Hardware Infection Research Articles

Magnetic resonance imaging of musculoskeletal infections.

Magnetic resonance imaging (MRI) is a powerful imaging modality in the evaluation of musculoskeletal (MSK) soft tissue, joint, and bone infections. It allows prompt diagnosis and assessment of the extent of disease, which permits timely treatment to optimize long-term clinical outcomes. MRI is highly sensitive and specific in detecting the common findings of MSK infections, such as superficial and deep soft tissue oedema, joint, bursal and tendon sheath effusions, lymphadenopathy, bone marrow oedema, erosive bone changes and periostitis, and bone and cartilage destruction and sequestration. Contrast-enhanced MRI allows detection of non-enhancing fluid collections and necrotic tissues, rim-enhancing abscesses, heterogeneously or diffusely enhancing phlegmons, and enhancing active synovitis. Diffusion-weighted imaging (DWI) is useful in detecting soft-tissue abscesses, particularly in patients who cannot receive gadolinium-based intravenous contrast. MRI is less sensitive than computed tomography (CT) in detecting soft-tissue gas. This article describes the pathophysiology of pyogenic MSK infections, including the route of contamination and common causative organisms, typical MR imaging findings of various soft tissue infections including cellulitis, superficial and deep fasciitis and necrotizing fasciitis, pyomyositis, infectious bursitis, infectious tenosynovitis, and infectious lymphadenitis, and of joint and bone infections including septic arthritis and osteomyelitis (acute, subacute, and chronic). The authors also discuss MRI findings and pitfalls related to infected hardware and diabetic foot infections, and briefly review standards of treatment of various pyogenic MSK infections.

Characterizing the trends in patient demographics, complications, and short-term outcomes after deep brain stimulation procedures

BackgroundIndications for deep brain stimulation (DBS) are rapidly growing within functional neurosurgery. The objective of this study was to characterize national trends in demographics and complications across distinct populations of DBS patients. MethodsWe identified patients from the 2008–2018 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File (PUF) who underwent an implantation or revision procedure for DBS. Summary statistics for postoperative infection rate, noninfectious complication rate, total hospital length of stay, discharge disposition, mortality, reoperation or readmission, and time from operation to readmission were obtained. Patients were categorized by diagnosis for DBS treatment. Outcomes for each diagnosis group were compared to outcomes for the total study population. ResultsDBS patients who underwent primary implantation procedures had low rates of postoperative infections (1.2%), noninfectious complications (0.8%), and mortality (0.1%) and a high likelihood of discharge home (97.6%). In addition, a large percentage of patients presented for revision or removal of neurostimulators (34.2% of cases) or treatment of long-term hardware infection (4.5%). Compared with patients with other diagnoses, patients with Parkinson disease experienced lower rates of noninfectious complications (odds ratio 0.32; 95% CI, 0.15–0.63; p = 0.002) and fewer unplanned reoperations (odds ratio 0.60; 95% CI, 0.39–0.92; p = 0.02). ConclusionAnalysis of a national database suggests that DBS is a relatively safe treatment across several different patient populations. These overall favorable results support the continued practice of DBS surgery and provide encouraging validation for increasing access to DBS therapy for new indications that are being actively investigated.

254. Excellent Outcomes with Oral Versus Intravenous Antibiotics for Bone and Joint Infections: A Single-Center Experience

Abstract Background The OVIVA trial, published in 2019, demonstrated equivalent efficacy of oral (PO) versus intravenous (IV) antibiotics for bone and joint infections. We report our group’s one-year outcomes in a cohort of such patients who received PO or IV antibiotics. Methods Our orthopedic surgery and orthopedic infectious diseases (ID) groups agreed to employ early switch to PO in patients with a first episode of non-vertebral osteomyelitis (OM), native or prosthetic joint infection (NJA or PJI), or hardware infections when a pathogen susceptible to highly bioavailable antibiotics had been identified and the patient was perceived to be at low risk for medication non-adherence. We reviewed patients 19+ years old seen in the Ortho ID clinic for one of these conditions from July 1st through December 31st, 2019. Data recorded included patient demographics and comorbidities, infection type and site, microbiology, and surgical and antibiotic management. Primary outcome was treatment failure at 1 year, defined as death, unplanned surgery at same site, or chronic antibiotic suppression. Results Forty patients (all IV antibiotics, n=17; initial or switch to PO, n=23) were included. Median IV duration was 15 days. PJI was the most common diagnosis (n=22), followed by other hardware infection and OM (n=7 each). Of the PJIs, 13/22 were managed with 2-stage exchange and 11/13 of these received all-IV therapy. Of the hardware infections, 4/7 underwent debridement and retention or single-stage exchange and all of these received initial or switch to PO therapy. Staphylococci (n=14 S. aureus and n=7 coagulase-negative) and streptococci (n=12) were the most common pathogens. Amoxicillin (n=8), trimethoprim-sulfa (n=6), and levofloxacin (n=3) were the most-used PO antibiotics. The PO group received longer treatment (mean 67 vs 48 days). No treatment failures occurred in the patients who started or switch to PO antibiotics, whereas 35% of patients who received all-IV therapy experienced failure. Conclusion Adopting known risk factors for poor outcome in bone and joint infection such as prior treatment failure and no identified pathogen as exclusion criteria for early switch to PO antibiotic therapy led to excellent one-year treatment outcomes across a range of musculoskeletal infections. Disclosures Angela Hewlett, MD, MS, Mapp Biopharmaceutical (Scientific Research Study Investigator) Angela Hewlett, MD, MS, Mapp Biopharmaceutical, Inc (Individual(s) Involved: Self): Scientific Research Study Investigator Nicolas W. Cortes-Penfield, MD, Nothing to disclose

793. Rifabutin Use in Staphylococcal Prosthetic Material Infections: A Case Series

BackgroundBacterial biofilm formation is of clinical concern among patients with staphylococcal infections involving prosthetic material. While rifampin has in-vitro, animal and clinical data to support its adjunctive role in these types of infections, its potent induction of multiple cytochrome P450 enzymes and P-glycoprotein transport system proteins can pose significant drug-drug interactions. Rifabutin has comparable in-vitro anti-staphylococcal activity but less drug-drug interaction potential than rifampin. However, minimal clinical data exists to support rifabutin use as adjunctive treatment of prosthetic infections.MethodsThis case series describes 7 patients who received adjunctive rifabutin for staphylococcal prosthetic material infections between February 2018 and January 2021 at Massachusetts General Hospital. The primary outcome of infection recurrence was defined as need for surgical intervention for suspected or proven recurrence infection within 6 months after starting rifabutin therapy. Incidence of adverse effects was the main secondary outcome.ResultsMost patients (6/7) had methicillin-sensitive S. aureus (MSSA) and one patient had S. epidermidis infection. Three patients had spinal fusion hardware infection, one patient had hardware-associated spinal osteomyelitis/ diskitis with epidural abscess, two patients had prosthetic joint infection, and one patient had MSSA bacteremia with left ventricular assistance device involvement. All patients except one underwent surgical management prior to starting rifabutin. Infection recurrence was noted in one of seven patients who required surgical washout. Adverse events were uncommon (n=1 treatment-related nausea, n=1 leukopenia).ConclusionThis small case series suggests favorable outcomes with use of rifabutin instead of rifampin for staphylococcal infections with prosthetic material involvement.Disclosures Sandra B. Nelson, MD, UpToDate (Other Financial or Material Support, author)

The Safety and Efficacy of Mandibular Distraction Osteogenesis Among Infants Less Than 3 kg.

Mandibular distraction osteogenesis (MDO) is a safe and effective surgery to address respiratory and feeding issues due to micrognathia in patients with Robin Sequence (RS). Previous studies examining postoperative complications in neonates receiving MDO have considered 4 kg as the cut-off for low weight; however, an increasing number of MDO interventions are performed in infants <4 kg. To determine if a weight <3 kg at time of MDO is a risk factor for postoperative complications or need for subsequent tracheostomy or gastrostomy tube (G-tube). Retrospective chart review. A retrospective review of all infants <6 months of age undergoing MDO at two tertiary pediatric hospitals from 2008 to 2018. Demographic data, syndromic status, weight, and age at time of surgery, length of postoperative hospital stay, and postoperative outcomes were recorded including tracheostomy placement, G-tube placement, hardware infection, reintubation, facial/marginal mandibular nerve damage, and need for revision MDO. Sixty-nine patients with RS were included. The mean age at MDO was 25 ± 20 days and mean weight was 3.32 ± 0.44 kg. There was no statistically significant correlation between weight (P=.699) or age (P=.422) and unfavorable postoperative outcomes. No patients (0%) underwent tracheostomy pre-MDO. Two patients (2.9%) required tracheostomy postsurgery; neither was <3 kg. Eight patients (11.6%) required a G-tube postoperatively. Newborns <3 kg who undergo MDO experience the same rates of success and complication as larger infants, suggesting that MDO is a safe and efficacious procedure in infants less than 3 kg. Laryngoscope, 132:1295-1299, 2022.

Palliative endoscopic third ventriculostomy for pediatric primary brain tumors: a single-institution case series.

Children with nonoperative brain tumors, such as diffuse intrinsic pontine gliomas (DIPGs), often have life-threatening hydrocephalus. Palliative shunting is common in such cases but can be complicated by hardware infection and mechanical failure. Endoscopic third ventriculostomy (ETV) is a minimally invasive alternative to treat hydrocephalus without implanted hardware. Herein, the authors report their institutional experience with palliative ETV for primary pediatric brain tumors. The authors conducted a retrospective review of consecutive patients who had undergone palliative ETV for hydrocephalus secondary to nonresectable primary brain tumors over a 10-year period at Rady Children's Hospital. Collected variables included age, sex, tumor type, tumor location, presence of leptomeningeal spread, use of a robot for ETV, complications, ETV Success Score (ETVSS), functional status, length of survival, and follow-up time. A successful outcome was defined as an ETV performed without clinically significant perioperative complications or secondary requirement for a new shunt. Fifteen patients met the study inclusion criteria (11 males, 4 females; average age 7.9 years, range 0.8-21 years). Thirteen patients underwent manual ETV, and 2 patients underwent robotic ETV. Preoperative symptoms included gaze palsy, nausea/vomiting, headache, lethargy, hemiparesis, and seizures. Tumor types included DIPG (3), intraventricular/thalamic glioblastoma (2), and leptomeningeal spread of medulloblastoma (2), anaplastic oligo-/astrocytoma (2), rhabdoid tumor (2), primitive neuroectodermal tumor (1), ganglioglioma (1), pineoblastoma (1), and embryonal carcinoma (1). The mean preoperative ETVSS was 79 ± 8.8. There was 1 perioperative complication, a wound breakdown consistent with refractory hydrocephalus. The mean follow-up was 4.9 ± 5.5 months overall, and mean survival for the patients who died was 3.2 ± 3.6 months. Two patients remained alive at a mean follow-up of 15.7 months. Palliative ETV was successful in 7 patients (47%) and unsuccessful in 8 (53%). While patients with successful ETV were significantly older (11.9 ± 5.6 vs 4.4 ± 4.1 years, p = 0.010), there were no significant differences in preoperative ETVSS (p = 0.796) or postoperative survival (p = 0.476) between the successful and unsuccessful groups. Overall, functional outcomes were similar between the two groups; there was no significant difference in posttreatment Karnofsky Performance Status scores (68.6 ± 19.5 vs 61.3 ± 16.3, p = 0.454), suggesting that including ETV in the treatment algorithm did not worsen outcomes. Palliative ETV is a safe and potentially efficacious treatment option in selected pediatric patients with hydrocephalus from nonoperative brain tumors. Close follow-up, especially in younger children, is required to ensure that patients with refractory symptoms receive appropriate secondary CSF diversion.

Magnetothermal nanoparticle technology alleviates parkinsonian-like symptoms in mice

Deep brain stimulation (DBS) has long been used to alleviate symptoms in patients suffering from psychiatric and neurological disorders through stereotactically implanted electrodes that deliver current to subcortical structures via wired pacemakers. The application of DBS to modulate neural circuits is, however, hampered by its mechanical invasiveness and the use of chronically implanted leads, which poses a risk for hardware failure, hemorrhage, and infection. Here, we demonstrate that a wireless magnetothermal approach to DBS (mDBS) can provide similar therapeutic benefits in two mouse models of Parkinson’s disease, the bilateral 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and in the unilateral 6-hydroxydopamine (6-OHDA) model. We show magnetothermal neuromodulation in untethered moving mice through the activation of the heat-sensitive capsaicin receptor (transient receptor potential cation channel subfamily V member 1, TRPV1) by synthetic magnetic nanoparticles. When exposed to an alternating magnetic field, the nanoparticles dissipate heat, which triggers reversible firing of TRPV1-expressing neurons. We found that mDBS in the subthalamic nucleus (STN) enables remote modulation of motor behavior in healthy mice. Moreover, mDBS of the STN reversed the motor deficits in a mild and severe parkinsonian model. Consequently, this approach is able to activate deep-brain circuits without the need for permanently implanted hardware and connectors.

Technique and Outcomes of Antibiotic Impregnated Polymethylmethacrylate Coated Plates

AIM: The purpose of this article is to describe a technique of coating hardware with antibiotic impregnated polymethylmethacrylate (PMMA) and to report the clinical series results. MATERIALS AND METHODS: Adults were retrospectively identified that underwent surgical stabilization of long-bone fractures with an antibiotic impregnated PMMA coated plate. Exclusion criteria included patients with less than one year follow-up, those with no documentation of radiographic union, and those with incomplete documentation on the type and amount of antibiotics used in the PMMA. Patient demographics, injury characteristics, as well as perioperative variables were collected from the electronic medical records. RESULTS: Six patients met inclusion and exclusion criteria are were included in this retrospective case series. Five patients were male. Four of the patients were treated for humerus fractures, one for an ulna fracture, and one for a both bone forearm fracture. Three of the patients had a history of an open fracture. Five of the patients went on to have fracture union with no evidence of persistent infection following antibiotic impregnated PMMA coated plating. One patient had persistent infection resulting in a nonunion requiring repeat operation. CONCLUSIONS: Antibiotic impregnated PMMA plating is an effective technique that may prove useful in cases of orthopedic hardware infection requiring further fixation. The use of this technique in a prophylactic setting for patients at high risk of infection and poor outcomes may prove to be of an even greater clinical significance.

Is It Possible to Save the Deep Brain Stimulation Hardware when Presenting with Wound Dehiscence or Hardware Infection?

Introduction: Deep brain stimulation (DBS) hardware complications have been traditionally managed by removal of the entire system. Explantation of the system results in prolonged interruption to the patient’s care and potential challenges when considering reimplantation of the cranial leads. The purpose of this study was to understand whether complete explantation can be avoided for patients initially presenting with wound dehiscence and/or infection of hardware. Methods: We performed a retrospective study that included 30 cases of wound dehiscence or infection involving the DBS system. Patients underwent reoperation without explantation of the DBS system, with partial explanation, or with complete explantation as initial management of the complication. Results: A total of 17/30 cases were managed with hardware-sparing wound revisions. The majority presented with wound dehiscence (94%), with the scalp (n = 9) as the most common location. This was successful in 76.5% of patients (n = 13). Over 11/30 patients were managed with partial explantation. The complication was located at the generator (91%) or at the scalp (9%). Partial explantation was successful in 64% of patients (n = 7). In cases that underwent a lead-sparing approach, 33% of patients ultimately required removal of the intracranial lead, and 2/30 cases of hardware infection were managed initially with total explantation. Discussion/Conclusion: Wound dehiscence can be successfully managed without complete removal of the DBS system in most cases. In cases of infection, removing the involved component(s) and sparing the intracranial leads may be considered. Wound revision without removal of the entire DBS system is safe and can improve quality of life by preventing or shortening the withdrawal of DBS treatment.

A simple technique of removal of a stripped and incarcerated cannulated screw adjacent to the calcar in the femoral neck in a resource-limited setting: A case report

Osteosynthesis of fracture neck of the femur with multiple cannulated screws is one of the standard techniques used, especially in non-elderly patients. Implant exit from the femoral neck is done in cases with hardware failure, infection, prominence, non-union, and pain among others. The femoral neck is unique due to its precarious blood supply, distribution of forces, and formation of dense trabeculae. The cannulated screw placed adjacent to the calcar region is known to get incarcerated due to increased osseointegration, bony ingrowth, and bending. These screws can present in various modes of fatigue for which different extraction techniques and sophisticated instruments have been employed, most of which are not readily available at every center. We present a case where a stripped and incarcerated screw was removed using a technique with simple instruments in a resource-limited setting which can be reproduced for any cannulated screw and in any center.

Contemporary management of pediatric open skull fractures: a multicenter pediatric trauma center study.

The authors sought to evaluate the contemporary management of pediatric open skull fractures and assess the impact of variations in antibiotic and operative management on the incidence of infectious complications. The records of children who presented from 2009 to 2017 to 6 pediatric trauma centers with an open calvarial skull fracture were reviewed. Data collected included mechanism and anatomical site of injury; presence and depth of fracture depression; antibiotic choice, route, and duration; operative management; and infectious complications. Of the fractures among the 138 patients included in the study, 48.6% were frontal and 80.4% were depressed; 58.7% of patients underwent fragment elevation. The average duration of intravenous antibiotics was 4.6 (range 0-21) days. Only 53 patients (38.4%) received a single intravenous antibiotic for fewer than 4 days. and 56 (40.6%) received oral antibiotics for an average of 7.3 (range 1-20) days. Wounds were managed exclusively in the emergency department in 28.3% of patients. Two children had infectious complications, including a late-presenting hardware infection and a superficial wound infection. There were no cases of meningitis or intracranial abscess. Neither antibiotic spectrum or duration nor bedside irrigation was associated with the development of infection. The incidence of infectious complications in this population of children with open skull fractures was low and was not associated with the antibiotic strategy or site of wound care. Most minimally contaminated open skull fractures are probably best managed with a short duration of a single antibiotic, and emergency department closure is appropriate unless there is significant contamination or fragment elevation is necessary.

Randomized double-blind sham-controlled trial of thalamic versus GPi stimulation in patients with severe medically refractory Gilles de la Tourette syndrome

BackgroundThere are still no sufficient data regarding the use of deep brain stimulation (DBS) in Gilles de la Tourette syndrome (GTS) and no agreement on optimal target. ObjectiveTo compare efficacy and safety of bilateral DBS of thalamus (centromedian-ventro-oral internus, CM-Voi) versus posteroventral lateral globus pallidus internus (pvl GPi)) versus sham stimulation, and baseline in severe medically refractory GTS. MethodsIn this randomized double-blind sham stimulation-controlled trial (RCT), 10 patients (3 women, mean age = 29.4 ± 10.2 SD, range 18–47) underwent three blinded periods each lasting three months including (i) sham, (ii) pvl GPi (on-GPi), and (iii) thalamic stimulation (on-thal) followed by an open uncontrolled long-term follow-up (up to 9 years) with individually determined target and stimulation settings. ResultsNine patients completed the RCT. At group level, on-GPi – but not on-thal – resulted in a significant tic reduction compared to baseline, but had no effect on premonitory urges and psychiatric comorbidities. Direct comparisons of targets resulted in inconsistent or negative (compared to sham) findings. During follow-up, we found no improvement of tics, comorbidities, and quality of life at group level, however, single patients benefitted continuously from thalamic DBS. At last follow-up 89.9 months (mean) after surgery, 50% of patients had discontinued DBS. Hardware infections occurred in 3/10 patients. ConclusionOur data suggest that the initial effect of pvl GPi DBS is superior to thalamic (CM-Voi) DBS. While half of the patients discontinued treatment, single patients benefitted from thalamic DBS even after years. It is likely that outcome is influenced by various factors beyond the mere change in tic severity.

1366. Microbiology of Acute Hematogenous Osteomyelitis in Hospitalized Children

BackgroundAcute hematogenous osteomyelitis affects 1 in 5,000 children in the U.S. and Staphylococcus aureus is the most common bacterial cause. At our institution, clindamycin is used empirically for osteomyelitis, despite increasing clindamycin-resistance over the years. The objective of this study is to describe microbiologic results and antibiotic resistance patterns in children hospitalized with acute hematogenous osteomyelitis.MethodsThis was a single-center retrospective cohort study of patients < 21 years of age with acute osteomyelitis hospitalized between 1/1/2010 and 5/31/2019 at Children’s National Hospital. We excluded patients with recent orthopedic surgery, hardware infection, penetrating trauma, or with an underlying immunocompromising condition. We performed chart review to collect data on location of infection; blood, synovial fluid, or surgical site cultures; culture results, and susceptibilities.ResultsOf the 162 encounters of acute osteomyelitis that met inclusion criteria, the average patient age was 8.3 years. Lower extremity infections were most common (105, 64.8%), followed by upper extremity (31, 19.1%), pelvis (14, 8.6%), spine (7, 4.3%), shoulder (4, 2.5%), rib (1, 0.6%) and mandible (1, 0.6%). Almost half of cases (73, 45%) had no positive cultures, and 89 cases (55%) had at least one positive culture from blood or local source (Figure 1). The most common pathogen was methicillin susceptible S. aureus (MSSA) followed by methicillin resistant S. aureus (MRSA) comprising 60 (67%) and 19 (20%) of culture-positive infections respectively. Other isolated pathogens included S. pyogenes (5, 5.6%) Salmonella species (2, 2.2%), S. pneumoniae (1, 1.1%), S. agalactiae (1, 1.1%), and Kingella kingae (1, 1.1%) (Figure 1). Among S. aureus infections, 69 (87%) were susceptible to clindamycin (85% among MSSA, 95% among MRSA).Categorized Blood and Wound Culture Results ConclusionAlmost half of all children with acute hematogenous osteomyelitis did not have any microbiologic data to guide antibiotic usage. S. aureus was the most common (87%) isolate, with more MSSA (74%) than MRSA (24%). Non-S. aureus isolates were more likely to grow from surgical specimen cultures than from blood cultures. Clindamycin resistance was more commonly seen in MSSA than in MRSA osteomyelitis.Disclosures All Authors: No reported disclosures

Extraperitoneal Bladder Injuries Associated With Pelvic Fracture Requiring Internal Fixation: What Is the Evidence?

Traumatic bladder injuries are commonly associated with pelvic fractures. While the majority of intraperitoneal bladder injuries are surgically repaired, extraperitoneal bladder injuries (EBIs) can be managed nonoperatively in the absence of complex injury patterns such as bladder neck injury or presence of bone spicules in the bladder. Concern for pelvic hardware contamination is one of the most common reasons for repairing EBIs at the time of orthopedic interventions for pelvic fracture (usually open reduction and internal fixation). However, given the inconsistent and limited evidence, practice patterns are different and largely depend on surgeon preferences and institutional management. In this review, we explore the roots for this concern and summarize the current evidence on risk of pelvic hardware infection with nonoperative management of EBIs.

Should Deep Brain Stimulation Programs Be Halted During the COVID-19 Pandemic? Balancing the Risk of COVID-19 Infection Against the Survival Benefits of DBS

To the Editor: The COVID-19 pandemic has rapidly spread over the world. Numerous infections and fatalities have been reported in almost all countries. Facing the challenge of steadily increasing patients, limited amount of protection equipment and ventilators, resources have been relocated towards emergency departments and intensive care units. Nonemergency elective procedures such as deep brain stimulation (DBS) for patients with Parkinson’s disease have been postponed. It has been discussed that most functional neurosurgery patients are vulnerable to the COVID-19 pandemic and at a higher risk for becoming critically ill infected. Therefore, most centers have halted their DBS programs. Undisputed is that hardware infections and battery replacements require urgent action to prevent sepsis, neuroinfections or akinetic crisis and death, eventually (1.Miocinovic S Ostrem JL Okun MS Bullinger KL Riva-Posse P Gross RE Buetefisch CM. Recommendations for deep brain stimulation device management during a pandemic.J Parkinsons Dis. 2020; 10 (https://doi.org/10.3233/JPD-202072.): 903-910Crossref PubMed Scopus (34) Google Scholar,2.Gross RE et al.Letter: evaluation and surgical treatment of functional neurosurgery patients with implanted deep brain stimulation and vagus nerve stimulation pulse generators during the COVID-19 pandemic.Neurosurgery. 2020; 87: E222-E226Crossref PubMed Scopus (8) Google Scholar). We would like to highlight the fact that Parkinson’s disease (PD) itself is a condition with high mortality rate and complement the rationale that for any functional neurosurgery procedure, and DBS for PD in particular, we should always weigh the imminent risk of a COVID-19 infection against the long term clinical benefits of the procedure. As it remains unclear how long the pandemic will last, and if there will be a second peak, this becomes crucially important. Despite progress in medical management of PD, it does not appear to have altered the mortality rate nor significantly delayed the onset of nonmotor symptoms. Life expectancy remains decreased with the main cause of death being respiratory failure from aspiration pneumonia caused by dysphagia due to brady- or dyskinesia and rigidity of the muscles involved in the act of swallowing. Other causes of death include the deterioration of general condition, cardiovascular disease, traumatic injuries due to postural instability and sepsis. Co-evolving depression and dementia as well as the need for admittance to residential care facilities are associated with higher mortality and increased risk of suicide. All in all, 11 years is the median duration from the onset of PD until death (3.Duarte J García Olmos LM Mendoza A Clavería LE. The natural history of Parkinson’s disease in the province of Segovia: mortality in a longitudinal study (20-year follow-up).Acta Neurol. Scand. 2013; 127 (https://doi.org/10.1111/ane.12003.): 295-300Crossref PubMed Scopus (27) Google Scholar). DBS of the subthalamic nucleus has become an established pillar of the therapy continuum of patients with beginning motor fluctuations and suboptimal medical management, mainly improving motor symptoms (4.Deuschl G Schade-Brittinger C Agid Y EARLYSTIM Study GroupNeurostimulation for Parkinson’s disease with early motor complications.N Engl J Med. 2013; 368: 2038Google Scholar). Moreover, it has shown to improve survival rates in PD patients. A prospective, open-labeled, nonrandomized study by Ngoga et al. followed 147 patients who were offered a DBS procedure by a joint medical/surgical movement disorders clinic over the course of a 10 years period; 106 patients underwent DBS procedure whilst 41 patients prefered medical management. The mortality rate of patients who underwent DBS was significantly lower (17%) compared to patients who received medical management (41.5%), so was admittance to residential nursing care (5.7% vs. 36.6%) (5.Ngoga D Mitchell R Kausar J Hodson J Harries A Pall H. Deep brain stimulation improves survival in severe Parkinson’s disease.J Neurol Neurosurg Psychiatry. 2014; 85 (https://doi.org/10.1136/jnnp-2012-304715.): 17-22Crossref PubMed Scopus (69) Google Scholar). It has been widely discussed whether improvement of survival is related to ameliorated mobility and axial motor functions, perceived improvement in swallowing ability or reduction in dopaminergic medication and drug-related side effects. DBS could prevent the development of motor complications at a much earlier time-point and before long-term sequelae occur, such as psychosocial limitations and deterioration of quality of life. Given all these factors, we strongly believe that PD patients with motor fluctuations should not be treated as nonurgent but interdisciplinary teams of neurologists and neurosurgeons should carefully balance the risk of nosocomial COVID-19 infection against the long-term survival benefits. Conflict of Interest: None for all authors. Dr. Bara developed the idea and wrote the manuscript. Prof. Maciaczyk supervised the work and performed the revisions. Both authors approved the final manuscript.

Functional outcome and complications of open reduction and internal fixation with plate for displaced midshaft clavicle fractures

Introduction: The purpose of the present study is to evaluate functional outcomes and complications associated with open reduction and internal fixation (ORIF) with plates for displaced midshaft clavicle fractures. Materials and Methods: A retrospective review was performed utilising hospital database for patients treated with ORIF with plate for displaced mid-shaft clavicle fracture from January 2016 to August 2018. The primary outcome measure was union. The secondary outcome measures were functional outcome (DASH), patient satisfaction with treatment and cosmetic appearance, pain, complications and reoperations. All selected patients were requested to attend out-patient department (OPD) for assessment of patient oriented functional outcome measures. Results: Thirty patients were included in the study. Eighty percent were male patients with male female ratio of 4:1, with an average age of 35years. Forty percent fractures were Robinson type 2B1 and 60% were type 2B2. All patients treated with ORIF had fracture union (ie union rate of 100%) at an average time of 7.9 weeks. Patient satisfaction rate was 83%. Mean DASH Score was 14.63 6.27. The complication rate was 33.33%. The common complications were reoperation rate (30%), symptomatic hardware (23.33%), implant failure (6.66%) and superficial infection (3.33%). Conclusion: Open reduction and internal fixation for displaced, midshaft clavicle fracture results in high rates of union and patient satisfaction, and improved functional outcome. Symptomatic hardware removal remains the most common cause of reoperation. Patients with complications reported significantly worst functional outcome scores than patients without complication. Keywords: Clavicle fracture, Mid-shaft, Plate fixation, Functional outcome, Union, Reoperations, Complications.

Deep Brain Stimulation Hardware Infections: A Case Series

BACKGROUND: The device-related infections and erosion of the surgical wound site are special circumstances among complications of deep brain stimulation (DBS).&#x0D; AIM: We aimed to discuss different aspects of hardware infections and contribute to the literature by presenting our treatment methods on four patients.&#x0D; MATERIAL AND METHODS: This study was carried out in the Department of Neurosurgery, School of Medicine Hospital, Dokuz Eylul University. Four DBS cases were included in the study, and a retrospective study was performed.&#x0D; RESULTS: Electrode placement to bilateral subthalamic nuclei was performed due to Parkinson’s Disease to all four patients. One of the patients was undergone surgical wound site revision 6 times and device removal at last due to device-related infection and erosion of the surgical wound site. The second patient was undergone surgical wound site revision for 2 times and device removal at last due to device-related infection and erosion of the surgical wound site. The third patient had a collection subcutaneously, where the pulse generator was placed. The collection was aspirated. The fourth patient was undergone surgical wound site revision and device removal at last due to device-related infection and erosion of the surgical wound site. All four patients were given IV antibiotics.&#x0D; CONCLUSION: For the treatment of DBS device-related infections, a long-term IV antibiotherapy is a suitable option before the decision of device removal.

A Multicenter, Retrospective, Case Series of Patients With Charcot Neuroarthropathy Deformities Undergoing Arthrodesis Utilizing Recombinant Human Platelet-derived Growth Factor With Beta-Tricalcium Phosphate

Charcot neuroarthropathy has traditionally been treated using both nonsurgical and surgical strategies. Recently, orthobiologics have been used to promote arthrodesis in Charcot reconstructions, obviating the need for bone graft in some cases. Recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) in combination with beta-tricalcium phosphate scaffold (β-TCP) is a bone graft substitute shown to have comparable efficacy to autograft in incidence of foot and ankle fusion. This multicenter, consecutive case series analyzed patients undergoing Charcot reconstructions utilizing rhPDGF-BB/β-TCP for joint fusion. In this cohort, 98 patients (62.24% male) with a mean age of 62.82 ± 10.28 years (range 40-87) had a fusion incidence of 217 of 223 joints (97.31%) with a mean time to fusion of 13.09 ± 4.87 weeks (range 6-30). There were 6 nonunions in the patient population. Fusion was defined as ≥50% osseous bridging based on computed tomography and/or radiographic consolidation, in addition to clinical findings. With an overall complication rate of 26.53% (26/98), adverse events occurring in more than 1 patient limb included hardware failures (n = 7, 7.14%), infection (n = 4, 4.08%), wound dehiscence (n = 4, 4.08%), amputation (n = 3, 3.06%), and death (n = 2, 2.04%). There were no adverse events related to the grafting material. From this review, we found rhPDGF-BB/β-TCP to be a safe and effective graft material that can be considered a viable alternative to autograft, even in high-risk patients such as those with Charcot neuroarthropathy.

Minimally invasive internal fixation of distal tibia fractures with a nonconventional implant:

Fractures of the distal end of the tibia without joint involvement are usually the result of high-energy trauma. Local anatomic conditions lead to high rates of infection, delayed consolidation, and exposure of fixation hardware. In this setting, minimally invasive techniques are indicated to mitigate the complications of surgical treatment. The aim of this study is to present an alternative for the surgical treatment of distal tibia fractures using a minimally invasive technique and a nonconventional implant. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Is coating of titanium implants effective at preventing Staphylococcus aureus infections? A meta-analysis of animal model studies.

To assess the effects of the available coating methods against methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) biofilm development on titanium implants. We searched the MEDLINE, Embase, and CENTRAL databases until May 18, 2019, for studies that used animal models of infections to evaluate various titanium implant coating methods to prevent S. aureus infection. Twenty-seven studies were eligible for inclusion in qualitative synthesis. Of those, twenty-three were considered in pair-wise meta-analysis. In addition, subgroup analysis of implant protection strategies relative to uncoated controls was performed, and any adverse events stemming from the coating applications were reported. Quality assessment was performed using SYRCLE's risk of bias tool for animal studies. Meta-analysis showed that active coating with antibiotics was favoured over uncoated controls (standardised mean differences [SMD] for MRSA and MSSA were -2.71 [95% CI, - 4.24 to - 1.18], p = 0.0005, and - 2.5 [- 3.79 to - 1.22], p = 0.0001, respectively). Likewise, large effect sizes were demonstrated when a combination of active and conventional non-degradable passive coatings was compared with controls (SMDs for MRSA and MSSA were -0.62 [95% CI, - 1.15 to - 0.08], p = 0.02, and - 1.93 [95% CI, - 2.87 to - 0.98], p < 0.001, respectively). As a standalone prevention method, active titanium coating with antibiotics yielded promising results against both MSSA and MRSA. Combinations between active and non-degradable passive coatings, potentially allowing for sustained antimicrobial substance release, provided consistent hardware infection protection. Thus, we recommend that future research efforts focus on combined coating modalities against S. aureus biofilm infections in the presence of titanium implants. CRD42019123462.