Presence Of Sinus Tract Research Articles

1300. Comparison of the Clinical Characteristics and Outcomes of Anaerobic Prosthetic Joint Infections (PJI) and Aerobic PJIs : A Retrospective Review

Abstract Background PJI is an uncommon but serious complication of joint arthroplasties that can result in significant morbidity and cost. There is a paucity of studies in the literature on PJIs caused by anaerobic organisms either as the sole pathogen or part of a polymicrobial infection. The purpose of this study was to compare the clinical presentation and outcomes of PJI caused by anaerobes as opposed to aerobes. Methods This was a retrospective review of 306 patients who met Musculoskeletal Infection Society (MSIS) criteria for PJI from 2014 to 2020 at the University of Iowa Hospitals and Clinics (UIHC). 38 patients with anaerobic PJI were compared to 268 patients with aerobic PJI. Statistical analyses were performed using Pearson’s Chi square, Fisher exact test, t-test, and binary logistic regression. Results PJI with anaerobes represented 12.4% of all PJI cases in our institution, which is higher than the 3-6% reported in literature. Patients with anaerobic PJI had longer duration of symptoms (19.4 weeks vs 10.9 weeks, p = 0.012), were more likely to have a sinus tract on exam (23.7% vs 5.9%, p < 0.001), less fever on presentation ( 13.2% vs 30.2%, p = 0.029), more radiographic abnormalities (50.0% vs 31.1%, p< 0.001), lower erythrocyte sedimentation rate (49.0mm/hr vs 67.7 mm/hr, p = 0.003), lower C-reactive protein (6.6 mg/dL vs 12.1mg/dL, p = 0.004), and more likely to be polymicrobial (42.1%vs 8.0%, p < 0.001) compared to aerobic PJI. There was a higher proportion of anaerobes in shoulder PJIs compared to other joints (39.5% vs 5.5%, p< 0.001). Two-stage exchange was the most common surgical treatment in patients with anaerobic PJI (39.4%) whereas debridement and implant retention was the most common (44.5%) surgical treatment done in patients with aerobic PJI. No significant differences were seen between the two groups in terms of recurrences. Independent factors associated with anaerobic infection were shoulder prosthetic joint (AOR 10.5, CI 3.4 - 32.8) and presence of sinus tract (AOR 10.1, CI 3.1 - 32.6). Conclusion Anaerobic cultures should be performed in patients with PJI, and they should especially be considered on the differential in patients with shoulder PJI, longstanding symptoms, sinus tract on examination and abnormalities noted on radiographs. Disclosures All Authors: No reported disclosures

The risk factors of polymicrobial periprosthetic joint infection: a single-center retrospective cohort study

BackgroundPeriprosthetic joint infection is a serious complication after total joint arthroplasty and polymicrobial PJI which compose a subtype of PJI often indicate worse outcomes compared to monomicrobial periprosthetic joint infection. However, a literature review suggested that there were limited number studies evaluating the risk factors of polymicrobial PJI.Materials and methodsBetween 2015 January and 2019 December, a total of 64 polymicrobial PJI patients and 158 monomicrobial PJI patients in a tertiary center were included in this study and corresponding medical records were scrutinized. The diagnosis of PJI was based on 2014 MSIS criteria. Logistic regression was used to identify the association between various variables and polymicrobial PJI and ROC curve was used to identify their efficiency.ResultsThe prevalence of polymicrobial PJI is 28.3% in our cohorts. After adjusting for the presence of sinus, previous and knee infection, isolation of enterococci (OR, 3.025; 95%CI (1.277,7.164) p = 0.012), infection with atypical organisms (OR, 5.032;95%CI: (1.470,17.229) p = 0.01), infection with gram-negative organisms (OR, 2.255; 95%CI (1.011,5.031) p = 0.047), isolation of streptococcus spp. (OR, 6; 95%CI (2.094,17.194) p = 0.001), and infection with CNS (OfR, 2.183;95%CI (1.148,4.152) p = 0.017) were risk factors of polymicrobial PJI compared to monomicrobial PJI. However, knee infection is related to a decreased risk of polymicrobial PJI with an adjusted OR = 0.479 (p = 0.023).ConclusionThis study demonstrated that the prevalence of polymicrobial PJI is 28.3% in PJI patients. Moreover, the presence of sinus tract and previous joint revisions were risk factors for identifying different bacterial species in the intraoperative specimens. Therefore, in these PJI cases, it is necessary to examine multiple specimens of both intraoperative tissue and synovial fluid for increasing the detection rate and obtaining resistance information.

Synovial fluid interleukin-6 is not superior to cell count and differential in the detection of periprosthetic joint infection.

AimsSynovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells (%PMN) are elevated at periprosthetic joint infection (PJI). Leucocytes produce different interleukins (IL), including IL-6, so we hypothesized that synovial fluid IL-6 could be a more accurate predictor of PJI than synovial fluid WBC count and %PMN. The main aim of our study was to compare the predictive performance of all three diagnostic tests in the detection of PJI.MethodsPatients undergoing total hip or knee revision surgery were included. In the perioperative assessment phase, synovial fluid WBC count, %PMN, and IL-6 concentration were measured. Patients were labeled as positive or negative according to the predefined cut-off values for IL-6 and WBC count with %PMN. Intraoperative samples for microbiological and histopathological analysis were obtained. PJI was defined as the presence of sinus tract, inflammation in histopathological samples, and growth of the same microorganism in a minimum of two or more samples out of at least four taken.ResultsIn total, 49 joints in 48 patients (mean age 68 years (SD 10; 26 females (54%), 25 knees (51%)) were included. Of these 11 joints (22%) were infected. The synovial fluid WBC count and %PMN predicted PJI with sensitivity, specificity, accuracy, PPV, and NPV of 82%, 97%, 94%, 90%, and 95%, respectively. Synovial fluid IL-6 predicted PJI with sensitivity, specificity, accuracy, PPV, and NPV of 73%, 95%, 90%, 80%, and 92%, respectively. A comparison of predictive performance indicated a strong agreement between tests.ConclusionsSynovial fluid IL-6 is not superior to synovial fluid WBC count and %PMN in detecting PJI.Level of Evidence: Therapeutic Level IICite this article: Bone Jt Open 2020;1-12:737–742.

Hidradenitis Suppurativa: Proposal of Classification in Two Endotypes with Two-Step Cluster Analysis

Introduction: Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent disorder of the pilosebaceous unit. Currently, several attempts have been made to classify this disease according to its pathogenesis and clinical manifestations. We attempted at classifying 103 patients using two-step cluster analysis. Methods: The final model included body mass index, C-reactive protein (CRP), and serum concentrations of IL-1, IL-6, IL-17, and IL-10 as continuous variables, and sex, later/early onset, anterior/posterior lesion sites, presence/absence of sinus tracts, nodules and abscesses, positive/negative history of pilonidal sinus, and presence/absence of mutations in gamma-secretase subunits (APH1A, APH1B, MEFV, NCSTN, PSEN1, PSEN2, PSENEN, PSTPIP1) as qualitative variables. Results: The resultant model defined two groupings or clusters: cluster 1 (64.9% of patients) characterized by nonobese males, with nodular lesions in posterior sites, early-onset HS, higher IL-10, presence of gamma-secretase mutations, and history of pilonidal sinus; and cluster 2 (35.1% of patients) characterized by obese females or males, with lesions in anterior sites, more presence of sinus tracts and abscesses and less nodules, later-onset HS, and higher concentrations of IL-1, CRP, IL-17, and IL-6. Severity measures (Hurley, HS-PGA, and IHS4) and tobacco use were discarded because the analysis found them to be less relevant for clustering. Conclusion: Our resultant model confirms the clinical impression that HS is a disease spectrum with two pathogenic poles defining two clusters or endotypes. The probability of having severe disease was equally distributed in the two clusters. The variable with the highest predictive value for clustering was involvement of typical anterior sites (axillae, submammary) or atypical posterior sites (back, gluteal). Serum concentrations of interleukins, tobacco use, and sex had a lower predictive power for clustering.

Crohn\u2019s disease: prevalence, MR features, and clinical significance of enteric and colonic sinus tracts

ObjectivesEnteric and colonic sinus tracts are inflammatory complications that precede intestinal fistulas in patients with Crohn’s disease (CD). The aim of this study was to retrospectively determine the prevalence, morphologic features, and outcome of sinus tracts using MR imaging.MethodsA consecutive cohort of 642 patients with known CD, referred for MR enterography or MR enteroclysis (study period 01/2014–09/2019), was evaluated retrospectively for the presence of sinus tracts, their locations, presence and length of coexisting strictures, bowel wall thickness, CDMI score, upstream dilation, and bowel distension. Clinical outcome was assessed using medical records. For metric data, means and standard deviation, as well as one-way ANOVA and Pearson’s correlation coefficient, were calculated.ResultsIn 36/642 patients with CD undergoing MRE, 49 sinus tracts (forty in small intestine, nine in left-sided colon) were detected with a prevalence of 6.9% in patients with MR-visible signs of CD (n = 519, overall prevalence of 5.6%). Mean segmental bowel wall thickness was 8.9 mm, and mean CDMI score was 9.3. All sinus tracts were located within a stenotic segment, showing mesenteric orientation within the small bowel and upstream dilation in 13 patients. Of 36 patients, 19 underwent immediate surgery and seven developed clinical progression within the segment containing the sinus tract.ConclusionsSinus tracts occur in 6.9% of patients with visible signs of CD. They are located within stenotic, severely thickened bowel segments with high MR inflammation scores. Their detection is clinically important, because they indicate a more aggressive phenotype and, if left untreated, may show severe progression.Key Points• Sinus tracts occur in 6.9% of patients with MR-visible signs of Crohn’s disease.• Sinus tracts are a radiological indicator of early penetrating Crohn’s disease, with a high risk of progression, and require dedicated treatment.• Sinus tracts can be recognized by characteristic findings and typically occur in stenotic, severely thickened bowel segments with high MR inflammation scores.

Serum interleukin 6 could be a valuable initial diagnostic tool in prosthetic knee joint infections.

Accurate preoperative diagnosis of prosthetic joint infection (PJI) in the absence of obvious clinical signs or laboratory findings is challenging. Interleukin 6 (IL-6) has been proposed as an infection marker but supportive data are limited. We studied the diagnostic utility of serum IL-6 in infected total knee arthroplasty (TKA). A prospective cohort study was done in 52 patients (59 knees) with a painful TKA. The abnormal limits for serum IL-6, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), synovial fluid white cell counts (WBC) and synovial fluid neutrophils (PMN) were determined from receiver operating characteristic curves. An infection was defined as the presence of sinus tract or positive culture > two separate tissue or fluid samples. We utilized Mann-Whitney test, Spearman's correlation and Fischer's exact test to determine the sensitivity, specificity, positive predictive value, negative predictive value (NPV) and accuracy of serum IL-6. The optimal threshold concentration of serum IL-6 was 9.14pg/ml. Independently, this yielded a sensitivity, specificity and NPV of 81%, 63% and 85%, respectively, and when combined with synovial fluid WBC, values were 100%, 90%, 100%, respectively. The sensitivity and specificity of ESR (70%, 63.6%), CRP (66.7%, 66.7%), synovial WBC (66.7%, 81%) and synovial PMN (82.4%, 73.7%) were also calculated. Serum IL-6 levels strongly correlate with all markers in PJI. Serum IL-6 improves the diagnosis of PJI over existing methods, especially when combined with synovial fluid WBC. Its optimal usage is as an excellent screening test to rule out infected total knee arthroplasty. Diagnostic Level II.

Correlation Between Volume of Root Canal, Cultivable Bacteria, Bacterial Complexes and Endotoxins in Primary Infection.

This clinical study was conducted to correlate the levels of endotoxins and culturable bacteria found in primary endodontic infection (PEI) with the volume of root canal determined by using Cone Beam Computed Tomography (CBCT); and to evaluate the bacterial diversity correlating with clinical features. Twenty patients with PEI were selected and clinical features were recorded. The volume (mm3) of root canal was determined by CBCT analysis. Root canal samples were analyzed by using kinetic LAL-assay test to determine the levels of endotoxins and anaerobic technique to determine the bacterial count (CFU/mL). DNA was extracted from all samples to determine bacterial diversity and quantified by using Checkerboard-DNA-DNA- Hybridization. Culturable bacteria and endotoxins were detected in 100% of the root canal samples. Linear regression analysis revealed a correlation between root canal volume and presence of anaerobic bacteria (p<0.05). Positive correlations were found between bacteria species and presence of different clinical features (p<0.05). After grouping the bacteria species into bacterial complexes, positive associations were found between green, orange and red complexes with presence of sinus tract (p<0.05). This clinical study revealed that larger root canals hold higher levels of culturable bacteria in PEI. Thus, the interaction of different virulent bacteria species in complexes seems to play an important role in the development of clinical features.

Development and Evaluation of a Prognostic Calculator for the Surgical Treatment of Periprosthetic Joint Infection

BackgroundPreoperative identification of patients at risk of failing surgical treatment for periprosthetic joint infection (PJI) is imperative to allow medical optimization and targeted prevention. The purpose of this study was to create a preoperative prognostic calculator for PJI treatment by assessing a patient's individual risk for treatment failure based on many preoperative variables. MethodsA retrospective review was performed of 1438 PJIs, treated at 2 institutions from 2000 to 2014. Minimum follow-up was 1 year. A total of 63 risk factors, including patient characteristics, microbiology data, and surgical variables were evaluated using logistic regression, in which coefficients were scaled to produce weighted scores. ResultsThe 10 significant risk factors for PJI treatment failure were in descending order of relative weight: irrigation and debridement (30 points), history of myocardial infarction (15 points), revision surgery (11 points), presence of sinus tract (10 points), resistant organisms (9 points), ever smoker (6 points), prior surgery (2.86 points per prior operation), synovial white blood cell count (8.3 × natural log of cell count), body mass index (0.66 per increment), and erythrocyte sedimentation rate (depends on both smoking and 2 stage, as these are higher order interaction factors). The area under the curve for this risk model was 0.6904 (95% confidence interval: 0.6476-0.7331). ConclusionIn this large cohort study, we were able to identify risk factors and their relative weight for predicting PJI treatment failure. Some of the identified factors are indeed modifiable and should be addressed before treating a patient for PJI.

Disappearance of Intracanal Medication: A Preliminary Clinical Finding from Retrospective Review of Teeth with Vertical Root Fracture

Objective The purpose of this article was to report the finding of the disappearance of intracanal medication as a supporting evidence of vertical root fracture (VRF) through non-surgical intervention. Methods A retrospective review of the dental records of patients seen by an endodontist in a private endodontic office from September 2013 to September 2016 was conducted by the same endodontist. Cases that met the inclusion and exclusion criteria were assigned as the subjects of this study, and data were extracted from their clinical and radiographic records. Patient's demographic features, pre-operative signs and symptoms, details of rendered clinical procedures, follow-up visits, clinical and radiographic findings were recorded. Seventeen teeth for which non-surgical exploratory re-treatment was initiated were included in this study. Calcium hydroxide-based intracanal medication was placed for 2-4 weeks. Obturation of the root canals was performed if the tooth showed improvement of clinical signs and symptoms. If not, a cone-beam computed tomography (CBCT) scan was proposed to the patient to rule out VRF. Results After the non-surgical re-treatment was initiated, 13 teeth showed improvement of clinical symptoms and the re-treatment was therefore completed. The remaining 4 teeth presented with unresolved clinical presentations (deep pocket, presence of sinus tract and/or tender to percussion and palpation). Four teeth showed partial disappearance of intracanal medication where VRF was confirmed using CBCT in 3 teeth and with a conventional periapical (PA) radiograph in 1 tooth. Conclusion The disappearance of intracanal medication during non-surgical intervention was often associated with VRF. Thus, this feature may serve as an aid in diagnosing VRF.

Disappearance of Intracanal Medication: A Preliminary Clinical Finding from Retrospective Review of Teeth with Vertical Root Fracture.

Objective:The purpose of this article was to report the finding of the disappearance of intracanal medication as a supporting evidence of vertical root fracture (VRF) through non-surgical intervention.Methods:A retrospective review of the dental records of patients seen by an endodontist in a private endodontic office from September 2013 to September 2016 was conducted by the same endodontist. Cases that met the inclusion and exclusion criteria were assigned as the subjects of this study, and data were extracted from their clinical and radiographic records. Patient’s demographic features, pre-operative signs and symptoms, details of rendered clinical procedures, follow-up visits, clinical and radiographic findings were recorded. Seventeen teeth for which non-surgical exploratory re-treatment was initiated were included in this study. Calcium hydroxide-based intracanal medication was placed for 2-4 weeks. Obturation of the root canals was performed if the tooth showed improvement of clinical signs and symptoms. If not, a cone-beam computed tomography (CBCT) scan was proposed to the patient to rule out VRF.Results:After the non-surgical re-treatment was initiated, 13 teeth showed improvement of clinical symptoms and the re-treatment was therefore completed. The remaining 4 teeth presented with unresolved clinical presentations (deep pocket, presence of sinus tract and/or tender to percussion and palpation). Four teeth showed partial disappearance of intracanal medication where VRF was confirmed using CBCT in 3 teeth and with a conventional periapical (PA) radiograph in 1 tooth.Conclusion:The disappearance of intracanal medication during non-surgical intervention was often associated with VRF. Thus, this feature may serve as an aid in diagnosing VRF.

A Novel Treatment Decision Tree and Literature Review of Retrograde Peri-Implantitis.

Although retrograde peri-implantitis (RPI) is not a common sequela of dental implant surgery, its prevalence has been reported in the literature to be 0.26%. Incidence of RPI is reported to increase to 7.8% when teeth adjacent to the implant site have a previous history of root canal therapy, and it is correlated with distance between implant and adjacent tooth and/or with time from endodontic treatment of adjacent tooth to implant placement. Minimum 2 mm space between implant and adjacent tooth is needed to decrease incidence of apical RPI, with minimum 4 weeks between completion of endodontic treatment and actual implant placement. The purpose of this study is to compile all available treatment modalities and to provide a decision tree as a general guide for clinicians to aid in diagnosis and treatment of RPI. Literature search was performed for articles published in English on the topic of RPI. Articles selected were case reports with study populations ranging from 1 to 32 patients. Any case report or clinical trial that attempted to treat or rescue an implant diagnosed with RPI was included. Predominant diagnostic presentation of a lesion was presence of sinus tract at buccal or facial abscess of apical portion of implant, and subsequent periapical radiographs taken demonstrated a radiolucent lesion. On the basis of case reports analyzed, RPI was diagnosed between 1 week and 4 years after implant placement. Twelve of 20 studies reported that RPI lesions were diagnosed within 6 months after implant placement. A step-by-step decision tree is provided to allow clinicians to triage and properly manage cases of RPI on the basis of recommendations and successful treatments provided in analyzed case reports. It is divided between symptomatic and asymptomatic implants and adjacent teeth with vital and necrotic pulps. Most common etiology of apical RPI is endodontic infection from neighboring teeth, which was diagnosed within 6 months after implant placement. Most common findings, radiographically and clinically, are lesions around implant apex and sinus tract. A small number of implants did not improve with treatment. Decision tree provides a path to diagnose and treat lesions to facilitate their management. Further studies are needed to focus on histologic data around periapical microbiota to establish specific etiology and differential diagnoses compared with marginal peri-implantitis and other implant-related conditions.

Determinants of methicillin-susceptible Staphylococcus aureus native bone and joint infection treatment failure: a retrospective cohort study.

BackgroundAlthough methicillin-susceptible Staphylococcus aureus (MSSA) native bone and joint infection (BJI) constitutes the more frequent clinical entity of BJI, prognostic studies mostly focused on methicillin-resistant S. aureus prosthetic joint infection. We aimed to assess the determinants of native MSSA BJI outcomes.MethodsRetrospective cohort study (2001–2011) of patients admitted in a reference hospital centre for native MSSA BJI. Treatment failure determinants were assessed using Kaplan-Meier curves and binary logistic regression.ResultsSixty-six patients (42 males [63.6%]; median age 61.2 years; interquartile range [IQR] 45.9–71.9) presented an acute (n = 38; 57.6%) or chronic (n = 28; 42.4%) native MSSA arthritis (n = 15; 22.7%), osteomyelitis (n = 19; 28.8%) or spondylodiscitis (n = 32; 48.5%), considered as “difficult-to-treat” in 61 cases (92.4%). All received a prolonged (27.1 weeks; IQR, 16.9–36.1) combined antimicrobial therapy, after surgical management in 37 cases (56.1%). Sixteen treatment failures (24.2%) were observed during a median follow-up period of 63.3 weeks (IQR, 44.7–103.1), including 13 persisting infections, 1 relapse after treatment disruption, and 2 super-infections. Independent determinants of treatment failure were the existence of a sinus tract (odds ratio [OR], 5.300; 95% confidence interval [CI], 1.166–24.103) and a prolonged delay to infectious disease specialist referral (OR, 1.134; 95% CI 1.013–1.271).ConclusionsThe important treatment failure rate pinpointed the difficulty of cure encountered in complicated native MSSA BJI. An early infectious disease specialist referral is essential, especially in debilitated patients or in presence of sinus tract.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-443) contains supplementary material, which is available to authorized users.

Detection of bacteria in endodontic samples and its association with defined clinical signs and symptoms of endodontic infection

Introduction : The role of bacteria in pulpal and periradicular lesions is well established. However, the association of bacterial species with signs and symptoms of endodontic infection is not well elucidated. The purpose of this study was to investigate the types of bacterial species in infected root canals (using MicroSeq 500 16S ribosomal ribonucleic acid, rRNA) and the association of bacterial species with clinical signs and symptoms of different pulpal and periapical infections. Materials and Methods: Microbial samples were obtained from 92 adult patients (one tooth with single root canal for each patient). Clinical data including signs and symptoms were collected. Polymerase chain reaction (PCR) (MicroSeq 500 16S rRNA) was used to detect bacteria in the infected root canals. Results: A total of 179 bacterial species were identified. Actinomyces viscosus and Streptococcus sanguis were associated with the presence of pain. While Staphylococcus haemolyticus and Veillonella spp. were associated with pain of palpation, the pain to percussion was associated with Actinomyces spp., Actinomyces naeslundii, and Actinomyces viscosus. Also, Streptococcus mitis, Bacteroides spp., and Veillonella spp. were associated with periapical swelling. The presence of sinus tract was found to be significantly associated with Neisseria spp. and Staphylococcus haemolyticus. The wet canal was significantly associated with the presence of Propionibacterium acnes and Bacteroides spp. Conclusions: There are significant associations between the presence of some bacterial species with clinical signs and symptoms of infected root canals.

Characteristics and outcome of 16 periprosthetic shoulder joint infections

Shoulder arthroplasties are increasingly performed, but data on periprosthetic joint infections (PJI) in this anatomical position are limited. We retrospectively investigated the characteristics and outcome of shoulder PJI after primary arthroplasty from 1998 to 2010 in a single centre. Periprosthetic joint infection was defined as periprosthetic purulence, presence of sinus tract or microbial growth. A Kaplan-Meier survival method was used to estimate relapse-free survival of prosthesis. From 1,571 primary shoulder prostheses, we evaluated 16 patients with a PJI at different stages, i.e, early (n = 4), delayed (n = 6) and late (n = 6) infections. The median patient age was 67 (range 53-86) years, and 69 % were females. The most commonly isolated microorganism was Propionibacterium acnes in 38 % of patients (monobacterial in four and polymicrobial in two patients). In 14 of the 16 patients, surgical interventions consisting of debridement and implant retention (6 patients), exchange (7) and explantation (1) were performed. Four patients had a relapse of infection with P. acnes (n = 3) or Bacteroides fragilis (n = 1). The relapse-free survival of the prosthesis was 75 % (95 % confidence interval 46-90 %) after 1 and 2 years, 100 % in six patients following the treatment algorithm for hip and knee PJI and 60 % in 10 patients not followed up. All but one of the relapses were previously treated without exchange of the prosthesis. As recommended for hip and knee PJI, we suggest treating shoulder PJI with a low-grade infection by microorganisms such as P. acnes with an exchange of the prosthesis. Cohort studies are needed to verify our results.

EXACERBACIÓN APICAL POSTERIOR A TRATAMIENTO ENDODÓNTICO

An endodontic treatment generates high expectations for the patient due to the popular belief treatment be uncomfortable, painful, stressful it takes several sessions to complete it. When the pulp is symptomatic, these expectations rise and the professional expects to finish and to remove all the symptoms to ensure the success of therapy. Endodontic exacerbations are complications than can be presented during endodontic treatment to form periapical inflammatory processes that occur at the end of treatment. Some factors influence the development of these complications such as pulp diagnosis, the presence of sinus tracts, extensive instrumentation, lack of instrumentation and irrigation, among others. This article describes the case of a premolar with an initial diagnosis of chronic suppurative apical periodontitis, endodontic retreatment under which introduced an error in the preparation by subinstrumentation to determine a working length that caused insufficient and inadequate cleaning apical injury.

Low Rate of Infection Control in Enterococcal Periprosthetic Joint Infections

Enterococcal periprosthetic joint infections (PJIs) are rare after joint arthroplasty. These cases are usually reported in series of PJIs caused by other pathogens. Because few studies have focused only on enterococcal PJIs, management and control of infection of these cases have not yet been well defined. We asked (1) what is the proportion of enterococcal PJI in our institutes; and (2) what is the rate of infection control in these cases? We respectively identified 22 and 14 joints with monomicrobial and polymicrobial PJI, respectively, caused by enterococcus. The diagnosis of PJI was made based on the presence of sinus tract or two positive intraoperative cultures. PJI was also considered in the presence of one positive intraoperative culture and abnormal serology. We determined the proportion of enterococcal PJI and management and control of infection in these cases. Minimum followup was 1.5years (mean, 3.2years). The proportion of monomicrobial enterococcal PJI was 2.3% (22 of 955 cases of PJI). Mean number of surgeries was two (range, 1-4). Initial irrigation and débridement was performed in 10 joints and eight patients needed reoperation. Seven of the 16 joints were initially managed using two-stage exchange arthroplasty and did not need further operation. Six patients had a definitive resection arthroplasty. Salvage surgeries (fusion and above-knee amputation) were performed in three cases (8%). The infection was ultimately controlled in 32 of the 36 patients. Management of enterococcal PJI is challenging and multiple operations may need to be performed to control the infection. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Detection of Porphyromonas endodontalis, Porphyromonas gingivalis and Prevotella intermedia in primary endodontic infections in a Chinese population

To assess the prevalence of three black-pigmented bacterial species (Porphyromonas endodontalis, Porphyromonas gingivalis and Prevotella intermedia) using microarray technology in root canals of teeth associated with primary endodontic infections in a Chinese population. Microbial samples were taken from root canals of 80 teeth with pulp necrosis and primary endodontic infections in a Chinese population. DNA extracted from the samples was amplified by PCR with universal bacterial primers based on 16S rRNA gene sequences, and the products hybridized with the microarrays in which the specific oligonucleotide probes were added. The results of hybridization were screened by a confocal laser scanner. Pearson chi-square test and the two-sided Fisher exact test were used to analyse whether a significant association existed between the species and symptoms as well as in co-existence of two target organisms by a statistical software package (SAS 8.02). The 16S rRNA gene microarray detected at least one of the three test species in 76% of the study teeth. P. endodontalis, P. gingivalis and P. intermedia were found in 50%, 33% and 45%, respectively. A significant association was found in the presence of the pair P. endodontalis / P. gingivalis (P < 0.005). Both P. endodontalis (P <0.05) and P. gingivalis (P <0.005) had a statistically significant association with the presence of a sinus tract. The simultaneous presence of P. endodontalis and P. gingivalis was also associated with the presence of a sinus tract (P<0.005) and abscess formation (P<0.05). The three black-pigmented bacteria were prevalent in teeth with pulp necrosis and primary endodontic infections in a Chinese population. P. gingivalis and P. endodontalis were associated with the presence of sinus tract and abscess formation.

Characteristics and outcome of 27 elbow periprosthetic joint infections: results from a 14-year cohort study of 358 elbow prostheses

Elbow arthroplasty is increasingly performed in patients with rheumatic and post-traumatic arthritis. Data on elbow periprosthetic joint infection (PJI) are limited. We investigated the characteristics and outcome of elbow PJI in a 14-year cohort of total elbow arthroplasties in a single centre. Elbow prosthesis, which were implanted between 1994 and 2007 at Schulthess Clinic in Zurich, were retrospectively screened for infection. PJI was defined as periprosthetic purulence, the presence of sinus tract or microbial growth. A Kaplan–Meier survival method and Cox proportional hazard analysis were performed. Of 358 elbow prostheses, PJI was identified in 27 (7.5%). The median patient age (range) was 61 (39–82) years; 63% were females. Seventeen patients (63%) had a rheumatic disorder and ten (37%) had osteoarthritis. Debridement and implant retention was performed in 78%, followed by exchange or removal of the prosthesis (15%) or no surgery (7%). The relapse-free survival (95% CI) was 79% (63–95%) after 1 year and 65% (45–85%) after 2 years. The outcome after 2 years was significantly better when patients were treated according to the algorithm compared to patients who were not (100% vs. 33%, p <0.05). In 21 patients treated with debridement and retention, the cure rate was also higher when the algorithm was followed (100% vs. 11%, p <0.05). The findings of the present study suggest that the treatment algorithm developed for hip and knee PJI can be applied to elbow PJI. With proper patient selection and antimicrobial therapy, debridement and retention of the elbow prosthesis is associated with good treatment outcome.

Ideal combination of sequences for perianal fistula classification and evaluation of additional findings for readers with varying experience

The aim of our study was to assess the contribution of various magnetic resonance imaging (MRI) sequences in determining the type of perianal fistula and in obtaining critical information for surgical decisions, as well as to define the optimal combination of sequences for readers with varying levels of experience. The study included 33 MRI examinations in 26 patients with suspected perianal fistula. The following sequences were obtained in both the coronal and axial planes: thin slice, high resolution T1-weighted (W) spin echo; T2-weighted turbo spin echo; short tau inversion recovery (STIR); and native and contrast enhanced T1-weighted gradient echo fast low-angle shot (FLASH) images with fat suppression (FS-CE-T1W-GRE). The examinations were interpreted by three radiologists with varying degrees of experience in two different sessions, and the inter-reader agreement was assessed. Seventeen of the patients underwent surgery. The agreement between the surgical findings and the MRI results were evaluated. A statistically significant concordance between the fistula classification and surgery was achieved with the FS-CE-T1W-GRE sequence for Reader 1 (Cramer's V=0.701, P = 0,022) and Reader 3 (Cramer's V=0.716, P = 0,043). For Reader 2, statistically significant concordance between fistula classification and surgery was achieved with the FS-CE-T1W-GRE (Cramer's V=0.703, P = 0,011) and the T2W images (Cramer's V=0.648, P = 0,027). For all sequences, there was statistically significant agreement between readers for fistula classification, internal opening location, and the presence of sinus tracts, abscess, a horseshoe component, and inflammation. For experienced readers, combining FS-CE-T1W-GRE images with either T2W or STIR images collected in both the coronal and axial planes was sufficient to make an assessment before deciding the surgical extent of the procedure.

Prevalence of odontogenic sinus tracts in 728 endodontically treated teeth

The primary aim of this study was to assess the prevalence of sinus tracts in endodontically treated teeth in an Iranian population. The second aim was to seek and analyze the relationship between the clinically detected sinus tracts and factors such as sex, age, tooth type and location. A total of 728 patients' records and radiographs were reviewed of 427 females and 301 males for demographic data, preoperative pulpoperiapical status of treated teeth and the presence of sinus tract. Data were analyzed using chi-square test. No significant differences were found for the prevalence of sinus tracts between two genders. Data showed that the highest prevalence of sinus tracts was in 10-19 year age group. Of 725 treated teeth, 107 teeth had sinus tracts (14.7%). Most odontogenic sinus tracts were associated with mandibular anterior teeth. Of 348 teeth with preoperative status of periapical inflammation and radiolucency, 107 teeth (30.75%) had an odontogenic sinus tract. Data showed that almost one in seven teeth referred for root canal treatment had a sinus tract.