single surgeon before and after cessation of routine LAP use were included.

OUTCOME MEASURES AND COMPARISONS

Deep and superficial SSIs were the measured outcomes.

RESULTS

There were 652 open procedures for fracture performed by a single surgeon: LAP was used in 36.7% (114/310) of procedures before stopping its use, after which 342 procedures were performed without LAP. Comparison of all procedures performed with and without routine LAP use demonstrated no difference in infection rates, although there was a trend for the group without LAP to have fewer superficial SSIs (proportional difference [PD] -2.0%, 95% confidence interval [CI] -4.1% to 0.1%; P = 0.05) and more deep SSIs (PD 3.9%, 95% CI, -0.2% to 7.9%; P = 0.06). Prematch analysis demonstrated that LAP use was associated with external fixation (PD 8.5%, 95% CI, 1.6%-16.2%; P = 0.005), longer operative times (median difference 56.0 minutes, 95% CI, 39.0-74.0; P < 0.0001), greater estimated blood loss (median difference 70.0, 95% CI, 50.0-100.0; P < 0.0001), and no difference in superficial (PD 2.4%; 95% CI, -0.8% to 6.8%; P = 0.07) or deep SSIs (PD -1.6%, 95% CI, -6.2% to 4.1%; P = 0.54). After propensity matching (108 vs. 108) to control for the above differences, the LAP group, compared with the no LAP group, had no difference in superficial SSIs and was less likely to have deep SSIs (PD -8.3%, 95% CI, -16.2% to -0.2%; P = 0.04).

CONCLUSIONS

The use of vancomycin and tobramycin LAP lowered the rate of deep SSIs after open treatment of fractures on propensity-matched analysis.

LEVEL OF EVIDENCE

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

Incidence of Surgical Site Infections and Acute Kidney Injuries After Topical Antibiotic Powder Application in Orthopaedic Trauma Surgery

OBJECTIVES

To compare the incidence of deep surgical site infections (SSI) and acute kidney injuries (AKI) in patients who did and did not receive topical antibiotics during the open treatment of fractures.

DESIGN

Retrospective comparative cohort.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Three hundred ninety-six patients undergoing open fixation of fractures.

INTERVENTION

The topical antibiotic group included 78 (20%) patients. Vancomycin only was used in 28 (7%) patients with the median dose (interquartile range) of 1 g (1-2 g) and vancomycin/tobramycin was used in 48 (12%) patients with a median dose (interquartile range) of 2 g (1-2 g)/1.2 g (1.2-1.2 g).

MAIN OUTCOME MEASUREMENTS

Deep SSI requiring debridement and AKI (>50% increase in creatinine compared with preoperative level).

RESULTS

There was no detectable difference in SSI between the topical antibiotic and control groups (13% vs. 10%, odds ratio (OR) 1.3, 95% confidence interval (CI) 0.6 to 2.9). Variables associated with SSI on multivariate analysis included open fracture (OR 3.2, CI 1.5 to 6.5) and an American Society of Anesthesiologists classification of >2 (OR 2.7, CI 1.3 to 5.3). There was no detectable difference in AKI between the topical antibiotic and control groups (1 (2%) vs. 7 (5%); OR 0.3, CI 0.04 to 3).

CONCLUSION

There was no detectable difference, with wide confidence intervals, in SSI and AKI between the topical antibiotic and control groups. Further studies need to be conducted to evaluate the relationship between topical antibiotics and clinical outcomes in orthopaedic trauma surgery.

LEVEL OF EVIDENCE

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

Can Topical Vancomycin Prevent Periprosthetic Joint Infection in Hip and Knee Arthroplasty? A Systematic Review

BACKGROUND

Periprosthetic joint infection (PJI) after hip and knee arthroplasty is a leading cause of revision surgery, inferior function, complications, and death. The administration of topical, intrawound vancomycin (vancomycin powder) has appeared promising in some studies, but others have found it ineffective in reducing infection risk; for that reason, a high-quality systematic review of the best-available evidence is needed.

QUESTIONS/PURPOSES

In this systematic review, we asked: (1) Does topical vancomycin (vancomycin powder) reduce PJI risk in hip and knee arthroplasty? (2) Does topical vancomycin lead to an increased risk of complications after hip and knee arthroplasty?

METHODS

A search of Embase, MEDLINE, and PubMed databases as of June 2020 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies comparing topical vancomycin in addition to standard infection prevention regimens (such as routine perioperative intravenous antibiotics) with standard regimens only in primary hip and knee arthroplasty were identified. Patients 18 years or older with a minimum follow-up of 3 months were included. No restrictions on maximal loss to follow-up or PJI definition were imposed. Studies were excluded if they included patients with a history of septic arthritis, used an antibiotic other than vancomycin or a different route of administration for the intervention, performed additional interventions that differed between groups, or omitted a control group. A total of 2408 studies were screened, resulting in nine eligible studies reviewing 3371 patients who received topical vancomycin (vancomycin powder) during a primary THA or TKA and 2884 patients who did not receive it. Groups were comparable with respect to duration of follow-up and loss to follow-up when reported. Study quality was assessed using the Newcastle-Ottawa scale, showing moderate-to-high quality for the included studies. The risks of PJI and overall complications in the topical vancomycin group were compared with those in the control group.

RESULTS

One of nine studies found a lower risk of PJI after primary THA or TKA, while eight did not, with odds ratios that broadly bracketed the line of no difference (range of odds ratios across the nine studies 0.09 to 1.97). In the six studies where overall complications could be compared between topical vancomycin and control groups in primary THA or TKA, there was no difference in overall complication risks with vancomycin (range of ORs across the six studies 0.48 to 0.94); however, we caution that these studies were underpowered to detect differences in the types of uncommon complications associated with vancomycin use (such as allergy, ototoxicity, and nephrotoxicity).

CONCLUSION

In the absence of clear evidence of efficacy, and without a sufficiently large evidence base reporting on safety-related endpoints, topical vancomycin (vancomycin powder) should not be used in routine primary THA and TKA. Adequately powered, multicenter, prospective trials demonstrating clear reductions in infection risk and large registry-driven audits of safety-related endpoints are required before the widespread use of topical vancomycin can be recommended.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Does the Organism Profile of Periprosthetic Joint Infections Change With a Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Protocol?

BACKGROUND

While vancomycin powder and dilute povidone-iodine (VIP) is associated with fewer total joint arthroplasty (TJA) periprosthetic joint infections (PJI), its effect on PJI organism profiles is unclear. This study evaluates primary TJA PJI organism profiles before and after the implementation of a VIP protocol.

METHODS

In total, 18,299 primary TJAs performed at a university-affiliated, not-for-profit orthopedic hospital from before (1/2012-12/2013) and after (1/2016-12/2019) a VIP protocol was initiated were reviewed to identify deep PJIs that occurred within 90 days of the index arthroplasty as defined by the Musculoskeletal Infection Society guidelines. Demographics, overall organism incidence (n/TJAs), and relative organism incidence (n/PJIs) from the two cohorts were compared.

RESULTS

In total, 103 TJA PJIs were identified (pre-VIP: 32/3982; VIP: 71/14,317). Following the introduction of VIP, the overall and relative incidence of coagulase-negative staphylococcal TJA PJIs significantly decreased (overall: 0.20% to 0.04%, P = .004; relative: 25.00% to 8.45%, P = .031). In response, the relative incidence of MSSA TJA PJIs significantly increased (18.75% to 40.85%, P = .042). Broken down by arthroplasty type, VIP was associated with a significantly lower overall incidence of coagulase-negative staphylococcal total knee arthroplasty (TKA) PJIs (0.27% to 0.06%, P = .015), a significantly lower overall incidence of MRSA TKA PJIs (0.18% to 0.03%, P = .031), and a nonsignificant decrease in the overall incidence of gram-negative TKA PJIs (0.18% to 0.04%, P = .059). No organism profile changes were found in total hip arthroplasty PJIs.

CONCLUSION

VIP is not associated with more difficult to treat primary TJA PJIs. While promising, these findings require a prospective randomized controlled trial for confirmation.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Reduce the Rate of Early Periprosthetic Joint Infection After Primary Total Knee Arthroplasty

BACKGROUND

Vancomycin powder and dilute povidone-iodine lavage (VIP) was introduced to reduce the incidence of periprosthetic joint infection (PJI) in high-risk total knee arthroplasty (TKA) patients. We hypothesize that VIP can reduce the incidence of early PJI in all primary TKA patients, regardless of preoperative risk.

METHODS

An infection database of primary TKAs performed before a VIP protocol was implemented (January 2012-December 2013), during a time when only high-risk TKAs received VIP (January 2014-December 2015), and when all TKAs received VIP (January 2016-September 2019) at an urban, university-affiliated, not-for-profit orthopedic hospital was retrospectively reviewed to identify patients with PJI. Criteria used for diagnosis of PJI were the National Healthcare Safety Network and Musculoskeletal Infection Society guidelines.

RESULTS

VIP reduced early primary TKA PJI incidence in both the high-risk and all-risk cohorts compared with the pre-VIP cohort by 44.6% and 56.4%, respectively (1.01% vs 0.56% vs 0.44%, P = .0088). In addition, after introducing VIP to all-risk TKA patients, compared with high-risk TKA patients, the relative risk of PJI dropped an additional 21.4%, but this finding did not reach statistical significance (0.56% vs 0.44%, P = .4212). There were no demographic differences between the 3 VIP PJI cohorts.

CONCLUSION

VIP is associated with a reduced early PJI incidence after primary TKA, regardless of preoperative risk. With the literature supporting its safety and cost-effectiveness, VIP is a value-based intervention, but given the nature of this historical cohort study, a multicenter randomized controlled trial is underway to definitively confirm its efficacy.

Systemic Absorption and Nephrotoxicity Associated With Topical Vancomycin Powder for Fracture Surgery

OBJECTIVES

To determine whether using topical vancomycin powder in fracture surgery may result in low levels of vancomycin in the serum and not result in nephrotoxicity.

DESIGN

Prospective observational at a single site as a substudy of the VANCO trial.

SETTING

Single, large urban level I trauma center.

PATIENTS/PARTICIPANTS

Fifty-eight patients with tibial plateau and pilon fractures randomized to the treatment arm at the principal investigator's site.

INTERVENTION

Topical vancomycin powder (1000 mg) applied directly in the wound over all metal implants at the time of wound closure.

MAIN OUTCOME MEASUREMENTS

Serum vancomycin levels at 1 hour and 6-8 hours after surgery. Secondary outcomes included serum creatinine before surgery, a day after surgery, and at 2 weeks postoperatively and complete blood count at 2 weeks postoperatively.

RESULTS

Except in 2 patients who also received intravenous vancomycin, none of the study patients had detectable (>5 µg/mL) serum vancomycin levels at 1 hour and 6-8 hours after surgery. One patient with a history of elevation of serum creatinine had a minor increase of serum creatinine but had undetectable vancomycin levels. None of the other patients had a clinically significant increase in creatinine levels.

CONCLUSIONS

Despite its relatively widespread usage, little data exist regarding the systemic levels and nephrotoxicity associated with the topical use of vancomycin powder in orthopaedic fracture surgery. These prospective data indicate that there seems to be little clinical concern regarding toxicity associated with systemic absorption of vancomycin powder in this specific clinical application.

LEVEL OF EVIDENCE

Therapeutic Level IV. See instructions for authors for a complete description of levels of evidence.

Topical Vancomycin Powder Decreases the Proportion of Staphylococcus aureus Found in Culture of Surgical Site Infections in Operatively Treated Fractures

OBJECTIVES

To determine whether patients with operatively treated fractures and surgical site infection after use of topical vancomycin powder have a lower proportion of Staphylococcus aureus infections than patients who did not receive topical vancomycin powder.

DESIGN

Retrospective cohort study.

SETTING

Level I trauma center.

PATIENTS

Treatment group: 10 of 133 patients (145 fractures) with surgical site infections who received intrawound vancomycin powder at the time of wound closure for fracture fixation. Control group: 175 patients who sustained deep surgical site infections during the same period but did not receive vancomycin powder.

INTERVENTION

Vancomycin powder or no vancomycin powder.

MAIN OUTCOME MEASUREMENT

Proportion of patients' cultures positive for S. aureus.

RESULTS

The proportion of cultures positive for S. aureus was significantly lower in patients with surgical site infection who received vancomycin powder than in those who did not receive vancomycin powder (10% [1 of 10 patients in the treatment group] vs. 50% [87 of 175 patients in the control group]; P = 0.02). A trend was observed for a lower proportion of methicillin-resistant S. aureus (0% vs. 23%; P = 0.12).

CONCLUSIONS

Vancomycin powder might alter the bacteriology of surgical site infections and decrease the proportion in culture of the most common organism typically present after fracture surgery infection. These findings suggest that the application of vancomycin powder might change the bacteriology of surgical site infections when they occur, regardless of the effect on overall infection rates. Although our bacteriology results are clinically and statistically significant, these findings must be confirmed in larger randomized controlled trials.

LEVEL OF EVIDENCE

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

Management of Periprosthetic Joint Infection in Total Elbow Arthroplasty

Periprosthetic joint infection (PJI) is a potentially devastating complication after total elbow arthroplasty (TEA) that can lead to significant morbidity for the patient as well as increased health care-related costs. Despite the potential morbidity associated with TEA PJI, evidence is limited regarding an optimal treatment algorithm. Initial management typically consists of either irrigation and debridement or 2-stage revision. A stable implant, a functioning triceps, and an intact soft tissue envelope are necessary to perform irrigation and debridement. Irrigation and debridement is associated with a relatively high risk of infection recurrence especially in chronic infections. Two-stage revision offers a lower recurrence risk, although there is a 25% chance of not completing the second stage. Resection arthroplasty, arthrodesis, and amputation are salvage options, whereas medical treatment, in the form of antibiotics alone, is reserved for poor surgical candidates. Further multicenter prospective study and retrospective review of registry data focusing on different treatment algorithms, prevention strategies, and functional outcomes would be helpful to elucidate the ideal management of elbow PJI.

Open elbow arthrolysis for post-traumatic elbow stiffness: an update

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path. Cite this article: Bone Joint Open 2020;1-9:576-584.

Post-traumatic elbow stiffness: Pathogenesis and current treatments

Post-traumatic elbow stiffness is a major cause of functional impairment after elbow trauma. A stiff elbow limits patients' ability to position their hand in space for optimal use of their upper extremities, and as such, is a frequent indication for reoperation. This article reviews current concepts on the pathogenesis of post-traumatic elbow stiffness. Current nonoperative treatment options include therapy, bracing, and manipulation under anesthesia, while operative treatment options include arthroscopic and open arthrolysis. The pros and cons of various treatment options are discussed, with a focus on the evidence supporting their use, the expected functional gains, and associated complications. Future directions in post-traumatic elbow stiffness are highlighted.

Intrasite Antibiotic Powder for the Prevention of Surgical Site Infection in Extremity Surgery: A Systematic Review

INTRODUCTION

Although the role of intrasite antibiotic powder in preventing surgical site infections (SSIs) has been extensively explored in spinal surgery, it remains underevaluated in the other orthopaedic subspecialties. This systematic review examines the utilization of intrawound antibiotic powder as a prophylactic measure against SSIs in orthopaedic procedures.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, electronic searches were conducted on Ovid MEDLINE, and PubMed. Only English language, nonspine clinical studies published before May 2018 were included.

RESULTS

The initial search identified 179 individual citations, and 11 studies met the eligibility criteria. All included studies were level III retrospective studies. Represented subspecialties included total joint arthroplasty, upper extremity, foot and ankle, and trauma. Eight studies demonstrated a statistically significant decrease in SSIs with the use of intrasite antibiotic powder.

DISCUSSION

There are no current guidelines for the use of intrasite antibiotic powder for the prevention of SSIs in orthopaedic procedures. Despite the lack of high-quality evidence available in the literature, published smaller studies do suggest a significant protective effect. However, recommendations with regard to this technique after common orthopaedic procedures cannot yet be made.

What Range of Motion and Functional Results Can Be Expected After Open Arthrolysis with Hinged External Fixation For Severe Posttraumatic Elbow Stiffness?

BACKGROUND

The elbow is more susceptible to loss of motion after trauma than any other joint. Open arthrolysis often is performed for posttraumatic elbow stiffness if the stiffness does not improve with nonsurgical treatment, but the midterm results of this procedure and factors that may limit recovery have not been widely studied.

QUESTIONS/PURPOSES

We reviewed patients who had undergone open arthrolysis with hinged external fixator for severe posttraumatic elbow stiffness (ROM ≤ 60°) with a minimum of 5 years followup to (1) analyze ROM gains; (2) assess functional improvement with the Mayo Elbow Performance Index (MEPI) and DASH, quality of life with the SF-36, pain with VAS, and ulnar nerve function with the Amadio rating scale and Dellon classification; and (3) identify complications and risk factors that might hinder mid-term elbow motion recovery after this procedure.

METHODS

Between March 2011 and December 2012, we generally offered patients with elbow stiffness an open arthrolysis procedure when function did not improve with 6 months of nonoperative therapy, and no contraindications such as immature heterotopic ossification or complete destruction of articular cartilage were present. During that time, 161 patients underwent open arthrolysis for posttraumatic elbow stiffness at our institution; 49 of them satisfied the study inclusion criteria (adults with elbow ROM ≤ 60° as a result of trauma) and exclusion criteria (stiffness caused by burns or central nervous system injuries, causative trauma associated with nonunion or malunion of the elbow, severe articular damage that would have necessitated joint arthroplasty, or prior elbow release). In general, a combined medial-lateral approach to the elbow was performed to address the soft tissue tethers and any blocks to elbow motion, and a hinged external fixator was applied for 6 weeks to maintain elbow stability and improve the efficacy of postoperative rehabilitation. These patients were evaluated retrospectively at a mean followup period of 69 months (range, 62-83 months), and demographics, disease characteristics, arthrolysis details, pre- and postoutcome measures as noted, and complications were recorded via an electronic database. Multivariate regression analysis was performed to identify factors associated with ROM recovery.

RESULTS

At final followup, total ROM increased from a preoperative mean of 27 ± 20° to a postoperative mean of 131 ± 11° (mean difference, 104°; 95% CI, 98°-111°; p < 0.001), and 98% (48 of 49) of patients achieved a functional ROM of 30° to 130°. Improvements were also found in functional scores (MEPI: 54 ± 12 to 95 ± 7, mean difference, 41 points; DASH: 48 ± 17 to 8 ± 8, mean difference, 40 points; both p < 0.001), life quality (physical SF-36: 46 ± 11 to 81 ± 12, mean difference, 35 points; mental SF-36: 43 ± 14 to 80 ± 9, mean difference, 37 points; both p < .001), pain (VAS: 2.5 ± 2.4 to 0.4 ± 0.8; mean difference, 2.0 points; p < 0.001), and ulnar nerve function (Amadio score: 7.8 ± 1.9 to 8.4 ± 0.8; mean difference, 0.6 points; p = 0.004). A total of 18% (nine of 49 patients) developed complications, including new-onset or exacerbated nerve symptoms (four patients), recurrent heterotopic ossification (two patients), and pin-related infections (three patients). No patients underwent subsequent surgery for any of the above complications. Lastly, the medium-term ROM was divided into ROM ≤ 120° (n = 9) and ROM > 120° (n = 40). After controlling for potential confounding variables such as duration of stiffness and tobacco use, we found that tobacco use was the only independent risk factor examined (odds ratio, 9; 95% CI, 2-47; p = 0.009) associated with recovery of ROM.

CONCLUSIONS

Satisfactory medium-term results were found for open arthrolysis with hinged external fixation with our protocol in patients who had severe posttraumatic elbow stiffness. Appropriate and sufficient releases of tethered soft tissues and correction of any blocks that affect elbow motion intraoperatively, a dedicated team approach, and an aggressive and systematic postoperative rehabilitation program are the core steps for this procedure. Additionally, the importance of preoperative discontinuation of tobacco use should be emphasized.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Vancomycin pre-soaking of the graft reduces postoperative infection rate without increasing risk of graft failure and arthrofibrosis in ACL reconstruction

PURPOSE

To investigate whether pre-soaking the graft in vancomycin during anterior cruciate ligament reconstruction (ACLR) reduces the postoperative infection rate and if this technique is associated with an increased rate of complications, including graft failure or arthrofibrosis.

METHODS

A retrospective review of a prospective database was performed in 1779 patients who underwent ACLR over a period of 5 years, analysing the rate of postoperative deep knee infection. Group 1 and 2 both received perioperative IV antibiotics, while only group 2 underwent ACLR with grafts pre-soaked in a 5 mg/ml vancomycin solution. To analyse possible side effects associated with vancomycin use, 500 patients out of the overall study population (100 patients per year) were randomly selected and retrospectively interviewed for further postoperative complications including graft failure and arthrofibrosis as well as subjective evaluation of their knee by completing the IKDC form with a minimum mean follow-up of 37 months.

RESULTS

In group 1, 22 out of 926 (2%) patients suffered a postoperative deep knee infection. In contrast, there were no postoperative infections in the second group of 853 patients (0%). 16 of 22 infections (73%) were caused by coagulase-negative Staphylococcus. Statistical analysis revealed a significantly reduced postoperative infection rate when bathing the autograft in vancomycin (p < 0.01). Analysis of the random sample revealed a significant decrease of graft failure with 8 reruptures in 257 patients (3%) in the vancomycin group compared to 16 cases of graft failure in 167 patients (10%) in the control group (p < 0.05). No differences were found in the rate of postoperative arthrofibrosis, Tegner or subjective outcome scores.

CONCLUSION

Prophylactic vancomycin pre-soaking of autografts during ACLR appears to be a viable, cost-effective and safe option to reduce the rate of deep infection compared to systemic antibiotics alone.

LEVEL OF EVIDENCE

III.

Systematic Review and Meta-Analysis of Intrawound Vancomycin in Total Hip and Total Knee Arthroplasty: A Call for a Prospective Randomized Trial

BACKGROUND

Topical intrawound vancomycin has been used extensively in spine surgery to decrease surgical site infections. However, the efficacy of intrawound vancomycin in total hip (THA) and total knee arthroplasty (TKA) to prevent periprosthetic joint infection (PJI) has not been established.

METHODS

The PubMed and MEDLINE databases were searched to identify studies utilizing intrawound vancomycin in primary and revision THA and TKA. Data for postoperative infection were pooled using random effect models with results reported as odds ratios (ORs) and 95% confidence intervals. Studies were weighted by the inverse variance of their effect estimates.

RESULTS

Of the 91 studies identified, 6 low-quality retrospective studies (level III) were pooled for further analysis. A total of 3298 patients were assessed, 1801 of which were treated with intrawound vancomycin. Overall, patients who received vancomycin had a decreased rate of PJI (OR 0.2530, P < .0001). When analyzed separately, TKA patients and THA patients who received intrawound vancomycin had lower rates of PJI (OR 0.3467, P = .0005 and OR 0.3672, P = .0072, respectively). Pooled primary TKA and THA patients receiving vancomycin saw the rate of PJI decrease (OR 0.4435, P = .0046). Pooled revision TKA and THA patients saw a similar decrease in infection rates (OR 0.2818, P = .0013). No apparent publication bias was observed; however, the results from this analysis are limited by the low quality of evidence and inherent potential for bias.

CONCLUSION

Intrawound vancomycin may reduce the risk of PJI in primary and revision TKA and THA. However, only low-quality evidence exists, highlighting the need for randomized controlled trials before broad adoption of this practice can be recommended given the potential implications of widespread use of vancomycin in hip and knee arthroplasty.

Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: prevention of periprosthetic shoulder infection

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. Over 800 international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form a consensus workgroup. The following proceedings on the prevention of periprosthetic shoulder infection come from 16 questions evaluated by delegates from the shoulder section.

Intrawound Antibiotic Powder Decreases Frequency of Deep Infection and Severity of Heterotopic Ossification in Combat Lower Extremity Amputations

BACKGROUND

Amputations sustained owing to combat-related blast injuries are at high risk for deep infection and development of heterotopic ossification, which can necessitate reoperation and place immense strain on the patient. Surgeons at our institution began use of intrawound antibiotic powder at the time of closure in an effort to decrease the rate of these surgical complications after initial and revision amputations, supported by compelling clinical evidence and animal models of blast injuries. Antibiotic powder may be useful in reducing the risk of these infections, but human studies on this topic thus far have been inconclusive.

PURPOSE

We sought to determine whether administration of intrawound antibiotic powder at the time of closure would (1) decrease the risk of subsequent deep infections of major lower-extremity combat-related amputations, and (2) limit formation and decrease severity of heterotopic ossification common in the combat-related traumatic residual limb.

METHODS

Between 2009 and 2015, 252 major lower extremity initial and revision amputations were performed by a single surgeon. Revision cases were excluded if performed specifically to address deep infection, leaving 223 amputations (88.5%) for this retrospective analysis. We reviewed medical records to collect patient information, returns to the operating room for subsequent infection, and microbiologic culture results. We also reviewed radiographs taken at least 3 months after surgery to determine the presence and severity of heterotopic ossification using the Walter Reed classification system. We grouped cases according to whether limbs underwent initial or revision amputations, and whether the limbs had a history of a prior infection. Apart from the use of antibiotic powder and duration of followup, the groups did not differ in terms of age, mechanism of injury, or sex. We then calculated the absolute risk reduction for infection and heterotopic ossification and the number needed to treat to prevent an infection.

RESULTS

Overall, administration of antibiotic powder resulted in a 13% absolute risk reduction of deep infection (14 of 82 [17%] versus 42 of 141 [30%]; p = 0.03; 95% CI, 0.20%-24.72%). In revision amputation surgery, the absolute risk reduction of infection with antibiotic powder use was 16% overall (eight of 58 versus 17 of 57; 95% CI, 1.21%-30.86%), and 25% for previously infected limbs (eight of 46 versus 14 of 33; 95% CI, 4.93%-45.14%). The number needed to treat to prevent one additional deep infection in amputation surgery is eight in initial amputations, seven in revision amputations, and four for revision amputation surgery on previously infected limbs. With the numbers available, we observed no reduction in the risk of heterotopic ossification with antibiotic powder use, but severity was decreased in the treatment group in terms of the number of residual limbs with moderate or severe heterotopic ossification (three of 12 versus 19 of 34; p = 0.03).

CONCLUSIONS

Our findings show that administration of intrawound antibiotic powder reduces deep infection in residual limbs of combat amputees, particularly in the setting of revision amputation surgery in apparently aseptic residual limbs at the time of the surgery. Furthermore, administration of antibiotic powder for amputations at time of initial closure decreases the severity of heterotopic ossification formation, providing a low-cost adjunct to decrease the risk of two complications common to amputation surgery.Level of Evidence Level III, therapeutic study.

Determining the effective timing of an open arthrolysis for post-traumatic elbow stiffness: a retrospective cohort study

Background

Following trauma, the elbow is the most susceptible to restricted motion among all joints. Open arthrolysis is often performed for post-traumatic elbow stiffness if that stiffness does not improve with non-operative management. However, the optimal timing for performing an open arthrolysis remains controversial. The purpose of this study was to compare the outcome (elbow motion and function) and the rate of complications among patients who had undergone early, median and late release procedures to establish an optimal time interval following the injury, after which, an effective open arthrolysis can be performed.

Methods

In this retrospective cohort study, we included total 133 patients, who had undergone open arthrolysis for post-traumatic elbow stiffness. The subjects were divided into 3 groups, with 31 patients in the early release group (arthrolysis performed at 6–10 months after injury), 78 patients in the median release group (at 11–20 months), and 24 patients in the late release group (at > 20 months). The release procedure in all patients was performed by the same surgeon, using the same technique. The general data, functional performance, and complications, if any, were retrospectively documented for all patients and statistically analysed.

Results

The demographic data and disease characteristics of all patients were comparable at baseline. Postoperatively, no significant differences were found among the three groups with respect to the range of motion (p = 0.067), Mayo Elbow Performance Score (p = 0.350) and its ratings (p = 0.329), visual analog scale score for pain (p = 0.227), Dellon classification for ulnar nerve symptoms (p = 0.497), and each discrete complication (all p values > 0.05).

Conclusions

At the final follow-up, our results showed no significant difference in the postoperative elbow motion capacities, functional scores and the rates of complications among patients who had undergone an early, median, and late release. Therefore, we have recommended that an early arthrolysis would be preferable due to its multiple advantages, and the conventionally observed interval of > 1 year after the injury, could be shortened.

Level of evidence

Level III; Retrospective Cohort Design; Therapeutic Study.

Boosting the antimicrobial action of vancomycin formulated in shellac nanoparticles of dual-surface functionality

We demonstrate a strong enhancement of the antimicrobial action of vancomycin encapsulated in shellac nanocarriers with cationic surface functionality which concentrate on the microbial cell membranes.

Use of Intrawound Antibiotics in Orthopaedic Surgery

Intrawound antibiotics have been used in orthopaedic surgery procedures to prevent the development of surgical site infections. Local delivery of antibiotic powder has demonstrated a notable reduction in surgical site infection in rabbit and rodent in vivo models, as well as in other surgical fields, including vascular, colorectal, cardiothoracic, and dermatologic surgery. Intrawound antibiotic powder has been used in many orthopaedic applications, including spine surgery, total joint arthroplasty, trauma, foot and ankle reconstruction, and elbow surgery. Although the theory behind the use of intrawound antibiotic powder is promising, it has potential adverse effects, including antibiotic resistance, circulatory collapse, and decreased bone healing. In addition, most studies in the orthopaedic literature on the use of intrawound antibiotic powder are retrospective in nature.

Preventing infection in shoulder surgery

Although rare, infection after shoulder surgery can represent a devastating complication. Infection can negatively affect clinical outcomes, and eradication often requires a protracted treatment course. Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes are among the most frequently isolated pathogens. Perioperative measures can be implemented to reduce infection risk. Here we review various perioperative practices and their efficacy at reducing infection after shoulder surgery.

Impact of different glucose metabolism status on clinical outcomes of open arthrolysis for post-traumatic elbow stiffness

BACKGROUND

Diabetes and prediabetes are worldwide public health problems and are considered predisposing factors for adverse functional outcomes after various orthopedic operations. The purpose of this retrospective study was to determine the impact of glucose metabolism status on functional outcomes and complications after open arthrolysis for post-traumatic elbow stiffness.

METHODS

The study included 152 patients with post-traumatic elbow stiffness undergoing arthrolysis, including 120 in the normoglycemic group, 21 in the impaired glucose regulation group, and 11 in the diabetes mellitus group. General patient data, functional performance, and complications were documented and analyzed.

RESULTS

Demographic data and disease characteristics were comparable at baseline. Postoperatively, significant differences were found in range of motion and the Mayo Elbow Performance Score: the diabetes mellitus group had the poorest clinical outcomes. However, there were no significant differences in forearm rotation, visual analog scale pain scores, and complication rates.

CONCLUSION

Patients with post-traumatic elbow stiffness and abnormal glucose metabolism were at increased risk of poorer outcomes after open arthrolysis, and patients with diabetes mellitus had the poorest performance. This study underlines the importance of glycemic control in patients with abnormal glucose metabolism before open arthrolysis.

Antibiotic Prophylaxis and Prevention of Surgical Site Infection in Shoulder and Elbow Surgery

Infection after orthopedic procedures is a devastating and serious complication associated with significant clinical and financial challenges to the health care system and unfortunate patient. The time and resource-intensive nature of treating infection after orthopedic procedures has turned attention toward enhancing prevention and establishing quality improvement measures. Prevention strategies throughout the perioperative period include host optimization, risk mitigation, reducing bacterial burden and proper wound management. Understanding the most common offending organisms of the shoulder, Propionibacterium acnes and coagulase negative Staphylococcus species, and their hypothesized mechanism of infection is crucial to selecting appropriate preventative measures.

In Vitro Effect of Vancomycin on the Viability of Articular Chondrocytes

OBJECTIVES

To characterize the in vitro toxicity of vancomycin on articular cartilage.

METHODS

Osteochondral samples extracted from fresh, juvenile porcine stifle (knee) joints were exposed to vancomycin saline concentrations of 2, 5, and 10 mg/mL and compared with a saline and nonsaline treated control. Comparison of chondrocyte viability was assessed with histology examination of chondrocyte degeneration using the Mankin criteria and a live/dead staining using ethidium homodimer-2 and calcien acetoxymethylester stain and confocal laser scanning microscopy.

RESULTS

A comparison of chondrocyte viability in the control sample and 2 mg/mL group showed no statistical difference (P = 0.38). The chondrocyte toxicity was statistically significantly higher in both the 5 mg/mL (P = 0.003) and 10 mg/mL (P < 0.001) experimental groups in comparison to the control sample. Chondrocyte death increased in a statistically significant dose-dependent fashion. Histologically, the Mankin scores were higher for the saline-treated group in comparison to the untreated control group.

CONCLUSIONS

Vancomycin is toxic to articular chondrocytes in concentrations of 5 mg/mL and greater. Strategies for controlling concentration must be developed before routine application of topical antibiotics around synovial joints is performed.

Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review

Surgical site infections remain a dreaded complication of orthopaedic surgery, affecting both patient economics and quality of life. It is important to note that infections are multifactorial, involving both surgical and patient factors. To decrease the occurrence of infections, surgeons frequently use local modalities, such as methicillin-resistant Staphylococcus aureus screening; preoperative bathing; intraoperative povidone-iodine lavage; and application of vancomycin powder, silver-impregnated dressings, and incisional negative-pressure wound therapy. These modalities can be applied individually or in concert to reduce the incidence of surgical site infections. Despite their frequent use, however, these interventions have limited support in the literature.

[Effectiveness of improved elbow anteromedial approach in treatment of ulna coronoid process fracture]

Objective

To observe the effectiveness of reduction and fixation by the improved elbow anteromedial approach in treatment of ulna coronoid process fracture.

Methods

Between January 2010 and December 2014, 13 patients with the ulna coronoid process fracture were treated with reduction and fixation by the improved elbow anteromedial approach. There were 10 males and 3 females with an average age of 37.2 years (range, 18-57 years). Five cases were caused by traffic accident, 7 cases by falling injury from height, and 1 case by object impact injury. Seven cases were the terrible triad of the elbow, 4 cases were the ulna coronoid process and radial head fractures, 1 case was the proximal radius and ulna fractures, and 1 case was the ulna coronoid process and distal radius fractures. According to Regan-Morrey classification criteria, the ulna coronoid process fracture was rated as type Ⅱ in 2 cases and as type Ⅲ in 11 cases. According to O'Driscoll classification criteria, 10 of the 13 cases were anterior coronoid fracture (8 cases of type Ⅱb, 2 of type Ⅱc), and 3 of basal fracture. The operation time, amount of intraoperative bleeding, postoperative complications, range of motion (ROM) of the elbow joint, Mayo elbow function index (MEPI) score and fracture healing time were recorded.

Results

The average operation time was 38.7 minutes (range, 30-55 minutes), and the average amount of intraoperative bleeding was 109.3 mL (range, 90-160 mL). All incisions healed at stage Ⅰ. There was no iatrogenic vascular or nerve injury. All patients were followed up 13-24 months (mean, 16.9 months). All fractures achieved clinical healing. The average healing time was 11.2 weeks (range, 8-16 weeks). There were 2 cases of heterotopic ossification. At last follow-up, the ROM of elbow flexion was 119-145° (mean, 132.4°); the ROM of elbow extension was -8-15° (mean, 7°). The ROM of forearm pronation was 68-90° (mean, 78.6°), and the ROM of forearm supination was 76-90° (mean, 84.3°). At last follow-up, the MEPI score was 70-100; and 9 cases were excellent, 3 cases were good, and 1 case was fair. The excellent and good rate was 92.3%.

Conclusion

Improved elbow anteromedial approach for the ulna coronoid process fracture can not only avoid the injuries of surrounding blood vessels and nerves, but also perform fracture reduction and fixation under direct vision. It is a safe, simple, and effective treatment method for the ulna coronoid process fracture.

The management and surgical intervention timing of enchondromas: A 10-year experience

Enchondroma, reportedly the most common primary tumor of the long bones of the hand, usually develops during the first till fourth decades of life. However, there has no consensus been reached regarding the surgical intervention timing for these patients. We aim to evaluate the optimal surgical intervention timing for the patients with fractures due to enchondromas, investigate the impact of pathological fractures on the treatment and outcomes in these patients.Medical records and X-rays of patients treated for enchondroma of the hand from 2005 to 2015 were retrospectively reviewed. We collected 148 cases in total and 92 of them had complete information including X-rays, medical records, and files of follow up.There were no significant differences in terms of consolidation time after surgery, recurrence rate, and DASH scores between the groups with and without fractures; the treatment costs were higher in the group with fractures than those without fractures; however, patients without fractures were able to resume work earlier than those with fractures.The pathological fractures associated with enchondromas have no significant impact on the treatment outcomes compared to those with simple nonfractured enchondromas. Although the cost was more expensive for patients treated primarily with pathological fractures due to enchondromas, these patients could resume their work normally much earlier than those treated by delayed surgery. Early surgical intervention is recommended for better results and no increased risks for patients with pathological fractures caused by enchondromas.

The cost effectiveness of vancomycin for preventing infections after shoulder arthroplasty: a break-even analysis

BACKGROUND

Increasing methicillin resistance and recognition of Propionibacterium acnes as a cause of infection in shoulder arthroplasty has led to the adoption of local vancomycin powder application as a more effective method to prevent expensive periprosthetic infections. However, no study has analyzed the cost effectiveness of vancomycin powder for preventing infection after shoulder replacement.

METHODS

Cost data for infection-related care of 16 patients treated for deep periprosthetic shoulder infection was collected from our institution for the break-even analysis. An equation was developed and applied to the data to determine how effective vancomycin powder would need to be at reducing a baseline infection rate to make prophylactic use cost effective.

RESULTS

The efficacy of vancomycin (absolute risk reduction [ARR]) was evaluated at different unit costs, baseline infection rates, and average costs of treating infection. We determined vancomycin to be cost effective if the initial infection rate decreased by 0.04% (ARR). Using the current costs of vancomycin reported in the literature (range: $2.50/1000 mg to $44/1000 mg), we determined vancomycin to be cost effective with an ARR range of 0.01% at a cost of $2.50/1000 mg to 0.19% at $44/1000 mg. Baseline infection rate does not influence the ARR obtained at any specific cost of vancomycin or the cost of treating infection.

CONCLUSIONS

We have derived and used a break-even equation to assess efficacy of prophylactic antibiotics during shoulder surgery. We further demonstrated the prophylactic administration of local vancomycin powder during shoulder arthroplasty to be a highly cost-effective practice.

Posttraumatic stiff elbow

Posttraumatic stiff elbow is a frequent and disabling complication and poses serious challenges for its management. In this review forty studies were included to know about the magnitude of the problem, causes, pathology, prevention, and treatment of posttraumatic stiff elbow. These studies show that simple measures such as internal fixation, immobilization in extension, and early motion of elbow joint are the most important steps that can prevent elbow stiffness. It also supports conservative treatment in selected cases. There are no clear guidelines about the choice between the numerous procedures described in literature. However, this review article disproves two major beliefs-heterotopic ossification is a bad prognostic feature, and passive mobilization of elbow causes elbow stiffness.

Infection after fracture osteosynthesis - Part II

In the first part of this article, we have discussed the pathogenesis, clinical presentation, diagnosis and classification of infection after fracture osteosynthesis with implants, termed here as osteosynthesis-associated infection (OAI). Prolonged antibiotic treatment is usually necessary. Implant retention and maintenance of fracture stability to allow for fracture healing in spite of infection are allowed for OAI. Depending on the severity of infection, status of fracture healing and host status, the treatment follows five common pathways. These are non-operative treatment, debridement with implant retention, conversion of fixation, implant removal and suppression therapy. The decision-making process leading to each treatment pathway and challenging scenarios is discussed in detail.

Local Intra-wound Administration of Powdered Antibiotics in Orthopaedic Surgery

Surgical site infection (SSI) is one of the most common complications after orthopaedic surgery, leading to significant morbidity and its associated costs. Surgical guidelines strongly recommend the use of systemic antibiotic prophylaxis to reduce the risk for developing SSI. Locally administered powdered antibiotics have the potential to provide remarkably high intra-wound concentrations without risk for systemic toxicity. However, a paucity of high quality evidence in the orthopaedic literature has prevented widespread adoption of this technique. The majority of clinical studies on local intra-wound antibiotics have evaluated the use of topical powdered vancomycin in spinal surgery, though only a single prospective study currently exists. This review will discuss all the available evidence describing the effectiveness, pharmacokinetics, and potential adverse effects with the use of topical powdered antibiotics in orthopedic surgery.

Spanish Broom (Spartium junceum L.) fibers impregnated with vancomycin-loaded chitosan nanoparticles as new antibacterial wound dressing: Preparation, characterization and antibacterial activity

In this work, we propose as new wound dressing, the Spanish Broom fibers impregnated with vancomycin (VM) loaded chitosan nanoparticles. Spanish Broom fibers were extracted by patented method DiCoDe and the morphological, physical and mechanical properties were investigated. Chitosan nanoparticles were prepared by ionic gelation using different weight ratios between chitosan (CH) and tripolyphosphate (TPP). Nanoparticles were characterized in terms of size, zeta potential, yield, encapsulation efficiency, stability and drug release. Finally, the antibacterial activity against Staphylococcus aureus as well as in vitro cytotoxicity on HaCaT cells were evaluated. The best formulation CH/TPP 4:1 was selected based on the encapsulation efficiency and yield. Spanish Broom fibers impregnated with loaded nanoparticles showed an increased antibacterial activity against S. aureus compared to the same fibers containing VM without nanoparticles. Moreover, these fibers were not toxic to HaCaT keratinocytes cells. In conclusion, Spanish Broom fibers impregnated with VM loaded CH/TPP nanoparticles would appear to be a promising candidate for wound dressing application.

Complications of Open Elbow Arthrolysis in Post-Traumatic Elbow Stiffness: A Systematic Review

Objective

The objective of this study was to systematically review the literature for a more comprehensive understanding of the complications of open elbow arthrolysis in patients with post-traumatic elbow stiffness and provide a reference for better prevention and treatment of them.

Methods

The PubMed, EMBASE, Cochrane Library, and Google Scholar databases were searched for therapeutic studies with a set of inclusion and exclusion criteria. Data were extracted from selected articles, and a statistical analysis was performed to evaluate related factors and management of the complications.

Results

Twenty-eight articles published between 1989 and 2013, involving 810 patients, were included. Most of the complications included in the selected articles were nerve complications, heterotopic ossification, elbow instability, infection, pin-related complications and repeat elbow contracture. The total complication rate was 24.3% ± 3.0%, and the reoperation rate was 34.0%. Furthermore, the statistical analysis revealed that preoperative range of motion (β = -0.004, P = 0.01) and proportion of female (β = 0.336, P = 0.04) were the independent factors affecting the total complication rate.

Conclusions

Various risk factors are related to each of the complications, and we found that patients with less preoperative ROM and a higher proportion of female gender may point to a higher total complication rate. Therefore, to further improve the overall outcomes of this procedure, more and larger prospective studies should be performed to further elucidate the effects of prophylactic interventions targeting the risk factors, thus improving the methods of prevention and treatment of complications.

Hernia, mesh, and topical antibiotics, especially gentamycin: seeking the evidence for the perfect outcome…

Inguinal hernia repair is a clean surgical procedure and surgical site infection (SSI) rate is generally below 2%. Antibiotic prophylaxis is not routinely recommended, but it may be a good choice for institutions with high rates of wound infection (>5%). Typical prophylaxis is the intravenous application of first or second-generation cephalosporins before the skin incision. However, SSI rate remains more than 2% in many centers in spite of intravenous antibiotic prophylaxis. Even a 1% SSI rate may be unacceptable for the surgeons who specifically deal with hernia surgery. A hernia center targets to be a center of excellence not only in respect of recurrence rate but also for other postoperative outcomes, therefore a further measure is required for an excellent result regarding infection control. Topical gentamycin application in combination with preoperative single-dose intravenous antibiotic may be a useful to obtain this perfect outcome. Data about this subject are not complete and high-grade evidence has not been cumulated yet. Prospective randomized controlled trials can make our knowledge more solid about this subject and help the surgeons who seek perfect outcome regarding infection control in inguinal hernia surgery.