Deep infection after hip hemiarthroplasty: risk factors for infection and outcome of treatments

AIMS

Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited.

METHODS

Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year.

RESULTS

A total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection.

CONCLUSION

Deep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures. Cite this article: Bone Jt Open 2021;2(11):958-965.

Appendix mass: do we know how to treat it?

INTRODUCTION

The traditional management of appendiceal mass has been an initial conservative approach followed by interval appendicectomy. More recently, the necessity of interval appendicectomy has been questioned by a growing amount of evidence in the surgical literature. The aim of this study was to review the available scientific evidence and to determine how appendiceal masses are currently being managed in the Mid-Trent region by general surgeons.

PATIENTS & METHODS

A literature search using Medline, Embase, Cinahl, HMIC and Biosis was carried out. A personal or telephonic survey of all consultants and specialist registrars working in general surgery in the Mid-Trent region (n = 67) was conducted recording their management protocol of 3 different clinical scenarios--a 14-year-old boy, a 29-year-old female and a 68-year-old male. Responses of the questionnaire were entered to a database in Microsoft Access 2000 and analysed.

RESULTS

The results showed that there was difference of opinion on the management of appendix mass in either scenario. Appendectomy (interval or emergency) is still practised by 75% of general surgeons in the Mid-Trent region and less that 25% manage asymptomatic appendix mass without interval appendectomy. Additionally, specialist registrars appear more likely not to offer patients interval appendicectomy after successful conservative management (P < 0.05).

CONCLUSIONS

At present, there is no agreed consensus on the management of appendiceal mass. There is a need to develop a protocol for the management of this common problem.

Use of hygiene advice and active immunisation to control an outbreak of hepatitis A

A community outbreak of at least 16 cases of hepatitis A is described. Salivary antibody testing of 126 children within a school in that community showed only one case of undiagnosed previous infection. Three other children had received hepatitis A vaccine previously, and this was reflected in their antibody titres. For the schools serving the community control measures included advice on good hygiene (supervised handwashing and additional cleaning in the schools). All close contacts of cases (household and childminding contacts and all staff in one school) were given active immunisation, though two subsequently developed hepatitis A, 17 and 27 days after vaccination. The use of human normal immunoglobulin (HNIG) was fully discussed with contacts, but was declined in all cases. The low prevalence of previous infection found in the schoolchildren implies that, in future, few adults will be immune. Public concern about blood products after the recent Department of Health decision to stop using British-sourced plasma may be a factor in limiting the uptake of HNIG, especially as there is now a perceived safer alternative, namely hepatitis A vaccine. Lack of evidence of spread of disease within the schools involved demonstrates that good hygiene, especially handwashing, remains the most important element in the control of hepatitis A.

A randomized controlled trial to evaluate the role of interferon as initial and maintenance therapy in patients with follicular lymphoma

The purpose of this study was to evaluate the role of interferon as initial and maintenance therapy in patients with newly diagnosed follicular lymphoma. Between 1984 and 1994, 204 patients with newly diagnosed Stage III or Stage IV follicular lymphoma were randomized to receive either, Chlorambucil (CB): 10 mg daily for 6 weeks, followed by a 2-week interval, with 3 subsequent 2-week treatment periods at the same dose, separated by 2-week intervals, or, CB given concurrently with interferon (IFN). IFN was given at a dose of 3 x 10(6)units thrice weekly, subcutaneously, throughout the 18-week treatment period. Responding patients were subsequently randomized to receive maintenance IFN at the dose and schedule described above, or to expectant management. The overall response rate was 161/204 (78%), complete remission being achieved in 24% of patients. Neither the addition of IFN to the initial treatment, nor the use of maintenance IFN influenced response rate, remission duration or survival. This study was undertaken to determine whether IFN, given in combination with, and then subsequent to, CB would alter the clinical course of patients with follicular lymphoma. Disappointingly, this objective was not achieved, no advantage having been demonstrated for the addition of IFN.

Leaching behaviour of a chromium smelter waste heap

This paper reports the results of geochemical sampling and modelling of leachates from a chromite ore processing residue (C.O.P.R.) pile under rainwater infiltration. The waste pile is located in the north of England and consists of 800,000 m3 of waste. The pH of fresh leachate is similar to that of a solution in equilibrium with portlandite Ca(OH)2, which is a major constituent of the waste. The in-gassing of CO2(g) causes the pH of the leachates to drop along the drainage ditch and calcite precipitation to occur. The extent of in-gassing is dependent upon the flow rate within the drainage ditch. The dissolution of solid solutions containing residual chromate is likely to control chromate concentrations within the leachate.

Evidence for airborne transmission of Norwalk-like virus (NLV) in a hotel restaurant

An outbreak of gastroenteritis followed a meal in a large hotel during which one of the diners vomited. The clinical features of the illness suggested Norwalk-like virus (NLV, small round structured virus) infection, and this was confirmed by electron microscopy and reverse transcriptase polymerase chain reaction (RT-PCR) of stool samples. Further characterization of the virus by nucleotide sequence analysis of the PCR amplicons revealed identical strains in all the affected individuals. The foods served at the meal could not be demonstrated to be the cause of the outbreak. Analysis of attack rates by dining table showed an inverse relationship with the distance from the person who vomited. No one eating in a separate restaurant reported illness. Transmission from person-to-person or direct contamination of food seems unlikely in this outbreak. However, the findings are consistent with airborne spread of NLV with infection by inhalation with subsequent ingestion of virus particles.

Premature luteal regression induced by equine chorionic gonadotropin and estrogen is suppressed by administration of exogenous interferon in red deer (Cervus elaphus)

Superovulation of red deer hinds with eCG causes premature luteal regression by inducing follicular hypersecretion of estrogen that activates the luteolytic mechanism. Six groups of hinds (n = 8 per group) were treated with progesterone-impregnated intravaginal controlled internal drug-releasing (CIDR) devices for 14 days to synchronize estrus (CIDR device withdrawal = Day 0). Group 1 served as controls; group 2 received an i.m. injection of 1200 IU eCG at -72 h; group 3 received similar eCG treatment as well as i.m. injections of 0.25 mg estradiol benzoate (EDB) at 72, 84, 96, and 108 h; group 4 received twice-daily i.m. injections of 4 mg recombinant bovine interferon-alpha(I)1 (IFN) from Days 2 to 7; group 5 received IFN and eCG as above; group 6 received IFN, eCG, and EDB. Ovarian response was determined by laparoscopy on Days 14 and 15. Progesterone profiles were determined from thrice-weekly plasma samples from Days -14 to 28. Both the incidence of visible signs of luteal regression and the variation in the time of termination of the luteal phase (plasma progesterone < 1 ng/ml) were greater in eCG+EDB-treated hinds than in control, IFN-, IFN+eCG-, and IFN+eCG+EDB-treated hinds (p < 0.05). The ovulation rate in the eCG+EDB-treated hinds was less than that in the eCG-, IFN+eCG-, and IFN+eCG+EDB-treated hinds (p < 0.05). These results suggest that treatment with interferon, the putative embryonic pregnancy recognition signal, suppresses premature luteal regression induced by hypersecretion of estrogen following treatment with eCG.

Weekly VAPEC-B chemotherapy for high grade non-Hodgkin's lymphoma: results of treatment in 184 patients

BACKGROUND AND PATIENTS: A weekly schedule of chemotherapy (VAPEC-B) has been used to treat 184 consecutive patients with high grade non-Hodgkin's lymphoma (NHL). Median age for the group was 57 years (range 17-84) and 56% had stage IV disease.

RESULTS

Following chemotherapy, 114 (62%) patients achieved CR or CR(u), 32 (17%) PR and 15 (8%) had not responded or progressed. Response to VAPEC-B was highly stage dependent with 70% or more of patients with stages I-III achieving CR or CR(u) but only 50% of those with stage IV. Twenty-four (15%) patients died during treatment with VAPEC-B and in 13 cases death was due to sepsis. This complication occurred mainly in patients with stage IV disease aged 60 years or older. After a median follow up period of 4.1 years, the actuarial 4 year survival for 184 patients is 45%, an overall result heavily influenced by the poor outcome for 103 patients with stage IV disease (4 year survival of 28%). Patients with earlier stage disease fared correspondingly better (44% for stage III, 68% for stage II and 80% for stage I).

CONCLUSIONS

VAPEC-B gives similar results to other chemotherapy regimens currently used in the treatment of high grade NHL and has the advantage of brevity. Caution is advised in patients over the age of 60 especially in the presence of stage IV disease and dose reduction or haemopoietic growth factor support should be considered in these circumstances.

Interferon alfa-2b in addition to chlorambucil in the treatment of follicular lymphoma: preliminary results of a randomized trial in progress

One hundred and twenty four patients with follicular lymphoma (32 with Stage III and 92 with Stage IV disease) have been randomized to receive chlorambucil alone or chlorambucil plus interferon alfa-2b. Responding patients are then randomized to receive either interferon alfa-2b maintenance therapy for up to 12 months or no further treatment. One hundred and eight patients are evaluable for response, the remainder are still receiving initial therapy. Clinical remission (complete or good partial remission) was achieved in 42/59 (71%) patients receiving chlorambucil alone and in 27/49 (55%) patients receiving the combination (P = NS). Preliminary analysis of remission duration shows a trend in favour of those patients receiving interferon throughout (P = 0.02). There is no significant difference between the groups in terms of survival, at a median follow up of 2.5 years. Interferon-associated toxicity was minor in most patients but led to discontinuation of therapy in six cases. Larger trials with longer follow-up periods are needed to confirm the beneficial role of interferon in the treatment of follicular lymphoma.

Interferon-alpha 2b in the treatment of follicular lymphoma: preliminary results of a trial in progress

Since 1985 the combination of chlorambucil (10 mg daily, initially for six weeks, then alternating fortnights for 12 weeks) and interferon-alpha 2b (Schering-Plough; 2 x 10(6) U/m2 three times weekly by subcutaneous injection for 18 weeks) has been compared in a randomised trial with chlorambucil alone in previously untreated patients with stage III or IV follicular lymphoma. Responding patients have subsequently been randomised to receive maintenance interferon-alpha 2b or no further treatment. Of the 124 treated patients, 108 are evaluable for response with a median follow-up of 30 months. The major toxicity was myelosuppression which was more frequent with chlorambucil and IFN alpha 2b in combination than with chlorambucil alone (P less than 0.01). There was no treatment-related mortality. Actuarial survival at three years is 75% for all patients, regardless of therapy. There was no significant difference in response rate according to initial therapy. For the 60 patients achieving a good response to initial therapy who have entered the second part of the trial, there has been a significant prolongation of remission duration in favour of maintenance IFN-alpha 2b (median not yet reached versus two years for the 'no treatment' arm, P less than 0.015). Fewest relapses have been seen in patients who received IFN-alpha 2b throughout. Accrual to this trial continues; this preliminary analysis indicates that maintenance IFN-alpha 2b may extend remission duration in follicular lymphoma.

114Inm oxine-labelled lymphocytes--therapeutic applications

It has shown that, after intravenous administration of autologous lymphocytes labelled with the beta-emitting radionuclide 114Inm, the cells initially migrate normally before succumbing to the toxic effects of the radiation. The radioactive material is then released from the cell and taken up by neighbouring radioresistant macrophages, thereby localizing a field of radiation to the site of lymphocyte death. Using this technique, lymphocytopoenia has been produced in rats. We have measured the whole-body distribution and excretion of radioactivity in patients who received escalating activities of 114Inm-labelled lymphocytes. All patients had active non-Hodgkin's lymphoma involving the spleen and liver which proved resistant to combination chemotherapy and conventional radiotherapy. Following intravenous administration, the labelled cells cleared rapidly from the vasculature with only 15% remaining in the peripheral blood at 30 min. The radioactivity continued to fall over the next 5 days to approximately 3% and was maintained at approximately 2% for up to 90 days. There was an almost immediate uptake of radioactivity by the spleen and liver which reached approximately 85% of the injected dose by 48 h. The localization of radioactivity stabilized by 48 h and thereafter the whole-body content fell by approximately 0.8% per day. Up to 5% of the administered radioactivity accumulated in the bone marrow. The activities administered were too low to produce a therapeutic response and no toxicity was experienced by the patients. A therapeutic study at higher activities is now underway.

A randomized trial of two types of adjuvant chemotherapy in radiotherapy-treated patients with clinical stages I and II high-grade non-Hodgkin's lymphoma

This paper reports the 8-year results of comparing the use of two types of adjuvant chemotherapy following involved field radiotherapy for clinical stages I and II high-grade non-Hodgkin's lymphoma. Twenty-four patients received 6 weeks of VAP plus 2 years of oral maintenance chemotherapy, and 30 had six cycles of CMOPP. Four patients were not in complete remission at completion of i.v. chemotherapy (CR rate 91%). Ten patients (18.5%) have relapsed (VAP/M = 5; CMOPP = 5), with only two of these remaining alive, both of them being disease free. There have been three deaths from intercurrent causes, one from malignant melanoma and the other two from myocardial infarction. The relapse-free survivals at 2, 5 and 8 years were 80%, 76% & 76% respectively. The overall survivals at the same time points were 86%, 72% & 68%. There were no significant differences in either relapse-free or overall survival for either of the two treatment groups. The shorter period of weekly intravenous chemotherapy (VAP/M) was better tolerated than 36 weeks of CMOPP, and the former appears to produce equivalent results.

Factors affecting remission and survival in patients with advanced Hodgkin's disease treated with MVPP

One hundred and fourteen patients with clinical or pathological stages IIIB and IV Hodgkin's disease have been treated with MVPP chemotherapy followed by radiotherapy to sites of previously bulky disease. The minimum follow-up is 2 years with a median of 5 years. The overall remission rate was 92 per cent with 74 per cent achieving CR. A discriminant analysis showed that the presence of bulky disease was the only independent factor that predicted a lower chance of CR (66 per cent vs 82 per cent, P = 0.045). The 5-year survival was 70 per cent overall and 85 per cent for CR patients. A Cox multivariate analysis demonstrated that stage III disease, age less than 36 years and female sex were all variables which independently predicted a more favourable prognosis in terms of overall survival. However, a similar analysis for survival of CR patients showed that age less than 36 years and the absence of bulky disease were the only two factors to independently predict a more favourable outcome. Of 14 patients who did not receive the chemotherapy according to protocol 5 have relapsed compared to 7 of 70 who did. A Cox analysis confirmed that this variable was the only one of significant prognostic import in predicting relapse-free survival. Using the Cox analyses we have been able to devise a scoring system which accurately predicts the outcome for these patients. This model may be useful in determining which patients have a worse prognosis following treatment with MVPP thus allowing more intensive therapy to be given to such patients while minimising treatment for those with favourable features.

Reconstitution of haemopoietic system with autologous marrow taken during relapse of acute myeloblastic leukaemia and grown in long-term culture

In long-term cultures of bone marrow from a patient with acute myeloblastic leukaemia (AML) the leukaemic chromosome marker, which was present in a proportion of the marrow cells even during morphological remission, was not detectable after seven days of culture. After florid relapse of AML, large-scale bone marrow cultures were established while the patient received conditioning with cyclophosphamide and total body irradiation as for an allogeneic bone marrow transplant. Marrow cultured for ten days was reinfused and three and six months later the patient was in clinical remission with a normal karyotype.

A randomized study comparing chemotherapy alone with chemotherapy followed by radiotherapy in patients with pathologically staged IIIA Hodgkin's disease

This paper reports the five-year follow-up (range, 1-8 years) of 56 patients with pathologic stage IIIA Hodgkin's disease randomized for chemotherapy alone or chemotherapy followed by radiotherapy to previous areas of disease (26 treated with mustine, vinblastine, procarbazine, and prednisolone [MVPP] alone, 30 with MVPP and radiotherapy). Of the 56 patients 53 (95%) achieved a complete remission with chemotherapy and of these only five (9%) have relapsed; three died of Hodgkin's disease. There was no improvement in relapse-free survival associated with the uses of radiotherapy following chemotherapy but in view of the small numbers of relapses and the excellent results following chemotherapy alone, a significant improvement could not be expected. The use of MVPP alone can be recommended as an alternative therapy for patients with stage IIIA Hodgkin's disease. This avoids both the physical and psychologic morbidity associated with the high relapse rate following extensive primary radiotherapy and the necessity of combined modality treatment for about half these patients. The question of whether radiotherapy should be given to areas of previous bulk following chemotherapy has not yet been answered in this trial which is continuing.