Reduction of deep sepsis following total hip arthroplasty.
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Air Microbiology↗
Biomedical subjects
R H Fitzgerald
Publications and source records attributed to R H Fitzgerald.
Peptococcus magnus: a significant human pathogen.
Peptococcus magnus was recovered from 10% of anaerobic cultures collected from suspected clinical infections over a 3.5-year period. It was the commonest species of anaerobic gram-positive cocci isolated (30%). To evaluate the clinical significance of this organism, we retrospectively reviewed the charts of 222 patients from whom P. magnus was isolated. Twenty-five patients had no evidence of infection, 151 had mixed infections, and 32 had infections from which only P. magnus was isolated (pure cultures). Mixed infections involved the following sites: bone and joint (32 cases), soft tissue (57 cases), foot ulcers (29 cases), abdominal cavity (16 cases), and miscellaneous (17 cases). The average number of organisms was four (2.5 facultatives and 1.5 anaerobes). Eighteen patients with pure cultures of P. magnus had bone or joint infections, and foreign bodies were present in 15 of these. Other pure cultures of P magnus infections included 12 soft tissue, one vascular graft, and one infected sternotomy with persistent bacteremia. Pure culture infections were usually chronic, and serious sequelae often resulted. Peptococcus magnus is frequently isolated from significant infections and seems particularly pathogenic in infections of bones and joints or in association with the presence of foreign bodies, or both.
Adult↗
Hinged total knee arthroplasty.
Analysis of an on-going prospective study of seventy-seven hinged total knee arthroplasties in sixty-seven patients revealed that most patients had improvement in function, although major complications occurred in eighteen knees (23.4 per cent. These complications included sepsis, loosening, patellar tendon rupture, peroneal palsy, and patellar subluxation. Eight of nine knees with deep sepsis required removal of the prosthesis, and three of sixteen knees with patellar pain required realignment of the quadriceps. When prosthetic failure occurred, salvage of a functional extremity was difficult. Hinged total arthroplasty is not without its problems, and a cautious approach to its use is indicated. Whenever possible, a moderately constrained replacement arthroplasty should be considered.
Adult↗
The transcapillary passage and interstitial fluid concentration of penicillin in canine bone.
Using [14C] benzyl penicillin, we determined the ability of penicillin to cross capillary membranes in the tibiae of dogs, the degree of protein-binding of penicillin in serum and tibial bone tissue, and the concentration of penicillin in the interstitial fluid space of tibial bone. Extraction studies demonstrated that the capillary membranes in bone were readily traversed by benzyl penicillin. Penicillin concentrations in filed cortical and crushed cancellous bone samples, measured by both isotopic and biological assays, ranged from 1.0 to 8.7 per cent of the simultaneous concentrations of penicillin in plasma. Twenty-one per cent of the penicillin in plasma was protein-bound, while 39 per cent of the penicillin in cortical bone was tissue-bound and not biologically active. Studies of the distribution of benzyl penicillin showed that it was distributed in equal concentrations in the plasma and in the interstitial fluid spaces of bone. The concentration of biologically active penicillin in the interstitial fluid spaces of bone correlated closely with the simultaneously observed plasma level in animals in which a steady-state equilibrium had been achieved.
Animals↗
Microbiologic environment of the conventional operating room.
Areas of potential contamination of the surgical wound in the conventional operating rooms include the back table, the unsterile suction receptacle, and the lack of a positive pressure relationship between the operating room and adjacent areas. Use of an impermeable hood with a large mask diminished contamination of the instrument table and the the wound from fallout of bacteria from the surgical team. The level of airborne bacterial comtamination in the operating room can be reduced by limiting the traffic and controlling the activity and the number of operating room personnel. Higher rates of postoperatively wound sepsis were noted in older operating rooms, particularly with difficult procedures and those performed later in the day. Conventional operating rooms should be categorized by the level of room air exchange per hour and the level of airborne bacterial contamination.
Air Microbiology↗
Reduction of deep sepsis after total hip arthroplasty.
The role of the operating room environment in the development of deep sepsis after total hip arthroplasty was studied at four centers. The incidence of deep sepsis after 5,865 total hip arthroplasties performed in the four centers varied from 0.5% to 2.3%. Procedures performed in a conventional operating room were associated with the highest incidence of deep sepsis (1.3%). The use of a vertical, unidrectional airflow system with a helmet aspirator suite was associated with the lowest incidence of deep sepsis (0.6%). Although patients with previous hip surgery had an increased incidence of deep sepsis regardless of the operating room environment, those procedures performed in a vertical, unidrectional facility had a lower incidence of deep sepsis. Newer techniques designed for the reduction of airborne contamination of the operative wound seem to reduce the incidence of deep-wound sepsis after total hip arthroplasty, especially in patients with previous hip surgery.
Arthroplasty↗
Total joint arthroplasty. Biologic causes of failure.
Hypersensitivity reactions and deep sepsis are the primary forms of biologic failure of total joint arthroplasty. Hypersensitivity reactions appear to be related to metal debris associated with metal articulating with metal arthroplasties. Although the incidence of deep sepsis following total joint arthroplasty is lower than initially feared, it remains a serious problem for both the patient and the surgeon. Fixation of prosthetic devices with methyl methacrylate appears safe. However, improved methods of fixation which are more compatible with osseous tissue are currently under study. The advantages of porous materials and the results of laboratory studies are reviewed.
Acute Disease↗
Arthrodesis of the knee following failed total knee arthroplasty.
In forty-five patients, who had an arthrodesis because of failed total knee arthroplasty, the cause was infection in forty, instability in two, failure of the prosthesis in two, and loosening in one. The arthrodesis succeeded in twenty-nine (81%) of thirty-six patients who had had a minimally or partially constrained arthroplasty and in five (56%) of nine who had had a hinge-type prosthesis inserted. The reasons for failure were severe bone loss, persistent sepsis, and loss of bone apposition after manipulation. The technique of arthrodesis did not seem to influence the final result. External fixation most commonly had to be used because of the infections and the device was kept in place for an average of ten weeks, after which immobilization in a cast was used until the arthrodesis healed.
Adult↗
Laboratory diagnosis of postoperative sepsis of the musculoskeletal system.
The diagnosis of acute sepsis after musculoskeletal surgery is based on the results of the clinical examination. Microbiologic evaluation of clinical specimens permits identification of the causal organism(s) and of the susceptibility studies. In the subacute stage of postoperative sepsis, roentgenographic examination, a peripheral leukocyte count, erythrocyte sedimentation rate, hemoglobin level, and nuclear scans can be helpful to the clinician. Frozen section histologic examination of tissues and Gram staining of fluids obtained at surgery have resolved the choice in differential diagnosis between aseptic and septic loosening of painful prosthetic components. Laboratory evaluation, including tissue biopsy, identifies the chronic complications of amyloidosis and malignant change in patients with long term sepsis of the musculoskeletal system.
Arthritis, Infectious↗
Total joint arthroplasty. The knee.
Total knee replacement has become an established form of treatment for gonarthrosis and usually results in excellent relief of pain and approximately 90 degrees of joint motion with satisfactory joint stability. The anatomic stability that cannot be restored at surgery must be provided for by additional prosthetic stability. Fixation of prosthetic devices, particularly in the tibia, is marginal and results in an increased incidence of loosening when the quality of bone is weak, as in osteoporosis, or when shear stress is increased because of malalignment or prosthetic constraint. Resurfacing techniques provide the greatest options if surgical revision is necessary. Surgical goals should be realistically assessed so as to maintain the best potential for future treatment options.
Arthroplasty↗
Penetration of methicillin, oxacillin, and cephalothin into bone and synovial tissues.
The penetrations of methicillin, oxacillin, and cephalothin into cortical bone and synovial tissues were studied 1 h after their intravenous administration in 105 patients having arthroplasty of the hip. Although the lowest serum levels were noted with cephalothin (P < 0.01), more patients receiving cephalothin achieved osseous drug levels inhibitory to staphylococci (P < 0.01). Differences in the penetration of the three agents into synovial tissues were not statistically significant.
Bone and Bones↗
Bacterial colonization of mutilating hand injuries and its treatment.
A total of 120 hand injuries were reviewed. Sixty-seven occurred between 1965 and 1972 and were analyzed retrospectively, and 53 occurred between 1972 and 1974 and were analyzed prospectively. The bacterial colonization was determined in 86 injuries. Injuries sustained while handling farm implements tended to be colonized by mixed gram-negative and gram-positive isolates. The gram-negative isolates usually were resistant to all antibiotics, with the exception of gentamicin. However, nine bacterial isolates were resistant to all agents tested. Injuries sustained in the home or industry were colonized by gram-positive organisms. Most were susceptible to semisynthetic penicillinase-resistant penicillins such as methicillin and its congeners. The use of parenteral prophylactic antimicrobial agents in the treatment of mutilating hand injuries was not significant in preventing infection, and their use does not seem to be indicated in farm implement-related injuries. Antimicrobials are of value in home- and industrial-related injuries only when the status of the wound so indicates.
Anti-Bacterial Agents↗
Endobronchial metastases.
Seventeen cases of endobronchial metastases are reviewed. Of these, six had the primary lesion in the breast. Treatment was by resection, radiation, or systemic therapy. Breast cancer patients with long disease-free intervals had the longest survival after bronchial metastases, and those with the most aggressive carcinomas and sarcomas had shorter survival.
Arm↗
Symposium on arthritis in older persons. Section II. Drugs and intrasynovial steroid therapy. Intrasynovial steroid therapy: uses and abuses. (Summary of presentation).
The indications and contraindications for use of intrasynovial steroid therapy are discussed. When properly used, the intrasynovial injection of steroids is a valuable method of treatment.
Aged↗
Symposium on arthritis in older persons. Section IV. Surgery and rehabilitation. Total joint replacement: lower extremities (Summary of presentation).
In experience with total joint replacement in the lower extremity, to date, total hip arthroplasty has been the most successful. Total arthroplasty operations as applied to the knee and ankle are giving promising results. These methods offer new avenues for relief of pain and deformity and stabilization of arthritic joints in the lower extremity.
Aged↗
Diphtheroid osteomyelitis.
Isolates of either Corynebacterium diphtheriae or Propionibacterium acnes from osteomyelitis are not necessarily contaminants, as shown by the cases of three patients who had bone and joint infections in which these organisms were pathogenic (one in pure culture and two in mixed cultures). Previous operation or other factors that compromise host resistance create the setting for these opportunistic organisms. Penicillin with or without streptomycin is the treatment of choice, but if penicillin or streptomycin cannot be used then the cephalosporins, clindamycin, and erythromycin are acceptable alternatives (depending on susceptibility studies). In general, the prognosis is good.
Aged↗
Deep wound sepsis following total hip arthroplasty.
After follow-ups ranging from two to five years on all but four (five hips) of 2,694 patients who had 3,215 total hip arthroplasties, deep wound infection had been demonstrated in forty-two hips (1.3 per cent). The infections among the 3,210 hips appeared during the immediate postoperative period or as long as five years after surgery. All operations were performed in conventional operating rooms. Previous operations, prolonged operating time, positive culture at operation, and unrecognized preoperative sepsis were related to the development of deep infection. In only eight of the forty-one patients (forty-two hips) was salvage of the prosthetic arthroplasty possible. The deaths of tree patients were directly attributable to the infection or its treatment.
Adult↗
Squamous-cell carcinoma complicating chronic osteomyelitis.
Treatment of carcinomatous degeneration in patients with chronic osteomyelitis requires differentiation between benign, penetrating epithelioma and invading, low-grade squamous-cell carcinoma. Although most lesions are low grade, analysis of the case histories of twenty-three patients treated at the Mayo Clinic indicates that these tumors do metastasize. When malignant-appearing epithelium invading bone is identified, ablative surgery is indicated. Inadequate surgical treatment resulted in the deaths of two patients in our series. Routine regional lymphadenectomy at the time of amputation seems unnecessary. Regional lymphadenopathy persisting for six to twelve weeks after amputation warrants surgical intervention. With prompt, aggressive surgical treatment, the prognosis for patients with squamous-cell carcinoma in an osteomyelitic cavity is good.
Adolescent↗